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Rogers DL, Raad M, Rivera JA, Wedin R, Laitinen M, Sørensen MS, Petersen MM, Hilton T, Morris CD, Levin AS, Forsberg JA. Life Expectancy After Treatment of Metastatic Bone Disease: An International Trend Analysis. J Am Acad Orthop Surg 2024; 32:e293-e301. [PMID: 38241634 DOI: 10.5435/jaaos-d-23-00332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/26/2023] [Indexed: 01/21/2024] Open
Abstract
INTRODUCTION The decision to treat metastatic bone disease (MBD) surgically depends in part on patient life expectancy. We are unaware of an international analysis of how life expectancy among these patients has changed over time. Therefore, we asked (1) how has the life expectancy for patients treated for MBD changed over time, and (2) which, if any, of the common primary cancer types are associated with longer survival after treatment of MBD? METHODS We reviewed data collected from 2000 to 2022 in an international MBD database, as well as data used for survival model validation. We included 3,353 adults who underwent surgery and/or radiation. No patients were excluded. Patients were grouped by treatment date into period 1 (2000 to 2009), period 2 (2010 to 2019), and period 3 (2020 to 2022). Cumulative survival was portrayed using Kaplan-Meier curves; log-rank tests were used to determine significance at P < 0.05. Subgroup analyses by primary cancer diagnosis were performed. RESULTS Median survival in period 2 was longer than in period 1 ( P < 0.001). Median survival (at which point 50% of patients survived) had not been reached for period 3. Median survival was longer in period 2 for all cancer types ( P < 0.001) except thyroid. Only lung cancer reached median survival in period 3, which was longer compared with periods 1 and 2 ( P < 0.001). Slow-growth, moderate-growth, and rapid-growth tumors all demonstrated longer median survival from period 1 to period 2; only rapid-growth tumors reached median survival for period 3, which was longer compared with periods 1 and 2 ( P < 0.001). DISCUSSION Median duration of survival after treatment of MBD has increased, which was a consistent finding in nearly all cancer types. Longer survival is likely attributable to improvements in both medical and surgical treatments. As life expectancy for patients with MBD increases, surgical methods should be selected with this in mind. LEVEL OF EVIDENCE VI.
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Affiliation(s)
- Davis L Rogers
- From the Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD (Rogers, Raad, Morris, Levin, and Forsberg), the Department of Defense Osseointegration Program, Henry M. Jackson Foundation, Bethesda, MD (Rivera), the Department of Orthopaedic Surgery, Karolinska University Hospital, Karolinska Intitutet, Stockholm, Sweden (Wedin), the Department of Orthopaedics, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (Laitinen), the Department of Orthopaedics, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark (Sørensen, and Petersen), and the Department of Orthopaedics, Groote Schuur Hospital, Cape Town, South Africa (Hilton)
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Tsukamoto S, Aiba H, Zuccheri F, Mavrogenis AF, Kido A, Honoki K, Tanaka Y, Donati DM, Errani C. Reoperation after surgery for bone metastasis of renal cell carcinoma. J Surg Oncol 2024; 129:629-640. [PMID: 37929793 DOI: 10.1002/jso.27501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND AND OBJECTIVE The prognosis of metastatic renal cell carcinoma (RCC) has markedly improved with the advent of molecular targeted therapies and immune checkpoint inhibitors. However, the therapeutic response in patients with bone metastasis remains low; therefore, surgery still plays a significant role in treatment of bone metastasis. It is important to maintain quality of life for patients with bone metastasis from RCC and avoid reoperation after surgery for bone metastasis. Therefore, we investigated the risk factors for reoperation after surgery in patients with bone metastasis from RCC. METHODS We retrospectively studied 103 bones of 97 patients who underwent surgery for bone metastasis of RCC from 2001 to 2023 at our institutions. RESULTS Reoperation was performed in 10 (9.7%) of 103 bones. There was no correlation between reoperation-free survival and any of the following variables: preoperative and postoperative radiotherapy, site of bone metastasis, indication for surgery (solitary bone metastasis or impending or pathologic fractures), surgical method (intramedullary nailing fixation, curettage, or en bloc resection), preoperative embolization, or survival. CONCLUSION The risk of reoperation for bone metastasis of RCC does not appear to be based on the surgical method.
