Metastatic bone disease

Metastatic bone disease

Most tumours that metastasise to bone are carcinomas. Some times, despite further investigations, the primary tumour is never found: these patients are described as having ‘carcinoma of unknown primary’. However, with advanced diagnostics and laborator y investigations the origin of most bone meta stases can be identified. Carcinomas usually spread to bone by the haematogenous route: the spine is the third most common site for metastases, after the lung and liver. Although most patients with metastatic cancer will have bone metastases in the spine before they die, tic. only 10% are symptoma Tumour cells metastasise to the spine via Batson’s venous plexus. These retroperitoneal veins have no valves and allow retrograde embolic spread to the spine and proximal long Figure 42.10 ). bones ( Bone metastases can be lytic, sclerotic or mixed. Lytic metastases are usually highly vascular or locally aggressive such Angelo Ma ff ucci , 1847–1903, Professor of Pathological Anatomy , Pisa, Italy , described enchondromatosis in association with soft tissue haemangiomas in 1881. Louis Xavier Edouard Léopold Ollier , 1830–1900, Professor of Surgery , Lyons, France, described enchondromatosis in 1899. Oscar V Batson , 1894–1979, American otolaryngologist. - - that there is no healing response from the bone. Metastases from prostate cancer may appear sclerotic. Metastases are rare in children, but bone metastases can occur from neuroblastoma, rhabdomyosarcoma and clear cell carcinoma of the kidney .

Figure 42.8 Ewing’s sarcoma of the proximal /f_i bula. The tumour is metadiaphyseal in location with a periosteal reaction and subtle onion-skinning. (a) (b) Figure 42.9 (a) Large fungating soft-tissue sarcoma of the buttock. /uni00A0 (b) Magnetic resonance imaging scan from the same patient showing a large fungating sarcoma of the buttock.

Summary box 42.1 Most common tumours metastasising to bone (93%) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Summary box 42.2 Most common sites of bone metastases /uni25CF /uni25CF /uni25CF

Proximal humerus Spine Proximal femur Figure 42.10 Common sites of metastatic bone disease (courtesy of Mr Andy Biggs, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust). Breast Lung Thyroid Prostate Renal Colon Spine Proximal femur and pelvis Proximal humerus

Metastatic bone disease

Patients with confirmed metastatic bone disease may require resuscitation for electrolyte imbalance, anaemia, cardiorespi - ratory problems or hypercalcaemia before surgical treatment can be considered. Hypercalcaemia can be treated e ff ectively with fluid resuscitation and bisphosphonate infusion. Surgical treatment in patients with metastatic bone disease is usually palliative; although complete resection of solitary metastases in selected patients may confer some survival bene - fit, the evidence for this is not strong. Surgery of the spine may be requir ed for stabilisation and/ or decompression when tumour extension puts the spinal cord at risk. Surgery in the peripheral skeleton is mainly for treat - ment of pain and (impending) pathological fracture. Renal metastases tend to be very v ascular and massive blood loss can be encountered during surgery . Therefore, pre - operative embolisation should be consider ed just before sur - gery to prevent blood loss ( Figure 42.30 ). Treatment of myeloma is mainly haematological. Non - surgical treatments including radiotherapy can lead to healing of bone lesions in some cases. Surgical treatment is often required for complications such as fracture and spinal cord compression. The following factors should be considered when contem plating surgical treatment for patients with metastatic bone disease: /uni25CF likely survival ( Figure 42.31 ) – consider the primary diag nosis and performance status; /uni25CF quality of life; /uni25CF fitness for anaesthesia and surgery; /uni25CF fracture risk; /uni25CF single or multiple bone lesions; /uni25CF response to adjuvant treatment such as radiotherapy and hormonal treatment; /uni25CF radiotherapy can be administered pre- or postoperatively . The risk of pathological fracture can be assessed using the Mirels score ( Table 42.7 ). However, this scoring system is prone to inter- and intraobserver variation. Hilton Mirels , contemporary , South African orthopaedic surgeon who now practises in the USA. - - Bone healing following a fracture through a metastasis is unpredictable and there can be local recurrence of the tumour after treatment. The approach is therefore di ff erent from the treatment of other fractures. The aim of surgery should be to improve pain and maintain mobility . Approaches that require prolonged protected weight-bearing to allow healing are not appropriate in this group of patients with reduced life expec - tancy . Therefore, as a general rule, prosthetic replacement of bones is preferred, particularly for epiphyseal and metaphyseal lesions. Metastases in the diaphysis may be most appropriately osthetic treated with an intramedullary nail. In the shoulder, pr replacements have a poor function and internal fixation may give better physical functioning. However, for hip lesions, the best treatment is often replacement surgery . Patients with solitary breast and renal metastases can have prolonged disease-free survival, so excision and replacement rather than fixation should be considered.

