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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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Wänman J, Kjartansdóttir S, Wolf O, Sundkvist J, Wennergren D, Mukka S. Age, sex, primary tumor type and site are associated with mortality after pathological fractures: an observational study of 1453 patients from the Swedish Fracture Register. J Orthop Surg Res 2023; 18:150. [PMID: 36859299 PMCID: PMC9976455 DOI: 10.1186/s13018-023-03620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/15/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Pathological fractures are challenging in orthopedic surgery and oncology, with implications for the patient's quality of life, mobility and mortality. The efficacy of oncological treatment on life expectancy for cancer patients has improved, but the metastatic pattern for bone metastases and survival is diverse for different tumor types. This study aimed to evaluate survival in relation to age, sex, primary tumor and site of the pathological fractures. METHODS All pathological fractures due to cancer between 1 September 2014 and 31 December 2021 were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, tumor type, fracture site and mortality were collected. RESULTS A total of 1453 patients with pathological fractures were included (48% women, median age 73, range 18-100 years). Unknown primary tumors were the most common primary site (n = 308). The lower extremities were the most common site of pathological fractures. Lung cancer had the shortest median survival of 78 days (range 54-102), and multiple myeloma had the longest median survival of 432 days (range 232-629). The site at the lower extremity had the shortest (187 days, range 162-212), and the spine had the longest survival (386 days, range 211-561). Age, sex, primary type and site of the pathological fractures were all associated with mortality. INTERPRETATION Age, sex, primary tumor type and site of pathological fractures were associated with survival. Survival time is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival.
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Affiliation(s)
- Johan Wänman
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden.
| | - Sonja Kjartansdóttir
- grid.8761.80000 0000 9919 9582Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Wolf
- grid.8993.b0000 0004 1936 9457Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jonas Sundkvist
- grid.12650.300000 0001 1034 3451Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - David Wennergren
- grid.8761.80000 0000 9919 9582Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sebastian Mukka
- grid.12650.300000 0001 1034 3451Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
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Banskota N, Fang X, Yuan D, Lei S, Zhang W, Duan H. Comparative Study of Proximal Femur Bone Tumor Patients Undergoing Hemiarthroplasty versus Total Hip Arthroplasty: A Meta-Analysis. J Clin Med 2023; 12:jcm12031209. [PMID: 36769857 PMCID: PMC9918064 DOI: 10.3390/jcm12031209] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Hemiarthroplasty and total hip arthroplasty are routinely performed procedures. A comparison of these procedures in tumor patients can be performed based on complications and functional outcomes. To weigh the advantages and disadvantages of both procedures, a comparative study is indeed required to decide which procedure is more beneficial for primary bone tumor patients. The outcomes of proximal femur tumor-resected patients were collected from research reports from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 30 December 2022. Differences between these two operative procedures in primary bone tumors patients were analyzed based on dislocation, infection, local recurrence, MSTS, and HHS. Six articles were included according to the selection criteria with a total of 360 patients. Our results showed that there was a significant difference in our primary outcome as hemiarthroplasty participants encountered less dislocation than those with total hip arthroplasty. Moreover, the secondary outcomes of our study were similar. Proximal femur bone tumors, when resected, tend to produce more complications and decrease functional ability due to extensive tumor extension and soft tissue involvement. The lower dislocation rate in hemiarthroplasty participants emphasizes the importance of preserving the acetabular head in hemiarthroplasty as a key to preventing dislocation.
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Affiliation(s)
| | | | | | | | - Wenli Zhang
- Correspondence: (W.Z.); (H.D.); Tel.: +86-18980601402 (H.D.)
| | - Hong Duan
- Correspondence: (W.Z.); (H.D.); Tel.: +86-18980601402 (H.D.)
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Gonzalez MR, Bryce-Alberti M, Pretell-Mazzini J. Management of Long Bones Metastatic Disease: Concepts That We All Know but Not Always Remember. Orthop Res Rev 2022; 14:393-406. [PMID: 36385751 PMCID: PMC9661996 DOI: 10.2147/orr.s379603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/05/2022] [Indexed: 01/28/2024] Open
Abstract
Bones are the third most common site of metastatic disease. Treatment is rarely curative; rather, it seeks to control disease progression and palliate symptoms. Imaging evaluation of a patient with symptoms of metastatic bone disease should begin with plain X-rays. Further imaging consists of a combination of (PET)-CT scan and bone scintigraphy. We recommend performing a biopsy after imaging workup has been conducted. Metastatic bone disease is managed with a combination of systemic treatment, radiotherapy (RT), and surgery. External beam RT (EBRT) is used for pain control and postoperatively after fracture stabilization. Single-fraction and multiple-fractions schemes are equally effective achieving pain control. Adequate assessment of fracture risk should guide the decision to stabilize an impending fracture. Despite low specificity, plain X-rays are the first tool to determine risk of impending fractures. CT scan offers a higher positive predictive value and can add diagnostic value. Surgical management depends on the patient's characteristics, tumor type, and location of fracture/bone stock. Fixation options include plate and screw fixation, intramedullary (IM) nailing, and endoprostheses. Despite widespread use, the need for prophylactic stabilization of the entire femur should be individually analyzed in each patient due to higher complication rates of long stems.
