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Metastatic Bone Disease For Postgraduate Orthopaedic Exams
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Metastatic Bone Disease For Postgraduate Orthopaedic Exams
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Segment:0 .
NICOLA EVANS: Good evening, everyone, and welcome to this evening's webinar, which is what's new in metastatic bone disease.
NICOLA EVANS: And I'm pleased to welcome Mr Gerrand from the Royal National Orthopaedic Hospital in the UK. So the format of the meeting will be that we will have the lecture and then we'll probably do the quiz straight after the lecture and then we'll do invited questions. So if you do have a question, then if you can type it in the chat, we'll keep an eye on the chat and we'll ask Mr Gerrand at the end after the quiz.
NICOLA EVANS: Following that we'll stop recording and we have space for three candidates to do a practice FIVA of 5 minutes each and then get feedback from the faculty that are attending this evening. So stop. With me this evening I have Hannah and Lydia from OA UK as well as Ashraf and Mohammed, who are part of the Orthopedic Academy faculty, and of course Mr Craig Gerrand, who is our guest this evening.
NICOLA EVANS: So as always, the video will be available on YouTube shortly as in a couple of days after today. So if you miss any part of it, you don't need to panic you can go back and watch it again. For those of you who want certificates, if you contact OR UK, fill in your feedback forms and they'll provide you with CPD certificates. So I think without any further ado, I will introduce Mr Gerrand, who has very kindly come to talk to us about really I find it very interesting metastatic bone disease.
NICOLA EVANS: So I hope you all will, too. Thank you, Mr Gerrand, over to you.
CRAIG GERRAND: Thank you very much. And it's a joy and delight to be here. Thanks very much for asking me to come and talk, I'm going to talk to you a bit about what's new in metastatic bone disease. And as you heard, happy to have a conversation about things afterwards.
CRAIG GERRAND: And so I work at the Royal National Orthopedic Hospital, which you might have heard of in Stanmore, and I've been there since 2018, having worked for many years before that in Newcastle. It's not as falling down as it used to be. There are some new bits, although there's still a long corridor, an entertaining slope, and there's still some bits in need of a bit of refurbishment. But you're welcome to come and visit.
CRAIG GERRAND: Just let me know if any of this is of interest to you. So we're going to talk a bit about metastatic bone disease. So these are the kind of things that you always wonder about if you're a trainee. These are the kind of questions you might have or if you're not a specialist in orthopedic oncology. So one of the questions is what's the diagnosis? And of course, that's an absolute classic for the exam. Don't fall into the trap of nailing a solitary metastasis.
CRAIG GERRAND: You've got to ask yourself, what's the diagnosis for this literally? And then, of course, should this patient have an operation? If they should have an operation, what operation should they have? And then who should do it? So we'll touch on some of these issues, but these are the kind of questions that people ask. So bone metastases are often a feature of cancer.
CRAIG GERRAND: They present in a number of ways. They cause pain, hypercalcemia, fracture, spinal cord compression and pancytopaenia. So these are patients who are generally not well and they're quite different to other orthopedic patients, you could argue, who very often would have a single system disease. They get pain from mechanical instability, intraosseous pressure and probably nerve involvement.
CRAIG GERRAND: But it's really mechanical instability is the thing that we are bound to see most of. Why do bone metastases occur? Well, this has to do with delivery of cancer cells to bone from the primary tumor. You'll be familiar with Batson's vertebral venous plexus, which is a valveless venous system which allows retrograde embolism and it's for that reason it is said that prostate cancer ends up more on the spine than in other places.
CRAIG GERRAND: But generally speaking, it's about the seed and the soil, if you like. That was a theory from Paget at the end of the 19th century, but where you commonly see metastases, these would be the vertebrae, pelvis, ribs, fermora and the skull. When tumour cells enter bone and they go through a metastatic cascade, they're to do so. They can be directly lytic, so they release metalloproteinases, which are enzymes, which attack connective attached base membranes and so on.
CRAIG GERRAND: They can stimulate osteoclasts and the products of bone matrix degradation such as TGF beta that can stimulate tumor cell growth. So there's a positive feedback. So you see in the diagram you get a tumor cell stimulates osteoblasts, osteoclasts, precursors that become lytic in bone, and that in turn releases TGF beta. And so this kind of cascade can be interrupted by some drugs like bisphosphonates.
CRAIG GERRAND: And that's particularly the case for tumors that are very lytic. They may this Fosamax may have a particular or denosumab, which is a RANK ligand antibody is particularly useful for, for example, GI tumors. Opponents of primary bone tumors, a lot of oxaliplatin. How big a problem is it? Well, there's a quarter of a million new cases of invasive cancer per annum in the UK. 40% of all people will get cancer.
CRAIG GERRAND: It causes about a quarter of all deaths and 60% of them were higher in fact, or had bone metastases. Five year survival is about 80% for breast and prostate cancer is improving. And so metastatic bone disease is something that you start to think about, not just the urgent fixation of fractures, but also the longevity of reconstruction. It's the first presentation of cancer in about a quarter of patients.
CRAIG GERRAND: And a figure from the state suggested that treatment of metastatic bone disease alone may account for 20% of the overall cost of cancer treatment. So it's a big deal. This is some figures from Scotland where the projected number of people living in people in Scotland dying from multimorbidity associated with palliative care is going to go up and up.
CRAIG GERRAND: So if you look at the graph, the purple graph is a projection for 2040 where you're going to see, particularly in the very elderly population, far more people dying of multimorbidity, which requires palliative care and for which the treatment of metastatic bone disease is a part. So you can see there's an increase in demand for it. The counter-argument to that might be that there'd be other treatments like drug treatment that might mitigate that to some extent.
CRAIG GERRAND: And I think it's certainly been the case in my professional lifetime with some diseases like multiple myeloma and breast cancer, where patients may have other lines of treatment they can take. And actually, there's a, we do see a response to things that a few years ago, we would have said, you know, that lesion definitely needs fixation, but now we'll see some response to treatment.
CRAIG GERRAND: So patients classically present with pain, swelling, pathological fracture, loss of use or neurological changes as and sometimes as an incidental finding and usually with an abnormal X-ray. But when you see an abnormal X ray, it's very important that you stop. And there's plenty of literature from quite good publications, and I'll show you some of them from a group in Leiden who've tried to codify some of what should happen when you see a patient with metastatic bone disease.
CRAIG GERRAND: And first thing you do is stop, think and stage and act. OK? so there's no need to take some of the pathological fracture directly to theatre, need to work them up to work out what it is that's going on, whether an operation is appropriate. It's one of my favorite pictures. I got a phone call when I was in theater to say this gentleman who's had prostate cancer has broken his leg and he needs an urgent operation.
CRAIG GERRAND: Is that all right? And of course, you look at this and you say to yourself, well, look, here's a little lesion in bone. And you ask yourself, where is it in the bone? Well, it's central. It's in the kind of proximal metastasis diagnosis. What is it doing to the bone? Well, it's obviously making a hole in the bone. What's the bone doing in response?
CRAIG GERRAND: Not very much, actually. It's not managing to wall this off at all, although there is this kind of possibly long standing calcification in it. Is there a matrix? Possibly again, this longstanding calssification represents a matrix. And is there a soft tissue mass? Not really. But if you look carefully, the subtleties, you just see that this is actually an open fracture.
CRAIG GERRAND: And this segment has come through. And although this patient had prostate cancer, this isn't prostate cancer at all. This is a differentiated contra sarcoma. An elderly gentleman. And the last thing everyone should do is nail this. This is a primary bone tumor with admittedly a poor prognosis.
CRAIG GERRAND: That's not something you can improve by making. And so this patient had first aid to the wound, had a biopsy of this and that's how come we made the diagnosis. And it went on to have an end of periprosthetic replacement, which this is the right treatment. So don't forget the basics. Take a history, examine the patient, and this is where you need to be a bit more general surgical if you like.
CRAIG GERRAND: You need to be examining some of these abdomen, the lymph nodes you would consider, I suppose, in some patients where they needed a breast exam or even a rectal exam or that would be basic trauma. You certainly want to make sure that you examine the patient properly and think about the basic investigations. So the blood tests, the ordinary x-rays before you get as far as the scans, you consider doing a biopsy if you don't know what it is and you consider staging.
CRAIG GERRAND: And it's obviously important for these complex patients to think about, including their oncologist, palliative care team, and also to work out what a patient's anesthetic options are. We commit them to quite big surgery. Biopsies are pretty straightforward to do. So here's a true cut biopsy. You can do this under local anesthetic for a tumor that has a large soft tissue mass.
CRAIG GERRAND: This is a true bone biopsy needle on the bottom left. And this is a picture of me doing a biopsy with a true cut needle of a bone tumor under local anesthetic. So they can be pretty straightforward to get some tissue and decide what this abnormal lesion is. There are systems and here's the Linden Group again and they suggest that actually if you have somebody with a suspected pathologic lesion, you want to do the appropriate investigations and work out whether this patient needs referral to an orthopedic oncology center, whether they just need care and comfort or interestingly in Linden, you can select euthanasia I understand.
CRAIG GERRAND: Whether their life expectancy is less or greater than six months, whether they have a fracture. And so to do that, you basically process in a systematic manner. So what's the origin of the lesion that you can see in bone? If you don't know where it's from and it looks like a metastases, then you would consider doing staging for the patient.
CRAIG GERRAND: So CT of chest, abdomen, thorax, possibly a PET-CT and then you can consider a biopsy. If they have a primary tumor with an unknown bone lesion, then again, you'd ultimately want to do a biopsy. If you know the patient has metastatic bone disease after you've done the biopsy, then you want to ask the questions in the box, but they still may have a primary bone tumor. Then you refer them to North West London Pathology Center.
CRAIG GERRAND: So what you're trying to do here is work out how extensive this patient's disease is. That's what the staging is about. What's their general health? Take your history and do blood tests. And what's the involved stages of the local bones? You need whole X-rays of the whole bone and then whether or not they're having a fracture. So you can refer to this later, if you like, but it gives you a general scheme for how you might approach a patient with this lesion.
