Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis

H Michael Yu, MD, ScM
Sarah E Hoffe, MD
Section Editors
Reed E Drews, MD
Thomas F DeLaney, MD
Janet Abrahm, MD
Deputy Editor
Diane MF Savarese, MD


Bone metastases are a common manifestation of distant relapse from many types of solid cancers, especially those arising in the lung, breast, and prostate [1]. Bone is the third most common organ affected by metastases, after the lung and liver. For hematologic malignancies, bone involvement can also be extensive in patients with multiple myeloma, and bone may be a primary or secondary site of disease involvement in patients with lymphoma. (See "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma" and "Primary lymphoma of bone".)

Bone metastases represent a prominent source of morbidity [2,3]. Skeletal-related events (SREs) that are due to bone metastases can include pain, pathologic fracture, hypercalcemia, and spinal cord compression. Across a wide variety of tumors involving bone, the frequency of SREs can be reduced through the use of osteoclast inhibitors, such as bisphosphonates or denosumab. (See "Overview of cancer pain syndromes", section on 'Multifocal bone pain' and "Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma" and "Hypercalcemia of malignancy: Mechanisms", section on 'Osteolytic metastases' and "Clinical features and diagnosis of neoplastic epidural spinal cord compression, including cauda equina syndrome" and "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors" and "The use of bisphosphonates in patients with multiple myeloma".)

An overview of the incidence, distribution, clinical presentation, diagnosis, and therapeutic options for patients with bone metastases is presented here. This will include the pathogenesis and diagnostic evaluation of bone metastases, analgesic approaches for patients with pain related to bone metastases, as well as the use of radiation therapy, bone-seeking radiopharmaceuticals, image-guided thermal ablation for bone metastases, management of pathologic and impending pathologic fractures, and the use of osteoclast inhibitors to prevent SREs in a wide variety of tumors associated with bone involvement; specific issues related to bone metastases in patients with prostate cancer, multiple myeloma, and primary lymphoma of bone (PLB) are discussed separately.

(See "Mechanisms of bone metastases".)

(See "Cancer pain management: Adjuvant analgesics (coanalgesics)", section on 'Adjuvant drugs used for bone pain' and "Cancer pain management: Use of acetaminophen and nonsteroidal antiinflammatory drugs", section on 'Efficacy'.)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Aug 23, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Mundy GR. Metastasis to bone: causes, consequences and therapeutic opportunities. Nat Rev Cancer 2002; 2:584.
  2. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 2006; 12:6243s.
  3. Pockett RD, Castellano D, McEwan P, et al. The hospital burden of disease associated with bone metastases and skeletal-related events in patients with breast cancer, lung cancer, or prostate cancer in Spain. Eur J Cancer Care (Engl) 2010; 19:755.
  4. Theriault RL, Theriault RL. Biology of bone metastases. Cancer Control 2012; 19:92.
  5. Nielsen OS. Palliative radiotherapy of bone metastases: there is now evidence for the use of single fractions. Radiother Oncol 1999; 52:95.
  6. Eastley N, Newey M, Ashford RU. Skeletal metastases - the role of the orthopaedic and spinal surgeon. Surg Oncol 2012; 21:216.
  7. Bubendorf L, Schöpfer A, Wagner U, et al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol 2000; 31:578.
  8. Lee YT. Breast carcinoma: pattern of metastasis at autopsy. J Surg Oncol 1983; 23:175.
  9. Dispenzieri A. POEMS syndrome: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol 2014; 89:214.
  10. Chia SK, Speers CH, D'yachkova Y, et al. The impact of new chemotherapeutic and hormone agents on survival in a population-based cohort of women with metastatic breast cancer. Cancer 2007; 110:973.
  11. Ryan CJ, Elkin EP, Cowan J, Carroll PR. Initial treatment patterns and outcome of contemporary prostate cancer patients with bone metastases at initial presentation: data from CaPSURE. Cancer 2007; 110:81.
  12. Walker MS, Miller PJ, Namjoshi M, et al. Relationship between incidence of fracture and health-related quality-of-life in metastatic breast cancer patients with bone metastases. J Med Econ 2013; 16:179.
