Table of contents

Bone metastasis

What's new

Updated 2024 ASTRO guidelines for external beam radiotherapy in bone metastasis.



Bone metastasis is the development of secondary tumors within the bone of cancer patients characterized by pathological osteolytic, osteoblastic lesions or mixed.
Bone metastasis is caused by disseminated tumor cells from various common malignancies including breast, prostate, lung, and kidney cancers, or multiple myeloma.
Disease course
The spread of tumor cells from the primary tumor to the bone results in pathologic osteolytic, osteoblastic (sclerotic), or mixed bone metastasis, which causes clinical presentation of severe pain, impaired mobility, pathologic fractures, spinal cord compression, bone marrow aplasia, and hypercalcemia. Disease progression is associated with increased morbidity and mortality.
Prognosis and risk of recurrence
The 1-year survival of bone metastasis from breast, prostate, and lung cancers are 51%, 35%, and 10%, respectively.


Key sources

The following summarized guidelines for the evaluation and management of bone metastasis are prepared by our editorial team based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS/MSTS 2024), the American Society for Radiation Oncology (ASTRO 2024), the European Society for Radiotherapy and Oncology (ESTRO 2024), the American Academy of Orthopaedic Surgeons (AAOS 2023), the European Society of Medical ...
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Diagnostic investigations

Diagnostic imaging
As per ESMO 2020 guidelines:
Obtain a radionuclide bone scan for the evaluation of clinical symptoms of possible bone metastasis and to determine the need for further evaluation based on bone scan results:
hot spots: obtain X-rays of abnormal areas to determine whether the cause is metastatic or benign; obtain CT or MRI if the X-ray results are normal
normal: obtain CT or MRI if clinical suspicion remains high
Review imaging alongside clinical information and, when available, biopsy findings by a multidisciplinary team.
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Diagnostic procedures

Biopsy: as per ESMO 2020 guidelines, consider performing a biopsy if CT or MRI results are normal but the suspicion of bone metastasis remains.

Medical management

General principles: as per ESMO 2020 guidelines, discuss the evaluation and management of patients with bone metastases/bone lesions within a multidisciplinary team with links to all therapeutic modalities of relevance.

More topics in this section

  • Bone-modifying agents (pretreatment dental evaluation)

  • Bone-modifying agents (initiating and choice of agent)

  • Bone-modifying agents (duration)

  • Bone-modifying agents (vitamin D supplementation)

  • Radium-223

  • Management of cancer treatment-induced bone loss

Therapeutic procedures

EBRT, indications: as per ASTRO 2024 guidelines, offer radiotherapy to reduce pain from osseous metastasis in patients with symptomatic bone metastases.
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More topics in this section

  • EBRT (technical considerations)

  • EBRT (reirradiation)

Surgical interventions

Indications for surgery: as per ESMO 2020 guidelines, evaluate structurally significant lesions in a long bone by an orthopedic surgeon to provide advice on suitability for surgery.
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Specific circumstances

Elderly patients
As per ESMO 2020 guidelines:
Recognize that elderly patients are at increased risk for fracture and are more likely to require pharmacological treatment to prevent cancer treatment-induced bone loss.
Obtain enhanced monitoring for the effects of comorbidities on treatment safety in elderly patients.

More topics in this section

  • Patients with spine metastasis (radiotherapy, pretreatment evaluation)

  • Patients with spine metastasis (radiotherapy, indications)

  • Patients with spine metastasis (radiotherapy, dosing)

  • Patients with spine metastasis (radiotherapy, technical considerations)

  • Patients with spine metastasis (radiotherapy, assessment of response)

  • Patients with spine metastasis (radiotherapy, toxicities)

  • Patients with spine metastasis (corticosteroids)

  • Patients with spine metastasis (surgical management)

  • Patients with femoral metastasis (evaluation)

  • Patients with femoral metastasis (bone-targeted therapy)

  • Patients with femoral metastasis (radiotherapy)

  • Patients with femoral metastasis (surgical management)

  • Patients with humeral metastasis

Preventative measures

Prevention of metastases: as per ESMO 2020 guidelines, offer adjuvant bisphosphonates (IV zoledronate or daily PO clodronate or ibandronate) in postmenopausal females or premenopausal females treated with GnRH analogs with early breast cancer deemed at significant risk for recurrence.
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Follow-up and surveillance

Assessment of treatment response: as per ESMO 2020 guidelines, obtain CT and MRI for routine response assessment of bone metastases and bone lesions from multiple myeloma.
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