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Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Hisaki Aiba
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Federica Zuccheri
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, Nara, Japan
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Davide Maria Donati
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Cevolani L, Campanacci L, Staals EL, Dozza B, Bianchi G, De Terlizzi F, Donati DM. Is the association of electrochemotherapy and bone fixation rational in patients with bone metastasis? J Surg Oncol 2023. [PMID: 36966436 DOI: 10.1002/jso.27247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/19/2023] [Accepted: 03/07/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Bone metastases are frequent in patients with cancer. Electrochemotherapy (ECT) is a minimally invasive treatment based on a high-voltage electric pulse combined with an anticancer drug. Preclinical and clinical studies supported the use of ECT in patients with metastatic bone disease, demonstrating that it does not damage the mineral structure of the bone and its regenerative capacity, and that is feasible and efficient for the treatment of bone metastases. Year 2014 saw the start of a registry of patients with bone metastases treated with ECT, whose data are recorded in a shared database. QUESTIONS/PURPOSES (1) Among patients who underwent ECT and internal fixation for bone metastasis, how many experienced a reduction of pain? (2) How many cases showed a radiological response? (3) How many patients presented local or systemic complication after ECT and fixation? PATIENTS AND METHODS Patients were treated in Bologna at Rizzoli Orthopaedic Institute between March 2014 and February 2022 and recorded in the REINBONE registry (a shared database protected by security passwords): clinical and radiological information, ECT session, adverse events, response, quality of life indicators, and duration of follow-up were registered. We consider only cases treated with ECT and intramedullary nail during the same surgical session. Patients included in the analysis were 32: 15 males and 17 females, mean age 65 ± 13 years (median 66, range 38-88 years), mean time since diagnosis of primary tumor 6.2 ± 7.0 years (median 2.9, range 0-22 years). Nail was indicated in 13 cases for a pathological fracture in, 19 for an impending fracture. Follow-up was available for 29 patients, as 2 patients were lost to follow-up and 1 was unable to return to controls. Mean follow-up time was 7.7 ± 6.5 months (median 5, range 1-24), and 16 patients (50%) had a follow-up longer than 6 months. RESULTS A significant decrease in pain intensity was observed at the mean Visual Numeric Scale after treatment. Bone recovery was observed in 13 patients. The other 16 patients remained without changes, and one presented disease progression. One patient presented a fracture occurrence during the ECT procedure. Among all patients, bone recovery was observed in 13 patients: complete recovery in 1 patient (3%) and partial recovery in 12 patients (41%). The other 16 patients remained without changes, and one presented disease progression. One patient presented a fracture occurrence during the ECT procedure. However, healing was possible with normal fracture callus quality and healing time. No other local or systemic complications were observed. CONCLUSION We found that pain levels decreased after treatment in 23 of the 29 cases for a pain relief rate of 79% at final follow-up. Pain is one of the most important indicators of quality of life in patients that undergo palliative treatments. Even if conventional external body radiotherapy is considered a noninvasive treatment, it presents a dose-dependent toxicity. ECT provides a chemical necrosis preserving osteogenic activity and structural integrity of bone trabeculae; this is a crucial difference with other local treatments and allows bone healing in case of pathological fracture. The risk of local progression in our patient population was small, and 44% experienced bone recovery while 53% of the cases remained unchanged. We observe intraoperative fracture in one case. This technique, in selected patients, improves outcome in bone metastatic patients combing both the efficacy of the ECT in the local control of the disease and the mechanical stability with the bone fixation to synergize their benefits. Moreover, the risk of complication is very low. Although encouraging data, comparative studies are required to quantify the real efficacy of the technique. Level of Evidence Level I, therapeutic study.
