Bone metastasis

Bone metastases are formations that are secondary to malignant tumors such as: myeloma, breast cancer, prostate cancer, lung cancer, kidney cancer, thyroid cancer, and non-Hodgkin's lymphoma.

Oncologists claim that most often the formation of metastases in the skeletal system is observed during the development of malignant tumors in the gastrointestinal tract, ovaries, cervix, and soft tissues.

The process of metastasis is the penetration of malignant tumor cells and their reaching any organs and tissues, as well as bone tissue, due to their circulation in the blood and lymphatic vessels.

When a patient is healthy, bone tissue is renewed in the body. It is characterized by cyclic resorption and bone formation. This process is caused by two types of cells: osteoclasts, which perform the function of destroying or absorbing bone tissue, and osteoblasts, which are responsible for its formation.

It is unlikely that anyone needs to spend much time proving the importance and role of bones and bone tissue in the human body, but we can outline several of their main purposes:

• the function of the frame in the human body;
• the function of storing minerals necessary for the body – calcium, magnesium, sodium, phosphorus;
• The bone marrow produces and stores most blood cells (red blood cells, white blood cells, platelets).

When cancer cells penetrate bone tissue, the functioning of the bones is affected, healthy cells are displaced, the interaction between such components as osteoclasts and osteoblasts is disrupted, thereby their work is separated. Depending on the pathogenesis, the division of bone metastases occurs into osteolytic (osteoclasts are activated, nothing happens to osteoblasts, which causes pathological bone resorption) and osteoblastic (osteoblasts are activated, and pathological bone formation occurs). With mixed metastases, both osteoclasts and osteoblasts are activated simultaneously.

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Symptoms of Bone Cancer Metastasis

The main symptoms of cancer metastases to the bones are:

• presence of bone pain;
• limited mobility in the area affected by metastases.

In addition, spinal cord compression often occurs, causing numbness in the limbs and abdominal area, patients often complain of problems with urination, signs of hypercalcemia increase, causing the patient to experience bouts of nausea, thirst, decreased appetite, and increased fatigue. The pathogenesis of bone metastases can be completely different, so in some cases clinical manifestations may even be absent.

Bone metastases in kidney cancer

When a patient is diagnosed with kidney cancer, bone metastases manifest themselves as pain where the affected bone is projected. In addition, pathological bone fractures also occur, the spinal cord is compressed, and palpation reveals formations.

Bone metastases in lung cancer

Lung cancer is often complicated by metastases to the bones, especially to the spine. The blood supply to the body largely affects bone tissue, since the blood flow brings various microelements to the bone, including tumor cells, which, upon entering the bone tissue, soon begin to destroy it. The destruction of bone tissue makes it fragile, which is why fractures occur so often.

Bone metastases usually occur where there is a good blood supply: these are the areas of the ribs, humerus and costal bones, cranial, pelvic and vertebral bones. The most dangerous thing in all this is that there are no symptoms at first, and when pain occurs, it may be too late. Bone metastases in lung cancer are mainly manifested by the symptom of hypercalcemia, then the patient has dry mouth, nausea, vomiting, excessive urine formation, which disturbs consciousness.

Breast cancer and bone metastases

Using the lymphatic and blood vessels as a route, the cancerous tumor metastasizes to various organs, including various bone sections.

Bone tissue is the place where breast cancer metastases occur quite often, along with such areas as the ovaries, lungs, brain, liver, etc.

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Prostate cancer and bone metastases

One of the most common cancer localizations, as a result of which metastases are formed in the bones, is the prostate gland. However, primary metastases in the bones from prostate cancer are formed extremely rarely. Metastasis due to prostate cancer occurs when the tumor disease is already in a late stage.

Metastases from prostate cancer usually affect the femur, lumbar spine, thoracic spine, pelvic bones, etc.

Metastases to the bones of the spine

If metastases have occurred in the bones of the spine, then any physical activity is contraindicated, lifting heavy objects is strictly prohibited, and rest is needed several times a day.

