Prognostic role of en-bloc resection and late onset of bone metastasis in patients with bone-seeking carcinomas of the kidney, breast, lung, and prostate: SSG study on 672 operated skeletal metastases

Survival and Prognostic Factors After Surgery in Single Spinal Metastasis: Comparison of Isolated-Single Spinal Metastasis and Single Spinal Metastasis With Other Metastasis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to evaluate the survival period in patients with a single spinal metastasis (SSM), subsequently comparing those with isolated-single spinal metastasis (I-SSM) and single spinal metastasis with other metastasis (O-SSM) after surgery, and to identify prognostic factors affecting their survival.

METHODS

A total of 135 patients were included, with 24 patients in the I-SSM group and 111 in the O-SSM group. Survival analysis was utilized to assess the survival of SSM patients, followed by a comparison of survival rates between the two groups. Univariate and multivariate analyses were conducted to identify significant prognostic factors for survival.

RESULTS

The overall median survival period for patients with single spinal metastasis (SSM) was 10.2 ± 1.8 months. Specifically, the median survival was 15.7 ± 5.7 months in the I-SSM group and 10.2 ± 1.5 months in the O-SSM group. The difference in survival periods between the two groups was not statistically significant (P = 0.345). Significant independent prognostic factors for survival included preoperative Karnofsky Performance Status (KPS) of 50 - 70 (OR 0.51, P = 0.017) and 80 - 100 (OR 0.46, P = 0.012), postoperative ambulatory status (OR 1.19, P = 0.028), and primary malignancy site [Group B (OR 2.67, P = 0.021), Group C (OR 2.90, P = 0.016)].

CONCLUSIONS

Patients with SSM have a median survival of 10.2 months, with no significant difference in postoperative survival between the I-SSM and O-SSM groups. Significant prognostic factors influencing the survival period after surgery include preoperative KPS, postoperative ambulatory status, and the primary malignancy site.

Risk Factors for Early Postoperative Morbidity and Mortality following Extremity Metastatic Pathologic or Impending Fracture Fixation

Background

As cancer survivorship continues to improve, the perioperative morbidity and mortality following surgical treatment of metastatic bone disease become an increasingly important consideration. The objective of this study is to identify risk factors for early postoperative complications and mortality following extremity prophylactic fixation and pathologic fracture stabilization.

Methods

A single-centre retrospective review of 185 patients (226 total surgeries) who underwent prophylactic fixation or pathologic fracture stabilization for extremity metastatic bone disease between 2005 and 2020 was performed. Skull, spine, pelvic, and revision surgeries along with diagnosis of primary bone neoplasm were excluded. Univariate, multivariate, and subgroup analyses were performed to identify predictors and independent risk factors for 30-day postoperative morbidity and mortality.

Results

Primary cancers included lung (n = 41), breast (n = 36), multiple myeloma (n = 35), prostate (n = 16), lymphoma (n = 11), renal cell carcinoma (n = 10), and other (n = 36). The 30-day postoperative complication and mortality rates were 32.30% (n = 73) and 17.26% (n = 39), respectively. The most common complications were pulmonary-related, cardiac events, surgical site infection, sepsis, and thromboembolism. Pathologic fracture, presence of extra-skeletal metastases, longer surgical duration, and blood transfusion requirements were associated with 30-day postoperative complications overall. A past medical history for cardiac disease was also associated with systemic but not local surgical complications. Pathologic fracture, presence of extra-skeletal metastases, lung cancer, blood transfusion requirements, and increasing pack-year smoking history were predictors for 30-day mortality. In the multivariate analysis, pathologic fracture (p=0.016) and presence of extra-skeletal metastases (p=0.029) were independent predictors of complications. For mortality, pathologic fracture (p=0.014), presence of extra-skeletal metastases (p=0.0085), and increased blood transfusion requirements (p=0.048) were independent risk factors.

Conclusions

The findings of this study provide additional guidance for perioperative risk assessment and patient counselling. Additionally, improving clinical assessment tools to identify and quantify patients at risk of pathologic fractures becomes increasingly important given the significant morbidity and mortality associated with pathologic fracture treatment.

Machine Learning-Assisted Decision Making in Orthopaedic Oncology

» Artificial intelligence is an umbrella term for computational calculations that are designed to mimic human intelligence and problem-solving capabilities, although in the future, this may become an incomplete definition. Machine learning (ML) encompasses the development of algorithms or predictive models that generate outputs without explicit instructions, assisting in clinical predictions based on large data sets. Deep learning is a subset of ML that utilizes layers of networks that use various inter-relational connections to define and generalize data.» ML algorithms can enhance radiomics techniques for improved image evaluation and diagnosis. While ML shows promise with the advent of radiomics, there are still obstacles to overcome.» Several calculators leveraging ML algorithms have been developed to predict survival in primary sarcomas and metastatic bone disease utilizing patient-specific data. While these models often report exceptionally accurate performance, it is crucial to evaluate their robustness using standardized guidelines.» While increased computing power suggests continuous improvement of ML algorithms, these advancements must be balanced against challenges such as diversifying data, addressing ethical concerns, and enhancing model interpretability.

Internal hemipelvectomy: A single institution's learning curve and longitudinal experience

BACKGROUND AND OBJECTIVES

Wide margin resection for pelvic tumors via internal hemipelvectomy is among the most technically challenging procedures in orthopedic oncology. As such, surgeon experience and technique invariably affect patient outcomes. The aim of this clinical study was to assess how an individual surgeon's experiences and advancements in technology and techniques in the treatment of internal hemipelvectomy have impacted patient outcomes at our institution.

METHODS

This study retrospectively examined a single tertiary academic institution's consecutive longitudinal experience with internal hemipelvectomy for primary sarcoma or pelvic metastases over a 26-year period between the years 1994 and 2020. Outcomes were assessed using two separate techniques. The first stratified patients into cohorts based on the date of surgery with three distinct "eras" ("early," "middle," and "modern"), which reflect the implementation of new techniques, including three-dimensional (3D) computer navigation and cutting guide technology into our clinical practice. The second method of cohort selection grouped patients based on each surgeon's case experience with internal hemipelvectomy ("inexperienced," "developing," and "experienced"). Primary endpoints included margin status, complication profiles, and long-term oncologic outcomes. Whole group multivariate analysis was used to evaluate variables predicting blood loss, operative time, tumor-free survival, and mortality.

