Metastatic Bone Cancer

Many types of cancer can unfortunately metastasise, or spread to the skeleton. Whilst all cancers can theoretically evolve this ability, the most common in our community are primary cancers of Breast, Prostate, Kidney, Lung and Gastro-Intestinal Tract origin. Metastatic bone cancer can cause catastrophic structural problems in the skeleton and subsequent pathological fracture. This can have tremendous impact on patients and can result in high morbidity and can shorten survivorship. The tissue type of the parent tumour will have a large impact on the manner in which the bone lesion is managed. As medical and radiation management of cancer is improving, so is the survivorship of people with these diseases & as such, management of Metastatic Bone Disease is best performed by a specialist team.

Care System & Principles

It is best practice for people with cancer to be overseen by a specialist who is a member of a multidisciplinary cancer care team. A multidisciplinary cancer care team is a group of health professionals that meet regularly to oversee the diagnosis and staging of cancer, as well as the development of individualised treatment plans for people with cancer.

The patient pathway is as follows:

1 – Referral→2 – Diagnosis→3 – Pathology→4 – Determination of Treatment

Patients with metastatic bone cancer may present to their general practitioners or commonly their oncologist (if already aware of a primary cancer problem) either with unremitting bone pain, functional pain in a joint, or may present with a pathological fracture. A pathological fracture is a situation that occurs when the bone has been weakened by the cancer and fails, in a situation that would not normally cause injury. This is often an emergency and will require acute care and specific planning for patients.

 

1 – Referral

When a patients’ primary care doctor or care provider first becomes aware of a possible metastatic cancer deposit in the bone, this will prompt initial simple investigations to be performed, such as an x-ray. After preliminary investigations confirm a bone abnormality, general practitioners and oncologists often refer patients to an orthopaedic surgeon, or preferably to a specialist bone tumour surgeon (orthopaedic oncology surgeon). Further imaging will often be required to enable adequate planning for surgical treatment.

2 – Diagnosis

Diagnosis is made after obtaining a history, performing a physical examination and completing investigations, occasionally including a biopsy of the tumour deposit. Further advanced imaging would often include CT imaging of the entire bone segment, as well as an MRI of the region and a whole-body bone scan to assess for any further metastatic deposits. Occasionally, a biopsy of the tumour deposit may be required to confirm the diagnosis and facilitate accurate planning. Imaging investigations are best performed prior to biopsy to avoid biopsy artefact from confounding the results of anatomic imaging. From these results a rational and tailored treatment plan will be formulated.

3 – Pathology

A biopsy is a procedure where a small sample of cells from the tumour is taken and studied to determine exactly what cell type the cancer is from. Biopsy for histologic examination is best performed after anatomic imaging of the tumour. The safest form of biopsy is an image-guided biopsy to target the most metabolically active area of the tumour and to avoid areas of necrosis. In some circumstances an open biopsy is necessitated and this will be performed by the Specialist Bone Tumour Surgeon. All approaches for biopsy are discussed in the multidisciplinary setting and under the guidance of the Specialist Bone & Soft Tissue Sarcoma Surgeon, as this will avoid poor biopsy placement and its catastrophic complications. Pre-biopsy MRI or CT scan is very useful to plan biopsy. Biopsy will be performed in line with the ultimate operative incision to allow excision of the biopsy track and clearance of the tumour. This is best undertaken under the supervision of or after consultation with a bone and soft tissue tumour surgeon.

4 – Determination of Treatment (Achieving Multidisciplinary Care)

The results of the imaging and any histological (pathology) results are discussed in a multidisciplinary setting where expert opinions related to the diagnosis and subsequent treatment can be offered. Consultation with patients and their families and support networks are integral to satisfactory outcomes & time is taken to achieve this.