  13. Brodowicz T, O'Byrne K, Manegold C. Bone matters in lung cancer. Ann Oncol 2012; 23:2215.
  14. Schulman KL, Kohles J. Economic burden of metastatic bone disease in the U.S. Cancer 2007; 109:2334.
  15. Svendsen ML, Gammelager H, Sværke C, et al. Hospital visits among women with skeletal-related events secondary to breast cancer and bone metastases: a nationwide population-based cohort study in Denmark. Clin Epidemiol 2013; 5:97.
  16. Miric A, Banks M, Allen D, et al. Cortical metastatic lesions of the appendicular skeleton from tumors of known primary origin. J Surg Oncol 1998; 67:255.
  17. Greenspan A, Norman A. Osteolytic cortical destruction: an unusual pattern of skeletal metastases. Skeletal Radiol 1988; 17:402.
  18. Choi J, Raghavan M. Diagnostic imaging and image-guided therapy of skeletal metastases. Cancer Control 2012; 19:102.
  19. Krishnamurthy GT, Tubis M, Hiss J, Blahd WH. Distribution pattern of metastatic bone disease. A need for total body skeletal image. JAMA 1977; 237:2504.
  20. Tubiana-Hulin M. Incidence, prevalence and distribution of bone metastases. Bone 1991; 12 Suppl 1:S9.
  21. Borgohain B, Borgohain N, Khonglah T, Bareh J. Occult renal cell carcinoma with acrometastasis and ipsilateral juxta-articular knee lesions mimicking acute inflammation. Adv Biomed Res 2012; 1:48.
  22. Koyama M, Koizumi M. FDG-PET images of acrometastases. Clin Nucl Med 2014; 39:298.
  23. Muindi J, Coombes RC, Golding S, et al. The role of computed tomography in the detection of bone metastases in breast cancer patients. Br J Radiol 1983; 56:233.
  24. Galasko CS. The value of scintigraphy in malignant disease. Cancer Treat Rev 1975; 2:225.
  25. Hamaoka T, Madewell JE, Podoloff DA, et al. Bone imaging in metastatic breast cancer. J Clin Oncol 2004; 22:2942.
  26. Perez DJ, Powles TJ, Milan J, et al. Detection of breast carcinoma metastases in bone: relative merits of X-rays and skeletal scintigraphy. Lancet 1983; 2:613.
  27. Even-Sapir E. Imaging of malignant bone involvement by morphologic, scintigraphic, and hybrid modalities. J Nucl Med 2005; 46:1356.
  28. Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am 2009; 91:1503.
  29. Rybak LD, Rosenthal DI. Radiological imaging for the diagnosis of bone metastases. Q J Nucl Med 2001; 45:53.
  30. Mahnken AH, Wildberger JE, Gehbauer G, et al. Multidetector CT of the spine in multiple myeloma: comparison with MR imaging and radiography. AJR Am J Roentgenol 2002; 178:1429.
  31. Yang HL, Liu T, Wang XM, et al. Diagnosis of bone metastases: a meta-analysis comparing ¹⁸FDG PET, CT, MRI and bone scintigraphy. Eur Radiol 2011; 21:2604.
  32. Frank JA, Ling A, Patronas NJ, et al. Detection of malignant bone tumors: MR imaging vs scintigraphy. AJR Am J Roentgenol 1990; 155:1043.
  33. Antoch G, Vogt FM, Freudenberg LS, et al. Whole-body dual-modality PET/CT and whole-body MRI for tumor staging in oncology. JAMA 2003; 290:3199.
  34. Steinborn MM, Heuck AF, Tiling R, et al. Whole-body bone marrow MRI in patients with metastatic disease to the skeletal system. J Comput Assist Tomogr 1999; 23:123.
  35. Haubold-Reuter BG, Duewell S, Schilcher BR, et al. The value of bone scintigraphy, bone marrow scintigraphy and fast spin-echo magnetic resonance imaging in staging of patients with malignant solid tumours: a prospective study. Eur J Nucl Med 1993; 20:1063.
  36. Daldrup-Link HE, Franzius C, Link TM, et al. Whole-body MR imaging for detection of bone metastases in children and young adults: comparison with skeletal scintigraphy and FDG PET. AJR Am J Roentgenol 2001; 177:229.
  37. Godersky JC, Smoker WR, Knutzon R. Use of magnetic resonance imaging in the evaluation of metastatic spinal disease. Neurosurgery 1987; 21:676.
  38. Baur-Melnyk A, Buhmann S, Becker C, et al. Whole-body MRI versus whole-body MDCT for staging of multiple myeloma. AJR Am J Roentgenol 2008; 190:1097.