RESULTS

A total of 72 patients who underwent internal hemipelvectomy were identified. Of these patients, 24 had surgery between 1994 and 2007 (early), 28 between 2007 and 2015 (middle), and 20 between 2016 and 2020 (modern). Twenty-eight patients had surgery while the surgeon was still inexperienced, 24 while developing, and 20 when experienced. Evaluation by era demonstrated that a greater proportion of patients were indicated for surgery for oligometastatic disease in the modern era (0% vs. 14.3% vs. 35%, p = 0.022). Fewer modern cases utilized freehand resection (100% vs. 75% vs. 55%, p = 0.012), while instead opting for more frequent utilization of computer navigation (0% vs. 25% vs. 20%, p = 0.012), and customized 3D-printed cutting guides (0% vs. 0% vs. 25%, p =  0.002). Similarly, there was a decline in the rate of massive blood loss observed (72.2% vs. 30.8% vs. 35%, p = 0.016), and interdisciplinary collaboration with a general surgeon for pelvic dissection became more common (4.2% vs. 32.1% vs. 85%, p < 0.001). Local recurrence was less prevalent in patients treated in middle and modern eras (50% vs. 15.4% vs. 25%, p =  0.045). When stratifying by case experience, surgeries performed by experienced surgeons were less frequently complicated by massive blood loss (66.7% vs. 40% vs. 20%, p = 0.007) and more often involved a general surgeon for pelvic dissection (17.9% vs. 37.5% vs. 65%, p = 0.004). Whole group multivariate analysis demonstrated that the use of patient-specific instrumentation (PSI) predicted lower intraoperative blood loss (p = 0.040). However, surgeon experience had no significant effect on operative time (p = 0.125), tumor-free survival (p = 0.501), or overall patient survival (p = 0.735).

CONCLUSION

While our institution continues to utilize neoadjuvant and adjuvant therapies following current guideline-based care, we have noticed changing trends from early to modern periods. With the advent of new technologies, we have seen a decline in freehand resections for hemipelvectomy procedures, and a transition to utilizing more 3D navigation and customized 3D cutting guides. Furthermore, we have employed the use of an interdisciplinary team approach more regularly for these complicated cases. Although our results do not demonstrate a significant change in perioperative outcomes over the years, our institution's willingness to treat more complex cases likely obscures the benefits of surgeon experience and recent technological advances for patient outcomes.

Reoperation after surgery for bone metastasis of renal cell carcinoma

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.

Surgical treatment for pelvic bone metastatic disease from renal cell carcinoma

INTRODUCTION

Pelvic bone metastases from renal cell carcinoma (RCC) are challenging due to their destructive pattern, poor response to radiotherapy and hypervascularity. The purpose of our study was to review a series of patients undergoing surgical treatment with the aim to investigate: 1) survival; 2) local disease control; and 3) complications.

METHODS

A series of 16 patients was reviewed. A curettage procedure was performed on 12 patients. In eight the lesion involved the acetabulum; a cemented hip arthroplasty with cage was performed in seven; a flail hip in one. Four patients received a resection; in two cases with acetabular involvement, reconstruction was performed with a custom-made prosthesis and with an allograft and prosthesis.

RESULTS

Disease-specific survival accounted for 70% at 3 years and 41% at 5 years. Only one local tumor progression after curettage occurred. Revision surgery (flail hip) was necessary for deep infection of the custom-made prosthesis.

CONCLUSION

A prolonged survival in patients affected by bone metastatic disease from RCC can justify also major surgical procedures. Due to a low local progression rate after intralesional procedures, curettage, cement and a total hip arthroplasty with cage, when feasible, should be considered as an alternative to more demanding surgeries like resections and reconstructions.

LEVEL OF EVIDENCE (OXFORD)

Level 4.

Intramedullary brachytherapy for the treatment of long bone metastatic disease: A case report

Case

A 56-year-old woman with metastatic melanoma and femoral lesions with impending pathologic fracture was indicated for intramedullary brachytherapy (IMBT) and intramedullary nail.

Conclusions

IMBT + intramedullary nail is a new technique for the treatment of long bone metastases. IMBT maximizes radiation to the tumor and minimizes radiation to surrounding tissues. It allows the patient to resume systemic treatment expediently. Our cadaver model and patient were both treated for femoral metastases; however, this technique allows for the treatment of any long bone. This is a safe technique that minimizes treatment time compared with other standard radiation regimens.

Individualized assessment predictive models for risk and overall survival in elderly patients of primary kidney cancer with bone metastases: A large population-based study

Background

Elderly people are at high risk of metastatic kidney cancer (KC), and, the bone is one of the most common metastatic sites for metastatic KC. However, studies on diagnostic and prognostic prediction models for bone metastases (BM) in elderly KC patients are still vacant. Therefore, it is necessary to establish new diagnostic and prognostic nomograms.

Methods

We downloaded the data of all KC patients aged more than 65 years during 2010-2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate logistic regression analyses were used to study independent risk factors of BM in elderly KC patients. Univariate and multivariate Cox regression analysis for the study of independent prognostic factors in elderly KCBM patients. Survival differences were studied using Kaplan-Meier (K-M) survival analysis. The predictive efficacy and clinical utility of nomograms were assessed by receiver operating characteristic (ROC) curve, the area under curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

A final total of 17,404 elderly KC patients (training set: n = 12,184, validation set: n = 5,220) were included to study the risk of BM. 394 elderly KCBM patients (training set: n = 278, validation set: n = 116) were included to study the overall survival (OS). Age, histological type, tumor size, grade, T/N stage and brain/liver/lung metastasis were identified as independent risk factors for developing BM in elderly KC patients. Surgery, lung/liver metastasis and T stage were identified as independent prognostic factors in elderly KCBM patients. The diagnostic nomogram had AUCs of 0.859 and 0.850 in the training and validation sets, respectively. The AUCs of the prognostic nomogram in predicting OS at 12, 24 and 36 months were: training set (0.742, 0.775, 0.787), and validation set (0.721, 0.827, 0.799), respectively. The calibration curve and DCA also showed excellent clinical utility of the two nomograms.

Conclusion

Two new nomograms were constructed and validated to predict the risk of developing BM in elderly KC patients and 12-, 24-, and 36-months OS in elderly KCBM patients. These models can help surgeons provide more comprehensive and personalized clinical management programs for this population.

Socioeconomic and insurance-related disparities in disease-specific survival among patients with metastatic bone disease

BACKGROUND

Approximately 5% of cancer patients in the United States presented with metastatic bone disease (MBD) at diagnosis. Current study explores the disparities in survival for patients with MBD.

METHODS

Patients with the diagnosis of MBD at presentation for the five most common primary anatomical sites were extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset (2010-2016). Kaplan-Meier and Cox Proportional Hazard models were used to evaluate survival, and prognostic factors for each cohort. Prognostic significance of socioeconomic status (SES) and insurance status were ascertained.

RESULTS

The five most common anatomical-sites with MBD at presentation included "lung" (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal and urothelium" (n = 7718) and "colon" (n= 3068). Lower SES was an independent risk factor for worse disease-specific survival (DSS) for patients with MBD originating from lung, prostate, breast and colon. Lack of insurance was an independent risk factor for worse DSS for MBD patients with primary tumors in lung and breast.

CONCLUSIONS

MBD patients from the five most common primary sites demonstrated SES and insurance-related disparities in disease-specific survival. This is the first and largest study to explore SES and insurance-related disparities among patients specifically afflicted with MBD. Our findings highlight vulnerability of patients with MBD across multiple primary sites to financial toxicity.

Management of Metastatic Disease in Long Bones

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Bone Metastasis

The incidence of metastatic bone disease is increasing, as patients with cancer are living longer [...]

