When Lung Cancer Spreads to Bone

How Bone Metastases Are Diagnosed and Treated

Spine metastasis (cancer spread to thoracic spine)

 stockdevil / Getty Images

In This Article

Lung cancer with bone metastases refers to the spread of cancer from the primary (original) tumor to the bone. The spread of cancer cells occurs either through the bloodstream or lymphatic system (a system of fluids, vessels, and organs that protect the body against foreign invaders).

Bone metastases from lung cancer affect between 30% to 40% of people with advanced lung cancer. In people with lung cancer, the bones are the third most common site for metastases after the liver and adrenal glands.

Although lung cancer that has spread to bone is not curable, there are treatments that can significantly increase survival times and improve your overall quality of life. Moreover, it's important to note that bone metastases are not all the same—some have more favorable outcomes than others.

Lung cancer with bone metastases is not the same thing as bone cancer in which cancer originates in the bones themselves.

Bones Affected

According to a 2014 review in Therapeutic Advances in Medical Oncology, the most common bones to which lung cancer most commonly spreads include (in order of frequency):

  • The spine
  • The ribs
  • The ilium (the widest part of the hip bone)
  • The sacrum (the triangular bone at the base of the spine)
  • The femur (thigh bone)
  • The humerus (upper arm bone)
  • The scapula (shoulder blade)
  • The sternum (breastbone)

Lung cancer can also sometimes spread to bones of the hands and feet.

Symptoms of Bone Metastases From Lung Cancer

Pain is typically the first symptom of bone metastases in around 80% of cases. The pain may initially feel like a dull muscle strain but gradually worsen and become severe. The pain is often worse at night or with movement.

If bone metastases involve the spine, compression of the spinal cord by the tumor may initially present with back pain as well as limb weakness. Numbness and paresthesia (a burning, prickly sensation) may also occur in areas below the site of the spinal compression.

The compression of nerves in the lumbar spine, referred to a nerve root compression, can cause radicular pain. The condition, also known as referred pain, is characterized by shooting pain in other distant parts of the body due to the pressure placed on nerves in the lower spine.

Complications

Bone metastases from lung cancer can cause severe complications as the malignancy progresses, undermining not only the spine and the integrity of the bones but also causing metabolic changes that can compromise a person's ability to function.

Cauda Equina Syndrome

Metastatic spinal cord compression (MSCC) can often present as a medical emergency. There may initially be localized edema (swelling around the site of the compression) and venous congestion (the disruption of normal blood flow). If treated early, these conditions can be reversed.

However, prolonged venous congestion due to MSCC can lead to severe vascular injury, spinal cord necrosis (tissue death), and permanent spinal cord damage.

In rare cases, metastatic spinal cord compression can lead to cauda equina syndrome, resulting in limb weakness, sciatica (radiating pain in the lower back and legs), the loss of reflexes in lower extremities, and the loss of bowel and/or bladder function.

Cauda equine syndrome is considered a medical emergency. If not promptly treated (typically with surgery), the symptoms can become permanent.

Pathological Fractures

Sometimes, the first sign of lung cancer metastasis to the bone is a fracture. This is referred to as a pathological fracture in which the integrity of bone is compromised as normal bone tissues are supplanted by cancer cells. These fractures can occur without any significant trauma, often happening spontaneously while performing everyday tasks or even rolling over in bed.

Pathological fractures are generally preceded or accompanied by constant pain. Pain from fractures in the spine or ribs will generally worsen while sitting or standing. Sciatica, deformity, and immobility are common outcomes of a pathological fracture due to bone metastases.

Hypercalcemia and Anemia

The breakdown of bone and the release of calcium into the bloodstream can cause a condition known as hypercalcemia (abnormally high blood calcium). Symptoms include extreme thirst, weakness, nausea or vomiting, decreased urination, and muscle and joint aches.

In people with bone metastases, hypercalcemia is considered a medical emergency and can lead to cardiac arrhythmia (abnormal heart rhythm), disorientation, and even death if not appropriately treated.

Bone metastases may also cause myelophthisic anemia, a severe type of anemia caused by the displacement of bone marrow with cancer cells. It typically occurs as the malignancy progresses, causing fatigue, weakness, shortness of breath, and low tolerance to exercise and physical activity.

Diagnosis

Bone metastases from lung cancer are diagnosed with imaging studies. In addition to confirming that cancer has spread to the bones, imaging studies can help identify the type of bone metastases involved.

Imaging tests used for the diagnosis of bone metastases include:

  • X-ray: X-rays can sometimes spot lesions caused by the loss of bone mineral but only when the lesions are large.
  • Computed tomography (CT): CT scans employ multiple X-ray images to create three-dimensional "slices" of internal organs and structures. They are more sensitive than X-rays and better able to differentiate between types of bone lesions.
  • Magnetic resonance imaging (MRI): MRI scans use powerful magnetic and radio waves to create highly detailed images. MRIs are more sensitive and specific than X-rays and CT scans in diagnosing bone metastases and can be used safely in pregnant women due to the lack of ionizing radiation.
  • Positron emission tomography (PET): PET scans are extremely sensitive in diagnosing bone metastases as they are able to detect abnormally active cell growth characteristic of cancer.
  • Bone scans: While an available option, bone scans are used less commonly today as they often cannot distinguish cancer from other bone conditions.

These imaging tests would be supported by blood tests, including a complete blood count (CBC) to check for anemia and other blood cell abnormalities and a comprehensive metabolic panel (CMP) to help identify hypercalcemia before it becomes serious.

Tissue biopsy and histology (the microscopic examination of tissues and cells) is not typically used in cases of bone metastasis unless the site of the primary tumor is unknown.

