Bone Metastases

Abstract

IN the following study an attempt will be made to correlate the various clinical features of the different metastatic lesions localized in the bones, together with the pathologic process involved; and to clarify the rather obscure results which have hitherto obtained with regard to the treatment of bone metastases (see Chart I and Table I). For purposes of analysis it has been found convenient to group the 334 cases of osseous metastases according to the primary tumor from which the dissemination occurred. The result of this analysis has brought forth many interesting and novel features in the natural history and clinical course of the various secondary bone deposits. Breast.—One hundred carcinomas of the breast were studied with secondary bone involvement. The majority of the primary lesions microscopically were found to be of the scirrhous type (58 cases); with a few instances of adenocarcinoma (six cases); medullary carcinoma (four cases); comedocarcinoma (three cases), and colloid carcinoma (two cases). In one patient the primary lesion was found to be fibrosarcoma. The bones most frequently involved were found to be, in the order of their incidence: the spine, pelvis, femur, skull, ribs, and humerus, while metastases in the forearm and the lower leg were of infrequent occurrence. There was no definite relation found between the primary lesion and the homologous bony structure. In 16 cases in which there were complete data, eight cases showed a primary lesion with contra-lateral bone metastases, while an equal number of patients revealed ipso-lateral osseous lesions. Many cases having multiple lesions on both sides of the body were valueless in determining this relation of primary tumor to metastases. Clinically, pain of a severe rheumatic character was an important feature. When the metastatic foci were located about the spine, girdle pains and many other neurological manifestations appeared. Occasionally, pain preceded roentgenologic evidence of bone metastases for from three to eighteen months. The majority of the cases eventually showed a secondary type of anemia, with its complications, as the disease progressed. An occasional case report in the literature (1, 2) was found in which a pseudo-pernicious type of anemia was present, with a color index of over one, a slight leukocytosis, nucleated red blood cells, myelocytes, and myeloblasts. The ordinary anemia of cancer, according to Piney (3), is not dependent upon the presence of carcinomatous deposits in the marrow, but upon intrinsic changes in this tissue. The terminal phase of the disease was a progressive emaciation, usually with much pain, and when the lungs were involved (19 cases) respiratory embarrassment, with spitting of blood and paroxysms of coughing, were added features of discomfort. Pathologic fracture occurred in 15 instances, 13 being in the femur, one in the ilium, and one case was recorded with multiple fractures of the ribs.