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Affiliation(s)
- Marcos R Gonzalez
- Facultad de Medicina Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Juan Pretell-Mazzini
- Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, FL, USA
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Bouthors C, Laumonerie P, Crenn V, Prost S, Blondel B, Fuentes S, Court C, Mazel C, Charles YP, Sailhan F, Bonnevialle P. Surgical treatment of bone metastasis from osteophilic cancer. Results in 401 peripheral and spinal locations. Orthop Traumatol Surg Res 2022; 108:103193. [PMID: 34954014 DOI: 10.1016/j.otsr.2021.103193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Peripheral and spinal bone metastases arise mainly from 5 osteophilic cancers: lung, prostate, kidney, breast and thyroid. Few studies combined results for the two types metastatic location (peripheral and spinal). Therefore we performed a multicenter retrospective study of surgically managed peripheral and spinal bone metastases to assess: (1) global function at a minimum 1 year's follow-up and; (2) factors affecting survival. HYPOTHESIS Global function is improved by surgery, with acceptable survival. MATERIAL AND METHOD Between 2015 and 2016, 386 patients were operated on in 11 centers for 401 metastases: 231 peripheral, and 170 spinal. Mean age was 62.6±12.5 years in the 212 female patients (54%) versus 66.4±11.5 years in the 174 males (46%) (p=0.001). Pre- to postoperative comparison was made on pain on VAS (visual analog scale), WHO (World Health Organization) score, Karnofsky score, walking and global upper-limb function. Survival was estimated at 4 years' follow-up. RESULTS The most frequent locations were in the femur (n=146, 36%) and thoracic spine (n=107, 27%). The primary cancer was revealed by the metastasis in 82 patients (21%). There were 55 general complications (14%) and 48 local complications (12%). Twenty-one patients (5.4%) died during the first month. VAS and Karnofsky sores improved: respectively, 6.6±2.3 vs. 3.4±2.1 (p<0.001) and 65±14 vs. 72±20 (p=0.01). Walking, upper-limb function and Frankel grade improved in respectively 49/86 (57%), 19/29 (66%) and 31/84 (37%) patients. Median survival was 13.3 months (95% CI: 10.8-17.1), and was related to the primary (log-rank, p<0.001): lung 6.5 months (95% CI: 5.2-8.9), prostate 11.1 months (95% CI: 5.3-43.6), kidney 12.9 months (95% CI: 8.4-22.6), breast 26.5 months (95% CI: 19.0-34.0), and thyroid 49.0 months (95% CI: 12.2-NA). On multivariate analysis, independent factors for death comprised internal fixation rather than prosthesis (OR=2.20; 95% CI: 1.59-3.04 (p<0.001)), high preoperative ASA score (OR=1.78; 95% CI: 1.40-2.28 (p<0.001)), preoperative chemotherapy (OR=1.26; 95% CI: 1.13-1.41 (p<0.001)) and major visceral metastasis (lung, brain, liver) (OR=11.80; 95% CI: 5.21-26.71 (p<0.001)). CONCLUSION Although function improved only slightly, pain relief and maintained autonomy suggest enhanced comfort in life, confirming the study hypothesis only partially. Factors affecting survival and clinical results argue for preventive surgery when possible, before general health status deteriorates. LEVEL OF EVIDENCE IV; retrospective observational.
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Affiliation(s)
- Charlie Bouthors
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France.
