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
