1、转移性骨肿瘤转移性骨肿瘤消化肿瘤内 伍远航 发生于骨转移的部位以中轴骨及下肢为多，尤其髋关节区域。发生在脊柱的转移肿瘤，腰椎最多，胸椎次之，颈椎最少。乳癌、肺癌和肾癌多转移到胸椎；前列腺癌、宫颈癌直肠癌多转移到腰椎；而鼻咽癌，甲状腺癌多趋向于颈椎转移。溶骨型：形成虫蛀样或地图状，骨质缺损，界限不清楚，边缘不规则，周围无硬化。溶骨区内可见残留骨小梁、残留骨皮质，无骨膜反应。成骨型：破坏可见斑点状、片状致密影，甚至为象牙质样，骨小梁紊乱、增厚、粗糙、受累骨体积可增大。混合型：兼有成骨和溶骨改变，可致骨膨胀。（1 1）疼痛）疼痛 是最常见的症状，脊柱-腰部胸背部、肋胸部、颈疼痛。胸椎-肋间神经痛。腰
2、椎-腹痛。骨盆-髋关节股内侧疼痛；股骨及肱骨上端-关节功能障碍。（2 2）肿块）肿块 压迫症状，麻木、肌肉无力或萎缩（3 3）压迫症状）压迫症状 脊柱-脊髓马尾或神经根的压迫症状，出现根性神经痛，感觉减退，肌力减弱以至麻痹，常伴括约肌功能障碍。骨盆者可引起直肠、膀胱的压迫症状，出现大小便功能障碍。（4 4）病理性）病理性骨折骨折（5 5）全身症状）全身症状 高钙血症、消瘦、贫血、低热、乏力、食欲减退等。1、症状与体征2、影像学检查PET-CT不能取代ECT(可存在相当比例假阴性,成骨性)，但是显示骨转移治疗反应优于ECT3、骨代谢生物标志物检测（溶骨性标志物 尿I型胶原氮端肽 uNTX,）(成
3、骨性 血清骨特异性碱性磷酸酶)4、组织学活检1、根据原发肿瘤的综合化疗，靶向，内分泌治疗等。2、双磷酸盐治疗（1、2、3代，不良反应）3、局部症状：放疗，外科，射频消融4、止痛非典型股骨非典型股骨骨折骨折(转子下及骨干)骨折,：与长期应用骨吸收抑制药物有关这些骨吸收抑制药物，包括双膦酸盐（如阿仑膦酸钠和新药地诺单抗）。这些药物可以用于逆转癌症或癌症治疗所致的骨质疏松。非典型股骨骨折的危险因素包括双膦酸盐应用超过5年、年轻患者、亚洲人种、维生素D浓度低、多种抗骨吸收的药物（如三苯氧胺+双膦酸盐）的应用、糖皮质激素或质子泵抑制剂的应用、碱性磷酸酶过少和风湿性关节炎等。该回顾性研究包括327位不同类
4、型肿瘤骨转移或骨髓瘤的患者。所有患者均静脉应用双膦酸盐，中位治疗剂量为43次，中位治疗时间为66个月。研究人群中共出现了4例非典型股骨骨折，发生率为1.2%，均为女性，3例为乳腺癌患者，1例为骨髓瘤患者。骨相关事件（骨相关事件（skeletal related event,SREskeletal related event,SRE）由于恶性肿瘤骨转移而发生的一系列骨相关事件，包括：病理性骨折；椎体骨折或压迫 为减轻骨痛、预防病理性骨折和椎体压迫而进行的放疗；由于治疗骨转移而进行的骨手术 高钙血症对来自三个随机临床试验，接受唑来膦酸对来自三个随机临床试验，接受唑来膦酸治疗的患者（治疗的患者（N=
5、1462)N=1462)测定骨标记物水平测定骨标记物水平根据基线和当前骨标记物水平对患者进行根据基线和当前骨标记物水平对患者进行分组分组NTXNTX：低水平组：低水平组：50 50 nmolnmol/mmolmmol creatininecreatinine 中等水平组：中等水平组：50-99 50-99 nmolnmol/mmolmmol creatininecreatinine 高水平组：高水平组：100 100 nmolnmol/mmolmmol creatininecreatinine观察骨转移病人接受唑来膦酸治疗每观察骨转移病人接受唑来膦酸治疗每3-43-4周周1 1次，共次，共24
6、24个月后个月后NTXNTX水平和临床终点的相关性水平和临床终点的相关性 乳腺癌乳腺癌 激素抗拒性前列腺癌激素抗拒性前列腺癌 (HRPC)(HRPC)非小细胞肺癌和其它实体肿瘤非小细胞肺癌和其它实体肿瘤 (NSCLC/OST)(NSCLC/OST)只有在基线和只有在基线和3 3个月均进行了个月均进行了NTX NTX 的病人被纳的病人被纳入了分析入了分析病人根据基线病人根据基线 NTX NTX 水平进行了分层水平进行了分层 正常正常 (64(10 个月个月 HRPC 10 个月个月 NSCLC 5 个月个月Patients received bevacizumab 7.5 mg/kg or pl
7、acebo followed by cisplatin 80 mg/m2 on day 1 plus capecitabine 1,000 mg/m2 twice daily for 14 days every 3 weeks.Fluorouracil was permitted in patients unable to take oral medications.Cisplatin was given for six cycles;capecitabine and bevacizumab were administered until disease progression or unac
8、ceptable toxicity.The primary end point was overall survival(OS).Median OS was 12.1 months with bevacizumab plus fluoropyrimidine-cisplatin and 10.1 months with placebo plus fluoropyrimidine-cisplatin(hazard ratio 0.87;95%CI,0.73 to 1.03;P .1002).Both median progression-free survival(6.7 v 5.3 month
9、s;hazard ratio,0.80;95%CI,0.68 to 0.93;P .0037)and overall response rate(46.0%v 37.4%;P .0315)were significantly improved with bevacizumab versus placebo.Multiple Cox regression showed(apart from regional differences)significant impact on outcome for:ECOG PS 1(HR 1.95;p 0.0003),prior gastrectomy(0.6
10、6;0.0005),bone mets(1.71;0.0097),intestinal type histology(0.74;0.003)and peritoneal mets(1.39;0.0015).774 pts were sorted by number of negative prognostic factors present at baseline and pooled into 3 different RGs:low(no covariates involved);moderate(1 covariate);high(1 covariate).Because of the l
11、arge prognostic impact,ECOG PS 1 and bone mets received a score of 2.OS survival analysis was performed by RG and region.ResultsResults:Approx.10%of pts belonged to the low RG,30%to the moderate RG and the remaining 60%to the high RG.OS by RG and region are shown in the table.ConclusionsConclusions:
