Introduction Metastatic cancer is the most common reason for a destructive bone lesion in adults carcinomas that commonly spread to bone include breast (16-37% of breast cancer patients develop spine mets) lung (12-15%) thyroid (4%) renal (3-6%) prostate (9-15%) Epidemiology Incidence bone is the 3rd most common site for metastatic disease (behind lung and liver) Demographics metastatic bone lesions are usually found in older patients (> 40 yrs) Anatomic location common sites of metastatic lesions include spine>proximal femur>humerus most common site of mets is spine thoracic spine is most common site of bony metastasis 2nd most common site of mets is proximal femur proximal femur is most common site of fracture secondary to metastatic bone lesions 65% nonunion rate 50% in femoral neck, 20% pertrochanteric, 30% subtrochanteric Etiology Pathophysiology mechanism of bone destruction (osteolysis) osteolytic bone lesions are caused by tumor induced activation of osteoclasts occurs through the RANK, RANK ligand (RANKL), osteoprotegrin pathway PTHrP positive breast cancer cells activate osteoblastic RANKL production osteoblastic bone metastases are due to tumor-secreted endothelin 1 Associated conditions metastatic hypercalcemia a medical emergency symptoms include confusion muscle weakness polyuria & polydipsia nausea/vomiting dehydration treatment hydration (volume expansion) loop diuretics bisphosphonates Principles of metastasis Mechanism of metastasis tumor cell intravasation E cadherin cell adhesion molecule (on tumor cells) modulates release from primary tumor focus into bloodstream avoidance of immune surveillance target tissue localization attaches to target organ endothelial layer via integrin cell adhesion molecule (expressed on tumor cells) extravasation into the target tissue induction of angiogenesis via vascular endothelial growth factor (VEGF) expression genomic instability decreased apoptosis Vascular spread Batson's vertebral plexus valveless venous plexus of the spine that provides a route of metastasis from organs to axial structure including vertebral bodies, pelvis, skull, and proximal limb girdles Mechanism of bone lysis oncogenic cell releases cytokines IL-6, IL-11, PTHrP, TGF-beta PTHrP and TGF-beta activate osteoblasts osteoblasts secrete RANKL, that binds to RANK on osteoclasts and activates osteoclasts Mechanism of bone sclerosis (prostate and breast mets) prostate cancer cells secrete endothelin 1 (ET-1) ET-1 binds to endothelin A receptor (ETAR) on osteoblasts and stimulates osteoblasts ET-1 decreasesWNT suppressor DKK-1 activates WNT pathway, increasing osteoblast activity Classification Tokuhashi score specific to metastatic disease to spine prognostic score based on 6 elements: general condition, extraspinal bony metastasis, number of vertebral bodies with metastasis, visceral metastasis, primary tumor, neurologic compromise score of 0-8: <6 months; 9-12 > 6 months, 12-15 >1 year Symptoms Symptoms pain axial night pain may be mechanical pain due to bone destruction or tumorigenic pain which often occurs at night metastatic hypercalcemia Physical exam neurologic deficits caused by compression of the spinal cord with metastatic disease to the spine hyper-reflexia Evaluation Workup for older patient with single bone lesion and unknown primary includes imaging AP and lateral of spine in region of pain CT of chest / abdomen / pelvis technetium bone scan to detect extent of disease myeloma and thyroid carcinoma are often cold on bone scan - evaluate with a skeletal survery labs CBC with differential ESR basic metabolic panel LFTs, Ca, Phos, alkaline phosphatase serum and urine immunoelectrophoresis (SPEP, UPEP) biopsy in patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to rule out a primary bone lesion should not treat a bone lesion without tissue diagnosis of the lesion metastatic adenocarcinoma not identified by CT of the chest, abdomen, and pelvis is most likely from a small lung primary tumor See table of evaluation algorithms based on patient factors Imaging Radiographic recommended views AP and lateral of involved area off spine findings purely lytic or mixed lytic/blastic lesions lung, thyroid, and renal are primarily lytic 60% of breast CA is blastic 90% of prostate CA is blastic CT scan helpful to identify metastatic lesions to the spine MRI useful to show neurologic compromise of the spine Studies Histology characteristic findings epithelial cells in clumps or glands in a fibrous stroma immunohistochemical stains positive Keratin CK7 (breast and lung cancer) TTF1 (lung cancer) Treatment General considerations NOMS framework: neurologic, oncologic, mechanical instability, systemic