management of metastasis bone disease

Dr. Achmad Basuki, Sp. OT

SMF Orthopaedi, Dharmais cancer center Hospital, Jakarta

The most common cause of a destructive lesion of skeletal in adult

More than Primary sarcoma of the boneThe skeleton is the third most common

target of metastatic cancer can be one of the earliest sites affectedWhich produces the greatest morbidity

- loss of functionality- loss of quality of life- decreased survival

The role of the orthopedist are

- to establish or confirm diagnosis

- to evaluate for risk of fracture or

impending fracture

- to stabilize or other wish surgical

treatment pathological fracture

Batson’s vertebra vein

plexus

The most common

site of bone

metastasis

Osteolytic

• Bone destruction is

mediated by osteoclasts

in patients with either

breast cancer or

multiple myeloma

Osteoblastic

• Excess bone formation is

mediated by osteoblasts

in patients with either

prostate or breast cancer

Mundy GR. Nat Rev Cancer.

2002;8:584-593.

STROMAL CELL/

OSTEOBLAST

PRECURSOR

OSTEOCLAST

PTHr PCa ++

PO 4

Mature

Osteoclast

Bone Re-absorption

Differentiation

RANK L

RANK r

Pathologic Fractures

8-30%

Bone pain

50%

Spinal cord

compression

5%

Hypercalcemia 10%

Decrease Quality

of life and

Negative impact

on survival

Diagnosis

treatment

Bone scan

NormalLESION

X-Ray abnormal area

CT or MRI

MetastasisNormal

Biopsi ?

MetastasisBenign

Normal

Malignancy

Biopsi

BONE PAIN

Pain control

Inhibition of osteolysis

Handling complication

Non surgery

surgery

1. Pain Control

- Analgesics

- Radiation

- Chemotherapy

2. Inhibition of Osteolysis

- Bisphosphonates

• Bind to resorption sites

Bisphosphonateshave a strong

affinity for calcium phosphate

• Direct effects on osteoclasts

• Indirect effects via other cells

Bisphosphonatesinhibit bone resorption

• Recruitment of cells

• Adhesion to bone

• Lifespan of cells (increasing rates of apoptosis)

• Cellular activity

Bisphosphonatesdecrease 4

parameters of osteoclast function

3. Handling complication

Surgical management it has to

benefit improving life

quality

goal :

1. to provide local tumor control

2. immediate weight bearing & function

indications :

- for diagnosis

-prophylactic fixation of impending fractures

- stabilization of pathologic fracture

General consideration

• Life expectancy at least 6 to 12 week consider for surgical candidate

• Patient recovery time from surgery should not outlast estimated time survival

• Provide immediately stable reconstruction

• Scoring assessment to predict the surgical candidate

Tomita K,

Kawahara N, Kobayashi T, Yoshida A, Murakami H,

Akamaru T. Surgical strategy for spinal

metastases. Spine. 2001;26:298-306.)

Walker MP, Yaszemski MJ, Kim CW, Talac R, Currier BL.

Metastatic

disease of the spine: evaluation and treatment. Clin Orthop

Relat Res. 2003;415 Suppl:S165-75.