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What is Bone Metastasis?

A bone tumor caused by the spread of cancer of some distant organ or tissue, to any bone, is called as Bone Metastasis. It is also known as Bone Secondary, Skeletal Metastasis or simply as ‘Bone or Skeletal mets’. They are often multiple at presentation.

Cancer affecting the bone is of two distinct types:

  • Primary Bone Cancer: This is cancer which arises in the bone itself‚ i.e. this cancer originates in the tissues of the bone. They are called Sarcomas. They are very rare tumors. The commonest bone sarcomas are Osteosarcoma, Ewing’s Sarcoma and Chondrosarcoma.
  • Secondary Bone Cancer: A bone tumor caused by the spread of cancer of some distant organ or tissue, to any bone‚ is called as Bone Metastasis. They are also called as Bone Secondary‚ Bone Metastasis‚ SkeletalMetastasis or simply as “Bone or Skeletal mets” Secondary Bone Cancer is far more common than Primary Bone Cancer. Often they are multiple at presentation‚ i.e. they may be found in more than one bone or/and at more than one location in a single bone‚ at the time of detection/diagnosis. Bone is a common site of metastasis for a number of different cancers. The cancers which spread most often to the bones are those from lung‚ breast‚ prostate‚ kidney and thyroid.
Can cancer really spread to the bone?

Absolutely. In-fact‚ bone‚ along with lymph nodes‚ lung and liver‚ are the four commonest sites for metastasis of all cancers. Of these‚ it is the bone metastases that cause the maximum discomfort and disability to the patient. Most causes of cancer related pain is due to Bone Metastasis.

Can cancer really spread to the bone?

Absolutely. In-fact‚ bone‚ along with lymph nodes‚ lung and liver‚ are the four commonest sites for metastasis of all cancers. Of these‚ it is the bone metastases that cause the maximum discomfort and disability to the patient. Most causes of cancer related pain is due to Bone Metastasis.

Which bones can be affected by metastasis?

Cancer can spread to any bone in the entire body. However‚ they most commonly affect the axial skeleton (skull‚ spine‚ sacrum and ribs) and the proximal large bones (femur‚ humerus and pelvis). Metastasis is rare in the bones distal to the elbow and the knee.

WHO CAN BE AFFECTED BY BONE METASTASIS?

Any patient with cancer is at a risk of developing Bone Metastasis. Even a person with a history of completely treated cancer and who is now apparently cancer free‚ runs the risk of developing Bone Metastasis‚ especially in the early years following the treatment. Certain cancers like those originating in lung‚ breast‚ prostate‚ thyroid and kidney show an increased tendency for Bone Metastasis.

Any patient with cancer is at a risk of developing Bone Metastasis. In-fact‚ even a person with a history of completely treated cancer‚ and who is apparently cancer free at present‚ also remains at a risk of developing metastasis in the future‚ which among other sites‚ could manifest in the bones. This risk is highest in the immediate years following the completion of treatment‚ and falls subsequently. Some cancers have a higher incidence of metastasizing to the bone as compared to others. Cancers that most often metastasize to bones are those from the lung‚ prostate‚ breast‚ thyroid and kidney.

In many cases‚ detection of Bone Metastasis may be the first indication of cancer in the body‚ i.e. to say‚ in many patients‚ Bone Metastasis may be found without a present or past history of cancer. These patients may realize that they have cancer‚ only after the detection of the Bone Metastasis. The primary source cancer may then be found on a thorough investigation of the patient. The biopsy of the bone lesion often gives strong clues about the possible source of the cancer‚ i.e. which organ/tissue the cancer has originated from. It is logical to conclude that any patient with a higher risk of cancer (e.g. smokers‚ tobacco users‚ etc.) also have a higher risk of Bone Metastasis‚ as Bone Metastasis is a consequence of cancer. Other than the increased risk of Bone Metastasis due to the particular type of cancer (e.g., lung, prostate‚ breast‚ thyroid and kidney cancers)‚ in a known case of cancer‚ some of the other risk factors for Bone Metastasis are‚ a larger disease‚ existing metastasis in other tissues (e.g. in lungs‚ liver‚ lymph nodes‚ etc.)‚ higher grade of disease‚ etc.

