Evaluation and Treatment of Extremity Metastatic Disease

  • Aaron T. Creek
  • Drew A. Ratner
  • Scott E. PorterEmail author
Part of the Cancer Treatment and Research book series (CTAR, volume 162)


Metastases can occur as part of the natural progression of a variety of malignancies and their mode of spread, manner of presentation, and prognosis are as variable as their primary sources. The ultimate goal of musculoskeletal treatment of skeletal metastases is to get the patient in question back to his or her previous level of function as soon as possible. Skeletal metastases are seldom life threatening and their treatment will rarely render someone cured of their primary disease. Nevertheless, involvement of a musculoskeletal specialist as a part of the multidisciplinary approach can and very often does provide significant improvement in patients’ qualities of life. The purpose of this chapter is to discuss the evaluation of a patient with suspected metastatic disease involving the musculoskeletal system and their pre-, intra-, and post surgical management as part of a multidisciplinary team.


Musculoskeletal Metastasis Carcinoma Bisphosphonate 


  1. 1.
    Weber K (2010) Evaluation of the adult patient with a destructive bone lesion. J Am Acad Orthopedic Surgery 18:169–179Google Scholar
  2. 2.
    Coleman R et al (2010) Metastasis and bone loss: advancing treatment and prevention. Cancer Treat Rev 36(8):615–620 (Published online 2010 May 15)Google Scholar
  3. 3.
    Narazaki DK, Alverga Neto CC, Baptista AM, Caiero MT, Camargo OP (2006) Prognostic factors in pathologic fractures secondary to metastatic tumors Clinics 61(4):313–320Google Scholar
  4. 4.
    Coleman R (2006) Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 12:6243sPubMedCrossRefGoogle Scholar
  5. 5.
    Jasmin C, Coleman, RE, Coia LR, Capanna R, Saillant G (2005) Textbook of bone metastases. Wiley, LondonGoogle Scholar
  6. 6.
    Sivasundaram R, Shah S, Ahmadi S, Wunder JS, Schemitsch EH, Ferguson PC, Zdero R (2013) The biomechanical effect of proximal tumor defect location on femur pathological fractures. J Orthopedic Trauma 27(8):e174–e180CrossRefGoogle Scholar
  7. 7.
    Higinbotham NL, Marcove RC (1965) The management of pathological fractures. J Trauma 5:792–798PubMedCrossRefGoogle Scholar
  8. 8.
    Healey JH, Brown HK (2000) Complications of bone metastases: surgical management. Cancer 88(S12):2940–2951PubMedCrossRefGoogle Scholar
  9. 9.
    Ahn SG, Lee HM, Cho S-H, Lee SA, Hwang SH, Jeong J, Lee H-D (2013) Prognostic factors for patients with bone-only metastasis in breast cancer. Yonsei Med J 54(5):1168–1177Google Scholar
  10. 10.
    Bloomfield DJ (1998) Should bisphosphonates be part of the standard therapy of patients with multiple myeloma or bone metastases from other cancers? An evidence-based review. J Clin Oncol 16:1218–1225PubMedGoogle Scholar
  11. 11.
    Katzmann JA (2009) Screening panels for monoclonal Gammopathiesltime to change. Clin Biochem Rev 30(3):105–111PubMedCentralPubMedGoogle Scholar
  12. 12.
    Jung K et al (2004) Comparison of 10 serum bone turnover markers in prostate carcinoma patients with bone metastatic spread: diagnostic and prognostic implications. Int J Cancer 111(5):783–791PubMedCrossRefGoogle Scholar
  13. 13.
    Aydiner A (1994) Serum tumor markers for detection of bone metastasis in breast cancer patients. Acta Oncol 33(2):181–186PubMedCrossRefGoogle Scholar
  14. 14.
