Skeletal Metastasis
Cancer affecting the skeleton is more often metastatic than primary
The skeleton is the 3rd most common site for metastases
The axial skeleton is involved in 70% of cases ( Batson's Valveless
Vertebral Vein System )
The commonest cause of bone metastases to the hand is lung cancer
Common Primary Tumours In Adults:
Adenocarcinomas of :
1. Breast
2. Prostate
3. Lung
4. Kidney
5. Thyroid
1. Breast
2. Prostate
3. Lung
4. Kidney
5. Thyroid
Common Primary Tumours in Children
Children:
1. Neuroblastoma
2. Wilm's Tumour
3. Rhabdomyosarcoma
4. Retinoblastoma
1. Neuroblastoma
2. Wilm's Tumour
3. Rhabdomyosarcoma
4. Retinoblastoma
Differential Diagnosis
Destructive Bone Lesion In An Adult Patient :1. Metastases
2. Multiple Myeloma (Picture)
3. Lymphoma
Lymphoma
Note the calcified para-aortic nodes. Destructive Bone Lesions in A Child < 10 Years :
Multiple Lesions :
1 ) Osteomyelitis
2 ) Eosinophilic Granuloma
3 ) Vascular Lesions
4 ) Metastases: Neuroblastoma, Wilm's Tumour
1 ) Osteomyelitis
2 ) Eosinophilic Granuloma
3 ) Vascular Lesions
4 ) Metastases: Neuroblastoma, Wilm's Tumour
CLINICAL PRESENTATIONS :
Patients can present in a variety of ways
It can mimic other pathologic entities and is hard to recognize.
It posts as a challenge to the treating orthopaedic surgeon, especially when patient present with a pathological fracture
It can mimic other pathologic entities and is hard to recognize.
It posts as a challenge to the treating orthopaedic surgeon, especially when patient present with a pathological fracture
PAIN :
Lesions may be extremely painful to asymptomatic
Most patient present with pain that is unresponsive to anti-inflammatory medications and narcotics.
2 types of pain :
Cancer pain : related to nociceptive stimuli
eg. Tissue stretching, tumour haemorrhage/necrosis,
compression of local structures, local irritation
- usually responds to any medical intervention that decreases the tumour burden or growth
eg. Chemotherapy, Radiotherapy etc
2. Functional/Mechanical pain : resulting from impending pathological fracture.
Most patient present with pain that is unresponsive to anti-inflammatory medications and narcotics.
2 types of pain :
Cancer pain : related to nociceptive stimuli
eg. Tissue stretching, tumour haemorrhage/necrosis,
compression of local structures, local irritation
- usually responds to any medical intervention that decreases the tumour burden or growth
eg. Chemotherapy, Radiotherapy etc
2. Functional/Mechanical pain : resulting from impending pathological fracture.
Neurological Complaints :
Spinal metastases with associated nerve root or cord compression
Pelvic metastases - leg pain mimics sciatica
Pelvic metastases - leg pain mimics sciatica
Disruption Of Heamatopoiesis :
Anemia ( Normochromic-normocytic )
HYPERCALCAEMIA :
Common with certain tumours :
1. Myeloma
2. Lymphoma
3. Lung
4. Breast
Early Symptoms :
- Polyuria, polydipsia
- Aneroxia
- Easy Fatigability
- Weakness
Late Symptoms :
- Apathy, irritability, depression
- Coma
- Profound muscle weakness
- Nausea, vomiting, abdominal pain
- Pruritus
1. Myeloma
2. Lymphoma
3. Lung
4. Breast
Early Symptoms :
- Polyuria, polydipsia
- Aneroxia
- Easy Fatigability
- Weakness
Late Symptoms :
- Apathy, irritability, depression
- Coma
- Profound muscle weakness
- Nausea, vomiting, abdominal pain
- Pruritus
Radiographs
Good quality biplanar ( AP-Lateral ) films that include the involved bone and one joint proximal and distal.
Pelvis :
AP view
Obturator Oblique View : anterior pelvic column & posterior wall of acetabulum
Iliac Oblique View : posterior pelvic column & anterior wall of acetabulum
A significant amount of bone must be destroyed before a lesion will appear lytic on X-ray film
Classification of radiological appearance :
1. Lytic (Renal Ca, Thyroid Ca, Breast Ca, Lung Ca, Head and Neck & CNS Malignancies )
2. Blastic ( Prostate Ca )
3. Mixed ( Breast Ca, Gastrointestinal Ca )
Pelvis :
AP view
Obturator Oblique View : anterior pelvic column & posterior wall of acetabulum
Iliac Oblique View : posterior pelvic column & anterior wall of acetabulum
A significant amount of bone must be destroyed before a lesion will appear lytic on X-ray film
Classification of radiological appearance :
1. Lytic (Renal Ca, Thyroid Ca, Breast Ca, Lung Ca, Head and Neck & CNS Malignancies )
2. Blastic ( Prostate Ca )
3. Mixed ( Breast Ca, Gastrointestinal Ca )
Breast Cancer (Blastic)
Metastasis from breast cancer can be blastic or lytic.Shown here is the blastic type.
