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Volume 11


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Volume 11

  1. 1. Volume 11Metastatic carcinoma----------Case 225-248 & 1107-1121
  2. 2. MetastaticCarcinoma To Bone
  3. 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. 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. 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. 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. 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. 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. 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. 10. CLASSIC Case #22545 year femalemetastatic breastlumbar spine
  11. 11. Oblique view
  12. 12. Opposite oblique
  13. 13. Lateral view
  14. 14. Lysis spinousprocess T-1
  15. 15. Case #226 X-ray Gross specimen tumor tumor tumor Autopsy specimen 45 yr female with metastatic breast
  16. 16. Photomic
  17. 17. Case #227 Bone scan 55 year female with metastatic breast
  18. 18. Case #22867 year malemetastatic prostatespine & pelvis
  19. 19. Skeletonized autopsyspecimen prostatemet to L-spine
  20. 20. Photomic showing dense blastic response
  21. 21. Blastic snowballmets to humerusand scapula
  22. 22. Case #229 85 year male with blastic prostate to pelvis
  23. 23. Case #230 67 year male with lytic type prostate to pelvis
  24. 24. Case #23170 year male with path fracture prox humerus lytic prostate
  25. 25. Case #23260 year femalemetastatic thyroidhand
  26. 26. X-ray showing twoaneurysmal lesions
  27. 27. Photo of large aneurysmal lesion in skull
  28. 28. Large lytic lesion in occiput
  29. 29. CT scan pelvis with large aneurysmal lesion in ilium
  30. 30. Photomic
  31. 31. Case #233 tumor 55 year male with aneurysmal renal CA met to ilium
  32. 32. Photomic
  33. 33. Photomic of renal cell CA
  34. 34. CT scan abdomen
  35. 35. Case #23456 year female withmetastatic colon to pelviswith fluffy periostealreactive bone formation
  36. 36. Same periostealresponse seen in tibia
  37. 37. Photomic
  38. 38. Case #23674 year malemetastatic lung CAmid finger
  39. 39. Photomic of squamous cell lesion in hand
  40. 40. Primary lung tumor
  41. 41. Case #237 94 year female with unknown primary mets to foot
  42. 42. AP view
  43. 43. Case #23855 year male with bilateral path fractures from lung CA mets
  44. 44. Post op x-ray with standard metal devices & radiolucent cement
  45. 45. Case #23960 year malemetastatic renalcell CA to femur
  46. 46. Post op cemented IM nail
  47. 47. Case #239.1 59 year male with pain in leg for 3 months
  48. 48. CT scan abdomen Bone scan
  49. 49. Sag T-1 PD Gad
  50. 50. Axial T-1 T-2 Gad
  51. 51. Case #24062 year femalepost op interlockingIM nail for metastaticbreast CA
  52. 52. Case #24172 year female with priorpath fracture from metastaticbreast treated with cementedIM nail and radiation therapy
  53. 53. Recurrent tumor seenat distal end of nail tumor
  54. 54. tumorSurgical photo of nail and tumor protruding into knee
  55. 55. medullary canalSurgical photo after removal of nail and condyles
  56. 56. Reconstruction with long stem cemented prosthesis
  57. 57. cementLateral photo of knee reconstruction
  58. 58. old fractureLateral x-ray 6 months later radiolucent cement
  59. 59. Case #242 73 year female with extensive metastatic disease pelvis and right hip
  60. 60. Photo after resectionof periacetabular tumorwith exposed remainingsolid iliac bone at notchlevel for placement ofcemented Steinman pins
  61. 61. Placement of 3 cementedSteinman pins
  62. 62. Completion of 2ndbatch of cement withall poly cup for THA
  63. 63. Pain free 5 yrs later with stable radiolucent cement
  64. 64. Case #243 tumor 50 year female with periacetabular lung met
  65. 65. Steinman pinsPost op x-ray cement
  66. 66. Case #243.1 57 year male with painful metastatic lung CA to pelvis
  67. 67. Bone scan
  68. 68. CT scan
  69. 69. X-ray following internal hemipelvectomy and THA
  70. 70. Case #24445 year malemetastatic lungto humerus
  71. 71. 2 years later afterradiolucent cementednail callous