What are the symptoms of Bone Metastasis?
  • Pain: Bone Metastasis is one of the most frequent and important causes of pain in people with cancer.

  • Fractures: This is one of the most serious complications of Bone Metastasis. Bone Metastasis weakens bones in the region of the metastasis‚ making them vulnerable to fracture due to trivial causes.

  • Swelling: This is not a usual presenting complaint in a patient with Bone Metastasis. By the time a swelling becomes obvious‚ the patient usually would have had complaints of pain in that region for some time.
  • Spinal cord compression: This is perhaps the most dreaded complication of Bone Metastasis. This occurs when cancer metastasizes to the spine (backbone). The symptoms of spinal cord compression may range from, just pain‚ to complete paralysis and loss of sensation of the body below the level of the compression.

  • High blood calcium levels. This is called as Hypercalcaemia. Symptoms of Hypercalcaemia could be nausea, vomiting, lethargy, moodiness, stomach pain, etc. If untreated, it can lead to coma.

Bone Metastasis can cause a number of problems. The most important of them are:

SymptomsOfBoneMetastasis
  • Pain: Bone Metastasis is one of the most frequent and important causes of pain in people with cancer. Initially, the pain may be vague and irregular. But it may soon become more persistent and the patient may have pain even at rest. Depending on the site of pain‚ it can cause various disabilities like‚ difficulty in walking‚ sitting‚ standing‚ or doing some specific work or activity. In some patients‚ the pain may be severe enough to affect sleep. However, it is important to know that not all skeletal pain means metastasis. In fact‚ most causes of bone pain could be explained due to other far more common causes like injury‚ sprain‚ arthritis‚ infection‚ etc. Nevertheless‚ it is always wise to investigate any unexplained pain‚ especially if it is persistent or worsening. If a person has had cancer in the past‚ or is being presently treated for cancer‚ it is important to investigate these complaints of pain as early as possible; as such a person is certainly at a risk of having Bone Metastasis. If these metastases are detected early‚ measures can be taken to control or treat them and avoid more serious consequences‚ which could occur if they are neglected.
  • Fractures: This is one of the most serious complications of Bone Metastasis. Bone Metastasis weakens bones in the region of the metastasis‚ making them vulnerable to fracture with trivial causes. This can cause serious disability and discomfort to the patient. Due to the weakened state of the bone‚ these fractures may occur when least expected‚ e.g. following a trivial fall at home‚ a minor slip in the bathroom/toilet or on a wet floor‚ while getting up from bed‚ while lifting a heavy object or even with a jolt experienced while travelling in a vehicle. The symptoms of this fracture may range from a sudden sharp pain around the area of the fracture‚ to very obvious signs of fracture like deformity in the limb‚ visible swelling‚ intense pain and inability to use the affected limb. This is called as a Pathological Fracture. However‚ it is very important to know that Pathological Fractures are far more often caused by some other medical conditions as compared to cancer. One of the most common causes of Pathological Fracture is Osteoporosis.
  • Swelling: This is not a usual presenting complaint in a patient with Bone Metastasis. By the time a swelling becomes obvious‚ the patient usually would have had complaints of pain in that region for some duration of time. When the metastasis is in a sub-cutaneous bone like the skull‚ mandible‚ clavicle‚ etc. the patient may sometimes present with a painless swelling initially. A painful swelling is always noticed in the region of a Pathological Fracture.
  • Spinal cord compression: This is perhaps the most dreaded complication of Bone Metastasis. This occurs when cancer metastasizes to the spine (backbone)‚ which is formed by a series of bones called the vertebrae. As we all know‚ the vertebrae have a hollow passage (called the vertebral canal or the spinal canal) through which passes the spinal cord. Metastasis to the vertebrae can cause them to become weak and susceptible to fracture. Furthermore‚ the metastatic disease could grow relentlessly in the vertebra and soon come out of the confines of the bone and encroach into the vertebral canal and exert pressure on the spinal cord. In either situation‚ there is a serious risk of injury to the spinal cord. The spinal cord is like a cable or an information highway, which connects the brain to the rest of the body. If this structure is damaged‚ the brain cannot send or receive signals from the part of the body‚ which is beyond the damaged part of the spinal cord. The symptoms of spinal cord compression/injury may range from just pain, to complete paralysis and loss of sensation of the body below the level of the compression. It may also cause loss of control of bladder and bowel function (inability to voluntarily control the passage of urine and stools).
  • High blood calcium levels: This is called as Hypercalcaemia. It occurs in about 10% of these patients. Metastasis in the bones can release excessive amounts of calcium into the circulation, which can cause trouble. Symptoms of Hypercalcaemia could be nausea, vomiting, lethargy, moodiness, stomach pain, irritability, confusion, thirst, constipation, excessive urination, extreme muscle weakness, irregular heartbeat, etc. If untreated, it can lead to coma.
What investigations can be done to detect/diagnose Bone Metastasis?

