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  • 1. Volume 11Metastatic carcinoma----------Case 225-248 & 1107-1121
  • 2. MetastaticCarcinoma To Bone
  • 3. Metastatic Carcinoma to Bone One of the major complications of carcinoma in the adult humanbeing is its potential to metastasize to bone. The incidence ofmetastatic carcinoma to bone is fifteen times greater than theincidence of primary sarcomas of all types. This amounts toapproximately 300,000 new cases each year. It has been stated thatabout 70% of all patients who die of advanced carcinoma willdemonstrate evidence of metastatic lesions in bone at time ofautopsy. The two most common metastatic tumors that go to boneinclude breast in females and prostate in males, followed next bykidney, thyroid and lung. Carcinomas that are least likely to go tobone include skin cancers, oral carcinoma, esophageal, cervical,stomach and colon carcinomas. The spine is by far the most commonsite for metastatic disease, followed next by the pelvis, femur, ribs,proximal humerus and skull. It is very unusual to find metastaticlesions distal to the knee or elbow but, if they are found there, the
  • 4. most common etiology would be lung carcinoma. Only 9% ofmetastatic lesions to bone will be solitary in nature. Breast cancer is by far the most common cause of metastaticdisease to bone in females, accounting for about 50% of all met-astatic carcinomas. Radiographically, the lesions appear as aprimary lytic focal destruction within the bone, frequentlyassociated with a ring of reactive bone seen at the periphery of thelytic process, giving a mixed lytic and blastic appearance.Generally, the more lytic the process is, the more likely a pathologicfracture and a worse prognosis. Likewise, with therapeuticapproaches including hormones, chemotherapy and radiationtherapy, the lytic component will decrease in volume and theblastic component will increase. This decreases the chance forfracture and decreases pain symptoms. With prostate carcinoma,lesions are usually more blastic in nature and pain is not a problem,and the incidence of pathological fracture is also reduced. How-ever, not all prostate metastases are blastic in nature. In the case
  • 5. of lytic prostate carcinoma metastases, patients have more pain, theincidence of pathological fracture is greater, and the prognosis isworse. Many carcinomas induce a hyperemic response in the surroundinghost tissue, creating an aneursymal appearance on the radiographicexamination. This is the case with many renal cell carcinomas, aswell as multiple myelomas. Much of the hemorrhagic lyticdestruction of bone is the result of the tumor cell activating osteo-clastic destruction in the surrounding bone, similar to what occursin hyperparathyroidism, and thus a significant medical treatment forthis lytic process is to inhibit the osteoclastic activity by the use ofbisphosphonate therapy, especially “Aredia,” which is given intra-venously on a monthly basis during the active phase of the disease.Mechanically speaking, it is sometimes advisable to use prophylacticembolization therapy to the hyperemic lesions prior to any surgicalprocedures, especially with lesions that have not been previouslyirradiated. This will markedly reduce the chance of excessive bleeding
  • 6. at the time of surgical reconstruction. The staging process designed to discover the primary source ofthe metastatic lesion of bone should include a routine CT scan ofthe chest and abdomen, looking for primaries in the lung,abdominal visera, along with a total skeletal bone isotope surveyto look for multifocal disease that frequently is characteristic formetastatic carcinoma. In the case of spine metastases, routineradiographs are notorious for not picking up early medullarylesions, whereas a bone isotope scan is very sensitive for lesionsin the spine. Likewise, lesions in the rib cage are also difficult topick up on routine radiographs. The prognosis for survival following a pathological fracturethrough a metastatic lesion is variable with the best prognosis seenin prostate carcinoma, with an average survival of about three years.Next would be breast carcinoma with an average survival of abouttwo years. Renal cell carcinoma averages a one year survival andlung is the worse prognosis of all with only a six month survival.