  39. Fayad LM, Kamel IR, Kawamoto S, et al. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skeletal Radiol 2005; 34:245.
  40. Yuh WT, Zachar CK, Barloon TJ, et al. Vertebral compression fractures: distinction between benign and malignant causes with MR imaging. Radiology 1989; 172:215.
  41. Dimopoulos MA, Hillengass J, Usmani S, et al. Role of magnetic resonance imaging in the management of patients with multiple myeloma: a consensus statement. J Clin Oncol 2015; 33:657.
  42. Qu X, Huang X, Yan W, et al. A meta-analysis of ¹⁸FDG-PET-CT, ¹⁸FDG-PET, MRI and bone scintigraphy for diagnosis of bone metastases in patients with lung cancer. Eur J Radiol 2012; 81:1007.
  43. Shen G, Deng H, Hu S, Jia Z. Comparison of choline-PET/CT, MRI, SPECT, and bone scintigraphy in the diagnosis of bone metastases in patients with prostate cancer: a meta-analysis. Skeletal Radiol 2014; 43:1503.
  44. Savelli G, Chiti A, Grasselli G, et al. The role of bone SPET study in diagnosis of single vertebral metastases. Anticancer Res 2000; 20:1115.
  45. Savelli G, Maffioli L, Maccauro M, et al. Bone scintigraphy and the added value of SPECT (single photon emission tomography) in detecting skeletal lesions. Q J Nucl Med 2001; 45:27.
  46. Ryan PJ, Fogelman I. The bone scan: where are we now? Semin Nucl Med 1995; 25:76.
  47. Roland J, van den Weyngaert D, Krug B, et al. Metastases seen on SPECT imaging despite a normal planar bone scan. Clin Nucl Med 1995; 20:1052.
  48. Sedonja I, Budihna NV. The benefit of SPECT when added to planar scintigraphy in patients with bone metastases in the spine. Clin Nucl Med 1999; 24:407.
  49. Zamagni E, Cavo M. The role of imaging techniques in the management of multiple myeloma. Br J Haematol 2012; 159:499.
  50. Dimopoulos M, Terpos E, Comenzo RL, et al. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple Myeloma. Leukemia 2009; 23:1545.
  51. Kao CH, Hsieh JF, Tsai SC, et al. Comparison and discrepancy of 18F-2-deoxyglucose positron emission tomography and Tc-99m MDP bone scan to detect bone metastases. Anticancer Res 2000; 20:2189.
  52. Gallowitsch HJ, Kresnik E, Gasser J, et al. F-18 fluorodeoxyglucose positron-emission tomography in the diagnosis of tumor recurrence and metastases in the follow-up of patients with breast carcinoma: a comparison to conventional imaging. Invest Radiol 2003; 38:250.
  53. Schirrmeister H, Glatting G, Hetzel J, et al. Prospective evaluation of the clinical value of planar bone scans, SPECT, and (18)F-labeled NaF PET in newly diagnosed lung cancer. J Nucl Med 2001; 42:1800.
  54. Schirrmeister H, Guhlmann A, Kotzerke J, et al. Early detection and accurate description of extent of metastatic bone disease in breast cancer with fluoride ion and positron emission tomography. J Clin Oncol 1999; 17:2381.
  55. Cook GJ, Fogelman I. The role of positron emission tomography in the management of bone metastases. Cancer 2000; 88:2927.
  56. Cook GJ, Houston S, Rubens R, et al. Detection of bone metastases in breast cancer by 18FDG PET: differing metabolic activity in osteoblastic and osteolytic lesions. J Clin Oncol 1998; 16:3375.
  57. Bury T, Barreto A, Daenen F, et al. Fluorine-18 deoxyglucose positron emission tomography for the detection of bone metastases in patients with non-small cell lung cancer. Eur J Nucl Med 1998; 25:1244.
  58. Coleman RE. Monitoring of bone metastases. Eur J Cancer 1998; 34:252.
  59. Shie P, Cardarelli R, Brandon D, et al. Meta-analysis: comparison of F-18 Fluorodeoxyglucose-positron emission tomography and bone scintigraphy in the detection of bone metastases in patients with breast cancer. Clin Nucl Med 2008; 33:97.
  60. Liu T, Cheng T, Xu W, et al. A meta-analysis of 18FDG-PET, MRI and bone scintigraphy for diagnosis of bone metastases in patients with breast cancer. Skeletal Radiol 2011; 40:523.
