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Secondary malignant tumours of bone

Metastatic lesions affecting bone are more common than primary bone tumours.
The typical tumours that spread to bone include:
Breast
Bronchus
Renal
Thyroid
Prostate
75% cases will affect those over the age of 50
The commonest bone sites affected are:
Vertebrae (usually thoracic)
Proximal femur
Ribs
Sternum
Pelvis
Skull
Pathological fracture
Osteolytic lesions are the greatest risk for pathological fracture
The risk and load required to produce fracture varies according to bone site. Bones with lesions that occupy 50% or
less will be prone to fracture under loading (Harrington). When 75% of the bone is affected the process of torsion
about a bony fulcrum may produce a fracture.
The Mirel scoring[1] system may be used to help determine the risk of fracture and is more systematic than
Harrington system described above.
Mirel Scoring system
Score points Site

Radiographic appearance Width of bone involved Pain

Upper extremity Blastic

Less than 1/3

Mild

Lower extremity Mixed

1/3 to 2/3

Moderate

Peritrochanteric Lytic

More than 2/3

Aggravated by function

Depending upon the score the treatment should be as follows:


Score

Risk of fracture

Treatment

9 or greater Impending (33%)

Prophylactic fixation

Borderline

Consider fixation

7 or less

Not impending (4%) Non operative management

Where the lesion is an isolated metastatic deposit consideration should be given to excision and reconstruction as
the outcome is better [2].
Non operative treatments
Hypercalcaemia- Treat with re hydration and bisphosphonates.
Pain- Opiate analgesics and radiotherapy.
Some tumours such as breast and prostate will benefit from chemotherapy and or hormonal agents.
Question 8 of 11
1
A 63 year old lady with metastatic breast cancer presents with bone pain. Radiological tests show a metastatic lytic
deposit to her femoral shaft. The lesion occupies 75% of the bone diameter. What is the most approprate
management?
A. Surgical fixation with a dynamic compression plate
B. Hemi-arthroplasty
C. Fixation with intramedullary nail

D. Radial radiotherapy
E. Chemotherapy
Even with surgical fixation only 30% of pathological fractures unite. The type of fixation should be chosen accordingly
A lesion of this nature is at high risk of spontaneous fracture. Whilst radiotherapy may palliate her symptoms of pain
it will not reduce the risk of fracture. In fit patients an intramedullary nail should be inserted. Very proximal lesions
may be best managed by a total hip replacement
Question 9 of 11
2
A 50 year old lady presents with pain in her proximal femur. Imaging demonstrates a bone metastasis from an
unknown primary site. CT scanning with arterial phase contrast shows that the lesion is hypervascular. From which
of the following primary sites is the lesion most likely to have originated?
A. Breast
B. Renal
C. Bronchus
D. Thyroid
E. Colon
Renal metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is
planned.
Question 10 of 11
September 2011
3
A 56 year old lady presents with a pathological fracture of the proximal femur. Which of the following primary sites is
the most likely source of her disease?
A. Thyroid
B. Breast
C. Kidney
D. Endometrium
E. None of the above
The correct answer is breast, because the question asks for the most likely primary site. Breast cancer is the
commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given.
Question 165 of 312
4
Which of the metastatic bone tumours described below is at the greatest risk of pathological fracture ?
A. Proximal humeral lesion from a prostate cancer
B. Vertebral body lesions from a prostate cancer
C. Peritrochanteric lesion from a carcinoma of the breast
D. Proximal humeral lesion from a carcinoma of the breast
E. Peritrochanteric lesion from a prostate cancer
Peritrochanteric lesions have the greatest risks of fracture (due to loading). The lesions from breast cancer are
usually lytic and therefore at higher risk rather than the sclerotic lesions from prostate cancer.

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