Chapter 094. Soft Tissue and Bone Sarcomas and Bone Metastases (Part 7) ppsx

Chapter 094. Soft Tissue and Bone Sarcomas
and Bone Metastases
(Part 7)

Cancer in the bone may produce osteolysis, osteogenesis, or both.
Osteolytic lesions result when the tumor produces substances that can directly
elicit bone resorption (vitamin D–like steroids, prostaglandins, or parathyroid
hormone–related peptide) or cytokines that can induce the formation of osteoclasts
(interleukin 1 and tumor necrosis factor). Osteoblastic lesions result when the
tumor produces cytokines that activate osteoblasts. In general, purely osteolytic
lesions are best detected by plain radiography, but they may not be apparent until
they are >1 cm. These lesions are more commonly associated with hypercalcemia
and with the excretion of hydroxyproline-containing peptides indicative of matrix
destruction. When osteoblastic activity is prominent, the lesions may be readily
detected using radionuclide bone scanning (which is sensitive to new bone
formation), and the radiographic appearance may show increased bone density or
sclerosis. Osteoblastic lesions are associated with higher serum levels of alkaline
phosphatase and, if extensive, may produce hypocalcemia. Although some tumors
may produce mainly osteolytic lesions (e.g., kidney cancer) and others mainly
osteoblastic lesions (e.g., prostate cancer), most metastatic lesions produce both
types of lesion and may go through stages where one or the other predominates.
In older patients, particularly women, it may be necessary to distinguish
metastatic disease of the spine from osteoporosis. In osteoporosis, the cortical
bone may be preserved, whereas cortical bone destruction is usually noted with
metastatic cancer.
Metastatic Bone Disease: Treatment
Treatment of metastatic bone disease depends on the underlying
malignancy and the symptoms. Some metastatic bone tumors are curable
(lymphoma, Hodgkin's disease), and others are treated with palliative intent. Pain
may be relieved by local radiation therapy. Hormonally responsive tumors are
responsive to hormone inhibition (antiandrogens for prostate cancer, antiestrogens

for breast cancer). Strontium 89 and samarium 153 are bone-seeking radionuclides
that can exert antitumor effects and relieve symptoms. Bisphosphonates such as
pamidronate may relieve pain and inhibit bone resorption, thereby maintaining
bone mineral density and reducing risk of fractures in patients with osteolytic
metastases from breast cancer and multiple myeloma. Careful monitoring of serum
electrolytes and creatinine is recommended. Monthly administration prevents
bone-related clinical events and may reduce the incidence of bone metastases in
women with breast cancer. When the integrity of a weight-bearing bone is
threatened by an expanding metastatic lesion that is refractory to radiation therapy,
prophylactic internal fixation is indicated. Overall survival is related to the
prognosis of the underlying tumor. Bone pain at the end of life is particularly
common; an adequate pain relief regimen including sufficient amounts of narcotic
analgesics is required. The management of hypercalcemia is discussed in Chap.
347.
Further Readings
Borden EC et al: Soft tissue sarcomas of adults: State of the translational
science. Clin Cancer Res 9:1941, 2003 [PMID: 12796356]
Helman LJ, Meltzer P: Mechanisms of sarcoma development.
Nat Rev
Cancer 3:685, 2003 [PMID: 12951587]
Mocellin S et al:
Adult soft tissue sarcomas: Conventional therapies and
molecularly targeted approaches. Cancer Treat Rev 32:9, 2006 [PMID: 16338075]
Pisters PW et al: Evidence-based recommendations for loc
al therapy for
soft tissue sarcomas. J Clin Oncol 25:1003, 2007 [PMID: 17350950]
Scurr M, Judson I: How to treat the Ewing's family of sarcomas in adult
patients. Oncologist 11:65, 2006 [PMID: 16401715]
Verweij J et al: Progression-free survival in gas
trointestinal stromal tumors

with high-
dose imatinib: Randomized trial. Lancet 364:1127, 2004 [PMID:
15451219]
Bibliography
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Hayden JB, Hoang BH:
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