Classification

The classification of bone metastases can help doctors predict the likely course and outcome of the disease. Unlike lung cancer staging, the classification of bone metastases does not direct how the disease is treated. Rather, it gives the doctor an idea of how the metastases will progress.

Bone metastases are typically classified based on imaging studies as follows:

  • Osteolytic: Osteolysis is characterized by the loss of bone mineral, leading to softened areas of bone (osteolytic lesions).
  • Sclerotic: Sclerosis is the abnormal increase in the thickness and density of tissues, leading to the formation of thick spots (sclerotic lesions) on the bone.
  • Mixed: Some people with bone metastases will have both osteolytic and sclerotic lesions.

Of the three, sclerotic metastases (also referred to as osteoblastic metastases) tend to progress slower than osteolytic metastases. Moreover, sclerotic metastases are less commonly associated with hypercalcemia than osteolytic metastases, which can actively leach calcium into the bloodstream.

Treatment

The treatment for lung cancer with bone metastases is primarily palliative—that is, it is meant to relieve symptoms rather than cure cancer. The primary goal of treatment is to reduce pain and either prevent or treat fractures and other serious complications.

What that said, for people with only a few metastases (referred to as oligometastatic disease), oncologists may consider treating the metastases aggressively with the hope of long-term survival.

Treatment options for bone metastases can be broadly classified as being either systemic (involving the whole body) or local (involving bone or bone-related symptoms).

Systemic Treatments

For most people with bone metastases, the treatment of the primary tumor may not only help control the spread of the disease but provide pain relief. Common options include:

  • Chemotherapy: Chemotherapy is typically used as the main treatment for metastatic cancer. It can help shrink tumors, slow the progression of the disease, and alleviate pressure on nerve roots and within bones that causes pain.
  • Target therapy: Targeted therapies are a newer form of treatment that targets and kills cancer cells with specific genetic mutations. Genetic profiling is conducted to see if you are a candidate for treatment. Therapy options include Tarceva (erlotinib), Tagrisso (osimertinib), and Xalkori (crizotinib).
  • Immunotherapy: Immunotherapeutic drugs work by harnessing your immune system to directly fight cancer. Opdivo (nivolumab) and Keytruda (pembrolizumab) are two drugs approved for such use.

Clinical trials should also be considered if you have advanced lung cancer with metastases, particularly if your current therapies aren't providing adequate control of the disease.

Local Treatments

The local treatment of bone metastases is mainly directed at providing pain relief and preventing fractures and spinal compression. Options include:

  • Analgesics: Analgesic pain killers are typically prescribed in a specific order based on their strength and side effects. Stronger nonsteroidal anti-inflammatory drugs (NSAIDs) like Celebrex (celecoxib) may be used first, followed by opioids like hydrocodone, fentanyl, and morphine if pain control cannot be achieved.
  • Corticosteroids: Corticosteroids, also known simply as steroids, provide pain relief by tempering the immune response and alleviating inflammation. They can support other pain treatments but are used cautiously due to the risk of side effects. Dexamethasone is a commonly prescribed oral steroid for people with cancer pain.
  • Radiation therapy: Radiation is commonly used to reduce pain, prevent fractures, and relieve spinal cord compression from bone metastases. Most people get substantial pain relief from radiation therapy, and some are able to achieve sustained relief with just one session.
  • Stereotactic body radiotherapy (SBRT): SBRT is a form of radiation therapy that delivers extremely precise, intense doses to cancer cells while minimizing damage to healthy cells. SBRT appears to provide better pain control with a single dose compared to multiple doses of standard external beam radiation. It can also be used to surgically remove metastases in people with one or a few metastatic tumors in the hope of achieving disease remission.
  • Intravenous radiation: In some cases, radiation may be delivered into the bloodstream to better control metastatic tumors. Referred to as targeted radionuclide therapy, the procedure involves an intravenous (into a vein) injection of a low-dose radioactive drug that has a high affinity for bone. The targeted approach is better able to reach individual bone metastases and provide more durable pain relief.
  • Bisphosphonates: Bisphosphonates are bone-building drugs commonly used to treat osteoporosis but are also prescribed to prevent the deterioration of bone in people with bone metastases. Options for people with lung cancer include Zometa (zoledronic acid) and Prolia (denosumab), both of which are delivered every few weeks by injection or intravenous infusion.
  • Surgery: Surgery is used primarily to stabilize bones if they fracture or to prevent a fracture in a bone that is weakened by cancer. Some of the options include orthopedic fixation (using metal screw and plates to stabilize or repair bone) and vertebroplasty (the injection of bone cement into spinal bones to prevent or relieve spinal compression).

Prognosis

The median survival time for people with bone metastases from lung cancer—that is, the amount of time after which 50% of people are alive and 50% have died—has increased in recent years due to the ever-increasing range of treatment options. However, it still hovers at just around 10 months.

Survival times are somewhat longer for women and people under 60 as well as those with lung adenocarcinoma, a single metastasis, or no history of fractures. People with sclerotic bone lesions also tend to survive longer than those with osteolytic or mixed bone metastases.

It is important to remember that some people have survived and lived well for many years following a diagnosis of bone metastases. Your general health at the time of the diagnosis and during treatment can play a large part in determining how long you can live successfully with your disease.

A Word From Verywell

Having bone metastases from lung cancer means that your cancer is stage 4 and no longer curable. As difficult as it is to learn this, don't give up hope. With properly staged palliative care, you can maintain a good quality of life with the support of family and friends.

To help you through the rough times, join a support group of others who fully understand what you are going through. Seek counseling from a psychologist or psychiatrist if you are depressed, anxious, or are unable to cope. Try not to focus on survival times but, instead, make every effort to care for yourself emotionally and physically so that you can continue to live the best life that you can.

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