Lung Cancer Bone Metastasis



Overview: Lung cancer metastasis to bone tissue is called lung cancer bone metastasis.

Lung cancer metastasis to bone tissue is called lung cancer bone metastasis may have symptoms such as bone pain, pathological fracture, numbness of limbs, hypercalcemia, anxiety, depression, etc. Lung tumor cells metastasize to bone tissue through the bloodstream and lymph to the main comprehensive treatment, including treatment of the primary disease of lung cancer, analgesia, bisphosphonates and psychological support

Definition

Lung cancer bone metastasis refers to the malignant tumor originating in the lungs that metastasizes to the bone to form a secondary tumor through direct invasion, blood circulation or lymphatic system.

Classification

Classified according to the lesion characteristics of bone metastasis:

Osteolytic type

Lung cancer bone metastasis is mainly bone resorption caused by osteoclasts, which mostly manifests as osteolytic type lesions.

Osteolytic bone metastasis accounts for about 70% of bone metastasis.

Osteogenic type

Commonly found in prostate cancer and bladder cancer, accounting for about 10% of bone metastases.

Bone metastases will have abnormal contributing bone manifestations.

Mixed type

Refers to the type in which both of the above types of bone metastases occur.

Morbidity

Lung cancer still ranks first among all cancers in the country in terms of incidence and mortality. Moreover, its onset is insidious, and about 50% of the cases are advanced (stage IV) when diagnosed, and bone metastasis is one of the main sites of hematogenous metastasis [1]. Vertebrae, pelvis, ribs and other flat bones are the favorable sites for lung cancer bone metastasis.

The incidence of lung cancer bone metastasis is about 10% to 15%, while about 2.3% of patients have bone metastasis as the first lung cancer symptom [1].

The most common sites of lung cancer bone metastasis are the spine and the proximal part of the trunk bone. It occurs in 50% of the spine, 25% of the femur, and 12% of the ribs and sternum [1].

Bone-related events complicate 46% of patients with bone metastases from lung cancer [1].

Bone metastases are not uncommon in advanced lung cancer, and are present in approximately 20% of patients with non-small cell lung cancer (NSCLC) at the time of presentation, and more frequently in patients with small cell lung cancer (SCLC), with an incidence of 30% to 40%.

Causes

Causes

The etiology of bone metastasis of lung cancer is very clear, which occurs as a malignant bone tumor that is directly invaded by the primary tumor or transferred to the bone through blood and lymphatic channels.

Lung cancer bone metastasis is mainly based on hematogenous dissemination. After lung cancer cells erode local blood vessels, the cancer embolus spreads through pulmonary veins or bronchial arteries and grows into red bone marrow, which is rich in blood and also rich in hematopoiesis.

Pathogenesis

Lung cancer bone metastasis is mainly bone resorption caused by osteoclasts, which mostly manifests as osteolytic lesions.

After lung cancer cells metastasize to bone, they release soluble mediators to activate osteoclasts and osteoblasts. Cytokines released by osteoclasts further promote tumor cells to secrete osteolytic mediators, thus forming a vicious circle.

High risk factors

The following factors are closely related to the increased risk of lung cancer bone metastasis and belong to the high-risk factors of this disease.

Late discovery of lung cancer and failure to control the development of the disease in time.

Failure to treat lung cancer in time after early detection, resulting in the spread of cancer to bone tissue.

Symptoms

Main Symptoms

In the early stage of lung cancer bone metastasis, patients may have no obvious symptoms, and with the progress of the disease, the following series of symptoms will appear, the most common symptom is bone pain.

Bone pain

Bone pain is the most common clinical symptom of patients with bone metastasis.

As the tumor grows, bone pain may appear, and the bone pain will gradually worsen with the progress of the disease.

Tumor secretion of pain mediators (e.g. prostaglandins, interleukin-1, tumor necrosis factor, etc.) and direct invasion of periosteum, nerves, and soft tissues by the tumor can lead to severe pain.

Bone pain may be persistent or intermittent, and the pain tends to worsen at night.

Pathological fracture

Pathological fracture is often the first symptom of bone metastatic cancer of lung cancer.

Cancer cells invade bone tissue and when the strength of bone is weakened, it may lead to pathological fracture.

And the fracture mostly occurs during activities without history of trauma.

Pathologic fracture mostly occurs in vertebrae, pelvis and long bones.