  • 7. A common form of nonsurgical treatment consists of radiationto the metastatic area which gives the best clinical response inprostate carcinoma, an intermediate response with breast cancer,and the worse response is seen with renal and gastrointestinalcarcinomas. Hormonal therapy is a common adjuvant treatmentfor prostate and breast cancer. Tamoxafin is a common anti-estrogen agent used for the treatment of breast carcinoma; it iseffective in 30% of all cases. Cytotoxic chemotherapy is nowcommonly used for metastatic carcinoma, especially in the middle-aged group that can tolerate this aggressive systemic protocol. Surgical treatment for metastatic cancer to bone can be used inmore advanced cases that do not respond to medical or radiationtherapy. It usually consists of either a prophylactic metallic fixation,with or without bone cement, or open reduction, internal fixation ofa fracture at the time of admission through the emergency roomwith an acute pathological fracture. One of the most commonareas for a pathological fracture is in the hip where bipolar or total
  • 8. hip prostheses can be implanted with bone cement, which allowsfor immediate weight bearing. The patients will usually undergoradiation therapy postoperatively and therefore porous ingrowthdevices should not be used. The femoral shaft is an other commonarea for pathological fracture and interlocking intramedullary nailswork well. If there is a large lytic defect, these devices should alsobe augmented with bone cement to avoid problems with subsidenceand breakdown of the interlocking system. If spinal metastases arepicked up early, radiation therapy will usually reduce the pain andprevent spinal cord compression. However, if the disease progressesand the cord is compromised, surgical intervention is indicated.Simple posterior laminectomy decompression is not advisable becauseof further kyphotic collapse with the destabilizing effect of theposterior element resection. Most spinal lesions are best approachedsurgically anteriorly where stabilization is obtained with eitherbone cement, allograft or metallic devices such as cages or anteriorbuttress plates. A recent approach to this problem is by means of a
  • 9. percutaneous technology with a vertebroplasty injection of bonecement into the vertebral body tumor site. This can be usedprophylactically to avoid compression fracture or, in some cases,to restore height after a compression fracture.
  • 10. CLASSIC Case #22545 year femalemetastatic breastlumbar spine
  • 11. Oblique view
  • 12. Opposite oblique
  • 13. Lateral view
  • 14. Lysis spinousprocess T-1
  • 15. Case #226 X-ray Gross specimen tumor tumor tumor Autopsy specimen 45 yr female with metastatic breast
  • 16. Photomic
  • 17. Case #227 Bone scan 55 year female with metastatic breast
  • 18. Case #22867 year malemetastatic prostatespine & pelvis
  • 19. Skeletonized autopsyspecimen prostatemet to L-spine
  • 20. Photomic showing dense blastic response
  • 21. Blastic snowballmets to humerusand scapula
  • 22. Case #229 85 year male with blastic prostate to pelvis
  • 23. Case #230 67 year male with lytic type prostate to pelvis
  • 24. Case #23170 year male with path fracture prox humerus lytic prostate
  • 25. Case #23260 year femalemetastatic thyroidhand
  • 26. X-ray showing twoaneurysmal lesions
  • 27. Photo of large aneurysmal lesion in skull
  • 28. Large lytic lesion in occiput
  • 29. CT scan pelvis with large aneurysmal lesion in ilium
  • 30. Photomic
  • 31. Case #233 tumor 55 year male with aneurysmal renal CA met to ilium
  • 32. Photomic
  • 33. Photomic of renal cell CA
  • 34. CT scan abdomen
  • 35. Case #23456 year female withmetastatic colon to pelviswith fluffy periostealreactive bone formation
  • 36. Same periostealresponse seen in tibia
  • 37. Photomic
  • 38. Case #23674 year malemetastatic lung CAmid finger
  • 39. Photomic of squamous cell lesion in hand
  • 40. Primary lung tumor
  • 41. Case #237 94 year female with unknown primary mets to foot
  • 42. AP view
  • 43. Case #23855 year male with bilateral path fractures from lung CA mets
  • 44. Post op x-ray with standard metal devices & radiolucent cement
  • 45. Case #23960 year malemetastatic renalcell CA to femur
  • 46. Post op cemented IM nail
  • 47. Case #239.1 59 year male with pain in leg for 3 months
  • 48. CT scan abdomen Bone scan
  • 49. Sag T-1 PD Gad
  • 50. Axial T-1 T-2 Gad
  • 51. Case #24062 year femalepost op interlockingIM nail for metastaticbreast CA
  • 52. Case #24172 year female with priorpath fracture from metastaticbreast treated with cementedIM nail and radiation therapy
  • 53. Recurrent tumor seenat distal end of nail tumor
  • 54. tumorSurgical photo of nail and tumor protruding into knee
  • 55. medullary canalSurgical photo after removal of nail and condyles
