Solitary Metastases: Illusion Versus Reality

From molecular mechanisms of prostate cancer to translational applications: based on multi-omics fusion analysis and intelligent medicine

Prostate cancer is the most common cancer in men worldwide and has a high mortality rate. The complex and heterogeneous development of prostate cancer has become a core obstacle in the treatment of prostate cancer. Simultaneously, the issues of overtreatment in early-stage diagnosis, oligometastasis and dormant tumor recognition, as well as personalized drug utilization, are also specific concerns that require attention in the clinical management of prostate cancer. Some typical genetic mutations have been proved to be associated with prostate cancer's initiation and progression. However, single-omic studies usually are not able to explain the causal relationship between molecular alterations and clinical phenotypes. Exploration from a systems genetics perspective is also lacking in this field, that is, the impact of gene network, the environmental factors, and even lifestyle behaviors on disease progression. At the meantime, current trend emphasizes the utilization of artificial intelligence (AI) and machine learning techniques to process extensive multidimensional data, including multi-omics. These technologies unveil the potential patterns, correlations, and insights related to diseases, thereby aiding the interpretable clinical decision making and applications, namely intelligent medicine. Therefore, there is a pressing need to integrate multidimensional data for identification of molecular subtypes, prediction of cancer progression and aggressiveness, along with perosonalized treatment performing. In this review, we systematically elaborated the landscape from molecular mechanism discovery of prostate cancer to clinical translational applications. We discussed the molecular profiles and clinical manifestations of prostate cancer heterogeneity, the identification of different states of prostate cancer, as well as corresponding precision medicine practices. Taking multi-omics fusion, systems genetics, and intelligence medicine as the main perspectives, the current research results and knowledge-driven research path of prostate cancer were summarized.

Research protocol to identify progression and death amongst patients with metastatic hormone-sensitive prostate cancer treated with available treatments: PIONEER IMI's "big data for better outcomes" program

Androgen deprivation therapy-based with or without first-generation anti-androgens, was the standard of care for patients with metastatic hormone-sensitive prostate cancer (mHSPC) for decades. However, the development of docetaxel chemotherapy and new androgen receptor-targeted agents, abiraterone acetate and prednisolone, apalutamide , enzalutamide and darolutamide (in combination with docetaxel chemotherapy) has proven that combination of treatments is more effective. Recently, intensification therapy, so-called "triplets", have emerged in the armamentarium of mHSPC treatment. Metastatic disease is a clinical state that remains poorly understood. The optimal diagnostic and management of patients with mHSPC are changing thanks to the development of new imaging techniques and therapies. The primary objective of this study is to develop and validate a predictive model for the occurrence of symptomatic progression, initiation of new treatments and death amongst patients with mHSPC treated with one of the approved treatment plans, on characteristics present at admission.

Where Do We Stand in the Management of Oligometastatic Prostate Cancer? A Comprehensive Review

Simple Summary

Oligometastatic prostate cancer is an intermediate stage between localised and metastatic disease. Today, there are many advances in the diagnosis of this stage of the disease, with the appearance of new imaging techniques and treatments, thanks to the development of new modalities, both local and systemic therapies, the emergence of personalised medicine, and theragnostics.

Abstract

Oligometastatic prostate cancer (OMPC) is an intermediate state between localised disease and widespread metastases that includes a spectrum of disease biology and clinical behaviours. This narrative review will cover the current OMPC scenario. We conducted comprehensive English language literature research for original and review articles using the Medline database and grey literature through December 2021. OMPC is a unique clinical state with inherently more indolent tumour biology susceptible to multidisciplinary treatment (MDT). With the development of new imaging techniques, patients with OMPC are likely to be identified at an earlier stage, and the paradigm for treatment is shifting towards a more aggressive approach to treating potentially curable patients. Multimodal management is necessary to improve patient outcomes due to the combination of available therapies, such as local therapy of primary tumour, metastasis directed therapy or systemic therapy, to reduce tumour load and prevent further disease progression. Additional prospective data are needed to select patients most likely to benefit from a given therapeutic approach.

MiR-30a and miR-200c differentiate cholangiocarcinomas from gastrointestinal cancer liver metastases

Prior studies have demonstrated the utility of microRNA assays for predicting some cancer tissue origins, but these assays need to be further optimized for predicting the tissue origins of adenocarcinomas of the liver. We performed microRNA profiling on 195 frozen primary tumor samples using 14 types of tumors that were either adenocarcinomas or differentiated from adenocarcinomas. The 1-nearest neighbor method predicted tissue-of-origin in 33 samples of a test set, with an accuracy of 93.9% at feature selection p values ranging from 10-4 to 10-10. According to binary decision tree analyses, the overexpression of miR-30a and the underexpression of miR-200 family members (miR-200c and miR-141) differentiated intrahepatic cholangiocarcinomas from extrahepatic adenocarcinomas. When binary decision tree analyses were performed using the test set, the prediction accuracy was 84.8%. The overexpression of miR-30a and the reduced expressions of miR-200c, miR-141, and miR-425 could distinguish intrahepatic cholangiocarcinomas from liver metastases from the gastrointestinal tract.