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Affiliation(s)
- Luca Cevolani
- 3rd Orthopaedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura Campanacci
- 3rd Orthopaedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eric Lodewijk Staals
- 3rd Orthopaedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Barbara Dozza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giuseppe Bianchi
- 3rd Orthopaedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Davide Maria Donati
- 3rd Orthopaedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
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Carrwik C, Tsagkozis P, Wedin R, Robinson Y. Predicting survival of patients with spinal metastatic disease using PathFx 3.0 - A validation study of 668 patients in Sweden. BRAIN & SPINE 2022; 2:101669. [PMID: 36506283 PMCID: PMC9729818 DOI: 10.1016/j.bas.2022.101669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/01/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
Introduction PathFx is a computer-based prediction model for estimating survival of patients with bone metastasis. The model has been validated in several studies, but this is the first validation using exclusively patients with spinal metastases. Research question Is PathFx 3.0 a tool useful for predicting survival for patients with spinal metastatic disease? Material and methods 668 patients (67% male, median age 67 years) presenting with spinal metastases at two university hospitals in Sweden 1991-2014 were included. Of those, the majority (82%, n = 551) underwent surgery. Data on all patients was analyzed with PathFx version 3.0, generating a probability of survival at 1, 3, 6, 12, 18 and 24 months. The predictions were compared to real survival data and the precision in estimation was evaluated with Receiver-Operating Characteristic curve (ROC) analysis where the Area Under Curve (AUC) was calculated. Brier score and decision curve analyses were also assessed. Results The AUC for 1-, 3-, 6- and 12 months survival predictions were 0.64 (95% CI 0.5-0.71), 0.71 (95% CI 0.67-0.75), 0.70 (95% CI 0.66-0.77) and 0.74 (95% CI 0.70-0.78). For 18- and 24 months survival the AUC were 0.74 (95% CI 0.69-0.78) and 0.76 (95% CI 0.72-0.81). The Brier scores were all 0.23 or lower depending on the estimated survival time. Discussion and conclusion PathFx 3.0 is a reasonably reliable tool for predicting survival in patients with spinal metastatic disease. As the PathFx computer model can be updated to reflect advancements in oncology, we suggest this type of model, rather than rigid point-based scoring systems, to be used for estimating survival in patients with metastatic spinal disease in the future.
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Affiliation(s)
- Christian Carrwik
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Corresponding author. Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Panagiotis Tsagkozis
- Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Rikard Wedin
- Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Armed Forces Centre for Defence Medicine, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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HSIEH HC, LAI YH, LEE CC, YEN HK, TSENG TE, YANG JJ, LIN SY, HU MH, HOU CH, YANG RS, WEDIN R, FORSBERG JA, LIN WH. Can a Bayesian belief network for survival prediction in patients with extremity metastases (PATHFx) be externally validated in an Asian cohort of 356 surgically treated patients? Acta Orthop 2022; 93:721-731. [PMID: 36083697 PMCID: PMC9463636 DOI: 10.2340/17453674.2022.4545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Predicted survival may influence the treatment decision for patients with skeletal extremity metastasis, and PATHFx was designed to predict the likelihood of a patient dying in the next 24 months. However, the performance of prediction models could have ethnogeographical variations. We asked if PATHFx generalized well to our Taiwanese cohort consisting of 356 surgically treated patients with extremity metastasis. PATIENTS AND METHODS We included 356 patients who underwent surgery for skeletal extremity metastasis in a tertiary center in Taiwan between 2014 and 2019 to validate PATHFx's survival predictions at 6 different time points. Model performance was assessed by concordance index (c-index), calibration analysis, decision curve analysis (DCA), Brier score, and model consistency (MC). RESULTS The c-indexes for the 1-, 3-, 6-, 12-, 18-, and 24-month survival estimations were 0.71, 0.66, 0.65, 0.69, 0.68, and 0.67, respectively. The calibration analysis demonstrated positive calibration intercepts for survival predictions at all 6 timepoints, indicating PATHFx tended to underestimate the actual survival. The Brier scores for the 6 models were all less than their respective null model's. DCA demonstrated that only the 6-, 12-, 18-, and 24-month predictions appeared useful for clinical decision-making across a wide range of threshold probabilities. The MC was < 0.9 when the 6- and 12-month models were compared with the 12-month and 18-month models, respectively. INTERPRETATION In this Asian cohort, PATHFx's performance was not as encouraging as those of prior validation studies. Clinicians should be cognizant of the potential decline in validity of any tools designed using data outside their particular patient population. Developers of survival prediction tools such as PATHFx might refine their algorithms using data from diverse, contemporary patients that is more reflective of the world's population.
