Bone CA and Metastatic Diseases

Question 1

What are the phases of therapeutic interventions?

Answer 1

Preventative
Restorative
Supportive
Palliative

Question 2

What is goal of preventative interventions?

Answer 2

Lessens impact of anticipated disability through education and training.
Conditioning program for a child facing prolonged chemo regime

Question 3

What is part of restorative interventions?

Answer 3

Aims to restore physical integrity

Mobility training and exercise following surgical excision of osteosarcoma

Question 4

What do you do in supportive interventions?

Answer 4

interventions to cope with or accommodate a disability

orthotic intervention for chemo induced neuropathy

Question 5

What is palliative interventions?

Answer 5

provide comfort of assistance when recovery is not expected

pain management or family training to allow discharge to home

Question 6

What are the primary bone malignancies?

Answer 6

relatively rare: 1/100,000
x35 with secondary bone disease (metastasis)

Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Malignant lymphoma of bone, parsteal, osteosarcoma, periosteal osteosarcoma

Question 7

Who gets osteosarcoma?

Answer 7

60 y.o. as secondary neoplasm often associated with Paget’s disease

Question 8

Where does osteosarcoma occur?

Answer 8

> 1/2 of cases in the metaphysis of distal femur or proximal tibia

Tendency of metastasis to lungs, other bones, but rarely other sites

Question 9

What is cause of osteosarcoma?

Answer 9

Unknown etiology

linked to radiation exposure

Question 10

What is medical management of osteosarcoma?

Answer 10

Follow diagnosis through x-ras, MRI, CT to define extent of disease
Biopsy: tumor with malignant osteoid-producing cells
Pre-operative chemo
Surgical excision of affected bone, 80% excised without amputation
Post-surgical chemo
70% long term survival, even with metastatic disease

Question 11

Who gets Ewing’s sarcomas?

Answer 11

Usually in >3 and

Question 12

Where do Ewing’s sarcomas occur?

Answer 12

60% of tumors in LEs or pelvic girdle

Tendency of mets to lungs and other bones

Question 13

What are signs and symptoms of ewing’s sarcoma?

Answer 13

First presentation of pain, may have low-grade fever and anemia

Question 14

What is medical management of Ewing’s sarcoma?

Answer 14

Onion skin appearance of cortical bone, mixed lytic appearance
X-rays, CT, MRI, bone scan and staging studies to define extent of disease
Several courses of pre-op multidrug chemo
Surgical resection has replaced XRT
Post-op chemo for approx. a year
50-75% survival of 5 years

Question 15

Who gets chondrosarcomas?

Answer 15

Usually males more than females

>40

Question 16

What does chondrosarcomas look like?

Answer 16

central portions of skeleton, especially the pelvis
Majority are low-grade and difficult to distinguish from benign cartilage disease histologically
Characteristic radiographic features

Question 17

What is medical management for chondrosarcoma?

Answer 17

Managed surgically
Chemotherapy and/or XRT are reserved for progression of disease
Excellent prognosis with low-grade disease

Question 18

When do they use limb sparing?

Answer 18

Success of limb salvage is compared against survival rate and function achieved through amputation.
They won’t spare the limb if they can’t get rid of all of the cancer.

Question 19

What are possible limb salvage procedures?

Answer 19

Allograft replacement (same species treatment )
Endoprosthetic insertion (artificial replacement of body part that is placed internally)
Allograft-prosthetic reconstructions
Vascularized bone graft
Arthrodesis
Rotationplasty

Question 20

What is important to consider with reconstruction in kids?

Answer 20

Complication free endoprosthetic or allograft reconstruction is an important issue in a young patient

Risk of: Infection, nonunion, delayed nonunion, OA, joint instability

Question 21

What are functional comparisons for amputation vs. limb sparing?

Answer 21

Strength: isometric and isokinetic
ROM
Gait quality: velocity, stride length, single limb support time, double limb support time
Aerobic capacity during gait

Question 22

What are other considerations for limb salvage vs. amputation?

Answer 22

Physical challenges, maintaining activity level
Psychological and social maturation, social isolation, body image and self-esteem issues
Pain management
Recurrent hospitalizations and multiple surgical interventions
Vocational issues
Retaining insurance, opportunities for rehab and prosthetic follow-up

Question 23

What are acute PT interventions?

