- See:
Bone Tumor Menu:
- Discussion:
- Types of Metastatic Carcinoma:
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breast cancer
-
renal cell ca:
-
prostatic cancer:
-
lung carcinoma:
-
thyroid cancer:
- may cause heavy bleeding if disturbed (consider need for embolization prior to biopsy or ORIF);
- iodine radioisotope scan can be useful for following metatasis;
-
lymphoma:
-
multiple myeloma:
- Work Up:
-
determine the diagnosis:
- the most important consideration in managing a patient w/ an apparent bone lesion is to determine whether the lesion represents a metstatic lesion,
a primary bone tumor (sarcoma), or infection;
- obviously, an elderly patient w/ advanced breast, lung, or prostate cancer which has spread to other organs does not require further
diagnostic work up of a new bone lesion;
- in contrast, a middle aged patient who has been "cured" of prior breast carcinoma, will require a methodical work up of a new bone lesion;
- for instance, a new pathologic osseous lesion in a patient previously treated with radiation, could occur from
radiation induced sarcoma rather than a new metastatic lesion;
- ref:
Evaluation of the patient with carcinoma of unknown origin metastatic to bone.
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history and physical exam:
- new onset pneumonia, wheezing, or worsening of asthma may indicate lung ca;
- hematuria or flank pain points to
renal carcinoma;
- change in bowel function or occult blood in the stool suggests rectal ca;
- carcinoma of the breast, testicles, rectum, prostate, or thyroid may be suggested by the presence of a mass on physical exam;
-
biopsy: indicated if the primary origin of the tumor is in doubt;
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labs:
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hypercalcemia should be ruled out in any patient w/ a bone lesion;
- most commonly used drugs are pamidronate and zoledronic acid (4 or 8 mg infused over five minutes and is treatment of choice);
- hematuria will help rule out
renal ca;
-
ESR helps rule out
multiple myeloma or infection;
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radiographic studies:
- radiographic work up should include either a
bone scan or a skeletal survey;
- CT scan is the study of choice for detection of pulmonary, abdominal, pelvic, and retroperitoneal metastasis;
- most skeletal metastases cause bone destruction and appear osteolytic on the roentgenogram;
- occasionally, the tumor cells provoke osteoblastic response, & x-ray show increased density (common w/ prostate ca);
- r/o pending fracture:
- always rule out pending frx of the proximal femur and proximal humerus;
-
pathologic frx of the proximal femur is amoung the most devastating devasting complications of metastatic
carcinoma, since patients will have constant pain and will not be able to leave the hospital bed;
- Treatment Options:
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osteoclast inhibiting agents:
- indications for treatment: patients w/ an abnormal bone scan and a CT or MRI showing bone destruction even if there is normal findings on plain x-rays;
- theory is that osseous metastasis and subsequent erosions will in part require recruitment of
osteoclasts;
-
bisphosphonates: (
etidronate,
pamidronate,
clodronate)
- of these pamidronate is the most frequently used (given as a once-monthly infusion over 1 - 2 hours);
- aminobisphosphonate:
fosamax;
- w/ metastatic lytic disease consider:
- pamidronate: 90 mg IV over 2 hours;
- zoledronic acid: 4 mg IV delivered over fifteen minutes every three to four weeks;
- references:
- Reduction in new metastases in breast cancer with adjuvant clodronate treatment. Diel IJ et al. N Engl J Med 339:357-363, 1998
- Bisphosphonates as anticancer drugs. Mundy GR. N Engl J Med 339:398-400, 1998
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Biochemical markers and skeletal metastases.
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radiation therapy:
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DVT prophylaxis
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management of metastatic disease to the spine:
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surgical fixation:
- w/ pathologic frx or pending frx, hardware failure/loss of fixation is more common w/
renal cell carcinoma because patients
tend to have long term survival and persistent local tumor osteolysis is common;
- as noted by R. Wedin MD et al 1999, endoprosthetic reconstruction has a lower failure rate than osteosynthetic devices;
- ref: Failures after operation for skeletal metastatic lesions of long bones. R. Wedin et al. CORR.. No 358 1999. p 128.
-
humeral IM nailing: (see
humeral nailing technique)
- references:
-
Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures.
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Treatment of pathologic fracture of the humerus.
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prophylactic femoral IM nailing:
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acetabular reconstruction:
- in the report by RA Marco et al 2000, 55 patients with metastatic disease of the acetabulum were treated with
operative acetabular reconstruction combined with a total hip replacement;
- 9 of the 18 patients who could not walk preoperatively regained the ability to walk;
- 14 of the 17 patients who originally were able to walk in the community retained that ability;
- median period of survival was nine months;
- patients with visceral metastases had a median period of survival of three months compared with twelve months for patients without visceral metastases;
- fourteen (25 percent) of the fifty-five patients had moderate local progression of the disease, and five of these patients had failure of the fixation;
- 14 early complications developed in twelve (22 percent) of the patients;
- ref: Functional and Oncological Outcome of Acetabular Reconstruction for the Treatment of Metastatic Disease. RA Marco MD et al. JBJS-A 82-A: 642-51, 2000
-
pathologic fracture
-
pathologic hip fracture:
- main issues involve low potential for fracture healing and possibility of concomitant lesions in the femoral shaft;
- w/ femoral neck or base of femoral neck fracture consider hemiarthroplasty;
- if metastatic lesions are present in the femoral shaft then consider long stemed prosthesis;
- references:
- Modular prostheses in metastatic bone disease of the proximal femur. Camnasino: Bull Hosp Joint Dis 54:211-214, 1996
- Head and neck replacement endoprosthesis for pathologic proximal femoral lesions. Clarke HD: Clin Orthop 353:210-217, 1998
- References:
