Role of Curative & Palliative Surgeries in Bone Metastases

  • Bone metastases comprise majority of bone cancer burden. An individual with bone metastases secondary to known cancer or sometimes, an unknown primary cancer can present with skeletal related events such as pain, pathological fractures (trivial trauma) or compression of spinal cord leading to weakness leading to disability and loss of function. A detailed personal and treatment history is elicited to identify the primary cancer followed by targeted investigations.
  • In an event of identification of primary cancer, the individual undergoes blood tests followed by imaging. In imaging, plain x-ray of involved bone is performed followed by either CT or MRI scan depending on the nature of presentation. A Trucut image guided biopsy is performed by either by the treating surgeon or by the interventional radiologist. An FDG PET CT scan is performed to identify any additional metastases in the body. When the primary cancer is unknown, all the above tests are completed in addition to certain targeted investigations. Identification of metastases and staging of the primary cancer provides an expected survival in addition to functional disability based on bone/bones involved. Breast, prostate cancer metastases have relatively longer survival rate to lungs, thyroid, kidney, intestines due to the tendency to spread slowly.
  • Bone metastases require a multi-disciplinary approach. Surgical Intervention for bone metastases have gradually gained acceptance and popularity due to increased awareness, functional demand of the individual, improving surgical expertise, improvements in implants and prosthesis to treat such bone metastases.
  • Palliative surgeries are performed for various indications such as single or dual bone metastases, compromised or weakened structure of a weight bearing bone, disabling pain secondary to metastases, extensive involvement of surrounding soft tissues, pathological fractures and impending pathological fractures.
  • Single or dual bone metastasis requires a different approach in either a curative or palliative setting due to perceived prolonged survival. The options include Tumour Endoprosthetic reconstruction, Intercalary Endoprosthetic reconstruction, interlocking nailing of long bones and plate-cement reconstruction. Tumour endoprosthetic reconstruction has the advantage of allowing immediate post-operative weight bearing ambulation or mobilisation. The ability to ambulate and perform daily activities improves self-confidence thereby attending to the psychological and social issues post metastases. It also reduces the risk of deep vein thrombosis, pressure sores, depression, pneumonia, constipation etc. which can happen when one is bed ridden.
  • Interlocking intramedullary nailing of long bones after curettage followed by cementation is performed for metastases in long bone of upper limb, impending pathological fracture in upper and lower limb bones and chronic pain with extensive bone metastases. This procedure is relatively inexpensive when compared to tumour endoprosthetic reconstruction and is viable option in multiple bone metastases setting. Often, situations needing interlocking nailing or plating requires addition of radiotherapy to affected area to provide pain palliation and also help strengthen the affected bone.
  • To summarize, primary cancer, treatment status of primary cancer, identification of bone metastases, number of bone metastases, bone involved, and functional status guide the type of surgical intervention.

 

Dr Srimanth B S

M.S, D.N.B Orthopaedics

Fellowship in Musculoskeletal Oncology (SNUH-Korea, Rizzoli-Italy, TMH-Mumbai)

Consultant Orthopaedic Oncologist

Department Of Surgical Oncology

Manipal Comprehensive Cancer Centre

Manipal Hospitals

 

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