Breast Ca (Lytic )
Lytic type of breast ca metastasis. Prostate Cancer
Metastasis from prostate cancer is typically blastic. Kidney Cancer
Renal cell carcinoma typically give rise to lytic and expansile lesion due to the high vascularity. Magnetic Resonance Imaging :
Imaging modality of choice for suspected bone metastases in the extremities and pelvisProvide images in multiple planes
Define the extent of soft tissue and intraosseous tumour extension & critical neurovascular structures
Very sensitive to early marrow replacement
Contrast-enhanced MRI : useful in monitoring tumour
response to chemotherapy
CT SCAN :
Assessment of bone anatomy and cortical destructionGold standard in assessing the amount and quality of bone remaining
Affects surgical treatment decisions and reconstruction options
-- esp in pelvic & acetabular lesions
NUCLEAR MEDICINE IMAGING :
99mTc or 201 Tl ( Thallium-201-chloride )Search for other skeletal sites of tumour involvement
Evaluate chemotherapeutic response of tumour
Virtually always +ve in metastatic bone disease
except :
-- Multiple Myeloma
-- Rapid and severe destructive lesion (lung, kidney)
-- Melanoma
ARTERIOGRAPHY :
Largely replaced by MRI and MRAUseful when vascular involvement of the tumour is suspected & in metastatic lesions where preoperative embolisation is considered
POSITRON EMISSION TOMOGRAPHY :
An important adjunct to CT scan and MRIHighly sensitive
Provides complementary metabolic information
Commonest radiotracer used :
Flourine-18-flourodeoxyglucose ( 18F-FDG )
- accumulates in area of high glycolysis and membrane transport of glucose
- both increased in malignant tissue, demonstrating tumour response to neoadjuvant chemotherapy
- detect bone metastases
- differentiating recurrent disease from scar
SKELETAL RESPONSES TO METASTATIC DISEASE
Metasatases are most often destructive and osteolytic than osteoblasticSubstances secreted by tumour cells activate both osteoblasts and osteoclasts
In most tumours, osteoclastic activation predominates
Osteoblastic lesions
Less commonIn adults : Prostate & Breast Ca
In children: Medulloblastoma,Lymphoma,Retinoblastoma
Osteoblastic response could be so pronounced that it obscures the underlying neoplasm
Diagnosis :
Biopsy & Histopathological Examination
After a thorough history and examination, blood tests and radiological investigations, 85% of the primary tumours that present initially with an osseous metastases can be identified.Subsequent treatment depends on the type of tumour.
In patients in whom no primary tumour is detected, results of chemotherapy is disappointing and may not be indicated.
MANAGEMENT
3 Main Goals:
1. Functional Preservation & Restoration
2. Pain Relief
3. Quality Of Life Extension
1. Functional Preservation & Restoration
2. Pain Relief
3. Quality Of Life Extension
GOAL OF SURGERY
Whether for an impending or pathological fracture, the goal are :
