X-ray of the patient’s femoral lesion
Anteroposterior x-ray of the patient’s right leg
A 63-year-old woman with a history of stage-4 non-small-cell lung cancer presents to the emergency department with increasing pain in her right femur. The pain started 3 months ago and is present with activities and at rest. The patient denies any known injury or precipitating event. A recent computed tomography (CT) scan shows metastatic disease to her liver, adrenal glands, and pelvis. A bone scan shows increased uptake in the bilateral femurs. X-rays and CT of the right femur show cortical erosion along the diaphysis of the midshaft femur with periosteal reaction consistent with metastatic disease. The lesion involves approximately 20% of the medial femoral cortex.
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Metastatic disease is the most common cause of a destructive bone lesion in adults. Symptomatic metastases to the spine, pelvis, and extremities occur in nearly 80% of all patients who have solid tumors. Tumors frequently associated with skeletal metastases include multiple myeloma, prostate cancer, breast cancer, lung cancer, thyroid cancer, and renal cancer.
The goals of treatment for patients with metastatic disease to the bone include pain control, prevention of pathologic fracture, prevention of tumor progression, and preservation of function. Several factors influence the appropriate treatment choice, including patient preference, life expectancy, risk for pathologic fracture, and patient’s functional status. Surgical stabilization may be indicated for those with complete or impending fracture. Impending fracture risk is determined by several factors, including presence of functional pain, site of involvement, and >50% destruction of cortical bone.1 Surgical stabilization is not indicated for the patient in our case because there was <50% cortical destruction and the pain was not related to activity. It is important to note that not all long bone metastatic lesions will result in pathologic fracture; only 10% to 30% of patients with a long bone lesion will experience a pathologic fracture.2
External beam radiation therapy (EBRT) is the standard treatment for painful skeletal metastases. EBRT delivers high-dose radiation from outside the body to a focused area of tumor tissue. The treatment kills tumor cells by damaging DNA with radiation, which helps prevent tumor progression. Local-field EBRT can provide pain relief in as many as 80% of patients, with complete relief in up to 30%.2 Pain relief has been shown to last as long as 6 months in at least 50% of patients.
EBRT is often administered in one dose or in a single fraction of radiation. If surgical stabilization is performed, EBRT is administered routinely postoperatively. Often patients receiving palliative care who undergo EBRT have short life expectancies and therefore recurrence after treatment is infrequent. Bisphosphonates are frequently used as adjunct therapy for patients with metastatic disease and have been shown to reduce the risk for skeletal-related events, including pathologic fracture, spinal cord compression, and malignant hypercalcemia.3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Impending fracture and prophylactic fixation. Orthobullets. http://www.orthobullets.com/pathology/8002/impending-fracture-and-prophylactic-fixation. Updated May 25, 2015. Accessed February 22, 2016.
- Yu M, Hoffe SE. Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with metastasis. UpToDate. http://www.uptodate.com/contents/overview-of-the-epidemiology-clinical-presentation-diagnosis-and-management-of-adult-patients-with-bone-metastasis. Updated November 17, 2015. Accessed February 22, 2016.
- Coleman R. Management of bone metastases. The Oncologist. 2000;5(6):463-470.