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Metastatic Cancer involving Long Bones
Aka: Metastatic Cancer involving Long Bones, Long Bone Metastases, Skeletal Metastases
- Pathophysiology: Cancers most prone to metastasize to long bones
- Most common cancers with bony metastases
- Breast Cancer
- Prostate Cancer
- Other common cancers with bony metastases
- Lung Cancer
- Renal Cancer
- Thyroid Cancer
- Symptoms
- Localized bone pain
- Dull, Intermittent pain
- Night pain and rest pain is pathognomonic for Cancer Pain
- Pain despite lack of injury history
- Weight-bearing related pain may predict Fracture
- Exam
- Focus on identifying primary cancer if not known
- Imaging
- General
- Multiple lesions are hallmark of metastatic bone cancer
- Plain film XRay: Indicated as first-line study
- Efficacy
- Test Sensitivity: Low (requires 50% Trabecular Bone loss before evident)
- Test Specificity: Highest among imaging studies
- Findings
- Lytic lesions: Lung Cancer, Thyroid Cancer, Renal Cancer
- Blastic lesions: Prostate Cancer
- Other cancers are mixed-type (lytic and blastic)
- Bone Scan
- Indications
- Identify additional metastatic cancer sites
- Evaluate bone pain in patient with known primary tumor
- Efficacy
- Test Sensitivity: High
- Identifies bony lesions down to 2 mm
- Identifies metastatic lesions up to 18 months before plain film xray
- Test Specificity: Low
- Computed Tomography (CT Scan)
- Indications
- Identify primary tumor site (CT chest, Abdomen and Pelvis)
- Evaluate bony cortex destruction
- Evaluate periarticular joint destruction
- Magnetic Resonance Imaging (MRI)
- Indications
- Evaluate spinal lesions
- Evaluate soft tissue spread of bony lesions
- Evaluate Bone Marrow destruction
- References
- Rosenthal (1997) Cancer 80:1595-607 [PubMed]
- Labs: Adjust based on primary tumor suspected
- Serum Protein Electrophoresis (SPEP)
- Evaluate for Multiple Myeloma
- Complete Blood Count with platelets
- Evaluate for Anemia and Thrombocytopenia
- Serum Creatinine
- Serum Calcium
- Evaluate for Hypercalcemia
- Serum Alkaline Phosphatase
- Prostate Specific Antigen (PSA)
- Labs: Biopsy Indications
- Confirm metastatic cancer in known primary cancer
- Evaluate bone tissue for advance lab testing (e.g. immunohistochemical stains)
- Evaluate bony lesion where primary tumor is unknown
- Rarely identifies the primary tumor
- Management
- Pain management
- Narcotic Analgesics
- NSAIDs
- Corticosteroids if nerve impingement from tumor mass
- Suppression of tumor growth or mass effect
- Calcitonin does not appear effective in reducing pain, morbidity, or cancer progression
- Bisphosphonates (started when bony metatastases are diagnosed)
- Pamidronate (Aredia) 90 mg IV every 3 weeks or
- Lipton (2000) Cancer 88:1082-90 [PubMed]
- Zoledronic acid (Zometa)
- Rosen (2004) Cancer 100:36-43 [PubMed]
- Chemotherapy
- Cancer-specific agents
- Hormonal therapy: Breast Cancer, Prostate Cancer
- Radiotherapy or Radiopharmacotherapy
- Surgical intervention indications
- Impending pathologic Fracture
- Decrease pain
- Improve morbidity and function
- References
- Hage (2000) Orthop Clin North Am 31:512-28 [PubMed]
- Riccio (2007) Am Fam Physician 76:1489-94 [PubMed]