Survival Prediction in Patients Treated Surgically for Metastases of the Appendicular Skeleton—An External Validation of 2013-SPRING Model

Simple Summary

Bone tumour metastases are highly prevalent among cancer patients. In case these have to be treated surgically due to impending or pathological fracture, estimation of patients’ life expectancy is of importance in order to choose the best treatment option possible. In the current study, the 2013-SPRING model, developed to predict prognosis of surgically treated bone metastasis patients, was validated in an external patient cohort of 303 bone metastasis patients. AUC ROCs at all three endpoints assessed (i.e., survival at 3, 6 and 12 months following surgery for bone metastases) were all above 0.780. Furthermore, stratification into type of surgery (endoprosthesis (n = 162) vs. osteosynthesis (n = 141) and metastasis location (upper limb (n = 65) vs. lower limb (n = 238)) revealed a comparable predictive accuracy of the 2013-SPRING model, albeit slightly better performance in the osteosynthesis as compared with endoprosthesis subgroup, as well as upper limb in comparison to lower limb subgroup was observed.

Abstract

Introduction: The aim of this study was to externally validate the 2013-SPRING model, a survival prediction tool for patients treated surgically for bone metastases in a retrospective patient cohort from a single institution. Moreover, subgroup analyses on patients treated with (A) endoprostheses or (B) osteosynthesis, as well as (C) upper limb and (D) lower limb metastases, were performed. Methods: Altogether, 303 cancer patients (mean age: 67.6 ± 11.1 years; 140 males (46.2%)) with bone metastases to the extremities, treated surgically between March 2000 and June 2018 at a single tertiary sarcoma centre, were retrospectively included. Median follow-up amounted to 6.3 (interquartile range (IQR): 2.3–21.8) months, with all patients followed-up for at least one year or until death. The 2013-SPRING model was applied to assess the prognostication accuracy at 3, 6 and 12 months. Models were validated with area under the curve receiver operator characteristic (AUC ROC; the higher the better), as well as Brier score. Results: Of the 303 patients, 141 had been treated with osteosynthesis (46.5%), and the remaining 162 patients with endoprosthesis (53.5%). Sixty-five (21.5%) metastases were located in the upper limbs, and two hundred and thirty-eight (78.5%) in the lower limbs. Using the 2013-SPRING model for the entire cohort, the accuracy of risk of death prediction at 3, 6 and 12 months, determined by the AUC ROC, was 0.782 (95% CI: 0.729–0.843), 0.810 (95% CI: 0.763–0.858) and 0.802 (95% CI: 0.751–0.854), respectively. Corresponding Brier scores were 0.170, 0.178 and 0.169 at 3, 6 and 12 months. In the subgroup analyses, predictive accuracy of the 2013-SPRING model was likewise encouraging, albeit being slightly higher in the osteosynthesis subgroup as compared with the endoprosthesis subgroup, and also higher in the upper limb in comparison to the lower limb metastasis subgroup. Conclusions: The current validation study of the 2013-SPRING model shows that this model is clinically relevant to use in an external cohort, also after stratification for surgical procedure and metastasis location.

The Prediction of Survival after Surgical Management of Bone Metastases of the Extremities—A Comparison of Prognostic Models

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.

Application of Endoprosthetic Replacement in Old Patients with Isolated Proximal Femoral Bone Metastases

BACKGROUND

Due to radical resection, endoprosthetic reconstruction (EPR) is more invasive and increases the risk of dislocation. Therefore, the suitability of EPR for elderly patients with metastatic tumor needs further investigation.

METHODS

Seventy-one adult patients with isolated proximal femoral bone metastases who underwent EPR were retrospectively analyzed and stratified into two groups: elderly age group (≥60 years, n = 31) and younger age group (<60 years, n = 40). The effect of age on prognosis was analyzed to determine whether EPR is beneficial in elderly patients with proximal femoral metastatic tumor. Cox regression modeling was used to evaluate the effect of different factors on postoperative survival outcomes.

RESULTS

Ten (32.26%) and 9 (22.50%) cases of perioperative complications were recorded in the elderly and younger age groups, respectively, with median survival times of 22.00 ± 4.61 months and 23.00 ± 2.85 months, respectively; a log-rank test showed that the difference was not statistically significant (p = 0.657). A Cox regression model was established with patient age as the covariable to evaluate whether it affected postoperative survival. The risk of death due to age was not significant (p = 0.649), but malignancy and femoral metastasis type were significantly associated with postoperative survival (p = 0.001 and p = 0.019).

CONCLUSION

Although older patients have a slightly higher incidence of postoperative complications than younger patients, they do not experience severe adverse consequences. With rigorous selection and careful preparation, EPR is appropriate for the treatment of proximal femoral metastases in older patients, including those with Harrington type I-II acetabular invasion.

Management of Pathologic Fractures around the Knee: Part 1-Distal Femur

Pathologic fractures secondary to metastatic disease are an increasingly prevalent problem. Such patients require multidisciplinary collaboration to optimize clinical outcomes. An established algorithm for clinical, laboratory, and radiographic work-up will ensure that each patient achieves the best outcome while avoiding catastrophic complications. Metastatic disease to the region of the knee is less commonly encountered than in other regions of the body, but it presents unique difficulties that merit discussion. Part one of this two-part article series will discuss the appropriate work-up of patients with suspected or impending pathologic fracture of the distal femur, highlight biopsy principles, address perioperative nonsurgical treatments that will optimize patient outcomes, and discuss available surgical treatment modalities.

A Tailored Approach for Appendicular Impending and Pathologic Fractures in Solid Cancer Metastases

Simple Summary

Patients with bone metastases often suffer with complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results, a tailored approach should be defined for managing impending or pathologic fractures in each individual case. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow.

Abstract

Advances in medical and surgical treatment have played a major role in increasing the survival rates of cancer patients with metastatic bone disease. The clinical course of patients with bone metastases is often impaired by bone complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results and prevent a detrimental impact on patients’ health, a tailored approach should be defined for any given patient. The optimal management of impending or pathologic fractures is unknown and relies on a multidisciplinary approach to tailor clinical decisions to each individual patient. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow. The present review covers the most recent data regarding impending and pathologic fractures in patients with bone metastases, and discusses the medical and surgical management of patients presenting with metastatic bone disease in different clinical settings.

Solitary prostate cancer liver metastasis: an exceptional indication for liver resection

INTRODUCTION

Prostatic cancer metastases (PCM) are usually systemic. Isolated PCM liver metastases (PCLM) are very rare. The treatment of PCM consists of hormono- and chemotherapy eventually combined with stereotactic radiation.

PATIENT AND DISCUSSION

A case of a 67-year old man presenting with a solitary, metachronous PCLM undergoing a left extended hepatectomy due to resistance to hormono- and chemotherapy is reported. He died of recurrent systemic disease 31 months later.

CONCLUSIONS

The very rare indication and possible role of liver resection in the treatment of PCLM is discussed.

