Metastatic Disease to the Skeleton Program

Metastatic bone disease

AHN’s approach to treating metastatic bone disease involves a multidisciplinary team of health care professionals, including oncologists, radiation oncologists, orthopedic surgeons, pain management specialists, nurses, and physical therapists. This collaborative approach aims to provide care that addresses all aspects of the disease and its impact on your life. Treatment for bone metastases focuses on relieving symptoms and improving quality of life.

Bone metastasis symptoms

Bone metastasis itself doesn't always cause symptoms. When symptoms do occur, they can vary depending on the size and location of the metastasis.

Common symptoms include:

• Pain: This is often the first noticeable symptom, described as a dull ache that worsens over time, particularly at night.
• Fractures: Weakened bones are more susceptible to fractures, even from minor injuries.
• Hypercalcemia: Bones release calcium into the bloodstream, potentially leading to nausea, constipation, fatigue, and confusion.
• Spinal cord compression: Metastasis in the spine can press on the spinal cord, causing pain, numbness, weakness, and even paralysis.

Bone metastasis treatment

Treating metastatic bone disease focuses on relieving symptoms and improving quality of life. Treatment plans are personalized based on factors like the primary cancer type, the location and extent of bone metastasis, and overall health.

Surgery

When preparing for surgery, it’s key to have health care professionals who are in your corner and understand the intricacies that come with preparation, the surgery itself, and recovery. AHN’s orthopaedic oncologists provide care that encompasses all areas of your health. These oncologists are highly trained in this rare specialty to deliver positive health outcomes.

Surgery for metastatic bone disease isn't always necessary, but it can play a vital role in specific situations including:

• Prophylactic surgery: Impending or actual fractures at weakened bones are at high risk of fracture. Prophylactic surgery can stabilize the bone before it breaks, using metal plates, rods, or screws (internal fixation) to strengthen it. This can prevent pain, disability, and complications associated with a fracture.
• Fracture fixation surgery: The process of fixing fractures if they do occur, using the same tools as above.
• Decompression surgery (for spinal cord compression): Metastasis in the spine can press on the spinal cord, causing severe pain, numbness, weakness, and potentially paralysis. Surgery might include removing the tumor pressing on the spinal cord or part of the vertebrae (bones in the spine) to relieve pressure.
• Kyphoplasty: This procedure is used to treat compression fractures using a balloon-like device to help prevent collapse of the vertebrae. 
• Tumor resection: When pain doesn't respond adequately to other treatments, surgery to remove the tumor or stabilize the bone may be considered. This aims to improve quality of life by significantly reducing pain levels. In some cases, complete surgical removal of the tumor might be possible. However, this isn't always feasible or the primary goal in metastatic disease.
• Joint replacement: If a bone tumor has extensively damaged a joint, replacing the joint (such as hip or knee replacement) can improve mobility and quality of life.

Ablation

Ablation for metastatic bone disease aims to reduce pain and improve quality of life, not to cure the cancer. The goal is to destroy the cancerous tissue within the bone, thus lessening the pressure on nerves and reducing bone destruction. AHN orthopaedic oncologists use the following ablation techniques to treat metastatic bone disease. Your oncologist will determine which option is right for your specific diagnosis.

• Cryotherapy: Using extreme cold to destroy cancer cells, this minimally invasive procedure can provides significant pain relief through direct nerve numbing during freezing, often making it suitable for lesions near nerves. Additionally, it can stimulate bone regeneration, helping to strengthen weakened bone, particularly in weight-bearing areas. The visible ice ball on imaging allows precise monitoring during the procedure. It is an effective way to control local tumor growth and reduce the risk of fractures.
• Radio frequency: This achieves effective and rapid local tumor destruction using heat. It is minimally invasive, requiring small incisions, and the procedure is generally quicker than cryotherapy. RFA is a reliable method for controlling painful bone metastases in areas that are not too close to critical structures. Its efficacy in tumor ablation makes it a popular choice.
• Embolization: This procedure uses heat to reduce pain and control tumor growth by blocking the blood supply to the metastatic lesion. This deprives the tumor of nutrients, leading to necrosis (death of tissue) and hindering its progression. Embolization can also be used to shrink tumors before surgery or combined with other therapies like chemotherapy to enhance their effectiveness. It's a good option for highly vascular metastases and for preoperative control of bleeding.

Chemotherapy

This delivers strong medicine to kill cancer cells. Our team monitors you closely to determine the correct dose for maximum effectiveness and to reduce side effects. Treatment aims to shrink tumors, slow cancer growth, and alleviate pain through intravenous (IV) infusions and sometimes oral medications. Common drugs used include docetaxel, paclitaxel, carboplatin, and cisplatin. Potential side effects include nausea, vomiting, hair loss, fatigue, and increased risk of infections.

