
<b> "Bone metastases are frequently one of the first signs of disseminated disease in cancer patients. ...  the treatment is primarily palliative: the intention is to relieve pain, prevent fractures, maintain activity and, if possible, to prolong survival.</b>  Besides analgesics the therapeutic options include local treatment with radiotherapy and/or surgery, and systemic treatment using chemotherapy, endocrine therapy, radioisotopes as well as bisphosphonates. Social and psychological supportive care is also very important. Radiotherapy plays an important role, but the other modalities such as bisphosphonates may also offer the same level of palliation, but their definite role has not been as clearly defined." 
Nielsen OS.  Palliative treatment of bone metastases. Acta Oncol 1996;35 Suppl 5:58-60  
&&url PMID: 9142968 

Bone metastases are not usually directly potentially life threatening, as lung, liver or brain metastases can be.  However, they can impair the quality of life significantly through pain, fractures, and disability,   And they do add their bulk to the total tumor load, which does have influence on survival time.

Bone develops as a result of a balance between the bone cells that break down bone [osteoclasts] and the bone cells that build up bone [osteoblasts].  Tumor metastases in bone develop from interactions between the bone cells and the tumor cells, destroying the bone's ability to bear loads, initially in disruption of the bone structure and microfractures, but finally in total loss of bone integrity.  

Complications from bone metastases include bone pain, fractures, hypercalcemia [too high level of calcium in the blood, which causes weakness and can create kidney failure], and compression of the spinal cord.   Bone metastases can massively impair quality of life.

<b>Surgery, Radiation, and now Bisphosphonates are the current first line treatments of choice for stabilization, pain, and hypercalcemia respectively.  </b>

Rib fractures and the collapse of vertebrae are most common.  Vertebral collapse results in loss of height.  Multiple, severe vertebral fractures can cause humpback and curved spine, which has a further effect in restriction of lung capacity.  <b>The most disability, however, is caused by the fracture of a long bone or compression of the spinal cord.</b>

Surgical intervention is the treatment of choice for unstable vertebrae or neurologic deficit, with the excision of the tumorous bone and stabilization of the spine. Surgery is the current first line treatment of choice for stabilization.  There are other treatment options available for those who cannot undergo surgery, of invaluable use in preventing, controlling, eradicating, or palliating metastatic bone tumors.  [And probably, whatever other treatment modality they choose, patients with bony LMS lesions should probably be on Bisphosphonates.   Ed.]

Surgical intervention, external beam radiotherapy, and systemic endocrine and chemotherapy treatments have been the classical methods of treatment of metastases to bone.  However, the opportunities for improving the management of metastatic bone disease have never been greater. <b> Recent developments have occurred in all aspects of cancer management with improvements in skeletal imaging, reconstructive orthopedic surgery, and radiotherapy-particularly through the development of bone-seeking 
radiopharmaceuticals, new endocrine and cytotoxic treatments, and an increasing use of bisphosphonates to prevent and treat skeletal complications, as well as embolization, radio frequency ablation, percutaneous alcohol injection, percutaneous vertebroplasty, and new specific molecules based on cellular signaling mechanisms. </b>

<b>"Multimodal therapy of tumor patients with osseous metastases is an interdisciplinary task. </b> The surgical treatment requires optimal integration, in terms of timing and extent of the procedure, into the overall treatment plan. In addition to surgery, modern therapeutic approaches include systemic chemotherapeutic, hormonal and immunological therapy, radiotherapy, and other drug therapy (i.e. bisphosphonates). We use classical stabilization methods with plates and bone cement or intramedullary nailing and also new implants with angular stability like an internal fixator and modular endoprothesis systems in operative therapy. Such stabilizing systems allow bridging of tumor defects in almost all parts of the skeleton. <b>The ultimate goal of any treatment and especially of operative intervention is a mobile patient with little or no pain and a good quality of life."  </b>[10]

Surgery, Palliative Radiation, and now Bisphosphonates are the current first line treatments of choice for stabilization, pain, and hypercalcemia respectively.  It is this compiler's choice to include many possible treatment modalities, for situations where the usual and usually available modalities might not be effective.  Chemotherapy is best saved for inoperable metastases that are potentially life threatening, such as lung, liver, or brain.  

10: Haas NP, Melcher I, Peine R. Metastases compromising physical stability Chirurg 1999 Dec;70(12):1415-21         


<b>Increasing Incidence of Vertebral Metastases</b>
After survival time was prolonged because of the advent of doxorubicin, sarcoma patients started showing an increased incidence of brain metastases, as patients lived long enough for these metastases to seed and grow. [For more information on this, see the Brain Metastasis section of Metastatic Disease on this website.]  Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases. Likewise, <b>as survival time for LMS continues to increase, but without a cure and without effective control over tumor seeding and growth, the incidence of metastatic LMS to the spine might also increase.</b>

References:
Fukutomi M, Yokota M, et.al. <b>Increased incidence of bone metastases in hepatocellular carcinoma.</b> Eur J Gastroenterol Hepatol 2001 Sep;13(9):1083-8
Harrington KD, <b>Orthopedic surgical management of skeletal complications of malignancy.</b> Cancer 1997 Oct 15;80(8 Suppl):1614-27