| | - Pierre Laumonerie
- Département de Chirurgie Orthopédique, Hôpital Pellegrin, Place Amélie Raba Léon, 33000 Bordeaux, France
| | - Vincent Crenn
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France
| | - Solène Prost
- Service de Neurochirurgie, Hôpital de la Timone, 264, Rue Saint Pierre, 13005 Marseille, France
| | - Benjamin Blondel
- Service de Neurochirurgie, Hôpital de la Timone, 264, Rue Saint Pierre, 13005 Marseille, France
| | - Stéphane Fuentes
- Service de Neurochirurgie, Hôpital de la Timone, 264, Rue Saint Pierre, 13005 Marseille, France
| | - Charles Court
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Christian Mazel
- Département de Chirurgie Orthopédique, Institut Montsouris, 42, Boulevard Jourdan, 75014 Paris, France
| | - Yann-Philippe Charles
- Service de Chirurgie du Rachis, Hôpital de Hautepierre, Avenue Molière, 67200 Strasbourg, France
| | - Fréderic Sailhan
- Service d'Orthopédie, Hôpital Cochin, 27, Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Paul Bonnevialle
- Département Universitaire d'Orthopédie Traumatologie, Hôpital Pierre Paul Riquet, Place Baylac, 31052 Toulouse Cedex, France
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- Société Française de Chirurgie Orthopédique et Traumatologique, SOFCOT, 56, Rue Boissonade, 75014 Paris, France
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Surgical Treatment of Metastatic Bone Disease in the Appendicular Skeleton: A Population-Based Study. Cancers (Basel) 2022; 14:cancers14051258. [PMID: 35267566 PMCID: PMC8909164 DOI: 10.3390/cancers14051258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Population-based studies of patients with bone metastases in the appendicular skeleton (aBM) requiring surgery for complete or impending fracture are rare. In this epidemiologically-based observational study we created a large population-based cohort of patients treated for aBM, aiming to: (1) monitor possible time-related changes of the incidence of surgical treatment of aBM-lesions, (2) examine differences in the population and care of patients treated at different treatment centers and (3) examine if findings from a previous pilot study regarding absence of a suitable biopsy of the lesions representing debut of cancer or a relapse has improved the awareness of aBM and hereby increased the focus on regular tumor biopsies and follow-up imaging of cancer patients. Methods: We examined a population-based cohort consisting of all patients treated for aBM 2014−2019. Procedures were performed at five secondary surgical centers (SSC) or one tertiary referral Musculoskeletal Tumor Center (MTC). Patients were followed until end of study (30 September 2021) or death. No patients were lost to follow-up. Results: Four-hundred-fifty-seven patients (493 primary aBM-lesions, 482 procedures) were included. Annual incidence of aBM-surgery was 46 aBM-lesions/million. MTC-patients had a significant better preoperative status than SSC-patients considering factors known for survival. Patients with complete fracture experienced longer surgical delay when treated at MTC compared to SSC: 4 (1−9) and 1 (1−3) days (p < 0.001), respectively. Overall survival for the entire cohort was 37% and 11% at 1 and 5 years (MTC and SSC 1 and 5 year respectively: 44% and 15% vs. 29% and 5%, p < 0.001). In patients with debut or relapse of cancer, 8% and 9% had insufficient biopsies, and 21% and 12% had no biopsy, respectively. Comparison showed no change over time. Conclusions: The current study highlights the low awareness on treating aBM at SSC and emphasizes the importance of caution in interpretation of studies not representing an entire population, thus introducing selection bias.
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Mou H, Wang Z, Zhang W, Li G, Zhou H, Yinwang E, Wang F, Sun H, Xue Y, Wang Z, Chen T, Chai X, Qu H, Lin P, Teng W, Li B, Ye Z. Clinical Features and Serological Markers Risk Model Predicts Overall Survival in Patients Undergoing Breast Cancer and Bone Metastasis Surgeries. Front Oncol 2021; 11:693689. [PMID: 34604031 PMCID: PMC8484887 DOI: 10.3389/fonc.2021.693689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background Surgical therapy of breast cancer and bone metastasis can effectively improve the prognosis of breast cancer. However, after the first operation, the relationship between preoperative indicators and outcomes in patients who underwent metastatic bone surgery remained to be studied. Purpose 1. Recognize clinical and laboratory prognosis factors available to clinical doctors before the operation for bone metastatic breast cancer patients. 2. Develop a risk prediction model for 3-year postoperative survival in patients with breast cancer bone metastasis. Methods From 2014 to 2020, patients who suffered from breast cancer bone metastasis and received therapeutic procedures in our institution were included for analyses (n=145). For patients who underwent both breast cancer radical surgery and bone metastasis surgery, comprehensive datasets of the parameters of interest (clinical features, laboratory factors, and patient prognoses) were collected (n=69). We performed Multivariate Cox regression to identify factors that were associated with postoperative outcome. 3-year survival prediction model and nomograms were established by 100 bootstrapping. Its benefit was evaluated by calibration plot, C-index, and decision curve analysis. The Surveillance, Epidemiology, and End Results database was also used for external validation. Results Radiotherapy for primary cancer, pathological type of metastatic breast cancer, lymph node metastasis, elevated serum alkaline phosphatase, lactate dehydrogenase were associated with postoperative prognosis. Pathological types of metastatic breast cancer, multiple bone metastasis, organ metastases, and elevated serum lactate dehydrogenase were associated with 3-year survival. Then those significant variables and serum alkaline phosphatase counts were integrated to construct nomograms for 3-year survival. The C-statistic of the established predictive model was 0.83. The calibration plot presents a graphical representation of calibration. In the decision curve analysis, the benefits are higher than those of the extreme curve. The receiver operating characteristic of the external validation of the model was 0.82, indicating a favored fitting degree of the two models. Conclusion Our study suggests that several clinical features and serological markers can predict the overall survival among the patients who are about to receive bone metastasis surgery after breast cancer surgery. The model can guide the preoperative evaluation and clinical decision-making for patients. Level of evidence Level III, prognostic study.
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Affiliation(s)
- Haochen Mou
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zhan Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Wenkan Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Guoqi Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hao Zhou
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Eloy Yinwang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Fangqian Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hangxiang Sun
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Yucheng Xue
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zenan Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Tao Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Xupeng Chai
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hao Qu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Peng Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Wangsiyuan Teng
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Binghao Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zhaoming Ye
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
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Lavignac P, Prieur J, Fabre T, Descamps J, Niglis L, Carlier C, Bouthors C, Baron-Trocellier T, Sailhan F, Bonnevialle P. Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases. Orthop Traumatol Surg Res 2020; 106:1025-1032. [PMID: 32763011 DOI: 10.1016/j.otsr.2020.03.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/07/2020] [Accepted: 03/24/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival. HYPOTHESIS The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies. METHODS Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)]. RESULTS Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer. CONCLUSION Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined. LEVEL OF EVIDENCE IV, retrospective study without control group.