Spinal cord compression

Tumor cells metastasized to the vertebral body will erode the vertebral body, causing deformation and fracture of the vertebral body, which will lead to the symptom of spinal cord compression at the compression site.

It is often manifested as nerve root pain, mostly intermittent, accompanied by symptoms such as numbness, soreness, back pain, and loss of muscle strength in the limbs.

If not detected in time, the disease continues to progress and may result in severe irreversible nerve damage, such as motor sensory impairment, paraplegia (loss of sensation below the site of invasion, urinary incontinence, constipation, and paralysis of the limbs), and so on.

Hypercalcemia

It is one of the causes of death in bone metastasis of lung cancer.

Patients may have symptoms such as heart failure, arrhythmia, sudden death, inattention, drowsiness, nausea, anorexia, vomiting and limb weakness.

Systemic symptoms

Lung cancer bone metastasis in advanced stage may also present systemic symptoms such as weakness, emaciation, anemia, low fever and so on.

Other Symptoms

Symptoms caused by lung cancer

Bone metastasis of lung cancer mostly occurs in the late stage of lung cancer, and it usually presents symptoms such as coughing, coughing up sputum, hemoptysis, dyspnea, fever, weakness, wheezing and so on.

Anxiety, depression

Patients with bone metastasis of lung cancer may gradually suffer from anxiety, depression, disappointment and loneliness due to pain and fear of death.

Therefore, the psychological needs of patients are massive, such as security, love and being loved, understanding, self-esteem and so on. If these needs are not recognized and better met, it is unlikely to obtain relief from pain and other symptoms.

Consultation

Department of Medicine

Orthopedics

Please consult the Department of Orthopedics when symptoms such as bone pain, pathologic fractures, and numbness in the limbs occur.

Department of Medical Oncology

Please consult the Department of Medical Oncology when there is a high degree of suspicion, or when you have been diagnosed with bone metastasis of lung cancer and need drug treatment.

Emergency Department

If you have difficulty in breathing, sudden fracture, etc., you should go to the Emergency Department immediately, and if the situation is critical, you can call 120 for help.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of information, common problems

Tips for seeking medical treatment

Patients may need to undergo imaging tests. Avoid wearing clothing with metal decorations (including buttons, sequins, etc.) and wear loose-fitting clothing that is easy to put on and take off.

Record the symptoms, duration and other relevant information for your doctor’s reference.

Preparation Checklist for Doctor’s Visit

Symptom Checklist

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Is there bone pain? When did it occur? Where is it located?

Is the pain intermittent or persistent and can the pain be tolerated?

Has there been a fracture?

Are there any symptoms of limb numbness, incontinence, or loss of limb mobility?

Are there any symptoms of nausea, vomiting, lack of concentration, drowsiness?

Are there any symptoms of cough, sputum, hemoptysis, chest pain, dyspnea?

List of medical history

Is there a history of lung cancer?

Are there any drug or food allergies?

Any history of surgery or trauma?

Checklist

Test results in the last six months, which can be brought to the doctor’s office

Specialized tests: pathology report, chest X-ray or CT report, tumor markers.

Laboratory tests: routine blood test, routine urine test, routine stool test, blood biochemistry test, blood calcium, alkaline phosphatase.

Other tests: magnetic resonance (MRI), PET-CT.

Diagnosis

Diagnosis is based on

Medical history

The patient may have a history of lung cancer.

Clinical manifestations

Symptoms

Patients may have no obvious clinical symptoms in the early stage, and some of them may show bone pain, pathologic fracture, numbness of limbs, urinary incontinence, nausea, vomiting and other symptoms.

Physical signs

The patient’s mental state is poor, the body is thin, and the painful area is painful to press, swollen, and has impaired mobility.

If pathological fracture of the spine occurs and compresses the spinal cord and nerves, examination reveals that the patient has decreased or lost sensation below the plane of involvement, and decreased muscle strength and muscle tone.

Laboratory examination

General examination

Patients are required to undergo blood routine, liver and kidney function, electrolytes, blood coagulation analysis and other necessary general examinations before treatment, which can determine the general condition of the patient and find out whether the patient has infection, anemia, thrombocytopenia, abnormal liver and kidney function, electrolyte disorders, and abnormal coagulation function.

Calcium test

Blood calcium test is performed to determine the presence of hypercalcemia.

