Osteolytic Lesions in Myeloma

Causes and treatment of bone deterioration in cancer.

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Osteolytic lesions (also known as osteoclastic lesions) are areas of damaged bone that can occur in people with malignancies, such as myeloma and breast cancer. These diseases, as well as others, can cause bones to become soft and prone to fracture. On an x-ray, the lesions appear as tiny holes, giving the bone a "moth-eaten" or "punched-out" appearance.

Symptoms

Osteolytic bone lesions can cause a range of symptoms irrespective of cancer itself.

  • Bone pain is common, can be severe, and is often accompanied by nerve damage from bone compression.
  • Osteoporosis is a progressive weakening of the bone.
  • Pathological fractures are caused by bones which have been weakened by cancer.
  • Hypercalcemia of malignancy occurs when bone breakdown releases excessive calcium into the bloodstream, causing symptoms such as nausea, vomiting, weakness, confusion, myalgia (muscle pain), arthralgia (joint pain) and arrhythmias (an irregular heart rate).

Causes

Osteolytic lesions form when the biological process of bone remodeling becomes imbalanced. Normally during this process, old cells on the skeleton are broken down and replaced by new ones. There are two types of cells involved in the process: osteoblasts, which are responsible for building bone, and osteoclasts, which release substances to break down bone as a part of the remodeling process.

Certain types of cancer can disrupt the production of new cells. For example, when myeloma invades bone tissue, it inhibits the osteoblasts from forming new bone while at the same time stimulating osteoclasts to increase cell breakdown.

Osteolytic lesions are also common in metastatic cancers (cancers that have spread beyond the site of the original tumor) including cancers of the prostate, thyroid, lungs, kidney, and breast. In cases of metastatic cancer, the osteolytic lesions are most often found in larger bones, such as the skull, spine, pelvis, ribcage, and long bones of the legs.

Diagnosis

Doctors will monitor patients with cancer, especially myeloma, for signs and symptoms of bone damage. There are a few different types of test they can use, including:

  • blood tests to check calcium levels
  • a bone scan using radiotracers to assess bone density
  • x-ray imaging to look for areas of damaged or weakened bone
  • CT scans or MRIs to see if cancer has spread (metastasized) to other areas of the body, including the skeleton and nervous system

Treatment

Osteolytic lesions are treated with a combination of low-dose radiation and bisphosphonates, a class of drug commonly used in people with osteoporosis.

Radiation therapy is often used to treat many types of cancer and has been shown to help control pain caused by osteolytic lesions.

Bisphosphonates are given intravenously approximately every four weeks. The medication is often given alongside cancer treatment such as chemotherapy. Bisphosphonates can have potentially serious side effects, including reduced kidney function and, in rare cases, osteonecrosis of the jaw (where the bone of the jaw begins to deteriorate).

Patients with cancer may also be prescribed medications such as Reclast (zoledronic acid) to prevent worsening of bone lesions or denosumab (XGEVA) to inhibit the protein that tells osteoclasts to destroy bone.

Other medications or treatments may be recommended depending on the cause of the osteolytic lesions and a person's symptoms.

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