CRAIG GERRAND: So of course, each kind of bone metastasis has its own personality, if you like. So breast cancer classically presents with mixed lytic or blastic picture. You can get response rates of 50% to 60% if they've got appropriate treatment options. And that's why it's important to know if this patient, for example, is treatment naive, if they've never had any treatment.
CRAIG GERRAND: And some of this might get better on treatment. And the five year survival is about 50% of those bone only metastases. And reconstructions need to be durable for that reason. And survival after bone metastatic breast cancer is getting better and it's better if you have ER positive disease. OK that's the first line on the left hand graph here. It's better if you have single metastases.
CRAIG GERRAND: And if you have a single bone metastases, about 70% of people are around at 10 years. So again, you want to treat that properly and with a durable reconstruction. This is a patient. It's one of my favorite X rays, which tells a story about a lot of things. I'm not going to bring it up in the VIVA. But say this class, this shows a patient of prostate cancer.
CRAIG GERRAND: Why do they have prostate cancer? Well, you can see that this is a very sclerotic so it's an osteoblastic metastasis. And that proximal femur, has been clamped to the femoral head on the right side of patients who got end stage osteoarthritis. And that's just a reminder to say that patients with metastatic bone disease, their pain might be due to something more mundane than a metastasis.
CRAIG GERRAND: And they've also got a ureter stenting. But this is a patient who's obviously had some kind of pelvic radiotherapy. So all that adds up together to a patient with metastatic prostate cancer. So 80% of patients with metastatic bone involvement in prostate cancer survive for 12 to 20 months often. often pelvic or spine. And fractures, actually they tend to be a bit like this sometimes.
CRAIG GERRAND: So they're more like stress fractures and the bones, quite sclerotic, but not normal. And so it can collapse. You can also get a little stress fractures rather than complete fractures. And if you're ever thinking about doing a femoral nail on a bone that looks like this, bear in mind it's going to be really hard to get anything down that canal. So if you're going to do it, you've got to have an image intensifier and a drill.
CRAIG GERRAND: And a lot of patients probably we think it's important to do that. Kidney cancer is classically listed. It's not uncommon for us to see a patient presenting with something like this, and they have a CT cap and they've got primary renal tumor. So a very lytic lesion like this is pretty classic for renal cancer.
CRAIG GERRAND: You can consider a section of this. And this is a condition where resection of one metastasis, particularly if the metastasis occurs several years after the primary tumor, is associated with a longer survival. They don't respond very well to radiotherapy. They're highly vascular. And in fact, a soft tissue mass like this is very often pulsatile.
CRAIG GERRAND: So if you feel it, you'll notice that it's very vascular. About a 30% five year survival is quoted, although that's improving, as we see from here. And that shows that even people with high grade disease is now 10 years old. These figures improve. There has been an improvement in survival, and that's due to immunotherapy and a bunch of other targeted example tyrosine kinase inhibitors that are making a difference.
CRAIG GERRAND: And here's a meta analysis that shows that if you do a mastectomy in these patients, it is associated with further with increased or better survival. So the hazard ratios are improved in favor of mastectomy. Lung cancer, however, classically lytic. About 15% to 40% of patients have both metastases.
CRAIG GERRAND: It can have a poor prognosis but this is changing and it's pretty common, particularly in places like Scotland, where it's one in 12 men, 1 in 13 women in Scotland will get lung cancer. And that's an epidemic. There are things that are making a difference. This shows that the survival has improved over recent decades, and things like immunotherapy and other targeted therapies, particularly for people who have specific mutations, is making a big difference for patients with lung cancer.
CRAIG GERRAND: Plasma cyetoma myeloma. If you see a lytic lesion like this, if you see a patient presenting with this, you've got to do basic stuff, right? You've got to do a protein electrophoresis. This could be myeloma, these are classically lytic, let's say, about 30% present with the pathological fractures. It's not unlikely that you'll see sometimes 5,000 people a year in the UK, 40%, five year survival also improving and usually in bones, the rich red marrow content, such of the proximal human spine.
CRAIG GERRAND: They are cold on bone scan generally. And again, that's a classic exam question. And for people who don't have a fracture, the response rate of this is actually pretty good. So someone who's treatment naive could get radiotherapy and bisphosphonates without reasonable expectation that would heal. And in fact, I have a colleague at Stanore called Sean Malloy, who has an interest in spinal myeloma, and he's stopped operating on patients with spine
CRAIG GERRAND: pretty much. And they get braced, they get conservative treatment. They don't have enough surgery. So why would you operate on somebody with metastatic bone disease? You do it to relieve pain, to restore function, maintain an independence, improve quality of life, and where you can, improve survival. We did a meta, we did a meta analysis AJ Malviya and myself some years ago looking at this, and there's good evidence for these things.
CRAIG GERRAND: When you're thinking about surgery, you think what you want to think yourself. What's causing symptoms? Is it that guy who has the osteoarthritic hip or is it somebody with a definite metastasis? What's the risk of fracture? Is there an alternative to surgery? How long are they going to live? Are they going to survive the surgery?
CRAIG GERRAND: And these are patients who have significant comorbidities. What operation should you do? And then who should do the surgery? So should they have if they have advanced disease, should have a straightforward nailing, for example, in a local hospital? Or should you put a patient at sort of close to end of life in an ambulance to go to the specialist center where they're a long way from their family?
CRAIG GERRAND: Well maybe some patients should have that, but also some should have treatment closer to their home. There are things that might put you off surgery, but the overall physical and emotional state of the patient, mental obtundation is said to be a contraindication to surgery so somebody who is not responsive. Haemopoetic depression.
CRAIG GERRAND: So it's interesting. We see this not infrequently patients have had radiotherapy or on other chemotherapy, but they don't have adequate cell counts. They go through surgery or they have such marrow replacement that the hemoglobin is low and their other cancer load so they may not be good surgical candidates. Patients with infected wounds
CRAIG GERRAND: so particularly if your going to put in big metal work, they've got a DVT, they have extensive neuromuscular encasement, their survival is very short. So somebody, for example, with lung cancer, it has a brain metastasis. You wouldn't be put into any sort of surgery. Prognosis is very poor. So it's patient factors, disease factors. So what's the prognosis of the patient,
CRAIG GERRAND: do they have other signs of disease? And there'll be some procedure specific contraindications to surgery. We get some quite interesting and challenging patients. So here's an 80-year-old patient. I mean, a patient that has come up in recent weeks and recently an 80-year-old patient, who had a thing called a gastrointestinal stromal tumor, which is an unusual kind of sarcoma, arises in the small bowel usually, with a metastases in the pelvis.
CRAIG GERRAND: And so the conversation from here, this has gradually got bigger over time. The conversation here was whether resection of this polygome metastasis, meaning solitary or very small number of one of the very small number of metastasis, should be resected for improved survival? This is a tumor that has a number of biologic treatments for it and it does develop mutations so you get responsible
CRAIG GERRAND: parliament and then you have to go to different agents. So reducing the number of cells might be beneficial, but for this elderly gentleman, the sort of resection that would have required for this large tumor that was adjacent to the prostate was really close, so we didn't operate. Some places, of course, may have a fracture, and that's an indication we're operating. And if you think someone's got a very high risk of having a fracture, then it's best to operate before it breaks because the procedure is more straightforward.
CRAIG GERRAND: It's been an elective function and the recovery is usually faster. So how do you know something is going to, something's going to fracture? Well, as these are classic exam questions, the Mirel's Rating System. Which we should know for the exam, but it has its downsides and it doesn't, for example, it doesn't, for example, think anything about how active the patient is, whether or not their lesion might respond to radiotherapy or other treatment, for example.
CRAIG GERRAND: And the other thing you have to consider is if you're going to put someone through an operation, they can't have any other treatment for quite some time. That could be as long as six or eight weeks. And for some people, that might be that might mean, they missed their window for systemic treatment. The thing that's really important, most important, I think, is mechanical pain. So if somebody has pain and weight bearing, that's the thing that really makes you concerned that they might fracture.
CRAIG GERRAND: So there's a Harrington system beginning 2.5cm in the proximal femur, something that's bigger than 2 and a half cm. So there's a fracture well that's true of cancer. It hasn't responded to radiotherapy so these are at risk. And Mirel system, in particular with functional pain lytic lesions and large lesions, a peri tronchater.
CRAIG GERRAND: There's the highest risk. It was another system here again from the Netherlands, which looks at the axial cortical involvement. So if you've got more than 3 centimeters of proximal distal cortical involvement in a long bone and a circumferential involvement greater than 50% in size, this bit over here, if that's more than 50% of the total length is more than three centimeters then they would say the risk of fracture is very high and the patient should be considered for operation.
CRAIG GERRAND: But these are the other little extras that you should consider. What else can you do apart from surgery, you don't have to operate on people, particularly if tumors are radiosensitive. If a chemo sensitive, treatment naive or the patient is not fit, then you've got some things, other things you can do.
CRAIG GERRAND: And just because you can't operate on someone doesn't mean we can't offer them a lot of other things. And here, if you have patients like this, if you have a good palliative care team available, then that's really helpful because they'll help contextualize this kind of big surgery for a patient at the end of life. Is that really the best way for somebody to spend their time having a big operation and recovering from that?
CRAIG GERRAND: If the prognosis is poor or if there are other ways in which the quality of life might be improved. So, for example, by using good pain techniques, radiotherapy, some radioisotopes can be helpful. Chemotherapy, hormonal therapy and so on. Splinted walking aids and embolisation are all things that should be in your toolbox for managing these patients.
CRAIG GERRAND: So in the upper limb in particular, you can put someone in a splint for someone in a sling that can get up and around and think about why you're working out what it is you want to do and whether or not other treatment might work. Performance status is really important. You've got to have a performance status of two or above to get chemotherapy, generally speaking, which means you've got to be out of bed more than half the day.
CRAIG GERRAND: Of course, if somebody has got a fracture, they're pretty much stuck in bed all day so they are seldom candidates for getting chemotherapy. So although this is a blunt instrument, it's fairly widely applied and exceptions are made for patients who are otherwise fit but in bed for a fracture but generally speaking, our role as orthopedic surgeons is to get people up and out of bed so that they can have further treatment.
