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05.11.2015 admin
To understand that taking care of patients with metastatic bone disease requires a multidisciplinary team approach — working with medical oncologists, radiation oncologists, radiologists, pathologists, etc.
As for the clinical problems for patients with metastatic bone disease, pain is the major issue.
When we look at the primary lesions that most often spread into the bones, by far the most common are breast, lung, and prostate, but thyroid and kidney are also common.
When you have a patient who has a lytic lesion or a destructive lesion in the skeleton and you do not know where it is coming from, medical history is the best way to focus your attention on what this might be. Prostate cancer metastasis are nearly always osteoblastic, and you will see dense lesions throughout the pelvis and lower spine. When you see an area in the bone that has a hole, the process has been underway for quite a while because 50 percent of the bone must be gone before you can notice it on an X-ray.
The differential diagnosis of a destructive lesion in a patient over 45 years, then, begins with metastatic bone disease.
Shown below, we have a chest CT scan, an abdominal CT that shows a large kidney mass, and a bone scan with widespread metastasis. Laboratory studies are not as helpful as the radiographs, but certainly need to be checked. If the staging work-up of metastatic disease shows no primary lesion, it is most likely from the lung or the kidney. The other, even more concerning scenario is the patient without any history of cancer, but with a destructive bone lesion.
Biopsies used to be done in the operating room for the most part, but we have now shifted to image-guided needle biopsies. From the orthopaedic standpoint, we have to decide when we should try to stabilize a weakened bone. The goals of surgery are primarily to relieve the patient of pain and, ideally, to allow them to get back to their daily activities, to allow them to be full weight-bearing or, at the very minimum, to facilitate nursing care. When you have something in the middle of the humerus, a metal rod, with cement around it can be used. We can use plates and screws, but then I might worry about a bone metastasis occurring more proximal in the bone. Something I did not mention earlier is that thyroid cancer and kidney cancer are so vascular that the patient can die during surgery because of blood loss.
Probably the most common area where lesions occur is around the femoral neck or the hip joint. In closing, there are many approaches used in helping patients with metastatic bone disease, with stability and pain management being our primary goal. About Arthritis CenterFounded in 1998, the Arthritis Center at Johns Hopkins is dedicated to providing quality education to patients and healthcare providers alike.
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Patient may present with bone pain without known primary cancer and be found to have metastatic bone cancer. Patient may present with a pathologic fracture occurring in an area of bone weakened by cancer. There is no consensus as to the utility of PET scans in the clinical evaluation of bone metastases. What are the radiological modes of presentation of secondary bone tumors in plain radiographs? Indicates the net result of bone resorption and repair showing osteoblastic, osteolytic and mixed lesions, as well as defining the bone anatomy. A skeletal survey (includes lateral skull, cervical spine, anteroposterior (AP) and lateral thoracic and lumbar spine, an AP pelvis and chest radiograph) is used as the primary investigation for bone metastases.
Radionuclide bone scanning is the preferred method for evaluating the entire skeleton for the presence of multiple lesions.
Reflects the metabolic reaction of bone to the disease process, with preferential uptake of the tracer at sites of active bone formation.
Metastases are usually multiple, irregularly distributed foci of tracer that do not correspond to any single anatomic structure. The probability that an abnormal scan represents metastatic tumor is directly related to the number of abnormal foci. Bone scans are also limited by a lack of specificity, with most false-positive results due to trauma, whether recalled by the patient or not. Also, it is reserved for patients with positive bone scans and negative radiographs in order to clarify pathology. MR: Even more sensitive than CT, especially for lesions involving the spine, because it can provide mutiplanar images and identify the nerve and spinal roots.
Although whole body MRI has the potential to detect more lesions in the axial skeleton (particularly the spine) than bone scan, it is generally not feasible in most centers due to time constraints. Whole body MRI techniques are rapidly advancing, and may replace technetium bone scanning in the future. All content of Journal of Endocrinology and Metabolism is permanently archived and preserved in Portico.
Bone scans, as you know, involve identifying intensity of bone response, or osteoblastic activity. Breast cancer can be a mixed picture; we either see dense bone, or we can see lytic destruction, or we can see a mixed pattern. We would routinely check the PSA, and we may have indication to check the thyroid function tests. Most commonly what we see in cancer patients who come to the clinic is that they have multiple bone lesions.
We have to then decide if they have metastatic cancer or if they have a primary tumor, like an osteosarcoma or chondrosarcoma. If it’s obvious that a patient needs a surgical procedure to fix a broken bone and allow him to walk, that is not a difficult decision. Someone with prostate cancer is probably less likely to fracture than someone with a large lytic renal cell carcinoma bone metastasis.
Therefore, when we decide whether to operate on a patient, the stability of the construct is very important.

