Download - Bone Metastasis Presentation 3
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Metastatic Bone
Disease
Aiman AwadDarlington Memorial Hospital
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Pathophysiology How tumour cells migrate to bone?
How tumour cells grow in bone?
Diagnosis. Primary or secondary.
Solitary or multiple.
If secondary, where is the primary? The local extension of the metastatic tumour.
Differential diagnosis.
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Pathophysiology
How tumour cells migrate to bone?
By 3 main mechanisms:
(1) direct extension,
(2) retrograde venous flow, and(3) seeding with tumour emboli via the blood
circulation
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Sources of Bone Metastases
Breast
Prostate
Kidny
Lung
Thyroid
Bladder
Gastrointestinal Tract.
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Bone metastasis
the most common locations include thefollowing:
Spine Pelvis Ribs Proximal limb girdles
Metastases distal to the knee and elbow are
extremely uncommon, but approximately 50% ofthese acral metastases are secondary to primarylung tumors. Carcinomas, such as those of thebreast and prostate, rarely exhibit such a distinctpattern.
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How tumour cells grow in bone?
There are two forms of bone Metastasis
Osteolytic bone disease.
Osteoblastic bone disease.
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Osteolytic bone disease
(1) Metastatic tumour cells releasehumoral factors that stimulateosteoclastic recruitment anddifferentiation.
(2)
Osteoclasts begin to break downbone.
(3) Bone resorption results in therelease of growth factors thatstimulate tumour cell growth.
(4) As the tumour proliferates, itproduces substances thatincrease osteoclast-mediatedbone resorption.
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Osteoblastic bone disease
1- Metastatic tumour cells releasegrowth factors that stimulate theactivity of osteoclasts.
2-Tumor cells also secrete growthfactors that stimulate the activity
of osteoblasts.3-Excessive new bone formation
occurs around tumour-celldeposits.
4-Osteoclastic activity releases
growth factors that stimulatetumor cell growth.
5-Osteoblastic activation releasesunidentified osteoblastic growthfactors that also stimulatetumour cell growth.
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Clinical Presentation
Pain initially related to activity thenprogressive day and night.
Pathological fracture.
Mass.
Abnormal radiographic finding detected
during the evaluation of an unrelatedproblem.
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Diagnosis of bone Metastasis
History and Physical Examination
Laboratory Investigation
X Ray Bone Scan
CT
MRI Biopsy
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METASTASES OF UNKNOWN ORIGIN
a patient over the age of 40 with a new, painfulbone lesion, multiple myeloma and metastaticcarcinoma are the most likely diagnoses
Prostate cancer and breast cancer are the twomost common primary sources for bonemetastasis.
If a patient has no known primary tumour, themost likely sources are lungcancer and renalcell carcinoma.
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Biopsy should not be done until theevaluation is complete:
1. The lesion may be a primary sarcoma of bone that mayrequire a biopsy technique that allows for future limbsalvage surgery;
2. Another more accessible lesion may be found3. If renal cell carcinoma is considered likely, the surgeon may
wish to consider preoperative embolization to avoidexcessive bleeding;
4. If the diagnosis of multiple myeloma is made by laboratorystudies, an unnecessary biopsy will be avoided;
5. The pathological diagnosis will be more accurate if aided byappropriate imaging studies; and
6. the pathologist and surgeon may be more assured of adiagnosis of metastasis made on frozen section analysis ifsupported by the preoperative evaluation. This is importantif stabilization of an impending fracture is planned for thesame procedure.
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physical examination
The evaluation begins with a historyfocusing on any previous malignancies.
Examination includes not only the involvedextremity, but also the thyroid, lungs,abdomen, prostate in men, and a breastexamination in women
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Laboratory analysis
should include a FBC, ESR , electrolytes, liverenzymes, alkaline phosphatase, a serum proteinelectrophoresis, and possibly prostate-specificantigen.
A FBC may be helpful to rule out infection andleukemia.
The ESR usually is elevated in infection,metastatic carcinoma, and small "blue cell"
tumors such as Ewing sarcoma, lymphoma,leukemia, and histiocytosis.
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A serum protein electrophoresis should be orderedif multiple myeloma is part of the differentialdiagnosis.
Hypercalcemia may be present with metastaticdisease, multiple myeloma, andhyperparathyroidism.
Alkaline phosphatase may be elevated inmetabolic bone disease, metastatic disease,osteosarcoma, Ewing sarcoma, or lymphoma.
Blood urea nitrogen and creatinine may beelevated with renal tumors, and a urinalysis mayreveal hematuria in this setting.
A basic metabolic panel may be indicated to
evaluate the overall health of a patient.
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plain roentgenograms
provides useful diagnosticinformation for evaluation ofbone lesions.
Most vertebral lesions in
adult patients aremetastases, myelomas, orhemangiomas.
The aggressiveness of thelesion, and whether it is likely
to be benign or malignant,usually can be determined bycareful evaluation of the plainfilms.
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Technetium bone scans
With the exception ofmyeloma, all malignantneoplasms of bonedemonstrate increased
uptake on technetium bonescans
A normal bone scan istherefore very reassuring;however, the converse
statement is not true becausemost benign lesions of bonealso demonstrate increaseduptake.
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Computed tomography (CT)
Helpful in assessingossification andcalcification and in
evaluating the integrityof the cortex
CT of the chest,abdomen, and pelvis
should be obtained forUnknown Metastasis.
Axial CT scan shows 2 rounded, mixedosteolytic-sclerotic lesions in thethoracic vertebral body of a 44-year-old woman with lung carcinoma.
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Magnetic resonance imaging (MRI)
the most accurate technique fordetermining the limits of diseaseboth within and outside bone.
not very useful in differentiatingbenign from malignant lesions.
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Biopsy
patient with a suspected primarymusculoskeletal malignancy should be referredbefore biopsy to the institution where definitivetreatment will take place
A biopsy should be planned as carefully as thedefinitive procedure.
Regardless of whether a needle biopsy or anopen biopsy is done, the biopsy track should be
considered contaminated with tumor cells The surgeon performing the biopsy should be
familiar with incisions for limb salvage surgery
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