CLINICAL CASE:
Bone Metastases
Dott. Alberto Bongiovanni, CDO-TR
IRST IRCCS, Meldola
Centro di Eccellenza
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Relationship Company/Organization
Advisory board CINV 2019 kyowa kirin
Case presentation
• Male, 47 years old
• Family History: mother dead at age of 53 for Breast Cancer
• Past Medical History: appendicectomy at 9 yo
• Smoker ( 1 pk/d)
May 2010
Because of dysuria and urinary retention he went to GPs and he underwent:
• PSA: 8.5 ng / ml
• Abdominal US: multiple hypoechoic nodulations spread to both lobes.
• Pelvic MRI: multiple nodulations suspected for heteroplastic lesions of prostatic origin with focal extraprostatic invasion, pT3a. No postive nodes
• Transrectal US- guided biopsy: prostate adenocarcinoma Gleason score 8 (4 + 4)
• Onco-Urologic Multidisciplinary Evaluation
June 2010: Prostate + LNN Surgery
Linee guida AIOM 2018
Patient started an adjuvant OT with LHRH analog and bicalutamide for a month and then only LHRH analog every 12 weeks with progressive decreasing of PSA.
Pathology report: prostate adenocarcinoma with right extra-prostatic invasion, Gleason score 3 + 4. 2/30 LLNN positive.
pT3a pN1. Postoperative PSA: 0.2 ng/ml;
Total Hip T score: -0.5
Total Lumbar spine T score: -0.75
CTX: 0.780 ng/ml 25OHVitD: 11.2 ng/mL
PTH: 71 pg/mL F.A.i.O: 22 µg/L
Bone Health evaluation
RF: Smoke MBI: 25
Aiom Guidelines 2012
January 2013
• As side effect of LHRH analog patient developed gynecomastia. During the shower patient noted a node in the left mammary site.
• PSA: < 0.003 ; blood testosterone : 0.15 ng/mL
• Breast ultrasound, Rx-mammography, MRI: solid nodular formation, with eterogeneous echostructure, hypervascularized. DM 2 x1 cm.
• Tru-cut: infiltrating ductal carcinoma Er 100% Pg 80% G2. cT1c cN0.
February 2013
• Left upper mammary external quadrantectomy:
Infiltrating ductal carcinoma pT2N1aM0.
G3, Ki-67 2 %, ER 90 %, PgR 100 %, Cerb-B2 1 +.
• Patient underwent complementary RT and adjuvant treatment with FEC ( 6 cycles) followed by Tamoxifen for 5 years.
16 th September 2018
• Since July 2018 Pain at the right leg, mainly in the external
rotation movements and climbing stairs.
a) first instance surgical
resection b) bioptic characterization
c) systemic staging d) b+c
What would you do?
28 th September 2018
Osteoncology Multidisciplinary Evaluation: imaging revision shows the presence of a large osteolytic lesion of the right femoral neck suspected for metastatic lesion.
Program:
- Biopsy
- Step protection with a stick on the left.
-Staging with CT scan with c/e -Psa evaluation
Results
• Bone Biopsy: metastatic lesion compatible with Breast origin .
G3, Ki-67 10 %, ER 90 %, PgR 100 %, Cerb-B2 1 +.
-CT scan with c/e : no visceral metastases; vertebral bone metastases
-PSA evaluation: 0.003
a) Surgical stabilization b) Trans arterial embolization
c) Radiotherapy d) a+b+c
What would you do?
Femoral lytic lesion….
a) Surgical stabilization b) Trans arterial embolization
c) Radiotherapy d) a+b+c
What would you do?
Femoral lytic lesion….
Impending fracture scoring system
15
thOctober 2018 CDO Multidisciplinary Evaluation
The revision of the radiological material shows the presence of multiple mixed lesions of various types, the major ones in the spine located on D10 and L3 Therapeutic program:
- surgical stabilization after trans arterial embolization, followed by radiotherapy.
- Step protection with a stick on the left.
………..
15
thOctober 2018 CDO Multidisciplinary Evaluation
Vertebral lesions….
a) Orthoses b) Bone target agents
c) Radiotherapy d)Spine Surgery
What would you do?
Vertebral lesions….
Campos et al TSJ 2014; Chow et al clin onc 2012; Lam et al IJ rad onco 2018
Vertebral lesions….
a) Orthesis b) Bone Target Agents
c) Radiotherapy d) Spine Surgery
What would you do?
15
thOctober 2018 Osteoncology Multidisciplinary Evaluation
The revision of the radiological material shows multiple mixed bone lesions , the greater located in the spine on D10 and L3
Therapeutic program:
- Surgical stabilization after trans arterial embolization, followed by radiotherapy.
- Step protection with a stick on the left.
- Vertebral protection with dorso lumbar spinal brace ( spinal plus) during the upright position.
- No indication to radiotherapy to be reserved in the event of the onset of pain or specific neurological symptoms
- Bone modifying agent with Denosumab after orthopantomography and dental visit, with calcium and vit D supplementation.
- Enrollment in the Italian Bone metastases data base
-02/12/2019 Patient started I line therapy with Faslodex + Palbociclib.
PALOMA 3 Phase III Trial
Clinical Benefit in Palbociclib plus Fulvestrant arm: 67%
Cristofanilli et al Lancet Oncology 2016
29 th October 2018
1. Transarterial embolization
2. Surgical stabilization
(intramedullary nail)
3. Radiotherapy:
(20 Gy 5 fractions)
31 th January 2019 Osteoncology Multidisciplinary Evaluation
Oct 2018 Jan 2019
Bone Only Metastases from Breast Cancer
Parkes , The oncologist 2018
31 th January 2019 Osteoncology Multidisciplinary Evaluation
Imaging shows a sclerotic modification of multiple mixed bone lesions as response according to MD anderson criteria . Femural lesion stabilized.
Therapeutic program:
-Continue with Faslodex and Palbociclib ( therapy well tolerated with no limiting toxicities)
- Continue with Denosumab with Vit D and calcium supplementation and routine dental visiting
- Patient starts progressive weaning off orthoses
• Understant Natural History of the disease is important but prospective multicentric studies are lacking
• Bone health management should be mandatory in a Osteoncology Center.
• Multidisciplinary approach is fundamental for the correct therapeutic strategy
• Multidisciplinary visit can avoid further diagnostic procedure and maximize the patients time/cost
• Multimodality strategy could improve disease control and patient’s quality of life
• Increase the knowledge on Bone metastases in a new therapeutic era.
Conclusions...
Osteoncology and
Rare Tumors Center CDO-TR
Director: Toni Ibrahim
Oncologists:
Alberto Bongiovanni Sebastiano Calpona Giandomenico Di Menna Lorena Gurrieri
Federica Recine Nada Riva
Valentina Fausti (Tr) Sivia De Bonis (Tr)
Lab Researchers:
Laura Mercatali Chiara Liverani Alessandro De Vita Chiara Spadazzi Giacomo Miserocchi
Data Manager:
Benedetta Rossi Monia Dall’Agata
Alessandra Affatato Statistic:
Flavia Foca Pharmacyst:
Valentina Di Iorio Specialist Nurse:
Venetia Zavoiu
Centro di Eccellenza
Member and Collaborations:
- National Network of Osteoncology - National Network of Rare Tumors
- EURACAN (European Reference Network) - University of Bologna, Milan and Ferrara, Italy - CNR, Faenza, Italy
- Alleanza Contro il Cancro - Princeton University, USA
- The Methodist Research Institute, Houston,USA - Leiden University, The Netherlends
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