There are several investigations which can help in the detection/diagnosis of Bone Metastases. Some of the important ones are as follows:

  • X-ray: This is one of the most common and useful investigations to look for Bone Metastasis.
  • Bone scan: Bone scan is generally regarded as the most cost-effective whole-body screening test for the detection of Bone Metastases.
  • Computed Tomography (CT) scan: CT-scan provides cross-sectional images of the affected bone, which may reveal details missed on a conventional X-ray.
  • Magnetic Resonance Imaging (MRI): It is highly sensitive and can pick up small and deep Bone Metastases.
  • Positron Emission Tomography (PET): The advantage of PET scan in the work-up for metastasis is that it can detect metastasis in most of the tissues of the body including the bone; unlike bone scan, which is specifically designed for the skeletal system only.
  • Blood investigations: Bone Metastasis can cause alterations in the blood levels of certain substances‚ e.g. calcium‚ Alkaline Phosphatase‚ etc. Elevated ‘Tumor Marker’ levels‚ in the presence of unexplained bone lesions‚ should raise the suspicion of Bone Metastasis due to the cancer represented by the Tumor Marker.

There are several investigations which can contribute in the detection/diagnosis of Bone Metastases. Some of the important ones are as follows:

  • X-ray: Despite the advances in medical imaging technology‚ standard plain X-ray with normal magnification remains one of the most common and useful investigations to detect Bone Metastasis. However‚ X-ray is generally best suited for imaging symptomatic areas only.
  • BoneScanMultipleLesionsBone scan: Bone scan is generally regarded as the most cost-effective whole-body screening test for the detection of Bone Metastases. This is a nuclear imaging investigation which is highly sensitive and can detect Bone Metastases earlier than X-ray. In a single study‚ the entire skeletal system of the patient can be investigated for Bone Metastasis. However‚ it is not a very specific investigation. This means that‚ although bone scan is very sensitive and picks up even small problems in the bones‚ it cannot help in identifying the cause of that problem. Bone scan also highlights other lesions like arthritis‚ healing fracture‚ benign bone tumor‚ infection‚ etc. It is‚ therefore‚ necessary to interpret the bone scan findings carefully.
  • Computed Tomography (CT) scan: CT-scan uses X-rays to provide cross-sectional images of the bone, which may reveal details missed on a conventional X-ray. It is particularly useful in targeting biopsy needles to‚ small and deep‚ difficult to access‚ suspected Bone Metastasis; located‚ for example‚ in the vertebrae.
  • Magnetic Resonance Imaging (MRI): MRI scans use radio waves and strong magnets instead of X-rays to provide pictures of bones and tissues. It is a highly sensitive investigation and can detect small and deep Bone Metastases early.
  • Positron Emission Tomography (PET): PET scan is a recent nuclear imaging investigation‚ useful in the staging of patients with cancer. The advantage of PET scan in the work-up for metastasis is that it can detect metastasis in most of the tissues of the body including the bone; unlike bone scan‚ which is specifically designed for the skeletal system only. In PET scan, radio-labelled glucose synthetic glucose molecules‚ with a positron emitting radioactive atomincorporated into its structure) is injected into the body‚ which is detected by the PET scanner machine. PET can detect accurately the various metastases in the body if there is any. However‚ in the detection of Bone Metastasis‚ the excellent sensitivity of a bone scan generally limits the need for a PET scan. PET scan is an expensive investigation.
  • Blood investigations: Bone Metastasis can cause alterations in the blood levels of certain substances. It can cause a rise in calcium and alkaline phosphatase levels. However‚ the blood level of these substances can also rise due to other causes. So‚ one must be cautious in interpreting the findings. Another useful investigation in the work-up for skeletal metastasis is the study of ‘Tumor Markers’ levels. ‘Tumor Markers’ are certain substances‚ which may be/are‚ found in higher quantities in blood‚ body tissue‚ body fluids‚ urine‚ etc.‚ in the presence of certain cancers‚ e.g. PSA in prostate cancer‚ etc. Elevated ‘Tumor Markers’levels, in the presence of unexplained bone lesions‚ should raise the suspicion of Bone Metastasis due to the cancer represented by the Tumor Marker. Except in some cancers, ‘Tumor Markers’‚ although helpful in some ways, are not very reliable and the interpretation of their values should be done in the light of other findings and evidence; a job best left to your treating doctor.
What is biopsy? What is its importance?