Intraoperative Cryotherapy in the Treatment of Metastatic Renal Cell Carcinoma of the Bone

Osseous metastases in renal cell carcinoma (RCC) are a heterogeneous mix of cells with hypervascular and rapidly destructive properties that frequently exhibit resistance to both radiation and chemotherapy. Despite this, some patients with isolated and oligometastatic disease have the potential to be cured. Regardless, aggressive metastatic control is critical to minimizing morbidity and mortality for all patients with metastatic RCC. Percutaneous cryoprobes were developed as a minimally invasive technique for both pain relief and tumor control. However, there is little evidence describing an alternative use of this technology in the operating room to assist with open tumor resections, and no formal role for its use in orthopedics exists. Therefore, the authors added this modality to their intraoperative treatment of osseous RCC to investigate whether it would influence their ability to obtain local metastatic control. The authors performed a retrospective chart review of prospectively obtained data to evaluate the role of intraoperative cryotherapy in the treatment of osseous RCC. From 2004 to 2017, cryotherapy was used in 43 procedures, alleviating the need for additional radiation 84% (36 of 43) of the time. Local tumor control was achieved in 100% (43 of 43) of cases. There were 2 wound-related complications and 1 pathologic fracture. Despite the study's limitations, the authors believe that cryotherapy contributed to the reliability and reproducibility of their intralesional resections. Given the palliative, and potentially curative, opportunities afforded by complete locoregional tumor control, the authors support further investigation into the use of intraoperative cryotherapy to treat osseous metastases secondary to RCC. [Orthopedics. 2021;44(5):e645-e652.].

The Surgical Management of Proximal Femoral Metastases: A Narrative Review

The proximal femur is a common location for the development of bony metastatic disease. Metastatic bone disease in this location can cause debilitating pain, pathologic fractures, reduced quality of life, anemia or hypercalcemia. A thorough history, physical examination and preoperative investigations are required to ensure accurate diagnosis and prognosis. The goals of surgical management is to provide pain relief and return to function with a construct that provides stability to allow for immediate weightbearing. Current surgical treatment options include intramedullary nailing, hemiarthroplasty or total hip arthroplasty and endoprosthetic reconstructions. Oligometastatic renal cell carcinoma must be given special consideration as tumor resection and reconstruction has survival benefit. Both tumor and patient characteristics must be taken into account before deciding on the appropriate surgical intervention.

Clinical features and outcomes of metastatic bone tumors of the pelvis

OBJECTIVE

The number of patients with metastatic bone tumors of the pelvis (MBTP) has increased, and the risk of metastasis and recurrence in the pelvic bones is difficult to assess. Therefore, we investigated the clinical features and oncological outcomes of patients with MBTP.

METHODS

We analyzed the clinical features and oncological outcomes of MBTP in 72 patients (42 men, 30 women; mean age, 50.5 years) from 2008 to 2017. Recurrence in the pelvic bones and survival rates were analyzed with regard to patients' potential contributing factors.

RESULTS

Enneking region I was the area most commonly containing MBTP (47.3%). Low- and high-grade tumors were identified in 40 and 32 patients, respectively. The most common pathological type was adenomatous carcinoma (34.7%), and the most common primary lesion was lung cancer (20.8%). The 3-year overall recurrence rate within the pelvic bones was 34.7%, and the 5-year overall survival rate was 29.2%.

CONCLUSION

Patients with MBTP have a high risk of recurrence in the pelvic bones and poor survival after multimodal treatment. Pelvic recurrence might be affected by the metastatic involvement, tumor grade, surgical margins, and type of surgery, whereas the survival rate tends to be associated with the tumor grade.

[Treatment of patients with metastatic lesions of the long bones]

OBJECTIVE

To optimize orthopedic care in patients with complicated course of metastatic lesions of the long bones.

MATERIAL AND METHODS

There were 201 patients (72 men and 129 women) who underwent orthopedic care for metastatic lesions of the long bones for the period from 2006 to 2019. Breast cancer metastases were diagnosed in 71 (35%) cases, kidney cancer - 56 (28%) patients, prostate cancer - 19 (9%) cases, metastases without a primary identified focus - 15 (8%) patients. Other forms were observed in 40 (20%) patients. All patients were divided into two groups. The first group included 136 patients (68%) who underwent segmental resections with bone replacement. Of these, 100 (73%) patients had secondary lesions of the lower limb bones and 36 (27%) patients with metastatic lesions of the upper limb bones. A threat of pathologic fracture was in 63 (46%) cases, fracture - in 73 (54%) patients. The second group consisted of 65 (32%) patients who underwent immersion osteosynthesis. Of these, 47 (72%) patients had metastatic lesions of the lower limb bones and 18 (28%) patients had secondary lesions of the upper limb bones. A threat of pathologic fracture was in 24 (37%) patients, fracture - in 41 (63%) patients.

RESULTS

In the first group, mean surgery time was 140 min, in the second group - 120 min. Mean blood loss in the first group was 600 ml, in the second group - 300 ml. Patients were activated on the 3^rd postoperative day in both groups. We analyzed surgical, anatomical and functional results in both groups using MSTS, Watkins and Karnofsky's scales.

CONCLUSION

Oncological replacement and osteosynthesis are the main methods of surgical treatment of secondary lesions of the long bones. However, our data emphasize advisability of bone replacement, since this method ensures the most adequate stabilization, pain syndrome relief and long-term improvement of the quality of life.

Effects of Surgical Intervention for Bone Metastases on Survival in Patients with Advanced Cancer: A Nationwide Population-Based Cohort Study

Purpose

With recent advances in surgical techniques and instruments, orthopedic surgeons are better equipped to treat metastatic bone disease. There has also been considerable progress in the non-surgical treatment of cancers, specifically in improving the survival rate of patients with advanced cancer. However, it remains unclear whether surgical resection of a metastatic bone lesion poses additional risk to the survival of patients with advanced cancer.

Patients and Methods

This study utilized data from the National Health Insurance Research Database (NHIRD) in Taiwan between 2000 and 2015. Patients aged ≥18 years, who had been recently diagnosed with bone metastases (BM), were enrolled and assigned to either the surgery or non-surgery groups. The demographic characteristics were analyzed, and the adjusted hazard ratios (aHR) of mortality were calculated using Cox regression analysis.

Results

Of the 4,549,226 individuals in the inpatient database of the NHIRD, 83,536 patients with BM were enrolled in this study. Among them, 8802 underwent surgical resection for skeletal metastatic lesion and 66,098 did not. Altogether, 28,691 patients died, including 2798 (31.8%) in the surgery group and 25,893 (39.2%) in the non-surgery group. The aHR for mortality was 0.7-fold lower in the surgery group (p < 0.001).

Conclusion

This study demonstrates that surgical resection of metastatic bone lesions did not pose any additional risk to survival outcomes. Thus, we believe that surgery, if indicated, could have a competitive role in the management of metastatic bone disease.

En Bloc Resection of Isolated Spinal Metastasis: A Systematic Review Update

STUDY DESIGN

This work was a systematic review.

OBJECTIVE

The objective of this work was to review the literature on the outcomes of en bloc resection of isolated spinal metastasis.

SUMMARY

Of background data: En bloc resection of isolated spinal metastasis is rarely performed and its utility debated, with the last review of the literature being performed over a decade ago. With significant advances in adjunctive oncology treatments, an updated review of whether there remains a role for this type of surgery is necessary.

