Bone Metastasis Presentation 3

8/4/2019 Bone Metastasis Presentation 3

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Metastatic Bone

Disease

Aiman AwadDarlington Memorial Hospital


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Pathophysiology How tumour cells migrate to bone?

How tumour cells grow in bone?

Diagnosis. Primary or secondary.

Solitary or multiple.

If secondary, where is the primary? The local extension of the metastatic tumour.

Differential diagnosis.


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Pathophysiology

How tumour cells migrate to bone?

By 3 main mechanisms:

(1) direct extension,

(2) retrograde venous flow, and(3) seeding with tumour emboli via the blood

circulation


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Sources of Bone Metastases

Breast

Prostate

Kidny

Lung

Thyroid

Bladder

Gastrointestinal Tract.
http://www.3dscience.com/3D_Images/Human_Anatomy/System_Composites/index.php


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Bone metastasis

the most common locations include thefollowing:

Spine Pelvis Ribs Proximal limb girdles

Metastases distal to the knee and elbow are

extremely uncommon, but approximately 50% ofthese acral metastases are secondary to primarylung tumors. Carcinomas, such as those of thebreast and prostate, rarely exhibit such a distinctpattern.


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How tumour cells grow in bone?

There are two forms of bone Metastasis

Osteolytic bone disease.

Osteoblastic bone disease.


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Osteolytic bone disease

(1) Metastatic tumour cells releasehumoral factors that stimulateosteoclastic recruitment anddifferentiation.

(2)

Osteoclasts begin to break downbone.

(3) Bone resorption results in therelease of growth factors thatstimulate tumour cell growth.

(4) As the tumour proliferates, itproduces substances thatincrease osteoclast-mediatedbone resorption.


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Osteoblastic bone disease

1- Metastatic tumour cells releasegrowth factors that stimulate theactivity of osteoclasts.

2-Tumor cells also secrete growthfactors that stimulate the activity

of osteoblasts.3-Excessive new bone formation

occurs around tumour-celldeposits.

4-Osteoclastic activity releases

growth factors that stimulatetumor cell growth.

5-Osteoblastic activation releasesunidentified osteoblastic growthfactors that also stimulatetumour cell growth.


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Clinical Presentation

Pain initially related to activity thenprogressive day and night.

Pathological fracture.

Mass.

Abnormal radiographic finding detected

during the evaluation of an unrelatedproblem.


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Diagnosis of bone Metastasis

History and Physical Examination

Laboratory Investigation

X Ray Bone Scan

CT

MRI Biopsy


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METASTASES OF UNKNOWN ORIGIN

a patient over the age of 40 with a new, painfulbone lesion, multiple myeloma and metastaticcarcinoma are the most likely diagnoses

Prostate cancer and breast cancer are the twomost common primary sources for bonemetastasis.

If a patient has no known primary tumour, themost likely sources are lungcancer and renalcell carcinoma.


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Biopsy should not be done until theevaluation is complete:

1. The lesion may be a primary sarcoma of bone that mayrequire a biopsy technique that allows for future limbsalvage surgery;

2. Another more accessible lesion may be found3. If renal cell carcinoma is considered likely, the surgeon may

wish to consider preoperative embolization to avoidexcessive bleeding;

4. If the diagnosis of multiple myeloma is made by laboratorystudies, an unnecessary biopsy will be avoided;

5. The pathological diagnosis will be more accurate if aided byappropriate imaging studies; and

6. the pathologist and surgeon may be more assured of adiagnosis of metastasis made on frozen section analysis ifsupported by the preoperative evaluation. This is importantif stabilization of an impending fracture is planned for thesame procedure.


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physical examination

The evaluation begins with a historyfocusing on any previous malignancies.

Examination includes not only the involvedextremity, but also the thyroid, lungs,abdomen, prostate in men, and a breastexamination in women


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Laboratory analysis

should include a FBC, ESR , electrolytes, liverenzymes, alkaline phosphatase, a serum proteinelectrophoresis, and possibly prostate-specificantigen.

A FBC may be helpful to rule out infection andleukemia.

The ESR usually is elevated in infection,metastatic carcinoma, and small "blue cell"

tumors such as Ewing sarcoma, lymphoma,leukemia, and histiocytosis.


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A serum protein electrophoresis should be orderedif multiple myeloma is part of the differentialdiagnosis.

Hypercalcemia may be present with metastaticdisease, multiple myeloma, andhyperparathyroidism.

Alkaline phosphatase may be elevated inmetabolic bone disease, metastatic disease,osteosarcoma, Ewing sarcoma, or lymphoma.

Blood urea nitrogen and creatinine may beelevated with renal tumors, and a urinalysis mayreveal hematuria in this setting.

A basic metabolic panel may be indicated to

evaluate the overall health of a patient.


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plain roentgenograms

provides useful diagnosticinformation for evaluation ofbone lesions.

Most vertebral lesions in

adult patients aremetastases, myelomas, orhemangiomas.

The aggressiveness of thelesion, and whether it is likely

to be benign or malignant,usually can be determined bycareful evaluation of the plainfilms.
http://www.emedicine.com/radio/images/336139-387840-5173.jpg


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Technetium bone scans

With the exception ofmyeloma, all malignantneoplasms of bonedemonstrate increased

uptake on technetium bonescans

A normal bone scan istherefore very reassuring;however, the converse

statement is not true becausemost benign lesions of bonealso demonstrate increaseduptake.
http://www.emedicine.com/radio/images/336139-387840-5191.jpg


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Computed tomography (CT)

Helpful in assessingossification andcalcification and in

evaluating the integrityof the cortex

CT of the chest,abdomen, and pelvis

should be obtained forUnknown Metastasis.

Axial CT scan shows 2 rounded, mixedosteolytic-sclerotic lesions in thethoracic vertebral body of a 44-year-old woman with lung carcinoma.
http://www.emedicine.com/radio/images/336139-387840-5179.jpghttp://www.emedicine.com/radio/images/336139-387840-5179.jpghttp://www.emedicine.com/radio/images/336139-387840-5179.jpghttp://www.emedicine.com/radio/images/336139-387840-5179.jpghttp://www.emedicine.com/radio/images/336139-387840-5179.jpghttp://www.emedicine.com/radio/images/336139-387840-5179.jpg


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Magnetic resonance imaging (MRI)

the most accurate technique fordetermining the limits of diseaseboth within and outside bone.

not very useful in differentiatingbenign from malignant lesions.


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Biopsy

patient with a suspected primarymusculoskeletal malignancy should be referredbefore biopsy to the institution where definitivetreatment will take place

A biopsy should be planned as carefully as thedefinitive procedure.

Regardless of whether a needle biopsy or anopen biopsy is done, the biopsy track should be

considered contaminated with tumor cells The surgeon performing the biopsy should be

familiar with incisions for limb salvage surgery


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Bone Metastasis Presentation 3