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Affiliation(s)
- Pierre Lavignac
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon 33076 Bordeaux cedex, France
| | - Jules Prieur
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon 33076 Bordeaux cedex, France
| | - Thierry Fabre
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon 33076 Bordeaux cedex, France.
| | - Jules Descamps
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Lucas Niglis
- Service d'orthopédie traumatologie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - Christophe Carlier
- Clinique chirurgicale orthopédique et traumatologique, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - Charlie Bouthors
- Service de chirurgie orthopédique et traumatologie et du rachis, hôpital Kremlin-Bicêtre, 78, rue du Général-Leclerc 94270 Le Kremlin-Bicêtre, France
| | - Thomas Baron-Trocellier
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse Cedex, France
| | - Fréderic Sailhan
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Clinique Arago, groupe Almaviva, 187, rue Raymond-Losserand, 75014 Paris, France
| | - Paul Bonnevialle
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse Cedex, France
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- SOFCOT, 56, rue Boissonade, 75014 Paris, France
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Surgical treatment of tibial metastases: Retrospective, multicenter, observational study of 25 patients. Orthop Traumatol Surg Res 2020; 106:1039-1045. [PMID: 31624032 DOI: 10.1016/j.otsr.2019.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/02/2019] [Accepted: 07/15/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition. HYPOTHESIS We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature. MATERIAL AND METHODS The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient. RESULTS Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment. CONCLUSION Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort. LEVEL OF EVIDENCE IV, retrospective study.
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Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis. Orthop Traumatol Surg Res 2020; 106:1047-1057. [PMID: 32768275 DOI: 10.1016/j.otsr.2020.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 02/03/2023]
Abstract
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.
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Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series. Orthop Traumatol Surg Res 2020; 106:997-1003. [PMID: 32273249 DOI: 10.1016/j.otsr.2019.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 02/03/2023]
Abstract
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.
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Thirty-day Postoperative Complications After Surgery For Metastatic Long Bone Disease Are Associated With Higher Mortality at 1 Year. Clin Orthop Relat Res 2020; 478:306-318. [PMID: 31714410 PMCID: PMC7438145 DOI: 10.1097/corr.0000000000001036] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of surgical treatment of a metastasis of the extremities may be offset by drawbacks such as potential postoperative complications. For this group of patients, the primary goal of surgery is to improve quality of life in a palliative setting. A better comprehension of factors associated with complications and the impact of postoperative complications on mortality may prevent negative outcomes and help surgeons in surgical decision-making. QUESTIONS/PURPOSES (1) What is the risk of 30-day postoperative complications after surgical treatment of osseous metastatic disease of the extremities? (2) What predisposing factors are associated with a higher risk of 30-day complications? (3) Are minor and major 30-day complications associated with higher mortality at 1 year? METHODS Between 1999 and 2016, 1090 patients with osseous metastatic disease of the long bones treated surgically at our institution were retrospectively included in the study. Surgery included intramedullary nailing (58%), endoprosthetic reconstruction (22%), plate-screw fixation (14%), dynamic hip screw fixation (2%), and combined approaches (4%). Surgery was performed if patients were deemed healthy enough to proceed to surgery and wished to undergo surgery. All data were retrieved by manually reviewing patients' records. The overall frequency of complications, which were defined using the Clavien-Dindo classification system, was calculated. We did not include Grade I complications as postoperative complications and complications were divided into minor (Grade II) and major (Grades III-V) complications. A multivariate logistic regression analysis was used to identify factors associated with 30-day postoperative complications. A Cox regression analysis was used to assess the association between postoperative complications and overall survival. RESULTS Overall, 31% of the patients (333 of 1090) had a postoperative complication within 30 days. The following factors were independently associated with 30-day postoperative complications: rapidly growing primary tumors classified according to the modified Katagiri classification (odds ratio 1.6; 95% confidence interval, 1.1-2.2; p = 0.011), multiple bone metastases (OR 1.6; 95% CI, 1.1-2.3; p = 0.008), pathologic fracture (OR 1.5; 95% CI, 1.1-2.0; p = 0.010), lower-extremity location (OR 2.2; 95% CI, 1.6-3.2; p < 0.001), hypoalbuminemia (OR 1.7; 95% CI, 1.2-2.4; p = 0.002), hyponatremia (OR 1.5; 95% CI, 1.0-2.2; p = 0.044), and elevated white blood cell count (OR 1.6; 95% CI, 1.1-2.4; p = 0.007). Minor and major postoperative complications within 30 days after surgery were both associated with greater 1-year mortality (hazard ratio 1.6; 95% CI, 1.3-1.8; p < 0.001 and HR 3.4; 95% CI, 2.8-4.2, respectively; p < 0.001). CONCLUSION Patients with metastatic disease in the long bones are vulnerable to postoperative adverse events. When selecting patients for surgery, surgeons should carefully assess a patient's cancer status, and several preoperative laboratory values should be part of the standard work-up before surgery. Furthermore, 30-day postoperative complications decrease survival within 1 year after surgery. Therefore, patients at a high risk of having postoperative complications are less likely to profit from surgery and should be considered for nonoperative treatment or be monitored closely after surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Leto G. Current status and future directions in the treatment of bone metastases from breast cancer. Clin Exp Pharmacol Physiol 2019; 46:968-971. [DOI: 10.1111/1440-1681.13139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/02/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Gaetano Leto