  • 56. Reconstruction with long stem cemented prosthesis
  • 57. cementLateral photo of knee reconstruction
  • 58. old fractureLateral x-ray 6 months later radiolucent cement
  • 59. Case #242 73 year female with extensive metastatic disease pelvis and right hip
  • 60. Photo after resectionof periacetabular tumorwith exposed remainingsolid iliac bone at notchlevel for placement ofcemented Steinman pins
  • 61. Placement of 3 cementedSteinman pins
  • 62. Completion of 2ndbatch of cement withall poly cup for THA
  • 63. Pain free 5 yrs later with stable radiolucent cement
  • 64. Case #243 tumor 50 year female with periacetabular lung met
  • 65. Steinman pinsPost op x-ray cement
  • 66. Case #243.1 57 year male with painful metastatic lung CA to pelvis
  • 67. Bone scan
  • 68. CT scan
  • 69. X-ray following internal hemipelvectomy and THA
  • 70. Case #24445 year malemetastatic lungto humerus
  • 71. 2 years later afterradiolucent cementednail callous
  • 72. Case #24546 year femalemetastatic breast andhumeral fracturefixed with cementedSteinman pins
  • 73. Case #24642 year female withlarge aneurysmalmetastatic renal lesionhumeral head & neck
  • 74. Post op cemented longstem Neer prosthesis
  • 75. Case #24774 year female withparaplegia 2nd to metastaticcolon CA to T-3 on 4
  • 76. T-4 tumorCT scan at T-4 level with vertebral canal filled with tumor
  • 77. duraPhoto at time of laminectomy decompression
  • 78. Photomic
  • 79. Posterior stabilization Steinman pins & sublaminar wires prior to cementation
  • 80. cement coverCementation completed
  • 81. 5 years laterwithout paraplegia
  • 82. Case #24854 year female withpath compression fracturefrom metastatic breastat T-12 level
  • 83. Sagittal T-2 MRI
  • 84. Macro section ofautopsy specimen ofanother case withmetastatic breast bulginginto floor of canal met
  • 85. Diagram of planned anterior reconstruction
  • 86. Photo of distraction rods
  • 87. hookDistraction rod in position ready for cementation
  • 88. cementCementation completed
  • 89. Post op x-ray cement
  • 90. Case #110714 year female with metastatic breast to right periacetabulum
  • 91. 3 months following local radiation therapy
  • 92. Close up showing excellent sclerotic response to RT
  • 93. L RBone scan
  • 94. tumor Coronal T-1 MRI
  • 95. Axial T-1 MRI
  • 96. Axial PD MRI
  • 97. Photomic
  • 98. Case #110853 year female withmetastatic breast toacetabulum with pathologicfracture
  • 99. Surgical exposureof bone deficientacetabulum
  • 100. Tronzo hip arthroplasty system
  • 101. Tronzo cup inposition priorto cementation
  • 102. Placement ofradiolucent cement
  • 103. Post op x-ray withradiolucent cement
  • 104. Case #110952 year female withmetastatic breast CAand pathologic fracturedistal femur
  • 105. TKA reconstruction
  • 106. Case #111058 yr female with metastatic breast distal femur with prior treat- ment with prophylactic device with current failure proximal
  • 107. Removal distal femur with failed fixation device
  • 108. Distal femoral resection specimen
  • 109. Reconstructed with distal femoral resection TKA
  • 110. Case #1111 46 year female with metastatic breast to pelvis
  • 111. 19 months post radiation therapy
  • 112. Case #1112 45 year female with metastatic breast to pelvis
  • 113. Case #111362 year female withblastic and lyticmetastases to L-spineand pelvis
  • 114. Case #111454 year female withmetastatic breast to distalfemur
  • 115. Lateral view
  • 116. Reconstruction withcemented IM nail
  • 117. Case #111567 year female withmetastatic breast to femur
  • 118. Lateral view
  • 119. Macro section ofresected specimen
  • 120. Photomic
  • 121. Case #111660 year female withmetastatic breastproximal tibia
  • 122. Lateral view
  • 123. Case #111756 year female withmetastatic breast tomid dorsal spine withvertebral body collapseand complete myelographicblock posterior
  • 124. AP view block
  • 125. Photomic
  • 126. Laminectomy decompressionand Harrington rod fixationwith autogenous cancellousiliac bone graft graft dura rod
  • 127. Post op x-ray
  • 128. Case #111862 year female withmetastatic breast tolower cervical spine
  • 129. Case #1119 68 year female with metastatic breast to distal humerus
  • 130. Triceps spliting posterior approachelbow cementCompletion of internal fixation with rods and cement
  • 131. Post op x-ray
  • 132. Case #112040 year male with metastatic breast to clavicle & path fracture
  • 133. Several months later
  • 134. tumorCoronal T-1 MRI
  • 135. Coronal PD MRI
  • 136. Photomic
  • 137. Case #1121 41 year male with metastatic renal cell CA to scapula
  • 138. Similar lesion in opposite proximal humerus
  • 139. R L Bone scan
  • 140. CT showing renal tumor
  • 141. Humeral head andneck resectionspecimen cut inpath lab
  • 142. Photomic showing clear cell pathology