Clinical value of dual-phase F-18 sodium fluoride PET/CT for diagnosing bone metastasis in cancer patients with solitary bone lesion

Background

The present study aimed to investigate whether dual-phase F-18 sodium-fluoride (NaF) positron emission tomography/computed tomography (PET/CT) could improve the diagnostic accuracy of detecting bone metastasis in cancer patients with a solitary bone lesion compared to conventional F-18 NaF PET/CT.

Methods

We retrospectively enrolled 113 cancer patients who underwent dual-phase F-18 NaF PET/CT for the differential diagnosis of a solitary bone lesion seen on bone scintigraphy. According to the dual-phase PET/CT protocol, an early-phase scan was acquired immediately after radiotracer injection and a conventional F-18 NaF PET/CT scan was performed. The diagnostic abilities of the visual analysis of conventional and dual-phase PET/CT scans and two quantitative parameters (lesion-to-blood pool uptake ratio on early-phase scan and lesion-to-bone uptake ratio on conventional scan) for detecting bone metastasis were compared. The final diagnosis of bone metastasis was made by histopathological confirmation or follow-up imaging studies.

Results

A metastatic bone lesion was diagnosed in 28 patients (24.8%). The sensitivity, specificity, and accuracy were 100.0%, 70.6%, and 77.9%, respectively, for visual analysis of conventional F-18 NaF PET/CT, 92.9%, 42.4%, 54.9%, respectively, for lesion-to-bone uptake ratio, 96.4%, 88.2%, and 90.3%, respectively, for visual analysis of dual-phase PET/CT, and 92.9%, 81.2%, and 83.2%, respectively, for lesion-to-blood pool uptake ratio. Visual analysis of dual-phase PET/CT was shown to have the highest area under the receiver operating characteristic curve value (0.923; 95% CI, 0.858-0.965) among all parameters.

Conclusions

Dual-phase F-18 NaF PET/CT showed a high diagnostic ability for detecting bone metastasis with improved specificity and accuracy compared to conventional F-18 NaF PET/CT in cancer patients. Dual-phase F-18 NaF PET/CT might help diagnose bone metastasis in patients with malignancies who were shown to have a solitary bone lesion on bone scintigraphy.

Timing, Sites, and Correlates of Lung Cancer Recurrence

INTRODUCTION

Understanding temporal and anatomic patterns of lung cancer recurrence could guide disease management and monitoring. However, these data are not available in population-based datasets and are not routinely recorded in clinical trials.

MATERIALS AND METHODS

We identified cases of stage 1 to 3 lung cancer diagnosed January 1, 2000, to December 31, 2017, in the tumor registry of a National Cancer Institute-designated comprehensive cancer center. For cases with documented disease recurrence, we recorded anatomic site(s) and timing. We estimated time to recurrence using Kaplan-Meier methods. Associations between case characteristics and recurrence features were assessed using univariable and multivariable logistic regression models and Cox regression models.

RESULTS

A total of 1619 cases of stage 1 to 3 lung cancer from 1549 patients were included in the analysis. Of these, 466 (30%) patients developed recurrent lung cancer. The most common type of first recurrence was distant disease, most commonly central nervous system (CNS) (37%). In multivariable analyses, race (P = .02) and primary treatment modality (P < .001) correlated with recurrent disease, whereas tumor histology (P = .004) and primary treatment modality (P < .001) were associated specifically with distant recurrence. Patient age (P = .05) and initial TNM stage (P = .001) correlated with timing of recurrence.

CONCLUSION

In this single-center series of stage 1 to 3 lung cancer, recurrent disease was associated with race, histology, and treatment modality, and most commonly occurred in the CNS. Modulation of clinical and radiographic disease monitoring according to recurrence risk, timing, and site may offer a means to identify future lung cancer when it remains asymptomatic and highly treatable.

