Bone Metastasis

Dr Ashok Rampurada
Consultant Orthopaedics
HCG Bangalore
 Introduction
• Skeletal metastases most common bone
tumour
• In the 1970s the average survival following
bone metastases was 7 months
• 1990 this had increased to 2 years

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 Introduction
• The prognosis continues to improve
• Metastatic lung cancer die within 6 months (4
to 5 years)
• Patients with breast, prostate, and kidney
cancer commonly live many years
• An isolated bone metastasis from a kidney
cancer can be treated with curative intent

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 Mechanism
• Stephan Paget
tumor cells-seeds
special environment-soil
• Tumor cells acquire a special “genetic signature”
• The microenvironment in bone-marrow stem cells
supports cancer cells in homing, differentiation, and
survival.
• Cancer cells influence osteoblasts and osteoclasts by
secreted factors such as parathyroid hormone–related
peptide (PTHrP) or endothelin I.This leads to osteolytic
or osteoblastic metastases in bone

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 Mechanism
• Metastases usually involve the axial skeleton
• Proximal segments of limb bones
• Extremely rare - distal to the elbows and
knees (50% lung or breast carcinoma)

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 Metastasis
Sites of predilection Osteolytic (75%)/Osteoblastic (15%)

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 Metastasis
• In women, ca breast
70% of all metastatic lesions
30% ca thyroid, uterus, and kidney
• Other tumors
ca of the stomach, colon, urinary bladder,
melanoma, and some neurogenic tumors
• Osteosarcoma and Ewing sarcoma
• In children aged 5 years and younger,
neuroblastoma

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 Why Important
• Variation in the standard of management of MBD
• Surgical techniques and implants
• Failure to intervene prophylactically
• Late referral
• Lack of understanding of the biomechanical basis
• Delays in the organisation of cancer and
orthopaedic services

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 Presentation
• Pain is the most frequent clinical symptom
• Acute admission with pathological fracture or
neurological compromise
• Referral to clinic with unexplained
musculoskeletal pain
• Referral from oncologist (surgeon, radiologist
or oncologist)

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 Mechanism of fracture
Bone destruction
‘stress riser’
‘open section’ defect in a
long bone
• Minor trauma
• Twisting movement
Soft tissue injury is minor

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 Role of Orthopaedic surgeon
• Prophylactic fixation where there is a risk of
fracture.
• Stabilization or reconstruction following
pathological fracture.
• Decompression of spinal cord and nerve roots
and/or stabilization for spinal instability

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 Prophylactic fixation
• Easier for the surgeon
• Less traumatic for the patient
• Avoid debilitating complications
• A pathologic fracture
extreme pain
urgent hospitalization
risk of surgery in less than ideal circumstances

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 Mirel scoring

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 Mirel score
• 1989-Hilton Mirel
• Ideal staging system
practical,
reproducible
accurately predict risk.
• Nature-0%, 32%, and 48%
• Size-0,5, and 81%

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 PRE-OPERATIVE ASSESSMENT
• A full medical history and examination is
mandatory
• Plain radiograph of the entire affected bone is
a minimum requirement
• Staging studies – MRI, PET-CT, Bone scan
• Biopsy

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 PRE-OPERATIVE ASSESSMENT
• Electrolyte Imbalance
and hypercalcaemia
• Oncologist
• Physician opinion
• Pain team

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 Aims of surgery
• Relieve pain and restore function
• The procedure should provide immediate
stability and allow weight bearing
• The fracture may not unite
• The fixation should aim to last the lifetime of
the patient.
• All lesions in the affected bone should, where
possible, be stabilized
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 Surgical treatment
Hip
• Fractures about the hip most frequent
• full medical and radiological assessment
• planning and use of appropriate implant

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 Hip
• 56 year old, Female
• Ca stomach primary
• Left prox femur
metastasis

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 MRI

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 Post op
• Femoral recon nail
• Bone Cement
• Mobilized after 2-3 days

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 Surgical treatment
Pelvis and Acetabulum
• The majority of pelvic lesions are treated with
prophylactic palliative radiotherapy alone
• Peri-acetabular lesions
• THR with acetabular reconstruction

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 Case 1

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 Pelvis and Acetabulum
• 48 years male
• Primary lung
• R acetabular lesion

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 Case 1

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 Shoulder Girdle and Upper Limb
• Metastatic lesions or fractures of the scapula
and clavicle are usually managed with
radiotherapy
• Humeral head-hemiarthroplasty
• Humerus Shaft- IM nailing
• Fore arm-Plate fixation
• Distal humerus-cast brace and radiotherapy

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 Upper Limb

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 Upper Limb

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 Upper Limb

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 Shafts of Major Long Bones
• Intramedullary nailing
• Load bearing rather than load sharing
• Packing of major bone defects with bone
cement

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 Long bones
• All of the lesions in the
affected bone should be
stabilised
• The entire bone and
operative site should be
included in the post-
operative radiotherapy

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 Endoprosthetic Surgery
• Extensive bone
destruction at the
metaphyses of major
long bones
• Custom or modular
endoprostheses
• proximal femur, but
lesions of the distal
femur, proximal tibia
and proximal or distal
humerus
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 Adjuvant therapy
• Radiotherapy-palliative
• Endocrine therapy
Bisphosphonates, Denosumab

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 HOSPITAL FACILITIES
• Dedicated orthopaedic
team
• Clean air theatre
• Adequate inventory trauma,
spinal and arthroplasty
implants
• Pathology service
• Anaesthetists familiar with
the metabolic disturbances
• MDT

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 Conclusion
• Skeletal metastases most common bone
tumour
• The prognosis continues to improve
• Variation in the standard of management of
MBD
• Prophylactic fixation

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 Conclusion
• Mirel scoring
• MDT
• Adjuvant therapy
• Quality of life
• Refer to higher centers

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 Thank You

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 Questions?

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