CRAIG GERRAND: And this is another way of looking at patients by trying to classify them into their prognostic groups. So operating in someone with a prognosis who ends up in the A group needs to have a very durable reconstruction. B, perhaps not so durable, C, perhaps they can have a nailing and D you probably shouldn't operate on. And the factors they say our clinical profile, which is a slightly vague thing, but they're either pretty fit or they're unfavorable or they're not fit.
CRAIG GERRAND: Karnofsky's very much like the ECOG score. So to show you some of these top scores on the left, poorer scores on the right, whether someone has visceral or brain metastases. So if you do have visceral bone mestasis, you're automatically going. And so this allows you some kind of rule of thumb as to whether or not this patient is going to live long enough to survive a cancer.
CRAIG GERRAND: And there are other things that people look at: Glasgow Prognostic Score. He takes albumin and CRP and combines them in a quite straightforward manner to give you a score. And this is how it correlates with this is how it correlates with survival in breast, bladder, that's esophageal and prostate cancer and sarcoma. So you can lose it sorry you can use a score like this.
CRAIG GERRAND: So, again, to get an overall handle on how well that patient is. When it comes to surviving surgery these are patients from our center, we've got this study authored by Rachael Baumber, who's one of the anaesthetists' at Stanmore. And it shows the overall survival of patients having surgery for metastatic bone disease in our center. So there's only about a quarter still alive at three years.
CRAIG GERRAND: Yeah and so so these things are high ASA, high white genitourinary, resting heart rate under 100 and the type of cancer are all predictive of reduced survival in this patient group. So breast cancer has a relative risk and has a ratio of 1, gynecological cancers 2 GI cancers 3. And so on lung cancer 2 and a 1/2. OK so again, this is a way in which you would get a handle on whether or not that patient is going to be well enough to survive surgery.
CRAIG GERRAND: In terms of surviving surgery, you want to avoid early complications. So patients who have early complications are associated with high mortality at one year. Again, another way of just making you think of that, actually what, what's the right thing for this patient? So once you've selected your patient, what operation are you going to do?
CRAIG GERRAND: Well, classically, trauma devices which are load sharing are not great for use in patients with metastatic disease. I think if you have a poor prognosis and you've got diaphyseal metastases and multiple metastases, then a nailing is a reasonable operation. The fixation of the proximal femur of assigning get screw leads to that sort of situation that you see in the X-ray.
CRAIG GERRAND: And so there's a high rate of failure so that's so generally speaking, replacement for that sort of lesion around the end of the bone is a better deal and is more likely to be durable than using a trauma device. It's always nice to consider, particularly if you're dealing with a small number of metastases, whether you can remove the tumor. And so I've got a slight preference for tasis where possible that we might consider curessing and plating them.
CRAIG GERRAND: And that gives you a chance to achieve better local control. You can put cement where the defect is, and it means you've got better fixation, you can follow it up with radiotherapy. However, it doesn't necessarily fix the whole of the bone, which for many years has been a kind of a guideline for the treatment of a metastic bone disease. When you're instrumenting the bone beware the frail patient with lung problems.
CRAIG GERRAND: So the patient has a pleural effusion or has multiple mets, you need to be careful about those when you're instrumenting the canal, either by nailing or by putting in a cement. OK, segmentation is good for defects, but be careful when you pressurize for the same reason. The cumulative rates of complications are as high as 40% as perioperative mortality is high.
CRAIG GERRAND: You look out for bleeding, thromoembolic disease. The risk is likely high. People should certainly have a Doppler scan before you operate on someone with metastastic bone disease. And that's really your starting point. And we do detect patients that way who have unexpected thromboembolic disease and some of those will get filtered before they have operations. Infection is not good,
CRAIG GERRAND: local recurrence rates can be high. Reconstructive failure can be high up to 40% five years again, often because of local recurrence. So why would you do an on block protection better local control fracture? Healing is unreliable. It be more durable, less bleeding because you're going outside the tumor, might be associated with better survival in some patients.
CRAIG GERRAND: This is a slightly unusual case where we had a solitary metastasis after several years from thyroid cancer and we treated it by a resection and a massive allograft. So that's OK if you've got a good biological environment and the patient doesn't need radiotherapy but it's slightly unusual, slightly unusual choice for that, but it allows us to do a resection that's close to the proximal femur to keep the femur.
CRAIG GERRAND: So in general, although the patient with metastastic bone disease trying to avoid this kind of reconstruction because you don't want to put them in protected weight bearing for a long period but in patients when the prognosis is quite good, this is not unreasonable. You want to be careful with the tumor, you don't want to spread it about. But this is cancer that has recurred in the skin after doing an arthoplasty.
CRAIG GERRAND: It's or open fixation of a metastasis in the femur. So be as meticulous as you can in terms of swabs around the wound. I like using aqueous bethodene around the wound where I can because it's slightly sinusoidal and make sure that you don't leave big lumps of tumor and irrigate it copiously afterwards. So what operation would you do? Well, complications from intermedullary nailing occur longer than a year, and for prosthetic reconstruction tend to occur earlier.
CRAIG GERRAND: And so if you have somebody with a very poor prognosis, a lot of these around these sort of charts around, then you might consider doing an intramedullary nailing because their complications are likely to be beyond a year. The life expectancy is short. And so this. here you've got let's take you through this, patients with impending pathological fractures, their life expectancy is less than two months either don't do anything or if you have to enter an intramedullary nail fixation in every extremis.
CRAIG GERRAND: Up to 12, up to a year intramedullary nail fixation all other things being equal. If you have a solitary renal tasis, sorry, then life expectancy more than 12 months, you can do intert-medudullary nail with added local medical treatment and that sort of thing. We carress it out and try and avoid that recurrence. Or you could do if it's next to the end of a joint. You can do resection prosthetic reconstruction, you can have a solitary metastasis, and you can resection reconstruct in lesions of diasphyseal joints.
CRAIG GERRAND: So you would take those out completely, essentially. So again, this gives you a sense of what kind of operations you should select patients in, based in what sort of situation, because you want to try and avoid this kind of situation where you've had in a renal metastatis but this is obviously not united on the left, despite reconstruction now. And so we've had to do a secondary operation for the proximal femoral artery.
CRAIG GERRAND: This is a patient, a young patient with breast cancer who's got essentially a nasty fracture from the federal neck. You can just see that on the left hand side. This is very good for a primary replacement with good function, whereas this, which is a metastatic lung cancer, that bit of bone needs to be replaced and very often it will come out in pieces. Use a modular implant system, usually with an eight coated collar, although patients notice that's not essential cements with the bipolar head.
CRAIG GERRAND: And that would be a of standard proximal femoral replacement. Some of them come with shock and take attachment pieces, which are occasionally of some use which help it to resist dislocation. I'm not sure it really gives you good abductor function. That's more of a soft tissue repair, I think. And this is a patient with an unusual prostatic sarcoma, metastasized to the tibia with a fracture, with pain on weight bearing, and a relatively um relatively limited prognosis.
CRAIG GERRAND: And so we've curated that, filled it with cement, put a plate on, and he's gone back to weight bear. Could have had a proximal tibia but that's an operation that takes a lot longer to get over. That is the right option for some patients. This patient with breast cancer, they showed an extraordinary and has a very arthritic knee. So this is quite a good solution to securitize along a new knee placement, which she did very well at.
CRAIG GERRAND: Another one from the clinic quite recently, lung cancer, a large lesion in the back of the femur that's best treated by this little parallel replacement. He couldn't straighten his knee, but once we've done this, he could get up and walk again. Again, it's getting on with his life. Here's the lesion, which is very vascular on the MRI scan. And this shows that these are in the kidney.
CRAIG GERRAND: This is metastatic renal cancer. And usually for this sort of thing, we would start with we would start with embolization. So we would do this to try and reduce the vascularity of it. For most extra renal cancers, it can be extremely vascular and so this is embolization. So you avascular interventional vascular technique available and we've taken out or replaced it with the rotating industry standard.
CRAIG GERRAND: Some patients have a lot of surgery and standard arthroplasty techniques can be quite useful. I'm sorry, so I've got the CT scan again. But you see, as we collapsed at the femoral head that this patient had a hip replacement, we TMT augment it. The leg bones did very well. And then the next thing I was surprised to hear is he broke the other hip.
CRAIG GERRAND: And meantime, he'd had spinal decompression, but so you had approximately one on the other side and then. Then I see this slightly different patient, this patient with me. I'm not a patient, the kind of people that we see. So you do have a number of options, obviously, but essentially we can go large if we need to. We can replace the whole thing.
CRAIG GERRAND: So, this patients are going to have a hip replacement on the reconstruction side. And in most bones you can replace this metastatic renal cancer in approximal humerus. And this is a baby Walker shoulder. So this is a constrained reverse ball and socket shoulder that helps you with one of the major problems or the major problem for you, proximal reconstruction, which is instability.
CRAIG GERRAND: And you know, there are even, we can do. Wrap around this patient has had a pseudoaneurysm because of metastases mefistofele so we've got a number of quite innovative solutions for the right patient or you can replace the whole humerus. Most implants now come with a silver coating. We often use it this thing, which is a tumor tube activity, but it's essentially a knitted polyester sleeve that you can use to enhance your soft tissue, such as your attachment.
CRAIG GERRAND: So what does high quality care look like? Well, for many years, the BOA published a metastastic bone disease guide to good practice, a study which you can still find, but actually, as with everything else, is now a based guideline for management. So I would suggest that you read that and know about it when it comes to the exam and actually just for your daily trauma take, because it's got some very useful advice on it.
CRAIG GERRAND: From Scotland again there's some very good studies from Downie et al looking at, asking people using what's called a Delphic technique so asking people what they think are the most important things for patients with metastatic bone disease. What does high quality care looked like? Well, it looks like prompt orthopedic assessment.
CRAIG GERRAND: It looks like rapid investigations, a surgical decision quickly, biopsy or solitary lesions, good oncology input early, adults with fractures should have surgery without delay, we should rehabilitate early the patients who are dying, that need's to be recognized. They need to have a good palliative care and ceiling of care. So everyone needs to agree what the maximum is going to be.