  72. 72. Case #24546 year femalemetastatic breast andhumeral fracturefixed with cementedSteinman pins
  73. 73. Case #24642 year female withlarge aneurysmalmetastatic renal lesionhumeral head & neck
  74. 74. Post op cemented longstem Neer prosthesis
  75. 75. Case #24774 year female withparaplegia 2nd to metastaticcolon CA to T-3 on 4
  76. 76. T-4 tumorCT scan at T-4 level with vertebral canal filled with tumor
  77. 77. duraPhoto at time of laminectomy decompression
  78. 78. Photomic
  79. 79. Posterior stabilization Steinman pins & sublaminar wires prior to cementation
  80. 80. cement coverCementation completed
  81. 81. 5 years laterwithout paraplegia
  82. 82. Case #24854 year female withpath compression fracturefrom metastatic breastat T-12 level
  83. 83. Sagittal T-2 MRI
  84. 84. Macro section ofautopsy specimen ofanother case withmetastatic breast bulginginto floor of canal met
  85. 85. Diagram of planned anterior reconstruction
  86. 86. Photo of distraction rods
  87. 87. hookDistraction rod in position ready for cementation
  88. 88. cementCementation completed
  89. 89. Post op x-ray cement
  90. 90. Case #110714 year female with metastatic breast to right periacetabulum
  91. 91. 3 months following local radiation therapy
  92. 92. Close up showing excellent sclerotic response to RT
  93. 93. L RBone scan
  94. 94. tumor Coronal T-1 MRI
  95. 95. Axial T-1 MRI
  96. 96. Axial PD MRI
  97. 97. Photomic
  98. 98. Case #110853 year female withmetastatic breast toacetabulum with pathologicfracture
  99. 99. Surgical exposureof bone deficientacetabulum
  100. 100. Tronzo hip arthroplasty system
  101. 101. Tronzo cup inposition priorto cementation
  102. 102. Placement ofradiolucent cement
  103. 103. Post op x-ray withradiolucent cement
  104. 104. Case #110952 year female withmetastatic breast CAand pathologic fracturedistal femur
  105. 105. TKA reconstruction
  106. 106. Case #111058 yr female with metastatic breast distal femur with prior treat- ment with prophylactic device with current failure proximal
  107. 107. Removal distal femur with failed fixation device
  108. 108. Distal femoral resection specimen
  109. 109. Reconstructed with distal femoral resection TKA
  110. 110. Case #1111 46 year female with metastatic breast to pelvis
  111. 111. 19 months post radiation therapy
  112. 112. Case #1112 45 year female with metastatic breast to pelvis
  113. 113. Case #111362 year female withblastic and lyticmetastases to L-spineand pelvis
  114. 114. Case #111454 year female withmetastatic breast to distalfemur
  115. 115. Lateral view
  116. 116. Reconstruction withcemented IM nail
  117. 117. Case #111567 year female withmetastatic breast to femur
  118. 118. Lateral view
  119. 119. Macro section ofresected specimen
  120. 120. Photomic
  121. 121. Case #111660 year female withmetastatic breastproximal tibia
  122. 122. Lateral view
  123. 123. Case #111756 year female withmetastatic breast tomid dorsal spine withvertebral body collapseand complete myelographicblock posterior
  124. 124. AP view block
  125. 125. Photomic
  126. 126. Laminectomy decompressionand Harrington rod fixationwith autogenous cancellousiliac bone graft graft dura rod
  127. 127. Post op x-ray
  128. 128. Case #111862 year female withmetastatic breast tolower cervical spine
  129. 129. Case #1119 68 year female with metastatic breast to distal humerus
  130. 130. Triceps spliting posterior approachelbow cementCompletion of internal fixation with rods and cement
  131. 131. Post op x-ray
  132. 132. Case #112040 year male with metastatic breast to clavicle & path fracture
  133. 133. Several months later
  134. 134. tumorCoronal T-1 MRI
  135. 135. Coronal PD MRI
  136. 136. Photomic
  137. 137. Case #1121 41 year male with metastatic renal cell CA to scapula
  138. 138. Similar lesion in opposite proximal humerus
  139. 139. R L Bone scan
  140. 140. CT showing renal tumor
  141. 141. Humeral head andneck resectionspecimen cut inpath lab
  142. 142. Photomic showing clear cell pathology