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Affiliation(s)
- Hsiang-Chieh HSIEH
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Hsin-Chu branch, Hsin-Chu City, Taiwan
| | - Yi-Hsiang LAI
- Department of Medical Education, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chia-Che LEE
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Hung-Kuan YEN
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Hsin-Chu branch, Hsin-Chu City, Taiwan,Department of Medical Education, National Taiwan University Hospital, Hsin-Chu branch, Hsin-Chu City, Taiwan
| | - Ting-En TSENG
- Department of Medical Education, National Taiwan University Hospital, Taipei City, Taiwan,Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Jiun-Jen YANG
- Department of Medical Education, National Taiwan University Hospital, Taipei City, Taiwan
| | - Shin-Yiing LIN
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Ming-Hsiao HU
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chun-Han HOU
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Rong-Sen YANG
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Rikard WEDIN
- Department of Trauma and Reparative Medicine, Karolinska University Hospital, and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Jonathan A FORSBERG
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Wei-Hsin LIN
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
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Trends in Diagnosis and Surgical Treatment of Bone Metastases among Orthopedic Surgeons. J Clin Med 2022; 11:jcm11154284. [PMID: 35893375 PMCID: PMC9341391 DOI: 10.3390/jcm11154284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 12/10/2022] Open
Abstract
Background: The proper diagnosis and treatment of bone metastases are essential for patient survival. However, several strategies for the treatment are practiced. Therefore, the aim of the study was to analyze what factors influence the choice of a method of treatment. Methods: An online survey was conducted within the Polish Society of Orthopedics and Traumatology. It consisted of 45 questions and was divided into four main parts: Participant Characteristics, Diagnosis and Qualification, Treatment, and Clinical Cases. Results: A total number of 104 responses were collected. The most frequently chosen methods were: Intramedullary nail (IMN) + Resection + Polymethyl methacrylate (PMMA) (30.47%) and IMN without tumor resection (42.13%), and in third place, modular endoprosthesis (17.25%). The less experienced group of orthopedic surgeons more often (47.5% vs. 39.5%) decided to perform IMN without tumor resection than the more experienced group (p = 0.046). Surgeons from district hospitals less frequently (13.7% vs. 23.1%) would decide to use modular endoprosthesis than surgeons from university hospitals (p = 0.000076). Orthopedists who performed ≥ 11 bone metastases surgeries per year would more often use modular endoprosthesis (34.8% vs. 13.2%) than those who performed ≤ 10 operations per year (p = 0.000114). Conclusion: Experience, place of work, and the number of metastasis surgeries performed during a year may influence the choice of treatment method in patients with bone metastases.