The normal reference value of serum total calcium is 2.12~2.74mmol/L (8.5~11.0mg/dl), and hypercalcemia can be judged to be present if serum total calcium is significantly elevated.

Tumor marker test

Such as glycan antigen 15-3 (CA15-3), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), cytokeratin fragment 19 (CYFRA21-1), gastrin-releasing peptide precursor (ProGRP), and squamous epithelial cell carcinoma antigen (SCC), etc., which can provide additional evidence for confirming the diagnosis of malignant lung tumors, and also used for the monitoring of recurrence or metastasis after surgery.

Alkaline phosphatase

It can reflect the rate of bone resorption and formation during bone metastasis, suggesting the degree of bone destruction and repair. In patients with lung cancer, the elevation of this index has certain diagnostic significance for bone metastasis.

Imaging

Radionuclide imaging

Including radionuclide bone scanning (ECT) examination and positron emission tomography (PET-CT) examination, which is the main means to screen bone metastasis.

ECT

PET/CT

PET/CT is more sensitive and specific for bone metastasis, among which 18F-FDG PET/CT is the most sensitive for metastasis of osteolysis and bone marrow.

18F-FDG PET/CT can not only reflect the systemic bone involvement, but also evaluate the systemic staging of the tumor.

X-ray

X-rays are routine orthopedic examinations and are often used for additional evaluation of clinically symptomatic areas or abnormalities detected by other imaging tests.

It can show a full picture of the localization of bones, and when bone destruction occurs, bone metastatic lesions can be seen on X-ray plain film, and it is difficult to detect early metastatic foci.

However, the sensitivity and specificity of X-ray examination for early diagnosis of bone metastasis of tumor are low. If bone metastasis of lung cancer is suspected, further examination should be carried out in order to avoid missed diagnosis.

CT/enhanced CT

CT has higher sensitivity than conventional X-ray flat film for detecting bone metastases, and is a more practical tool for diagnosis of bone metastases and evaluation of the degree of bone destruction, which can more accurately show bone destruction and its surrounding soft tissue mass.

Enhanced CT helps to show the blood supply characteristics of bone metastases, the relationship between the lesion and the surrounding nerve and blood vessel structures. It also helps to determine whether the metastatic tumor tissue in the spine protrudes into the spinal canal and compresses the dural sac and nerve roots.

CT is more valuable for patients with positive whole-body bone imaging and negative X-ray film, local symptoms, suspected bone metastasis and contraindication of MRI. The sensitivity of CT diagnosis is lower for early metastasis in the bone cortex and infiltration of the bone metastasis marrow mass.

Magnetic resonance imaging (MRI)

MRI has higher sensitivity and specificity for the diagnosis of bone metastasis, and can more accurately show the site of metastatic invasion, range and surrounding soft tissue invasion through multi-plane and multi-sequence imaging observation; enhanced MRI helps to show more metastatic foci.

MRI has better sensitivity than whole-body bone imaging, and can show early bone metastases that cannot be shown by ECT, especially suitable for detecting metastases in the spine, accompanied by neurological symptoms.

MRI has high sensitivity to early metastatic foci in the bone marrow cavity and is the tool of choice for evaluating intramedullary infiltration of bone metastases. And MRI helps to distinguish bone metastasis from other bone lesions, such as infectious lesions, benign and malignant fractures. However, the usefulness of MRI for long bones of the limbs, especially cortical bone metastases, has some limitations.

When bone metastasis is suspected, and whole-body bone imaging and X-ray radiographs still cannot be determined, MRI examination can provide diagnostic evidence.

Pathologic examination

Bone biopsy is the gold standard for diagnosing tumor bone metastasis.

Bone biopsy should be performed on bone lesions when cancer patients are combined with a single bone lesion, when the primary lesion is inconvenient or cannot be sampled to determine the type of pathology, and when the determination of the nature of the bone lesion has a definitive significance for staging and treatment.

Biopsy of bone metastatic lesions should follow the principles of biopsy sampling of musculoskeletal system tumors, mostly under CT-guided or ultrasound-guided, using puncture needles to cut or extract tumor tissues, and cautiously using surgical incision biopsy.

Diagnostic criteria

The diagnosis of bone metastasis of lung cancer should fulfill one of the following two conditions.