Biopsy is a minor surgical procedure in which a small piece of the tumor tissue is sampled and sent for evaluation to a pathologist‚ who examines it under a microscope to establish its exact histological identity/name (diagnosis). The pathologist can find out whether it is Primary or Secondary Bone Cancer. In case of Secondary Bone Cancer‚ the pathologist can often identify the source of the cancer (i.e. in which distant organ‚ the cancer originated from)‚ which helps in localizing the primary source cancer and thus‚ in initiating effective treatment.

Biopsy is a minor surgical procedure where a small piece of the tumor tissue is sampled and sent to the laboratory for evaluation by a pathologist. The pathologist‚ after processing the tissue sample‚ examines thin slices of it under a microscope to identify whether it is cancerous tissue and if so, what type of cancer it is‚ i.e. its exact histological identity/name (diagnosis). The pathologist can find out whether it is Primary or Secondary Bone Cancer. In case of Secondary Bone Cancer, the pathologist can often identify the source of the cancer (i.e. in which distant organ‚ the cancer originated from)‚ which helps in localizing the primary source cancer‚ and thus in initiating effective treatment.

As a general rule‚ biopsy of any skeletal tumor should be planned and executed as for a primary malignant bone tumor. This is especially true when the bone lesion is solitary‚ i.e. when only one bone tumor is detected after a complete work-up of the patient. This is because, if it turns out to be a primary malignant bone tumor (Sarcoma)‚ the biopsy scar and track have to be included in the surgical excision (To know more about this‚ see the section on Malignant Bone Tumors.). A patient may present with bone tumor in various possible scenarios‚ e.g.:

  • He/she could be having some cancer now‚ or had cancer in the past‚ or may never have had cancer;
  • He/she could be also having metastasis in the liver/lung/brain/etc.‚ or may not have any other metastatic lesion in the body;
  • He/she may be having a solitary bone lesion‚ or multiple bone lesions;
  • The patient may have a known primary cancer now‚ the situation of which may range from eminently treatable to‚ not-treatable;
  • Despite the clinical and radiological suspicion of metastasis‚ the bone lesion could still be a primary malignant bone tumor‚ a benign bone tumor‚ bone infection‚ etc.

The diagnostic and therapeutic approach to any patient with suspicious bone lesion/s depends on the consideration of these large numbers of variables and their complex interactions. It is quite possible that a biopsy is not needed in some situations. Thus‚ a decision for a biopsy‚ and when needed‚ the procedure itself‚ is best left to a surgeon with experience in bone tumor treatment. A badly done biopsy can affect the future treatment of the bone disease‚ especially if it turns out to be a primary malignant bone tumor.

Several biopsy techniques are available‚ including Fine Needle Aspiration Biopsy‚ Core Needle Biopsy‚ Incisional Biopsy‚ Excisional Biopsy‚ etc. Biopsy for bone tumors is generally done as a small open surgery (Open Biopsy)‚ or with the help of special biopsy needles (Core Needle Biopsy). Between the two‚ Core Needle Biopsy is generally the preferred method for doing a biopsy as it is a simple‚ reliable‚ minimally invasive‚ safe and quick procedure. The correct method for your situation is best decided by your doctor.

