When is surgery necessary or just particularly helpful for bone metastases? There are situations in which invasive approaches may be appropriate for the long bones (of the arms and legs). First, surgery can be helpful for persistent or increasing pain despite completing palliative radiation therapy. It is also an attractive option for a single well-defined lytic cancer lesion (a tumor that destroys bone, in contrast to a blastic bone lesion that creates extra bone but chaotically, so it is still structurally unstable) that is involving more than 50% of the strong outer cortex of a bone. Surgery is also indicated for involvement of the upper (or proximal) femur, the thigh bone, that involves a fracture of the part of the femur that is part of the hip joint, or if there is diffuse involvement of metastatic disease in a long bone. Surgery can provide structural stability to avoid a serious fracture and extended disability, and also provide pain relief at the same time. The stabilizing surgery involves a lot of hardware, and the surgery is similar to a sterile version of working in a machinist’s shop (at least that was my impression when I had my limited role in med school surgical rotation).
However, surgery would not be recommended for patients who are so debilitated that the time for recovery would be expected to include most of their expected survival (weeks), or for patients who are so debilitated that a rigorous surgery would be more dangerous than their body can handle and would likely cause more harm than good.
For compression fractures of a spinal verterbra, which can be weakened by cancer as well as garden variety osteoporosis, there are also minimally invasive procedures known as vertebroplasty or kyphoplasty that can be performed by specialist orthopedic surgeons or interventional radiologists. Both of these procedures entail inserting a needle under anesthesia and imaging guidance into a vertebra that has collapsed and is causing pain. At that point, cement can be directly injected into the vertebra to prop and keep it decompressed (normal size/height), which is the procedure called vertebroplasty. The very related procedure of kyphoplasty first inflates a balloon through the end of the needle in the middle of the collapsed verterbal body in order to prop it open, and then fills the balloon with cement.
(Click any of the above images to enlarge)
Both of these procedures can and generally do lead to immediate and very significant pain relief. The majority of patients who have one of these procedures don’t have cancer, just vertebral compression fractures from osteoporosis. My patients who have had this have often had significant pain relief or complete resolution immediately after the procedure and have no recovery time involved.
So while invasive interventions are not often required for management of bone metastases, in certain situations they can be very helpful. I’ll finish up my discussion of managing bone metastases with a post on the potential value of systemic, or “whole body” therapy for bone metastases with bisphosphonates like Zometa/zoledronate and other related drugs.
posted by Dr. West @ 9:54 am link to this post
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February 28th, 2008 at 9:48 am
Dr. West,
I am so glad I looked on Onctalk.com for info about bone metastasis. It helps a lot to understand the medical problem and options for treatment.
My father (NSCLC adeno stage IV, diagnosed in Dec 07 mets to T6, T7, L-not sure the number now, liver and adrenal gland) had spine MRI on Feb 15th, and we got a call from an oncologist next day – he was concerned because the tumor in T6 is touching the spinal cord. The onc asked my father to go to the ER for exam ASAP, since he was worrying for case of paralysis.
My father had radiation on T6, T7 for 14 days – ended in Jan 7 2008.
At the ER a spine surgeon reviewed the MRI and said it is no need for immediate intervention considering my dad is walking and active. We were referred to see a orthopedic spine surgeon.
We met with the ortho spine surgeon two days ago and he said that there is no concern for pressing the spinal cord now, but he said that the T6 has fracture, compression.
The options he gave were: Do nothing, have a kyphoplasty or more complex procedure of removing the tumor/vertebrae – he did not really recommend that since it has recovery time.
Same day I talk to my dad’s onc and she said to wait, her main concern was the tumor there and she wanted a radiation onc to see my dad first.
My questions are:
What are really the options here?
If he has the kyphoplasty, as per the surgeon, this is only to relieve pain. No really strengthening the vertebrae and another fracture is possible.
Since my dad already had radiation to this place, can more radiation be given? Would CK be an appropriate treatment to the T6? What would be the success rate?
My dad is very active and we want to keep his quality of life as long as possible.
Should we explore the removing of the tumor – as per surgeon that would mean probably replacing the vertebrae and it is a complex procedure. I remember reading some info about removing tumor from the spine on this website, but can’t find it now. Do you have an experience with similar situation? What really would be the recovery time – weeks?
I was shocked when the spine ortho said that there is a fracture. 4 doctors in the ER reviewed the MRI and no one mention fracture. We were totally unprepared for that.
All different questions came up after we left the spine clinic. My dad had full bone scan in Dec 2007 – if the fracture was there would that be detected with the bone scan.?
My dad’s is treated now in a cancer center (Stanford) and the hospital has its own clinics. Would you expect communication between doctors to be easier? Do doctors communicate, or they just send you to the other doctor and you need to figure it out. Should we expect the onc to be the main doctor to discuss treatment? My dad would have his 3rd chemo next week - carbo/Alimta and Zometa. 1st chemo was Alimta only.
Thank you for the opportunity to share my concerns and ask questions.
Ivelina.
February 28th, 2008 at 11:28 pm
Ivelina,
You’ve already described the options, and I don’t have anything more to add to that. I don’t think people would be inclined to do more radiation in the same area in the absence of an emergency like new symptoms of spinal cord compromise by the tumor despite prior radiation.
I’m an oncologist, and I think your very specific questions about response likelihood to more radiation and recovery time from surgery are really more appropriate for those specialists. I don’t have enough direct experience to comment on these points.
I really think his case is very specific, and I don’t have enough details to comment on what would be expected to be seen on an MRI in the past.
I wish I could be more helpful, but I’m here really to answer more general questions and really can’t get into such extremely specific points about one person’s care. I also can’t speculate about what the communication might be like in one system or another, but in most cases the medical oncologist is the most central person coordinating the overall plan.
-Dr. West