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Metastatic Lesions In Thoracic And Lumbar Vertebrae

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Use Of Imaging In The Management Of Metastatic Spine Disease With Percutaneous Ablation And Vertebral Augmentation

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Center Expert des Métastases Osseuses (CEMOS), Département de Rhumatologie, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre Bénite, France

Spinal Tumor Common Causes, Symptoms, And Treatment Options

Received: October 1, 2021 / Revised: November 7, 2021 / Approved: November 10, 2021 / Published: November 15, 2021

Great progress has been made in patients with stage IV bone metastases to control disease progression, resulting in longer survival. Self-autonomy and return to physical activity is now frequent. Thus, assessment of the strength of tumor bone has become a problem, especially with the rapid variations of the bone tumor aspect (from lytic to sclerosing and vice versa), which we can observe during treatment. This review will explain the currently available imaging techniques, the limits of the existing fracture risk scores in bone metastases, and the new numerical simulation techniques emerging in biomechanics.

Great progress has been made in treating cancer patients and survival has improved significantly, even for stage IV bone metastases patients. Locomotive health has become a crucial issue for patient autonomy and quality of life. The focus of the reflection is on the fracture risk evaluation of bone metastases to guide the physician’s decisions about physical activity, prescription of antiresorptive agents, and local intervention through radiation therapy, surgery, and interventional radiology. An important mandatory step, since bone metastases can be asymptomatic and spread throughout the skeleton, is to identify the bone metastasis site by cartography, especially within weight-bearing bones. For each site, the evaluation of fracture risk is based on qualitative approaches using images and scores such as Mirel’s and spinal instability neoplastic score (SINS). However, this approach has important limitations and there is a need to develop new tools for risk assessment of bone metastases and myeloma fracture. Personalized numerical simulation qCT-based imaging represents one of these emerging tools for assessing bone tumor strength and estimating the risk of femoral and vertebral fracture. The next generation of numerical simulation and artificial intelligence will take into account multiple loads to integrate movement and obtain conditions even closer to real life, to guide patient rehabilitation and activity within a personalized medical approach.

Bone is one of the most common sites for metastases. The clinical cases submitted to our weekly multidisciplinary bone metastases meetings highlight the benefits and challenges of modern therapies across all oncology specialties. For example, new treatment methods have greatly improved the control of disease progression, resulting in longer survival; thus, autonomy, movement and return to sports activities become a problem. Additionally, locally, we now observe rapid variations of the bone metastasis aspect (from lytic to sclerosing) with certain drugs, suggesting some large variation in local bone strength. Currently, doctors cannot accurately estimate this strength and therefore make recommendations. We thus observe an increasing gap between the existing fracture bone scoring classifications and the current bone metastatic patient’s local and global prognosis enabled by new targeted therapies. This topic is all the more important because these rapid bone changes can change the care strategy, for example, choosing a temporary claim instead of orthopedic surgery, or choosing an aggressive eradication treatment, such as stereotactic radiotherapy on a regressive lesion that was initially considered too large but related to potential neurological complications after relapse. Thus, there is a need to develop new tools to reliably estimate bone metastatic strength and its progression to optimize patient care strategies and physical activity in the medium and long term. In addition, these bone metastasis meetings treat both long bones and vertebrae, therefore these tools should be useful for both sites and, in the future, include stresses related to movements and sports activities. Furthermore, the bone strength behavior of solid bone metastases and myeloma bone lesions is probably different and deserves a separate analysis. All these points needed to be reviewed, from the bedside to the bench, in a single manuscript bringing together all fields of research and considering both bone sites (vertebrae and long bones). This challenge could be accepted with the contribution of a unique consortium, enabling a multidisciplinary approach, consisting of a bone metastasis physician (CBC), an osteoarticular radiologist (JBP) and basic expert researchers in the pathophysiology of bone metastasis (PC) and bone biomechanics and numerical simulation (HF and DM). This group already works together with MEKANO’s research protocol on a daily basis and therefore offers a top-level holistic translational approach to serving patients. Interestingly, the progress made by the consortium has led to a new care strategy and conceptualization, which is presented in the last figure of the review.

Osseous Sarcoidosis Mimicking Metastatic Breast Cancer

Bone spread occurs early during cancer progression and follows a complex multistep process, involving specific cellular properties of certain cancer cell subpopulations of the primary tumor, such as loss of cell-cell interactions, epithelial-to-mesenchymal transition, migration/invasion, and dissemination through circulation [1, 2, 3, 4, 5]. These properties are required for cancer cells to colonize a distant organ, settle in this new environment and create a metastatic niche. In the bone, the pattern of metastatic spread follows the distribution of the red bone marrow, such as in the vertebrae, sternum, pelvis, and epiphysis/metaphysis of long bones, where vascularization and hematopoiesis are enriched. Once in the bone marrow niche, these cells, known as disseminated tumor cells (DTCs), can remain dormant, sometimes for years or decades, before becoming clinically detectable [6]. This latency period is known as tumor dormancy and involves a dynamic interplay between cancer cells and cells from the bone marrow microenvironment, such as spindle-shaped N-cadherin+/CD45 osteoblast cells (SNO), CXCL-12-abundant reticular (CAR) cells, stromal cells, mesenchymal stem cells and immune cells [4, 7, 8, 9]. Changes in the bone environment in favor of osteoclast-mediated bone resorption are sufficient to trigger quiescent cell reactivation, thus bone-targeted agents, such as bisphosphonates, by reducing bone resorption, enhance the elimination of DTC in the bone marrow of breast cancer patients with minimal residual disease [4, 10]. Additional signals are likely to be involved in tumor cell reactivation, and the identification of these molecular players is under intense investigation as they may represent an opportunity for therapeutic targeting. Upon reactivation, tumor cells proliferate and alter the functions of osteoclasts and osteoblasts, promoting bone destruction. Insights into the molecular mechanisms that either initiate, promote, or both, the development of bone metastases have recently been extensively reviewed [4, 11].

Since tumor cells disseminate in the bone marrow long before the development of clinically detectable metastases, and quiescent cell reactivation leads to the development of bone metastases that remain localized or widespread throughout the skeleton [4], it is essential in the clinic to perform a comprehensive screening of the skeleton for the presence of bone ( micro)metastases using positron emission tomography (PET) scanning or magnetic resonance imaging (MRI). However, due to the image resolution limit (about 3-5mm), the presence of error codes can never be ruled out. Skeletal metastases can be asymptomatic. The first symptom to appear in patients with symptomatic bone metastases is usually a continuous, persistent, increasing bone pain requiring analgesics that are easy to morphinize. In some stages of the bone disease, the pain can be so severe that local measures such as radiotherapy, surgery or interventional radiology are necessary. In parallel with bone pain, symptomatic bone metastases expose patients to secondary fractures and nerve or marrow compression. It is estimated that 50% of progressing bone metastases will lead to skeletal complications

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