Metastases to the bones of the hip and pelvis

When metastases have formed in the femur, pelvic bone, it is necessary to avoid putting stress on the leg that was affected. It is good to use a cane or crutches during this period.

Metastases are often localized in the pelvic bones and hip joints. This area is second only to the spine in terms of bone metastases. When a patient is diagnosed with prostate cancer, the pelvic bones are the first to be affected by metastases, sometimes even before the spine is affected. This area is the site of metastasis from such forms of cancer as breast cancer, malignant tumors of the thyroid and parathyroid glands, prostate cancer, lung cancer, liver cancer, lymph node cancer, kidney cancer, uterus cancer, and cancer of the urinary system.

Metastases to the bones of the extremities

The extremities are the third most common area where cancer of various forms metastasizes. The shoulder area is most often affected by thyroid cancer and malignant breast tumors, lung cancer, colon and rectal cancer, liver cancer and biliary tract cancer. If a pathological fracture occurs in the shoulder area, this may be the first "alarm bell" of the above-mentioned diseases. The humerus may also be metastasized when the patient suffers from melanoma, cancer of the urinary system, malignant chemodectoma (paraganglioma), lymphogranulomatosis.

The radius and ulna are mainly affected when a cancerous tumor of the breast, lungs, and kidneys is diagnosed. The hand can be metastasized when a cancerous tumor affects the thyroid and mammary glands, colon, kidney, liver, prostate gland, and bladder. In addition, the cause of such metastasis can be melanoma, lymphogranulomatosis, malignant heodectoma, primary periosteal sarcoma (which originates from the jaws, or more precisely, the lower section), liposarcoma in soft tissues.

The tibia is mostly affected by lung cancer, the fibula - when the colon and prostate gland are affected. Breast cancer can metastasize to the bones of the foot.

Metastases to the bones of the skull

When metastasis occurs in the skull, its vault and base are mainly affected, often in the presence of damage to the bones of the face. Very often, metastases are detected even before the primary malignant tumor is detected. In most cases, this occurs when kidney cancer is subsequently diagnosed.

Metastases in the bones of the vault and base, using the hematogenous route, usually cause malignant tumors of the mammary glands, cancer of the thyroid and parathyroid glands, colon, prostate, lungs, as well as the presence of sympathoblastoma, retinoblastoma in the patient.

When a single metastasis is diagnosed in the cranial bones, specialists strongly recommend examining other organs to immediately exclude the possibility that they were also affected. If by that time it is still unknown which location was affected by the primary malignant tumor, then at first they suspect that the kidney, mammary gland, thyroid gland, liver are affected by cancer. If a similar situation happened to a child, then they suspect retinoblastoma and medulloblastoma.

When metastases form in the bony parts of the face, the paranasal sinuses, upper and lower jaws, and eye sockets are affected. Metastasis of the paranasal sinuses most often occurs due to kidney cancer.

Cranial metastases may also appear in the upper jaw; both jaws are usually not affected at the same time.

The orbit can be affected by metastases from breast cancer, kidney cancer, thyroid cancer, adrenal cancer, melanoma. When X-rayed, the appearance of such metastases usually resembles a retrobulbar tumor.

Diagnosis of bone cancer metastases

In order to diagnose cancer metastases to bones, their prevalence and the level of neglect of the case, skeletal scintigraphy is performed. Thanks to it, bone metastases can be detected in any corner of the human skeleton. In addition, such a study is effective even in very short terms, at a time when there are not many metabolic disorders in the bones. Therefore, bisphosphonates can be prescribed on time, or even in advance, because scintigraphy plays an extremely important role.

As for X-ray examination, the initial stages of metastasis will not provide sufficient information. It becomes possible to determine the size of the lesion and its exact location in the bones only when the metastatic formation matures, and this happens when the bone mass is already half destroyed.

X-ray examination of bone metastases makes it possible to differentiate the types of metastases during diagnosis. The presence of dark spots (loose zones) in gray-white bone tissue indicates the presence of lytic metastases. With white spots on the images, which are somewhat lighter in tone than the bone tissue (with a dense or sclerotic area), we can conclude that we are dealing with blastic metastases.

