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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Surgery for Bone Metastases? When, Why, and How?
Wed, 02/21/2007 - 09:54
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

When is surgery necessary or just particularly helpful for bone metastases? There are situations in which invasive approaches may be appropriate for the long bones (of the arms and legs). First, surgery can be helpful for persistent or increasing pain despite completing palliative radiation therapy. It is also an attractive option for a single well-defined lytic cancer lesion (a tumor that destroys bone, in contrast to a blastic bone lesion that creates extra bone but chaotically, so it is still structurally unstable) that is involving more than 50% of the strong outer cortex of a bone. Surgery is also indicated for involvement of the upper (or proximal) femur, the thigh bone, that involves a fracture of the part of the femur that is part of the hip joint, or if there is diffuse involvement of metastatic disease in a long bone. Surgery can provide structural stability to avoid a serious fracture and extended disability, and also provide pain relief at the same time. The stabilizing surgery involves a lot of hardware, and the surgery is similar to a sterile version of working in a machinist's shop (at least that was my impression when I had my limited role in med school surgical rotation).

However, surgery would not be recommended for patients who are so debilitated that the time for recovery would be expected to include most of their expected survival (weeks), or for patients who are so debilitated that a rigorous surgery would be more dangerous than their body can handle and would likely cause more harm than good.

For compression fractures of a spinal verterbra, which can be weakened by cancer as well as garden variety osteoporosis, there are also minimally invasive procedures known as vertebroplasty or kyphoplasty that can be performed by specialist orthopedic surgeons or interventional radiologists. Both of these procedures entail inserting a needle under anesthesia and imaging guidance into a vertebra that has collapsed and is causing pain. At that point, cement can be directly injected into the vertebra to prop and keep it decompressed (normal size/height), which is the procedure called vertebroplasty. The very related procedure of kyphoplasty first inflates a balloon through the end of the needle in the middle of the collapsed verterbal body in order to prop it open, and then fills the balloon with cement.

compression fracture before bone tamp start Balloon inflation middle fill cement remove bone tamp

(Click any of the above images to enlarge)

Both of these procedures can and generally do lead to immediate and very significant pain relief. The majority of patients who have one of these procedures don't have cancer, just vertebral compression fractures from osteoporosis. My patients who have had this have often had significant pain relief or complete resolution immediately after the procedure and have no recovery time involved.

So while invasive interventions are not often required for management of bone metastases, in certain situations they can be very helpful. I'll finish up my discussion of managing bone metastases with a post on the potential value of systemic, or "whole body" therapy for bone metastases with bisphosphonates like Zometa/zoledronate and other related drugs.

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