  61. Hahn S, Heusner T, Kümmel S, et al. Comparison of FDG-PET/CT and bone scintigraphy for detection of bone metastases in breast cancer. Acta Radiol 2011; 52:1009.
  62. Völker T, Denecke T, Steffen I, et al. Positron emission tomography for staging of pediatric sarcoma patients: results of a prospective multicenter trial. J Clin Oncol 2007; 25:5435.
  63. Peterson JJ. F-18 FDG-PET for detection of osseous metastatic disease and staging, restaging, and monitoring response to therapy of musculoskeletal tumors. Semin Musculoskelet Radiol 2007; 11:246.
  64. Staudenherz A, Steiner B, Puig S, et al. Is there a diagnostic role for bone scanning of patients with a high pretest probability for metastatic renal cell carcinoma? Cancer 1999; 85:153.
  65. Brown DH, Leakos M. The value of a routine bone scan in a metastatic survey. J Otolaryngol 1998; 27:187.
  66. Fogelman I, Cook G, Israel O, Van der Wall H. Positron emission tomography and bone metastases. Semin Nucl Med 2005; 35:135.
  67. Bortot DC, Amorim BJ, Oki GC, et al. ¹⁸F-Fluoride PET/CT is highly effective for excluding bone metastases even in patients with equivocal bone scintigraphy. Eur J Nucl Med Mol Imaging 2012; 39:1730.
  68. Cheng X, Li Y, Xu Z, et al. Comparison of 18F-FDG PET/CT with bone scintigraphy for detection of bone metastasis: a meta-analysis. Acta Radiol 2011; 52:779.
  69. Chang MC, Chen JH, Liang JA, et al. Meta-analysis: comparison of F-18 fluorodeoxyglucose-positron emission tomography and bone scintigraphy in the detection of bone metastasis in patients with lung cancer. Acad Radiol 2012; 19:349.
  70. Lee JW, Lee SM, Lee HS, et al. Comparison of diagnostic ability between (99m)Tc-MDP bone scan and (18)F-FDG PET/CT for bone metastasis in patients with small cell lung cancer. Ann Nucl Med 2012; 26:627.
  71. Rong J, Wang S, Ding Q, et al. Comparison of 18 FDG PET-CT and bone scintigraphy for detection of bone metastases in breast cancer patients. A meta-analysis. Surg Oncol 2013; 22:86.
  72. Poulsen MH, Petersen H, Høilund-Carlsen PF, et al. Spine metastases in prostate cancer: comparison of technetium-99m-MDP whole-body bone scintigraphy, [(18) F]choline positron emission tomography(PET)/computed tomography (CT) and [(18) F]NaF PET/CT. BJU Int 2014; 114:818.
  73. Qiu ZL, Xue YL, Song HJ, Luo QY. Comparison of the diagnostic and prognostic values of 99mTc-MDP-planar bone scintigraphy, 131I-SPECT/CT and 18F-FDG-PET/CT for the detection of bone metastases from differentiated thyroid cancer. Nucl Med Commun 2012; 33:1232.
  74. Ota N, Kato K, Iwano S, et al. Comparison of ¹⁸F-fluoride PET/CT, ¹⁸F-FDG PET/CT and bone scintigraphy (planar and SPECT) in detection of bone metastases of differentiated thyroid cancer: a pilot study. Br J Radiol 2014; 87:20130444.
  75. Ma DW, Kim JH, Jeon TJ, et al. ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography for the evaluation of bone metastasis in patients with gastric cancer. Dig Liver Dis 2013; 45:769.
  76. van Lammeren-Venema D, Regelink JC, Riphagen II, et al. ¹⁸F-fluoro-deoxyglucose positron emission tomography in assessment of myeloma-related bone disease: a systematic review. Cancer 2012; 118:1971.
  77. Vallabhajosula S, Solnes L, Vallabhajosula B. A broad overview of positron emission tomography radiopharmaceuticals and clinical applications: what is new? Semin Nucl Med 2011; 41:246.
  78. von Eyben FE, Kairemo K. Meta-analysis of (11)C-choline and (18)F-choline PET/CT for management of patients with prostate cancer. Nucl Med Commun 2014; 35:221.
  79. Kannivelu A, Loke KS, Kok TY, et al. The role of PET/CT in the evaluation of skeletal metastases. Semin Musculoskelet Radiol 2014; 18:149.