METHODS

The authors performed a systematic review of English literature over the last decade on en bloc resection of isolated spinal metastasis in adults using the PubMed, Google Scholar, OVID, and Cochrane database. They excluded studies with <5 reported cases. The studies were appraised by 2 coauthors and examined for the patient and tumor characteristics, surgical time, estimated blood loss, length of hospital stay, cost, complications, functional outcomes, rates of local recurrence, metastasis, and survival.

RESULTS

Only 5 articles (148 patients) were included in this study. The average operative time was 6.5 hours, and estimated blood loss was 1742 mL. Only 73% of patients maintained their functional independence, but 35.1% experienced a complication, 6.1% had local recurrence, and the overall survival was 52% with an average time to death of 15 months.

CONCLUSIONS

There remains a paucity of data limiting the understanding of the value of en bloc resection for isolated spinal metastasis. However, despite this limitation, our literature review suggests that en bloc resection offers a low local recurrence rate (6.1%) and maintained functional independence (73%), but requires long operative times (mean 6.5 h), causes significant blood loss (mean 1742 mL), and results in high complication rates (35.1%) with poor overall survival (52% with an average time to death of 15 mo).

The IlluminOss® photodynamic bone stabilization system for pathological osteolyses and fractures of the humerus: indications, advantages and limits in a series of 12 patients at 24 months of minimum follow-up

Background

Locked titanium nails are considered the reference treatment for metastatic bone lesions of the humerus in patients with aggressive histotypes, high risk of fracture or when estimated survival is lower than 6 months.Nevertheless, they are responsible for CT and MRI artifacts which interfere with postoperative radiotherapy and follow-up.The IlluminOss® is an intramedullary stabilization system which is introduced inside the humeral canal in a deflated state, and is then distended with a monomer which hardens after exposure to blue light,stabilizing the segment; it does not cause artifacts, allowing easier and more effective radiotherapy and follow-up.

The aim of this study is to report our experience, indications, possible advantages and limitations of this stabilization system at 24 months of minimum follow-up in a series of 12 patients affected by pathological fractures or impending fractures of the humerus.

Methods

This is a retrospective case-series that included all patients who underwent surgery with the IlluminOss® Photodynamic Bone Stabilization System for pathological osteolyses and fractures of the humerus. Intraoperative and postoperative complications were valued.

Results

12 patients and 13 procedures were included in the study. All surgeries were performed without intraoperative complications. No early postoperative complications were noted. The wounds healed in all cases and stitches were removed at two weeks from surgery, so the patients were able to perform chemotherapy after three weeks. All patients except one had a painless active range of motion which reached 90°.The VAS score was 7 preoperatively and 2.6 at one month from surgery. Pain relief was also associated to radiotherapy and chemotherapy.

Unfortunately, two nail ruptures were reported at 4 and 12 months of follow-up.

No artifacts were noted in the postoperative CT scans so the radiotherapy plans were easily performed without the need of dose compensation.

Conclusions

The IlluminOss® intramedullary stabilization system can provide primary stability in humeral fractures and impending fractures;the surgical technique is easy and minimally invasive.Moreover,it does not present artifacts at postoperative imaging,probably giving a better chance to perform prompt radiotherapy and chemotherapy.However, randomized clinical studies are necessary to verify its potential strength and if precocious adjuvant radio- and chemotherapy are associated to a reduction of the local progression rate.

New concepts in the surgical treatment of actual and impending pathological fractures in metastatic disease

INTRODUCTION

Long bone metastases are a disease of high social importance. The goals of surgical treatment are to relieve pain, maintain or restore joint function, and prevent or treat pathological fractures. "Oligometastases" is a disease with a limited number (3-5) of metastatic lesions in the same body district, where an aggressive treatment can be carried out with "curative" intent. This study aimed to evaluate patients with bone metastases surgically treated to determine how surgical treatment can influence prognosis and quality of life, comparing solitary metastasis, oligometastases, and multiple metastases.

PATIENTS AND METHODS

This is a retrospective analysis of 130 patients with long bone metastases surgically treated between October 2015 and August 2019: 40 patients had solitary metastasis; 38 had less than three metastases (oligometastases), and 52 had multiple metastases. Surgery was resection and reconstruction with a cemented prosthesis (95) or nailing (35).

RESULTS

Overall survival was significantly better in patients with solitary metastasis or oligometastases than in those with multiple metastases (p <0.0001). Patients treated with resection and prosthesis had significantly better survival than those treated with nailing (p <0.0001). Implant complications requiring surgical revision occurred in 20 patients treated with prostheses, while no complications occurred in patients treated with nailing.

DISCUSSION

Survival of cancer patients has improved in the last two decades, leading to an increase of diagnosed metastases. Patients with oligometastases have a survival similar to those with a single metastasis. Optimal implants survival curves should stay above the curves of patients survival.

CONCLUSIONS

Since there are no differences in survival, patients with oligometastases should be treated as patients with a solitary lesion, with more aggressive surgery (wide resection and reconstruction with prosthesis). Intramedullary nailing is still indicated in metaphyseal or diaphyseal metastases in patients with advanced disease or poor prognosis when the life expectancy does not overcome the expected survival of the nail, avoiding the need for further surgery.

En bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases

PURPOSE

To evaluate the short-term clinical efficacy and complications of en bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases.

METHODS

A total of 21 patients with humeral diaphyseal bone metastases treated with en bloc resection and intercalary prosthesis implantation from August 2014 to August 2019 were retrospectively analysed. The visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale were used to assess pain, limb function, and quality of life. Survival of the patients was analysed using the Kaplan-Meier method.

RESULTS

The patients were followed up for 12-57 months (mean: 22 months); the operative time was 68-114 minutes (mean: 76.24 min); the osteotomy length was 6.5-10 cm (mean: 8.02 cm); and the intra-operative blood loss was 95-125 ml (mean: 104.71 ml). At three, six and 12 months after surgery, the VAS and NHP scores were lower, whereas the MSTS, ISOLS, and KPS scores were higher than those before surgery, and the differences were statistically significant (P < 0.05). The survival time was four to 24 months (mean: 19.46 months). Thesix month and one year survival rates were 80.95% and 52.38%, respectively. During the follow-up period, no complications occurred except for aseptic prosthesis loosening in one patient.

CONCLUSIONS

En bloc resection and intercalary prosthesis implantation can reduce pain, improve limb function, prolong survival time, and improve quality of life in patients with humeral diaphyseal bone metastases.

Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series

INTRODUCTION

The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival.

HYPOTHESIS

The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival.

MATERIAL AND METHODS

The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy.

RESULTS

After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]).

CONCLUSIONS

Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted.

LEVEL OF EVIDENCE

IV, retrospective study.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis

INTRODUCTION

The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated.

HYPOTHESIS

We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function.

MATERIALS AND METHODS

Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively.

RESULTS

Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing.

CONCLUSIONS

Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival.

LEVEL OF EVIDENCE

IV, retrospective study.

Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series

INTRODUCTION

Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors.

HYPOTHESIS

The French data for clinical results, survival and complications are in agreement with the international literature.

