Bone Metastases and Pathological Fractures Imperial College Healthcare NHS Trust Bone Metastases and Pathological Fractures Occupational Therapy (Oncology & Palliative Care), COTSSO, 10 April 2013 Author: Nimisha Panchmatia Version: 1.0 Category: Presentations Circulation: COTSSO London, United Kingdom Bone Metastases and Pathological Fractures Author: Nimisha Panchmatia Version: 1.0 Circulation: Department Only London, United Kingdom © Imperial College Healthcare NHS Trust. All rights reserved. These materials may be reproduced only with written approval from Imperial College Healthcare NHS Trust. Such approvals must be requested via e-mail — Imperial College Healthcare NHS Trust [nimisha.panchmatia@imperial.nhs.uk] ICHT Page 0

Overview Case Studies Epidemiology Patho-physiology Signs and Symptoms Investigation Treatment Re-visit Case Studies Recommendations And Red Flags

Case Study 1 Mrs. Shawley, 77 yr. old lady transferred from Ealing hospital with 2 weeks h/o traumatic injury to neck, whilst attempting to lift her husband. Mrs. Shawley presented with severe neck and girdle pain, neck in flexion and lateral rotation and difficulty extending, pain radiating to head when attempting to extend neck, pain and tingling numbness when attempting to lift arm over 90 and unable to tolerate collar. Investigations: X-ray, bloods, Bone Scan, CTCAP and MRI spine. Diagnosis on admission: Advanced Renal Ca. with lung and Bone mets C5 pathological fracture with partial cord compression at C3-4 Past Medical history: hypertension

Case Study 1 Treatment : Dexamethasone, Bed rest initially with hard collar (Miami-J collar to be worn), Neurosurgery, Post-op- Miami J collar and Chemo-radiotherapy. Social History: Lived with husband in a first floor maisonette housing association flat. - Two flights of stairs to access the flat. - Inside the flat – Living room and open plan kitchen with hospital bed, commode, armchair provided for Mrs. Shawley’s husband. - Bedroom, toilet and the bathroom upstairs. - Slept on the landing on a fold up bed so that she could attend to her husband’s needs during night. - Declined Social services input and was the main carer for husband .

Case Study 2 Mr. Rohan 66 yr. old gentleman diagnosed with metastatic Prostate Ca. (Feb 2012) with extensive boney and spinal mets was admitted on 3.04.13 with history of severe ( R) upper limb pain and inability to move ( R ) upper limb. Mr. Rohan experienced sudden pain and seemed to have heard ‘’crack’’ when attempting to open bottle of oromorph. Investigation on this admission: X-ray humerus, elbow and wrist Diagnosis: Spiral pathological fracture of ( R) distal shaft humerus. Past Medical History: Recent admission 3.03.13 – 6.03.13 7.03.13 – 26.03.13 During both these admission Mr. Rohan presented to hospital with bony pain ribs, shoulder, groin and back and also presented with difficulty walking.

Case Study 2 Treatment: Radiotherapy for spine and bone mets during previous admissions Chemotherapy Conservative management of the pathological fracture Social History: Lives alone in a 2nd floor sheltered accommodation flat. Lift to access the flat. - Provided with bathing and toileting adaptations

Epidemiology Cancer is one of the major cause of morbidity and mortality across the world. In UK approximately 1 in 3 will be diagnosed with cancer during their lifetime and I in 4 die of cancer. Bone is the third most common metastatic site after lung and liver. Metastatic cancer invades the bone in 60–84% of patients with cancer. Common Source of bone metastases are – - Solid Tumours Breast Ca., Prostate Ca., Lung Ca., Thyroid Ca. and Renal Ca. - Haematological Malignancy Multiple Myeloma

Epidemiology - Incidence Disease Incidence of bone metastases in cancers (%) Myeloma 95-100 Breast 75-85 Prostate Lung 30-40 Renal 20-25

Epidemiology - Survival Disease Advanced disease median survival (months) Myeloma 6-54 Breast 20-24 Prostate 35-40 Lung < 6 Renal 12

Epidemiology - Survival Estimated survival following pathological fracture reduces. Fractures and single boney metastases vs fracture and multiple boney metastases (24 versus 6 months). Fracture and good overall performance status vs fracture and a poor performance status (14 months median survival versus 5 months).

