METASTASIS BONE

DISEASE
Metastatic bone disease is the most common
malignancy of bone, it is estimated that 70% of all
malignant bone tumors are metastatic in origin.

Bone is the third most common site of metastatic

process after lung and liver. 80% of metastatic
bone disease arise from Ca of breast, prostate,
lung, kidney and thyroid.

Typical location are thoracolumbal spine, pelvis,

ribs, skull and proximal of femur and humerus.
 DIAGNOSIS

Pain is an important symptom of musculoskeletal metastases, but

it is nonspecific. The pain pattern can be helpful if, in addition to
being activity related, it is present at rest and at night, especially in
patients older than 50 years..

Testing
• Laboratory tests that can be used to aid in the diagnosis of
metastatic bone disease include the following:
• Serum alkaline phosphatase: Indirect reflection of bone
destruction
• Serum protein electrophoresis
• Urinalysis, urine protein electrophoresis
• N-telopeptide of type II collagen: Marker of bone resorption but
not widely used
Imaging studies
• The following radiologic studies may be used to evaluate metastatic
bone disease:
• Radiography: For the basic assessment of the extent of a tumor and
the degree of cortical erosion; can also be used for skeletal survey in
patients with multiple myeloma
• Computed tomography scanning: Most sensitive imaging modality to
detect bone destruction, providing the best assessment of the extent
of cortical destruction
• Magnetic resonance imaging: Most sensitive study for the assessment
of the anatomic (intramedullary and extraosseous) extent of a lesion
• Bone scanning: Very sensitive study for the detection of occult lesions
and the assessment of the biologic activity of lesions
• Angiography: Depicts devascularization of vascular metastases; may
also be used to assess pain palliation in patients with nonresectable
metastases
Procedures
• Biopsies should be obtained from any soft-tissue mass
or, if no soft-tissue mass is present, from the most
accessible bone in a mechanically safe area (eg,
metaphysis vs diaphysis, acetabulum vs
subtrochanteric femur).

In selected patients with metastatic disease of the spine,

the following diagnostic procedures may be performed:
• Percutaneous core needle biopsy
• Open biopsy
 MANAGEMENT

The life span of patients with metastatic bone disease is limited;

thus, the goal of management needs to be centered on
returning as much function as possible as rapidly as possible.
Patients with metastatic bone disease are generally treated with
surgery or radiation therapy.

Radiation therapy
• Radiation therapy remains a primary therapeutic modality for
the treatment of spinal metastasis, because nearly 95% of
patients who are ambulatory at the start of radiation therapy
remain so. Consequently, the possibility of regaining cord
function once it is lost as a result of spinal metastasis is
dismal. Therefore, such loss needs to be avoided by early
diagnosis, treatment, and, if indicated, surgical intervention.
Surgery
• The goals of surgical intervention for spinal surgery in
patients with metastatic bone disease includes
decreasing or eliminating pain, decompressing neural
elements to protect cord function, and mechanically
stabilizing the spine. [1, 2] Anterior or posterolateral
decompression, combined with anteroposterior
reconstruction, may be used in the following:

Diagnostic spinal surgery

• Cervical spinal surgery
• Thoracic and lumbar spinal surgery
Vertebroplasty, in which polymethylmethacrylate is percutaneously
introduced, may be a minimally invasive treatment alternative for
patients with one- or two-level vertebral body compression
fractures. [3]

For the management of long bone metastatic disease accompanied

by an impending or completed fracture, open internal fixation is
usually the preferred method of treatment. Stabilization with a
locked intramedullary device followed by radiation therapy to the
entire bone as soon as the surgical wounds have healed is
preferred. [4]
Devices and/or procedures used in the surgical fixation of long
bones include the following:
• Standard or cemented stems
• Dynamic hip screws or plates
• Intramedullary fixation devices
• Total hip arthroplasty

Pharmacotherapy
Medications used in the treatment of metastatic bone disease
include the following:
• Monoclonal antibody antineoplastic agents (eg, denosumab)
• Calcium metabolism modifiers/bisphosphonates (eg,
pamidronate, zoledronate, and ibandronate)