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    Metastases Bone Disease

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    muhammad rustam
    This document discusses metastatic bone disease, which occurs when cancer spreads from a primary tumor site to the bones. The most common primary cancers that metastasize to bone are breast, lung, prostate, kidney, and thyroid cancers. Diagnosis involves a medical history, physical exam, lab tests, and imaging like plain X-rays, bone scans, CT, MRI, and biopsy to confirm. Treatment aims to control the cancer systemically with chemotherapy and locally with surgery and/or radiation therapy. Metastatic bone disease can cause pain, fractures, and spinal cord/nerve compression.

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    Metastases Bone Disease

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    muhammad rustam
    75 views59 pages
    This document discusses metastatic bone disease, which occurs when cancer spreads from a primary tumor site to the bones. The most common primary cancers that metastasize to bone are breast, lung, prostate, kidney, and thyroid cancers. Diagnosis involves a medical history, physical exam, lab tests, and imaging like plain X-rays, bone scans, CT, MRI, and biopsy to confirm. Treatment aims to control the cancer systemically with chemotherapy and locally with surgery and/or radiation therapy. Metastatic bone disease can cause pain, fractures, and spinal cord/nerve compression.

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    This document discusses metastatic bone disease, which occurs when cancer spreads from a primary tumor site to the bones. The most common primary cancers that metastasize to bone are breast, lung, prostate, kidney, and thyroid cancers. Diagnosis involves a medical history, physical exam, lab tests, and imaging like plain X-rays, bone scans, CT, MRI, and biopsy to confirm. Treatment aims to control the cancer systemically with chemotherapy and locally with surgery and/or radiation therapy. Metastatic bone disease can cause pain, fractures, and spinal cord/nerve compression.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    75 views59 pages

    Metastases Bone Disease

    Uploaded by

    muhammad rustam
    This document discusses metastatic bone disease, which occurs when cancer spreads from a primary tumor site to the bones. The most common primary cancers that metastasize to bone are breast, lung, prostate, kidney, and thyroid cancers. Diagnosis involves a medical history, physical exam, lab tests, and imaging like plain X-rays, bone scans, CT, MRI, and biopsy to confirm. Treatment aims to control the cancer systemically with chemotherapy and locally with surgery and/or radiation therapy. Metastatic bone disease can cause pain, fractures, and spinal cord/nerve compression.

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    © All Rights Reserved
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    of 59

    dr. Muhammad Rustam HN, M.Kes,Sp.

    OT

    Metastatic
    Bone Disease
    Introduction
     The most common cause of destructive bone
    lesions in the adult
     The skeleton is the most common organ to be
    affected by metastatic of cancer, and the site of
    disease which produces the greatest morbidity
     It is the third most common site
     60% - 84% of all cases of metastatic disease invade bone
     Primary tumors most likely to metastasize :
     Breast (37 %)
     Lung (15 %)
     Prostate (15 %)
     Kidney (6 %)
     Thyroid (4 %)
    Introduction

    Definition

    A secondary malignant tumor that has


    spread to the skeleton from a primary
    carcinoma in an extraskeletal site.
    Epidemiology

     Age: middle-aged and elderly (>50)


     Most common bony site: spine, pelvis, ribs,
    skull
     Primary tumor:
    Breast - 60%
    Prostate - 35%
    Kidney - 30%
    Lung - 15%
    Thyroid - 10%
     Common location of metastatic
    bone disease :
     Skull
     Proximal humerus metaphysis
     Vertebra
     Femur
    Pathogenesis

     3 mechanisms:
    -direct extension
    -retrograde venous flow
    -seeding with tumor emboli via the blood
    circulation
     Metastatic bone lesions: osteolytic,
    osteoblastic and mixed
     Osteolytic: destructive processes
     Osteoblastic: new bone growth that is
    stimulated by the tumour
    Patophysiology
    Tumor cells penetrating the surrounding
    extracellular matrix

    Migrate through hematogen (Batson


    plexus) and lymphogen

    Adherence and invasion of tumor cells at


    extraceluler matrix

    Neoangiogenesis

    Release factors that can lyse bone that


    increase osteoclast activation
    PATHOGENESIS

    Batson’s venous plexus


    From Essential of Skeletal Radiology p977
    DIAGNOSIS & TREATMENT of MST’s ALGORITHM
    MST
    Plain x-ray Clin. assessment
    FNAB Laboratories

    Non Neoplasm Benign In Doubt Malignant

    Open Biopsi -Thorax PA/LAT & CT


    -Scintigraphy
    Observation Surgery

    Primary Metastasis

    Stage I & II Stage III


    •MRI regional
    •CT regional Palliative - MST
    •Angiography Score

    SURGERY - CHEMOTx - RADIATION


    Diagnosis
     History Taking
     Physical examination
     Laboratory analysis
     Plain radiography
     Bone scanning
     CT-Scan
     MRI
     Biopsy (histopatological examination)
    Diagnosis

    Clinical presentation
     Most skeletal mets are asymptomatic 
    discovered incidentally
     diffuse bone pain (70%)  periosteum
    stretching
     pathologic fracture (9,29%)common in
    breast Ca
    Pathologic fracture
    Medical history
     History related with the primary tumor (family
    history, early manifestation of tumor, previous
    tumor removal)
    Breast tumor, Lung, Prostate, Kidney, Thyroid, etc

     Pain
     Progressive
     Unrelenting night pain
     Non-mechanical
     Precipitated by minor trauma (irritation of nociceptor)

     Neurologic symptoms of radicular pain .