    Mundy G (2002) Metastasis to bone: causes, consequences, and therapeutic opportunities. Cancer 2:584–593PubMedGoogle Scholar
  15. 15.
    McNeil BJ (1984) Value of bone scanning in neoplastic disease. Semin Nucl Med 14:277–286PubMedCrossRefGoogle Scholar
  16. 16.
    Damle NA, Bal C, Bandopadhyaya GP, Kumar L, Kumar P, Malhotra A, Lata S (2013) The role of 18F-fluoride PET-CT in the detection of bone metastases in patients with breast, lung and prostate carcinoma: a comparison with FDG PET/CT and 99mTc-MDP bone scan. Jpn J Radiol 31(4):262–269PubMedCrossRefGoogle Scholar
  17. 17.
    Rougraff BR, Kneisl JS, Simon MA (1993) Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy. J Bone Joint Surg Am 75:1276–1281PubMedGoogle Scholar
  18. 18.
    Clayer M, Duncan W (2006) Importance of biopsy of new bone lesions in patients with previous carcinoma. Clin Orthop Rel Res 451:208–211CrossRefGoogle Scholar
  19. 19.
    Cronin CG, Cashell T, Mhuircheartaigh JN, Swords R, Murray M, O’Sullivan GJ, O’Keeffe D (2009) AJR Am J Roentgenol 193(5):W407–W410PubMedCrossRefGoogle Scholar
  20. 20.
    Ward WG, Kilpatrick S (2000) Fine-needle aspiration biopsy of primary bone tumors. Clin Orthop Relat Res 373:80–87PubMedCrossRefGoogle Scholar
  21. 21.
    Yang YJ, Damron TA (2004) Comparison of needle core biopsy and fine-needle aspiration for diagnostic accuracy in musculoskeletal lesions. Arch Pathol Lab Med 128(7):759–764PubMedGoogle Scholar
  22. 22.
    Mankin HJ, Mankin CJ, Simon MA (1996) The hazards of the biopsy, revisited. For the members of the musculoskeletal tumor society. J Bone Joint Surg 78(5):656–663PubMedGoogle Scholar
  23. 23.
    Ward WG, Savage P, Boles C, Kilpatrick SE (2001) Fine-needle aspiration biopsy of sarcomas and related tumors. Cancer Control 8(3):232–238PubMedGoogle Scholar
  24. 24.
    Wong R, Wiffen PJ (2002) Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database Syst Rev 2002(2):CD002068Google Scholar
  25. 25.
    Finley RS (2002) Bisphophonates in the treatment of bone meatastases. Sem Onc 29(1)(4):132–138Google Scholar
  26. 26.
    Walkington L, Coleman RE (2011) Advances in management of bone disease in breast cancer. Bone 48(1):80–87PubMedCrossRefGoogle Scholar
  27. 27.
    Groot MT, Boeken Kruger CGG, Peiger RCM, Uyl-de Groot CA (2003) Costs of prostate cancer, metastatic to the bone in the Netherlands. Eur Urol 43(3):226–232Google Scholar
  28. 28.
    Jeremic B (2001) Single fraction external beam radiation therapy in the treatment of localized metastatic bone pain. a review. J Pain Symptom Manage 22(6):1048–1058PubMedCrossRefGoogle Scholar
  29. 29.
    Callstrom MR, Dupuy DE, Solomon SB, Beres RA, Littrup PJ, Davis KW, Paz-Fumagalli R, Hoffman C, Atwell TD, Charboneau JW, Schmit GD, Goetz MP, Rubin J, Brown KJ, Novotny PJ, Sloan JA (2013) Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial. Cancer 119(5):1033–1041PubMedCrossRefGoogle Scholar
  30. 30.
    Toyota N, Naito A et al (2005) Radiofrequency ablation therapy combined with cementoplasty for painful bone metastases: initial experience. Cardiovasc Intervent Radiol 28(5):578–583Google Scholar
  31. 31.
    Fidler M (1973) Prophylactic internal fixation of secondary neoplastic deposits in long bones. BMJ 1(5849):341PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Mirels H (1989) Metastatic disease in long bones a proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 249:256–264PubMedGoogle Scholar
  33. 33.