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The Prediction of Survival after Surgical Management of Bone Metastases of the Extremities—A Comparison of Prognostic Models. Curr Oncol 2022; 29:4703-4716. [PMID: 35877233 PMCID: PMC9320475 DOI: 10.3390/curroncol29070373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/19/2022] [Accepted: 06/27/2022] [Indexed: 11/24/2022] Open
Abstract
Individualized survival prognostic models for symptomatic patients with appendicular metastatic bone disease are key to guiding clinical decision-making for the orthopedic surgeon. Several prognostic models have been developed in recent years; however, most orthopedic surgeons have not incorporated these models into routine practice. This is possibly due to uncertainty concerning their accuracy and the lack of comparison publications and recommendations. Our aim was to conduct a review and quality assessment of these models. A computerized literature search in MEDLINE, EMBASE and PubMed up to February 2022 was done, using keywords: “Bone metastasis”, “survival”, “extremity” and “prognosis”. We evaluated each model’s performance, assessing the estimated discriminative power and calibration accuracy for the analyzed patients. We included 11 studies out of the 1779 citations initially retrieved. The 11 studies included seven different models for estimating survival. Among externally validated survival prediction scores, PATHFx 3.0, 2013-SPRING and potentially Optimodel were found to be the best models in terms of performance. Currently, it is still a challenge to recommend any of the models as the standard for predicting survival for these patients. However, some models show better performance status and other quality characteristics. We recommend future, large, multicenter, prospective studies to compare between PATHfx 3.0, SPRING 2013 and OptiModel using the same external validation dataset.
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Arpornsuksant P, Morris CD, Forsberg JA, Levin AS. What Factors Are Associated With Local Metastatic Lesion Progression After Intramedullary Nail Stabilization? Clin Orthop Relat Res 2022; 480:932-945. [PMID: 34962492 PMCID: PMC9007189 DOI: 10.1097/corr.0000000000002104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/10/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pathologic fracture of the long bones is a common complication of bone metastases. Intramedullary nail stabilization can be used prophylactically (for impending fractures) or therapeutically (for completed fractures) to preserve mobility and quality of life. However, local disease progression may occur after such treatment, and there is concern that surgical instrumentation and the intramedullary nail itself may seed tumor cells along the intramedullary tract, ultimately leading to loss of structural integrity of the construct. Identifying factors associated with local disease progression after intramedullary nail stabilization would help surgeons predict which patients may benefit from alternative surgical strategies. QUESTIONS/PURPOSES (1) Among patients who underwent intramedullary nail stabilization for impending or completed pathologic fractures of the long bones, what is the risk of local progression, including progression of the existing lesion and development of a new lesion around the nail? (2) Among patients who experience local progression, what proportion undergo reoperation? (3) What patient characteristics and treatment factors are associated with postoperative local progression? (4) What is the difference in survival rates between patients who experienced local progression and those with stable local disease? METHODS Between January 2013 and December 2019, 177 patients at our institution were treated with an intramedullary nail for an impending or completed pathologic fracture. We excluded patients who did not have a pathologic diagnosis of metastasis before fixation, who were younger than 18 years of age, who presented with a primary soft tissue mass that eroded into bone, and who experienced nonunion from radiation osteitis or an avulsion fracture rather than from metastasis. Overall, 122 patients met the criteria for our study. Three fellowship-trained orthopaedic oncology surgeons involved in the care of these patients treated an impending or pathologic fracture with an intramedullary nail when a long bone lesion either fractured or was deemed to be of at least 35% risk of fracture within 3 months, and in patients with an anticipated duration of overall survival of at least 6 weeks (fractured) or 3 months (impending) to yield palliative benefit during their lifetime. The most common primary malignancy was multiple myeloma (25% [31 of 122]), followed by lung carcinoma (16% [20 of 122]), breast carcinoma (15% [18 of 122]), and renal cell carcinoma (12% [15 of 122]). The most commonly involved bone was the femur (68% [83 of 122]), followed by the humerus (27% [33 of 122]) and the tibia (5% [6 of 122]). A competing risk analysis was used to determine the