Clinical or pathological diagnosis of lung cancer and biopsy of bone lesion is consistent with lung cancer metastasis.

Pathologic diagnosis of lung cancer is clear, with typical imaging manifestations of bone metastasis.

Differential diagnosis

Lung cancer bone metastasis should be differentiated from primary osteosarcoma and multiple myeloma.

Primary osteosarcoma

Similarity: both of them can destroy bone quality, cause pathological fracture and symptoms such as bone pain and swelling.

Differences: Osteosarcoma occurs in the metaphysis of long bones of the limbs, while the most common sites of lung cancer bone metastasis are pelvis and vertebrae. Through bone biopsy, osteosarcoma can be found to contain a large amount of sarcoma-like stroma, while tumor bone-like tissue can be seen in lung cancer bone metastasis.

Multiple myeloma

Similarities: Both can present with bone destruction, bone pain, localized swelling and other symptoms.

Differences: Multiple myeloma occurs in children and adolescents, and there are no dead bones and calcified foci in X-ray examination, while dead bones and calcified foci will appear in X-ray examination of lung cancer bone metastases.

Treatment

Aims of treatment: To improve quality of life, prolong life, relieve symptoms and psychological pain, and prevent or delay serious bone-related events such as pathologic fractures.

Treatment principles.

A multidisciplinary comprehensive treatment model should be adopted according to the patient’s organic condition, tumor pathology type, lesion involvement range (clinical staging) and development trend, and an individualized comprehensive treatment plan should be formulated in a planned and rational manner.

Systemic treatment is the mainstay, in which chemotherapy, molecular targeted therapy and immunotherapy can be used as anti-tumor treatment modalities for lung cancer.

Reasonable local treatment can better control the symptoms related to bone metastases, in which surgery is recommended for the treatment of isolated bone metastases, and radiation therapy is also an effective local treatment.

Bisphosphonates can prevent and delay the occurrence of bone-related events. Symptomatic pain management can significantly improve the quality of life of patients.

For patients with isolated bone metastases, a physical status score of 0-1, and a non-N2 and completely resectable lung lesion, the guideline-recommended treatment regimen is complete surgical resection of the primary lung lesion + radiation therapy for the bone metastatic lesion + systemic systemic chemotherapy + bisphosphonate/disumab therapy [7].

For patients with isolated bone metastases, a physical status score of 0-1, and a lung lesion of N2 or T4, the guideline-recommended treatment regimen is sequential or simultaneous radiotherapy for the primary lung lesion + radiotherapy for the bone metastatic lesion + bisphosphonate/disumab + systemic systemic chemotherapy [7].

General treatment

Analgesic drugs

Pharmacological analgesic treatment for patients with lung cancer bone metastasis pain should follow the five basic principles of oral administration, stepwise administration, on-time administration, individualized administration and attention to specific details, in order to obtain the best pain-relieving effect and reduce the adverse reactions.

Non-steroidal anti-inflammatory drugs

Commonly used drugs include aspirin, ibuprofen, celecoxib and acetaminophen.

The use of such drugs may cause gastrointestinal reactions, gastrointestinal bleeding, liver damage and other adverse reactions, patients should follow the doctor’s instructions for the use of medication, severe liver injury, allergic to such drugs should be prohibited.

Opioids

Commonly used drugs include morphine, oxymorphone hydrochloride, oxycodone and so on.

These drugs can inhibit the cortical nociceptive area of the brain, play a strong analgesic effect, can be used to relieve moderate and severe pain.

These drugs have strong physiological dependence, and adverse reactions such as headache, dizziness, vomiting, nausea, constipation, depression or euphoria may occur after the use of the drug. Patients should strictly follow the doctor’s instructions for the use of the drug, and if serious adverse reactions occur after the use of the drug, it should be discontinued in accordance with the doctor’s instructions.

Calcium-lowering drugs

Commonly used drugs include sodium alemphosate, sodium lisdexamfetamine, calcitonin and so on.

Adverse reactions such as nausea, vomiting, dyspepsia, abdominal pain, diarrhea, gastrointestinal flatulence, dysphagia, etc. may occur after use of the drug, and the drug should be used in strict compliance with medical advice. Those who are allergic to such drugs should be prohibited from using them.

Bone-modifying drugs

Bisphosphonates and disulfiram are preferentially recommended.