illness neurologic: measure of epidural spinal cord compression (ESCC) 0-1 low grade, 2-3 high grade oncologic: responsiveness to radiation mechanical instability: spinal instability neoplastic score (SINS) SINS: 0-6 no surgical consultation required, 7-18 surgical consultation advisable systemic illness: formulation of prognosis from disease burden, medical comorbidities, functional status Nonoperative palliative care indications life expectancy of < 6 months Tokuhashi scoring system can be used to determine life expectancy radiation alone indications may be indicated in patients who are not surgical candidate no signs of neural compression, neurologic deficit, or instability Operative neurologic decompression, spinal stabilization, and postoperative radiation indications metastatic lesions to spine with neurologic deficits in patients with life expectancy of > 6 months technique preoperative embolization indicated in metastatic renal and thyroid CA to spine Complications Recurrence Hardware failure and spinal instability Nonunion of fracture Wound complications Immediate soft tissue reconstruction has a lower complication rate than delayed reconstruction in patients undergoing revision metastatic spine tumor surgery Prognosis Median survival in patients with metastatic bone disease thyroid: 48 months prostate: 40 months breast: 24 months kidney: variable depending on medical condition but may be as short as 6 months lung: 6 months Tokuhashi score (see classification section)
QUESTIONS 1 of 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Previous Next (SBQ18SP.15) A 68-year-old male with a history of colon cancer presents with worsening thoracic back pain, incontinence, and lower extremity weakness and numbness. Figure A is an MRI of the thoracic spine. Figure B is the tissue biopsy of the lesion. Which of the following statement is true regarding her condition? QID: 211267 FIGURES: A B Type & Select Correct Answer 1 On physical exam he will likely have hyper-reflexic patellar tendon reflexes 61% (1081/1782) 2 Tumor cells localize to vertebral body via binding osteocalcin 8% (151/1782) 3 Osteolytic lesions are due to local release of endothelin-1 5% (81/1782) 4 Radiation should be performed followed immediately by surgical decompression 11% (189/1782) 5 Embolization should be performed before surgical decompression 15% (260/1782) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ18SP.17) A 59-year-old female patient with a history of metastatic breast cancer presents with increasing lower back pain that has worsened over the last 2 months She denies any motor weakness in the lower extremities, numbness, tingling, or any bowel and bladder changes. Figure A shows the current radiographs of the lumbar spine. Figures B, C, and D are the MRI images of the lumbar spine. Figure E is a recent biopsy of one of the lesions seen on imaging. What would be the most appropriate treatment for the spinal lesions? QID: 211289 FIGURES: A B C D E Type & Select Correct Answer 1 Embolization 3% (58/1696) 2 Laminectomy with posterior spinal fusion 5% (81/1696) 3 External beam radiation 84% (1421/1696) 4 Anterior column reconstruction with posterior stabilization 7% (125/1696) 5 Hemilaminectomy 0% (4/1696) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ18SP.49) What factor has been shown to improve outcomes in revision metastatic spine surgery? QID: 211641 Type & Select Correct Answer 1 Preoperative radiation therapy 37% (611/1644) 2 Surgery at greater than 6 levels 10% (157/1644) 3 Tobacco use by patient 5% (83/1644) 4 Immediate soft tissue reconstruction 38% (619/1644) 5 Utilization of posterior approach 10% (166/1644) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ18.230) A 48-year-old woman with a history of chronic low back pain, narcotic dependence for 2 years, and recent IV drug abuse presents to the emergency room with worsening low back pain. She denies fever and chills, pain in her neck, or pain in her lower extremities. Physical exam shows normal strength, a negative Hoffman sign, 2+ patellar reflexes, and flexion of the 1st toes with a Babinski exam. Laboratory studies show a WBC of 12,000, a CRP of 3 mg/L, and an ESR of 13 mm/h. Plain radiographs are obtained and depicted in Figures A and B. What is the most appropriate next step in management? QID: 213126 FIGURES: A B Type & Select Correct Answer 1 CT of the chest, abdomen, and pelvis 55% (1083/1966) 2 MRI of the cervical spine 8% (166/1966) 3 Blood cultures and empiric IV antibiotics 17% (331/1966) 4 NSAIDS and physical therapy with close follow-up with a spine surgeon in 2 weeks 19% (366/1966) 5 Kyphoplasty 0% (5/1966) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12SP.100) Which