1. Reinforce or replace the compromised bone with rigid and durable construct.
2. Provide functional stability and pain relief.
1. Reinforce or replace the compromised bone with rigid and durable construct.
2. Provide functional stability and pain relief.
PRINCIPLES OF SURGICAL MANAGEMENT :
1. Understand the patient's prognosis
2. Provide adequate perioperative antibiotic coverage and optimize patient's medical condition before surgery
3 Verify histology in lesions that present as the first skeletal metastases
4 Actual management of pathological fracture is secondary and proceeds only after all necessary diagnostic tests are completed
5. In patients with previous radiation fields, ensure adequate soft tissue coverage and carefully avoid unnecessary trauma to soft tissue flaps
6. Remove as much of the lesion as possible without negatively affecting the ability to provide proper fixation
7. Intralesional margins are acceptable because the intent of surgery is to mechanically reinforce rather than to surgically cure
8. Use internal fixation ± bone cement or cemented prosthetic replacements as indicated to create a stable, durable construct and to fulfill the goal of immediate return to function. Fixation in this setting must persist for the life of the patient
9. Use adjuvant therapy in the form of postoperative radiation therapy and/or chemotherapy when indicated
2. Provide adequate perioperative antibiotic coverage and optimize patient's medical condition before surgery
3 Verify histology in lesions that present as the first skeletal metastases
4 Actual management of pathological fracture is secondary and proceeds only after all necessary diagnostic tests are completed
5. In patients with previous radiation fields, ensure adequate soft tissue coverage and carefully avoid unnecessary trauma to soft tissue flaps
6. Remove as much of the lesion as possible without negatively affecting the ability to provide proper fixation
7. Intralesional margins are acceptable because the intent of surgery is to mechanically reinforce rather than to surgically cure
8. Use internal fixation ± bone cement or cemented prosthetic replacements as indicated to create a stable, durable construct and to fulfill the goal of immediate return to function. Fixation in this setting must persist for the life of the patient
9. Use adjuvant therapy in the form of postoperative radiation therapy and/or chemotherapy when indicated
Prophylactic Internal Fixation
Fidler (1973) assessed fracture rates based on radiological involvement :
If less than 50% diameter :
-- 2.3% incidence of fracture
If greater than 50% :
-- 60% go on to fracture
Fidler M : Prophylactic internal fixation of secondary neoplastic deposits in bone. Br Med J 1:341-343, 1973
If less than 50% diameter :
-- 2.3% incidence of fracture
If greater than 50% :
-- 60% go on to fracture
Fidler M : Prophylactic internal fixation of secondary neoplastic deposits in bone. Br Med J 1:341-343, 1973
Mirels Objective Scoring System
Mirels H : Metastatic disease in long bones. A proposed scoring system for diagnosing pathological fractures. Clin Orthop 249:256-264, 1989
The scoring system depends on 4 parameters:
1. Pain (1=Mild, 2=Moderate, 3=Functional)
2. Diameter of lesion (1=<1/3, 2=1/3-2/3, 3=>2/3)
3. Type of lesion (1=Blastic, 2=Mixed, 3=Lytic)
4. Site (1=Upper Limb, 2=lower Limb, 3=Peritrochanteric)
Prophylactic Fixation is indicated if score >9
1. Pain (1=Mild, 2=Moderate, 3=Functional)
2. Diameter of lesion (1=<1/3, 2=1/3-2/3, 3=>2/3)
3. Type of lesion (1=Blastic, 2=Mixed, 3=Lytic)
4. Site (1=Upper Limb, 2=lower Limb, 3=Peritrochanteric)
Prophylactic Fixation is indicated if score >9
Factors to consider.
1. Overall health of the patient + life expectancy
2. Expected response of the tumour and patient to adjuvant interventions like radiotherapy
3. Surgeon's experience and capability at bone reconstruction
4. The reconstructability of the affected bone
5. Extent of functional disruption that would occur if a fracture does occur ( eg. UL vs LL )
6. It is always easier and better to fix an impending pathological fracture than to heal one
2. Expected response of the tumour and patient to adjuvant interventions like radiotherapy
3. Surgeon's experience and capability at bone reconstruction
4. The reconstructability of the affected bone
5. Extent of functional disruption that would occur if a fracture does occur ( eg. UL vs LL )
6. It is always easier and better to fix an impending pathological fracture than to heal one
RELATIVE CONTRAINDICATIONS TO SURGERY
1. Moribund patient
2. Distorted mental status
3. Disorientated, agitated, flailing patient
4. Multiple risks :
a) Infections
b) Poor rehabilitation support
c) Fluid overload
5. Severely limited life expectancy- Insufficient time to heal and enjoy the benefits of restored or preserved functions
7. Unrestorable function : Disease too extensive- no good reconstruction is possible
8. Venous thromboembolic disease of the lower limb
2. Distorted mental status
3. Disorientated, agitated, flailing patient
4. Multiple risks :
a) Infections
b) Poor rehabilitation support
c) Fluid overload
5. Severely limited life expectancy- Insufficient time to heal and enjoy the benefits of restored or preserved functions
7. Unrestorable function : Disease too extensive- no good reconstruction is possible
8. Venous thromboembolic disease of the lower limb
Criteria For Internal Fixation
1. > 50% cortical bone destruction2. High Stress Site :
a) Subtrochanteric region
b) Femoral Diaphysis
c) Humeral Diaphysis
d) Humeral anatomic neck
3. Purely lytic lesion
4. Weight bearing pain
5. Pain following irradiation
SURGICAL OPTIONS :
1. Internal Fixation
2. Prosthetic Devices
2. Prosthetic Devices
Internal Fixation-Intramedullary Nail
Usually statically lockedCement augmentation as necessary
Used for diaphyseal lesion
Internal Fixation-Plating
Supplement with cementUsed as buttress plate
Used for metaphyseal lesion
Curette the tumour while conserving cortical bone
PROSTHETIC DEVICES
Indications:1. Femoral Neck Fractures
2. Large destructive proximal femoral lesions (picture)
3. Large destructive lesions of proximal humerus
Endoprosthesis
The destructed proximal femur was resected and reconstructed with long stem endoprosthesis. Conservative management
Indicated when the goals of pain relief and functional preservation or restoration are unattainable or unreasonable with surgical management or when these goals can be met satisfactorily with medical management alone
eg. A metastatic lesion detected during a screening study but clinically asymptomatic & has no risk of fracture.