    Physical examination

     Thorough examination (local tenderness,


    deformity, limitation of motion, signs of nerve
    root or spinal cord compression)
     Pain
     Neurologic symptoms of radicular pain,
    Hyperreflexia, pathologic reflexes, and
    abnormal motor and sensory examinations.
     Examination focused on potential primary
    tumor
    Diagnosis

    History and physical exam


     new onset pneumonia, wheezing, or
    worsening of asthma  lung ca
     hematuria or flank pain  renal carcinoma
     change in bowel function or occult blood in
    the stool  rectal ca
     carcinoma of the breast, testicles, rectum,
    prostate, or thyroid  presence of a mass
     presentation:
    1. bone weakness which predispose to pathologic
    fractures.
    2. Pain which results in reduced mobility.
    3. Large bony lesions which causes palpable
    masses.
    4. neurologic impairment due to spinal epidural
    compression.
    5. Anemia (decreased red blood cell production) is
    a common blood abnormality in these patients
    6. Some patients have history of the primary
    malignant tumor symptoms, BUT others did not
    complain of anything before.
    Laboratorium examination
    Relevant laboratory evaluation :
    - Complete blood count
    - ESR, C-Reactive protein
    - Basic metabolic panel such as serum calcium level, and
    tumor marker.
    Radiography

    PLAIN RADIOGRAPHY
    BONE SCAN
    CT
    CT-MYELOGRAPHY
    MRI
    Plain radiography

     Assessing overall spinal


    alignment and spinal
    instability
     30-50% trabecular bone
    must be destroyed
    before radiographic
    evidence of bone
    destruction is apparent
    Radiograph examination
     Plain radiograph : assessing
    spinal alignment and
    stability, metastatic lesions
    and/or pathologic
    compression fractures

    Destruction of pedicular cortical bone, manifested by the loss


    of the pedicle (arrow) and described as the “winking owl” sign
    INVESTIGATION

    winkling owl sign Melanoma with T-spine metastasis


    From Essential of Skeletal Radiology p986
    Bone metastases to the finger.
    Radiograph shows a
    destructive expanded
    osteolytic lesion in the
    metacarpal of the thumb in a
    55-year-old man with lung
    carcinoma.
    Mets (adults)
     lytic  blastic
     Lung  Prostate
     Kidney  Stomach
     colon  Bladder
     Thyroid

    Breast cancer cause both lytic and blastic


    Typical x-ray appearance of osteolytic bone metastases. This plain pelvic x-ray film
    of a 75-year-old patient with breast carcinoma shows multiple osteolytic bone
    lesions. =>decrease in bone density .
    typical x-ray appearance of osteoblastic bone metastases. This plain pelvic x-
    ray film of a patient with prostate cancer shows multiple osteoblastic
    metastases to the pelvis and lumbar (L4) and sacral (S1) vertebral
    bodies.=>increase in bone density
     Pathologic fracture.
    Radiograph shows a
    displaced fracture
    through an osteolytic
    lesion in the distal
    femur of a 53-year-old
    woman with lung
    carcinoma.
    • Spinal epidural
    compression in a 70-
    year-old man with leg
    weakness. Lateral
    lumbar myelogram
    shows a complete
    epidural block due to
    a destructive
    osteolytic lesion of
    the L3 vertebral body.
    Lumbar puncture was
    performed at the L2-3
    level
    Technetium-99 bone scan

     Useful test for lesion with


    osteoblastic response
     False negative usually occur
    most commonly tumor
    have minimal osteoblastic
    response
    X-ray RadioIsotope

    Pt. presented with pain in the right upper thigh, xray showing METS in
    upper 1/3 of the femur, however radioisotope scan revealed many
    deposits in other parts of the skeleton. Zaid Samkari 34
    CT and CT myelography

     CT  Helpful in
    defining bony integrity
     CT-myelography
     useful for patients who
    cannot undergo MRI
    MRI

     Choice for evaluation of


    metastatic disease of the spine
     Bone involvement, soft tissue
    extension and neural element
    compression can be assessed
     Sensitivity 93% and specificity
    97% reported in assessment of
    metastatic disease
    CT-Scan MRI

