bone metastases
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Etiology
Physical examination
Clinical manifestations
- most commonly spine, pelvis, ribs, skull, upper arm & long bones of the leg involved[4]
- bone pain is often the first symptom[3]
- the pain often comes and goes at first
- it tends to be worse at night & may be relieved by movement
- later on, it can become constant & may be worse during activity
- pathologic bone fracture may occur
- spinal cord compression may occur
Laboratory
- serum chemistries
- serum calcium may be high
- serum alkaline phosphatase may be high
- serum protein electrophoresis
- urinalysis
- complete blood count
- serum prostate-specific antigen (men)
Radiology
- radiography
- computed tomography
- most sensitive study to detect bone destruction[5]
- magnetic resonance imaging
- most sensitive study for assessment intramedullary & extraosseous involvement[5]
- bone scan
- very sensitive study for detection of occult lesions & assessment of lesion activity
Management
- symptomatic relief of pain from uncomplicated bone metastases
- radiotherapy: 8 Gy treatment to the appropriate target once
- effective benefit covered by hospice
- investigational FLASH proton radiotherapy can be delivered at 1000 times the dose rate of conventional-dose-rate photon radiotherapy for its potential normal tissue-sparing effects[9][10]
- radiotherapy: 8 Gy treatment to the appropriate target once
- see spinal cord compression for vertebral metastases
- intravenous radiopharmaceutical
- indication: targeted radiotherapy not feasible or practical
- strontium-89 is 148 mBq (4mCi) IV over 1-2 minutes with hydration (> 500 mL)
- samarium-153 is 37 mBq/kg (1 mCi/kg) IV over 1-2 minutes with hydration (> 500 mL)
- intravenous radium-223 (50 kBq/kg) improves symptoms & overall survival in patients with bone-limited or bone-predominant metastatic prostate cancer[6][7]
- dexamethasone 4 mg PO/IV every 6-12 hours in conjunction with radiotherapy, duration ?[1]
- decreases neuropathic pain & bone pain
- reduces vasogenic edema
- prophylactic radiation to asymptomatic, high-risk bone metastases reduces pathologic fractures, spinal cord compression, orthopedic surgery, or palliative radiation therapy & hospitalizations in patients with lung cancer, breast cancer, prostate cancer & other cancers[13]
- not useful
- epidural glucocorticoids: lack of evidence supporting use in patients with pain from bone metastases
- calcitonin: evidence does not support use to control pain from bone metastases[12]
- bisphosphonate to prevent bone fractures
- denosumab may be alternative to bisphosphonate (NGC)
More general terms
Additional terms
References
- ↑ 1.0 1.1 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
- ↑ Taylor JW, Schiff D. Metastatic epidural spinal cord compression. Semin Neurol. 2010 Jul;30(3):245-53. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20577931
- ↑ 3.0 3.1 American Cancer Society Bone Metastasis http://www.cancer.org/treatment/understandingyourdiagnosis/bonemetastasis/bone-metastasis-detailed-guide-toc
- ↑ 4.0 4.1 OrthoInfo Metastatic Bone Disease http://orthoinfo.aaos.org/topic.cfm?topic=a00093
- ↑ 5.0 5.1 5.2 Chansky HA, Gellman H Medscape: Metastatic Bone Disease http://emedicine.medscape.com/article/1253331-overview
- ↑ 6.0 6.1 Parker C et al. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med 2013 Jul 18; 369:213 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23863050 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1213755
Vapiwala N and Glatstein E. Fighting prostate cancer with radium-223 - Not your madame's isotope. N Engl J Med 2013 Jul 18; 369:276 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23863055 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1304041 - ↑ 7.0 7.1 Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
- ↑ Handkiewicz-Junak D, Poeppel TD, Bodei L, et al. EANM guidelines for radionuclide therapy of bone metastases with beta-emitting radionuclides. Eur J Nucl Med Mol Imaging. 2018 Feb 16. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29453701 https://link.springer.com/article/10.1007%2Fs00259-018-3947-x
- ↑ 9.0 9.1 Mascia AE, Daugherty EC, Zhang Y et al Proton FLASH Radiotherapy for the Treatment of Symptomatic Bone Metastases. The FAST-01 Nonrandomized Trial. JAMA Oncol. Published online October 23, 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36273324 https://jamanetwork.com/journals/jamaoncology/fullarticle/2797843
Jarvis LA, Zhang R, Pogue BW The First FLASH Clinical Trial - The Journey of a Thousand Miles Begins With 1 Step. JAMA Oncol. Published online October 23, 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36273321 https://jamanetwork.com/journals/jamaoncology/fullarticle/2797844 - ↑ 10.0 10.1 Daugherty EC, Mascia AE, Zhang Y et al FLASH Radiotherapy for the Treatment of Symptomatic Bone Metastases (FAST-01): Protocol for the First Prospective Feasibility Study. JMIR Res Protoc. 2022 Oct 4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36206189 Free article
- ↑ Chow E, Meyer RM, Ding K et al Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a double-blind, randomised placebo-controlled, phase 3 trial. Lancet Oncol. 2015 Nov;16(15):1463-1472 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26489389 Clinical Trial.
- ↑ 12.0 12.1 Martinez-Zapata MJ, Roque M, Alonso-Coello P, Catala E. Calcitonin for metastatic bone pain. Cochrane Database Syst Rev. 2006 Jul 19;2006(3):CD003223. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16856000 PMCID: PMC9676422 Free PMC article
- ↑ 13.0 13.1 Gillespie EF et al. Prophylactic radiation therapy versus standard of care for patients with high-risk asymptomatic bone metastases: A multicenter, randomized phase ii clinical trial. J Clin Oncol 2024 Jan 1; 42:38. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37748124 PMCID: PMC10730067 (available on 2025-01-01) https://ascopubs.org/doi/10.1200/JCO.23.00753
- ↑ Hsu SH, Wang SY. Trends in Provision of Palliative Radiotherapy and Chemotherapy Among Hospices in the United States, 2011-2018. JAMA Oncol. 2020 Jul 1;6(7):1106-1108. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32352492 PMCID: PMC7193522 Free PMC article.