When conducting a radioisotope study of the skeletal bones (osteoscintigraphy), a gamma camera is used to study the surface of the entire body. Two hours before this, a specific osteotropic radiopharmaceutical Rezoskan 99m Tc is administered. With the help of this diagnostic technology, pathological foci of hyperfixation of this drug in the bones are determined. It is also possible to visualize how widespread or isolated the metastatic process is and to ensure the presence of dynamic control, how the treatment is carried out using biophosphonates.

In addition, computed tomography is used to diagnose cancer metastases to bones. CT biopsy is performed by means of computed tomography, but it can only detect ostelial foci.

Magnetic resonance imaging is also used to detect cancer metastases in bones.

Laboratory testing can determine markers of bone resorption in urine (the ratio of urinary N-terminal telopeptide to creatinine), the amounts of calcium and alkaline photophosphatase in the blood serum.

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Treatment of bone metastases of cancer

If bone metastases are treated in a timely manner, new foci of bone metastasis occur less frequently, and patient survival increases. Since skeletal complications (pain syndrome, pathological fractures, spinal cord compression, hypercalcemia) occur less frequently, it becomes much easier for them to live, which is also an important achievement.

Conducting systemic drug therapy includes antitumor therapy (use of cytostatics, hormone therapy, immunotherapy) and maintenance therapy - treatment with biophosphonates and analgesics. Locally, bone metastases are treated with radiation therapy, surgery, radiofrequency ablation, cementoplasty.

Patients who have bone metastases are treated with completely different methods; there is no universal one. Each patient is prescribed their own treatment, paying attention to how the disease progresses and where exactly the metastases are located.

The use of physiotherapeutic procedures is not practiced. Only in cases where the doctor has approved it is permissible to perform physical exercises.

Pain relief for bone metastases of cancer

When bone tissue of one or two areas contains bone metastases, the most effective treatment method, which also has an analgesic effect, is radiation therapy. Eighty-five percent of cases where radiation therapy was used are characterized by an analgesic effect that lasts for quite a long time. In addition, when metastases are found in the bone, anti-inflammatory and opioid drugs have proven to be very effective.

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Chemotherapy for bone metastases

Chemotherapy for bone metastases, hormonal therapy, target therapy - all these methods are also characterized by a positive effect. Also, specialists recommend combining these methods, using in addition radiation irradiation, which usually affects one or more bone metastases, which are characterized by causing the greatest pain. Radiation therapy can also be carried out in such a form when radioactive strontium-89 is administered intravenously, in which case bone metastases begin to absorb it. The use of drugs such as "Zometa" and "Aredia" also relieve pain from cancer metastasis to bones by improving bone structure. They practice such a method as immobilizing (immobilizing) the diseased limb.

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Treatment of bone metastases with biophosphonates

In the treatment of bone metastases, intravenous and oral biophosphonates are used. The drugs that are administered intravenously include Zometa (zoledronic acid) and Bondronate (ibandronic acid). Oral administration includes Bonefos (clodronic acid) and Bondronate in tablets.

Treatment of bone metastases with Zometa

Zometa is the most effective drug of the biophosphonate group, is an intravenous nitrogen-containing biophosphonate of the third generation. It is active in the presence of any of the known types of metastasis: in the presence of lytic, blastic, mixed metastases to the bones. Zometa also gives an effect in patients who have hypercalcemia due to tumor development, as well as osteoporosis

Zometa is characterized by a selective action, which is "felt" by bone metastases. Zometa is characterized by penetration into bone tissue, concentration around osteoclasts, causing their apoptosis, reducing secretion, which occurs due to lysosomal enzymes. Due to the action of the drug, the adhesion of tumor cells in bone tissue is disrupted and tumor resorption in bone is disrupted. An important difference from other drugs of the biophosphonate class is that Zometa causes inhibition of vascular neoplasms in tumor cells (the presence of an antiageogenic effect), and also because of it their apoptosis occurs.

