Orthopaedic perspective on bone metastasis

Abstract

The incidence of cancer is increasing worldwide, with the advent of a myriad of new treatment options, so is the overall survival of these patients. However, from an orthopaedic perspective, there comes the challenge of treating more patients with a variety of metastatic bone lesions. The consequences of such lesions can be significant to the patient, from pain and abnormal blood results, including hypercalcemia, to pathological fracture. Given the multiple options available, the treatment of bone metastasis should be based on a patientby patient manner, as is the case with primary bone lesions. It is imperative, given the various lesion types and locations, treatment of bone metastasis should be performed in an individualised manner. We should consider the nature of the lesion, the effect of treatment on the patient and the overall outcome of our decisions. The dissemination of primary lesions to distant sites is a complex pathway involving numerous cytokines within the tumour itself and the surrounding microenvironment. To date, it is not fully understood and we still base a large section of our knowledge on Pagets historic "seed and soil" theory. As we gain further understanding of this pathway it will allow us develop more medical based treatments. The treatment of primary cancers has long been provided in a multi-disciplinary setting to achieve the best patient outcomes. This should also be true for the treatment of bone metastases. Orthopaedic surgeons should be involved in the multidisciplinary treatment of such patients given that there are a variety of both surgical fixation methods and non-operative methods at our disposal. MINIREVIEWS© 2013 Baishideng. All rights reserved.Key words: Bone metastases; Diagnosis; Pathophysiology; Surgical treatment, Medical treatment Core tip: This paper discusses the pathophysiology and patient implications of bone metastasis. We aim to describe the orthopaedic input into the management of this condition, especially in a multi-disciplinary setting. We believe that orthopaedics do not have a significant enough involvement in the treatment of long bone metastasis, although from this paper we feel we have many options to offer. The future of metastasis treatment may be targeted at the molecular level but current management options do require an understanding of musculoskeletal oncology to obtain best patient outcomes through operative and non-operative means.Molloy AP, O'Toole GC. Orthopaedic perspective on bone metastasis. World

Common Pitfalls in the Management of Bone Metastasis of the Extremities - a Current Concept and Systematic Review of the Literature

“…Therefore, highest priority is given to diagnostic workup rather than to rapid surgical treatment of the fracture (23). Although sensitivity for detecting small metastases is limited, x-rays of the symptomatic bone and surrounding joints should always be performed (21,22,28,29). It is essential to avoid missing proximal or distal metastases, as this can cause pathological fractures in precisely those areas when full weight bearing is applied after surgical fixation (30).…”

“…Radiologically, the characteristics of such lesions can be described as osteoblastic, osteolytic or mixed lytic-sclerotic and may hint at the possible primary (20,21,23,28,31,32). While metastases due to prostate carcinoma are mostly osteoblastic, the bony lesions of lung, thyroid or renal primaries usually appear to be osteolytic (21,23,25,31).…”

“…Additional three dimensionality of the anatomical sites as well as higher resolution are given by CT and magnetic resonance imaging (MRI) (20-22, 25, 27, 33). CT allows accurate visualization of cortical integrity and consequently assists in the evaluation of cortical bone destruction (20,25,28,33,34). As previously mentioned, CT can also be useful in localizing the lesion in the setting of a percutaneous biopsy (20,21).…”

“…With 91% sensitivity and 95% specificity, MRI is well suited to detect small bony metastases (21,26,28). In addition, it provides valuable information about the extent of intramedullary as well as extraosseous soft tissue involvement, which helps in planning surgical and radiation therapy (20,21,32,33).…”

Caracterização de metástases ósseas em neoplasias ocultas e neoplasias previamente diagnosticadas

“…No entanto, o local mais frequente é a coluna vertebral, seguido pelos ossos constituintes da bacia, os arcos costais e o fémur 3 . O microambiente do osso é ideal para a progressão tumoral e, desta forma para a metastização, dada a sua vascularização e a produção de moléculas de adesão, sendo também uma fonte de moléculas de angiogénese e reabsorção 4 . Com este estudo, pretende-se caracterizar uma amostra de doentes internados com o diagnóstico de metastização óssea, assim como comparar um grupo de doentes com neoplasia previamente conhecida com um grupo de doentes sem neoplasia identificada.…”