Background
Lung cancer is the most common tumor in the world. According to statistics, there were nearly 2.5 million new cases in 2022, accounting for 12.4% of all cancers worldwide [ 1 ]. Lung cancer was also the leading cause of cancer death with an estimated 1.8 million deaths (18.7%) [ 1 ]. Globally, it is the leading cause of death in men and the second leading cause of death among women [ 2 ]. Most lung cancers (approximately 80–85%) are non-small cell lung cancer (NSCLC), which are further subdivided into lung adenocarcinoma (LUAD), squamous cell carcinoma (SCC), and large cell carcinoma. Around 33% of lung cancer patients present with distant metastases, with the bone being the most frequently affected site [ 3 ]. These bone metastases commonly involve the spine and ribs the axial skeleton, particularly the spine and ribs [ 4 ]. Complications of bone metastasis include bone pain, skeletal destruction, and pathological fractures [ 5 , 6 ]. However, the complete resorption of the pelvis and hip on one side as an initial presentation of advanced lung cancer is extremely rare and has been seldom reported.
Here, we described a case of a woman who experienced chronic pelvic and left hip pain due to metastasis from lung cancer for one year. Additionally, we conducted a literature review to.
summarize recent advancements in the diagnosis and treatment of lung cancer-related bone metastases. We aimed to investigate factors affecting diagnosis and treatment decision in pelvic and hip metastasis by presenting a case (a woman with complete resorption of the pelvis and hip on one side due to lung cancer) and analyze the potential treatments via conducting a comprehensive literature review.
Case presentation
A 56-year-old woman visited the senior orthopaedic surgeon (YC) for intermittent.chronic pain in her left hip, which had persisted for over 1 year and worsened over the past 2 weeks, on July 19, 2024 (Fig. 1 ). Initially on May 17, 2023, the patient experienced left hip pain after walking, which relieved after rest. However, her left hip pain gradually worsened, and 5 months later, the patient was unable to walk independently and crutches became necessary. Over the following five months, she gradually lost the mobility in her left hip and had to be confined to a wheelchair for daily activities. Imaging studies revealed neoplastic lesions in her left hip, left proximal femur, and sacral vertebra (Figs. 2 and 3 a-b). Thus, a diagnosis of bone tumors involving the left hip and vertebrae was established. The patient underwent conservative treatments including acupuncture, herbal medicine, and oral analgesic, which provided partial pain relief. However, 7 weeks later, the patient began experiencing pain in her left knee, which progressed to a flexion deformity and lower limb length discrepancy. In July 2024, she developed pain in her left chest and back. During the course of her illness, the patient also suffered from sleep disturbances caused by pain and experienced a weight loss of over 10 kg. The patient was a farmer with no history of smoking, alcohol consumption, or any documented chronic illnesses. The timeline of the patient’s clinical presentation and diagnostic process is summarized in Fig. 1 .
The patient underwent a pelvic X-ray, computed tomography (CT) scans with three-dimensional reconstruction of both hips, and a chest X-ray. Pelvic radiographs showed extensive lamellar bone erosion involving the left sacrum, the left iliac bone, the left proximal femur, the left ischiatic bone, and bilateral pubic bone (Fig. 2 ). Most of the affected bone structures had disappeared, with evident osteolytic changes. CT imaging of both hip joints confirmed the extensive patchy bone destruction observed on pelvic radiographs. Furthermore, multiple enlarged lymph nodes were identified in the left inguinal region. Additionally, multiple circular, low-density osteolytic lesions were also observed in the L3-5 vertebrae (Fig. 3 a, b). Chest X-ray showed disorganized lung texture in both lungs and multiple bilateral lung nodules of variable sizes, predominantly in the right lung. The right lower lung exhibited a patchy area of increased density with ill-defined margins (Fig. 4 ). A subsequent biopsy of the left iliac bone indicated the diagnosis of bone metastasis originating from lung adenocarcinoma (Fig. 5 a, b). Further immunohistochemical analysis showed positive staining for cytokeratin (CK), thyroid transcription factor-1 (TTF-1), and novel aspartic proteinase of the pepsin family A (Napsin A), and negative staining for special AT-rich sequence binding protein 2 (SATB2) and GATA binding protein 3 (GATA3) (Fig. 5 c–e), confirming the diagnosis of metastatic lung adenocarcinoma. Gene test results showed positive epidermal growth factor receptor (EGFR) exon 21 L858R and tumor protein 53 (TP 53). Upon confirmation of widely metastatic disease (involving the pelvis, spine, femur, and lungs) and the patient’s generally debilitated state with significant weight loss. After a multidisciplinary consultation, it was determined that the patient was not suitable for orthopedic surgery. The priority was swiftly transitioning to systemic therapy. Therefore, the patient began to receive targeted therapy with almonertinib mesylate. Unfortunately, she passed away one week after this treatment due to the advanced stage of metastatic lung adenocarcinoma.