MATERIALS AND METHOD

The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%).

RESULTS

There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before.

CONCLUSION

The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Molecular mechanisms and clinical management of cancer bone metastasis

As one of the most common metastatic sites of malignancies, bone has a unique microenvironment that allows metastatic tumor cells to grow and flourish. The fenestrated capillaries in the bone, bone matrix, and bone cells, including osteoblasts and osteoclasts, together maintain the homeostasis of the bone microenvironment. In contrast, tumor-derived factors act on bone components, leading to subsequent bone resorption or excessive bone formation. The various pathways involved also provide multiple targets for therapeutic strategies against bone metastases. In this review, we summarize the current understanding of the mechanism of bone metastases. Based on the general process of bone metastases, we specifically highlight the complex crosstalk between tumor cells and the bone microenvironment and the current management of cancer bone metastases.

Current concepts in the surgical treatment of skeletal metastases

Symptomatic metastatic bone disease affects a large proportion of patients with malignant tumours and significantly impairs patients’ quality of life. There are still controversies regarding both surgical indications and methods, mainly because of the relatively few high-quality studies in this field. Generally, prosthetic reconstruction has been shown to result in fewer implant failures and should be preferred in patients with a good prognosis. Survival estimation tools should be used as part of preoperative planning. Adjuvant treatment, which relies on radiotherapy and inhibition of osteoclast function may also offer symptomatic relief and prevent implant failure. In this review we discuss the epidemiology, indications for surgery, preoperative planning, surgical techniques and adjuvant treatment of metastatic bone disease.

Modified Harrington's procedure for periacetabular metastases in 89 cases: a reliable method for cancer patients with good functional outcome, especially with long expected survival

Background and purpose - The pelvis is the 3rd most common site of skeletal metastases. In some cases, periacetabular lesions require palliative surgical management. We investigated functional outcome, complications, and implant and patient survival after a modified Harrington's procedure.Patients and methods - This retrospective cohort study included 89 cases of surgically treated periacetabular metastases. All patients were treated with the modified Harrington's procedure including a restoration ring. Lesions were classified according to Harrington. Functional outcome was assessed by Harris Hip Score (HHS) and Oxford Hip Score (OHS). Postoperative complications, and implant and patient survival are reported.Results - The overall postoperative functional outcome was good to fair (OHS 37 and HHS 76). Sex, age, survival > 6 and 12 months, and diagnosis of the primary tumor affected functional outcome. Overall implant survival was 96% (95% Cl 88-100) at 1 year, 2 years, and 5 years; only 1 acetabular implant required revision. Median patient survival was 8 months (0-125). 10/89 patients had postoperative complications: 6 major complications, leading to revision surgery, and 4 minor complications.Interpretation - Our modified Harrington's procedure with a restoration ring to achieve stable fixation, constrained acetabular cup to prevent dislocation, and antegrade iliac screws to prevent cranial protrusion is a reliable reconstruction for periacetabular metastases and results in a good functional outcome in patients with prolonged survival. A standardized procedure and low complication rate encourage the use of this method for all Harrington class defects.

Spinal metastases from lung cancer: Survival depends only on genotype, neurological and personal status, scarcely of surgical resection

BACKGROUND

For patients with non-small cell lung cancer (NSCLC), the spinal column is the most common site for bone metastasis. Studies that assess survival prognostic factors associated with specific lung spinal metastases (SpM) are weak and required the incorporation of genotype mutations.

METHODS

A prospective French national multicenter database of patients treated for SpM between January 2014 and 2017.818 lung SpM were diagnosed over the course or at the time of diagnosis of 210 consecutive patients with NSCLC.

RESULTS

Median overall survival (OS) time for all patients from the lung SpM event was 5.9 months (SD 0.609). For 122 patients (61%), lung tumor and SpM were diagnosed synchronously. In univariate analysis, good World Health Organisation (WHO) status (p < 0.0001), ambulatory status (Frankel score) (p < 0.0001), the absence of spine epiduritis (p < 0.0001), immunotherapy after SpM diagnosis (p < 0.0001), ALK gene rearrangement (p < 0.0001) and EGFR mutation (p < 0.0001) were associated with longer survival, whereas spine surgery showed no association (0.141). Cox multivariate proportional hazard model identified that EGFR + status (HR: 0.339, 95% CI 0.166-0.693; p = 0.003), good WHO status (p < 0.0001) and good neurological status (Frankel E; p < 0.001 and D; p = 0.018) were associated with higher median OS. Whereas the other factors, including ALK + status, epiduritis and immunotherapy were not independent prognostic factors of survival.

CONCLUSION

Survival in SpM must be prognosticated from general health performance status: clinical (WHO) and neurological (Frankel) as well as the EGFR mutation status. Immunotherapy, surgery and epiduritis have not demonstrated prognostic value. Therefore, surgical prognostic scoring algorithms should incorporate genotype subtypes in NSCLC cancers to adapt surgical treatment.

Evaluating the reoperation rate and hardware durability of three stabilizing implants for 105 malignant pathologic humerus fractures

INTRODUCTION

Many patients sustaining a malignant pathologic humerus fracture (MPHF) elect for surgical stabilization. Complications prompting reoperation can occur, leading to additional quality of life and financial cost. One common event preceding reoperation is a broken implant (BI). The purpose of this study was to identify the rate of reoperation following surgical stabilization of MPHF with three techniques - photodynamic bone stabilization (PBS), intramedullary nail (IMN), and cemented plate fixation (CPF) - and estimate to what extent improved implant durability might prevent reoperation.

MATERIALS AND METHODS

Retrospective data collection was performed, identifying 105 procedures (100 patients) who underwent non-articular MPHF surgery from 2010-2016: 19 PBS, 65 IMN, 21 CPF. All patients were followed for at least two years or until death.

RESULTS

Reoperation rates were similar at one year (10.5%,6.2%,4.8%, p = 737), two years (15.8%,6.2%,9.5%, p = 375), and final evaluation (15.8%,7.7%,14.3%, p = 248). The rate of BI for PBS, IMN, and CPF was 10.5%,0%, and 4.8% (p = 049 PBS/IMN) at one year, 15.8%,0%, and 9.5% (p = 010 PBS/IMN) at two years, and 15.8%,0%, and 14.3% (p = 010 IMN/PBS, p = 013 IMN/CPF) at final evaluation.

CONCLUSIONS

Reoperation rate was not significantly different at any time point. However, IMN surgery resulted in the lowest rate of broken implants (zero), statistically significant versus PBS at all time periods and versus CPF at final follow-up. PBS may eventually offer selected advantages for MPHF management, but current data suggests fragility must be thoughtfully considered.

Novel prognostic nomograms for female patients with breast cancer and bone metastasis at presentation

Background

There is a paucity of literature about prognostic evaluation for patients with breast cancer (BC) and bone metastasis at presentation. To date, little is known about how to accurately predict the prognosis of BC patients with bone metastasis at presentation. Thus, an accurate prediction tool of prognosis in this population is urgently needed. Our goal is to construct novel and prognostic nomograms for BC patients with bone metastasis at presentation.