12、Outside of Asia,high-risk pts with AGC may benefit from the addition of bev to cisplatin/capecitabine.This predictive effect was not observed for pts with 1 risk factors,although there were few pts with 0 or 1 risk factors.The lack of efficacy of treatment in Asian pts with AGC cannot be explained b
13、y the number of prognostic factors at baseline.Methods:Methods:8,373 patients with GC(not gastro-esophageal junction cancer)treated from January 1998 to May 2008.Skeletal metastasis was defined if there is radiographically positive finding or no benign radiographic explanation could be found after99
14、mTc-labeled bone scan.Results:Results:There were 203(2.4%)patients identified to have skeletal metastases,and majority had poorly differentiated carcinoma(n=152,75%).We found that 117(58%)patients had synchronous metastases Most patients(n=180,89%)involved multiple sites and spine(86%)was most frequ
15、ently involved.Eighty-three patients(41%)developed skeletal-related events(SRE);80 patients received radiotherapy or operation,three suffered pathologic fracture,two developed hypercalcemia.As for treatment,120(59%)patients received chemotherapy radiotherapy,and remaining 83 received local therapy o
16、r supportive care only.Median survival after skeletal metastases was 103(95%CI,80-126)days.Multivariate analysis revealed initial alkaline phosphatase(158 mg/mL)(relative risk RR 1.72,p=0.006),bone marrow involvement(RR 3.30;p=0.026),and poor performance status(ECOG 3-4)(RR 1.95,p=0.009)comprised po
17、or prognosis for survival.59 of them(28%)had bone metastasis at the GC diagnosis and149(62%)developed bone metastasis after GC diagnosis.137/208 patients included in this study(66%)were male,consistent with the well-known male predominance of GC.The median age was 61years.Tumor histology was intesti
18、nal in 38.9%of patients,diffuse in 33.7%and mixed plus undifferentiated in the remaining 27.4%.81.4%of patients have been submitted to D2 nodes dissection,the remaining 18.6%to D1 dissection.86.3%of patients developed also visceral metastasesIntriguingly,in multivariate analysis,only D2 lymph nodes
19、dissection independently correlates with a shorter survival after bone disease occurrence(p:0.008;HR:2.285).median overall survival time of 14 months(CI 95%,12.02515.975)median time to diagnosis of bone metastasis of 8 months(CI 95%,6.1259.875 months).The median level of maximum bone pain experience
20、d after diagnosis of bone metastasis was 8 months(range,010)At the time of bone metastases diagnosis,27%of patients showed an ECOG Performance Status of 2 or 3The median time to first SRE after confirmed diagnosis of bone metastasis was 2 months(CI 95%,1.53602.464 months),indicative of the severity
21、of bone metastasis in GC.The mediantime to second SRE was 4 months(CI 95%,3.4574.865 months).Median survival from the diagnosis of bone metastasis was 6 months(CI 95%,5.0686.932 months).Median survival after development of the first SRE was 3 months(CI 95%,2.0493.951 months).Median survival in patients who did not experience SREs was 5 months(CI 95%,3.7856.125 months).1,骨转移流行病学，表现，诊断，常规治疗2，NTX在癌症患者中高表达及临床意义3，唑来膦酸的应用，与NTX变化预后影响4,AVAGST 胃癌骨转移贝伐5，2010 胃癌骨转移预后6，2013胃癌骨转移，SRE发生的影响因素及预后Thank You,么么哒么么哒！