Between Core Needle Biopsy (CNB) and Open Biopsy (OB), which is better and why?

Core Needle Biopsy in skilled hands‚ offers significant advantages over Open Biopsy and therefore‚ it is the preferred method for obtaining tumor tissue samples.

The goal of a biopsy procedure is to obtain a sample of tumor tissue so that it can be studied by the pathologist to identify the exact nature of the disease and establish its identity (diagnosis)‚ as treatment of any tumor depends on its diagnosis. Generally‚ it is possible to obtain a larger quantity of tissue sample (which makes it easier for the pathologist to process and study the material) through an Open Biopsy. However‚ the material obtained by Core Needle Biopsy‚ in most cases‚ is adequate for a skilled pathologist. In many other ways‚ the advantages and benefits offered by a CNB are superior to that of an OB.

As mentioned in the above paragraph; CNB is a simple, reliable, minimally-invasive, safe and quick procedure. To see a table comparing CNB with OB, see the section on Malignant Bone Tumors. This table makes it quite obvious that Core Needle Biopsy in skilled hands, offers significant advantages over Open Biopsy and therefore, it is the preferred method for obtaining tumor tissue samples. Nevertheless, there may be some situations where an open biopsy procedure could be the more suitable option.

Why is it important to identify a Bone Metastasis as different from a Primary Bone Tumour? Is it not enough to know that there is cancer in the bone?

Bone Metastasis is different from Primary Bone Cancer. The treatment strategy‚ treatment options‚ treatment goals‚ prognosis‚ etc. are different for Primary and Secondary Bone Cancers. Moreover‚ the behavior of the Bone Metastases and their response to treatment depends on, which cancer caused the metastasis. Metastatic cancer is named by associating it with the identity of the primary source cancer. Although the local treatment for Bone Metastases may be similar‚ their specific systemic treatment depends on knowing the primary cancer causing the metastasis. It is therefore‚ important to identify the primary source cancer responsible for the metastasis.

Bone Metastasis is different from Primary Bone Cancer. Unlike Primary Bone Cancer‚ where the cancer arises from the bone tissue itself‚ in Secondary Bone Cancer‚ the tumor forms in the bone following an implantation of cancer cells from a cancer of some distant organ/tissue that has reached the bone through the circulatory system. It is important to understand that the tissue of the metastatic focus in the bone is identical to the tissue of the primary cancer. This means that a lung cancer which has spread to the bone‚ under the pathologist’s microscope‚ looks similar to the lung cancer from which it has originated. This resemblance does not end with just the appearance; they resemble each other physiologically too, and therefore‚ in their nature and behavior. Metastatic cancer is named by associating it with the identity of the primary source cancer. The bone cancer in the above example is called as ‘Bone Metastasis of lung cancer’. The treatment strategy‚ treatment options‚ treatment goals‚ prognosis‚ etc. are different for Primary and Secondary Bone Cancers. Moreover‚ the behavior of the Bone Metastases and their response to treatment depends on‚ which cancer caused the metastasis. Although the local treatment for Bone Metastases may be similar‚ their specific systemic treatment depends on knowing the primary cancer that caused the metastasis. It is therefore‚ important to identify the primary source cancer responsible for the metastasis.

Can Bone Metastasis be cured?

Bone Metastasis basically means that the patient has some cancer in the body which has spread to the bone. So‚ there is no concept like curing a Bone Metastasis‚ as it represents just one part of the cancer affecting the person. However‚ it can be treated. This can offer serious benefits in terms of survival and quality of life. The outcome of treatment depends on various factors like the type of cancer‚ the number of metastasis‚ etc.

Bone Metastasis basically means that the patient has some cancer in the body which has spread to the bone. So‚ there is no concept like curing a Bone Metastasis‚ as it represents just one part of the cancer affecting the person. However‚ it can be treated. This treatment forms a part of the treatment of the primary cancer which has spread to the bone. The goal of treatment of Bone Metastases is to arrest their growth and to prevent any complications due to them‚ alleviate any symptoms caused by them‚ or treat any complications that might have occurred. This can offer serious benefits in terms of survival and quality of life. Effective treatment may add years to the life of some patients‚ and rare cases have been reported of patients being cured of their cancer‚ despite having Bone Metastasis. The outcome of treatment depends on various factors like the type of cancer‚ the number of metastasis‚ etc.