These drugs can be selectively absorbed by osteoclasts, inhibit the activity and maturation of osteoclasts, inhibit the spread of tumor cells, and thus alleviate tumor bone metastasis.

Bone-modifying drugs are recommended when imaging tests suggest bone destruction or bone metastasis after diagnosis of lung cancer and there are no contraindications to their use; they are not recommended for those who are only at risk of bone metastasis but have not been diagnosed with bone metastasis.

It is recommended to use the drug for at least 9 months, and the long-term use of the drug will be judged according to the benefit of the drug.

Serious adverse events clearly associated with bone-modifying drug therapy, such as osteonecrosis of the jaw, nephrotoxicity, hypocalcemia, etc., should be discontinued, or if the clinician believes that there is no benefit from continued use of the drug.

Chemotherapy

Commonly used chemotherapeutic agents include cisplatin and carboplatin.

Systemic chemotherapy can improve the patient’s general condition and quality of life. For bone metastases, a combination of bisphosphonate drugs is usually needed at the same time.

The use of chemotherapy may cause diarrhea, constipation, vomiting, nausea, bone marrow suppression, alopecia, liver and kidney function damage and other adverse reactions, should follow the doctor’s instructions to use the drug, the occurrence of adverse reactions, should be immediately informed to the doctor to dispose of.

Molecular Targeted Therapy

Molecular targeted therapy is to treat the driver genes that may lead to cell cancer, and tumor cell growth can be inhibited through targeted therapy.

EGFR tyrosine kinase inhibitors targeting epidermal growth factor receptor (EGFR) mutation, commonly used drugs include gefitinib, erlotinib, erlotinib, afatinib, ositinib and so on.

Tyrosinase inhibitors targeting ALK fusion gene and ROS1, commonly used drugs include crizotinib and ceritinib.

Therapeutic drugs targeting VEGF include bevacizumab.

Immunotherapy

Immunotherapeutic drugs provide a new treatment option for advanced lung cancer, which can prolong the median overall survival time of patients.

Commonly used drugs include Navulizumab, Pabolizumab, Tilerizumab, Atelizumab and so on.

Radiation therapy

Radiation therapy is one of the effective treatments for bone metastasis of lung cancer, which can reduce or eliminate the symptoms, improve the quality of life, prolong the survival, and also prevent the occurrence of pathologic fracture and spinal cord compression and alleviate the symptoms of spinal cord compression. Radiotherapy includes external irradiation and radionuclide therapy.

External radiation therapy

External radiation therapy is the first choice of palliative radiotherapy for bone metastasis of lung cancer. For patients with intractable pain that cannot be relieved after chemotherapy and bisphosphonate treatment, vertebral instability, impending pathologic fracture and spinal cord compression, localized radiotherapy can rapidly and effectively relieve pain caused by bone destruction and soft tissue lesions.

Indications for external radiation therapy:

Bone metastases with painful symptoms, pain relief and restoration of function.

Selective palliative radiotherapy for weight-bearing site bone metastases (e.g., spinal or femoral metastases).

Stereotactic radiotherapy for bone widow metastases.

Radionuclide therapy

Radionuclide therapy is an effective treatment for bone metastasis of lung cancer, and the commonly used drug is 89Sr. Since some patients will have obvious bone marrow suppression and slow recovery after radionuclide therapy, which will affect the subsequent systemic treatment such as chemotherapy. Therefore, the indications should be strictly grasped, confirmed by imaging before treatment, and evaluated by multidisciplinary joint assessment, so as to choose the appropriate treatment plan and proper timing for patients, which cannot be preferred.

Indications

Multiple bone metastatic tumors with clear diagnosis.

Primary bone tumors failed to be surgically resected or postoperative residual lesions or with multiple metastases in the bone.

Hemoglobin >90g/L, white blood cells ≥3.5×109/L, platelets ≥80×109/L within 1 week before treatment.

Contraindications

Absolute contraindication: pregnant or lactating patients.

Relative contraindications: Decrease in blood counts to a certain range: total leukocytes >2.4×109/L, platelets ≥60×109/L, creatinine >180 μmol/L and/or glomerular filtration rate (GFR) <30 mL/min.

Precautions

Avoid large field radiotherapy (hemi-radiotherapy) within 3 months after treatment.

Chemotherapeutic agents with long-acting myelosuppressive effects should be discontinued within 4 to 8 weeks before treatment and 6 to 12 weeks after treatment.

