Updated: 7/1/2019

Metastatic Cancer to Bone

Topic
Review Topic
0
0
Questions
3
0
0
Evidence
1
0
0
 
Introduction
  • Metastatic cancer is the most common reason for a destructive bone lesion in adults
    • bone is the third most common site for metastatic disease (behind lung and liver)
    • carcinomas that commonly spread to bone include
      • breast
      • lung
      • thyroid
      • renal
      • prostate
  • Age & location
    • metastatic bone lesions are usually found in older patients (> 40 yrs)
    • common sites of metastatic lesions include
      • axial skeleton (vertebral bodies, pelvis, ribs)
      • proximal limb girdle
        • proximal femur is most common site of fracture secondary to metastatic bone lesions
  • Mechanism 
    • mechanism of bone destruction (osteolysis)
      • metastatic bone destruction (causing osteolytic bone lesions) is caused by tumor induced activation of osteoclasts
        • occurs through the RANK, RANK ligand (RANKL), osteoprotegrin pathway 
    • mechanism of tumor metastasis
      • metastasis requires
        • tumor cell intravasation
        • avoidance of immune surveillance
        • target tissue localization
        • extravasation into the target tissue
        • induction of angiogenesis
        • genomic instability
        • decreased apoptosis
  • Prognosis
    • median survival in patients with metastatic bone disease
      • thyroid: 48 months
      • prostate: 40 months
      • breast: 24 months
      • kidney: variable depending on medical condition but may be as short as 6 months
      • lung: 6 months
  • Metastatic hypercalcemia
    • a medical emergency
    • treat with hydration and loop diuretics
Presentation
  • Symptoms
    • pain
      • may be mechanical pain due to bone destruction or tumorigenic pain which often occurs at night
    • pathologic fracture
      • occurs at presentation in 8-30% of patients with metastatic disease
    • malignant hypercalcemia
      • confusion
      • polyuria & polydipsia
      • nausea/vomiting
      • dehydration
  • Physical exam
    • metastatic hypercalcemia
      • muscle weakness
Evaluation
  • Workup for older patient with single bone lesion and unknown primary includes
    • imaging 
      • plain radiographs 
      • CT of chest / abdomen / pelvis
      • technetium bone scan
    • labs
      • CBC with differential
      • ESR
      • basic metabolic panel
      • LFTs, Ca, Phos, alkaline phosphataseserum and urine immunoelectrophoresis (SPEP, UPEP)
    • biopsy 
      • in patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to rule out a primary bone lesion
Imaging
  • Radiographic characteristics
    • purly lytic or mixed lytic/blastic lesions
      • 30% of lung CA is blastic
      • 60% of breast CA is blastic
      • 90% of prostate CA is blastic
    • cortical metastasis are common in lung cancer  
    • lesions distal to elbow and knee are usually from lung or renal primary  
Histology
  • Characteristic findings of metastatic lesions
    • epithelial cells in clumps or glands in a fibrous stroma   
  • Immunohistochemical stains positive
    • Keratin
    • CK7 (breast and lung cancer)
    • TTF1 (lung cancer)
Treatment
  • Nonoperative
    • bisphosphonate therapy 
      • IV pamidronate prevents osteoclatic bone destruction
    • radiation alone 
      • indications
        • indicated in radiosenstive tumors such as breast cancer, prostate cancer, multiple myeloma and lymphoma
        • indicated to shrink mets that are causing spinal cord compression 
  • Operative
    • prophylactic IM nailing or arthroplasty with adjuvent radiation
      • indications
        • impending fx that meets criteria
    • spinal neurologic decompression, stabilization, with postoperative radiation therapy   
      • indications
        • metastatic lesions to the spine showing compression of neural elements and progressive neurologic deficits that are decreasing the quality of life in patient with life expectancy of greater than six months
Differentials & Groups
 
Malignant lesion in older patient(1)
 
Multiple lesion in older patient(1)
 
Epithelial glands on histology
 
Benefits from Bisphonate therapy
 
Treatment is wide resection and radiation(2)
Metastatic bone disease
 
 
 
 
Myeloma
 
     
   
Lymphoma
 
           
Chondrosarcoma
               
MFH / fibrosarcoma
               
Secondary sarcoma
               
Pagets disease    
     
 
 
Fibrous dysplasia            
 
 
Synovial sarcoma        
     
 
Hyperparathyroidism    
           
Gomus tumor        
       
Soft tissue sarcomas (3)                
ASSUMPTIONS: (1) Older patient is > 40 yrs; (2) assuming no impending fracture (3) High-grade soft tissue sarcomas includes angiosarcoma, synovial sarcoma, liposarcoma, desmoid tumor, MFH/fibrosarcoma: exception is rhabdomysarcoma which is treated with chemotherapy and wide resection
 
 
IBank
  Location
Xray
Xray
CT
B. Scan
MRI
MRI
Histo(1)
Case A prox femur
 
Case B pelvis
 
   
Case C hand (thyroid CA)
 
     
Case D hand (lung CA)
 
   
Case E femur (lung CA)
 
     
Case F pelvis
 
     
Case G renal CA (angio)
 
     
(1) - histology does not always correspond to clinical case 

 

Please rate topic.

Average 5.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

You have 100% on this question.
Just skip this one for now.

(M2.ON.4676) A 67-year-old woman is brought to the emergency room after complaining of back pain with a gradual loss of sensation in her lower extremities. She was recently diagnosed with radiosensitive metastatic breast cancer and was scheduled to receive chemotherapy and palliative surgery. Her temperature is 99.0°F (37.2°C), blood pressure is 133/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for decreased sensation bilaterally over the patient's lower extremities. She demonstrates 2/5 strength of leg extension on the left and 1/5 on the right which is slightly worse than her baseline neurological exam taken 2 months ago. Pain to her lumbar region worsens with coughing. An initial CT scan of the spine does not demonstrate any unstable fractures of the spine. A MRI of the spine is ordered and pending. Which of the following is the most appropriate next step in management? Review Topic

QID: 107229
1

Biopsy

0%

(0/4)

2

Chemotherapy

0%

(0/4)

3

Palliative pain management

25%

(1/4)

4

Radiation therapy

25%

(1/4)

5

Surgical decompression

50%

(2/4)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.ON.62) An 80-year-old male with known metastatic prostate cancer presents to your office with vague complaints of "achy bones." Strangely, he refers to you using the name of another physician. On physical exam, he is afebrile, but mildly tachycardic at 100 beats/min. Mucous membranes are dry. Cardiac exam shows regular rhythm and no murmurs. The patient has diffuse, nonfocal abdominal pain. He cannot articulate the correct date. You check the patient's serum calcium level, which is found to be 15.3 mg/dL. What is the best next step in management? Review Topic

QID: 106435
1

Pamidronate

10%

(2/21)

2

Intravenous normal saline

67%

(14/21)

3

Calcitonin

5%

(1/21)

4

Furosemide

5%

(1/21)

5

Hemodialysis

10%

(2/21)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 2
ARTICLES (1)
Topic COMMENTS (4)
Private Note