skeletal metastases in malignant tumors prof. dr. nazem shams professor of general surgery &...

Post-graduate Course

Skeletal Metastases in Malignant Tumors

Prof. Dr. Nazem ShamsProfessor of General Surgery & Surgical

OncologyFaculty of Medicine

Mansoura University


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.


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.


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.



1. 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.



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.



3. Perineural Spread:

Perineural space via the fifth cranial nerve have been speculated.


Theories of Metastasis

1. Anatomical2. Soil & seed3. Surface properties.


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.


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.


Common Sources of Metastasis to Bone

Primary sitePercent of Metastatic bony involvement

Breast50-85%

Prostate50-75%

Renal30-50%

Lung30-50%

Thyroid39%

Liver8%

Pancreas5-10%

Colorectal5-10%

Gastric5-10%

Ovary2-6%


Sites of Bone Predilection for Metastasis in Each Tumor

Primary TumorThe commonly affected bone

1. BreastVertebrae especially the thoracic vertebraeProximal femur

2. ProstateThoracic & Lumbar vertebrae and pelvis

3. LungThoracic vertebrae

4. KidneyThoracic vertebrae

5. G.I.T.Lumbaosacral vertebrae

6. Squamous cell carcinoma

Skull, clavicle and tibia

7. NeuroblastomaFemur especially lower femoral diaphysisHumerus especially medial margin of upper humerusSkull

8. Non Hodgkin’s lymphoma

Upper lumbar & lower thoracic vertebraePelvis & ribs

9. Burkitt’s lymphomaFacial bones

10. Hodgkin’s lymphomaProximal femurThoracic spine


Sites of Bone Predilection for Metastasis in Each Tumor

Primary TumorThe commonly affected bone

11. Leukaemia

A. InfantDistal femur & Proximal tibiaHumerusVertebral bodiesIliac crest

B. AdultProximal end of humerusFemur & tibia

12. Peripheral lesions in the hand or foot, usually have their origin in the lung, kidney, breast, uterus, oesophagus & melanoma of the skin.


Clinical Presentation

1. Pain2. Pathological Fracture3. Swelling4. Neurological Manifestations5. General symptoms6. Paraneoplastic syndrome


Diagnostic Approaches

I. Laboratory Investigations:

1. Blood picture2. Blood glucose3. Blood electrolytes4. Urine5. Enzymes6. Tumor markers



II. Radiological Diagnosis.

1. Plain radiography2. Myelography3. Angiography4. Tomography5. Bone scanning6. Computerized axial scan7. MRI8. PET



II. Radiological Diagnosis.1. Plain radiography



II. Radiological Diagnosis.2. Myelography



II. Radiological Diagnosis.3. Angiography



II. Radiological Diagnosis.4. Tomography



II. Radiological Diagnosis.5. Bone scanning



II. Radiological Diagnosis.6. Computerized axial scan



II. Radiological Diagnosis.7. MRI



II. Radiological Diagnosis.8. PET



III. Biopsy

1. Needle biopsy2. Open biopsy


Types of Skeletal Metastasis

Primary focusUsual type of

skeletal Metastasis

Relative Frequency

Very commonCommonInfrequentRare

BreastLytic and mixedx

Lung

CarcinomaPredominantly lytic

x

CarcinoidPredominantly blastic

x

ProstatePredominantly blastic, lytic in older age group

x

KidneyLytic-expandingX

ThyroidLytic-expandingX




skeletal Metastasis

Relative Frequency


G.I.T

OesophagusLyticx

StomachPredominantly blastic

x

ColonPredominantly lytic, occasionally blastic

xx

RectumPredominantly lytic

X

Biliary TreelyticX

PancreasLyticX




skeletal Metastasis

Relative Frequency


Female Reproductive System

Uterus:Corpus

lyticX

CervixLytic or mixedX

OvaryPredominantly lytic

Urinary Bladder

Predominantly lytic, blastic if prostate is involved

X

TestisPredominantly lytic, occasionally blastic

x




skeletal Metastasis

Relative Frequency


Head, Neck and C.N.S.

BrainLytic or blasticX

Neuroblastoma

Lytic, mixed and blastic

X

Paranasal sinusesLyticX

NasopharynxLytic or blasticX

Skin

EpidermoidLyticx

MelanomaLytic-expandingx


Schemes for Treatment of Skeletal Metastasis

I. Treatment policy of metastasisII. Treatment of skeletal metastasis

1) Surgical management2) Radiation therapy3) Hormonal therapy4) Chemotherapy5) Radioneuclide



III. Treatment of complications1) Pain2) Pathological fractures3) Spinal cord compression4) Hypercalcaemia



IV. Prophylactic treatment1) Adjuvant chemotherapy2) Adjuvant hormonal therapy



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.


Surgical Management of Skeletal Metastasis

1. Amputation:

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


Surgical Management of Skeletal Metastasis

2. Prophylactic Internal Fixation:Indications:-1) Impending fracture.2) Pain3) Involvement of one-half of the cortex4) 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


Radiation Therapy

1. Localized irradiation2. Hemibody irradiation


Hormonal Therapy

1) Casteration2) Oestrogenic hormones3) Androgenic hormones4) Progestins5) Antioestrogens6) Aminoglutethemide7) Bilateral adrenalectomy8) Hypophysectomy9) Thyroxin


Cancer Patients Referred for Pain Relief in Pain-clinics

1. Traumatic: Pathological fractures Amputation stump and phantom limb pain

2. Skeletal: Osteolytic lesions Osteoprosis with consequent degenerative

and mechanical changes Hypercalcaemia


Cancer Patients Referred for Pain Relief in Pain-clinics

3. Neurological: Nerve lesions due to compression or

invasion Central pain

4. Diagnostic and psychosomatic problems.


Destructive Procedures in Treatment of Pain

1) Dorsal rhizotomy2) Commissural myelotomy3) Anterolateral cordotomy4) Trans-sphenoidal haypophysectomy5) Rhizotomy of the cranial nerves6) Subarachinoid injection of phenol7) Intrathecal & extradural opiates


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.


Bone Metastasis of Unknown Primary

Percent of occult primary malignancy presents by bony involvement

Primary sitePercent of Metastatic bony involvement

Lung4%

Breast33%

Pancreas28%

Liver31%

Colorectal13%

Gastric9%

Renal66%

Prostate25%


Benign Tumors with Metastasis

skeletal metastases in malignant tumors prof. dr. nazem shams professor of general surgery &...

Documents

development of metastasis

clinical course

ovary slide

lung thoracic vertebrae

prostate thoracic vertebrae

kidney lumbaosacral

bone marrow

vertebral venous system