Coagulation tests should be performed before treatment to exclude subclinical disseminated intravascular coagulation.

Patients with bone pain not due to bone tumors are excluded.

Surgery

Indications

Those who are expected to survive for more than 3 months.

Good general condition, able to tolerate surgical trauma and anesthesia.

Patients are expected to have a better quality of life after surgical treatment than before surgery, and even to be able to regain motor system function immediately, which will help further treatment and care.

A long tumor-free period is expected after treatment of the primary tumor.

Those for whom systemic treatment is effective but localized symptoms develop.

Isolated bone metastatic lesions.

Those at high risk of pathologic fracture.

Those who have developed spinal instability or spinal cord compression or are at high risk.

Contraindications

Expected survival shorter than 3 months.

Generalized extensive bone destruction.

Extensive metastases involving multiple organs.

Poor general condition with contraindications to surgery.

Purpose

Obtain histological diagnosis of bone metastatic lesions to facilitate further medical treatment of the tumor.

To relieve pain.

Prevent or treat fractures.

Improve the quality of survival.

Reduce or avoid complications arising from impaired motor system function and indirectly improve patient survival.

Interventional therapy

Ablation

It is a precise and minimally invasive treatment technique that uses the biological effect produced by heat to directly cause irreversible damage or coagulative necrosis of tumor cells in the lesion tissue. It includes radiofrequency ablation, microwave ablation, laser ablation, cryoablation and high-intensity focused ultrasound.

Indications

Those who cannot tolerate surgery or refuse surgery or recurrence after radiotherapy due to poor general condition.

The number of lesions is less than 5, and the edge of the lesion is ≥1cm from the spinal cord, nerves and other important structures.

Moderate to severe pain, pain score ≥4.

Contraindication

Severe hepatic, renal, cardiac, pulmonary and cerebral insufficiency.

Severe bleeding tendency, platelet count <50×109/L.

Osteoplasty

It is an interventional technique to inject methyl methacrylate (also known as bone cement) into the lesion through a puncture channel, so as to stabilize the bone structure, relieve pain and locally control the tumor. It includes percutaneous vertebroplasty, kyphoplasty, generalized irregular bone and long bone cement infusion in extremities.

Indications

Percutaneous vertebroplasty is suitable for various osteolytic bone primary tumors or bone metastases.

Contraindications

Serious neurological disorders or poor general condition that makes it difficult to tolerate surgery and anesthesia.

Uncorrectable coagulation disorder.

Tumor invades important organs, nerves and blood vessels.

Active infection.

The lesion has more than 5 metastases or extensive diffuse metastases.

Brachytherapy

It is a minimally invasive treatment method in which a sealed solid radiation source is placed inside the human lesion to treat the tumor. The radiation generated kills tumor cells and reduces the biological pain caused by the tumor tissue.

Indications

Those who refuse or are not suitable for surgical resection, refuse external radiation therapy, have recurrence after surgery or external radiation therapy, and the tumor size is ≤ 7cm.

There is a suitable puncture path.

Good physical condition.

Can tolerate radioactive particle implantation surgery.

Life expectancy ≥ 3 months.

Contraindications

Severe bleeding tendency, platelet count <50×109/L.

Severe coagulopathy (prothrombin time <18s), prothrombin activity ≤40%, and discontinuation of anticoagulant therapy and/or antiplatelet agents for less than 1 week.

Tumor ulcer.

No suitable puncture route.

Pre-planned target area dose does not meet the prescribed dose design requirements.

Psychosocial supportive therapy

Some studies have shown that lung cancer patients have the highest prevalence of depression of any malignancy.

Psycho-psychiatrists should evaluate patients for psycho-spiritual symptoms, and psychological pain that reaches the significance of clinical diagnosis needs to be treated accordingly by psycho-psychiatrists to improve patients’ psycho-spiritual pain.

For psychological pain that does not reach clinical diagnosis, clinical staff can give appropriate psychological support and patient education to reduce the patient’s fear and worry about the progress of the disease, and adapt to the state of the disease.

Psychological pain that reaches the significance of clinical diagnosis requires consultation and cooperative guidance from psychiatrists. If necessary, appropriate medication can be given.