    Bony destruction is well delineated on computed


    tomographic (arrows)
    biopsy

     Accomplished by confirming presence of primary lesion


    through metastatic workup
     Workup includes:
     ct chest, abdomen and pelvis
     Chest radiograph
     Bone scan
     Appropriate laboratory studies
     Serum protein electrophoresis
     Bone biopsy : crucial means of
    making a diagnosis or distinguishing
    between local conditions that closely
    resemble one another

    Radical surgery should never be undertaken for a


    suspected neoplasm without first confirming the
    diagnosis histologically, no matter how ‘typical’ or
    ‘obvious’ the xray appearances may be.
    Biopsy
    FNAB (closed biopsy) Open biosy
    1. Cheaper than open biopsy 1. Invasive procedure
    2. Minimally invasive 2. Biopsy is a technically
    simple procedure but a
    3. Done by surgeon or complex cognitive skill
    pathologist 3. Biopsy should be performed
    4. Indication for bone tumor by the surgeon who will be
    with cortical break doing the definitive
    treatment
    5. Interpretation; by well
    trained pathologist 4. Place of biopsy
    a. Longitudinal
    6. Confirmation by b. In line with incision for
    musculoskeletal tumor team definitive surgery
    Differential Diagnosis
     Primary bone tumor
     Stress fracture
     Metabolic bone disease
     Osteonecrosis
    TREATMENT

    Musculoskeletal Tumor

    Systemic Control Locale Control

    Chemotherapy Surgery
    External Radiation
    Internal Radiation
    Systemic Controle

     Preoperative; neoadjuvant
     Objective
    a. Downsize of staging
    b. Facilitate of surgery (pseudocapsule)
    c. Prevent micrometastatic
     Posaoperative; adjuvant
    Treatment:
    • Can be divided into:
    a) Systemic therapy, aimed at cancer cells that have
    spread throughout the body, includes chemotherapy,
    hormone therapy, and immunotherapy.
    b) Local therapy, aimed at killing cancer cells in one
    specific part of the body, includes radiation therapy
    and surgery.
    MEDICAL TREATMENT

    Managing secondary
    Chemotherapy
    effect of tumor
    • Effective in certain • Corticosteroid
    types (primary • Biphosphonates
    tumor: lymphoma • Analgesic agents
    and
    neuroblastoma)
    • Used as adjuvant
    or neoadjuvant
    therapy
    Managing secondary effect of
    tumor
    Analgesic
    Corticosteroid Biphosphonates
    agents

    Primary adjuvant
    Reduce spinal to reduce
    osteolytic tumor
    NSAID
    cord edema
    progression

    Effective in Decreasing risk of Opioid (morphine


    pathological and
    treating pain fractures hydromorphone)

    Relieving local
    pain (inhibiting
    bone resorption)
    RADIATION THERAPY
     Reducing bone pain and
    progression of tumour growth
     90% will receive some relief
     Complications: radiation
    induced osteonecrosis &
    theoretically may increase
    rate of stress # or non-union
     Indication: No risk for fracture
     Recurrence of pain because of
    biomechanical weakness 
    operative stabilisation
    Treatment:
     Surgery is indicated mainly in case of fractures or large
    metastatic mass.
     If bone destruction is extensive, resulting in imminent or
    actual pathologic fracture we may need:
     surgical fixation
     resection and reconstruction
     Surgical intervention provide stabilization and help minimize
    morbidity
    Primary aims of surgery

    Relieve pain

    Prevent or reverse neurological


    compromise
    Decompression of neural structures

    Correction of deformity
    Anterior Plate Fixation

     A, Lateral MRI of burst fracture. B, After anterior decompression, strut


    grafting, and fixation with Z-plate. C, Postoperative CT scan shows
    complete canal decompression
    METASTASIS KARSINOMA
    MAMMA PADA FEMUR
    A B

    METASTASIS KARSINOMA BRONKOGENIK PADA RADIUS DISTAL

    Gambar A. Foto inisial


    Gambar B. Lesi yang sama 6 bulan kemudian
    METASTASIS KARSINOMA SEL
    RENAL PADA HUMERUS
    METASTASIS KARSINOMA TIROID PADA
    HUMERUS DISTAL
    METASTASIS KARSINOMA PROSTAT
    PADA TULANG BELAKANG
    Diagnosis banding tumor metastasis dan
    tumor primer pada tulang

    TUMOR TUMOR
    KELAINAN
    METASTASIS PRIMER
    Biasanya Biasanya
    Jumlah lesi
    multipel tunggal
    Ukuran lesi Biasanya kecil Biasanya besar
    Penyebaran
    Jarang Sering
    kista oseus
    Realsi Terutama Terutama
    osteoblas endosteal periosteal
    PROGNOSIS

    Median survival rate


     Thyroid : 48 months
     Prostate : 40 months
     Breast : 24 months
     Kidney : Variable
     Lung : 6 months

    Derek Moore. Metastatic disease of spine: orthobullets, Augts 2016


    dedicatio pro humanitate

    THANKS

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