Metastatic cancer to the skeleton and extremities, is a disease of the bones and soft tissue that orginated elsewhere in the body. Cancer is, by definition, a condition in which the body’s normal cells lose their normal regulatory mechanisms, and divide “out of control”, eventually spreading to other parts of the body. This is metastatic cancer. One of the frequent sites of many cancers to spread is the bones of the skeleton. Once this occurs, the bones are not only very painful, but can also become very brittle and weak, and may break with very little or even no stress. The role of the orthopaedic oncologist in these conditions is to determine what the likelihood is that the bone will break, and decide what the best treatment to prevent that is.
Preventing Pathologic Fractures from Metastatic Cancer
Prevention of cancer-related fractures, also called “pathologic fractures”, is far superior to treatment of a pathologic fracture after it occurs. Although the required operation may be the same, there is significantly more pain, healing time, and interruption of the patient’s overall cancer treatment plan once the fracture occurs. For this reason, many patients will be referred to the orthopedic oncologist even if the pain is mild or there is no pain at all. This is because the orthopaedic oncologist is the doctor best trained to identify which lesions are likely to cause a fracture and therefore should be surgically treated quickly, and which lesions can be managed with other means, such as radiation therapy or pain control plus the patient’s usual cancer medication regimen.
Radiation therapy is an excellent modality for controlling pain from a cancerous lesion in the bone that does not interfere with the strength of the bone. In these cases the patient can continue to use the limb (meaning carry and push with the arms or walk on the legs) and will be referred to a radiation oncologist for treatment of the bone lesion. One common regimen is a 10 day treatment course of radiation to the affected bone, but the exact protocol for each patient will be determined by the radiation oncologist. Radiation continues to have effect for 6-8 weeks after the treatment is completed, so even if the pain does not resolve immediately, it usually will after some time has passed. The rate of control of bone pain from a non-structural cancer lesion using radiation therapy without surgery is high, and so whenever possible we refer patients for this kind of treatment if it is clear that surgery can be avoided.
Surgery for Metastatic Cancer
Surgery for metastatic cancer to the skeleton usually involves strengthening the affected bone mechanically so that it can not break. In most cases, this involves surgically placing a metal or carbon fiber rod into the bone, like “rebar” to support it from the inside. This is typically a relatively minimally invasive operation that is done before the bone breaks. However, if the bone breaks, the operation is the same, but the recovery typically takes a lot longer, because there is actually a break that needs to heal. Other surgical treatments may include placing screws in a bone such as the pelvis, or occasionally a plate on the bone when a rod cannot be used. In some cases, bone cement is added to the area of the lesion to give additional cases, however, this is rarely needed. In most cases the patient can resume full weight bearing immediately after surgery.
Chemotherapy Before Surgery
In most cases where the patient is receiving chemotherapy, it will need to be stopped prior to the operation, and until wound healing takes place. This is accomplished by a discussion between the treatment teams to coordinate the timing. Even in the surgical cases, radiation therapy is still used, typically after the operation, to prevent the lesion from getting worse and potentially overwhelming the surgical implant.
Typically, pain is significantly improved after this type of operation. If the patient is able to, a physical therapy course is begun after surgery and continued until normal function is achieved. In addition to these treatments, a bone strengthener medication, known as XGEVA or Zometa, may be helpful in preventing additional lesions from popping up.
Dr. Abraham will typically communicate with your treating oncologist and plan out the details of timing of surgery.
Call (267)715-0700 to make an appointment.