Methods

We searched Surveillance, Epidemiology, and End Results (SEER) database for BC patients with bone metastasis at presentation between 2010 and 2016. Multivariate analysis was performed to obtain significantly independent variables. Then, novel prognostic nomograms were constructed based on those independent predictors.

Results

Tumor grade, histological type, primary tumor size, tumor subtype, surgery, chemotherapy and number of metastatic organs except bone were recognized as significantly independent variables of both overall survival (OS) and cancer-specific survival (CSS). Then those significant variables were integrated to construct nomograms for 3- and 5-year survival. Calibration plots for the 3- and 5-year survival in training and validation sets showed that the prediction curve was close to a 45 degree slash. The C-indices of OS in training and validation cohorts were 0.705 and 0.678, respectively. Similar results were observed for CSS in training and validation cohorts.

Conclusions

Our proposed nomograms can effectively and accurately predict the prognosis of BC patients with bone metastasis at presentation, which provide a basis for individual treatments for metastatic lesions.

Survival in breast cancer patients with spine metastases: Prognostic assessment involving molecular markers

BACKGROUND

To clarify and update the prognostic assessment for heterogeneous population of patients with breast cancer and spine metastases (SpM), using molecular markers.

METHODS

The patient data used in this study was obtained from a French national multi-center database of patients treated for breast cancer with SpM between 2014 and 2017. 556 SpM cases were diagnosed.

RESULTS

Median overall survival (OS) time for all patients following the SpM event was 43.9 months. First, we confirmed 3 previously known significant prognostic factors for survival of patients with SpM: young age [HR: 2.019, 95% CI 1.343-3.037; p = 0.001], good WHO status [ Status 0 HR: 2.823, 95% CI 1.231-3.345; p < 0.0001] or [ Status 1 HR: 1.956, 95% CI 0.768-2.874; p = 0.001] and no-ambulatory neurological status: Frankel A-C [HR: 0.438, 95% CI 0.248-0.772; p = 0.004]. Secondly, we determined the effect of gene mutations on survival in patients with SpM, and we identified that HER2+ cancer subtype [HR: 1.567, 95% CI 0.946-2.557; p = 0.008] was an independent predictor of longer survival, whereas basal cancer subtype [HR: 0.496, 95% CI 0.353-0.699; p < 0.0001] was associated with a poorer prognosis. Other factors including the number of SpM, surgery, extraspinal metastases, synchrone metastases, metastasis-free survival, and SpM recurrence were not identified as prognostically relevant to survival.

CONCLUSION

Survival and our ability to estimate it in breast cancer patients with SpM has improved significantly. Therefore, SpM prognostic scoring algorithms should be updated and incorporate genotypic data on subtypes to make treatment more adaptive.

Molecular imaging of bone metastases using bone targeted tracers

Molecular imaging using bone targeted tracers has been used in clinical practice for almost fifty years and still plays an essential role in the diagnosis and follow-up of bone metastases. It includes both [99mTc]bisphosphonates for bone scan and [18F]NaF for positron emission tomography/computed tomography (PET/CT) which are very sensitive to detect osteoblastic activity, but it is important to consider several aspects to increase the specificity of reported findings (such as specific tracer characteristics and mechanism of action, patient's clinical history, common metastatic patterns, changes after treatment, limitations of the technique, variations and pitfalls). This will enable useful information for clinical management being provided in the report. Furthermore, iatrogenic skeletal adverse events are common and they should also be identified, as they have impact on patient's quality of life. This review makes a brief summary of the mechanism of action of bone targeted tracers, followed by a discussion of classic patterns of bone metastasis, treatment response assessment and iatrogenic skeletal complications. The value of hybrid imaging techniques with bone targeted tracers, including single photon emission computed tomography and PET/CT is also explored. The final part summarizes new bone targeted tracers with superior imaging characteristics that are being developed, and which may further enhance the applications of radionuclide bone imaging.

Revision rate of reconstructions in surgically treated diaphyseal metastases of bone

INTRODUCTION

Skeletal metastases can weaken the bone, necessitating surgery, and surgical treatment options vary. The aim of this study was to investigate the revision rate of reconstructions in surgically treated diaphyseal skeletal metastases.

MATERIALS AND METHODS

Between 2000 and 2018 at Helsinki and Tampere university hospitals in Finland, a total of 164 cases with diaphyseal skeletal metastases were identified from a prospectively maintained database. Tumor location was humerus, femur, and tibia in 106 (65%), 53 (32%), and 5 (3.0%) cases, respectively. A total of 82 (50%) cases were treated with intramedullary nailing (IMN), 73 (45%) with IMN and cementation, and 9 (5%) with another technique.

RESULTS

In the upper extremity, implant survival (IS) was 96.4% at 1, 2, and 5 years; in the lower extremity, it was 83.8%, 69.1%, and 57.6% at 1, 2, and 5 years, respectively. Lower extremity IS for impending lesions was 100% at 1, 2, and 5 years, and in cases operated for true pathologic fracture, it was 71.6%, 42.9%, and 21.5% at 1, 2, and 5 years, respectively. In IMN cases without cement, the complication rate was 16% (13/82) when compared to 6% (4/73) in IMN cases with cementation.

DISCUSSION

We would advocate for early intervention in patients with metastatic bone disease affecting the femur rather that watchful waiting with the risk for fracture and the need for urgent intervention. However, this choice must be balanced against the underlying risk of surgical intervention in a potentially fragile population with often limited prognoses.

The PI3K inhibitor buparlisib suppresses osteoclast formation and tumour cell growth in bone metastasis of lung cancer, as evidenced by multimodality molecular imaging

Non‑small cell lung cancer (NSCLC) metastasis commonly occurs in bone, which often results in pathological fractures. Sustained phosphoinositide‑3‑kinase (PI3K) signalling promotes the growth of PI3K‑dependent NSCLC and elevates osteoclastogenic potential. The present study investigated the effects of a PI3K inhibitor on NSCLC growth in bone and osteoclast formation, and aimed to determine whether it could control symptoms associated with bone metastasis. A bone metastasis xenograft model was established by implanting NCI‑H460‑luc2 lung cancer cells, which contain a phosphatidylinositol‑​4,5‑bisphosphate 3‑kinase catalytic subunit α mutation, into the right tibiae of mice. After 1 week, the tumours were challenged with a PI3K inhibitor (buparlisib) or blank control for 3 weeks. Tumour growth and burden were longitudinally assessed in vivo via reporter gene bioluminescence imaging (BLI), small animal positron emission tomography/computed tomography (CT) [18F‑fluorodeoxyglucose (18F‑FDG)] and single‑photon emission computed tomography/CT [99mTc‑methylene diphosphonate (99mTc‑MDP)] imaging. Tibia sections of intraosseous NCI‑H460 tumours were analysed by immunohistochemistry (IHC), western blotting and flow cytometry. Dynamic weight bearing (DWB) tests were further performed to examine the improvement of symptoms associated with bone metastasis during the entire study. Administration of buparlisib significantly inhibited the progression of bone metastasis of NSCLC, as evidenced by significantly reduced uptake of 18F‑FDG, 99mTc‑MDP and BLI signals in the treated lesions. In addition, buparlisib appeared to inhibit the expression of tartrate‑resistant acid phosphatase and receptor activator of nuclear factor‑κB ligand, as determined by IHC. Buparlisib also resulted in increased cell apoptosis, as determined by a higher percentage of Annexin V staining and increased caspase 3 expression. Furthermore, buparlisib significantly increased weight‑bearing capacity, as revealed by DWB tests. The PI3K inhibitor, buparlisib, suppressed osteoclast formation in vivo, and exhibited antitumour activity, thus leading to increased weight‑bearing ability in mice with bone metastasis of lung cancer. Therefore, targeting the PI3K pathway may be a potential therapeutic strategy that prevents the structural skeletal damage associated with bone metastasis of lung cancer.