risk of progression in our patients at 1 month, 3 months, 6 months, and 12 months after surgery. A proportion of patients who ultimately underwent reoperation due to progression was calculated. A univariate analysis was performed to determine whether lesion progression was associated with various factors, including the age and sex of the patient, use of adjuvant therapies (radiation therapy at the site of the lesion, systemic therapy, and antiresorptive therapy), histologic tumor type, location of the lesion, and fracture type (impending or complete). Patient survival was assessed with a Kaplan-Meier curve. A p value < 0.05 was considered significant. RESULTS The cumulative incidence of local tumor progression (with death as a competing risk) at 1 month, 3 months, 6 months, and 12 months after surgery was 1.9% (95% confidence interval 0.3% to 6.1%), 2.9% (95% CI 0.8% to 7.5%), 3.9% (95% CI 1.3% to 8.9%), and 4.9% (95% CI 1.8% to 10.3%), respectively. Of 122 patients, 6% (7) had disease progression around the intramedullary nail and 0.8% (1) had new lesions at the end of the intramedullary nail. Two percent (3 of 122) of patients ultimately underwent reoperation because of local progression. The only factors associated with progression were a primary tumor of renal cell carcinoma (odds ratio 5.1 [95% CI 0.69 to 29]; p = 0.03) and patient age (difference in mean age 7.7 years [95% CI 1.2 to 14]; p = 0.02). We found no associations between local disease progression and the presence of visceral metastases, other skeletal metastases, radiation therapy, systemic therapy, use of bisphosphonate or receptor activator of nuclear factor kappa-B ligand inhibitor, type of fracture, or the direction of nail insertion. There was no difference in survivorship curves between those with disease progression and those with stable local disease (= 0.36; p = 0.54). CONCLUSION Our analysis suggests that for this population of patients with metastatic bone disease who have a fracture or impeding fracture and an anticipated survival of at least 6 weeks (completed fracture) or 3 months (impending fracture), the risk of experiencing local progression of tumor growth and reoperations after intramedullary nail stabilization seems to be low. Lesion progression was not associated with the duration of survival, although this conclusion is limited by the small number of patients in the current study and the competing risks of survival and local progression. Based on our data, patients who present with renal cell carcinoma should be cautioned against undergoing intramedullary nailing because of the risk of postoperative lesion progression. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Carol D. Morris
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan A. Forsberg
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
- Division of Orthopaedics, Department of Surgery, Uniformed Services University, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Adam S. Levin
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
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Li MD, Ahmed SR, Choy E, Lozano-Calderon SA, Kalpathy-Cramer J, Chang CY. Artificial intelligence applied to musculoskeletal oncology: a systematic review. Skeletal Radiol 2022; 51:245-256. [PMID: 34013447 DOI: 10.1007/s00256-021-03820-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 02/02/2023]
Abstract
Developments in artificial intelligence have the potential to improve the care of patients with musculoskeletal tumors. We performed a systematic review of the published scientific literature to identify the current state of the art of artificial intelligence applied to musculoskeletal oncology, including both primary and metastatic tumors, and across the radiology, nuclear medicine, pathology, clinical research, and molecular biology literature. Through this search, we identified 252 primary research articles, of which 58 used deep learning and 194 used other machine learning techniques. Articles involving deep learning have mostly involved bone scintigraphy, histopathology, and radiologic imaging. Articles involving other machine learning techniques have mostly involved transcriptomic analyses, radiomics, and clinical outcome prediction models using medical records. These articles predominantly present proof-of-concept work, other than the automated bone scan index for bone metastasis quantification, which has translated to clinical workflows in some regions. We systematically review and discuss this literature, highlight opportunities for multidisciplinary collaboration, and identify potentially clinically useful topics with a relative paucity of research attention. Musculoskeletal oncology is an inherently multidisciplinary field, and future research will need to integrate and synthesize noisy siloed data from across clinical, imaging, and molecular datasets. Building the data infrastructure for collaboration will help to accelerate progress towards making artificial intelligence truly useful in musculoskeletal oncology.