Regular follow-up keeping an eye for progression of lesion or clinical symptoms (eg pain, impending fracture)
Generally includes :
- Radiotherapy
- Chemotherapy
- Hormonal therapy
Ca Breast : Anti-estrogen
Ca Prostate : Antiandrogens & LHRH Agonists
- Pain management
- Metabolic or pharmacologic manipulations (Biphosphonates)
- Nutrition
- Psychological support
eg. A metastatic lesion detected during a screening study but clinically asymptomatic & has no risk of fracture.
Regular follow-up keeping an eye for progression of lesion or clinical symptoms (eg pain, impending fracture)
Generally includes :
- Radiotherapy
- Chemotherapy
- Hormonal therapy
Ca Breast : Anti-estrogen
Ca Prostate : Antiandrogens & LHRH Agonists
- Pain management
- Metabolic or pharmacologic manipulations (Biphosphonates)
- Nutrition
- Psychological support
Radiotherapy :
Overall 85% response rate
Complete pain relief in 50%, partial pain relief in 35%
More than half respond within 1-2 weeks
Median duration of pain relief 12-15 weeks
Tumor necrosis followed by collagen proliferation, woven bone formation, and replacement with lamellar bone
Recalcification by 2-3 months
Various dose and fractionization schedules
Complete pain relief in 50%, partial pain relief in 35%
More than half respond within 1-2 weeks
Median duration of pain relief 12-15 weeks
Tumor necrosis followed by collagen proliferation, woven bone formation, and replacement with lamellar bone
Recalcification by 2-3 months
Various dose and fractionization schedules
Biphosphonates
Inhibit bone resorption by :
1. Interaction with molecules on the osteoclast surface
2. Prevention of osteoclast attachment to the bone matrix
3. Incorporation of the drug into the inorganic bone matrix itself
4. Forms an analog to calcium hydroxyapatite that is more resistant to osteoclast degradation than the native matrix
1. Interaction with molecules on the osteoclast surface
2. Prevention of osteoclast attachment to the bone matrix
3. Incorporation of the drug into the inorganic bone matrix itself
4. Forms an analog to calcium hydroxyapatite that is more resistant to osteoclast degradation than the native matrix
PROGNOSIS
Coleman RE : Skeletal complications of malignancy. Cancer 80-1588, 1997
Median Survival in months:
(Percentage of 5 year survival in bracket)
Thyroid - 48 (40)
Prostate -40 (25)
Breast - 24 (20)
Myeloma - 20 (10)
Kidney - 6 (10)
Lung - <6 (<5)
Melanoma - <6 (<5)
(Percentage of 5 year survival in bracket)
Thyroid - 48 (40)
Prostate -40 (25)
Breast - 24 (20)
Myeloma - 20 (10)
Kidney - 6 (10)
Lung - <6 (<5)
Melanoma - <6 (<5)
Link List for Bone Metastasis
- Skeletal Metastasis AAOS
- Learn more about skeletal metastasis at AAOS
- Mechanism of tumour metastasis
- Molecular mechanism of tumour metastasis to bone. A 'must read' by MMED candidates.
- Ebook on skeletal metastasis
- Treatment of metastatic bone disease by Martin Malawer.
- Metastatic carcinoma of long bone
- Journal article on metastatic carcinoma of long bone.
- Metastatic Melanoma
- Bone metastasis from malignant melanoma
- Management of bone metastasis
- Management of Bone Metastases in Advanced Breast Cancer
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- santosh v nair santosh v nair Feb 4, 2009 @ 8:11 am
- my question is that skeletal metastases is curable or not. my mother in law few years back operated breast ( cancer), but today she is facing next cancer that is skeletal metastases. kindly
guide me
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Reply
- stemcells stemcells Mar 27, 2008 @ 2:15 pm
- Wonderful source of Information!
There is a way to improve anyone's quality of life as well as their Health.
Without Health You cannot really enjoy Life fully.
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