PubMed · 6965805
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K P Heidelberger, B Schnitzer, D Tilford, A K Poznakski, R Heyn. 1980. Case report 107.. https://doi.org/10.1007/bf00347097
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Nuclear medicine provides information about bone physiology that complements anatomic imaging modalities. Following a review of the principles of bone scintigraphy, scintigraphic imaging of orthopedic problems, such as primary and secondary neoplastic disease of the skeleton, occult fracture, stress fracture, and osteomyelitis are discussed.
Pain management often is difficult in patients with bone metastases. Metastatic disease represents >40% of oncologic practice, and >70% of patients with metastatic disease have uncontrolled cancer-related pain. Significant morbidity caused by pathologic fracture and spinal cord compression can result from untreated bone metastases. Representing both a manifestation of systemic disease as well as causing localized symptoms, bone metastases require a multidisciplinary therapeutic approach. Radiation therapy provides both localized and systemic treatment options in addition to chemohormonal therapies and surgery. External beam irradiation provides palliation in >70% of patients through tumor regression of a localized lesion. Systemic radiopharmaceuticals treat multifocal disease either alone or as an adjuvant to external beam irradiation. Efficient and comprehensive management of bone metastases is imperative because of the associated symptoms, prior therapies, complex underlying medical problems, and clinical presentations that often require emergent interventions. Intensification of pain may be observed with hormonal therapy and systemic radiopharmaceuticals. Symptomatic relief from antineoplastic therapies generally requires 4-12 weeks and may be related to reossification. Symptoms, occurring due to the disease and/or while awaiting response to therapy, must be aggressively managed. Persistent or recurrent pain after therapy may be due to bony instability or fracture before reossification occurs. An Interdisciplinary Bone Metastases Clinic, with representatives from Diagnostic Radiology, Medical Oncology, Nuclear Medicine, Orthopedic Surgery, Pain and Symptom Management, Physical Medicine and Rehabilitation, and Radiation Oncology, was developed that allows coordinated evaluation, treatment, and symptom management of these complex clinical presentations.
The major clinical manifestations of multiple myeloma are related to enhanced bone destruction resulting in osteolytic lesions, osteoporosis, and pathologic fractures in most patients as well as hypercalcemia and spinal cord compression in many individuals. These patients frequently require radiation therapy or surgery. In an attempt to reduce these complications, bisphosphonates have been evaluated in several large randomized trials in patients also receiving chemotherapy. Oral etidronate given daily showed no clinical benefit, whereas the use of oral clodronate daily did reduce the development of new osteolytic lesions but did not significantly affect bone pain or rates of pathologic fractures. A large, randomized, double-blind study was conducted in which Stage III multiple myeloma patients received either pamidronate (90 mg) or placebo as a 4-hour infusion every 4 weeks for 21 cycles in addition to antimyeloma chemotherapy. The proportion of patients with at least one skeletal complication was significantly reduced in the pamidronate group compared with the placebo group. Although survival was not different between the pamidronate and placebo groups overall, patients in whom first-line chemotherapy had failed when they entered the trial lived longer with pamidronate treatment than those receiving placebo. Patients who received pamidronate had significant decreases in bone pain, had less analgesic drug use, and had better Eastern Cooperative Oncology Group performance status than patients receiving placebo. Pamidronate was safe and well tolerated during the trial.