of the following tumors are most likely to cause the condition seen in Figure A? QID: 3798 FIGURES: A Type & Select Correct Answer 1 Breast, Renal, Osseous, Lung 5% (148/2823) 2 Breast, Hepatic, Colon, Lung 3% (82/2823) 3 Breast, Osseous, Renal, Hepatic 1% (26/2823) 4 Breast, Renal, Prostate, Lung 85% (2401/2823) 5 Breast, Renal, Prostate, Colon 5% (150/2823) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12SP.78) A 60-year-old female presents with a 2-month history of low back pain. Imaging is seen in Figures A and B. Which of the following is LEAST likely to be true? QID: 3776 FIGURES: A B Type & Select Correct Answer 1 This patient is positive for mutations in the BRCA1 gene 9% (288/3360) 2 The patient is positive for mutations in the APC gene and has a positive guaiac-based fecal occult blood test (gFOBT) 34% (1133/3360) 3 The patient has a 30 pack year smoking history 6% (214/3360) 4 The patient presents with an ataxic gait, limb weakness, and is found to have a mutations of the von Hippel–Lindau tumor suppressor (VHL) gene 36% (1195/3360) 5 The patient presents with confusion, generalized weakness, and total serum calcium level of 12.1 mmol/L 15% (505/3360) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (SBQ12SP.65) Which of the following metastatic tumours should be treated with embolisation prior to surgical management? QID: 3763 Type & Select Correct Answer 1 Renal, thyroid 94% (3091/3283) 2 Breast, renal 2% (70/3283) 3 Liver, breast 1% (36/3283) 4 Lung, colon 1% (34/3283) 5 Prostate, thyroid 1% (42/3283) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.162) A 62-year-old male patient presents with severe lower back pain radiating to his right lower abdomen and right leg. He previously underwent a right nephrectomy for renal cell carcinoma. On physical exam, he has weakness with right knee extension which is affecting his ability to ambulate. An MRI is performed and is shown in Figures A and B. Staging studies determine this to be an isolated metastatic lesion. What is the next best step in this patient's treatment? QID: 4522 FIGURES: A B Type & Select Correct Answer 1 Chemotherapy alone 1% (36/5462) 2 Radiation alone 3% (142/5462) 3 Vertebroplasty 1% (48/5462) 4 Embolization, surgical decompression and stabilization followed by radiation 87% (4765/5462) 5 Surgical decompression and stabilization followed by radiation 8% (441/5462) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.124) A 68-year-old male presents to the emergency room with neck pain and progressive weakness to the point that he is unable to walk. Prior to this event he was in good health and active. On physical exam he is an ASIA C. Radiographs, computed tomography, and an MRI are show in Figure A,B, and C respectively. A CT of the chest, abdomen, and pelvis shows a single resectable lesion in the rectum consistent with a primary malignancy. Sagittal images of the spine show a single metastatic lesion in the thoracic spine, but no signs of thoracic canal compromise. He has no other metastatic bone lesions. What is the best treatment for this patient? QID: 4484 FIGURES: A B C Type & Select Correct Answer 1 Surgical decompression and stabilization followed by radiation 76% (3495/4611) 2 Radiation followed by surgical decompression and fusion 14% (664/4611) 3 Radiation alone 5% (226/4611) 4 Chemotherapy alone 1% (45/4611) 5 Palliative measures 3% (144/4611) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ09SN.21.1) A 50-year-old woman with a history of metastatic breast cancer reports progressive back pain and lower extremity weakness over the past 2 weeks. The weakness has progressed to a point where she can only ambulate short distances with a walker. A sagittal T2-weighted MRI scan is shown in Figure A, and a sagittal contrast-enhanced T1-weighted MRI scan is shown in Figure B. Her cancer is found to be positive for a chromosomal translocation and the oncology team expects her to respond well to targeted therapy with a life expectancy of more than 3 years. What would be the most appropriate definitive treatment for this patient? QID: 9110 FIGURES: A B Type & Select Correct Answer 1 Palliative chemotherapy and radiation 1% (15/1670) 2 Targeted radiation therapy 2% (26/1670) 3 Laminectomy alone with posterior instrumented fusion with immediate pre-operative and post-operative radiation therapy 11% (187/1670) 4 Corpectomy and anterior column reconstruction, followed by posterior instrumented fusion 83% (1385/1670) 5 Kyphoplasty with TLSO bracing, followed by biopsy-targeted medical management 2% (39/1670) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.83) You are caring for a 63-year-old