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)
1. Cheaper than open biopsy
2. Minimally invasive
3. Done by surgeon or
pathologist
4. Indication for bone tumor
with cortical break
5. Interpretation; by well
trained pathologist
6. Confirmation by
musculoskeletal tumor team
Open biosy
1. Invasive procedure
2. Biopsy is a technically
simple procedure but a
complex cognitive skill
3. Biopsy should be performed
by the surgeon who will be
doing the definitive
treatment
4. Place of biopsy
a. Longitudinal
b. In line with incision for
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