Metastases

Patho-physiology - Bone Metastases Mechanism

Axial Skeleton Includes the bones of the skull, vertebral column and rib cage. Forms the long axis of the body. Involved in protection, support and carrying other body parts. Primarily trabecular, with a high bone turnover.

Appendicular Skeleton Includes the bones of the upper and lower limbs and girdles (shoulder bones and hip bones). Involved in locomotion and manipulation of the environment. Primarily cortical, with low turnover.  

Bone Remodelling Process

Effect on Bone Remodelling

Metastatic Lesions Classification - Osteolytic Lesions. - Osteoblastic. Osteoclast activation differ between malignancies.

Osteolytic Lesions Metastases from myeloma, lung cancer and renal cancer cause lytic bone lesions. Characterised by increased osteoclastic activity. Abnormally high rate of bone destruction/resorption. More prone to pathologic fracture.

Osteoblastic Lesions Metastases from prostate cancer cause blastic bone lesions. Characterised by laying of new bones cells on the trabecular bone surface before osteoclastic activity. Increasing local bone mass. Sclerotic in appearance. Considered to be at less risk of fracture.

Mixed - Osteolytic And Osteoblastic Lesions Breast cancer cells exhibit mixed picture of both lytic and sclerotic areas. Fractures usually occuring in lytic areas.

Signs And Symptoms

Common Sites of Metastases Bones close to the center of the body. Common site is spine. Other areas - Femur - Humerus - Ribs - Pelvis - Skull.

Pain Common presenting symptom. Develops gradually over the period of weeks to month, becoming progressively severe. Localised and often felt at night or on weight bearing. Described as constant, dull pain, gradually progressive in intensity. Described as referred pain, spasms, paroxysms of stabbing pain if mets are accompanied with nerve compression. Background pain - moderate at rest. Breakthrough/Incident/Movement Related pain – pain exacerbated by movements or on change of positions i.e. standing, walking or sitting. Breakthrough pain is a challenge to manage as it primarily experienced at the end of dosing interval of regular analgesic.

Metastatic Spinal Cord Compression

Metastatic Spinal Cord Compression The mechanical compression caused by the posteriorly growing mass, results in - mechanical injury - ischaemia - venous stasis and - infarction Pain is radicular or referred . - Tends to be unilateral when arising from compression at cervical and lumbar spine. - Tend to be bilateral when arising from thoracic spine. Pain is exacerbated in recumbency, neck flexion, straight leg raise, coughing, local pressure . Relieved with sitting up or lying still. neurological deficits - weakness, sphincter and bowel impairment and sensory loss indicate disease progression.

Hypercalcaemia Elevated plasmatic ionised calcium. Symptoms are evident calcium level >= 3mmol/l Associated with pain, nausea, vomiting, anorexia, constipation, weakness, dehydration, mental disturbances, confusion and polyuria.

Pathological Fractures

Pathological Fractures Occurs in less than 1 % of patients with advanced carcinoma. May be the first presenting sign of bone metastases in some cases. Consequences - Leads to loss of functions in affected region and thus - Leads to loss of independence - Limits participation in activities of daily living tasks - Decreased quality of life. Inflicts a dismal burden on a patient at the end of life.

Properties Of Bone Material Property Structural Property Organic Matrix (40%) Inorganic Martix (60%) Shape and Distribution of Cortical can Cancellous Bone Collagen (90%) Matrix protein (10%) Proteogycans Calcium Hydroxyapatite

Pathological Fracture Metastatic bone disease can result in fracture in one of the two ways. Increase the stress around the small lesions/hole in the bone. - Decrease in the bone’s torsional strength. - Torsional loads to bone occur most frequently in tasks which involve turning or pivoting form a standing position. - Example getting up from the chair to transfer. Larger metastatic lesion reduce the overall bone strength by 90%

Pathological Fractures The incidence of pathological fracture is uncertain. Destruction of cortical bone results in reduction in load-bearing capabilities. Trabecular disruption and micro-fractures. Occur spontaneously or following trivial injury. Frequently in the vertebral body and the proximal end of long bone. Emphasis on attempts to predict sites at risk of fracture to reduce patient burden. A research study demonstrated that it is not possible to predict PRECISELY the position and/or the movement that will lead to fracture.

