Bone Metastases – Diagnosis & Treatment
Hematological / Oncological
The most common site for bone metastases is the vertebra. Although it also occurs in long bones, pelvis, ribs, sternum, and skull.
Complications of bone metastasis are called skeletal-related events (SREs) and include most commonly bone pain, pathologic fractures and hypercalcemia, and less commonly nerve root or spinal cord compression.
Spine Instability Neoplastic Score (SINS) can help determine the need for a surgical referral based on stability of pathologic spinal fractures.
- Breast, prostate, and lung cancer make up near 80% of bone metastases.
- Also kidney, lymphoma, multiple myeloma, thyroid.
- Bone pain attributed to metastases is the principal source of cancer-related pain and can severely impact quality of life.
Investigations in the ED
- Imaging: High-risk fracture features for the potential to develop a pathological fracture include painful lesion, >2.5cm in size and >50% of the bone is involved.
- Xray: useful but misses less severe bone metastases.
- CT: more sensitive (74%).
- MRI: 95% sensitivity and 90% specificity for bone metastases and can also detect cord compression (6).
- Specific labs: CBC, Cr/GFR, Calcium, ALP, Serum Protein Electrophoresis (SPEP), UPEP, ECG.
- Benign bone tumor.
- Malignant bone tumor.
- Infection (osteomyelitis).
- Initial trial with NSAIDs and acetaminophen with step-up to opioids as needed in the setting of acute pathologic fractures and associated pain.
- IV fluids are the key.
- Ensure adequate renal function.
- May initiate bisphosphonate therapy in ED if severe hypercalcemia and cardiac instability.
- Alternately zoledronic acid 4mg IV over 15mins or pamidronate 60 – 90 mg IV over 2 hours.
- Moderate asymptomatic hypercalcemia can treated with fluids and calcitonin 4 IU/kg IV.
- Inpatient vs outpatient decision based on:
- Unstable fractures.
- Extent of metastases.
- Spinal cord compromise.
- Referral to specialists (surgery and oncology).
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
There is wide spread agreement in the studies about what is included in skeletal-related events and how they should be managed. There is little variation between studies in the diagnosis and treatment of bone metastases and their complications.
Spinal Instability Neoplastic Score: An Analysis of Reliability and Validity From the Spine Oncology Study Group.
Fourney DR, Frangou EM, Ryken TC, Dipaola CP, Shaffrey CI, Berven SH, et al. 2011 Aug [cited 2021 Apr 10];29(22):3072–7.
J Clin Oncol [Internet]
A Novel Classification System for Spinal Instability in Neoplastic Disease From the Spine Oncology Study Group.
Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. (October 15, 2010 – Volume 35 – Issue 22 – p E1221-E1229)
*Combined Neurosurgery and Orthopaedic Spine Program
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jun 01, 2021
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