Figure 42.30 (a) Lytic metastasis of renal cell carcinoma. (b) Angiogram shows increased vascularity. 1.0 Breast Lung 0.8 Myeloma 0.6 Other Prostate 0.4 Renal Cum. survival Thyroid 0.2 0 0 10 5 Time (years) Figure 42.31 Cumulative survival curves of patients who present with bony metastasis. (c) Following embolisation. TABLE 42.7 The Mirels scoring system for risk of pathological fracture. Score 1 2 3 Site Upper limb Lower limb Peritrochanteric Pain Mild Moderate Functional Size <1/3 1/3–2/3

2/3 Lesion Blastic Mixed Lytic Score >8, high risk of fracture – urgent prophylactic /f_i xation should be considered; score <8, low risk of fracture – orthopaedic interven

tion may not be required.

Treatment of bone metastases /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Surgery cannot lengthen life but may shorten it The spine may need to be stabilised and nerves or the cord decompressing Long bones will need to be stabilised if a pathological fracture is imminent Patients who have a possibility of long-term survival may need excision and prosthetic reconstruction Radiotherapy often relieves pain

Metastatic bone disease

Most tumours that metastasise to bone are carcinomas. Some times, despite further investigations, the primary tumour is never found: these patients are described as having ‘carcinoma of unknown primary’. However, with advanced diagnostics and laborator y investigations the origin of most bone meta stases can be identified. Carcinomas usually spread to bone by the haematogenous route: the spine is the third most common site for metastases, after the lung and liver. Although most patients with metastatic cancer will have bone metastases in the spine before they die, tic. only 10% are symptoma Tumour cells metastasise to the spine via Batson’s venous plexus. These retroperitoneal veins have no valves and allow retrograde embolic spread to the spine and proximal long Figure 42.10 ). bones ( Bone metastases can be lytic, sclerotic or mixed. Lytic metastases are usually highly vascular or locally aggressive such Angelo Ma ff ucci , 1847–1903, Professor of Pathological Anatomy , Pisa, Italy , described enchondromatosis in association with soft tissue haemangiomas in 1881. Louis Xavier Edouard Léopold Ollier , 1830–1900, Professor of Surgery , Lyons, France, described enchondromatosis in 1899. Oscar V Batson , 1894–1979, American otolaryngologist. - - that there is no healing response from the bone. Metastases from prostate cancer may appear sclerotic. Metastases are rare in children, but bone metastases can occur from neuroblastoma, rhabdomyosarcoma and clear cell carcinoma of the kidney .

Figure 42.8 Ewing’s sarcoma of the proximal /f_i bula. The tumour is metadiaphyseal in location with a periosteal reaction and subtle onion-skinning. (a) (b) Figure 42.9 (a) Large fungating soft-tissue sarcoma of the buttock. /uni00A0 (b) Magnetic resonance imaging scan from the same patient showing a large fungating sarcoma of the buttock.

Summary box 42.1 Most common tumours metastasising to bone (93%) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Summary box 42.2 Most common sites of bone metastases /uni25CF /uni25CF /uni25CF

Proximal humerus Spine Proximal femur Figure 42.10 Common sites of metastatic bone disease (courtesy of Mr Andy Biggs, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust). Breast Lung Thyroid Prostate Renal Colon Spine Proximal femur and pelvis Proximal humerus

