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oncology

Metastatic Bone Disease

advanced
6 min
28 marks
6 questions
Clinical Scenario
A 62-year-old woman with known breast cancer treated 5 years ago presents with 6 weeks of progressive left thigh pain. The pain is constant, worse at night, and she has difficulty weight-bearing. She has lost 5kg over the last 3 months. On examination, she has tenderness in the proximal thigh and walks with an antalgic gait. X-ray shows a lytic lesion in the subtrochanteric region with 70% cortical destruction.
AP radiograph of the left femur showing a pathological fracture through a lytic metastatic lesion in the subtrochanteric region. There is a transverse fracture through an area of cortical destruction with surrounding permeative lysis. The patient had known breast carcinoma. Staging CT shows multiple additional skeletal lesions. Surgical stabilization with cephalomedullary nail is required.
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AP radiograph of the left femur showing a pathological fracture through a lytic metastatic lesion in the subtrochanteric region. There is a transverse fracture through an area of cortical destruction with surrounding permeative lysis. The patient had known breast carcinoma. Staging CT shows multiple additional skeletal lesions. Surgical stabilization with cephalomedullary nail is required.

Source: Skeletal Metastasis as Detected by 18F-FDG PET: Impact on Cancer Staging • PMC5056322 • CC-BY

Questions

Question 1 (4 marks)

What are the common primary tumors and their radiographic patterns?

Question 2 (5 marks)

How do you assess fracture risk using the Mirels score?

Question 3 (6 marks)

Describe the principles of surgical management.

Question 4 (5 marks)

What is the workup for metastatic bone disease of unknown primary?

Question 5 (4 marks)

Discuss medical management and bisphosphonates.

Question 6 (4 marks)

What are the outcomes and prognostic factors?

Exam Day Cheat Sheet

Must Mention

  • •BLT + Kosher Pickle (Breast, Lung, Thyroid, Kidney, Prostate)
  • •Mirels ≥9 = prophylactic fixation
  • •Protect entire bone
  • •Expect no healing, immediate WB
  • •Embolize renal/thyroid pre-op
  • •Bisphosphonates reduce skeletal events

Common Pitfalls

  • •Missing Mirels score
  • •Wrong pattern by primary
  • •Inadequate fixation
  • •Not embolizing renal
  • •Missing unknown workup
  • •Wrong survival estimates