Zometa is usually presented as a concentrate for infusions. One bottle usually contains four milligrams of the active substance (zoledronic acid). This is the dose that is administered at one time. Before administering to the patient, the concentrate is diluted in one hundred milliliters of saline. Intravenous infusion occurs within fifteen minutes. If the solution was prepared in advance but not used, then it can be stored for twenty-four hours at a temperature of +4 - +8 ° C. The frequency and severity of side effects of Zometa are similar to other intravenous biophosphonates, that is, the entire drug group is characterized by similar adverse effects. When using Zometa, in rare cases, the temperature may rise, muscles and back may hurt. The presence of a flu-like syndrome is noted during the first two days after the infusion of Zometa was performed. But it can be easily stopped if you take non-specific anti-inflammatory drugs. The gastrointestinal tract may react to Zometa, causing nausea and vomiting. Redness and swelling at the site where Zometa was injected intravenously have been observed in very rare cases, and symptoms resolve within one to two days.

Bone metastases are a diagnosis for which a drug such as Zometa is one of the most widely used. It gives good results not only when lytic and mixed metastases are observed, but also when we are dealing with blastic foci.

Zometa is prescribed immediately after bone metastases have been detected. This drug is used for a long time, usually in combination with other methods of treating bone metastases - chemotherapy, hormone therapy, radiation therapy.

The American Society of Clinical Oncologists' recommended course of Zometa treatment is:

• two years, when prostate cancer with bone metastasis is observed;
• one year for breast cancer with bone metastasis, as well as if multiple myeloma is observed;
• nine months if bone metastases are caused by various other significant tumors.

Intravenous infusions of Zometa 4 mg are administered every three to four weeks.

Effects that are observed as a result of using the drug Zometa:

• anesthesia;
• increasing the amount of time that passes before the first bone complication appears;
• reducing the frequency of complications in bone tissue and the likelihood that they will occur;
• prolongation of the interval between the occurrence of the first complication and the occurrence of the second;
• Zometa's antiresorptive properties and its ability to enhance the effects of antitumor drugs help to increase the duration and improve the quality of life of patients facing the problem of bone metastasis.

Treatment of bone metastases with Bondronat

Bondronat (ibandronic acid) is a drug belonging to the class of biophosphonates, with the help of which patients with the problem of metastasis in bone tissue due to the development of malignant tumors are treated. Along with Zometa and Bonefos, it is one of the most widely used drugs used for this diagnosis. An important advantage of Bondronat compared to other biophosphonates is the ability to use it both intravenously and orally.

Bondronat is prescribed when the patient has metastatic bone lesions to reduce the risk of hypercalcemia, pathological fractures; also to reduce pain, reduce the need for radiation therapy if there is pain syndrome and a risk of fractures; the presence of hypercalcemia in malignant tumors.

Bondronat exists in two forms - it is administered intravenously and taken orally. When administered intravenously, drip infusions are used in a hospital setting. Bondronat is diluted to obtain a special solution. To prepare it, 500 ml of 0.9% sodium chloride solution or 5% dextrose solution are required, in which Bondronat concentrate is diluted. The infusion is carried out one to two hours after the solution is prepared.

If we are dealing with Bondronat tablets, they are taken half an hour before meals or drinks, as well as other medications. The tablets must be swallowed whole, washed down with a glass of water, and it is necessary that the patient is in a "sitting" or "standing" position, and then an hour after that, do not take a horizontal position. Chewing and sucking tablets is contraindicated, as oropharyngeal ulcers may form. Also, these tablets cannot be washed down with mineral water, which contains calcium in large quantities.

When Bondronat is used for metastatic bone lesions in breast cancer, the drug is most often used as an infusion, with 6 mg administered intravenously over fifteen minutes every three to four weeks. The concentrate for the preparation of an infusion solution is diluted in 100 ml of 0.9% sodium chloride or 5% dextrose solution.

For the treatment of hypercalcemia in cancerous tumors, intravenous infusions are administered over a period of one to two hours. Bondronat therapy begins after adequate hydration with 0.9% sodium chloride solution. The severity of hypercalcemia determines the dose: in its severe form, 4 mg of Bondronat is administered, moderate hypercalcemia requires 2 mg. The maximum dose that can be administered to a patient at one time is 6 mg of the drug, but increasing the dose does not increase the effect.

