Contemporary management of metastatic bone disease: tips and tools of the trade for general practitioners

Metastatic bone disease has a significant effect on a patient's mortality and health-related quality of life. An aging US population and improved survival rates of patients with cancer have led to an increase in the incidence of symptomatic bony metastatic lesions that may require orthopaedic care. Skeletal-related events in neoplastic disease include pain, pathologic fracture, hypercalcemia, and neural compression, including spinal cord compression. The clinical evaluation and diagnostic study of a patient with a skeletal lesion of unknown etiology should be approached carefully. In patients with widespread metastatic disease, the treatment of a skeletal-related event may be limited to stabilization of the pathologic fracture or local disease control. The treatment of metastatic bone disease is guided by the nature of the skeletal-related event, the responsiveness of the lesion to adjuvant care, and the overall condition and survival expectations of the patient. Impending pathologic fractures are often more easily treated, with less morbidity and easier recovery for patients, than completed fractures. Quality of life is the most important outcome measure in these patients. When surgery is indicated, the approach, choice of fixation, and use of adjuvant should allow for immediate and unrestricted weight bearing. Because metastatic lesions to the skeleton have a limited capacity for spontaneous healing, surgical fixation should be durable for the life expectancy of the patient. In the epiphyseal region of long bones, replacement arthroplasty is generally preferred over internal fixation. Metaphyseal and diaphyseal regions can generally be addressed with intramedullary nailing or plate fixation with adjuvant. The specific treatment of acetabular lesions is dictated by the anatomy and the degree of bone loss. Spinal stability and neural compromise are important considerations in choosing a strategy for managing spine tumors. Effective surgical approaches to metastatic disease of the spine may include vertebral augmentation or open decompression and realignment of the spinal column with internal fixation. Radiation therapy is an important adjunctive modality in the treatment of metastatic bone disease. Medical management consists of symptom control, cytotoxic chemotherapy, and targeted therapy. Emerging technologies, including radiofrequency ablation, cementoplasty, and advances in intraoperative imaging and navigation, show promise in the treatment of metastatic bone disease.