musculoskeletal and connective tissue disorders
Metastatic Bone Tumors
Treatment of Metastatic Bone Tumors
Usually radiation therapy for symptomatic or large or progressively enlarging lesions Surgery to stabilize bone at risk of pathologic fracture or resect highly diseased bone (with joint reconstruction if needed) Kyphoplasty or vertebraplasty for certain painful vertebral fractures Treatment of metastatic bone tumors depends on the type of tissue involved (which organ tissue type). Radiation therapy, combined with selected chemotherapeutic or hormonal drugs, is the most common treatment modality. Radiation therapy is used for lesions that are symptomatic and for larger lesions that, if they progress, risk leading to pain, fracture, and/or a more difficult stabilization procedure. Early use of radiation (ranging from single treatment 8 Gy to multiple treatments to 30 Gy) and bisphosphonates (eg, zoledronate,pamidronate) ordenosumabslows bone destruction. Some tumors are more likely to heal after radiation therapy; eg, blastic lesions of prostate and breast cancer are more likely to heal than lytic destructive lesions of lung cancer and renal cell carcinoma. Denosumabis used to block the receptor activator of nuclear factor kappa-B ligand (RANKL) to reduce progressive bone destruction and thus treat and prevent pain and/or pathologic fractures due to metastases from a variety of primary cancers. Sometimesdenosumabis indicated to delay the development of skeletal metastatic disease.Denosumabis used to reduce skeletal-related metastatic events (eg, radiation therapy to bone, repair of impending or pathological fracture, spinal cord impression or malignant hypercalcemia) or obviate the need for additional radiation therapy. If bone destruction is extensive, resulting in imminent or actual pathologic fracture, surgical fixation or resection and reconstruction may be required to provide stabilization and help minimize morbidity. When the primary cancer has been removed and only limited bone metastasis remains (especially if the metastatic lesion appears≥1 year after the primary tumor), en bloc excision sometimes combined with radiation therapy, chemotherapy, or both rarely may be curative. Insertion of methyl methacrylate into the spine (kyphoplasty or vertebraplasty) relieves pain and expands and stabilizes compression fractures that do not have epidural soft tissue extension. This image shows bone destruction due to a metastasis secondary to renal cell carcinoma in the proximal femur. The location and extent of bone destruction make the risk of fracture extremely high (imminent fracture). Image courtesy of Michael J. Joyce, MD, and David M. Joyce, MD. This x-ray shows a large metastatic lytic lesion of the femoral medial condyle with imminent fracture. Image courtesy of Michael J. Joyce, MD, and David M. Joyce, MD. This image shows a failed surgical management of a metastatic breast lesion requiring a second operation. Image courtesy of Michael J. Joyce, MD, and David M. Joyce, MD. 