  80. Kido DK, Gould R, Taati F, et al. Comparative sensitivity of CT scans, radiographs and radionuclide bone scans in detecting metastatic calvarial lesions. Radiology 1978; 128:371.
  81. Horger M, Claussen CD, Bross-Bach U, et al. Whole-body low-dose multidetector row-CT in the diagnosis of multiple myeloma: an alternative to conventional radiography. Eur J Radiol 2005; 54:289.
  82. Chassang M, Grimaud A, Cucchi JM, et al. Can low-dose computed tomographic scan of the spine replace conventional radiography? An evaluation based on imaging myelomas, bone metastases, and fractures from osteoporosis. Clin Imaging 2007; 31:225.
  83. Hur J, Yoon CS, Ryu YH, et al. Efficacy of multidetector row computed tomography of the spine in patients with multiple myeloma: comparison with magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography. J Comput Assist Tomogr 2007; 31:342.
  84. Pianko MJ, Terpos E, Roodman GD, et al. Whole-body low-dose computed tomography and advanced imaging techniques for multiple myeloma bone disease. Clin Cancer Res 2014; 20:5888.
  85. Regelink JC, Minnema MC, Terpos E, et al. Comparison of modern and conventional imaging techniques in establishing multiple myeloma-related bone disease: a systematic review. Br J Haematol 2013; 162:50.
  86. Colletti PM, Dang HT, Deseran MW, et al. Spinal MR imaging in suspected metastases: correlation with skeletal scintigraphy. Magn Reson Imaging 1991; 9:349.
  87. Kattapuram SV, Khurana JS, Scott JA, el-Khoury GY. Negative scintigraphy with positive magnetic resonance imaging in bone metastases. Skeletal Radiol 1990; 19:113.
  88. Dinter DJ, Neff WK, Klaus J, et al. Comparison of whole-body MR imaging and conventional X-ray examination in patients with multiple myeloma and implications for therapy. Ann Hematol 2009; 88:457.
  89. Ghanem N, Lohrmann C, Engelhardt M, et al. Whole-body MRI in the detection of bone marrow infiltration in patients with plasma cell neoplasms in comparison to the radiological skeletal survey. Eur Radiol 2006; 16:1005.
  90. Gleeson TG, Moriarty J, Shortt CP, et al. Accuracy of whole-body low-dose multidetector CT (WBLDCT) versus skeletal survey in the detection of myelomatous lesions, and correlation of disease distribution with whole-body MRI (WBMRI). Skeletal Radiol 2009; 38:225.
  91. Lauenstein TC, Goehde SC, Herborn CU, et al. Three-dimensional volumetric interpolated breath-hold MR imaging for whole-body tumor staging in less than 15 minutes: a feasibility study. AJR Am J Roentgenol 2002; 179:445.
  92. Caracciolo JT, Temple HT, Letson GD, Kransdorf MJ. A Modified Lodwick-Madewell Grading System for the Evaluation of Lytic Bone Lesions. AJR Am J Roentgenol 2016; 207:150.
  93. Ulano A, Bredella MA, Burke P, et al. Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements. AJR Am J Roentgenol 2016; 207:362.
  94. Kara M, Pradel C, Phan C, et al. CT Features of Vertebral Venous Congestion Simulating Sclerotic Metastases in Nine Patients With Thrombosis of the Superior Vena Cava. AJR Am J Roentgenol 2016; 207:80.
  95. Raphael B, Hwang S, Lefkowitz RA, et al. Biopsy of suspicious bone lesions in patients with a single known malignancy: prevalence of a second malignancy. AJR Am J Roentgenol 2013; 201:1309.
  96. Monfardini L, Preda L, Aurilio G, et al. CT-guided bone biopsy in cancer patients with suspected bone metastases: retrospective review of 308 procedures. Radiol Med 2014; 119:852.
  97. Wedin R, Bauer HC, Skoog L, et al. Cytological diagnosis of skeletal lesions. Fine-needle aspiration biopsy in 110 tumours. J Bone Joint Surg Br 2000; 82:673.
  98. Alcalay M, Azais I, Brigeon B, et al. Strategy for identifying primary malignancies with inaugural bone metastases. Rev Rhum Engl Ed 1995; 62:632.
  99. Rougraff BT, Kneisl JS, Simon MA. Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993; 75:1276.
  100. Bollen L, Wibmer C, Van der Linden YM, et al. Predictive Value of Six Prognostic Scoring Systems for Spinal Bone Metastases: An Analysis Based on 1379 Patients. Spine (Phila Pa 1976) 2016; 41:E155.