What is the treatment for Bone Metastasis?

The most important treatment for any metastasis is the effective treatment of the primary cancer with systemic medication‚ which may be in the form of chemotherapy‚ hormone therapy‚ systemic radiotherapy‚ etc. In addition to the cancer treatment‚ there are a variety of treatment options available for specific treatment of the Bone Metastasis. Targeted treatment of specific Bone Metastasis is usually done only when they are symptomatic‚ have caused complications‚ or show signs suggestive of an impending complication. This may involve the use of radiotherapy‚ surgery‚ radiofrequency ablation‚ etc. Often more than one treatment modality may be employed.

The most important treatment for any metastasis is the effective treatment of the primary cancer with systemic medication (medication which is injected or ingested and therefore reaches all the tissues of the body through the blood).This may be in the form of chemotherapy‚ hormone therapy in hormone sensitive cancers (e.g. breast cancer‚ prostate cancer‚ etc.)‚ systemic radiotherapy in cancers where it is useful (e.g. radio-iodine treatment in thyroid cancer)‚ etc. In addition to the cancer treatment‚ there are a variety of treatment options available for specific treatment of the Bone Metastasis. Local treatment of Bone Metastasis is usually done only when they are symptomatic‚ have caused complications‚ or show signs suggestive of an impending complication. Often more than one treatment modality may be employed. The following are some of the important treatment modalities that are useful in the management of Bone Metastasis.

  • Chemotherapy: Chemotherapy is one of the most important modalities of systemic treatment of cancer. The exact chemotherapy regimen depends on‚ which cancer caused the metastasis. The most effective systemic treatment of the primary is also the best treatment for the secondaries‚ as they are basically made of the same tissue. Chemotherapy may not be used in the treatment of all cases of Bone Metastasis. For example‚ in some types of cancer‚ effective chemotherapy may not be available‚ while in some situations‚ chemotherapy may not be considered safe for the patient. All aspects of a given case have to be considered‚ before deciding on the use of chemotherapy for the treatment of Bone Metastasis.
  • Hormone Therapy: This is also called as Endocrine Therapy. This is one of the major treatment modalities in the management of certain types of cancer. Some cancers are sensitive to particular hormones in the blood‚ e.g. in some breast cancers‚ the cells have receptors for the hormone estrogen‚ which respond to the estrogen in the blood and stimulate the growth of these tumors. Hormone Therapy uses drugs‚ which either prevent specific hormones from forming‚ or acting on the tumor cells; there by‚ inhibiting the growth of these cancers. Thus, hormone therapy can work in two different ways. In one method‚ the level of the offending hormone in the blood is lowered by stopping or reducing its manufacture in the body‚ consequently stopping/reducing the stimulation of the cancer cells. In the other method‚ the receptors to the hormone on the cancer cells are blocked‚ which prevents them from getting stimulated by the hormone. In both methods‚ the stimulation of the cancer cells by the offending hormone is interfered with‚ thus inhibiting the growth of these cancers. Some of the well-known hormone sensitive cancers are certain breast cancers‚ prostate cancer‚ endometrial cancer‚ etc.
  • Radiation Therapy: Radiotherapy is a form of cancer treatment where a certain type of energy called as ‘ionizing radiation’ is used to injure or destroy cancer cells. ‘Ionizing radiation’is made of either powerful electromagnetic rays (X-rays/gamma rays)‚ or high energy sub-atomic particles like atomic nuclei‚ protons‚ neutrons‚ etc. Radiotherapy is useful in relieving pain and controlling the growth of the Bone Metastasis. The response to radiotherapy is variable and depends on several factors‚ including the type of cancer causing the metastasis.

    Radiotherapy is not administered to all Bone Metastases. The role of Radiotherapy in a situation of Bone Metastasis is‚ generally, to relieve the symptoms caused due to the disease in the bone. It is used to treat symptomatic (i.e.‚ painful) Bone Metastases‚ in situations where other options of treatment (chemotherapy and/or hormone therapy) are not available‚ or have not proven effective. In some cases‚ it may be used to prevent a complication like a fracture‚ or spinal cord compression‚ when such an event seems likely (although‚ not imminent – which would otherwise merit surgery as the treatment of choice).