- Laboratory of Experimental Pharmacology Department of Health Promotion Sciences School of Medicine University of Palermo 90127 Palermo Italy
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14
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Revision rate of reconstructions in surgically treated diaphyseal metastases of bone. Eur J Surg Oncol 2019; 45:2424-2430. [PMID: 31133372 DOI: 10.1016/j.ejso.2019.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/05/2019] [Accepted: 05/19/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Abstract
Skeletal metastases exert a profound effect on patients and society, and will be encountered by most orthopedic surgeons. Once a primary malignancy is diagnosed, multidisciplinary management should focus on maximizing the quality of life while minimizing disease- and treatment-related morbidity. This may be best achieved with discerning attention to the unique characteristics of primary cancer types, including pathologic fracture healing rates, longevity, and efficacy of adjuvant therapies. Some lesions may respond well to nonsurgical measures, whereas others may require surgery. A single surgical intervention should allow immediate unrestricted activity and outlive the patient. In certain scenarios, a therapeutic benefit may be provided by excision with a curative intent. In these scenarios, or when endoprosthetic reconstruction is necessary, patients may be best referred to an orthopedic oncologist.
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Prognostic and risk factors in patients with metastatic bone disease of an upper extremity. J Bone Oncol 2018; 13:71-75. [PMID: 30591860 PMCID: PMC6303409 DOI: 10.1016/j.jbo.2018.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/15/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022] Open
Abstract
Background The aim of this study was to evaluate survival of metastatic bone disease of an upper extremity, and to identify the prognostic factors that influence survival. Methods Patients with metastatic bone disease of an upper extremity between 2008 and 2015 were reviewed from the database of a tertiary university hospital. Results Of 102 patients, 48 males and 54 females with a median age of 61 (range, 28–82 years), the humerus (64.7%), clavicle (13.7%), and scapula (12.7%) were the common sites for bone metastasis of an upper extremity. Fifty-nine (57.8%) presented with pathologic fracture. No history of cancer was found in 76.5% of patients. The mean onset of metastatic bone disease after the first diagnosis of primary cancer was 4.74 ± 14.07 months (range, 0–84 months). Lung (31.4%) was the most common primary cancer followed by liver (14.7%), breast (12.7%), thyroid (7.8%), and renal (3.9%). Eighty-two cases (80.39%) died from the disease such that the median survival was 4.08 months (95% CI 2.57–6.17). The significant risk factors were the type of primary tumor (P < 0.001, HR = 4.44; 95% CI, 1.99–9.90) and ECOG performance status (P = 0.021, HR = 2.11, 95% CI 1.12–3.99). Conclusions Patients with metastatic bone disease of an upper extremity have a limited life expectancy. The type of primary tumor and ECOG performance status were the important prognostic factors that influenced overall survival. Our data help in the management of patients, families, and doctors, so as to avoid over- or under-treatment.
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Hovgaard TB, Horstmann PF, Petersen MM, Sørensen MS. Patient survival following joint replacement due to metastatic bone disease - comparison of overall patient and prostheses survival between cohorts treated in two different time-periods. Acta Oncol 2018; 57:839-848. [PMID: 29293034 DOI: 10.1080/0284186x.2017.1420910] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Improvements in medical treatment for cancer have increased survival of cancer patients. We hypothesize that improvement in cancer treatment is reflected in increased survival after surgical intervention for metastatic bone disease (MBD) and that subsequent revision surgery does not pose a risk for survival. METHODS We identified a retrospective consecutive cohort who received bone resection and reconstruction (BRR) with implants (including total joint replacements (with or without wide resection) or bone reconstruction with an intercalary spacer or revisions procedures for failed implants with BBR technique) due to MBD from 2003 to 2008 (early cohort) and 2009 to 2013 (late cohort) at a tertiary referral center. We registered epidemiological data, type of implant (primary or a revision implant), patient survival (Kaplan-Meier), implant survival (competing risk analysis) and complications to surgery. RESULTS Three hundred and eleven procedures were performed in 291 patients (289 primary BRR (270 patients, early cohort n = 130 late cohort n = 140) and 22 revision BRR (21 patients)). Overall survival was 44% (95% confidence intervals (95% CI): 39-50) and 32% (95% CI: 27-38) after 1 and 2 years. No difference in survival between the early and late cohort was found (p = .458), or between primary and revision BRR (p = .465). Time from diagnosis of cancer to surgery was shorter in the early cohort (p < .001). The cumulative incidence of failure of implant was 2% (95% CI: 0-3%) at 1 year and 3% (95% CI: 1-6%) at 2 years. One year cumulative implant failure for revision implants was 5% (95% CI: 0-13%) at 1 and 2 years. The risk of failure was not statistical significant between primary and revision implant (p = .293) in competing risk analysis. DISCUSSION We were not able to identify an increased survival after surgery for MBD over time, however, we found an increased interval from diagnosis to surgery for MBD. This study suggests that revision surgery for MBD does not pose a risk for survival.
