Adjuvant Therapy for Metastatic Bone Disease (video)

Overview

  • Skeleton is the third commonest metastatic site
  • Breast, prostate, lung, kidney and thyroid primaries
  • Multidisciplinary, aiming for pain control, fracture prevention and function
  • Radiotherapy, systemic therapy and bone modifying agents reduce skeletal related events
  • Mirels’ score predicts long bone fracture risk
  • Radiotherapy to the whole operative field after fixation
  • Embolise renal cell and thyroid metastases before surgery

Adjuvant Therapy for Metastatic Bone Disease by Dr Vikram David

Bone School – Tumour – by Mr Grant Pang

Management of Metastatic Bone Disease by Mr Grant Pang

Classification

SINS

Scores location, pain, lytic or blastic bone, alignment, vertebral body collapse and posterolateral element involvement, for a total of 0 to 18.

ScoreCategory
0 to 6Stable
7 to 12Potentially unstable
13 to 18Unstable

Original publication Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fourney DR. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010;35(22):E1221-9.

NOMS

  • Neurological (Bilsky grade), oncological, mechanical (SINS) and systemic domains
  • High-grade compression from a radioresistant tumour gets separation surgery then SBRT
  • Lymphoma and myeloma receive conventional radiotherapy
  • Instability needs stabilisation regardless of radiosensitivity

Management

  • Single 8 Gy fraction equals fractionated pain relief, with more retreatment
  • SBRT overcomes radioresistance in renal cell carcinoma and melanoma, with vertebral compression fracture risk
  • Radiotherapy to the whole implant after pathological fracture fixation, once the wound heals
  • Zoledronic acid reduces skeletal-related events but needs renal dose adjustment
  • Denosumab is slightly more effective, needs no renal adjustment, but rebound fractures follow stopping
  • Both carry jaw osteonecrosis, hypocalcaemia and atypical femoral fracture risks
  • Hypercalcaemia treated with intravenous saline and bisphosphonate, then denosumab or calcitonin
  • Acute cord compression needs dexamethasone and urgent multidisciplinary decision
  • Treat a solitary lesion as primary sarcoma until proven otherwise
  • Mirels score predicts impending long bone fracture
  • Fixation should outlast the patient, protect the whole bone and allow immediate weight-bearing
  • Consider embolisation for renal cell and thyroid metastases

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.