Multimodal Treatment of Bone Metastasis-A Surgical Perspective

Abstract

Over the past decades there has been an increase in the incidence of cancer worldwide. With the advancement in treatment, patient survival has improved in tandem with the increasing incidence. This, together with the availability of advanced modern diagnostic modalities, has resulted in more cases of metastatic bone disease being identified. Bone metastasis is an ongoing problem and has significant morbidity implications for patients affected. Multimodal treatment strategies are required in dealing with metastatic bone disease, which include both surgical and non-surgical treatment options. In the multidisciplinary team, orthopedic surgeons play an important role in improving the quality of life of cancer patients. Surgical intervention in this setting is aimed at pain relief, restoration of function and improvement in functional independence. In selected cases with resectable solitary metastasis, surgical treatment may be curative. With the advancement of surgical technique and improvement in implant design and manufacture, a vast array of surgical options are available in the modern orthopedic arena. In the majority of cases, limb salvage procedures have become the standard of care in the treatment of metastatic bone disease. Non-surgical adjuvant treatment also contributes significantly to the improvement of cancer patient care. A multidisciplinary approach in this setting is of paramount importance.

Keywords: bone metastasis; metastases; metastatic; metastatic bone disease; multimodal; prophylactic surgery.

Figure 1

AP radiograph of a left humerus demonstrating a lytic metastatic lesion (arrow) in the proximal diaphysis. Note the extensive cortical involvement, predisposing it to a pathological fracture.

Figure 2

Pelvic CT Scan showing a left sided periacetabular renal cell carcinoma metastasis. (A) Involvement of the left supraacetabular region by a large lytic metastatic lesion (arrow). (B) Note the extensive extraosseous involvement (arrow).

Figure 3

MRI scan demonstrating a right proximal humerus metastatic lesion. (A) T2 weighted MRI sequence showing the extent of intramedullary involvement (arrow). (B) T1 weighted MRI sequence showing complete involvement of the proximal humerus with cortical breach at the medial calcar region (arrow).

Figure 4

Bone scan demonstrating increase uptake at the right humerus diaphysis and right femoral head (arrows), highlighting the sites of bone metastasis.

Figure 5

PET-CT scan demonstrating a left proximal femur metastatic lesion. (A) Coronal and (B) axial cuts of the PET-CT images demonstrating intense FDG uptake at the left femoral head, neck and intertrochanteric region.

Figure 6

A 54-year-old patient with a left proximal humeral diaphyseal renal cell solitary metastasis treated with wide resection and reconstruction using a fibular allograft and locking plate internal fixation. (A) MRI of left humerus showing a metastatic lesion (arrow). (B,C) Intraoperative fluoroscopic images after intercalary resection of the proximal humerus diaphysis and reconstruction using a fibular strut graft (arrows). (D) Note the preservation of the native humeral head and the locking plate fixation.

Figure 7

Left femoral diaphyseal metastatic lesion from breast carcinoma treated with curettage followed by cement-plate surgical fixation. (A) MRI showing a left femur diaphyseal intramedullary metastatic lesion. (B) The same lesion seen on plain X-ray. Note the mixed lytic sclerotic appearance of the lesion. (C,D) AP and lateral post-operative X-rays after curettage and cement-plate surgical fixation.

Figure 8

Right proximal femur metastatic melanoma treated with a calcar replacing hemiarthroplasty. (A) Large destructive lytic metastatic lesion involving the head and neck of the right femur. (B) X-ray post reconstruction with a calcar replacing hemiarthroplasty implant.

Figure 9

Reconstruction using a left proximal femur replacement endoprosthesis following resection. The modularity of these implants allow for accurate restoration of limb length.

Figure 10

Right proximal femur bone metastasis treated with a locked intramedullary nail. (A). Destructive lytic lesion involving the proximal femur greater trochanter area (arrow). (B) Postoperative X-ray after fixation with a cephalomedullary nail. Note the proximal fixation spanning the femoral head and neck. (C) Distal locking bolt fixation to ensure axial and rotational stability.

Figure 11

(A) AP and (B) lateral radiographs of a right distal femur modular endoprosthesis. The modularity of these implants allow for reconstruction of long segments of bone defects.

Figure 12

Modular total elbow endoprosthesis implant. These implants allow for reconstruction of a large segment of bone defect while preserving some elbow function.

Figure 13

Enneking classification system of the pelvis (Zone 1–4).

Figure 14

(A) Pre-embolization angiography demonstrating the rich blood supply to the left pelvic metastatic lesion. (B) Post-embolization fluoroscopic image showing complete devascularization of the metastatic lesion.