Table Of ContentBone Metastases
Springer-Verlag Berlin Heidelberg GmbH
Dominique G. Poitout (Ed.)
Bone Metastases
Medical, Surgical and Radiological Treatment
With 36 Figures
i
Springer
Dominique G. Poitout, MD, Prof. Chief of Dept.
Service de Chirurgie Orthopedique et de Traumatologie,
Centre Hospitalier Nord, Chemin des Bourrely, 13915 Marseille Cedex 20,
France
British Library Cataloguing in Publication Data
Bone metastases: medical, surgical and radiological treatment
1. Bone metastasis - Treatment 2. Bone metastasis - Surgery
I. Poitout, Dominique G.
616.9'9471'06
ISBN 978-1-4471-3253-0 ISBN 978-1-4471-3251-6 (eBook)
DOI 10.1007/978-1-4471-3251-6
Library of Congress Cataloging-in-Publication Data
Bone metastases: medical, surgical and radiological treatment / Dominique Poitout (ed.).
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4471-3253-0
1. Bones-Cancer-Surgery. 2. Bones-Cancer-Treatment. 3. Metastasis-Treatment.
I. Poitout, Dominique G.
[DNLM: 1. Bone Neoplasms-secondary. 2. Bone Neoplasms-drug therapy. 3. Bone
Neoplasms-radiotherapy. 4. Orthopedic Procedures. WE 258 B7108 2002]
RD675.B657 2002
616.99' 47106-dc21 2001040002
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ISBN 978-1-4471-3253-0
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Foreword
by Professor Antonie H.M. Taminiau
As the population becomes older, it might be expected that the incidence of
cancer will increase and that cancer will be the main cause of death in the near
future. Based on the incidence patterns, the risk (life table method) of developing
cancer before the age of 75 years is about 25% for males and females. If the
incidence pattern is maintained, nearly four out of ten men and 3.5 out of ten
women will get cancer during their lives. The majority of these patients will be
over 45 years of age. Less than 10% of all new cancer patients are younger than
45 years and children seldom develop cancer. Treatment of primary cancer,
depending on the type and stage of the disease, may eure the patient. When
the cancer has metastasised, however, the possibility of eure is generally limited
and therefore attention should be focussed more on quality of life than on
survival. Bone metastases may seriously affect this quality of life.
The incidence of bone metastases in cancer patients is reported to be as high as
30-70%. More than 80% of these are due to carcinoma of the breast, prostate,
lung or kidney. The majority of these metastases are predominantly found in
the axial skeleton. Bone metastases are often asymptomatic unless soft tissues
are involved or fracture occurs. Stabilisation of impending and pathological
fractures is the treatment of choice and effects pain relief, restoration of
limb function and early mobilisation, and therefore improves the quality of
life.
In skeletal metastases the risk of a pathological fracture is related primarily to
the degree of tumour extension and of bone destruction. The overall incidence of
fractures due to bone metastases is 5-10%.
The development of an impending fracture, pathological fracture or spinal
metastases is not necessarily a terminal event. Since the life span of these patients
has been extended, proper treatment of the lesions significantly adds to the
life quality of the individual patient. Postoperative radiotherapy is an essential
part of treatment, as are chemotherapy and hormonal therapy in sensitive
car-cinomas.
In this book the multidisciplinary approach for treatment of bone metastases
is discussed extensively by all disciplines. The new strategies in medical treat
ment (chemotherapy, immunotherapy, biphosphonates, hormonal and cement
containing drugs) are illuminated. The role and interaction of radiotherapy and
surgery of long bones and spine are discussed. Spinal decompression and stabil
isation are increasingly important in metastatic disease. This book is an excellent
state-of-the-art summary of all the aspects concerning bone metastases and will
y
vi Foreword
serve as a guideline for any doctor confronted with the problems of these
patients.
Antonie H.M. Taminiau,
Orthopaedic Oncology,
Leiden University Medical Centre,
The Netherlands
Foreword
by Professor Michel Forest
A metastasis of cancer to bone is a frequent clinical problem, and is often associ
ated with significant morbidity due to osteolysis.
Metastatic bone lesions are much more common than are primary malignant
bone tumors, and compromise the patient's health by causing intense pain,
osteolysis, pathological fractures, hypercalcemia, and bone marrow replacement,
Much progress has been made recently on the biology of boneresorbing cells
and on the understanding of the multistep process of bone metastases that
involves interactions between tumor ceHs and the unique microenvironment of
bone.
The management chaHenge for patients with metastatic bone disease needs, in
most cases, a multimodality approach to optimize care and quality of life. This
books is the reflect of various treatment modalities, the weH established ones as
weH as new approaches in the fields of orthopedic surgery, radiation therapy,
chemotherapy, systemic therapy ( endocrine treatment changes and assessment of
the use ofbiphosphonates).
This work includes also important contributions on diagnosis ( imaging and
pathology ), and on the management of palliative care.
