Chapter 094. Soft Tissue and Bone Sarcomas
and Bone Metastases
(Part 7)

Cancer in the bone may produce osteolysis, osteogenesis, or both.
Osteolytic lesions result when the tumor produces substances that can directly
elicit bone resorption (vitamin D–like steroids, prostaglandins, or parathyroid
hormone–related peptide) or cytokines that can induce the formation of osteoclasts
(interleukin 1 and tumor necrosis factor). Osteoblastic lesions result when the
tumor produces cytokines that activate osteoblasts. In general, purely osteolytic
lesions are best detected by plain radiography, but they may not be apparent until
they are >1 cm. These lesions are more commonly associated with hypercalcemia
and with the excretion of hydroxyproline-containing peptides indicative of matrix
destruction. When osteoblastic activity is prominent, the lesions may be readily
detected using radionuclide bone scanning (which is sensitive to new bone
formation), and the radiographic appearance may show increased bone density or
sclerosis. Osteoblastic lesions are associated with higher serum levels of alkaline
phosphatase and, if extensive, may produce hypocalcemia. Although some tumors
may produce mainly osteolytic lesions (e.g., kidney cancer) and others mainly
osteoblastic lesions (e.g., prostate cancer), most metastatic lesions produce both
types of lesion and may go through stages where one or the other predominates.
In older patients, particularly women, it may be necessary to distinguish
metastatic disease of the spine from osteoporosis. In osteoporosis, the cortical
bone may be preserved, whereas cortical bone destruction is usually noted with
metastatic cancer.
Metastatic Bone Disease: Treatment
Treatment of metastatic bone disease depends on the underlying
malignancy and the symptoms. Some metastatic bone tumors are curable
(lymphoma, Hodgkin's disease), and others are treated with palliative intent. Pain
may be relieved by local radiation therapy. Hormonally responsive tumors are
responsive to hormone inhibition (antiandrogens for prostate cancer, antiestrogens

with high-
dose imatinib: Randomized trial. Lancet 364:1127, 2004 [PMID:
15451219]
Bibliography
Burgert EO et al: Multimodal therapy for the management of nonpelvic
localized Ewing's sarcoma of bone: IESS II. J Clin Oncol 8:15
14, 1990 [PMID:
2099751]
Cangir A et al: Ewing's sarcoma metastatic at diagnosis—
results and
comparisons of two intergroup studies. Cancer 66:887, 1990 [PMID: 2201433]
Hayden JB, Hoang BH:
Osteosarcoma: basic science and clinical
implications. Orthop Clin North Am 37:1, 2006 [PMID: 16311106]
Jablons D et al: Metastasectomy for soft tissue sarcoma—
further evidence
for efficacy and prognostic indicators. J Thorac Cardiovasc Surg 97:695, 1989
[PMID: 2709861]
Lindberg RD et al: Conservative surgery and post-
operative radiotherapy in
300 adults with soft tissue sarcomas. Cancer 47:2391, 1981 [PMID: 7272893]
NIH Consensus Development Panel on Limb Sparing Treatment of Adult
Soft Tissue Sarcomas and Osteosarcomas. JAMA 254:1791, 1985
Roth JA: Resection
of pulmonary metastases from osteogenic sarcoma.
Cancer Bull 42:244, 1990
Wittig JC et al: Osteosarcoma: A multidisciplinary approach to diagnosis
and treatment. Am Fam Physician 65:1123, 2002 [PMID: 11925089]