Literature review
A literature review was conducted using 3 major databases—PubMed ( https://pubmed.ncbi.nlm.nih.gov/ ), Web of Science ( https://www.webofscience.com/wos/woscc/basic-search ), and EBSCOhost ( https://search.ebscohost.com/ )—to identify English-language publications on bone metastasis of lung cancer from 2005 to 2025. The search terms include “lung cancer”, “bone destruction”, “bone metastasis”, and “case report”. Only articles published in English with full-text availability were included in the review.
A total of 17 cases from 17 articles were identified and included in the review (Table 1 ) [ 7 – 23 ]. All cases were diagnosed as lung cancer with bone metastasis. The average age of the 17 patients was 60.0 ± 11.8 years old, with a predominance of male patients (male-to-female ratio of approximately 1.4:1). This indicates that patients with bone metastasis of lung cancer are relatively older, and men are slightly more affected than women. The most common metastatic sites were the skull (29.4%, 5/17) and the spine (23.5%, 4/17). Metastases to finger and toe bones (17.6%, 3/17), ribs (11.8%, 2/17), femur (11.8%, 2/17), hip bones (11.8% 2/17), mandible (5.9%, 1/17), patella (5.9%, 1/17), scapula (5.9%, 1/17), and humerus (5.9%, 1/17) have also been reported. Eleven patients received treatments such as surgery, radiotherapy, or chemotherapy.
Table 1
Clinical data of the 17 patients with bone metastasis of lung cancer
M: Male, F: Female, NA: Not available
| Authors | Year | Age | Sex | Primary disease | Symptom of metastasis | Location of metastasis | Treatments on primary site | Treatments of bone metastasis | Outcomes |
| Ulubaş et al. | 2005 | 51 | F | Lung squamous cell carcinoma | Headache, left shoulder, arm and back pain | Thoracic vertebra, skull | NA | NA | NA |
| Akjouj et al. | 2006 | 57 | M | Lung adenocarcinoma | Left thumb swelling pain | Phalange | NA | NA | NA |
| Davis et al. | 2007 | 68 | M | Lung squamous cell carcinoma | Neck pain | C2 vertebra | Radiation therapy and pain medication | Rigid collars fixing the spine | Died of respiratory distress |
| Kamper et al. | 2011 | 69 | F | Lung squamous cell carcinoma | Left occipital subcutaneous tumor | Occipital bone | Palliative chemotherapy, cranial irradiation | Metastasectomy | NA |
| Zelenak et al. | 2012 | 59 | F | Non-small cell lung cancer | Headache, hearing loss, and facial pain | Sphenoid bone, mastoid, frontal bone | Chemotherapy | High-dose steroids, radiation treatments | Passed away three weeks later |
| Bing et al. | 2013 | 71 | M | Lung squamous cell carcinoma | Right knee pain | Right patella | NA | Patellectomy | NA |
| Ni et al. | 2013 | 31 | F | Lung adenocarcinoma | Neck pain | C1 vertebra | Radiation therapy, analgesic medication | Rigid cervical spine brace | No recurrence for 9 months |
| Lambe et al. | 2014 | 72 | M | Lung squamous cell carcinoma | Swelling and pain | Finger and toe bones | Chemotherapy | External beam radiotherapy | Passed away two weeks later |
| Tun et al. | 2014 | 72 | F | Non-small cell lung cancer | Pain in the right shoulder | Right scapula, liver | Chemotherapy | Cryoablation | Passed away two years later |
| Liang et al. | 2016 | 59 | M | Lung adenocarcinoma | Left facial numbness and toothache | Maxilla, sternum, rib | NA | NA | NA |
| Xie et al. | 2017 | 45 | M | Lung adenocarcinoma | The left thumb swolling and pain | Metacarpal bone | Lobectomy | Thumb resection | NA |