    Robial N, Charles YP, Bogorin I, Godet J, Beaujeux R, Boujan F, Steib JP (2012) Is preoperative embolization a prerequisite for spinal metastases surgical management? Orthop Traumatol Surg Res 98(5):536–542PubMedCrossRefGoogle Scholar
  34. 34.
    Fang T, Dong J, Zhou X, McGuire RA Jr, Li X (2012) Comparison of mini-open anterior corpectomy and posterior total en bloc spondylectomy for solitary metastases of the thoracolumbar spine. J Neurosurg Spine 17(4):271–279PubMedCrossRefGoogle Scholar
  35. 35.
    Nilsson J, Gustafson P, Fornander P, Ornstein E (2000) The Harrington reconstruction for advanced periacetabular metastatic destruction: good outcome in 32 patients. Acta Orthopaedica 71(6):591–596CrossRefGoogle Scholar
  36. 36.
    Vena VE, Hsu J, Rosier RN, O’Keefe RJ (1999) Pelvic reconstruction for severe periacetabular metastatic disease. Clin Orthop Relat Res 362:171–180PubMedGoogle Scholar
  37. 37.
    Walker RH (1993) Pelvic reconstruction/total hip arthroplasty for metastatic acetabular insufficiency. Clin Orthop Relat Res 294:170–175PubMedGoogle Scholar
  38. 38.
    Allan DG, Bell RS, Davis A, Langer F (1995) Complex acetabular reconstruction for metastatic tumor. J Arthroplasty 10(3):301–306PubMedCrossRefGoogle Scholar
  39. 39.
    Wedin R, Bauer HCF (2005) Surgical treatment of skeletal metastatic lesions of the proximal femur Endoproththesis or reconstruction nail? J Bone Joint Surg Br 87(12):1653–1657Google Scholar
  40. 40.
    Ashford RU et al (2012) The modern surgical and non-surgical management of appendicular skeletal metastases. Orthop Trauma 26(3):184–199Google Scholar
  41. 41.
    Frassica FJ, Frassica DA (2003) Evaluation and treatment of metastases to the humerus. Clin Orthop Relat Res 415:S212–S218PubMedCrossRefGoogle Scholar
  42. 42.
    Hill C et al (1981) Prophylactic cefazolin versus placebo in total hip replacement report of a multicentre double-blind randomised trial. Lancet 1(8224):795–796PubMedCrossRefGoogle Scholar
  43. 43.
    Donati D, Biscaglia R (1998) The use of antibiotic-impregnated cement in infected reconstructions after resection for bone tumours. J Bone Joint Surg Br 80(6):1045–1050PubMedCrossRefGoogle Scholar
  44. 44.
    Bickels J, Kollender Y, Wittig JC, Cohen N, Meller I, Malawer MM (2005) Vacuum-assisted wound closure after resection of musculoskeletal tumors. Clin Orthop Relat Res 441:346–350PubMedCrossRefGoogle Scholar
  45. 45.
    Falanga A, Rickles FR (1999) Pathophysiology of the thrombophilic state in the cancer patient. In: Seminars in thrombosis and hemostasis, vol 25, issue 02. Thieme Medical Publishers Inc, New York, pp 173–182Google Scholar
  46. 46.
    Townsend PW, Rosenthal HG, Smalley SR, Cozad SC, Hassanein RE (1994) Impact of postoperative radiation therapy and other perioperative factors on outcome after orthopedic stabilization of impending or pathologic fractures due to metastatic disease. J Clin Oncol 12(11):2345–2350PubMedGoogle Scholar
  47. 47.
    Fuchs B, Trousdale RT, Rock MG (2005) Solitary bony metastasis from renal cell carcinoma: significance of surgical treatment. Clin Orthop Relat Res 431:187–192PubMedCrossRefGoogle Scholar
  48. 48.
    Evenski A, Ramasunder S, Fox W, Mounasamy V, Temple HT (2012) Treatment and survival of osseous renal cell carcinoma metastases. J Surg Oncol 106(7):850–855PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Aaron T. Creek
    • 1
  • Drew A. Ratner
    • 1
  • Scott E. Porter
    • 1
    Email author
  1. 1.Department of Orthopaedic SurgeryGreenville Health SystemGreenvilleUSA

Personalised recommendations