Skeletal Metastases in Malignant Tumors

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Skeletal Metastases in Malignant Tumors

• Prof. Dr. Nazem Shams
• Professor of General Surgery Surgical Oncology
• Faculty of Medicine
• Mansoura University

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Introduction

• Importance of dealing with this subject
  originating from recent methods of management
  even in late terminal cases- for better quality
  of life rather than aiming for cure.

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Metastatic Potential of Tumors

• The development of metastasis is a complex and
  highly selective process that is dependant upon
  the interplay of host and intrinsic
  characteristics of tumor cells, adhesive
  capacities, cell motility, enzyme secretion and
  others.

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Routes of Metastasis

• The routes by which cancer cell emboli ordinarily
  reach the skeleton is the blood stream (venous or
  arterial).
• The role taken by lymphatic is not important due
  to apparent absence of lymph channels in bone
  marrow,
• There is also a minute role for perineural
  spread.

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Routes of Metastasis

• Venous Route.
• Vertebral venous system which is a network of
  valveless veins around the spinal dura mater and
  the vertebrae.
• This system has cranial and body wall connection
  and even connections with the veins in the wall
  of the vessels of extermities.
• When the intrathoracic or intra-abdominal
  pressure rises, as in coughing or sneezing, a
  reversed flow in the venous vertebral system can
  occur.

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Routes of Metastasis

• 2. Arterial Spread
• Cancer cell emboli reaching the lungs by way of
  caval circulation sometimes pass through the
  lungs instead of being arrested in them.

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Routes of Metastasis

• 3. Perineural Spread
• Perineural space via the fifth cranial nerve have
  been speculated.

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Theories of Metastasis

1. Anatomical
2. Soil seed
3. Surface properties.

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Incidence of Bone Metastasis

• The overall incidence of skeletal metastasis
  rates 70 or more.
• If one considers the prostate, kidney and
  thyroid, the incidence of skeletal metastasis in
  cases which have run their full clinical course.
• Sometimes the primary lesion is clinically silent
  and bone metastasis gives the first information
  about the presence of tumor as in kidney, lung
  and pancreas as well as lymphoma.

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Sites of Bone Metastasis

• The vertebral column particularly in the lumbar
  area and the sacrum, the rib cage including the
  sternum, the femoral and humeral shafts, the
  pelvic bones and the calvarium are the general
  sites of predilection.

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Common Sources of Metastasis to Bone
Percent of Metastatic bony involvement Primary site
50-85 Breast
50-75 Prostate
30-50 Renal
30-50 Lung
39 Thyroid
8 Liver
5-10 Pancreas
5-10 Colorectal
5-10 Gastric
2-6 Ovary
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Sites of Bone Predilection for Metastasis in Each
Tumor
The commonly affected bone Primary Tumor
Vertebrae especially the thoracic vertebrae Proximal femur Breast
Thoracic Lumbar vertebrae and pelvis Prostate
Thoracic vertebrae Lung
Thoracic vertebrae Kidney
Lumbaosacral vertebrae G.I.T.
Skull, clavicle and tibia Squamous cell carcinoma
Femur especially lower femoral diaphysis Humerus especially medial margin of upper humerus Skull Neuroblastoma
Upper lumbar lower thoracic vertebrae Pelvis ribs Non Hodgkins lymphoma
Facial bones Burkitts lymphoma
Proximal femur Thoracic spine Hodgkins lymphoma
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Sites of Bone Predilection for Metastasis in Each
Tumor
The commonly affected bone Primary Tumor
Leukaemia
Distal femur Proximal tibia Humerus Vertebral bodies Iliac crest Infant
Proximal end of humerus Femur tibia Adult
Peripheral lesions in the hand or foot, usually have their origin in the lung, kidney, breast, uterus, oesophagus melanoma of the skin. Peripheral lesions in the hand or foot, usually have their origin in the lung, kidney, breast, uterus, oesophagus melanoma of the skin.
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Clinical Presentation

1. Pain
2. Pathological Fracture
3. Swelling
4. Neurological Manifestations
5. General symptoms
6. Paraneoplastic syndrome

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Diagnostic Approaches

• Laboratory Investigations
• Blood picture
• Blood glucose
• Blood electrolytes
• Urine
• Enzymes
• Tumor markers

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography
• Myelography
• Angiography
• Tomography
• Bone scanning
• Computerized axial scan
• MRI
• PET

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Plain radiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

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Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

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Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

32
Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

33
Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

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Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

35
Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

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Diagnostic Approaches

• Radiological Diagnosis.
• Myelography

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Diagnostic Approaches

• Radiological Diagnosis.
• Angiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Angiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Angiography

