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Approach to metastatic bone disease.....
- 1. Case 1 57yr oldlady left thigh pain Dx with breast Ca 2yrs ago Mastectomy + chemo done How to proceed?
- 2. Case 2 75yr oldgentleman DM/Hpt Slipped and fell How to proceed?
- 3. Approach to metastaticbone disease
- 4. Outline • Defination • Epidemiology •Common sites • Pathophysiology • Types of lesion • Aims of Rx • Presentation • Investigation • Managements
- 5. Definition • Secondary malignantneoplastic disease of the skeletal system as a result of metastasis from a primary tumour
- 6. Epidemiology • Aging population= increased incidence of Metastatic bone disease • Site for mets • Lung -> Liver -> Bone • Lytic lesions in patients >40 yrs - MBD should be considered
- 7. Common sites • Breast •Lung • Thyroid • Kidney • Prostate • Hematological • commonest site = spine > proximal femur > humerus
- 8. Pathophysiology • Paget's Seed& Soil theory • The 'seeds' (tumor cells) require appropriate 'soil' (the bone micro- environment) to establish skeletal metastasis
- 10. Types of lesions •Osteolytic bone lesions • Tumor cells secrete PTHrP (PTH related peptide) • Bone resorption result in release of • Transforming growth factor-β (TGF- β) • Insulin-like growth factor-1 (ILGF-1) • Stimulate tumor cells to multiply and release more PTHrP • “Vicious cycle”
- 11. Types of lesions •Osteoblastic lesion • Due to tumor-secreted endothelin 1
- 12. Aim • Diagnose primary •Decide on skeletal stabalization
- 13. Presentation • Pain • HyperCa •Stones, bones, abdominal groans & pshycic moans • Pathological #
- 15. Management • Multidisciplinary approach •Treat life threatening conditions first! • GOALS: • pain relief • preserve/restore function • maximising quality of life
- 16. Non - operativeMx • Non-operative • Radiotherapy • Chemotherapy • Bisphosphonates - Denosumab • Hormonal therapy
- 17. Operative • Solitary lesion- CURATIVE - Rx as primary sarcoma • Multiple lesion - PALLIATIVE
- 18. Indications for surgery •pathological fracture • prophylaxis to lesions that are high risk of fracture • survival > 6 weeks
- 19. Risk assessment VsPrognosis • Risk assessment • Harrington’s criteria • Mirel’s score • Prognosis • WITHOUT spine mets : Katagiri score • WITH spine mets : Tomita score OR Tokuhashi score
- 20. Harringtons • Harrington’s criteria- fix if any of these occur • cortical bone destruction > 50% • lesion > 2.5cm dimension in proximal femur • pathological avulsion fracture of lesser trochanter • persisting stress pain despite irradiation
- 21. Mirels Score Risk offracture Treatment 9 and above 33% Fixation 8 15% ? Dilemma 7 and below 5% Irradiation and observation Mirels criteria Score 1 2 3 Site upper limb lower limb peritrochanteric Pain mild moderate functional Lesion blastic mixed lytic Size < 1/3 1/3 to 2/3 > 2/3
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- 27. Take home message •Consider MSD in patients with lytic bonlesions >40yrs 1. Lytic lesion OR fracture 2. Established primary or unknown primary 3. Solitary or Multiple 4. Risk assessment 5. Prognostic scoring
- 28. Case 1 57yr oldlady left thigh pain Dx with breast Ca 2yrs ago Mastectomy + chemo done How to proceed?
- 29. Case 2 75yr oldgentleman DM/Hpt Slipped and fell How to proceed?
Editor's Notes
- #10 Detachment of tumor cells Invasion of tumour cells into surrounding tissue to reach vessels Intravasation into vessels lumen Evasion ( Avoidance) of host defense mechanism Adherence to endothelium at remote location Extravasation from vessels into surrounding tissue Survival and growth within the tissue Establish own blood supply