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Affiliation(s)
- Thea Bechmann Hovgaard
- Department of Orthopedic Surgery, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Frederik Horstmann
- Department of Orthopedic Surgery, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael Mørk Petersen
- Department of Orthopedic Surgery, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michala Skovlund Sørensen
- Department of Orthopedic Surgery, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Donnelly TD, Woolf DK, Farrar NG. Management of metastatic bone disease in the appendicular skeleton. ACTA ACUST UNITED AC 2018. [DOI: 10.1302/2048-0105.71.360580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- T. D. Donnelly
- Specialty Registrar, Trauma and Orthopaedics, Mid-Cheshire Hospitals NHS Foundation Trust, Crewe, UK
| | - D. K. Woolf
- Consultant Clinical Oncologist, The Christie NHS Foundation Trust, Manchester, UK and The University of Manchester, Manchester, UK
| | - N. G. Farrar
- Consultant Orthopaedics Surgeon, Mid-Cheshire Hospitals NHS Foundation Trust, Crewe, UK
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Szendrői M, Antal I, Szendrői A, Lazáry Á, Varga PP. Diagnostic algorithm, prognostic factors and surgical treatment of metastatic cancer diseases of the long bones and spine. EFORT Open Rev 2017; 2:372-381. [PMID: 29071122 PMCID: PMC5644421 DOI: 10.1302/2058-5241.2.170006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Oncological management of skeletal metastases has changed dramatically in the last few decades. A significant number of patients survive for many years with their metastases. Surgeons are more active and the technical repertoire is broader, from plates to intramedullary devices to (tumour) endoprostheses. The philosophy of treatment should be different in the case of a trauma-related fracture and a pathological fracture. A proper algorithm for establishing a diagnosis and evaluation of prognostic factors helps in planning the surgical intervention. The aim of palliative surgery is usually to eliminate pain and to allow the patient to regain his/her mobility as well as to improve the quality of life through minimally invasive techniques using life-long durable devices. In a selected group of patients with an oncologically controlled primary tumour site and a solitary bone metastasis with positive prognostic factors, which meet the criteria for radical excision (approximately 10% to 15% of the cases), a promising three to five years of survival may be achieved, especially in cases of metastases from breast and kidney cancer. Spinal metastases require meticulous evaluation because decisions on treatment mostly depend on the tumour type, segmental stability, the patient’s symptoms and general state of health. Advanced radiotherapy combined with minimally invasive surgical techniques (minimally invasive stabilisation and separation surgery) provides durable local control with a low complication rate in a number of patients.
Cite this article: EFORT Open Rev 2017;2:372-381.
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Affiliation(s)
- Miklós Szendrői
- Department of Orthopaedics, Semmelweis University, H-1082 Budapest, Üllői 78/b, Hungary
| | - Imre Antal
- Department of Orthopaedics, Semmelweis University, H-1082 Budapest, Üllői 78/b, Hungary
| | - Attila Szendrői
- Department of Urology, Semmelweis University, H-1082 Budapest, Üllői 78/b, Hungary
| | - Áron Lazáry
- National Center for Spinal Disorders, H-1126 Budapest, Királyhágó u.1., Hungary
| | - Péter Pál Varga
- National Center for Spinal Disorders, H-1126 Budapest, Királyhágó u.1., Hungary
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Kirkinis MN, Lyne CJ, Wilson MD, Choong PFM. Metastatic bone disease: A review of survival, prognostic factors and outcomes following surgical treatment of the appendicular skeleton. Eur J Surg Oncol 2016; 42:1787-1797. [PMID: 27499111 DOI: 10.1016/j.ejso.2016.03.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/27/2016] [Accepted: 03/31/2016] [Indexed: 12/30/2022] Open
Abstract
Survival data and prognostic factors may help to provide insight when deciding on the appropriate orthopaedic treatment for patients presenting with metastatic bone disease. This review was conducted to look at the outcomes following orthopaedic surgery for metastatic lesions in the extremities. The literature was identified through the Medline and Embase database and further refined via a set of inclusion and exclusion criteria. Overall, patients presenting with metastatic bone disease from renal cell cancer or breast cancer had the longest survival rate. Important factors found to predict prognosis was the presence of visceral metastasis, multiple metastases, pathological fracture and the type of primary tumour involved. These prognostic factors may help to direct future inquiry into metastatic bone disease and help determine the type of surgery to use in a metastatic setting in order to avoid complications and unnecessary revisions as well as provide durability.