| Fukai et al. | 2018 | 76 | F | Non-small cell lung cancer | Headache, diplopia | Sphenoid bone | Left lower lobectomy | Radiation therapy, zoledronic acid | Passed away five months later |
| Zhan et al. | 2019 | 70 | M | Lung squamous cell carcinoma | Right hip pain and motion limitation | Right hip | Chemotherapy | Proximal femoral prosthesis revision, tumor prosthesis resection | Passed away three months later |
| Wang et al. | 2020 | 60 | F | Lung squamous cell carcinoma | Swelling, pain, and loss of range of motion in the left knee joint | Femur, rib, bilateral frontal lobes | Thoracoscopic lobectomy | Metastasectomy, bone grafting | Passed away one year later |
| Hou et al. | 2023 | 57 | M | Lung adenocarcinoma | Right upper arm pain | Right humeral | NA | NA | NA |
| D’Mello et al. | 2024 | 50 | M | Lung adenocarcinoma | Right-sided numbness, pain, and headache | Sphenoid sinus | NA | NA | NA |
| Chen et al. | 2024 | 53 | M | Lung adenocarcinoma | Swelling and pain in his left thigh and back | Femur, ilium, ischium, pubic bone and spine | Osimertinib, an EGFR-tyrosine kinase inhibitor | Left proximal femoral replacement | No recurrence for 6 months |
Analysis of the 17 cases revealed that diagnostic delays were a common theme. Outcomes were frequently poor, with 7 of the 9 cases where outcomes were reported resulting in patient death, often within months of diagnosis. This aligns with the established understanding that the presentation with skeletal-related events (SREs), especially extensive ones, is a marker of poor prognosis [ 24 ].The cases that reported better outcomes, such as the one treated with osimertinib [ 23 ], involved less extensive disease and/or earlier integration of effective systemic therapy. This contrast underscores that survival is less determined by the metastatic site itself and more by the overall tumor burden, the pace of disease progression, and the timeliness of effective systemic treatment.
The main diagnostic challenge in lung cancer with bone metastasis is the nonspecific nature of symptoms, particularly bone pain. Suchh bone pain is often misdiagnosed as arthritis or musculoskeletal strain. Furthermore, radiographic detection has limited sensitivity for early-stage lytic lesions, and metastases in highly vascularized regions like vertebrae or pelvis may be mistaken for primary bone tumors. Most critically, biopsy confirmation involves significant risks when lesions are in critical regions such as the spine or skull, making a definitive diagnosis more difficult.
There are some challenges in the treatment of bone metastasis from lung cancer. For patients requiring surgical intervention, procedures are often technically demanding. Additionally, impaired respiratory function in these patients leads to poor surgical tolerance and an increased risk of perioperative complications related to anesthesia [ 25 ]. Conventional chemotherapy is ineffective due to increased drug resistance caused by congenital or acquired reasons. Furthermore, the applicability of targeted therapy and immunotherapy remains limited because their use usually requires the presence of specific target genes [ 26 ].
Discussion and conclusion
Lung cancer spreading to pelvis and hip is rare. Furthermore, near-complete destruction of the pelvis and hip on one side due to metastatic lung cancer, as reported in this case, is extremely rare.