  101. Portenoy RK, Lesage P. Management of cancer pain. Lancet 1999; 353:1695.
  102. Buga S, Sarria JE. The management of pain in metastatic bone disease. Cancer Control 2012; 19:154.
  103. Gough N, Miah AB, Linch M. Nonsurgical oncological management of cancer pain. Curr Opin Support Palliat Care 2014; 8:102.
  104. Tannock IF, de Wit R, Berry WR, et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Engl J Med 2004; 351:1502.
  105. Woolf DK, Padhani AR, Makris A. Assessing response to treatment of bone metastases from breast cancer: what should be the standard of care? Ann Oncol 2015; 26:1048.
  106. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 2005; 97:798.
  107. Lutz S, Berk L, Chang E, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys 2011; 79:965.
  108. Finlay IG, Mason MD, Shelley M. Radioisotopes for the palliation of metastatic bone cancer: a systematic review. Lancet Oncol 2005; 6:392.
  109. Wood TJ, Racano A, Yeung H, et al. Surgical management of bone metastases: quality of evidence and systematic review. Ann Surg Oncol 2014; 21:4081.
  110. Haentjens P, Casteleyn PP, Opdecam P. Evaluation of impending fractures and indications for prophylactic fixation of metastases in long bones. Review of the literature. Acta Orthop Belg 1993; 59 Suppl 1:6.
  111. Mirels H. Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. 1989. Clin Orthop Relat Res 2003; :S4.
  112. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; :256.
  113. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 2010; 35:E1221.
  114. Fourney DR, Frangou EM, Ryken TC, et al. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol 2011; 29:3072.
  115. van der Linden YM, Dijkstra SP, Vonk EJ, et al. Prediction of survival in patients with metastases in the spinal column: results based on a randomized trial of radiotherapy. Cancer 2005; 103:320.
  116. Dürr HR, Müller PE, Lenz T, et al. Surgical treatment of bone metastases in patients with breast cancer. Clin Orthop Relat Res 2002; :191.
  117. Incarbone M, Nava M, Lequaglie C, et al. Sternal resection for primary or secondary tumors. J Thorac Cardiovasc Surg 1997; 114:93.
  118. Noguchi S, Miyauchi K, Nishizawa Y, et al. Results of surgical treatment for sternal metastasis of breast cancer. Cancer 1988; 62:1397.
  119. Lequaglie C, Massone PB, Giudice G, Conti B. Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms. Ann Surg Oncol 2002; 9:472.
  120. Kollender Y, Bickels J, Price WM, et al. Metastatic renal cell carcinoma of bone: indications and technique of surgical intervention. J Urol 2000; 164:1505.
  121. Lin PP, Mirza AN, Lewis VO, et al. Patient survival after surgery for osseous metastases from renal cell carcinoma. J Bone Joint Surg Am 2007; 89:1794.
  122. Chen CY, Huang KG, Abdullah NA, et al. Successful treatment of isolated fibular bone metastasis in a uterine endometrial cancer of clear cell carcinoma. Eur J Gynaecol Oncol 2013; 34:347.
  123. Onesti JK, Mascarenhas CR, Chung MH, Davis AT. Isolated metastasis of colon cancer to the scapula: is surgical resection warranted? World J Surg Oncol 2011; 9:137.
  124. Nakamura H, Kawasaki N, Taguchi M, Kitaya T. Reconstruction of the anterior chest wall after subtotal sternectomy for metastatic breast cancer: report of a case. Surg Today 2007; 37:1083.
  125. Yasko AW, Rutledge J, Lewis VO, Lin PP. Disease- and recurrence-free survival after surgical resection of solitary bone metastases of the pelvis. Clin Orthop Relat Res 2007; 459:128.
  126. Ratasvuori M, Wedin R, Hansen BH, et al. Prognostic role of en-bloc resection and late onset of bone metastasis in patients with bone-seeking carcinomas of the kidney, breast, lung, and prostate: SSG study on 672 operated skeletal metastases. J Surg Oncol 2014; 110:360.
  127. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366:643.
  128. Tancioni F, Lorenzetti MA, Navarria P, et al. Percutaneous vertebral augmentation in metastatic disease: state of the art. J Support Oncol 2011; 9:4.
  129. Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol 2011; 12:225.
Topic Outline