Answer 23

Mobility training: bed mobility, transfers
Strengthening within precautions
ROM within precautions
Gait training with protective WBing
Endurance activities

Question 24

What are late PT interventions?

Answer 24

Joint function
Strengthening
Quality, effectiveness, and efficiency of gait

Question 25

What is cause of metastatic bone disease?

Answer 25

High prevalent complication of CA | 70-85% of patients who die of CA have bone metastasis

Question 26

Where are common cancers that lead to metastatic bone disease?

Answer 26

``` PT Barnum Loves Kids Prostate Thyroid Breast Lungs Kidney ```

Question 27

What are two possible lesions in metastatic bone disease?

Answer 27

Osteolytic: destruction of bone by stimulated bone resorption Osteoblastic: dense, new bone growth with likely lytic processes and compromised bone quality

Question 28

What are risks of lesions?

Answer 28

Combinationg can occur in same patients Risk of hypercalcemia, pathologic fracture, pain, and SC compression Relatively long clinical course (24 months in metastatic breast CA)

Question 29

What is a pathologic fracture?

Answer 29

Severe complication of osseous metastatic disease. | Incidence in patient with bone mets is 9.5%

Question 30

What is treatment for pathologic fractures?

Answer 30

Protective unweighting prescription: must evaluate integrity of structures with proposed weight redistribution Prophylactic repair is controversial due to uncertainty in determining fracture risk

Question 31

What are predictors for pathologic fractures?

Answer 31

Use x-rays and bone scans to have measure of cortical involvement. Studies support using % of cortical involvement to determine fracture risk Pain aggravated with functional activity may be a predictor Cortical involvement limited to long bones not spine Treatments change nature of lesions Dynamic processes in metastatic lesions

Question 32

What are characterizations of patients more likely to fracture?

Answer 32

Younger patients (mean age 59) Greater number of sites involved with bony metastases Presence of 2 or more pathologic fractures

Question 33

What is ideal rehab for bone cancer?

Answer 33

Active pain free AROM only No resistive training on involved or painful extremities, no PROM, no passive stretching Limit MMT to uninvolved extremities Inform patients of risks and risks of bed rest

Question 34

What is intervention for hip, pelvis, and LE bone cancer?

Answer 34

Surgical intervention: IM rod or bipolar prosthesis Allows for early WBing, compressive and rotational force tolerance Gait training with AD; no fall tolerance Strengthening Non operative patient: goal of unloading, minimize stairs

Question 35

What is intervention for bone cancer in UE?

Answer 35

Fracture brace, sling, IM rod in larger humeral lesions, compression plate, or cemented prosthesis of humeral head Prophylactic fixation of lesion to allow use of AD Consider UE and LE WB demands and realistic mobility Early AROM, distal ROM and edema management

Question 36

What is intervention for spine cancers?

Answer 36

XRT, chemo, hormone therapy, surgical resection for neurological compromise or instability Pain management Back protective transfers, use of AD, sparing ambulation abilities Orthotic prescription, minimize flexion and rotation Normalization of trunk biomechanics

Question 37

What is multiple myeloma?

Answer 37

type of leukemia acquired injury to DNA of a cell in lymphocyte development B-lymphocytes transform into malignant cells Abnormal cells accumulate in bone marrow causing tumor

Question 38

Where do bone lesions occur in multiple myeloma?

Answer 38

Lytic bone lesions typically involving ribs, T-spine, pelvis, humerus, sternum, skull, and others

Question 39

Is multiple myeloma a bone cancer or a type of leukemia?

Answer 39

It is a hematologic cancer that begins in the immune system and affects the bone. Fracture may be first sign of disease

Question 40

What is multiple myeloma sequelae?

Answer 40

``` Weakens bone Causes hypercalcemia Compromise immune system Causes anemia Prevent kidneys from filtering blood ```

Question 41

How is multiple myeloma diagnosed?

Answer 41

Radiographic testing: CT and x-rays more specific Lab blood and urine tests for high levels of antibody proteins Bone marrow biopsy and or bone marrow aspiration

Question 42

What is medical management of multiple myeloma?

Answer 42

``` Treatable but not curable Prognosis of 24-30 months Systemic treatment: chemo Local treatment: XRT Neutropenic precautions Dialysis Orthotics ```

Question 43

What are PT interventions for multiple myeloma?

Answer 43

Back pain and compression fractures are common Considerations as with metastatic compression fractures Spinal orthotics AROM Maintain ambulation activities