Prognosis

Cure situation

Since bone metastasis of lung cancer occurs in the late stage of lung cancer, although pain and other uncomfortable symptoms can be effectively relieved and the quality of life can be improved with active treatment, the disease cannot be completely cured and is prone to recurrence after treatment, so the overall prognosis is poor.

Comprehensive clinical studies have shown that the median survival time of patients with lung cancer bone metastasis is only 8-30 months, and the 1-year survival rate after treatment is only 40%-50% [11-14].

[Hint].

The 1-year survival rate refers to the proportion of patients who survive for more than 1 year after the tumor has been treated with various comprehensive treatments, and it does not mean that patients can only survive for 1 year.

Median survival is the survival time that 50% of patients can exceed, for example, a total of 1001 people participated in the clinical trial, the survival time of each person is ranked in descending order, and the survival time of the 501st person is 30 months, which indicates that the median survival period is 30 months in this clinical trial.

Survival rates, median survival, etc. are statistics used in clinical studies, usually based on the results of previous studies of large groups of people with a particular cancer (e.g., staging), and these statistics do not predict nor represent the survival of any individual.

Prognostic Factors

Prognostic factors are factors that have an impact on a patient’s overall survival and quality of life.

The prognosis of lung cancer bone metastases is closely related to the condition of the primary lesion, and the higher the stage of the primary lesion, the worse the prognosis.

Lung cancer bone metastasis patients with obvious clinical symptoms and complications (i.e., bone-related events) will significantly shorten patients’ survival, and some studies have shown that survival time can be shortened by half [16].

Daily

Daily Management

Dietary management

Lung cancer bone metastasis is a chronic consumptive disease, and patients need to replenish energy through diet, so low-fat and high-calorie foods should be the main focus.

The diet should be rich in vegetables, fruits and whole grains, reduce excessive sugar, fatty foods and red and processed meat intake, and minimize alcohol intake.

Foods such as lean meat, beef, lamb, fish, eggs, apples, bananas, oranges, cucumbers, tomatoes, and celery can generally be eaten.

Life management

For patients who have already suffered from pathological fracture, it is necessary to observe the pulse, color, skin temperature, sensation, swelling and movement disorder of the distal end of the fracture, and avoid massaging the fracture site so as not to cause secondary injury.

For patients who have been bedridden for a long period of time, they should massage the pressure area regularly and help the patient to turn over. If pathological fracture has occurred in the spinal area, they should be turned over axially to avoid damaging the spinal cord and causing paraplegia.

For patients with radiation therapy, the skin in the radiotherapy irradiation field should be kept locally dry and clean, and soft underwear should be worn to avoid pressure sores.

Psychological support

Patients with bone metastasis of lung cancer are prone to anxiety and depression, so good mood and mindset cannot be replaced by drugs.

After diagnosis, patients may develop a sense of fear and may be afraid of pain, abandonment and death. With the encouragement and help of doctors, family and friends, patients need to get rid of their fears as soon as possible, face the disease squarely, actively follow the doctor’s instructions for treatment, and have an optimistic attitude towards the prognosis.

Family members should pay attention to listening to the patient’s heart, improve the patient’s psychological tolerance, and relieve anxiety symptoms.

It is recommended that the patient’s family give support so that the patient can face the surgery and other treatments positively with a good mindset.

During and after treatment, family members are advised to encourage the patient to do work and household chores that are within their ability, so as to reintegrate into social roles.

Follow-up and review

Patients with bone metastasis of lung cancer should receive long-term treatment, and should follow up and review during the treatment period so that doctors can adjust the treatment plan according to the changes of the condition in time.

Generally, patients are required to undergo review once a month, and if there is aggravation of pain or suspected pathological fracture, they should consult doctor immediately.

To follow the doctor’s instructions to choose the review program, generally should review the lesion site X-ray, CT, etc., in order to observe the bone quality changes. Chest CT and MRI should be reviewed to observe the changes of lung cancer.

Prevention

If bone metastasis has not yet occurred, lung cancer patients should remove the primary lesion as early as possible through comprehensive treatment means such as surgery, radiotherapy and chemotherapy to prevent bone metastasis as far as possible.

If bone metastasis has already occurred, surgery, radiotherapy and other comprehensive treatments should be used as early as possible to prevent pathologic fracture, spinal cord compression, paraplegia and other serious consequences.

Patients with bone metastasis of lung cancer have fragile bones and should prohibit violent exercise to avoid pathological fracture.