CRAIG GERRAND: Every hospital has to have about this metastastic bone care pathway. It should be education. We should know by collecting outcome data what the impact of our surgery is. But we know from a recent audit that the resource, the Oncology Society audit says a wide variation in care and delays for patients who have metastatic bone disease. This shows the patients in a.
CRAIG GERRAND: Patients in a specialized center on the left? It does take longer for them to get from fracture to surgery. So one of the disadvantages of referring to specialists center is that length of time I know from experience locally patients spend a long time languishing in other hospitals before they get to us. And I think that that's really a call to arms for everybody. The patients who have metastatic bone disease get them investigated quickly and get them the oncology advice that you need quickly to try and make a decision and get them to the care they need as quickly as possible.
CRAIG GERRAND: It doesn't have to be as fast as within 24 hours for a hip fracture. But the same arguments apply. The longer people wait, the harder it is for them to rehabilitate. So to conclude, patients with metastatic bone disease deserve timely and appropriate surgery. It's got much to offer them. You should stop thinking stage and act. Don't miss a primary implement.
CRAIG GERRAND: Consider the whole patient in the diagnosis. And wherever you are, consider what your local services and pathways are and how you're going to meet quality standards for this very rewarding, ask the patient. And that if you're all still there is the end of my talk. So we'll move on to the next bit if that's alright?
NICOLA EVANS: That's great. Thank you so much Mr Gerrand. I found it really interesting, so I haven't got any questions yet so people can have a little think about that while we launch the poll. So if you can all answer quickly, it's completely anonymous. And then we'll move through and Mr Gerrand can discuss the answers with us.
CRAIG GERRAND: So you seem to say it's a slightly upside down question for which apologies. But basically these are statements from the BOAST guidelines apart from one. And the first was, as each unit should have, an agreed policy for the multidisciplinary discussion management of metastatic bone disease, including clear pathways from referral. Yes, they should say that's supported, so that's not the answer.
CRAIG GERRAND: All specialist centers should have agreed pathways to enable prompt opinions, advice and transfer to the network. Yes, you should. But that's not it either. Prodromal history of a link to your night pain raised suspicion of MVD and should be documented along with injuries circumstances. Again, that's in the statement.
CRAIG GERRAND: So that's not the answer. Patients should have an pathologic approach to the hip, should have an operation within 24 hours. That is not in the guidelines, that is not in the BOAST guidelines because as we've said, what you want to do is be investigating. You want to stop and think before you act. So that means that some patients are going to need an MRI scan. They might need a biopsy.
CRAIG GERRAND: And so one of the tradeoffs, as we discussed, is that it takes longer to go. That is the correct answer. So 70% of people got early and then metastatic bone disease without an obvious primary site. It should be discussed with the local acute oncology service. And that's also in there. So if you're following these guidelines, you'll involve the oncologists.
CRAIG GERRAND: So thank you for that. OK I guess we do the next one. And this is a question about renal metastases, which is not true. Again, I don't question. So complete removal of a solitary metastasis, maybe improve with improved survival. That's true. It's not that.
CRAIG GERRAND: Renal metastases are usually avascular. No, they're usually really vascular. So that's the one. And the other points you should discuss with the treating oncologist relatively insensitive to radiotherapy. And the patients may present with the bone metastasis and the CT caps required. They're all true.
CRAIG GERRAND: OK OK. Next one. I think everyone's answered that. I'll just go straight ahead with that one so that. Yes this is a question about lytic reasons in bone. So lytic reasons in bone. Again, I'm asking you, which is not true. Apologies it was upside down, which is false.
CRAIG GERRAND: So multiple myeloma. If you've got a lytic lesion in bone in an adult, you should always exclude it with a plasma protein. Yes, you should. The affirmative zone. So again, part of your vocabulary should be how you look at the lytic lesion in bone. What? what's around the edges, is it geographic?
CRAIG GERRAND: Is it permeative or is it mothing geographic? Bone hasn't a chance to wall off. Those are ones you can draw around with a pencil. They're more likely to be at the benign end of the spectrum. These are sort of permeative and more likely to be malignant. That's also true. Bone metastatic and prostate cancer can be osteoblastic as well as osteolystic. That's true. It's not that.
CRAIG GERRAND: Mechanical pain is associated with the risk of fracture. Yes, it is, Mirel's scoring and from clinical practice. And it's always possible to tell whether legs and bones are primary bone tumor from imaging alone. Of course it isn't. And that's why you got to investigate them and make sure you don't miss a primary treatment. So the answer. That's the answer.
CRAIG GERRAND: That's not true. I hope they were suitably educational and only a bit confusing as multiple choices tend to be.
NICOLA EVANS: That is great. Thank you. Thank you very much. I've got a couple of questions. So the first one is from Aditya Kaja, who's written, if there's a newly diagnosed metastatic bone lesion, is there a mandate for a complete skeletal survey?
CRAIG GERRAND: Yeah so a skeletal survey, so basically that's a thing isn't it? It's a collective agreement taken to mean a, a collection of plane films that we would use in myeloma traditionally where a bone scan isn't as sensitive. So if you wanted to identify whether the patient had not traditionally have done a skeletal survey, however, that's been superseded in many places by a whole body MRI scan.
CRAIG GERRAND: So a whole body MRI will give you more detail about whether that plasma site you've found litigation in bone biopsy is full of plasma cells, whether that is a solitary plasma cytoplasm, which is a precursor to generally whether it's multiple. So if you have somebody with a solitary bone lesion, particularly if they're over 40, they should have some kind of skeleton injury.
CRAIG GERRAND: It might be a whole body bone scan, that might be a whole body MR. And if it's myeloma and you don't have whole body MR, then you might do the skeletal survey, which is a bunch of x-rays. So, yes, that's part of the workup. And generally speaking, if you're under 40 and you've got a lytic lesion bone, you send them along the sarcoma path whereas
CRAIG GERRAND: it's more likely to be that, if they're over 40, then you really must work people up locally as metastatic disease. So that means taking ownership, finding out if they've had a recent diagnosis of cancer, if they've got an oncologist, asking their oncologist if they have a new lesion, whether that might be metastasis. And so that's so important. I hope I've answered the question.
NICOLA EVANS: Thank you. Aditya's also put a follow up to say: the spec, do spec's play any role?
CRAIG GERRAND: Do specs play any role? It's not something we use routinely as part of that. But there are, I suppose, as a way of whole body imaging, possibly but it's not something
CRAIG GERRAND: It's not, it wouldn't be a topic I'd pick.
NICOLA EVANS: Great thank you. We've got Syed.
CRAIG GERRAND: I am nailing them, I say. NICOLA EVANS Yeah Yeah!
NICOLA EVANS: Syed's asked has two questions. But I am...INAUDIBLE
CRAIG GERRAND: How important is the ventral canal? Well, the answer is I don't I'm not sure of the evidence for venting it, but it's not a bad idea, particularly if you've got very frail patients with a pre-existing chest disease. And certainly you'd want to make sure when you're reaming the canal, if you can, that you aspirate it thoroughly and that you're not turning the femur into a massive syringe.
CRAIG GERRAND: Essentially. That's also the case if you've got a long stemmed cemented implant. So I think the answer to that is I mean, I don't do, to be honest, I don't do very much nailing for metastatic bone disease. When I work at the moment, previously, I would fairly or pretty often drill a hole at the bottom of the femur and put a sack into it because I know the patients at risk and then I know I've done everything I can.
CRAIG GERRAND: What I have learned is that patients who have pre-existing chest problems, you've got to be super careful. With irrigation of the surgical site hypertonic fluid is a fact. Yes, we do. AUDIO OUT If I see whether there's any evidence for it, I don't know. The things that definitely we do, it's because it's fairly harmless.
CRAIG GERRAND: There are other things that are definitely sinusoidal and so things like chlorhexidine, aqueous chlorhexidine is available is very sinusoidal. And a few years ago there were people who'd accidentally used it to do arthroscopy and there's no doubt that it completely destroys the inside of a joint, it completely destroys articular cartilage, and similarly very sort of basic compound that would destroy cells as is aqueous bethadine, which is available
CRAIG GERRAND: and I would say if I'm particularly concerned that there might be a tumour leak, I'll pack bethadine soaked swabs around the wound, I can't prove to you that it's one of those things that makes you feel better. That's it. And what have we got further down? Is there any yoyal bone cement in the treatment of bone cancer? So, yes, there certainly is. Mechanically right, so if you're adding bone cement to your construct there are papers that say that in metastatic bones disease get longer, more durable reconstructions.
CRAIG GERRAND: And of course, bone cement is used by some interventional, interventional radiologists and some spinal surgery, vertebral plastic or injection of holes in bone as part of a sort of palliative procedure. So there is that role. And the other question I suppose, you're alluding to is whether or not the bone cement actually kills the cancer. And we have it probably does a bit you know, it does heat up and it may around the edges reach a temperature that it will kill rogue tumor cells.
CRAIG GERRAND: But that's no substitute for a proper cure charge. There were some years ago cements that had chemotherapy agents in them that didn't really catch on, I think, because people didn't really want to be handling cement for the site in the metal theater. So that hasn't really it hasn't really caught on. And there are other methods for delivering chemotherapy agents now that are done, particularly by again, by interventional radiologists.
CRAIG GERRAND: You can deliver the chemotherapy through, for example, live antacids, but that sort of thing hasn't really caught on. OK Salim Bob-Manual says, how do you avoid the pitfalls of missing a primary bone tumor in a known patient with a metastatic cancer? So the rule of thumb, I would say, is if they have a solitary metastasis, then that's the one that you need to investigate with a biopsy.
CRAIG GERRAND: If they have multiple metastases, then it's much less of an issue. Even if it turned out to be a sarcoma, because you're not really in a situation where you're going to unfortunately affect a cure. So it's really the solitary bone metastasis that you are obliged to know what it is before you do something like that, maybe. And so those are the places beware the solitary metastasis and that's a classic exam pitfall.