This integrated approach is written by authoritative experts in the various
fields of diagnosis and treatment, and without any doubt, this relevant and organ
ized text reflecting a great experience on the new improvements and develop
ments of the therapeutic approaches, should be of utmost value for the quality of
life of patients requiring often palliative and supporting treatments for many
months or sometimes years
Michel Forest, M.D., Professor of Pathology
Höpital Cochin,
Paris,
France
vii
Preface
This book will discuss the actual approach of Bone Metastases in the fields of
diagnosis, medical and surgical treatment.
Bone metastases are frequently one of the first signs of disseminated disease in
cancer patients and a major source of morbidity. Skeletal metastases may appear
radiographicallyas osteolytic, osteoblastie or mixed lesions. As a general rule, the
radiographie appearance of a skeletal metastasis does not necessarily indieate the
primary lesion. However, in some clinieal instances, the radiographic findings
may be very evocative.
Bone metastases are very frequent but probably underestimated, as shown by
studies on iliac crest biopsies. They may be indieative of a clinically silent tumour.
The diagnosis is based on biopsies of bone marrow, needle puncture of suspicious
zones or surgieal biopsies. The spine, skull and pelvis are the most common sites,
but the ribs and the epiphysis and metaphysis of long bones mayaiso be affected.
Metastases in the distal bones are rare, but are more likely to affect the metatarsal
and metacarpal bones than the phalanges. Some tumours (breast, prostate,
thyroid, kidney and lung) have specific affinities for the bone tissue. Bone lesions
mayaiso occasionally result from endometrial carcinoma. These tumour types
arise in endocrine-dependent organs. Tumour development and progression can
also be influenced by the hormonal environment.
Bone metastases may occur only in the marrow, they may lead to an osteo
blastic appearance. Histologically, the diagnosis is easy if the primary tumour is
known, but difficult when the original cancer is silent. In some cases, the patho
logist will be able to specify the starting point with certainty. More often, it will
only be possible to suggest a diagnosis without confirrnation of the origin, unless
the metastasis is very differentiated and re pro duces the primary tumour (hyper
nephroma, oat-cell carcinoma of lung, adenocarcinoma of thyroid). In these
circumstances, immuno-histochemistry helps to specify the diagnosis. The mech
anisms of metastatie growth involve cellular chemotactic factors and connections
with the caval venous system at the vertebral level, in the vascular bone network.
It is what the optimum systemie treatment for bone metastases depends on the
tumour type. Chemotherapy is demonstrably effective in the treatment of bone
metastases.
The role of immunotherapy in the treatment of cancer is very limited and
restrieted to the use of interferon and IL-2. Objective responses in bone metas
tases have been observed in renal cell cancer and metastatie melanoma.
Biphosphonates represent a major therapeutie advance in the management of
tumour-induced osteolysis and skeletal morbidity, successfully treat hyper
calcaemic episodes, relieve bone pain and may lead to recalcification of lytic
ix
x Preface
metastases. Prolonged use of clodronate or pamidronate decreases the frequency
of skeletal-related events in patients with metastatic bone disease. Another puta
tive role for biphosphonate treatment is the prevention or delaying of the devel
opment of bone metastases in breast cancer patients.
Hormonal therapy is aimed at depriving tumours of hormonal stimuli by low
ering either oestrogen or androgen levels or by competitively blocking their
receptors. Newagents that are currently available (anti-oestrogens, anti
aromatases, lutinising hormone-releasing hormone (LH-RH) agonists) have an
enlarged spectrum of activity, but also less toxicity. Reduction in tumour volume
or inhibition of tumour growth can be consistently obtained and disease-related
symptoms relieved in a significant number of treated patients.
External local radiotherapy remains the major treatment of bone metastasis.
Radiation therapy is usually performed to relieve local bone pain, to prevent
pathological fracture, vertebral collapse, and to promote healing in pathological
fracture and relief of spinal cord compression.
External radiotherapy with high-energy photons can be delivered for all bone
metastases, as there is no difference of response according to histological type.
Results seem to depend on the location of the bone metastases.
Systemic radiation therapy using beta-emitting radionucleotides is used in
patients with generalised pain, and give less bone marrow toxicity than hemibody
external irradiation. Radiosurgical treatment reduces pain and maintains mobility
in patients with an average life expectancy of 10 months. As well as increasing the
patient's comfort, radiosurgical treatment allows basic treatment of the illness to
be continued.
Surgery for bone metastasis is palliative, with the following aims :
• Suppression of the pain associated with the metastasis
• Prevention of pathological fractures
• Stabilisation of the bone using osteosynthesis or a prosthesis
• Conservation of function, allowing rapid rehabilitation
• Continuation of medical treatment and an early return horne.
Vertebral stabilisation and adjuvant treatment have allowed considerable thera
peutic progress over recent decades. The best results are obtained when operations
are performed before the patient becomes malnourished and before multiple
metastatic sites develop. From the surgical point of view, extended excision as total
vertebrectomy gives better results than limited surgery.
For long-term survival, control of the tumour is essential. Advances in implant
design and surgical techniques have allowed a more aggressive approach to these
tumours, with rewarding results.
We have only recently become aware that the sick can think, have emotions and
feelings, and that we should accompany them on the psycho-effective path.
All these subjects are developed in the next chapters by specialists of these dif
ferent topics.
D.G. Poitout
