www.rvh.on.caDecember 2018Marcie Dunn NP

PRESENTATION AND MANAGEMENT OF METASTATIC BONE DISEASE

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• Advanced age and previous history of cancer are the most important factors

• Primary Bone cancers are uncommon• Skeleton is the most common place for metastases to occur• Most often associated with primary cancers of Breast, Prostate, Lung,

Kidney and Thyroid• Mets most often seen in vertebrae, ribs, cervical spine, proximal femur,

sternum and skull.• Rarely seen in the bone of the feet and hands but when seen is often

related to primary lung carcinomas

Development of Bone Metastases

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• Deep Pain• Poorly localized• Pain increases with activity• Describes as burning, aching, throbbing or stabbing• Pain is usually progressive and eventually becomes constant• Pain is often worse at night• Becomes more difficult to weight bear• Usual non pharmaceutical management of pain is not effective• May be some soft tissue edema

Clinical presentation of Bone Mets

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• back pain may be already existing depending on patient lifestyle i.e. history of heavy labour therefore may go undiagnosed as mets

• Pathologic fractures may be present• Hypercalcemia may be present• Unexplained changes in appetite• Unexplained changes in weight – loss of 10% within one month• Palpable lump or mass• Proximal muscle wasting• Night time pain unrelieved by position change and analgesics• No history of injury that would result in this type of pain

Clinical presentation

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Clinical Presentation continued

-new onset of anemia-new onset peripheral neuropathy or GI/GU

dysfunction related to spinal cord compression

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Metastatic Spinal Cord Compression• S&S include numbness, paresthesia and paresis in extremities (most commonly in the

legs and feet) which can lead to paralysis if left untreated• Difficulty with bladder and bowel function – incontinence or retention

• May be difficulty to distinguish if previous neuropathy from chemotherapy

• Important to assess pt’s functional status at every visit and for pt to report changes immediately

• Goals of treatment, stage of disease and prior performance status need to be considered before implementing treatment

• Goal of treatment is to prevent further deterioration or reverse neurologic dysfunction

• May include radiation oncologists, medical oncologists, physiatrists, PHCP, physiotherapy and occupational therapy

• Spinal decompression can be achieved through radiation and/or chemotherapy

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Hypercalcemia and Bone Mets• Hypercalcemia affects up to 10% to 30% of cancer patients, and

cancer-related hypercalcemia is the leading cause of hypercalcemia in hospitalized patients.

• Breast, Lung and Myeloma most often affected• cancer-related hypercalcemia has a poor prognosis, as it is most

often associated with disseminated disease• pathogenesis of hypercalcemia in malignancy is increased

osteoclastic bone resorption• Common clinical features can be general ( dehydration, polyuria,

polydipsia), gastrointestinal ( nausea, vomiting, constipation, anorexia), or neurologic ( fatigue, delirium, myopathy)

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Types of Bone Mets

Mets can be osteoblastic – the bones look too white

Mets can be osteolytic – the bones look dark and holey

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Origins of Bone Mets

OSTEOBLASTICProstateCarcinoidGastricSmall cell lung cancerHodgkin’s lymphoma

OSTEOLYTICRenal cellMelanomaMultiple MyelomaNon small cell lungThyroidNon Hodgkins Lymphoma

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Origins of Bone Mets

Mixed Osteoblastic and Osteolytic-Breast-Gastrointestinal-Squamous cell of primary tumour

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Radiographic image of Bone Mets

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