We do not use this very often for patients who have a limited lifespan, but more in young people who have primary tumors that we can cure. Depending on the particular histology, if it has a chance of progressing, we will go in and scrape out all the gross tumor and fill it with cement. When you have a tumor taking up a third of the pelvis, and you are scraping it out to put in your reconstruction, the tumor will continue to bleed because there is no blood vessel you can tie off. With an elderly patient who has a hip fracture, you have to decide whether it was due to cancer or to osteoporosis. Each case is individual and care of these patients requires a multidisciplinary team approach.
Physicians and other health care professionals are encouraged to consult other sources and confirm the information contained within this site. That was awhile ago, but it was a great opportunity to learn more about the musculoskeletal system. About 50 percent of those have the possibility of spreading into the skeletal system, which is the third most common site, after the liver and the lung. Why do breast cancer cells specifically go into the lung, or why do they spread into certain organs, whereas other cancers spread into completely different organs? I have seen squamous cell cancer of the tongue and fallopian tube cancer with bone metastasis.
An incredibly destructive lesion will not show up on a bone scan because it is so lytic that there is no osteoblastic response.
You can imagine that this can cause quite a problem at the level of the hip joint as it becomes weak and the person continues to put weight on it. If a patient is having knee pain, the pain may be coming from a lesion at the hip, so we image the entire femur. A CBC is helpful because patients with multiple myeloma frequently are anemic; and the SPEP and UPEP, with various immunofluorescence studies to look for myeloma. The diagnosis is not really in question, and we generally are not looking to do biopsies of those bone lesions.
The surgeon felt that this, given the history, must be metastatic prostate cancer and so put in a short nail to try to stabilize the area, improve the pain, and decrease the risk of fracture. For bone biopsies, patients often need a bit of sedation as it’s not terribly comfortable putting the needle through the bone. So, if it is the first time they present, and there is no diagnosis of cancer, you do need a biopsy.
When we take care of cancer patients, we need to be attuned to their nutritional status and metabolic status.
Co-morbid conditions and predicted lifespan are also very important in deciding whether to take someone into the operating room. We have to decide what type of implant to use, taking into account what part of the body it’s going to be used in.
Biomedical engineering is very active in coming up with new implants, better implants, stronger metals and the like.
But with renal cancer, it tends to continue to grow; medicines and radiation do not work very well. We took out the whole section with the rod and put in a replacement segment at the top (this is the slide you’ve chosen).
This provides a better construct, and sometimes the tumor is better controlled if you radiate microscopic disease rather than macroscopic disease. Therefore, we send these patients to interventional radiology to have the lesion embolized 24 hours before surgery.
The way we fix these two particular fractures is extremely different, so it is very important to make that differentiation. Some of the spine metastases involve the whole vertebral body and can involve taking out an entire segment of the spine.
It is the most symptomatic site, and there is an increase in the number of cases as time goes on because of a number of factors. He felt that it was the capacity of the tumor cell to secrete particular growth factors or cytokines that then found a fertile soil in the environment of the lung, liver, or other organ. The cells spread to additional organs, and then have to have the right signals to be able to break out of the microvasculature and land in a particular organ matrix, and grow there. Imaging also may include the bone scan, sensitive at detecting osteoblastic activity, and the MRI scan, which I find useful in evaluating the spine. If you mistreat a primary bone lesion, you can actually compromise the patient’s limb or their life, so indeterminate lesions require a biopsy. Sometimes bone lesions have a very thin cortex or there is a soft tissue mass coming out of the bone, so it is not as uncomfortable. We need to make sure that we don’t just fix the top part of the femur but that we fix the entire bone because someone could have a metastasis just below.
There was still disease there, but thinking this man was not going to survive very long, the lower humerus was left in so he could have a normal elbow. We have to use three-dimensional imaging before planning surgery to know how much of the bone is destroyed. I will talk about how to recognize some of the lesions that patients have, as well as some of the toys that we play with when we try to help patients with these problems, from an orthopaedic surgical standpoint. The cell then has the right environment to grow in, whereas other environments might not be as conducive, might not have the right factors. The vast majority, 99.99 percent of tumor cells, are eliminated by the body’s immune system so they never make it to the end organ. Patients are forced to be immobilized if they cannot walk due to lesions in the lower extremities. She had knee pain, and I was very slow to recognize that she had metastatic disease in the knee because I was just not thinking that pancreatic cancer would be a primary tumor likely to spread that way.
Osteosarcoma, fibrosarcoma, and MFH are not seen very often in an older patient, but we do occasionally see them and they need to be in our memory bank. CTs are getting remarkably better, but I generally do not use a CT scan other than to stage the visceral organs. Calcium really is important only if it is incredibly high, which would signify later stage disease.

We need to look a little more carefully if they are complaining of back pain and they have a history of breast cancer. There also are FNA, or fine needle aspirations, and core needle biopsies, which take a bigger piece of tissue.
