Presentation
Bone metastases may present with:
- pain
- pathological fracture
- impending fracture
- hypercalcaemia
- spinal cord compression
- an incidental destructive lesion
In an adult with an unexplained destructive bone lesion, metastasis and myeloma are common considerations.
Evaluation
Local lesion
- full-length radiographs of the involved bone
- CT for cortical destruction and surgical planning
- MRI for marrow/soft-tissue extent and neural compression
Search for primary disease
Guided by history, examination and epidemiology. Investigations may include:
- FBC, renal/liver profile, calcium and bone profile
- serum protein electrophoresis/free light chains when myeloma is possible
- selected tumour markers only when clinically appropriate
- CT chest/abdomen/pelvis or targeted imaging
If the diagnosis remains uncertain, biopsy is performed before definitive fixation unless the clinical context makes the diagnosis unequivocal.
Impending fracture
Assess:
- pain with function
- site
- lesion size and cortical destruction
- lytic versus blastic character
- expected survival
Scoring systems such as Mirels can support but should not replace clinical judgement.
Risk assessment considers:
- pain
- lesion size
- site
- cortical destruction
- lytic character
- mechanical demand
Scoring systems such as Mirels can support decision-making but should not substitute for clinical judgement or modern imaging assessment.
Fixation principles
Reconstruction should be durable enough for the patient's expected lifespan and allow rapid mobilisation.
Options include:
- intramedullary fixation
- plate/cement reconstruction
- endoprosthetic replacement
- arthroplasty around joints
Treatment is integrated with oncology, radiotherapy and palliative-care goals.
Clinical problem
Metastatic bone disease is more common than primary malignant bone tumour in adults. Management aims to:
- relieve pain
- prevent or treat pathological fracture
- preserve mobility
- maintain independence
- support systemic cancer treatment
Treatment should match expected survival and functional goals.
Common patterns
Metastases may be:
- lytic
- sclerotic
- mixed
Common primary sources include breast, prostate, lung, kidney and thyroid cancers, but any suspicious lesion still requires appropriate diagnostic reasoning.
Unknown primary
For a destructive bone lesion without a known cancer diagnosis:
- history and examination
- blood tests
- staging imaging
- tumour-specific investigations where indicated
- biopsy when diagnosis remains uncertain
Do not assume every lesion in an older patient is a metastasis.
Prophylactic fixation
Fixation before fracture can:
- simplify surgery
- reduce morbidity
- permit earlier mobilisation
- preserve function
The construct should be durable for the patient’s expected lifespan and often needs to protect the entire involved bone.
Pathological fracture
Surgery must address:
- poor biological healing potential
- extensive bone loss
- need for immediate stability
In some locations, endoprosthetic replacement is preferable to fixation because it provides immediate durable load bearing.
Adjuvant oncology treatment
Radiotherapy is important for pain control and local disease management. Systemic therapy depends on tumour biology.
Coordination with oncology is essential.
Spine
Metastatic spinal disease requires assessment of:
- neurological deficit
- mechanical instability
- tumour radiosensitivity
- systemic disease
- overall prognosis
Spinal cord compression is an oncological emergency.
FRCS synthesis
The operation for metastatic disease should be designed to outlast the patient, permit immediate function and avoid dependence on biological union when that is unlikely.