Ten years ago, a diagnosis of metastatic bone disease (MBD) was almost always considered a death sentence. Most patients were given a nine- to 12-month life expectancy when cancer metastasized to the bone. MBD means that cancer has spread from a different organ to the bone; this is stage 4 cancer. The most common cancers that spread to bone include kidney, breast, prostate, thyroid, and lung cancers. We also care for multiple myeloma patients with tumors in the bone similar to MBD patients.
Advancements in medical oncology over the last decade have created a paradigm shift in MBD care, transitioning toward a more hopeful model focused on managing metastatic cancer by keeping patients active and mobile.
Orthopaedic oncologists are integral to this shift, giving patients access to the latest customized treatments for MBD, which affects about 400,000 people with each year.
Orthopedic oncologists are surgeons who specialize in treating patients with bone or soft tissue cancers – most specifically sarcomas or MBD. The Ortho-Oncology team at UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center has become a leader in MBD care, conducting clinical trials and research, as well as pioneering advancements in bone-stabilization surgery, intraoperative radiation and ablation therapies, and limb-salvage techniques.
Our program unites experts in orthopedic surgery, medical oncology, radiation oncology, pathology, musculoskeletal radiology, and physical medicine and rehabilitation. Working together, we help adult and pediatric patients with bone cancer maintain mobility and quality of life.
Dramatic changes in stabilization surgery
Bones are built somewhat like PVC pipes – there is a thick outer cortex that gives bone strength with the inside filled with spongy bone marrow. When cancer spreads to the bone, it can create weak points or holes in the cortex that lead to fractures. Prophylactic stabilization can help prevent fractures before they occur.
Your orthopaedic oncologist can reinforce the bone using implanted hardware such as rods, plates, screws, and/or cement. The surgeon may need to replace a portion of the bone with metal in the form of a joint replacement surgery.
These surgeries are crucial to help patients maintain mobility and minimize pain to help patients undergo treatment for their cancer. Data from the American Academy of Orthopedic Surgeons has shown that undergoing surgery to prevent a fracture typically provides better outcomes than surgery to repair a fracture.
Patients who get proactive stabilization surgery tend to have:
- Shorter hospital stays
- Fewer complications in recovery
- Faster return to daily activities
At UT Southwestern, we are using innovative techniques to improve bone strength and patient function. Creative solutions to improve function include mega joint replacement surgeries, minimally invasive ablation with cement and screw fixation, custom designed implants, and intraosseous radiation therapy.
We are a center that can offer new technology such as IlluminOss, custom orthopaedic implants, or Osseointegration. IlluminOss is a technology that fills the bone with a cement-like substance that conforms to the interior of the bone and improves strength and adjuvant fixation. IlluminOss is approved by the U.S. Food and Drug Administration (FDA) to prevent femur, tibia, humerus, and other long bone fractures as a supplement to standard stabilization. This is a great option for patients with tumor that weakens the bone. We are experts in working with biomedical engineers to design patient-specific implants when indicated or offering amputees the option of osseointegration to improve function with a prosthesis.
Patients with MBD may be more susceptible to complications or infections as they recover from orthopaedic surgery due to a compromised immune system and side effects associated with some cancer treatments. Accordingly, our orthopaedic oncologists meet regularly with other cancer specialists to discuss each patient’s surgery options and how best to control their cancer before and after the procedure.
Orthopaedic oncologists can surgically stabilize bone or rebuild joints, but they need help from other specialists to kill the cancer cells. Patients with MBD often need radiation therapy to eliminate or shrink their tumors before or after surgery. There are many radiation therapy techniques that can destroy cancer cells and improve the ability of the bone to heal.
Cold and hot ablation intraoperative procedures have also been game changers in the management of MBD, in some cases reducing the need for post-surgical radiation therapy and pain medication:
- Cryoablation: A thin, very cold wand is placed into or near the tumor, freezer-burning the cancer cells to destroy them.
- Radiofrequency ablation: Hot radio waves sent through a fine needle into the tumor can eliminate the cancer cells.
Medical therapies to rebuild bone
Bone is a living tissue made of many cells. Osteoblasts are cells that build new bone and osteoclasts are cells that break down bone. MBD rapidly increases the number of osteoclasts, breaking down bone far too fast and leaving it weak and susceptible to fracture. Several medications can help alter bone metabolism and decrease bone pain or fracture. The two most common medications used for MBD include denosumab and zoledronic acid.
Orthopaedic surgery for MBD is only a small part of the entire treatment plan that focuses on improving quality of life, decreasing pain, and maintaining function. It is crucial that patients continue with a systemic therapy plan guided by their medical oncologist. This would include some form of chemotherapy, immunotherapy, or stem cell transplant to eradicate cancer in their entire body.
Metastatic bone disease is a complex condition that requires collaborative care from a dedicated team of specialists. Though there is not yet a cure for MBD, advancements in treatment continue to improve and offer patients with stage 4 cancer more active and meaningful years of life.