    Typically‚ radiation is administered to the site of Bone Metastasis in the form of ‘External Beam Radiotherapy’, either as a single treatment‚ or in around 5 to 10 treatment sessions (also called as fractions) over a week to 2–week period. It is a painless and non-invasive procedure – almost like getting an X–ray.

    In some situations‚ where there are multiple Skeletal Metastases‚ external beam radiotherapy may be given to the entire upper or lower half of the body‚ and if necessary‚ 2 to 4 weeks later‚ to the whole of the other half of the body. This is called ‘Hemibody Irradiation’.

    Another type of Radiation Therapy useful in treatment of Skeletal Metastasis is called ‘Radiopharmaceutical Therapy’or ‘Internal Radiotherapy’. This method uses systemically administered radioactive isotopes‚ which is delivered intravenously or through the mouth (injected or ingested). It is best indicated for treating patients with multiple symptomatic Skeletal Metastases. In this form of treatment‚ bone seeking radioactive substances like strontium – 89 or Samarium – 153 are used‚ which accumulate in the regions of Bone Metastasis and give off radiation directly to the affected area‚ providing relief from the pain due to the metastases. A very effective and widely used Radiopharmaceutical Therapy is the use of radioactive–iodine (Iodine–131‚ which is avidly taken up by the thyroid cancer cells) in the specific treatment of metastases of some varieties of thyroid cancer.

  • Bisphosphonates: This is a class of drugs‚ which is making news in the management of Bone Metastasis. These drugs slow the bone damage caused by metastases. They are used to decrease the risk of complications like fractures‚ and to lower the abnormally high blood calcium levels (hypercalcemia) seen in some patients with Bone Metastasis. It is also suggested that bisphosphonates reduce the pain due to Bone Metastasis.
  • Surgery: The goals of surgery are‚ to preserve or restore the strength‚ stability and function of the skeletal system‚ alleviate pain‚ and preserve or restore the neurological function in cases of vertebral metastases with spinal cord compression. Surgery is usually the last resort in the treatment of Bone Metastasis.

    There are, however‚ a few situations where surgery is the best way to treat Bone Metastasis:

    • Management of fracture or impending fracture: Surgery is the best way to treat a Pathological Fracture caused by Bone Metastasis. It offers the quickest relief from this difficult situation. Surgery is also the best way to avoid a fracture and therefore‚ its consequences‚ in situations where a fracture appears imminent.
    • Relieving spinal cord compression and/or stabilization of the spine: Spinal cord compression with paralysis or weakness in the lower part of the body is perhaps the most devastating of all complications of Bone Metastasis. Spinal metastasis can also cause to instability of the spine which can cause excruciating pain. Both these conditions can confine the patient to a bed, unable to get up and be independent. In patients presenting with symptoms of spinal cord compression, surgery is the best option for relieving the pressure on the spinal cord quickly and therefore, perhaps offers the best chance of recovery of the lost power and sensation. It is also the best way to relieve the pain due to instability of the spine. Certain cases of painful vertebral body metastasis can be treated with percutaneous vertebroplasty procedures (injection of bone cement into the vertebral body through a special needle).
    • Very large bone metastasis in the extremity: Sometimes‚ the patient may come very late for the management of Bone Metastasis. The metastatic bone disease may be very large and painful. Some of these tumors may break through the skin and cause profuse bleeding which cannot be easily controlled. In all these conditions‚ amputation is a very useful choice of surgical treatment and can offer tremendous relief from pain and disability
  • Radiofrequency Ablation (RFA): In RFA‚ heat is generated at the tip of a probe that is inserted into the tumor under image guidance (fluoroscope or CT scan). This local heat‚ which is generated due to ionic agitation and resultant friction caused by a high frequency alternating current flowing through the electrodes at the tip of the probe, kills the tissues around the probe tip. RFA is a very effective alternative for treating small‚ deep seated‚ painful bone metastasis‚ especially in situations where surgery is not feasible. It can often prove helpful in controlling pain in Bone Metastasis‚ which has failed to respond to radiation and powerful painkilling medication.