BONES METASTASES BONES METASTASES n Multiple bone lesions

BONES METASTASES

BONES METASTASES n Multiple bone lesions - more often n Single metastases (myeloma, thyroid and kidney cancers) must be differentiated from primary bone tumors n Osteolytic (lung, colon carcinomas, melanoma) Osteoblastic (multiple myeloma, breast and kidney carcinomas) – correspond to the reaction of the host bone to the metastases Mixed – characteristic for fast growing tumors (bone reaction cannot keep up with the tumor rate of growth) n n

CLINICAL MANIFESTATION n Pain – the principal symptom n n Tends to be worse at night May be partially relieved by activity As the lesions progress becomes more constant n Atelectasis n Thromboembolic disease n Loss of ambulatory ability n

DIAGNOSIS Plain radiography n n Remains the most specific test The fastest, least expensive, most readily available Greatly assists surgical planning Should be the first test in the evaluation of pain! Bone scintigraphy n n n Extremely sensitive Shows disease much earlier than radiographs* Practical – screens the entire body at one time Any abnormality found on bone scan should be assessed with plain radiographs (does not evaluate the structural integrity of the skeleton) False-negative bone scans – multiple myeloma, lung cancer, melanoma** Can be used to evaluate the response to therapy

DIAGNOSIS CT n n n Very effective in evaluating the 3 -dimensional integrity of bone Very useful in evaluating tumors in the pelvic and shoulder girdles Demonstrates the bone mineral content and cortical integrity better than MRI n n n The best method to evaluate bone marrow, the first site of most metastatic cancers Especially suited to the spine Helpful in distinguishing pathologic fracture due to osteoporosis from that due to tumor

DIAGNOSIS Biopsy • CT-guided needle biopsy - satisfactory when the lesion is osteolytic - may be especially helpful in determining cancer regrowth or necrosis in area that has been already irradiated • Open surgical biopsy when the lesion is osteoblastic or there is a thick overlying cortical rim * Increased fracture risk

TREATMENT - RADIOTHERAPY n Should be considered in all but the few cases: - the disease is very responsive to systemic treatment (e. g. germ cell tumor, lymphoma) - the lesions are resectable for cure * More than 80% of patients with a limited number of well-localized bony metastases can be treated effectively by external beam radiation

TREATMENT - RADIOTHERAPY n • Relieves pain, at least, in 80 -90% of patients* -> reduces the need for narcotic analgesics -> improves activity Arrests local tumor growth * localized external radiation * hemibody radiation – for widely disseminated bone disease

TREATMENT - SURGERY n Tumor excision – should be considered for isolated solitary metastases in case of long projected survival (renal or thyroid cancers) n Amputation * n Internal fixation of pathologic fractures** n External fixation*** Principal surgical adjuvant – radiotherapy

TREATMENT n n – SYSTEMIC RADIONUCLIDES Very effective in treating symptomatic bone metastases Treats all involved sites rapidly and selectively (reduced toxicity) Relieves pain Heals the underlying bone lesions n Sr-89 (low-energy β emission)– response rates 50 -90% Rh-185 (β and γ emission) n Causes bone marrow supression n May be complemented by local external beam radiation for optimal palliation of symptoms n

TREATMENT - BISPHONATES n n n Treat hypercalcemia Stop bone reabsorption Reduce pain New-generation bisphonates may prevent the development of bony metastases Do not have a cytotoxic effect Do not interfere with other commonly used chemotherapeutic agents