The decision for conservative orthopedic management was based on the extensiveness of the skeletal destruction, which precluded effective surgical reconstruction, and the presence of widespread metastatic disease, which shifted the focus to systemic control. While the identification of an EGFR L858R mutation made her a candidate for targeted therapy, this testing was performed on the bone biopsy specimen after her presentation to our hospital. The tragic outcome, with the patient succumbing just one week after initiating almonertinib mesylate, starkly illustrates how advanced tumor burden and clinical deterioration can preclude the effective application of otherwise potent targeted agents [ 26 ]. The 13-month interval from the initial symptom (left hip pain after walking) to the definitive diagnosis highlights a critical challenge in oncology. Early bone pain is non-specific. Benign musculoskeletal diseases such as arthritis or strain can also cause bone pain, often leading to delayed diagnosis [ 24 ]. In this case, the initial intermittent pain and partial response to conservative therapies (acupuncture, analgesics) may have provided a false sense of security. This underscores the imperative for clinicians to maintain a high index of suspicion for malignancy in cases of persistent, progressive, or mechanically incongruous bone pain, particularly in middle-aged and older adults, and to pursue advanced imaging promptly.
The extent of bone destruction is not merely a radiographic finding but a direct reflection of high tumor burden and aggressive disease biology. Such extensive involvement is strongly correlated with the development of SREs, including pain, hypercalcemia, and pathological fractures, which collectively diminish quality of life and are independent predictors of shorter survival [ 6 , 27 ].
The differential diagnosis for progressive lytic bone lesions in an adult is broad and includes primary bone tumors (e.g., chondrosarcoma, giant cell tumor of bone), other metastatic carcinomas (e.g., breast, kidney, thyroid), hematological malignancies (e.g., multiple myeloma), and infectious processes (e.g., chronic osteomyelitis). The initial misattribution of symptoms to degenerative or mechanical causes is a common pitfall. This case reinforces the necessity of including metastasis high in the differential for atypical bone pain, prompting a systematic workup that includes CT/MRI and, ultimately, biopsy for definitive diagnosis.
Bone metastases most commonly affect the axial bones which contain more red bone marrow, suggesting that circulatory, cellular, and extracellular matrix properties within this region may contribute to the formation of bone metastases [ 24 ]. The most common early symptom of bone metastasis from lung cancer is persistent and progressively worsening bone pain. It is usually manifested as deep dull pain or soreness, and the pain often intensifies during activity, weight-bearing or night rest. Serious complications include pathological fractures, where the strength of bones decreases due to tumor destruction. It can occur under slight external force or daily activities and is more common in weight-bearing bones such as the femur and spine. The most urgent situation is spinal cord compression, which is an emergency of tumor metastasis. It is manifested as abnormal sensations below the compressed plane, weakness or paralysis of movement, and dysfunction of urination and defecation. Other important symptoms and signs include nausea, vomiting, confusion and polyuria caused by hypercalcemia [ 24 ]. Anemia, susceptibility to infection and bleeding tendency caused by bone marrow suppression. Local masses or swelling at the site of superficial metastasis. And common systemic depletion symptoms of advanced tumors such as fatigue and weight loss.
Imaging examinations are the key to diagnosing and evaluating bone metastasis of lung cancer. The vast majority of metastatic lesions present as osteolytic destruction, showing as insect-eroded or punctured bone defect areas on X-rays or CT scans, while a few present as osteogenic or mixed destruction [ 27 ]. Radionuclide bone scanning is a sensitive whole-body screening tool that can detect radioactive concentration foci with local metabolic abnormalities. MRI is most sensitive for detecting early bone marrow infiltration, soft tissue invasion and evaluating spinal cord compression. CT can clearly show the details of bone destruction and the risk of fractures. PET-CT has high value in systemic staging and assessment of metabolic activity [ 28 ].