Metastatic bone disease

Patients with confirmed metastatic bone disease may require resuscitation for electrolyte imbalance, anaemia, cardiorespi - ratory problems or hypercalcaemia before surgical treatment can be considered. Hypercalcaemia can be treated e ff ectively with fluid resuscitation and bisphosphonate infusion. Surgical treatment in patients with metastatic bone disease is usually palliative; although complete resection of solitary metastases in selected patients may confer some survival bene - fit, the evidence for this is not strong. Surgery of the spine may be requir ed for stabilisation and/ or decompression when tumour extension puts the spinal cord at risk. Surgery in the peripheral skeleton is mainly for treat - ment of pain and (impending) pathological fracture. Renal metastases tend to be very v ascular and massive blood loss can be encountered during surgery . Therefore, pre - operative embolisation should be consider ed just before sur - gery to prevent blood loss ( Figure 42.30 ). Treatment of myeloma is mainly haematological. Non - surgical treatments including radiotherapy can lead to healing of bone lesions in some cases. Surgical treatment is often required for complications such as fracture and spinal cord compression. The following factors should be considered when contem plating surgical treatment for patients with metastatic bone disease: /uni25CF likely survival ( Figure 42.31 ) – consider the primary diag nosis and performance status; /uni25CF quality of life; /uni25CF fitness for anaesthesia and surgery; /uni25CF fracture risk; /uni25CF single or multiple bone lesions; /uni25CF response to adjuvant treatment such as radiotherapy and hormonal treatment; /uni25CF radiotherapy can be administered pre- or postoperatively . The risk of pathological fracture can be assessed using the Mirels score ( Table 42.7 ). However, this scoring system is prone to inter- and intraobserver variation. Hilton Mirels , contemporary , South African orthopaedic surgeon who now practises in the USA. - - Bone healing following a fracture through a metastasis is unpredictable and there can be local recurrence of the tumour after treatment. The approach is therefore di ff erent from the treatment of other fractures. The aim of surgery should be to improve pain and maintain mobility . Approaches that require prolonged protected weight-bearing to allow healing are not appropriate in this group of patients with reduced life expec - tancy . Therefore, as a general rule, prosthetic replacement of bones is preferred, particularly for epiphyseal and metaphyseal lesions. Metastases in the diaphysis may be most appropriately osthetic treated with an intramedullary nail. In the shoulder, pr replacements have a poor function and internal fixation may give better physical functioning. However, for hip lesions, the best treatment is often replacement surgery . Patients with solitary breast and renal metastases can have prolonged disease-free survival, so excision and replacement rather than fixation should be considered.

Figure 42.30 (a) Lytic metastasis of renal cell carcinoma. (b) Angiogram shows increased vascularity. 1.0 Breast Lung 0.8 Myeloma 0.6 Other Prostate 0.4 Renal Cum. survival Thyroid 0.2 0 0 10 5 Time (years) Figure 42.31 Cumulative survival curves of patients who present with bony metastasis. (c) Following embolisation. TABLE 42.7 The Mirels scoring system for risk of pathological fracture. Score 1 2 3 Site Upper limb Lower limb Peritrochanteric Pain Mild Moderate Functional Size <1/3 1/3–2/3

2/3 Lesion Blastic Mixed Lytic Score >8, high risk of fracture – urgent prophylactic /f_i xation should be considered; score <8, low risk of fracture – orthopaedic interven

tion may not be required.

Treatment of bone metastases /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Surgery cannot lengthen life but may shorten it The spine may need to be stabilised and nerves or the cord decompressing Long bones will need to be stabilised if a pathological fracture is imminent Patients who have a possibility of long-term survival may need excision and prosthetic reconstruction Radiotherapy often relieves pain

Metastatic bone disease

Most tumours that metastasise to bone are carcinomas. Some times, despite further investigations, the primary tumour is never found: these patients are described as having ‘carcinoma of unknown primary’. However, with advanced diagnostics and laborator y investigations the origin of most bone meta stases can be identified. Carcinomas usually spread to bone by the haematogenous route: the spine is the third most common site for metastases, after the lung and liver. Although most patients with metastatic cancer will have bone metastases in the spine before they die, tic. only 10% are symptoma Tumour cells metastasise to the spine via Batson’s venous plexus. These retroperitoneal veins have no valves and allow retrograde embolic spread to the spine and proximal long Figure 42.10 ). bones ( Bone metastases can be lytic, sclerotic or mixed. Lytic metastases are usually highly vascular or locally aggressive such Angelo Ma ff ucci , 1847–1903, Professor of Pathological Anatomy , Pisa, Italy , described enchondromatosis in association with soft tissue haemangiomas in 1881. Louis Xavier Edouard Léopold Ollier , 1830–1900, Professor of Surgery , Lyons, France, described enchondromatosis in 1899. Oscar V Batson , 1894–1979, American otolaryngologist. - - that there is no healing response from the bone. Metastases from prostate cancer may appear sclerotic. Metastases are rare in children, but bone metastases can occur from neuroblastoma, rhabdomyosarcoma and clear cell carcinoma of the kidney .