NICOLA EVANS: That's great. Thank you very much. So I think if that's all the questions, what we'll do is we will stop recording and we will move on to the Viva sessions.
Segment:0 .
NICOLA EVANS: Good evening, everyone, and welcome to this evening's webinar, which is what's new in metastatic bone disease.
NICOLA EVANS: And I'm pleased to welcome Mr Gerrand from the Royal National Orthopaedic Hospital in the UK. So the format of the meeting will be that we will have the lecture and then we'll probably do the quiz straight after the lecture and then we'll do invited questions. So if you do have a question, then if you can type it in the chat, we'll keep an eye on the chat and we'll ask Mr Gerrand at the end after the quiz.
NICOLA EVANS: Following that we'll stop recording and we have space for three candidates to do a practice FIVA of 5 minutes each and then get feedback from the faculty that are attending this evening. So stop. With me this evening I have Hannah and Lydia from OA UK as well as Ashraf and Mohammed, who are part of the Orthopedic Academy faculty, and of course Mr Craig Gerrand, who is our guest this evening.
NICOLA EVANS: So as always, the video will be available on YouTube shortly as in a couple of days after today. So if you miss any part of it, you don't need to panic you can go back and watch it again. For those of you who want certificates, if you contact OR UK, fill in your feedback forms and they'll provide you with CPD certificates. So I think without any further ado, I will introduce Mr Gerrand, who has very kindly come to talk to us about really I find it very interesting metastatic bone disease.
NICOLA EVANS: So I hope you all will, too. Thank you, Mr Gerrand, over to you.
CRAIG GERRAND: Thank you very much. And it's a joy and delight to be here. Thanks very much for asking me to come and talk, I'm going to talk to you a bit about what's new in metastatic bone disease. And as you heard, happy to have a conversation about things afterwards.
CRAIG GERRAND: And so I work at the Royal National Orthopedic Hospital, which you might have heard of in Stanmore, and I've been there since 2018, having worked for many years before that in Newcastle. It's not as falling down as it used to be. There are some new bits, although there's still a long corridor, an entertaining slope, and there's still some bits in need of a bit of refurbishment. But you're welcome to come and visit.
CRAIG GERRAND: Just let me know if any of this is of interest to you. So we're going to talk a bit about metastatic bone disease. So these are the kind of things that you always wonder about if you're a trainee. These are the kind of questions you might have or if you're not a specialist in orthopedic oncology. So one of the questions is what's the diagnosis? And of course, that's an absolute classic for the exam. Don't fall into the trap of nailing a solitary metastasis.
CRAIG GERRAND: You've got to ask yourself, what's the diagnosis for this literally? And then, of course, should this patient have an operation? If they should have an operation, what operation should they have? And then who should do it? So we'll touch on some of these issues, but these are the kind of questions that people ask. So bone metastases are often a feature of cancer.
CRAIG GERRAND: They present in a number of ways. They cause pain, hypercalcemia, fracture, spinal cord compression and pancytopaenia. So these are patients who are generally not well and they're quite different to other orthopedic patients, you could argue, who very often would have a single system disease. They get pain from mechanical instability, intraosseous pressure and probably nerve involvement.
CRAIG GERRAND: But it's really mechanical instability is the thing that we are bound to see most of. Why do bone metastases occur? Well, this has to do with delivery of cancer cells to bone from the primary tumor. You'll be familiar with Batson's vertebral venous plexus, which is a valveless venous system which allows retrograde embolism and it's for that reason it is said that prostate cancer ends up more on the spine than in other places.
CRAIG GERRAND: But generally speaking, it's about the seed and the soil, if you like. That was a theory from Paget at the end of the 19th century, but where you commonly see metastases, these would be the vertebrae, pelvis, ribs, fermora and the skull. When tumour cells enter bone and they go through a metastatic cascade, they're to do so. They can be directly lytic, so they release metalloproteinases, which are enzymes, which attack connective attached base membranes and so on.
CRAIG GERRAND: They can stimulate osteoclasts and the products of bone matrix degradation such as TGF beta that can stimulate tumor cell growth. So there's a positive feedback. So you see in the diagram you get a tumor cell stimulates osteoblasts, osteoclasts, precursors that become lytic in bone, and that in turn releases TGF beta. And so this kind of cascade can be interrupted by some drugs like bisphosphonates.
CRAIG GERRAND: And that's particularly the case for tumors that are very lytic. They may this Fosamax may have a particular or denosumab, which is a RANK ligand antibody is particularly useful for, for example, GI tumors. Opponents of primary bone tumors, a lot of oxaliplatin. How big a problem is it? Well, there's a quarter of a million new cases of invasive cancer per annum in the UK. 40% of all people will get cancer.
CRAIG GERRAND: It causes about a quarter of all deaths and 60% of them were higher in fact, or had bone metastases. Five year survival is about 80% for breast and prostate cancer is improving. And so metastatic bone disease is something that you start to think about, not just the urgent fixation of fractures, but also the longevity of reconstruction. It's the first presentation of cancer in about a quarter of patients.
CRAIG GERRAND: And a figure from the state suggested that treatment of metastatic bone disease alone may account for 20% of the overall cost of cancer treatment. So it's a big deal. This is some figures from Scotland where the projected number of people living in people in Scotland dying from multimorbidity associated with palliative care is going to go up and up.
CRAIG GERRAND: So if you look at the graph, the purple graph is a projection for 2040 where you're going to see, particularly in the very elderly population, far more people dying of multimorbidity, which requires palliative care and for which the treatment of metastatic bone disease is a part. So you can see there's an increase in demand for it. The counter-argument to that might be that there'd be other treatments like drug treatment that might mitigate that to some extent.
CRAIG GERRAND: And I think it's certainly been the case in my professional lifetime with some diseases like multiple myeloma and breast cancer, where patients may have other lines of treatment they can take. And actually, there's a, we do see a response to things that a few years ago, we would have said, you know, that lesion definitely needs fixation, but now we'll see some response to treatment.
CRAIG GERRAND: So patients classically present with pain, swelling, pathological fracture, loss of use or neurological changes as and sometimes as an incidental finding and usually with an abnormal X-ray. But when you see an abnormal X ray, it's very important that you stop. And there's plenty of literature from quite good publications, and I'll show you some of them from a group in Leiden who've tried to codify some of what should happen when you see a patient with metastatic bone disease.
CRAIG GERRAND: And first thing you do is stop, think and stage and act. OK? so there's no need to take some of the pathological fracture directly to theatre, need to work them up to work out what it is that's going on, whether an operation is appropriate. It's one of my favorite pictures. I got a phone call when I was in theater to say this gentleman who's had prostate cancer has broken his leg and he needs an urgent operation.
CRAIG GERRAND: Is that all right? And of course, you look at this and you say to yourself, well, look, here's a little lesion in bone. And you ask yourself, where is it in the bone? Well, it's central. It's in the kind of proximal metastasis diagnosis. What is it doing to the bone? Well, it's obviously making a hole in the bone. What's the bone doing in response?
CRAIG GERRAND: Not very much, actually. It's not managing to wall this off at all, although there is this kind of possibly long standing calcification in it. Is there a matrix? Possibly again, this longstanding calssification represents a matrix. And is there a soft tissue mass? Not really. But if you look carefully, the subtleties, you just see that this is actually an open fracture.
CRAIG GERRAND: And this segment has come through. And although this patient had prostate cancer, this isn't prostate cancer at all. This is a differentiated contra sarcoma. An elderly gentleman. And the last thing everyone should do is nail this. This is a primary bone tumor with admittedly a poor prognosis.
CRAIG GERRAND: That's not something you can improve by making. And so this patient had first aid to the wound, had a biopsy of this and that's how come we made the diagnosis. And it went on to have an end of periprosthetic replacement, which this is the right treatment. So don't forget the basics. Take a history, examine the patient, and this is where you need to be a bit more general surgical if you like.
CRAIG GERRAND: You need to be examining some of these abdomen, the lymph nodes you would consider, I suppose, in some patients where they needed a breast exam or even a rectal exam or that would be basic trauma. You certainly want to make sure that you examine the patient properly and think about the basic investigations. So the blood tests, the ordinary x-rays before you get as far as the scans, you consider doing a biopsy if you don't know what it is and you consider staging.
CRAIG GERRAND: And it's obviously important for these complex patients to think about, including their oncologist, palliative care team, and also to work out what a patient's anesthetic options are. We commit them to quite big surgery. Biopsies are pretty straightforward to do. So here's a true cut biopsy. You can do this under local anesthetic for a tumor that has a large soft tissue mass.
CRAIG GERRAND: This is a true bone biopsy needle on the bottom left. And this is a picture of me doing a biopsy with a true cut needle of a bone tumor under local anesthetic. So they can be pretty straightforward to get some tissue and decide what this abnormal lesion is. There are systems and here's the Linden Group again and they suggest that actually if you have somebody with a suspected pathologic lesion, you want to do the appropriate investigations and work out whether this patient needs referral to an orthopedic oncology center, whether they just need care and comfort or interestingly in Linden, you can select euthanasia I understand.
CRAIG GERRAND: Whether their life expectancy is less or greater than six months, whether they have a fracture. And so to do that, you basically process in a systematic manner. So what's the origin of the lesion that you can see in bone? If you don't know where it's from and it looks like a metastases, then you would consider doing staging for the patient.
CRAIG GERRAND: So CT of chest, abdomen, thorax, possibly a PET-CT and then you can consider a biopsy. If they have a primary tumor with an unknown bone lesion, then again, you'd ultimately want to do a biopsy. If you know the patient has metastatic bone disease after you've done the biopsy, then you want to ask the questions in the box, but they still may have a primary bone tumor. Then you refer them to North West London Pathology Center.
CRAIG GERRAND: So what you're trying to do here is work out how extensive this patient's disease is. That's what the staging is about. What's their general health? Take your history and do blood tests. And what's the involved stages of the local bones? You need whole X-rays of the whole bone and then whether or not they're having a fracture. So you can refer to this later, if you like, but it gives you a general scheme for how you might approach a patient with this lesion.