The main difference from Zometa and an important advantage over this drug lies in the absence of a negative effect of Bondronat on the kidneys.

Treatment of bone metastases with Bonefos

Bonefos is a bone resorption inhibitor. It enables inhibition of bone resorption in tumor processes and bone metastases. It helps suppress osteoclast activity and reduce serum calcium levels. In patients with bone metastases, pain is reduced, progression of the metastasis process is delayed, and new bone metastases do not develop. The use of Bonefos may be caused by osteolysis due to malignant neoplasms: myeloma disease (multiple myeloma), cancer metastases to bone (breast cancer, prostate cancer, thyroid cancer), hypercalcemia in cancerous neoplasms.

Bonefos is a powerful agent for the treatment of metastasis in breast cancer. Bonefos helps to reduce bone pain; reduce the likelihood of severe hypercalcemia developing. Bonefos is characterized by good gastrointestinal tolerance and lack of nephrotoxicity.

In case of hypercalcemia caused by tumor processes, Bonefos is administered intravenously by infusions in the amount of 300 mg during the day. For this purpose, a special solution is prepared from the contents of the ampoule and 500 ml of 0.9% sodium chloride solution or 5% glucose solution. The infusion is carried out daily for two hours for five days, but not more than a week.

After the serum calcium level has normalized, Bonefos is taken orally at 1600 mg per day.

When hypercalcemia is treated with Bonefos tablets or capsules, therapy usually begins with high doses of about 2400-3200 mg per day and the doctor gradually reduces the daily dose to 1600 mg.

In case of osteolytic changes in bones caused by the occurrence of malignant tumors without hypercalcemia, the specialist selects the dosage of Bonefos on an individual basis. Usually they start with 1600 mg orally, sometimes the dose is gradually increased, but it is calculated so that it does not exceed 3600 mg per day.

Bonefos 400 mg capsules and tablets are swallowed whole. 800 mg tablets can be divided into two parts to make them easier to swallow, but crushing and dissolving them is not recommended. 1600 mg Bonefos is taken in the morning on an empty stomach, the tablets should be washed down with a glass of water. For two hours after taking the drug, you should refrain from eating and drinking, as well as from taking other medications. In the case of a dose exceeding 1600 mg, it is divided into two doses. The second dose should be taken between meals, so that two hours have passed after the meal or an hour remains before it. Milk, as well as food containing calcium or other divalent cations that interfere with the absorption of clodronic acid, the main substance of the drug, are strictly prohibited. If the patient suffers from renal failure, the daily oral dose of Bonefos should not exceed 1600 mg.

Prognosis for bone metastases

There is a table of the frequency of bone metastases in patients suffering from various tumors. According to it:

• in breast cancer, the incidence of metastasis is 65-75%, survival from the moment bone metastases are detected is from nineteen to twenty-five months;
• When a patient is diagnosed with prostate cancer, metastases can develop in 65-75%, the patient can live another year to thirty-five months;
• In lung cancer, metastases develop in thirty to forty percent of cases, and survival from the moment they are detected is six to seven months.

Life expectancy with bone metastases

• Bone metastases detected as a result of kidney cancer result in the patient having about a year to live; the incidence of metastases in this form of cancer is twenty to twenty-five percent;
• Bone metastases from thyroid cancer occur in sixty percent of cases, in which case the median patient survival is forty-eight months;
• The incidence of blood metastases in melanoma ranges from fourteen to forty-five percent, and the median survival from the moment the presence of bone metastases is detected is six months.

Bone cancer metastases are an unpleasant and life-threatening situation, but not a final verdict. The main thing with bone metastases is to understand that this is not the end. If they are detected in time, then it is possible to save the life of a cancer patient and the ability to fully function, work, etc. If you completely trust the doctor and follow everything he prescribes. Timely use of prescribed medications, sleep patterns, and eat properly.

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