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Diagnostic Approaches

• Radiological Diagnosis.
• Tomography

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Diagnostic Approaches

• Radiological Diagnosis.
• Tomography

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Diagnostic Approaches

• Radiological Diagnosis.
• Tomography

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Diagnostic Approaches

• Radiological Diagnosis.
• Tomography

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Diagnostic Approaches

• Radiological Diagnosis.
• Tomography

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Diagnostic Approaches

• Radiological Diagnosis.
• Tomography

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Bone scanning

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Diagnostic Approaches

• Radiological Diagnosis.
• Computerized axial scan

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Diagnostic Approaches

• Radiological Diagnosis.
• Computerized axial scan

56
Diagnostic Approaches

• Radiological Diagnosis.
• MRI

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Diagnostic Approaches

• Radiological Diagnosis.
• MRI

58
Diagnostic Approaches

• Radiological Diagnosis.
• MRI

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Diagnostic Approaches

• Radiological Diagnosis.
• MRI

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Diagnostic Approaches

• Radiological Diagnosis.
• MRI

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Diagnostic Approaches

• Radiological Diagnosis.
• PET

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Diagnostic Approaches

• Radiological Diagnosis.
• PET

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Diagnostic Approaches

• Radiological Diagnosis.
• PET

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Diagnostic Approaches

• Radiological Diagnosis.
• PET

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Diagnostic Approaches

• Radiological Diagnosis.
• PET

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Diagnostic Approaches

• Biopsy
• Needle biopsy
• Open biopsy

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Types of Skeletal Metastasis
Relative Frequency Relative Frequency Relative Frequency Relative Frequency Usual type of skeletal Metastasis Primary focus
Rare Infrequent Common Very common Usual type of skeletal Metastasis Primary focus
x Lytic and mixed Breast
Lung
x Predominantly lytic Carcinoma
x Predominantly blastic Carcinoid
x Predominantly blastic, lytic in older age group Prostate
X Lytic-expanding Kidney
X Lytic-expanding Thyroid
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Types of Skeletal Metastasis
Relative Frequency Relative Frequency Relative Frequency Relative Frequency Usual type of skeletal Metastasis Primary focus
Rare Infrequent Common Very common Usual type of skeletal Metastasis Primary focus
G.I.T
x Lytic Oesophagus
x Predominantly blastic Stomach
x x Predominantly lytic, occasionally blastic Colon
X Predominantly lytic Rectum
X lytic Biliary Tree
X Lytic Pancreas
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Types of Skeletal Metastasis
Relative Frequency Relative Frequency Relative Frequency Relative Frequency Usual type of skeletal Metastasis Primary focus
Rare Infrequent Common Very common Usual type of skeletal Metastasis Primary focus
Female Reproductive System
X lytic Uterus Corpus
X Lytic or mixed Cervix
Predominantly lytic Ovary
X Predominantly lytic, blastic if prostate is involved Urinary Bladder
x Predominantly lytic, occasionally blastic Testis
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Types of Skeletal Metastasis
Relative Frequency Relative Frequency Relative Frequency Relative Frequency Usual type of skeletal Metastasis Primary focus
Rare Infrequent Common Very common Usual type of skeletal Metastasis Primary focus
Head, Neck and C.N.S.
X Lytic or blastic Brain
X Lytic, mixed and blastic Neuroblastoma
X Lytic Paranasal sinuses
X Lytic or blastic Nasopharynx
Skin
x Lytic Epidermoid
x Lytic-expanding Melanoma
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Schemes for Treatment of Skeletal Metastasis

• Treatment policy of metastasis
• Treatment of skeletal metastasis
• Surgical management
• Radiation therapy
• Hormonal therapy
• Chemotherapy
• Radioneuclide

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Schemes for Treatment of Skeletal Metastasis

• Treatment of complications
• Pain
• Pathological fractures
• Spinal cord compression
• Hypercalcaemia

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Schemes for Treatment of Skeletal Metastasis

• Prophylactic treatment
• Adjuvant chemotherapy
• Adjuvant hormonal therapy

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Schemes for Treatment of Skeletal Metastasis

• The treatment policy differs whether the
  metastasis is solitary or multiple and also
  differs according to the state of primary cancer
  and the general condition of the patient.

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Surgical Management of Skeletal Metastasis

• Amputation
• Aims at palliation of pain if extensive cortical
  destruction around more distal fractures,
  fungation, intractable pain and vascular
  insufficiency.

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Surgical Management of Skeletal Metastasis

• Prophylactic Internal Fixation
• Indications-
• Impending fracture.
• Pain
• Involvement of one-half of the cortex
• High risk femur
• Pure lysis are seen on the roentgneogram
• The development of malignant lesion previously
  not demonstrable in the bone
• Involvement of even a small portion of the cortex
• Increasing pain
• Carcinoma of the lung was the tumor type most
  likely to be associated with one or more high
  risk factors
• Subtrochantric metastatic bone lesions secondary
  to carcinoma of the lung

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Radiation Therapy

1. Localized irradiation
2. Hemibody irradiation

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Hormonal Therapy

1. Casteration
2. Oestrogenic hormones
3. Androgenic hormones
4. Progestins
5. Antioestrogens
6. Aminoglutethemide
7. Bilateral adrenalectomy
8. Hypophysectomy
9. Thyroxin

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Cancer Patients Referred for Pain Relief in
Pain-clinics

• Traumatic
• Pathological fractures
• Amputation stump and phantom limb pain
• Skeletal
• Osteolytic lesions
• Osteoprosis with consequent degenerative and
  mechanical changes
• Hypercalcaemia

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Cancer Patients Referred for Pain Relief in
Pain-clinics

• Neurological
• Nerve lesions due to compression or invasion
• Central pain
• Diagnostic and psychosomatic problems.

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Destructive Procedures in Treatment of Pain

1. Dorsal rhizotomy
2. Commissural myelotomy
3. Anterolateral cordotomy
4. Trans-sphenoidal haypophysectomy
5. Rhizotomy of the cranial nerves
6. Subarachinoid injection of phenol
7. Intrathecal extradural opiates

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Management of Spinal Cord Compression

• Spinal cord compression from malignant tumor
  metastatic to the epidural space will inevitably
  result in permanent neurological damage unless
  emergency measures are taken.
• It should also be noted that epidural lesions
  below L1-2 region can result in compression on
  the cauda equina rather than the spinal cord
  itself.

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Bone Metastasis of Unknown Primary

• Percent of occult primary malignancy presents by
  bony involvement

Percent of Metastatic bony involvement Primary site
4 Lung
33 Breast
28 Pancreas
31 Liver
13 Colorectal
9 Gastric
66 Renal
25 Prostate
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Benign Tumors with Metastasis