Role of surgery in oligometastatic prostate cancer

Androgen deprivation therapy as single modality therapy was the standard management for oligometastatic prostate cancer (PCa). Current paradigm shifts toward a multimodality therapy approach, targeting all sites of disease, including treatment of the primary in the form of radical prostatectomy or radiation therapy. The objective of this article was to reveiw the literature regarding the role of surgery in oligometastatic PCa. PubMed and MEDLINE electronic databases were queried for English language articles from January 1, 1980 to March 31, 2019. Keywords use included oligometastatic PCa, metastatic prostate cancer (mPCa), radical prostatectomy, and cytoreductive prostatectomy. Preclinical, prospective, and retrospective studies were included. There is no published randomized controlled trials, evaluating the role of surgery in mPCa. Preclinical and retrospective data suggest benefit of primary tumor treatment in mPCa. Current literature supports the concept of cytoreductive surgery as it can prevent late symptomatic local progression, has acceptable complications, and may prolong survival in patients with mPCa. Surgery is a feasible procedure in mPCa which may improve outcome in mPCa. However, there is no Level 1 evidence, yet that support the role of surgery in mPCa. The results from well-organized prospective, randomized controlled trials are awaited before performing radical prostatectomy for mPCa in clinical practice.

Characterization of Solitary Lesions in the Extremities on Whole-Body Bone Scan in Patients With Known Cancer: Contribution of Single-Photon Emission Computed Tomography/Computed Tomography

Background: Solitary lesions in the extremities showing ^99mTc-methylene diphosphate (MDP) uptake are often encountered on whole-body bone scan (WBS), and proper interpretation of this diagnostic method is important for patients with known cancer. The purpose of this study was to summarize the characteristics of solitary lesions in the extremities of patients with known cancer and to evaluate the diagnostic accuracy of single-photon emission computed tomography/computed tomography (SPECT/CT) in differentiating bone metastases from benign bone lesions.

Methods: This study was a retrospective review of 86 patients (54 males and 32 females; mean age, 57.88 ± 10.97 years; range, 31–81 years) with known cancer who underwent WBS and showed solitary lesions with ^99mTc-MDP uptake in the extremities and then underwent SPECT/CT for further diagnosis. SPECT/CT images were independently interpreted by two experienced nuclear medicine physicians. The diagnostic accuracy of SPECT/CT in differentiating malignant from benign solitary lesions in the extremities was evaluated. Inter-reviewer agreement was assessed by using weighted k statistics. The standard diagnostic criterion was based on biopsy or radiologic follow-up over at least 12 months.

Results: In total, 23 bone metastases and 63 (73.26%) benign lesions were diagnosed. The majority (16/23, 69.57%) of bone metastases were found in the diaphyses. The most common benign bone disease was a benign bone tumor (31.75%, 20/63). The majority (13/20, 65%) of benign bone tumors were enchondromas. In the proximal and distal extremities, the most common disease was degeneration (27.11%, 16/59), followed by benign bone tumors and osteonecrosis of the femoral head (ONFH) (22.03%, 13/59). In the diaphyses of the extremities, bone metastasis was the most common disease, accounting for 64% (16/25) of the findings. For the SPECT/CT analysis, the accuracy was 94.19% (81/86) for reviewer 1 and 95.34% (82/86) for reviewer 2. The weighted kappa score for inter-reviewer agreement was 0.813.

Conclusion: When solitary disease of the extremities is detected by WBS in patients with known cancer, benign lesions may be more common than malignant lesions. SPECT/CT resulted in not only fewer equivocal lesions but also in higher diagnostic accuracy.

Local ablative stereotactic body radiotherapy for oligometastatic prostate cancer

PURPOSE OF REVIEW

The oligometastases is considered an intermediate state of the disease between localized and wide spread metastases. Local ablative therapy to oligometastatic prostate cancer is gaining significant traction and stereotactic body radiotherapy (SBRT) is an emerging treatment modality for this patient population. In this review, we report our literature review of SBRT to prostate oligometastases. Current evidence on the role of SBRT in oligometastatic prostate cancer reported in the last 10 years was summarized. Criteria for inclusion included studies with prostate cancer only as the primary site.

RECENT FINDINGS

The unique properties of the oligometastatic prostate cancer appear to carry a better prognosis than wide spread metastatic disease, especially if these metastases are amenable to local ablative therapies. Our literature review revealed that local ablative therapy, using SBRT to prostate oligometastases, is associated with significant 2-years local control and acceptable toxicity profile.

SUMMARY

SBRT to oligometastatic prostate cancer patients is feasible and carries an acceptable toxicity profile. The randomized phase II and III trials, currently underway, should clearly define the real benefit of this approach on progression-free and overall survival outcomes.