CRAIG GERRAND: So of course, each kind of bone metastasis has its own personality, if you like. So breast cancer classically presents with mixed lytic or blastic picture. You can get response rates of 50% to 60% if they've got appropriate treatment options. And that's why it's important to know if this patient, for example, is treatment naive, if they've never had any treatment.
CRAIG GERRAND: And some of this might get better on treatment. And the five year survival is about 50% of those bone only metastases. And reconstructions need to be durable for that reason. And survival after bone metastatic breast cancer is getting better and it's better if you have ER positive disease. OK that's the first line on the left hand graph here. It's better if you have single metastases.
CRAIG GERRAND: And if you have a single bone metastases, about 70% of people are around at 10 years. So again, you want to treat that properly and with a durable reconstruction. This is a patient. It's one of my favorite X rays, which tells a story about a lot of things. I'm not going to bring it up in the VIVA. But say this class, this shows a patient of prostate cancer.
CRAIG GERRAND: Why do they have prostate cancer? Well, you can see that this is a very sclerotic so it's an osteoblastic metastasis. And that proximal femur, has been clamped to the femoral head on the right side of patients who got end stage osteoarthritis. And that's just a reminder to say that patients with metastatic bone disease, their pain might be due to something more mundane than a metastasis.
CRAIG GERRAND: And they've also got a ureter stenting. But this is a patient who's obviously had some kind of pelvic radiotherapy. So all that adds up together to a patient with metastatic prostate cancer. So 80% of patients with metastatic bone involvement in prostate cancer survive for 12 to 20 months often. often pelvic or spine. And fractures, actually they tend to be a bit like this sometimes.
CRAIG GERRAND: So they're more like stress fractures and the bones, quite sclerotic, but not normal. And so it can collapse. You can also get a little stress fractures rather than complete fractures. And if you're ever thinking about doing a femoral nail on a bone that looks like this, bear in mind it's going to be really hard to get anything down that canal. So if you're going to do it, you've got to have an image intensifier and a drill.
CRAIG GERRAND: And a lot of patients probably we think it's important to do that. Kidney cancer is classically listed. It's not uncommon for us to see a patient presenting with something like this, and they have a CT cap and they've got primary renal tumor. So a very lytic lesion like this is pretty classic for renal cancer.
CRAIG GERRAND: You can consider a section of this. And this is a condition where resection of one metastasis, particularly if the metastasis occurs several years after the primary tumor, is associated with a longer survival. They don't respond very well to radiotherapy. They're highly vascular. And in fact, a soft tissue mass like this is very often pulsatile.
CRAIG GERRAND: So if you feel it, you'll notice that it's very vascular. About a 30% five year survival is quoted, although that's improving, as we see from here. And that shows that even people with high grade disease is now 10 years old. These figures improve. There has been an improvement in survival, and that's due to immunotherapy and a bunch of other targeted example tyrosine kinase inhibitors that are making a difference.
CRAIG GERRAND: And here's a meta analysis that shows that if you do a mastectomy in these patients, it is associated with further with increased or better survival. So the hazard ratios are improved in favor of mastectomy. Lung cancer, however, classically lytic. About 15% to 40% of patients have both metastases.
CRAIG GERRAND: It can have a poor prognosis but this is changing and it's pretty common, particularly in places like Scotland, where it's one in 12 men, 1 in 13 women in Scotland will get lung cancer. And that's an epidemic. There are things that are making a difference. This shows that the survival has improved over recent decades, and things like immunotherapy and other targeted therapies, particularly for people who have specific mutations, is making a big difference for patients with lung cancer.
CRAIG GERRAND: Plasma cyetoma myeloma. If you see a lytic lesion like this, if you see a patient presenting with this, you've got to do basic stuff, right? You've got to do a protein electrophoresis. This could be myeloma, these are classically lytic, let's say, about 30% present with the pathological fractures. It's not unlikely that you'll see sometimes 5,000 people a year in the UK, 40%, five year survival also improving and usually in bones, the rich red marrow content, such of the proximal human spine.
CRAIG GERRAND: They are cold on bone scan generally. And again, that's a classic exam question. And for people who don't have a fracture, the response rate of this is actually pretty good. So someone who's treatment naive could get radiotherapy and bisphosphonates without reasonable expectation that would heal. And in fact, I have a colleague at Stanore called Sean Malloy, who has an interest in spinal myeloma, and he's stopped operating on patients with spine
CRAIG GERRAND: pretty much. And they get braced, they get conservative treatment. They don't have enough surgery. So why would you operate on somebody with metastatic bone disease? You do it to relieve pain, to restore function, maintain an independence, improve quality of life, and where you can, improve survival. We did a meta, we did a meta analysis AJ Malviya and myself some years ago looking at this, and there's good evidence for these things.
CRAIG GERRAND: When you're thinking about surgery, you think what you want to think yourself. What's causing symptoms? Is it that guy who has the osteoarthritic hip or is it somebody with a definite metastasis? What's the risk of fracture? Is there an alternative to surgery? How long are they going to live? Are they going to survive the surgery?
CRAIG GERRAND: And these are patients who have significant comorbidities. What operation should you do? And then who should do the surgery? So should they have if they have advanced disease, should have a straightforward nailing, for example, in a local hospital? Or should you put a patient at sort of close to end of life in an ambulance to go to the specialist center where they're a long way from their family?
CRAIG GERRAND: Well maybe some patients should have that, but also some should have treatment closer to their home. There are things that might put you off surgery, but the overall physical and emotional state of the patient, mental obtundation is said to be a contraindication to surgery so somebody who is not responsive. Haemopoetic depression.
CRAIG GERRAND: So it's interesting. We see this not infrequently patients have had radiotherapy or on other chemotherapy, but they don't have adequate cell counts. They go through surgery or they have such marrow replacement that the hemoglobin is low and their other cancer load so they may not be good surgical candidates. Patients with infected wounds
CRAIG GERRAND: so particularly if your going to put in big metal work, they've got a DVT, they have extensive neuromuscular encasement, their survival is very short. So somebody, for example, with lung cancer, it has a brain metastasis. You wouldn't be put into any sort of surgery. Prognosis is very poor. So it's patient factors, disease factors. So what's the prognosis of the patient,
CRAIG GERRAND: do they have other signs of disease? And there'll be some procedure specific contraindications to surgery. We get some quite interesting and challenging patients. So here's an 80-year-old patient. I mean, a patient that has come up in recent weeks and recently an 80-year-old patient, who had a thing called a gastrointestinal stromal tumor, which is an unusual kind of sarcoma, arises in the small bowel usually, with a metastases in the pelvis.
CRAIG GERRAND: And so the conversation from here, this has gradually got bigger over time. The conversation here was whether resection of this polygome metastasis, meaning solitary or very small number of one of the very small number of metastasis, should be resected for improved survival? This is a tumor that has a number of biologic treatments for it and it does develop mutations so you get responsible
CRAIG GERRAND: parliament and then you have to go to different agents. So reducing the number of cells might be beneficial, but for this elderly gentleman, the sort of resection that would have required for this large tumor that was adjacent to the prostate was really close, so we didn't operate. Some places, of course, may have a fracture, and that's an indication we're operating. And if you think someone's got a very high risk of having a fracture, then it's best to operate before it breaks because the procedure is more straightforward.
CRAIG GERRAND: It's been an elective function and the recovery is usually faster. So how do you know something is going to, something's going to fracture? Well, as these are classic exam questions, the Mirel's Rating System. Which we should know for the exam, but it has its downsides and it doesn't, for example, it doesn't, for example, think anything about how active the patient is, whether or not their lesion might respond to radiotherapy or other treatment, for example.
CRAIG GERRAND: And the other thing you have to consider is if you're going to put someone through an operation, they can't have any other treatment for quite some time. That could be as long as six or eight weeks. And for some people, that might be that might mean, they missed their window for systemic treatment. The thing that's really important, most important, I think, is mechanical pain. So if somebody has pain and weight bearing, that's the thing that really makes you concerned that they might fracture.
CRAIG GERRAND: So there's a Harrington system beginning 2.5cm in the proximal femur, something that's bigger than 2 and a half cm. So there's a fracture well that's true of cancer. It hasn't responded to radiotherapy so these are at risk. And Mirel system, in particular with functional pain lytic lesions and large lesions, a peri tronchater.
CRAIG GERRAND: There's the highest risk. It was another system here again from the Netherlands, which looks at the axial cortical involvement. So if you've got more than 3 centimeters of proximal distal cortical involvement in a long bone and a circumferential involvement greater than 50% in size, this bit over here, if that's more than 50% of the total length is more than three centimeters then they would say the risk of fracture is very high and the patient should be considered for operation.
CRAIG GERRAND: But these are the other little extras that you should consider. What else can you do apart from surgery, you don't have to operate on people, particularly if tumors are radiosensitive. If a chemo sensitive, treatment naive or the patient is not fit, then you've got some things, other things you can do.
CRAIG GERRAND: And just because you can't operate on someone doesn't mean we can't offer them a lot of other things. And here, if you have patients like this, if you have a good palliative care team available, then that's really helpful because they'll help contextualize this kind of big surgery for a patient at the end of life. Is that really the best way for somebody to spend their time having a big operation and recovering from that?
CRAIG GERRAND: If the prognosis is poor or if there are other ways in which the quality of life might be improved. So, for example, by using good pain techniques, radiotherapy, some radioisotopes can be helpful. Chemotherapy, hormonal therapy and so on. Splinted walking aids and embolisation are all things that should be in your toolbox for managing these patients.
CRAIG GERRAND: So in the upper limb in particular, you can put someone in a splint for someone in a sling that can get up and around and think about why you're working out what it is you want to do and whether or not other treatment might work. Performance status is really important. You've got to have a performance status of two or above to get chemotherapy, generally speaking, which means you've got to be out of bed more than half the day.
CRAIG GERRAND: Of course, if somebody has got a fracture, they're pretty much stuck in bed all day so they are seldom candidates for getting chemotherapy. So although this is a blunt instrument, it's fairly widely applied and exceptions are made for patients who are otherwise fit but in bed for a fracture but generally speaking, our role as orthopedic surgeons is to get people up and out of bed so that they can have further treatment.