For Example - Case Study 1 Pre-Op Post-Op

For Example - Case Study 2

Diagnostic Modalities X- Ray Radioisotope Bone Scan CT Scan MRI PET Scan

TREATMENT Analgesia – for constant and incident pain Radiotherapy Bisphosphonates Orthopaedic Surgery Palliative Chemotherapy

Therapy Goals Physiotherapy Goals Comprehensive exercise program to improve balance and stability. Maintain mobility as pain permits.  Post-op, weight bearing and early mobilisation as advised by the orthopaedic surgeons. Instruction on back sparing transfers and evaluation for possible need for a brace and /or orthosis, in case of MSCC.

Therapy Goals Occupational Therapy Goals Enhance participation in all activities of daily living tasks including personal care, social and leisure activities. Achieved through use of compensatory techniques as pain allows. Use of aids/adaptations and environmental adjustments in patients’ home to alleviate pain, risk of fractures and thus increase participation. Assessment of upper extremity function prior to weight bearing through the upper extremities i.e. use of walking aid or carrying, lifting, pushing, pulling activities.

Case Study 1 - Therapy Input Mrs. Shawley was required to wear the Miami –J collar during functional activities. Joint Occupational Therapy and Physiotherapy transfer , mobility assessment and close liaison with palliative care team with symptoms issues. Other OT intervention- ADL assessment, environmental assessment, rehabilitation practice with activities involving use of upper limb, education on precautions and pacing activities, liaison with NOK with updates and discharge plans. Joint OT and physio referral to community therapy team Liaison with social services and community palliative care team. Mrs. Shawley was discharged home with community support where she lived independently for approx 10-11 months. Her husband was in a NH.

Case Study 2 Mr. Rohan was independent with transfers and mobility on the ward. Daily review by palliative care team for pain management. Since Mr. Rohan was ( R) dominant he was experiencing problems with ADL tasks such as feeding, using cutlery, donning and doffing socks etc. Therefore small living aids such as sock aid, dycem mat, bread board and other long handled aids were provided at the time of discharge. Referred to Social Services for once a day carer to assist with personal care task, as his sister was to complete other domestic tasks. Known to community palliative care team from previous admissions.

Red Flags Sudden and quick increase of pain indicates a possibility of an imminent pathological fracture or epidural compression. Vague complaints of pain, leg weakness and dysesthesias should be investigated. Increasing and/or radiating pain with changes in sensibility along with other neurological complications like paresis or loss of strength can indicate spinal cord compression, compression of spinal nerves or cauda-equina compression. These symptoms are an emergency and warrant early detection and intervention to maintain functional outcome, especially in MSCC.

Recommendations Individualistic treatment planning. Understanding of medical condition, previous medical history, treatment options and prognosis. Modify therapy assessment to compensate for pain and risk of fractures. Pain assessment i.e. intensity, quality, distribution and temporal relation, prior to session. Use of compensatory strategies and assistive devises and/or orthoses.

Recommendations Ensure patients’ baseline pain is adequately controlled and they have access to ‘’as needed’’ analgesia for movement related pain.  Ongoing pain assessment i.e. continuously monitor and rate the movement related pain, before, during and after treatment sessions.   Manual muscle testing, passive or active-assistive range of motion assessment is not to be carried out routinely. Assess active movement within pain limits. If manual muscle testing is a must in case of MSCC, then should be done within pain limit. Avoid resistive exercise or load bearing activities.

End of Slides Imperial College Healthcare NHS Trust All queries must be addressed to Nimisha Panchmatia [nimisha.panchmatia@imperial.nhs.uk] © 2013 Imperial College Healthcare NHS Trust. All rights reserved. Reproduction of this publication in any form without prior written permission is forbidden. The information contained herein has been obtained from sources believed to be reliable. Imperial College Healthcare NHS Trust disclaims all warranties as to the accuracy, completeness or adequacy of such information. Imperial College Healthcare NHS Trust shall have no liability for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice. Bone Metastases and Pathological Fractures Author: Nimisha Panchmatia Version: 1.0 Circulation: Department Only London, United Kingdom © Imperial College Healthcare NHS Trust. All rights reserved. These materials may be reproduced only with written approval from Imperial College Healthcare NHS Trust. Such approvals must be requested via e-mail — Imperial College Healthcare NHS Trust [nimisha.panchmatia@imperial.nhs.uk] ICHT Page 43