Hormonal therapy

This stops the growth of hormone-sensitive tumors by preventing the body from producing hormones or blocking the hormones using oral medications and injections.

Types may include:

• Aromatase inhibitors (e.g., anastrozole, letrozole): Block estrogen production, commonly used in breast cancer.
• Selective estrogen receptor modulators (e.g., tamoxifen): Block estrogen's effects in certain tissues, often used in breast cancer.
• Luteinizing hormone-releasing hormone (LHRH) agonists (e.g., leuprolide, goserelin): Lower testosterone production, commonly used in prostate cancer. 

Side effects vary depending on the specific drugs, but can include hot flashes, vaginal dryness, sexual dysfunction, bone loss.

Immunotherapy

Intravenous infusions are used to boost the body's immune response to fight cancer cells. Immune checkpoint inhibitors help the immune system recognize and attack cancer cells. Potential side effects include fatigue, flu-like symptoms, skin reactions, and inflammation of organs (in some cases).

Radiation therapy

This therapy delivers radiation from outside the body to the tumor site with multiple treatments over a period of days or weeks. The goal is to destroy cancer cells, relieve pain, and reduce tumor size. Stereotactic radiosurgery uses highly focused radiation beams to target the tumor with high precision. Potential side effects include skin irritation, fatigue, hair loss (dependent on area treated), and nausea.

During and after treatment

Depending on your specific course of treatment, your AHN care team will coordinate support during and after to ensure your whole health is taken into account to create improved health outcomes. During and after treatment, you can access:

• Palliative care that focuses on relieving pain and managing other symptoms to improve quality of life. AHN has palliative care resources that are tailored to your needs.
• Supportive care to help manage side effects of treatment, provide emotional support, and address practical concerns. Accessing supportive care at AHN is just one of the many ways you can your whole health is taken into consideration.

Metastatic disease specialists

AHN’s metastatic disease specialists are highly skilled, compassionate health care professionals who understand the complexities of this disease. You can expect personalized care that takes into account your specific needs.

Surgery

How to get care

To make an appointment you can:

• Call our scheduler: (412) 359-8614
• Schedule online
• Use MyChart and schedule with Dr. Lisa Ercolano to make an appointment

Please bring all relevant imaging on a CD or through PowerShare with correlating reports for review by our team to your initial appointment.

Expect to meet the orthopedic oncology team and get a brief overview of the treatment timeline. Your appointments may be overwhelming, so write down your questions and bring them with you to the office. Bring someone who can act as your support. These people can help you remember details discussed in the office and be there or you, if needed, throughout the appointment.

Clinical trials and research

AHN participates in clinical trials of new therapies that are open for patients who qualify and wish to participate. Patients are screened for consideration with ongoing clinical trials at every stage of their treatment.

What is a clinical trial?

Clinical trials are studies that try to answer questions about new ways to treat cancer with medications, radiation, or surgical techniques. Previous trials have shown how new methods of treatment improve survival and quality of life and reduce the risk of issues returning. You participate in a clinical trial only if you volunteer to do so and meet criteria for inclusion in the study, and you can stop participating in a trial at any time.

Who can join a clinical trial?

The plan for the trial, called a protocol, explains what the trial will do and how the study will be done. Based on the questions the research is trying to answer, each clinical trial protocol outlines specific criteria necessary to be eligible to join the trial.

Common criteria for entering a trial are:

• Having a certain type or stage of cancer.
• Having received a certain kind of therapy in the past.
• Being in a certain age group.
• Federal rules help ensure that clinical trials are run in an ethical manner, with your rights and safety protected. It’s to ensure that you’re not put at increased risk by participating in the trial, and that the results of the study are accurate and meaningful.

Currently active cancer clinical trials

If you would like to participate in a clinical trial and help our innovative team discover groundbreaking cancer solutions, ask your doctor if you’re eligible to participate in one. Find currently active clinical trials that are open for participation.

Refer your patient to an AHN specialist

Referrals are sent to Allegheny Orthopaedic Associates (AOA) - Lisa Ercolano

• All outside referrals can be faxed to (412) 359-4988. Referrals should include relevant office notes and imaging of concern.
  • When the referral is received, we will call the patient directly to schedule an appointment.
• Providers can call our office to discuss a particular case or patient with a provider directly. 
• We are able to fax or share information via EPIC EMR to share any information necessary to the patient's primary doctor or an outside facility.

For more information about referring your patient to an AHN specialist, read the Independent Physician Referral FAQs.