Traitement des métastases osseuses du cancer du rein

TREATING PATIENTS WITH BONE METASTASES FROM RENAL CELL CARCINOMA

Bone metastases (BMs) are common and cause morbidity in cancer patients. One third of metastatic renal cancer (mRCC) patients present metastatic disease to the bone. BMs cause severe complications such as fracture, spinal cord compression and pain requiring surgery or radiotherapy. Hypercalcaemia is a common feature in mRCC as well as an established poor prognosis factor. BMs impact negatively on prognosis and affect quality of life. Correct management of BMs from RCC requires a multimodal evaluation to optimize care and quality of life. In this review, we discuss current evidences on the role of systemic treatments in BMs management, bone-targeting agents benefits in skeletal-related events prevention and local therapeutic approaches to BM in mRCC. Define prognosis of systemic disease and identify the main goal of treatment are crucial for the selection of the best strategy.

Treatment of pathologic fractures of the proximal femur

BACKGROUND

Metastatic lesions to the proximal femur occur frequently and require special consideration due to the high risk of pathologic fractures. Type of surgery might influence patient survival considering the growing concept of oligometastases. In fact, the use of modular tumor megaprosthesis is increasing in the last decades compared to intramedullary nailing. Aim of this study was to evaluate oncological and functional results of treatment in patients with pathologic or impending fracture of the proximal femur, with patient survival being the primary, complications the secondary, and functional results the tertiary endpoint.

METHODS

Between 2016 and 2017, 40 patients with pathologic fracture (29 cases) or impending fracture according to the Mirels score (11 cases) of the proximal femur, were treated in our Institute and prospectively collected. There were 29 females (72.5%) and 11 males (27.5%), with a mean age at diagnosis of the metastasis of 63.6 years (range 35 to 92 years). Patients were treated due to bone metastases (commonly develop from breast cancer) or hematologic malignancies. Considering number of lesions, 17 patients had less than three bone metastases. Surgical procedures included intramedullary nailing (7 patients), conventional endoprosthesis (4 patients) and modular endoprosthetic replacement (29 patients). Adjuvant treatments included chemotherapy (13 cases), radiation therapy (8 cases) or both (15 cases), and selective arterial embolization (6 pre-op). Oncological results were evaluated considering the survival of patients. Functional results were assessed as pain intensity in VAS score and MSTS score.

RESULTS

The mean follow-up of patients was 10.2 months (range 6-26.3 years). At the latest evaluation, 23 patients were alive with disease, 3 patients were alive without evidence of disease and 14 patients were dead with disease. There was a significant better survival in patients treated with PFR compared to IMN and EPR groups (p = 0.0080). No differences in term of survival were found comparing impending vs actual pathological fracture and oligo vs multiple metastases. After surgery, all patients experienced improvement in quality of life resulting from reduction in pain. Mean MSTS score was 22.4. The overall complications rate was 22.5%. The most frequent complication was dislocation followed by wound dehiscence and deep infections.

CONCLUSION

Modular tumour prosthesis for proximal femur replacement provides good functional outcome, relative low incidence of complications and higher life quality in the medium term. Oncologic results were influenced by type of surgery, biased by the correct indications for resection and nailing. Preoperative general health condition, life expectancy and ambulatory capacity may influence treatment strategy. With the numbers available, the patients with actual pathologic or impending fracture of the proximal femur treated with resection had a significantly higher survival, especially those with metastases from renal carcinoma or multiple myeloma.

Pathologic fractures of the distal femur: Current concepts and treatment options

Pathologic fractures of the distal femur caused by bone metastases are not as common as those in the proximal femur but provide great difficulty to adequately treat. This systematic review shows that insufficient literature exists to draw clinically relevant conclusions for essential questions, such as "what factors indicate an endoprosthetic reconstruction for distal femur pathologic fractures?" Due to paucity of literature in the systematic review, a current concepts review (including treatment flowchart), based on instructional reviews and experience, was also performed.

Trends in the surgical treatment of pathological fractures of the long bones

Aims

The aim of this study was to assess the current trends in the estimation of survival and the preferred forms of treatment of pathological fractures among national and international general and oncological orthopaedic surgeons, and to explore whether improvements in the management of these patients could be identified in this way.

Materials and Methods

All members of the Dutch Orthopaedic Society (DOS) and the European Musculoskeletal Oncology Society (EMSOS) were invited to complete a web-based questionnaire containing 12 cases.

Results

A total of 96 of 948 members of the DOS (10.1%; groups 1 and 2) and 33 of 182 members of the EMSOS (18%; group 3) replied. The estimation of survival was accurate by more than 50% of all three groups, if the expected survival was short (< 3 months) or long (> 12 months). General orthopaedic surgeons preferred using an intramedullary nail for fractures of the humerus and femur, irrespective of the expected survival or the origin of primary tumour or the location of the fracture. Oncological orthopaedic surgeons recommended prosthetic reconstruction in patients with a long expected survival.

Conclusion

Identifying patients who require centralized care, as opposed to those who can be adequately treated in a regional centre, can improve the management of patients with pathological fractures. This differentiation should be based on the expected survival, the type and extent of the tumour, and the location of the fracture. Cite this article: Bone Joint J 2018;100-B:1392–8.

Treating patients with renal cell carcinoma and bone metastases

INTRODUCTION

Bone metastases (BMs) are common and cause morbidity in cancer patients. This review focuses on evidence in BMs from metastatic renal cell carcinoma (mRCC) management and discusses current evidence on the role of systemic treatments in BMs management, bone-targeting agents' benefits in skeletal-related events prevention and local therapeutic approaches to BM in mRCC. Areas covered: A comprehensive review of literature concerning incidence, prognosis, and therapeutic approaches of BMs was performed, focusing on the latest emerging evidence in management of BMs from mRCC. Expert commentary: One-third of mRCC patients present metastatic disease to the bone. BMs impact negatively the prognosis and decrease quality of life. Adequate management of BMs from RCC requires a multimodal evaluation to optimize care and quality of life. Both tyrosine-kinase inhibitors and immunotherapy may be effective in BMs treatment. BMs cause severe complications such as fracture, spinal cord compression, and pain requiring surgery or radiotherapy and several local approaches are available to achieve a local control of the disease. Defining prognosis of systemic disease and identifying the main goal of treatment is crucial for the selection of the best strategy.