Bone CA and Metastatic Diseases Flashcards
What are the phases of therapeutic interventions?
Preventative
Restorative
Supportive
Palliative
What is goal of preventative interventions?
Lessens impact of anticipated disability through education and training.
Conditioning program for a child facing prolonged chemo regime
What is part of restorative interventions?
Aims to restore physical integrity
Mobility training and exercise following surgical excision of osteosarcoma
What do you do in supportive interventions?
interventions to cope with or accommodate a disability
orthotic intervention for chemo induced neuropathy
What is palliative interventions?
provide comfort of assistance when recovery is not expected
pain management or family training to allow discharge to home
What are the primary bone malignancies?
relatively rare: 1/100,000
x35 with secondary bone disease (metastasis)
Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Malignant lymphoma of bone, parsteal, osteosarcoma, periosteal osteosarcoma
Who gets osteosarcoma?
60 y.o. as secondary neoplasm often associated with Paget’s disease
Where does osteosarcoma occur?
> 1/2 of cases in the metaphysis of distal femur or proximal tibia
Tendency of metastasis to lungs, other bones, but rarely other sites
What is cause of osteosarcoma?
Unknown etiology
linked to radiation exposure
What is medical management of osteosarcoma?
Follow diagnosis through x-ras, MRI, CT to define extent of disease
Biopsy: tumor with malignant osteoid-producing cells
Pre-operative chemo
Surgical excision of affected bone, 80% excised without amputation
Post-surgical chemo
70% long term survival, even with metastatic disease
Who gets Ewing’s sarcomas?
Usually in >3 and
Where do Ewing’s sarcomas occur?
60% of tumors in LEs or pelvic girdle
Tendency of mets to lungs and other bones
What are signs and symptoms of ewing’s sarcoma?
First presentation of pain, may have low-grade fever and anemia
What is medical management of Ewing’s sarcoma?
Onion skin appearance of cortical bone, mixed lytic appearance
X-rays, CT, MRI, bone scan and staging studies to define extent of disease
Several courses of pre-op multidrug chemo
Surgical resection has replaced XRT
Post-op chemo for approx. a year
50-75% survival of 5 years
Who gets chondrosarcomas?
Usually males more than females
>40
What does chondrosarcomas look like?
central portions of skeleton, especially the pelvis
Majority are low-grade and difficult to distinguish from benign cartilage disease histologically
Characteristic radiographic features
What is medical management for chondrosarcoma?
Managed surgically
Chemotherapy and/or XRT are reserved for progression of disease
Excellent prognosis with low-grade disease
When do they use limb sparing?
Success of limb salvage is compared against survival rate and function achieved through amputation.
They won’t spare the limb if they can’t get rid of all of the cancer.
What are possible limb salvage procedures?
Allograft replacement (same species treatment )
Endoprosthetic insertion (artificial replacement of body part that is placed internally)
Allograft-prosthetic reconstructions
Vascularized bone graft
Arthrodesis
Rotationplasty
What is important to consider with reconstruction in kids?
Complication free endoprosthetic or allograft reconstruction is an important issue in a young patient
Risk of: Infection, nonunion, delayed nonunion, OA, joint instability
What are functional comparisons for amputation vs. limb sparing?
Strength: isometric and isokinetic
ROM
Gait quality: velocity, stride length, single limb support time, double limb support time
Aerobic capacity during gait
What are other considerations for limb salvage vs. amputation?
Physical challenges, maintaining activity level
Psychological and social maturation, social isolation, body image and self-esteem issues
Pain management
Recurrent hospitalizations and multiple surgical interventions
Vocational issues
Retaining insurance, opportunities for rehab and prosthetic follow-up
What are acute PT interventions?
Mobility training: bed mobility, transfers Strengthening within precautions ROM within precautions Gait training with protective WBing Endurance activities
What are late PT interventions?
Joint function
Strengthening
Quality, effectiveness, and efficiency of gait
What is cause of metastatic bone disease?
High prevalent complication of CA
70-85% of patients who die of CA have bone metastasis
Where are common cancers that lead to metastatic bone disease?
PT Barnum Loves Kids Prostate Thyroid Breast Lungs Kidney
What are two possible lesions in metastatic bone disease?
Osteolytic: destruction of bone by stimulated bone resorption
Osteoblastic: dense, new bone growth with likely lytic processes and compromised bone quality
What are risks of lesions?
Combinationg can occur in same patients
Risk of hypercalcemia, pathologic fracture, pain, and SC compression
Relatively long clinical course (24 months in metastatic breast CA)
What is a pathologic fracture?
Severe complication of osseous metastatic disease.
Incidence in patient with bone mets is 9.5%
What is treatment for pathologic fractures?
Protective unweighting prescription: must evaluate integrity of structures with proposed weight redistribution
Prophylactic repair is controversial due to uncertainty in determining fracture risk
What are predictors for pathologic fractures?
Use x-rays and bone scans to have measure of cortical involvement.
Studies support using % of cortical involvement to determine fracture risk
Pain aggravated with functional activity may be a predictor
Cortical involvement limited to long bones not spine
Treatments change nature of lesions
Dynamic processes in metastatic lesions
What are characterizations of patients more likely to fracture?
Younger patients (mean age 59)
Greater number of sites involved with bony metastases
Presence of 2 or more pathologic fractures
What is ideal rehab for bone cancer?
Active pain free AROM only
No resistive training on involved or painful extremities, no PROM, no passive stretching
Limit MMT to uninvolved extremities
Inform patients of risks and risks of bed rest
What is intervention for hip, pelvis, and LE bone cancer?
Surgical intervention: IM rod or bipolar prosthesis
Allows for early WBing, compressive and rotational force tolerance
Gait training with AD; no fall tolerance
Strengthening
Non operative patient: goal of unloading, minimize stairs
What is intervention for bone cancer in UE?
Fracture brace, sling, IM rod in larger humeral lesions, compression plate, or cemented prosthesis of humeral head
Prophylactic fixation of lesion to allow use of AD
Consider UE and LE WB demands and realistic mobility
Early AROM, distal ROM and edema management
What is intervention for spine cancers?
XRT, chemo, hormone therapy, surgical resection for neurological compromise or instability
Pain management
Back protective transfers, use of AD, sparing ambulation abilities
Orthotic prescription, minimize flexion and rotation
Normalization of trunk biomechanics
What is multiple myeloma?
type of leukemia
acquired injury to DNA of a cell in lymphocyte development
B-lymphocytes transform into malignant cells
Abnormal cells accumulate in bone marrow causing tumor
Where do bone lesions occur in multiple myeloma?
Lytic bone lesions typically involving ribs, T-spine, pelvis, humerus, sternum, skull, and others
Is multiple myeloma a bone cancer or a type of leukemia?
It is a hematologic cancer that begins in the immune system and affects the bone.
Fracture may be first sign of disease
What is multiple myeloma sequelae?
Weakens bone Causes hypercalcemia Compromise immune system Causes anemia Prevent kidneys from filtering blood
How is multiple myeloma diagnosed?
Radiographic testing: CT and x-rays more specific
Lab blood and urine tests for high levels of antibody proteins
Bone marrow biopsy and or bone marrow aspiration
What is medical management of multiple myeloma?
Treatable but not curable Prognosis of 24-30 months Systemic treatment: chemo Local treatment: XRT Neutropenic precautions Dialysis Orthotics
What are PT interventions for multiple myeloma?
Back pain and compression fractures are common
Considerations as with metastatic compression fractures
Spinal orthotics
AROM
Maintain ambulation activities