The medical oncologists and our colleagues in interventional radiology and radiation oncology — we put our heads together to find what is best for each individual patient. They have less pain, and can return more quickly to their primary treatment if you can repair the bone before it’s broken. We almost always stabilize the entire bone, and post-operative radiotherapy is incredibly important.
You took measurements and told the factory you wanted something, say, 200 millimeters in length. But he surprised us and continued living far after this procedure, to the point where he actually developed increased disease and an impending fracture. However, it does not make sense to do this in someone who has a limited lifespan because of the lengthy time it takes for the bone to heal. When patients have a broken hip due to osteoporosis and they come through the emergency room, they usually just get a couple of screws put in their hip, or a plate and screws, and that works. If they have a progressive neural deficit, and their bone is broken into the canal, we usually do surgery because radiation is not effective. In 1928, Ewing felt the reason that cancer cells spread to particular organs had to do with the blood supply, the circulation — whether it was the portal circulation, the systemic circulation or Batson’s plexus, which is a plexus of vessels in the lower portion of the spine and pelvis, valveless veins that allow retrograde flow. Anemia and hypocalcemia are some of the medical problems that occur when you have an extensive bone load of tumor.
When you are working with an older patient who has back pain, and a history of cancer, spine metastases should be considered. Then, there are post-radiation sarcomas, Paget’s disease related to sarcoma, hyperthyroidism, and insufficiency fractures.
Alkaline phosphatase is generally high when you have any type of destructive activity in the bone. So the surgeon just spread the tumor cells up and down the femur, and it has gone in through the gluteal muscles, so the patient, in order to have a curative procedure, now requires a hindquarter amputation. This requires excellent musculoskeletal pathologists and excellent radiologists who are able to put the needle exactly where the lesion is and evaluate the tissue.
There is no cookie-cutter approach to this because everyone has different needs at home, different activity demands, different projected life spans. When we stabilize people who have fractures in their skeleton, we are not curing the cancer. There also are a couple new approaches, called vertebroplasty and kyphoplasty, which involve injecting an acrylic cement to stabilize and reduce pain. When someone has prostate cancer, often the metastases are focused around the pelvis and lower spine. And, with involvement of the upper extremities, they often cannot use external aids that could help them walk.
Other common sites of metastasis are the pelvis, ribs, skull, and the proximal long bones — something to keep in the back of your mind when you have a positive bone scan in those areas. If you have a patient who complains of pain in their extremities that won’t go away, that is something to be concerned about.
They do it at JHH under either ultrasound for soft tissue masses, big thigh masses, etc., or they do it under CT guidance for the bones. He does not have great shoulder function, but he’s able to flex his elbow to 90 degrees and he seems to be doing quite well.
You may have seen this technique in patients who have osteoporotic fractures, but there is also a role for these approaches in patients who have spine metastasis, especially multiple myeloma, who frequently have collapse of vertebral bodies.
The tumor cells stimulate the osteoclast, the bone-resorbing cell, with mediators such as tumor necrosis factor, transforming growth factors, colony stimulating factors, prostaglandins, 1,25-dihydroxyvitamin D3, or parathyroid hormone-related protein. A physical examination is also important — a routine examination to feel for masses, to feel for tender areas, to check the joint range of motion. We now have radioactive isotopes that we can use for bone metastasis, and we have radiofrequency ablation, where interventional radiologists place a probe within a small bone lesion, increase the temperature and basically fry the cancer cells.
Most tumors do not spread into a joint but near a joint, and can cause a joint effusion if it is near the end of the femur, at the upper part of the tibia, or around the shoulder.
Some patients have bone pain because they are on Zometa® or they are on thalidomide or other agents that can cause bone pain.
It is a way to decrease pain in patients, especially those who have not responded to radiation.
After the patient heals from surgery, we treat the patient with 10 days of external beam radiation therapy. And finally, interventional radiologists can do radiofrequency ablations in small areas around the pelvis to provide pain relief in very sick patients or patients who have not been able to be managed with radiation or maybe are not surgical candidates.
But generally, a joint effusion is not what we see in these particular patients but rather just pain, tenderness, and an inability to walk, a limp, or holding the arm in a protective fashion. And with an older patient, it’s important to do a breast examination, a thyroid examination, and question the person about blood in the stool, blood in the urine, etc. Plain X-rays of the involved bone and the chest, a whole body bone scan, and a CT scan of the chest, abdomen and pelvis are the major tests used to screen for metastatic disease.
These particular tests are going to identify almost all patients who have some type of primary cancer. Now, medical oncologists are very interested in using PET scans routinely on patients to try to identify where the disease is and identify if there is spread throughout the body. A biopsy is necessary if it is not obvious that the patient has widespread metastasis from a particular primary site.

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