J KMA Special Issue Chung Soo Han, MD Department of Orthopaedic Surgery, Kyung Hee University College of Medicine E mail : cshan1129@yahoo.co.kr J Korean Med Assoc 2006; 49(12): 1097-1109J Korean Med Assoc 2006; 49(10): 773-80 Abstract M etastatic bone tumor is a clinical challenge to most orthopaedic surgeons, and physicians. The bone lesions present pain, can progress to pathologic fractures, and cause neurologic deficits. The adequate treatment for the lesions can mean the difference between good and poor quality of life during their remaining time. The goals of the treatment are relief of pain, preservation of function, and maintenance of independence. In orthopaedic field, the goals include prophylactic fixation of metastatic deposits when there is a risk of fracture, stabilization or reconstruction after pathological fracture, and decompression the spinal cord and nerve roots and/or stabilization the spine. To achieve the goals, we should understand the evaluation methods, a pathogenesis of metastasis and the characters of the specific metastatic site. Finally we should have a knowledge about the treatment strategy and understand what the indications of operative treatment are and which conservative managements is correct for the metastatic bone lesions. It is important to consider the type of primary cancer, location of metastasis, extent of disease, expected patient life span, comorbidities, and level of pain when making treatment recommendations. New discoveries and modifications of existing treatments such as percutaneous stabilization of spinal compression fractures and the use of bisphosphonates may decrease the need for invasive surgical management of metastatic bone lesions in the future. Metastatic bone disease should be approached systematically by multidisciplinary team that has various treatment options, and then quality of life of the patients can be improved during their remaining life span. All the doctors participating in the treatment should try to do their best to get an optimal goal, even though the patients should be informed clearly that the treatments may not be curative. Keywords : Metastatic bone tumor; Treatment options 1097
Han CS Location of primary neoplasm producing metastatic bone lesions Primary site No. of lesions(%) Breast 2,020 (40) Lung 2,646 (13) Prostate 2,296 (6) Kidney 2,284 (6) Gastrointestinal tract 2,255 (5) Bladder 2,160 (3) Thyroid 2,110 (2) Total 5,006 Rothman Simone The Spine, 5th ed. Elsevier, 2006: 1248 1098
Radiologic features of metastatic bone lesion Feature Primary lesion Osteolytic Lung, Thyroid, Kidney, Colon Osteoblastic Prostate, Bladder, Stomach Mixed Breast 1099
Han CS Predicting the risk of pathologic fracture Points 1 2 3 Image Blastic Mixed Lytic Size <1 / 3 1 / 3 to 2 / 3 >2 / 3 Site Upper extremity Lower extremity Peritrochanteric Pain Mild Moderate Mechanical Clin Orthop 1989; 249: 256-64 1100
A (A) Osteolytic lesion associated with pathologic fracture was found in femoral neck of 48 year old female patient who had chemotherapy for breast cancer. It was proved as being a bone metastasis from breast cancer. (B) Acetabulum was intact and hemiarthroplasty was performed. B 1101
Han CS A B C (A) A 50 year old female patient who had hepatoma showed osteolytic lesion associated with pathologic fracture in left subtrochanteric area. Then reconstruction intramedullary device was applied. (B) Refracture occurred associated with metal failure of reconstruction intramedullary device at postoperative 23 months. (C) Proximal femoral replacement was performed via tumor prosthesis. 1102
A (A) A pathologic fracture occurred in osteolytic lesion of left femoral shaft of 53 year old male patient who had renal cell cancer (B) An intramedullary device was inserted in the femur B 1103
Han CS A B C (A) 76 year old female patient complaint severe back pain and progressive dysuria and weakness of lower extremities. Her third thoracic vertebra showed compression fracture in X ray(black arrow) (B) In MRI, the third thoracic vertebral lesion that had homogenous low signal intensity and disrupted end plates compressed spinal cord and it was found through various work-up that she had lung cancer (C) Her spinal cord was decompressed via en bloc spondylectomy of third thoracic vertebra and her vertebra was stabilized via posterior instrumentation and mesh cage 1104
Tokuhashi's scoring system for spinal metastasis Characteristic Score General condition (performance status) Poor (PS 10 40%) 0 Moderate (PS 50 70%) 1 Good (PS 80 100%) 2 No. of extraspinal bone metastases foci 3 0 1 2 1 0 2 No. of metastases in the vertebral body 3 0 2 1 1 2 Metastases to the major internal organs Unremovable 0 Removable 1 No metastases 2 Primary site of the cancer Lung, osteosarcoma, stomach, bladder, esophagus, pancreas 0 Liver, gallbladder, unidentified 1 Others 2 Kidney, uterus 3 Rectum 4 Thyroid, breast, prostate, carcinoid tumor 5 Palsy Complete (Frankel A, B) 0 Incomplete (Frankel C, D) 1 None (Frankel E) 2 Criteria of predicted prognosis: Total Score (TS)0 8=>6 mo; TS 9 11= 6 mo; TS 12 15= 1yr Spine 2005; 30(19): 2186-91 1105
Han CS Eur Rev Med Pharmacol Sci 2004; 8(6): 265-74 1106
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