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MESH Headings
- Bone Neoplasms/complications
- Bone Neoplasms/mortality
- Bone Neoplasms/secondary
- Bone Neoplasms/surgery
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Carcinoma/complications
- Carcinoma/mortality
- Carcinoma/secondary
- Carcinoma/surgery
- Carcinoma, Hepatocellular/complications
- Carcinoma, Hepatocellular/mortality
- Carcinoma, Hepatocellular/secondary
- Carcinoma, Hepatocellular/surgery
- Carcinoma, Renal Cell/complications
- Carcinoma, Renal Cell/mortality
- Carcinoma, Renal Cell/secondary
- Carcinoma, Renal Cell/surgery
- Extremities
- Female
- Fractures, Spontaneous/etiology
- Fractures, Spontaneous/prevention & control
- Fractures, Spontaneous/surgery
- Humans
- Kidney Neoplasms/mortality
- Kidney Neoplasms/pathology
- Liver Neoplasms/mortality
- Liver Neoplasms/pathology
- Lung Neoplasms/mortality
- Lung Neoplasms/pathology
- Male
- Mortality
- Orthopedic Procedures/methods
- Prognosis
- Prostatic Neoplasms/mortality
- Prostatic Neoplasms/pathology
- Survival Rate
- Thyroid Neoplasms/mortality
- Thyroid Neoplasms/pathology
- Treatment Outcome
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Affiliation(s)
- M N Kirkinis
- School of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne Medical School, Level 2 West, Medical Building (181), Victoria 3010, Australia
| | - C J Lyne
- School of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne Medical School, Level 2 West, Medical Building (181), Victoria 3010, Australia
| | - M D Wilson
- School of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne Medical School, Level 2 West, Medical Building (181), Victoria 3010, Australia
| | - P F M Choong
- School of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne Medical School, Level 2 West, Medical Building (181), Victoria 3010, Australia; University of Melbourne, Department of Surgery, St. Vincent's Hospital Melbourne, Level 2, Clinical Sciences Building, 29 Regent Street, Fitzroy, Victoria 3065, Australia; Department of Orthopaedics, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia; Bone and Soft Tissue Tumour Unit, Peter MacCallum Cancer Centre, 2 St Andrews Pl, East Melbourne, Victoria 3002, Australia.
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Kirkinis MN, Spelman T, May D, Choong PFM. Metastatic bone disease of the pelvis and extremities: rationalizing orthopaedic treatment. ANZ J Surg 2016; 87:940-944. [PMID: 27091575 DOI: 10.1111/ans.13615] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 03/20/2016] [Accepted: 03/22/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Choosing the appropriate treatment for patients presenting with impending or pathological fractures is difficult and understanding the prognosis based on certain characteristics can help inform the decision to treat and construct to use in a palliative setting. We retrospectively analysed patients presenting with metastatic bone disease in the extremities and pelvis. METHODS Patients presenting with metastatic bone disease to the extremities or pelvis who underwent orthopaedic treatment from 1996 to 2012 were identified. Survival rates were calculated using life table analysis. Univariate and multivariate analysis was achieved with Cox proportional hazards regression. RESULTS There were a total of 462 patients. An overall 1-, 2- and 5-year survival rate of 45%, 29% and 13% was identified, respectively. In the multivariate analysis, preoperative haemoglobin was found to be an independent predictor of better survival while lung histotype, age, pathological fracture and previous combined therapy were negative predictors of survival. Patients undergoing prosthetic replacement had a significantly longer period of hospitalization in comparison to those undergoing internal fixation. CONCLUSION This study has contributed to our understanding of the survival rate and survival prognostication for patients presenting for orthopaedic treatment of metastatic bone disease.
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Affiliation(s)
- Maria N Kirkinis
- School of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tim Spelman
- The University of Melbourne Department of Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Deborah May
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Peter F M Choong
- School of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Ratasvuori M, Lassila R, Laitinen M. Venous thromboembolism after surgical treatment of non-spinal skeletal metastases - An underdiagnosed complication. Thromb Res 2016; 141:124-8. [PMID: 27017349 DOI: 10.1016/j.thromres.2016.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 02/10/2016] [Accepted: 03/10/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND AIM Venous thromboembolism (VTE) is a severe complication associated both with major orthopaedic surgery and cancer. However, survival and postoperative complications of skeletal metastases despite their thrombogenic potential, have received little attention in both the clinical management and research setting. This single-centre observational cohort study aimed to evaluate the incidence and impact of VTE in association with cancer surgery targeted to the management of fractures secondary to skeletal metastases. METHODS Data were collected retrospectively from the medical database. We included consecutive 306 patients operated for 343 non-spinal skeletal metastases during a 15-year period (1999-2014). The incidence of VTE and its risk factors were assessed using binary logistic regression analysis. Kaplan-Meier and Cox regression analyses were used to evaluate variables affecting survival. RESULTS The rate of symptomatic VTE was 10% (30/306) during the 3-month postoperative period, while 79% received thromboprophylaxis. Fatal pulmonary embolism (PE) rate was high, 3.3% (10/306) after surgery. Intraoperative oxygen saturation drop, pulmonary metastases and intramedullary nailing were independent risk factors for VTE. Indicators of decreased survival were lung cancer, intramedullary nailing, multiple skeletal and pulmonary metastases, anaemia, leukocytosis, and PE. CONCLUSION Relationship between fractures secondary to skeletal metastases and VTE needs further clinical attention. Whether the survival of patients with fractures secondary to skeletal metastases can be improved by targeted thromboprophylactic means should be studied further.
