Imaging showing cancer in the hip bone as a result of bone metastasis.

Learn how orthopedic oncologists are optimizing patients’ quality of life thanks to innovative therapies.

The approach for treating bone metastasis is much different today than it was a few decades ago. Advancements in medical, surgical and radiation therapies are extending survival rates — which has created new opportunities for orthopedic oncologists to improve patients’ quality of life and extend people’s lives.

In the past, many orthopedic surgeons focused solely on fixing bones that were broken or at risk of breaking secondary to the disease, explains Lee Zuckerman, MD, an orthopedic oncologist with USC Orthopaedic Surgery, part of Keck Medicine of USC, who specializes in treating musculoskeletal tumors and metastatic disease.

“Most people with bone metastasis died within three to six months, so the focus of most orthopedic surgeons was to only fix the bone or prevent it from breaking, not address the cancer,” he says. “As an orthopedic oncologist, we treat the cancer in order to give patients the best functional outcomes and chances at survival. In most cases, we are able to do both with just one surgery.”

A portrait of Dr. Lee Zuckerman. — Lee Zuckerman, MD

Accurately diagnosing metastatic bone cancer

Approximately 50% of patients with advanced cancers will develop bone metastasis. The bone is the third most common site for cancer to spread, following the lung and the liver. While it is possible for any cancer to spread to bone, the five most likely to do so are prostate, breast, lung, thyroid and kidney cancers. 

Despite how common bone metastasis is, Zuckerman strongly emphasizes that physicians need to consider all options before reaching a diagnosis. He stresses the importance of sending patients to an orthopedic oncologist for a biopsy of the tumor.

“If you operate on a sarcoma assuming it is metastatic disease, it risks spreading the cancer further or leading to an amputation. A lesion could also be a benign finding in the bone and may not need surgery at all,” Zuckerman says. “It also matters how the biopsy is done, as an improper biopsy can lead to an amputation or other complications, and having that opinion from an orthopedic oncologist is vital.” 

Cancer origin influences treatment strategy 

In addition to surgery, bone metastasis treatment options include chemotherapy, immunotherapy, hormone therapy and radiation. Bone-modifying drugs, including medications that treat osteoporosis, can also help treat metastatic bone disease by preventing fractures and by preventing new and existing tumors in the bone from growing. Research shows significant benefit for patients with advanced breast, lung and prostate cancers.

H. Paco Kang, MD, an orthopedic oncologist with USC Orthopaedic Surgery, says the range of possible treatments underscores the importance of getting metastatic bone disease treated at an experienced cancer center such as the USC Norris Comprehensive Cancer Center, part of Keck Medicine. “Because of the newer cutting-edge medical treatments available to our cancer patients, our bone-treatment strategies are really tailored to each individual and their cancer subtypes,” he adds.

The location of the primary tumor strongly influences surgical strategies. “A prostate cancer patient, for instance, might need radiation therapy and no surgery depending on the size, location and nature of their tumor,” explains J. Dominic Femino, MD, an orthopedic oncologist with USC Orthopaedic Surgery and chief of the USC Musculoskeletal Oncology Center for Keck Medicine. “That is because the prostate in particular tends not to be as destructive when it goes to bone.”

In comparison, tumors that spread from the kidney, thyroid and breast tend to cause more significant biomechanical problems and increased fracture risk. “In those cases, we will take out a larger segment of bone to remove all of the cancer and then reconstruct the bone,” Zuckerman says. 

Kang points out that with certain cancers like kidney cancer, complete (radical) removal of the tumor with the bone has been shown to improve survival outcomes in patients.

A portrait of Joseph Dominic Femino, MD. — J. Dominic Femino, MD

Skeletal location of the bone metastasis also informs surgery decisions, Zuckerman adds. “If the patient has disease around the hip, then they are at a higher fracture risk because of the significant stress put on the bone while standing and walking. That is a lot different than if they have disease in their shoulder, for instance, or in a bone where no significant weight is placed during regular activities.”

Amputations for metastatic disease are very rare. In the circumstance when an amputation is necessary, advanced amputation techniques are available at Keck Medicine. This includes osseointegration, which involves connecting a patient’s prosthesis directly to the bone at the amputation site to enhance stability and balance, and targeted muscle reinnervation (TMR) and regenerative nerve peripheral interface (RPNI) to decrease phantom limb pain and nerve pain. These advanced techniques are not commonly performed at most hospitals and can significantly improve quality of life after an amputation.

Using ablation to target bone metastasis

Whenever possible, the USC Orthopaedic Surgery team prefers a minimally invasive approach to remove tumors in the bone. As Femino explains, ablation has been a particularly successful option for treating tumors around the hip socket and pelvis. 

“We make a very small incision and do a percutaneous ablation where we use a radiofrequency probe to burn the tumor and kill it,” Femino says. “Then we can provide stabilization to that area with injection of bone cement and screws.”

“Or in some cases,” he continues, “we use a photodynamic stabilization technique where we can insert photodynamic rods or balloons that fill up that space. Activating them with UV light makes them solid and provides stabilization.” 

Kang says this technique has been particularly impactful to patients with pelvic lesions. In the past, major surgery was needed to stabilize these patients. “With newer techniques like these, however, there is now an opportunity to achieve the same or better outcomes with a few keyhole incisions,” Kang says.

This minimally invasive approach has been shown to relieve pain, minimize blood loss and reduce recovery time. Patients usually go home the same day, and they do not need to pause their drug therapies to have the procedure. 

Reconstructing the bone to save mobility 

Helping patients maintain their mobility is a primary goal when treating metastatic bone cancer. Zuckerman has pioneered a technique using magnetic lengthening nails to improve bone reconstruction. 

“I use the magnetic nails to create new bone. It is similar to surgery to make someone taller,” Zuckerman says. “We insert a rod that moves about one millimeter per day, and it tricks the body into thinking the bone is broken. Over a couple of months, the body forms new bone in there. There is less risk of infection or failure because it is the patient’s own bone.”

The allograft technique using the magnetic lengthening nails was also pioneered by Zuckerman. “We take out the patient’s bone, put in the cadaver bone, and then the magnetic rod pushes the bone together. We are getting very good healing rates with this option.”

In addition to relieving pain, a top goal of bone reconstruction surgery is to help patients improve their mobility as quickly as possible. Most patients are able to ambulate within days and can expect a full recovery with the help of physical therapy. 

“At USC Orthopaedic Surgery, we specialize in the treatment of bone tumors, and these advances are making a big difference in the overall quality of life for patients,” Femino says. “They spend less time in the hospital and more time doing the things that are important to them.”

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