Metastatic Lesions

Posted bythespinebookadminPosted inTopics, Tumor

Common Mets to Bone 

BLT with Pickles on Rye 

Breast 

Lung 

Thyroid 

Prostate 

Renal 

Patchell 2005 

  • RCT of  
    • Surgery + Rads vs Rads only 
    • Used fusion 
  • Outcomes 
    • Surgery + Rads > Rads 
    • Regaining ability to walk : 62% vs 19% 
  • Stopped trial early 
  • Conclusion: Aggressive treatment with Surgery along with Radiation 

*bone most common site of mets behind lung and liver 

Spine>proximal humerus>femur 

*breast and prostate most common due to Baston Epidural plexus connection with pelvic/ mammary veins 

Staging Workup for Single Bone Lesion with Unknown Primary 

  • Imaging 
    • XR of Limb 
    • CT Chest Abdo Pelvis 
    • Bone Scan Tech 99  
      • (Skeletal Survey if Multiple Myeloma or Thyroid as often cold on bone scan) 
  • Labs 
    • CBC with Diff 
    • ESR 
    • Basic metabolic panel 
    • LFTs, Ca, Phos, Alk Phosphatase 
    • Serum and urine electrophoresis (SPEP and UPEP) 
  • Biopsy 
    • Do not treat a bone lesion without a biopsy 
  • Local and Systemic Staging 

Goals of surgery 

  • Stability 
  • Decompression 
  • Pain contror

Radiology 

  • Decreased T1, increased T2 
    • Except hemangioma and chordoma increased in both 
    • T2 increases in lymphoma 
  • Gadolinium preferred 

Pathophysiology 

  • Mechanism of destruction (osteolysis):  
    • Osteolytic lesions: tumour activation of osteoclasts via RANKL osteoprotegrin pathway 
    • Osteoblastic lesions: tumour secreted endothelin 1 

Presentation 

  • Pain (65%) 
    • Progressive 
    • No relief with rest and night 
  • Neuro symptoms (20%) 
    • Inc risk with thoracic mets – less space for cord 
    • Patients with neuro deterioration 
      • 35% regain lost motor function 
      • Bowel/ bladder – unlikely to return 
      • Aggressive treatment  (surgery + rads) – 60% will regain ability to walk 

Prognosis 

  • Tokuhasi Score (higher the score, the better the patient is)  
    • Higher score – more aggressive procedure, lower score – conservative 
    • General Condition 
    • Extraspinal Bony Mets 
    • Bone Spine Mets 
    • Mets to Internal Organs 
    • Primary Site (thyroid breast prostate best; lung/ stomach/ bladder/ liver worst) 
    • Neurologic Compromise 

Treatment of Mets 

  • Goals 
    • Pain control 
    • Maintain / recover neuro function 
    • Local tumour control 
    • Spinal stability 
    • QoL (walking) 
  • DeWald Classification of Mets 
    • Class 1 – no collapse + pain 
      • A – <50% body destruction – no surgery 
      • B – >50% body destruction – maybe surgery 
      • C – pedicle destruction – maybe surgery 
    • Class 2 – collapse deformity +immunocompetent 
      • Good risk for surgery 
    • Class 3 – collapse deformity immunocompromised 
      • Greater risk for surgery 
    • Class 4 – collapse deformity paralysis immunocompetent 
      • Relative surgical emergency 
    • Class 5 – collapse deformity paralysis immunocompromised 
      • Not a good operative risk 
  • NOMS Framework 
    • Neurologic (measure ESCC epidural spinal cord compression) 
      • 0 – bone only 
      • 1 – extension into epidural space no deformation of cord 
        • A – sac untouched 
        • B – sac deformed cord abut 
        • C – cord abut but no deformation 
      • 2 – compression with visible CSF 
      • 3 – compression CSF not visible 
      • 2&3 get decompression before radiation unless highly sensitive 
    • Oncologic (need tissue Dx) 
      • Radiosensitive 
        • High Sensitivity: Lymphoma, Semimoma, MM, Ovarian, Neuroendo 
        • Intermediate: Breast and Prostate 
        • Mx: Conventional External Beam Radiation 
      • Radioresistant 
        • Renal, Thyroid, Hepatocellular, Colon, NSLCL, Sarcoma, Melanoma 
          • Low ESCC N1- Stereotactic Radiosurgery 
          • High Grade N2 or 3 
            • Decompression and stabilization before radiation 
              • Because you will give such high doses of radiation, you will harm the cord – so you must separate the two prior to radiation 
    • Mech Stability 
      • SINS score 
        • Location (Juntional, Mobile, Semi Rigid, Rigid) 
        • Pain (Yes No) 
        • Bone lesion Type (Lytic, Mixed, Blastic) 
        • Spinal Alignment (Norma, Denovo deformity of kypho, subluxation or translation) 
        • Vertebral Body Collapse (Collapse ><50%, No collapse with >50% involvement) 
        • Posterior involvement 
    • Systemic Illness 
      • ECOG score 
        • Limited or Extensive 
  • Preop Embolization for RCC and Thyroid 
  • Epidural Disease Grade – Bilsky 
    • Need separation surgery if the epidural disease is touching the cord 

New Therapy Low Radiosensitivity 

  • Breast Ca  
  • NSCL  
    • Epidermal growth factor receptor 
      • Tyrosine kinase inhibitors (immunotherapy erlotinib and chemo) 
  • RCC new immunotherapies (sunitinib and panzopanib) with more than 50% disease control 
    • SBRT 
  • Melanoma with positive B gene RAF mutation – responds better to imnunotheapy now 

B Cell Lymphoma – Chemotherapy 

Lymphoma – shows up more on MRI than the CT 

Breast Ca –  

SINs Score 

Stable 0-5 

Potentially unstable 6-10 

Unstable >11 

  • Designed for Rad Onc; to keep them from radiating something that is unstable 

Mechanical pain – will change with posture and it indicates instability 

Bone quality – obvious