female with metastatic breast cancer to the lumbar spine. Her neurological examination shows significant weakness in leg function and she is having difficulty ambulating. Imaging shows significant neural element compression by the tumor and complete erosion of the L1 vertebrae. She has no other sites of metastatic disease and is otherwise healthy. What treatment option do you recommend to best maintain her function? QID: 2896 Type & Select Correct Answer 1 Palliative therapy 1% (40/3648) 2 Complete neural element decompression 0% (13/3648) 3 Complete neural element decompression with instrumentation to stabilize the spine 9% (338/3648) 4 Complete neural element decompression, instrumentation, and postoperative chemotherapy 23% (846/3648) 5 Complete neural element decompression, instrumentation, and postoperative radiotherapy 66% (2403/3648) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ09.51) A 59-year-old female with a history of biopsy proven metastatic renal cell carcinoma presents with a thoracic spine lesion consistent with renal cell carcinoma. She has lower extremity weakness and sustained clonus bilaterally. What is the most appropriate management prior to surgery? QID: 2864 Type & Select Correct Answer 1 Blood cultures 0% (12/2608) 2 High dose IV methylprednisone 3% (83/2608) 3 Arterial embolization 89% (2310/2608) 4 CT guided cryotherapy 2% (46/2608) 5 Radiation therapy 6% (150/2608) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.66) A 47-year-old female, otherwise in good general condition, has intractable back pain from metastatic breast cancer isolated to her spine. She has failed progressive multi-agent chemotherapy and hormone therapy. Her exam is normal except for slight sensory dysesthesia, hyperreflexic patellar tendons, and mild gait instability which she reports has been worsening. Cervical, thoracic, and lumbar MRI show an isolated metastatic lesion involving the T9 vertebral body with moderate cord compression of the ventral spinal cord. At this stage what is the best treatment? QID: 452 Type & Select Correct Answer 1 Change chemotherapy protocol to Cyclophosphamide, Hydroxydanurubicin, Oncovin, Prednisone 1% (13/1712) 2 Posterior spinal decompression after vertebral body kyphoplasty 5% (94/1712) 3 Thoracic corpectomy, instrumented spinal fusion, and postoperative radiotherapy 81% (1394/1712) 4 Radiation therapy 11% (187/1712) 5 Palliative care unit 1% (15/1712) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ08.204) A 67-year-old retired male custodian complains of progressively worsening low back pain over the past 6 months. He has not seen a doctor in the past 15 years. He admits to a 40 pack year smoking history, fatigue, and an unintentional 15 pound weight loss over the past year. A radiograph of the pelvis is provided in Figure A. Which of the following would most likely confirm the diagnosis? QID: 590 FIGURES: A Type & Select Correct Answer 1 Urine immunoelectrophoresis (UPEP) 13% (221/1723) 2 Thyroid biopsy 1% (11/1723) 3 CBC and blood smear 3% (56/1723) 4 Prostate biopsy 81% (1391/1723) 5 Renal ultrasound 2% (37/1723) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ07.111.1) A 70-year-old female has unrelenting lower back pain and severe left anterior thigh pain. She has hip flexion weakness on the left that is limiting her ambulation. A representative image from her abdominal CT (Figure A) as well as a sagittal MRI of her spine (Figure B) is shown below. Nonoperative management has failed. She undergoes a biopsy of her spinal lesion, which is depicted in Figure C. What is the next appropriate step in management? QID: 214192 FIGURES: A B C Type & Select Correct Answer 1 Percutaneous kyphoplasty 1% (12/1738) 2 Preoperative embolization of spinal lesion the morning of corpectomy and stabilization 89% (1548/1738) 3 External beam radiation 4% (73/1738) 4 Postoperative embolization of spinal lesion the morning after anterior corpectomy and stabilization 2% (43/1738) 5 Immediate anterior corpectomy and stabilization of the spine 3% (53/1738) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ05.207) A 59-year-old female presents with a metastatic spinal tumor and has a lytic lesion in the T12 vertebral body. The process of bone resorption in her lytic lesion is mediated by QID: 1093 Type & Select Correct Answer 1 Direct resorption of bone by tumor cells 2% (26/1169) 2 Neoangiogenesis of the vertebral body 1% (16/1169) 3 Macrophage-mediated bony destruction 7% (77/1169) 4 Tumor induced activation of osteoclasts 89% (1035/1169) 5 Necrosis of the vertebral body 1% (9/1169) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
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