CRAIG GERRAND: And this is another way of looking at patients by trying to classify them into their prognostic groups. So operating in someone with a prognosis who ends up in the A group needs to have a very durable reconstruction. B, perhaps not so durable, C, perhaps they can have a nailing and D you probably shouldn't operate on. And the factors they say our clinical profile, which is a slightly vague thing, but they're either pretty fit or they're unfavorable or they're not fit.
CRAIG GERRAND: Karnofsky's very much like the ECOG score. So to show you some of these top scores on the left, poorer scores on the right, whether someone has visceral or brain metastases. So if you do have visceral bone mestasis, you're automatically going. And so this allows you some kind of rule of thumb as to whether or not this patient is going to live long enough to survive a cancer.
CRAIG GERRAND: And there are other things that people look at: Glasgow Prognostic Score. He takes albumin and CRP and combines them in a quite straightforward manner to give you a score. And this is how it correlates with this is how it correlates with survival in breast, bladder, that's esophageal and prostate cancer and sarcoma. So you can lose it sorry you can use a score like this.
CRAIG GERRAND: So, again, to get an overall handle on how well that patient is. When it comes to surviving surgery these are patients from our center, we've got this study authored by Rachael Baumber, who's one of the anaesthetists' at Stanmore. And it shows the overall survival of patients having surgery for metastatic bone disease in our center. So there's only about a quarter still alive at three years.
CRAIG GERRAND: Yeah and so so these things are high ASA, high white genitourinary, resting heart rate under 100 and the type of cancer are all predictive of reduced survival in this patient group. So breast cancer has a relative risk and has a ratio of 1, gynecological cancers 2 GI cancers 3. And so on lung cancer 2 and a 1/2. OK so again, this is a way in which you would get a handle on whether or not that patient is going to be well enough to survive surgery.
CRAIG GERRAND: In terms of surviving surgery, you want to avoid early complications. So patients who have early complications are associated with high mortality at one year. Again, another way of just making you think of that, actually what, what's the right thing for this patient? So once you've selected your patient, what operation are you going to do?
CRAIG GERRAND: Well, classically, trauma devices which are load sharing are not great for use in patients with metastatic disease. I think if you have a poor prognosis and you've got diaphyseal metastases and multiple metastases, then a nailing is a reasonable operation. The fixation of the proximal femur of assigning get screw leads to that sort of situation that you see in the X-ray.
CRAIG GERRAND: And so there's a high rate of failure so that's so generally speaking, replacement for that sort of lesion around the end of the bone is a better deal and is more likely to be durable than using a trauma device. It's always nice to consider, particularly if you're dealing with a small number of metastases, whether you can remove the tumor. And so I've got a slight preference for tasis where possible that we might consider curessing and plating them.
CRAIG GERRAND: And that gives you a chance to achieve better local control. You can put cement where the defect is, and it means you've got better fixation, you can follow it up with radiotherapy. However, it doesn't necessarily fix the whole of the bone, which for many years has been a kind of a guideline for the treatment of a metastic bone disease. When you're instrumenting the bone beware the frail patient with lung problems.
CRAIG GERRAND: So the patient has a pleural effusion or has multiple mets, you need to be careful about those when you're instrumenting the canal, either by nailing or by putting in a cement. OK, segmentation is good for defects, but be careful when you pressurize for the same reason. The cumulative rates of complications are as high as 40% as perioperative mortality is high.
CRAIG GERRAND: You look out for bleeding, thromoembolic disease. The risk is likely high. People should certainly have a Doppler scan before you operate on someone with metastastic bone disease. And that's really your starting point. And we do detect patients that way who have unexpected thromboembolic disease and some of those will get filtered before they have operations. Infection is not good,
CRAIG GERRAND: local recurrence rates can be high. Reconstructive failure can be high up to 40% five years again, often because of local recurrence. So why would you do an on block protection better local control fracture? Healing is unreliable. It be more durable, less bleeding because you're going outside the tumor, might be associated with better survival in some patients.
CRAIG GERRAND: This is a slightly unusual case where we had a solitary metastasis after several years from thyroid cancer and we treated it by a resection and a massive allograft. So that's OK if you've got a good biological environment and the patient doesn't need radiotherapy but it's slightly unusual, slightly unusual choice for that, but it allows us to do a resection that's close to the proximal femur to keep the femur.
CRAIG GERRAND: So in general, although the patient with metastastic bone disease trying to avoid this kind of reconstruction because you don't want to put them in protected weight bearing for a long period but in patients when the prognosis is quite good, this is not unreasonable. You want to be careful with the tumor, you don't want to spread it about. But this is cancer that has recurred in the skin after doing an arthoplasty.
CRAIG GERRAND: It's or open fixation of a metastasis in the femur. So be as meticulous as you can in terms of swabs around the wound. I like using aqueous bethodene around the wound where I can because it's slightly sinusoidal and make sure that you don't leave big lumps of tumor and irrigate it copiously afterwards. So what operation would you do? Well, complications from intermedullary nailing occur longer than a year, and for prosthetic reconstruction tend to occur earlier.
CRAIG GERRAND: And so if you have somebody with a very poor prognosis, a lot of these around these sort of charts around, then you might consider doing an intramedullary nailing because their complications are likely to be beyond a year. The life expectancy is short. And so this. here you've got let's take you through this, patients with impending pathological fractures, their life expectancy is less than two months either don't do anything or if you have to enter an intramedullary nail fixation in every extremis.
CRAIG GERRAND: Up to 12, up to a year intramedullary nail fixation all other things being equal. If you have a solitary renal tasis, sorry, then life expectancy more than 12 months, you can do intert-medudullary nail with added local medical treatment and that sort of thing. We carress it out and try and avoid that recurrence. Or you could do if it's next to the end of a joint. You can do resection prosthetic reconstruction, you can have a solitary metastasis, and you can resection reconstruct in lesions of diasphyseal joints.
CRAIG GERRAND: So you would take those out completely, essentially. So again, this gives you a sense of what kind of operations you should select patients in, based in what sort of situation, because you want to try and avoid this kind of situation where you've had in a renal metastatis but this is obviously not united on the left, despite reconstruction now. And so we've had to do a secondary operation for the proximal femoral artery.
CRAIG GERRAND: This is a patient, a young patient with breast cancer who's got essentially a nasty fracture from the federal neck. You can just see that on the left hand side. This is very good for a primary replacement with good function, whereas this, which is a metastatic lung cancer, that bit of bone needs to be replaced and very often it will come out in pieces. Use a modular implant system, usually with an eight coated collar, although patients notice that's not essential cements with the bipolar head.
CRAIG GERRAND: And that would be a of standard proximal femoral replacement. Some of them come with shock and take attachment pieces, which are occasionally of some use which help it to resist dislocation. I'm not sure it really gives you good abductor function. That's more of a soft tissue repair, I think. And this is a patient with an unusual prostatic sarcoma, metastasized to the tibia with a fracture, with pain on weight bearing, and a relatively um relatively limited prognosis.
CRAIG GERRAND: And so we've curated that, filled it with cement, put a plate on, and he's gone back to weight bear. Could have had a proximal tibia but that's an operation that takes a lot longer to get over. That is the right option for some patients. This patient with breast cancer, they showed an extraordinary and has a very arthritic knee. So this is quite a good solution to securitize along a new knee placement, which she did very well at.
CRAIG GERRAND: Another one from the clinic quite recently, lung cancer, a large lesion in the back of the femur that's best treated by this little parallel replacement. He couldn't straighten his knee, but once we've done this, he could get up and walk again. Again, it's getting on with his life. Here's the lesion, which is very vascular on the MRI scan. And this shows that these are in the kidney.
CRAIG GERRAND: This is metastatic renal cancer. And usually for this sort of thing, we would start with we would start with embolization. So we would do this to try and reduce the vascularity of it. For most extra renal cancers, it can be extremely vascular and so this is embolization. So you avascular interventional vascular technique available and we've taken out or replaced it with the rotating industry standard.
CRAIG GERRAND: Some patients have a lot of surgery and standard arthroplasty techniques can be quite useful. I'm sorry, so I've got the CT scan again. But you see, as we collapsed at the femoral head that this patient had a hip replacement, we TMT augment it. The leg bones did very well. And then the next thing I was surprised to hear is he broke the other hip.
CRAIG GERRAND: And meantime, he'd had spinal decompression, but so you had approximately one on the other side and then. Then I see this slightly different patient, this patient with me. I'm not a patient, the kind of people that we see. So you do have a number of options, obviously, but essentially we can go large if we need to. We can replace the whole thing.
CRAIG GERRAND: So, this patients are going to have a hip replacement on the reconstruction side. And in most bones you can replace this metastatic renal cancer in approximal humerus. And this is a baby Walker shoulder. So this is a constrained reverse ball and socket shoulder that helps you with one of the major problems or the major problem for you, proximal reconstruction, which is instability.
CRAIG GERRAND: And you know, there are even, we can do. Wrap around this patient has had a pseudoaneurysm because of metastases mefistofele so we've got a number of quite innovative solutions for the right patient or you can replace the whole humerus. Most implants now come with a silver coating. We often use it this thing, which is a tumor tube activity, but it's essentially a knitted polyester sleeve that you can use to enhance your soft tissue, such as your attachment.
CRAIG GERRAND: So what does high quality care look like? Well, for many years, the BOA published a metastastic bone disease guide to good practice, a study which you can still find, but actually, as with everything else, is now a based guideline for management. So I would suggest that you read that and know about it when it comes to the exam and actually just for your daily trauma take, because it's got some very useful advice on it.
CRAIG GERRAND: From Scotland again there's some very good studies from Downie et al looking at, asking people using what's called a Delphic technique so asking people what they think are the most important things for patients with metastatic bone disease. What does high quality care looked like? Well, it looks like prompt orthopedic assessment.
CRAIG GERRAND: It looks like rapid investigations, a surgical decision quickly, biopsy or solitary lesions, good oncology input early, adults with fractures should have surgery without delay, we should rehabilitate early the patients who are dying, that need's to be recognized. They need to have a good palliative care and ceiling of care. So everyone needs to agree what the maximum is going to be.