Nowadays, histology and immunohistochemistry analysis are valuable tools for determining the primary origin of neoplastic diseases. Moreover, it plays a very important role in classifying tumors into subtypes and making accurate decisions about the choice of treatment. Ye et al. found that TTF-1 and Napsin A are highly sensitive and specific for the detection of primary lung adenocarcinoma [ 29 ]. Su et al. reported that the positivity of TTF-1, cytokeratin 7 (CK 7), and cytokeratin 20 (CK 20) could distinguish it as primary lung adenocarcinoma and metastatic lung adenocarcinoma [ 30 ]. For the diagnosis of SCC, Mukhopadhyay et al. found that p63, cytokeratin 5/6 (CK 5/6), and other positive markers show a more significant role [ 31 ].
This case also underscores a critical practice point: the presence of destructive bone lesions of unknown origin should always trigger an investigation for a primary malignancy. Given that the lungs are the most common source of metastatic bone disease, chest imaging (preferably CT) is an early step in diagnosing the presence of metastasis, regardless of whether the patient has a history of smoking or not [ 3 ].
Different treatments depend on the nature of the cancer and the area affected. At present, the clinical treatment of bone metastases in NSCLC mainly includes [ 32 ]: (a) surgical prevention of imminent pathological fractures or stabilization of existing pathological fractures; (b) radiotherapy including external beam radiotherapy and radionuclide therapy; (c) bone-targeted agents including bisphosphonates and denosumab; (d) platinum-based chemotherapy combined with bone targeting drugs; (e) targeted therapy mainly consisting of three generations of epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI); and (f) immunotherapy includes immune checkpoint inhibitors represented by pembrolizumab. In this patient, the extreme skeletal destruction and poor performance status limited the applicability of local interventions, making effective systemic therapy with almonertinib the cornerstone of the management plan. Unfortunately, her rapid demise precluded the potential benefits of this strategy, highlighting the narrow therapeutic window in end-stage disease. Generally, a multidisciplinary approach should be adopted for patients. In addition to standardized systemic therapy, aggressive local treatments such as surgery and radiotherapy should be used to maximize survival benefits and quality of life.
In conclusion, our case highlights the importance of early diagnosis and treatment of bone metastasis and adds valuable insight to the medical literature. Accurate diagnosis of the primary malignancy requires an integrated approach combining clinical presentation, imaging studies, and pathological analysis. The management of bone metastasis requires a patient-centered, multidisciplinary, and individualized strategy to optimize outcomes and enhance our understanding of hip metastasis originating from lung cancer. For patients presenting with such advanced disease, as in this case, the integration of early palliative care alongside oncological treatment is paramount. The focus must expand beyond tumor control to actively managing pain, addressing nutritional deficits, providing psychosocial support, and optimizing overall quality of life, in accordance with modern oncology guidelines.
Acknowledgements
We thank the patient and families for their participation.
Abbreviations
Non-small cell lung cancer
Lung adenocarcinoma
Squamous cell carcinoma
Computed tomography
Magnetic resonance imaging
Cytokeratin
Thyroid transcription factor-1
Novel aspartic proteinase of the pepsin family A
Epidermal growth factor receptor
Skeletal-related events
Author contributions
WJH and YC designed the research and analyzed the data. WJH and CQY contributed significantly to the creation of charts and tables and oversaw the submission process for manuscripts. Data were collected by ZLH, WJL, HXZ and WL. WJH and YC drafted the manuscript. The final draft will be reviewed by YC. All authors reviewed and approved the final version.
Funding
This study was supported by grants from the National Natural Science Foundation of China (82060406, 82360429), Natural Science Foundation of Guangxi (2022JJA141126), Advanced Innovation Teams and Xinghu Scholars Program of Guangxi Medical University, China Postdoctoral Science Foundation (2019M650235), Key R&D Project of Qingxiu District, Nanning, Guangxi (2021003).
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
All the procedure consent forms and details have been approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University. And all processes were performed in accordance with relevant guidelines and regulations. We confirm that we have obtained the informed consent of all subjects/legal guardians to participate in this study.
Consent for publication
We confirm that we obtained informed consent from all subjects/legal guardians for publishing information and images in this manuscript.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Wenjun Hao and Chaoquan Yang contributed equally to this work.
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Associated Data
Data Availability Statement
No datasets were generated or analysed during the current study.