Figure 42.8 Ewing’s sarcoma of the proximal /f_i bula. The tumour is metadiaphyseal in location with a periosteal reaction and subtle onion-skinning. (a) (b) Figure 42.9 (a) Large fungating soft-tissue sarcoma of the buttock. /uni00A0 (b) Magnetic resonance imaging scan from the same patient showing a large fungating sarcoma of the buttock.

Summary box 42.1 Most common tumours metastasising to bone (93%) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Summary box 42.2 Most common sites of bone metastases /uni25CF /uni25CF /uni25CF

Proximal humerus Spine Proximal femur Figure 42.10 Common sites of metastatic bone disease (courtesy of Mr Andy Biggs, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust). Breast Lung Thyroid Prostate Renal Colon Spine Proximal femur and pelvis Proximal humerus

Metastatic bone disease

Patients with confirmed metastatic bone disease may require resuscitation for electrolyte imbalance, anaemia, cardiorespi - ratory problems or hypercalcaemia before surgical treatment can be considered. Hypercalcaemia can be treated e ff ectively with fluid resuscitation and bisphosphonate infusion. Surgical treatment in patients with metastatic bone disease is usually palliative; although complete resection of solitary metastases in selected patients may confer some survival bene - fit, the evidence for this is not strong. Surgery of the spine may be requir ed for stabilisation and/ or decompression when tumour extension puts the spinal cord at risk. Surgery in the peripheral skeleton is mainly for treat - ment of pain and (impending) pathological fracture. Renal metastases tend to be very v ascular and massive blood loss can be encountered during surgery . Therefore, pre - operative embolisation should be consider ed just before sur - gery to prevent blood loss ( Figure 42.30 ). Treatment of myeloma is mainly haematological. Non - surgical treatments including radiotherapy can lead to healing of bone lesions in some cases. Surgical treatment is often required for complications such as fracture and spinal cord compression. The following factors should be considered when contem plating surgical treatment for patients with metastatic bone disease: /uni25CF likely survival ( Figure 42.31 ) – consider the primary diag nosis and performance status; /uni25CF quality of life; /uni25CF fitness for anaesthesia and surgery; /uni25CF fracture risk; /uni25CF single or multiple bone lesions; /uni25CF response to adjuvant treatment such as radiotherapy and hormonal treatment; /uni25CF radiotherapy can be administered pre- or postoperatively . The risk of pathological fracture can be assessed using the Mirels score ( Table 42.7 ). However, this scoring system is prone to inter- and intraobserver variation. Hilton Mirels , contemporary , South African orthopaedic surgeon who now practises in the USA. - - Bone healing following a fracture through a metastasis is unpredictable and there can be local recurrence of the tumour after treatment. The approach is therefore di ff erent from the treatment of other fractures. The aim of surgery should be to improve pain and maintain mobility . Approaches that require prolonged protected weight-bearing to allow healing are not appropriate in this group of patients with reduced life expec - tancy . Therefore, as a general rule, prosthetic replacement of bones is preferred, particularly for epiphyseal and metaphyseal lesions. Metastases in the diaphysis may be most appropriately osthetic treated with an intramedullary nail. In the shoulder, pr replacements have a poor function and internal fixation may give better physical functioning. However, for hip lesions, the best treatment is often replacement surgery . Patients with solitary breast and renal metastases can have prolonged disease-free survival, so excision and replacement rather than fixation should be considered.

Figure 42.30 (a) Lytic metastasis of renal cell carcinoma. (b) Angiogram shows increased vascularity. 1.0 Breast Lung 0.8 Myeloma 0.6 Other Prostate 0.4 Renal Cum. survival Thyroid 0.2 0 0 10 5 Time (years) Figure 42.31 Cumulative survival curves of patients who present with bony metastasis. (c) Following embolisation. TABLE 42.7 The Mirels scoring system for risk of pathological fracture. Score 1 2 3 Site Upper limb Lower limb Peritrochanteric Pain Mild Moderate Functional Size <1/3 1/3–2/3

2/3 Lesion Blastic Mixed Lytic Score >8, high risk of fracture – urgent prophylactic /f_i xation should be considered; score <8, low risk of fracture – orthopaedic interven

tion may not be required.

Treatment of bone metastases /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Surgery cannot lengthen life but may shorten it The spine may need to be stabilised and nerves or the cord decompressing Long bones will need to be stabilised if a pathological fracture is imminent Patients who have a possibility of long-term survival may need excision and prosthetic reconstruction Radiotherapy often relieves pain