CRAIG GERRAND: Every hospital has to have about this metastastic bone care pathway. It should be education. We should know by collecting outcome data what the impact of our surgery is. But we know from a recent audit that the resource, the Oncology Society audit says a wide variation in care and delays for patients who have metastatic bone disease. This shows the patients in a.
CRAIG GERRAND: Patients in a specialized center on the left? It does take longer for them to get from fracture to surgery. So one of the disadvantages of referring to specialists center is that length of time I know from experience locally patients spend a long time languishing in other hospitals before they get to us. And I think that that's really a call to arms for everybody. The patients who have metastatic bone disease get them investigated quickly and get them the oncology advice that you need quickly to try and make a decision and get them to the care they need as quickly as possible.
CRAIG GERRAND: It doesn't have to be as fast as within 24 hours for a hip fracture. But the same arguments apply. The longer people wait, the harder it is for them to rehabilitate. So to conclude, patients with metastatic bone disease deserve timely and appropriate surgery. It's got much to offer them. You should stop thinking stage and act. Don't miss a primary implement.
CRAIG GERRAND: Consider the whole patient in the diagnosis. And wherever you are, consider what your local services and pathways are and how you're going to meet quality standards for this very rewarding, ask the patient. And that if you're all still there is the end of my talk. So we'll move on to the next bit if that's alright?
NICOLA EVANS: That's great. Thank you so much Mr Gerrand. I found it really interesting, so I haven't got any questions yet so people can have a little think about that while we launch the poll. So if you can all answer quickly, it's completely anonymous. And then we'll move through and Mr Gerrand can discuss the answers with us.
CRAIG GERRAND: So you seem to say it's a slightly upside down question for which apologies. But basically these are statements from the BOAST guidelines apart from one. And the first was, as each unit should have, an agreed policy for the multidisciplinary discussion management of metastatic bone disease, including clear pathways from referral. Yes, they should say that's supported, so that's not the answer.
CRAIG GERRAND: All specialist centers should have agreed pathways to enable prompt opinions, advice and transfer to the network. Yes, you should. But that's not it either. Prodromal history of a link to your night pain raised suspicion of MVD and should be documented along with injuries circumstances. Again, that's in the statement.
CRAIG GERRAND: So that's not the answer. Patients should have an pathologic approach to the hip, should have an operation within 24 hours. That is not in the guidelines, that is not in the BOAST guidelines because as we've said, what you want to do is be investigating. You want to stop and think before you act. So that means that some patients are going to need an MRI scan. They might need a biopsy.
CRAIG GERRAND: And so one of the tradeoffs, as we discussed, is that it takes longer to go. That is the correct answer. So 70% of people got early and then metastatic bone disease without an obvious primary site. It should be discussed with the local acute oncology service. And that's also in there. So if you're following these guidelines, you'll involve the oncologists.
CRAIG GERRAND: So thank you for that. OK I guess we do the next one. And this is a question about renal metastases, which is not true. Again, I don't question. So complete removal of a solitary metastasis, maybe improve with improved survival. That's true. It's not that.
CRAIG GERRAND: Renal metastases are usually avascular. No, they're usually really vascular. So that's the one. And the other points you should discuss with the treating oncologist relatively insensitive to radiotherapy. And the patients may present with the bone metastasis and the CT caps required. They're all true.
CRAIG GERRAND: OK OK. Next one. I think everyone's answered that. I'll just go straight ahead with that one so that. Yes this is a question about lytic reasons in bone. So lytic reasons in bone. Again, I'm asking you, which is not true. Apologies it was upside down, which is false.
CRAIG GERRAND: So multiple myeloma. If you've got a lytic lesion in bone in an adult, you should always exclude it with a plasma protein. Yes, you should. The affirmative zone. So again, part of your vocabulary should be how you look at the lytic lesion in bone. What? what's around the edges, is it geographic?
CRAIG GERRAND: Is it permeative or is it mothing geographic? Bone hasn't a chance to wall off. Those are ones you can draw around with a pencil. They're more likely to be at the benign end of the spectrum. These are sort of permeative and more likely to be malignant. That's also true. Bone metastatic and prostate cancer can be osteoblastic as well as osteolystic. That's true. It's not that.
CRAIG GERRAND: Mechanical pain is associated with the risk of fracture. Yes, it is, Mirel's scoring and from clinical practice. And it's always possible to tell whether legs and bones are primary bone tumor from imaging alone. Of course it isn't. And that's why you got to investigate them and make sure you don't miss a primary treatment. So the answer. That's the answer.
CRAIG GERRAND: That's not true. I hope they were suitably educational and only a bit confusing as multiple choices tend to be.
NICOLA EVANS: That is great. Thank you. Thank you very much. I've got a couple of questions. So the first one is from Aditya Kaja, who's written, if there's a newly diagnosed metastatic bone lesion, is there a mandate for a complete skeletal survey?
CRAIG GERRAND: Yeah so a skeletal survey, so basically that's a thing isn't it? It's a collective agreement taken to mean a, a collection of plane films that we would use in myeloma traditionally where a bone scan isn't as sensitive. So if you wanted to identify whether the patient had not traditionally have done a skeletal survey, however, that's been superseded in many places by a whole body MRI scan.
CRAIG GERRAND: So a whole body MRI will give you more detail about whether that plasma site you've found litigation in bone biopsy is full of plasma cells, whether that is a solitary plasma cytoplasm, which is a precursor to generally whether it's multiple. So if you have somebody with a solitary bone lesion, particularly if they're over 40, they should have some kind of skeleton injury.
CRAIG GERRAND: It might be a whole body bone scan, that might be a whole body MR. And if it's myeloma and you don't have whole body MR, then you might do the skeletal survey, which is a bunch of x-rays. So, yes, that's part of the workup. And generally speaking, if you're under 40 and you've got a lytic lesion bone, you send them along the sarcoma path whereas
CRAIG GERRAND: it's more likely to be that, if they're over 40, then you really must work people up locally as metastatic disease. So that means taking ownership, finding out if they've had a recent diagnosis of cancer, if they've got an oncologist, asking their oncologist if they have a new lesion, whether that might be metastasis. And so that's so important. I hope I've answered the question.
NICOLA EVANS: Thank you. Aditya's also put a follow up to say: the spec, do spec's play any role?
CRAIG GERRAND: Do specs play any role? It's not something we use routinely as part of that. But there are, I suppose, as a way of whole body imaging, possibly but it's not something
CRAIG GERRAND: It's not, it wouldn't be a topic I'd pick.
NICOLA EVANS: Great thank you. We've got Syed.
CRAIG GERRAND: I am nailing them, I say. NICOLA EVANS Yeah Yeah!
NICOLA EVANS: Syed's asked has two questions. But I am...INAUDIBLE
CRAIG GERRAND: How important is the ventral canal? Well, the answer is I don't I'm not sure of the evidence for venting it, but it's not a bad idea, particularly if you've got very frail patients with a pre-existing chest disease. And certainly you'd want to make sure when you're reaming the canal, if you can, that you aspirate it thoroughly and that you're not turning the femur into a massive syringe.
CRAIG GERRAND: Essentially. That's also the case if you've got a long stemmed cemented implant. So I think the answer to that is I mean, I don't do, to be honest, I don't do very much nailing for metastatic bone disease. When I work at the moment, previously, I would fairly or pretty often drill a hole at the bottom of the femur and put a sack into it because I know the patients at risk and then I know I've done everything I can.
CRAIG GERRAND: What I have learned is that patients who have pre-existing chest problems, you've got to be super careful. With irrigation of the surgical site hypertonic fluid is a fact. Yes, we do. AUDIO OUT If I see whether there's any evidence for it, I don't know. The things that definitely we do, it's because it's fairly harmless.
CRAIG GERRAND: There are other things that are definitely sinusoidal and so things like chlorhexidine, aqueous chlorhexidine is available is very sinusoidal. And a few years ago there were people who'd accidentally used it to do arthroscopy and there's no doubt that it completely destroys the inside of a joint, it completely destroys articular cartilage, and similarly very sort of basic compound that would destroy cells as is aqueous bethadine, which is available
CRAIG GERRAND: and I would say if I'm particularly concerned that there might be a tumour leak, I'll pack bethadine soaked swabs around the wound, I can't prove to you that it's one of those things that makes you feel better. That's it. And what have we got further down? Is there any yoyal bone cement in the treatment of bone cancer? So, yes, there certainly is. Mechanically right, so if you're adding bone cement to your construct there are papers that say that in metastatic bones disease get longer, more durable reconstructions.
CRAIG GERRAND: And of course, bone cement is used by some interventional, interventional radiologists and some spinal surgery, vertebral plastic or injection of holes in bone as part of a sort of palliative procedure. So there is that role. And the other question I suppose, you're alluding to is whether or not the bone cement actually kills the cancer. And we have it probably does a bit you know, it does heat up and it may around the edges reach a temperature that it will kill rogue tumor cells.
CRAIG GERRAND: But that's no substitute for a proper cure charge. There were some years ago cements that had chemotherapy agents in them that didn't really catch on, I think, because people didn't really want to be handling cement for the site in the metal theater. So that hasn't really it hasn't really caught on. And there are other methods for delivering chemotherapy agents now that are done, particularly by again, by interventional radiologists.
CRAIG GERRAND: You can deliver the chemotherapy through, for example, live antacids, but that sort of thing hasn't really caught on. OK Salim Bob-Manual says, how do you avoid the pitfalls of missing a primary bone tumor in a known patient with a metastatic cancer? So the rule of thumb, I would say, is if they have a solitary metastasis, then that's the one that you need to investigate with a biopsy.
CRAIG GERRAND: If they have multiple metastases, then it's much less of an issue. Even if it turned out to be a sarcoma, because you're not really in a situation where you're going to unfortunately affect a cure. So it's really the solitary bone metastasis that you are obliged to know what it is before you do something like that, maybe. And so those are the places beware the solitary metastasis and that's a classic exam pitfall.
NICOLA EVANS: That's great. Thank you very much. So I think if that's all the questions, what we'll do is we will stop recording and we will move on to the Viva sessions.
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