Management of Lung Cancer Presenting with Solitary Bone Metastasis

Abstract

Lung neoplasm is the main cause of cancer-related mortality, and bone metastasis is among the most common secondary tumors. The vast majority of patients also present with multiple bone metastases, which makes systemic and adjuvant pain therapy preferable to surgery. The optimal approach for a resectable non-small-cell lung tumor that also presents a unique, resectable bone metastasis is not fully established. The number of papers addressing this subject is small, and most are case reports; nevertheless, survival rates seem to increase with radical surgery. The sequencing of local versus systemic treatment should always be discussed within the multidisciplinary team that will choose the best approach for each patient. As targeted systemic therapies become more accessible, radical surgery, together with existing reconstructive methods, will lead to an increase in life expectancy and a better quality of life.

Keywords: bone metastasis resection reconstruction; lung cancer; radical therapy; solitary bone metastasis; targeted therapy.

Figure 1

A 65-year-old man with a pulmonary neoplasm of the left-upper lobe confirmed by fibrobronchoscopy with right-scapular metastasis and invasion of adjacent soft tissues. Prior to radical pulmonary surgery, the patient underwent partial resection of the scapula (internal third), acromion, coracoid process, and lateral end of the clavicle (external third), together with the invaded soft tissue (subscapularis, suprascapularis, and infraspinatus muscles; humeral and clavicular insertion of the pectoralis major muscle; and insertion of the pectoralis minor and deltoid muscle). (A) Intra-operative view of scapular tumor mass (external third) invading the soft tissues and integument. (B) Post-excision tumoral aspect with soft tissue reconstruction that did not require prosthetic materials or skin graft. (C) CT scan of a left-upper lobe lung tumor diagnosed as lung cancer by fibrobronchoscopy.

Figure 2

Pre-operative X-ray (A) of a 49-year-old male complaining of pain in the left hip that started three months earlier. An area of osteolysis at the level of the lesser trochanter was detected on the radiograph of the left hip. A computed tomographic (CT) scan of the pelvis (B) was performed, which revealed an osteolytic tumor at the level of the lesser trochanter. Following the biopsy, a diagnosis of bone metastasis secondary to a lung carcinoma was made. A chest CT scan revealed a spiculated, iodophilic nodule with retraction of the overlying pleura at the level of the apical segment of the right lower lobe (S6—Fowler) (C). The preoperative staging was a pulmonary tumor with single bone metastasis. Following multidisciplinary consensus, the patient was subjected to the radical resection of the pulmonary tumor followed by reconstruction of the left proximal femur (D).

Figure 3

Preoperative X-ray (A) of a 56-year-old male with a history of recently diagnosed non-small-cell lung cancer (NSCLC) and a pathological bone fracture. After multidisciplinary evaluation, no other secondary tumor was found. Due to the fracture, the approach chosen was metastatic resection followed by intramedullary nail and acrylic bone cement (B). The conduct in the case of this patient was to carry out periodic imaging evaluations and to replace the nail if the local and general situation allowed a push-through modular component. Imaging evaluations performed at 12 months detected multiple metastases, so replacement with a modular component was abandoned.