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Affiliation(s)
- Maire Ratasvuori
- Department of Orthopaedics, Unit of Musculoskeletal Surgery, Tampere University Hospital, 33521 Tampere, Finland; Department of Hand Surgery, Helsinki University Central Hospital, 00260 Helsinki, Finland
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, Cancer Center HUSLAB and Clinical Chemistry, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland
| | - Minna Laitinen
- Department of Orthopaedics, Unit of Musculoskeletal Surgery, Tampere University Hospital, 33521 Tampere, Finland; Coxa Hospital for Joint Replacement, 33520 Tampere, Finland.
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Stevenson JD, McNair M, Cribb GL, Cool WP. Prognostic factors for patients with skeletal metastases from carcinoma of the breast. Bone Joint J 2016; 98-B:266-70. [DOI: 10.1302/0301-620x.98b2.36185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Aims Surgical intervention in patients with bone metastases from breast cancer is dependent on the estimated survival of the patient. The purpose of this paper was to identify factors that would predict survival so that specific decisions could be made in terms of surgical (or non-surgical) management. Methods The records of 113 consecutive patients (112 women) with metastatic breast cancer were analysed for clinical, radiological, serological and surgical outcomes. Their median age was 61 years (interquartile range 29 to 90) and the median duration of follow-up was 1.6 years (standard deviation (sd) 1.9, 95% confidence interval (CI) 0 to 5.9). The cumulative one- and five-year rates of survival were 68% and 16% (95% Cl 60 to 77 and 95% CI 10 to 26, respectively). Results Linear discriminant analysis identified a ‘quadruple A’ predictor of survival by reclassifying the sum of the albumin, adjusted calcium, alkaline phosphatase and age covariates each multiplied by a determined factor. The accuracy of this ‘quadruple A’ predictor was 90% with a sensitivity of 100% and a specificity of 88%. A receiver operating characteristic (ROC) curve revealed an area under the curve of 79%. Survival analysis for this ‘quadruple A’ predictor (< = one or > one year survival) was statistically significant using the log rank test (p = 0.0004) and Cox proportional hazard (p = 0.001). Multivariate analysis showed the 'quadruple A' predictor to be the only independent predictor of survival (p = 0.01). Discussion The 'quadruple A' predictor, together with other positive predictors of survival, can be used by oncologists, orthopaedic and breast surgeons to estimate survival and therefore guide management. Cite this article: Bone Joint J 2016;98-B:266–70.
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Affiliation(s)
- J. D. Stevenson
- Robert Jones and Agnes Hunt Orthopaedic
Hospital, Oswestry, Shropshire, SY10
7AG, UK
| | - M. McNair
- Robert Jones and Agnes Hunt Orthopaedic
Hospital, Oswestry, Shropshire, SY10
7AG, UK
| | - G. L. Cribb
- Robert Jones and Agnes Hunt Orthopaedic
Hospital, Oswestry, Shropshire, SY10
7AG, UK
| | - W. P. Cool
- Robert Jones and Agnes Hunt Orthopaedic
Hospital, Oswestry, Shropshire, SY10
7AG, UK
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Abstract
INTRODUCTION The concept of impending fracture has been developed to help address this difficult skeletal-related problem. There is no consensus on the subject in the literature and a specific definition of impending fracture has not been outlined. DISCUSSION There is disagreement in the literature on the best criteria for the diagnosis of impending fracture. A method of discrimination for patients who need preventative treatment for a metastatic lesion has not yet been established. CONCLUSIONS Current score systems consider variables like size, location and treatment response and are easy to remember. However, these score systems have never been evaluated prospectively and rigorously, their sensitivity is low and they do not take into account potentially relevant factors that can influence patient prognosis. A consistent tool to evaluate impending fractures would be of great value to guide the treatment of metastatic bone disease.
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Affiliation(s)
- Andrea Piccioli
- Orthopedics Oncology, "Palazzo Baleani", Teaching Hospital Policlinico Umberto I, Rome, Italy
| | - Maria Silvia Spinelli
- Department of Orthopaedic Oncology, Agostino Gemelli Hospital, Catholic University of Rome, Largo Francesco Vito 1, Rome, Italy.
| | - Giulio Maccauro
- Department of Orthopaedic Oncology, Agostino Gemelli Hospital, Catholic University of Rome, Largo Francesco Vito 1, Rome, Italy
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