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Affiliation(s)
- Matthew D Li
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Harvard Medical School, Harvard Graduate Program in Biophysics, Harvard University, Cambridge, MA, USA.,Geisel School of Medicine At Dartmouth, Dartmouth College, Hanover, NH, USA
| | - Edwin Choy
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Connie Y Chang
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tsukamoto S, Kido A, Tanaka Y, Facchini G, Peta G, Rossi G, Mavrogenis AF. Current Overview of Treatment for Metastatic Bone Disease. Curr Oncol 2021; 28:3347-3372. [PMID: 34590591 PMCID: PMC8482272 DOI: 10.3390/curroncol28050290] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/13/2021] [Accepted: 08/26/2021] [Indexed: 12/16/2022] Open
Abstract
The number of patients with bone metastasis increases as medical management and surgery improve the overall survival of patients with cancer. Bone metastasis can cause skeletal complications, including bone pain, pathological fractures, spinal cord or nerve root compression, and hypercalcemia. Before initiation of treatment for bone metastasis, it is important to exclude primary bone malignancy, which would require a completely different therapeutic approach. It is essential to select surgical methods considering the patient’s prognosis, quality of life, postoperative function, and risk of postoperative complications. Therefore, bone metastasis treatment requires a multidisciplinary team approach, including radiologists, oncologists, and orthopedic surgeons. Recently, many novel palliative treatment options have emerged for bone metastases, such as stereotactic body radiation therapy, radiopharmaceuticals, vertebroplasty, minimally invasive spine stabilization with percutaneous pedicle screws, acetabuloplasty, embolization, thermal ablation techniques, electrochemotherapy, and high-intensity focused ultrasound. These techniques are beneficial for patients who may not benefit from surgery or radiotherapy.
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Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
- Correspondence: ; Tel.: +81-744-22-3051
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
| | - Giancarlo Facchini
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Giuliano Peta
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Giuseppe Rossi
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 41 Ventouri Street, 15562 Athens, Greece;
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Groot OQ, Bindels BJJ, Ogink PT, Kapoor ND, Twining PK, Collins AK, Bongers MER, Lans A, Oosterhoff JHF, Karhade AV, Verlaan JJ, Schwab JH. Availability and reporting quality of external validations of machine-learning prediction models with orthopedic surgical outcomes: a systematic review. Acta Orthop 2021; 92:385-393. [PMID: 33870837 PMCID: PMC8436968 DOI: 10.1080/17453674.2021.1910448] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - External validation of machine learning (ML) prediction models is an essential step before clinical application. We assessed the proportion, performance, and transparent reporting of externally validated ML prediction models in orthopedic surgery, using the Transparent Reporting for Individual Prognosis or Diagnosis (TRIPOD) guidelines.Material and methods - We performed a systematic search using synonyms for every orthopedic specialty, ML, and external validation. The proportion was determined by using 59 ML prediction models with only internal validation in orthopedic surgical outcome published up until June 18, 2020, previously identified by our group. Model performance was evaluated using discrimination, calibration, and decision-curve analysis. The TRIPOD guidelines assessed transparent reporting.Results - We included 18 studies externally validating 10 different ML prediction models of the 59 available ML models after screening 4,682 studies. All external validations identified in this review retained good discrimination. Other key performance measures were provided in only 3 studies, rendering overall performance evaluation difficult. The overall median TRIPOD completeness was 61% (IQR 43-89), with 6 items being reported in less than 4/18 of the studies.Interpretation - Most current predictive ML models are not externally validated. The 18 available external validation studies were characterized by incomplete reporting of performance measures, limiting a transparent examination of model performance. Further prospective studies are needed to validate or refute the myriad of predictive ML models in orthopedics while adhering to existing guidelines. This ensures clinicians can take full advantage of validated and clinically implementable ML decision tools.
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Affiliation(s)
- Olivier Q Groot
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Bas J J Bindels
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Paul T Ogink
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Neal D Kapoor
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
| | - Peter K Twining
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
| | - Austin K Collins
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
| | - Michiel E R Bongers
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
| | - Amanda Lans
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jacobien H F Oosterhoff
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
| | - Aditya V Karhade
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Joseph H Schwab
- Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA;;
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