Radiosurgical techniques for the treatment of brain neoplasms: A short review

Radiotherapy has long been used as an adjunct to neurosurgery for the treatment of malignant and benign intracranial tumors and other intracranial lesions. Intracranial tumors can be irradiated in three different ways: I) fractional radiotherapy, II) stereotactic radiotherapy and III) stereotactic radiosurgery. The third is most often by means of a gamma knife or a specially designed linear accelerator. Additionally, radiosurgery is increasingly used in combination with systemic therapy to treat metastases.

Feasibility of split-course stereotactic ablative radiotherapy for oligometastases

Background

There is growing interest in the use of stereotactic ablative radiotherapy (SABR) for oligometastases. However, extreme caution should be exercised in treating tumors closely located to organs at risk (OARs) with SABR. To reduce complications, we have applied split-course SABR to oligometastases closely located to OARs or to those being retreated with radiotherapy.

Methods

We retrospectively reviewed the records of patients with oligometastases who were treated with planned split-course SABR between January 2012 and December 2016.

Results

A total of 23 patients with 29 oligometastatic lesions were enrolled. The primary diagnoses were bone and soft tissue cancers in 13 lesions, liver cancers in 12 lesions, and colorectal cancers in four lesions. The median tumor volume was 78 cm3 (range, 4-1781 cm3). The lesions were treated with 1-3 fractions in the first stage of SABR (first SABR), and one or two fractions in the second stage of SABR (second SABR). The time interval between the two stages was about 4 weeks. A partial response was noted in 16 lesions (55%) after the first SABR, and practical reductions in the doses to OARs were observed in the second SABR compared with the first SABR. The 1-, 2- and 3-year local control rates were 92%, 65% and 43%, respectively. No Grade 4 or 5 toxicities were observed during or after treatment.

Conclusion

Split-course SABR appeared to be feasible for the treatment of oligometastases closely located to OARs.

Management of Pulmonary Oligometastases by Stereotactic Body Radiotherapy

Aims and Background

The aim of the study was to evaluate the feasibility, toxicity and effectiveness of active breathing control-guided stereotactic body radiotherapy in the management of pulmonary oligometastases.

Methods and Study Design

Between June 2010 and June 2012, 20 patients (13 males, 7 females) with 31 pulmonary metastases referred to the Department of Radiation Oncology, Gulhane Military Medical Academy were treated using active breathing control-guided stereotactic body radiotherapy. Response Evaluation Criteria in Solid Tumors and Common Terminology Criteria for Adverse Events were used in the assessment of treatment response and toxicity, respectively.

Results

Assessment of treatment response revealed complete response, partial response, stable disease, and progressive disease in 30%, 25%, 30%, and 15% of the patients, respectively. At a median follow-up of 14 months, local control was 85% and overall survival was 70%, with negligible treatment-related toxicity.

Conclusions

Stereotactic body radiotherapy is safe and effective in the management of pulmonary oligometastases. It offers favorable treatment outcomes as a viable non-invasive therapeutic modality.

[11C]choline-PET-guided Helical Tomotherapy and Estramustine in a Patient with Pelvic-Recurrent Prostate Cancer: Local Control and Toxicity Profile after 24 Months

[11C]choline positron emission tomograhy can be useful to detect metastatic disease and to localize isolated lymph node relapse after primary treatment in case of prostate-specific antigen failure. In case of lymph node failure in prostate cancer patients, surgery or radiotherapy can be proposed with a curative intent. Some reports have suggested that radiotherapy could have a role in local control of oligometastatic lymph node disease. This is the first reported case of [11C]choline positron emission tomography-guided helical tomotherapy concomitant with estramustine for the treatment of pelvic-recurrent prostate cancer. At 24 months after the end of helical tomotherapy, prostate-specific antigen was undetectable and no late toxicities were recorded. A disease-free survival of 24 months, in the absence of any type of systemic therapy, is uncommon in metastatic prostate cancer. The therapeutic approach of the case report is discussed and a literature review on the issue is presented.

Volumetric modulated arc therapy for thoracic node metastases: a safe and effective treatment for a neglected disease

Purpose

To evaluate the outcome of Stereotactic Body Radiation Therapy (SBRT) with Volumetric Modulated Arc Therapy (VMAT) for thoracic node metastases.

Results

18 out of 29 patients presented with isolated thoracic node metastases with no other sites of disease. Median prescribed dose was 45Gy (range 30–60Gy).

Acute toxicity was recorded as G0 in 28 patients, while one patient was scored as G1. Late toxicity was G0 in 26 patients, one patient was scored G1, one as G2, and one as G4 presented acute myocardial infarction.

During follow up, the best local response was complete remission in 14 patients and partial remission in 11 patients. With a median follow up of 12 months (range 2–35) 9 patients died from disease progression, 10 were still alive with distant metastases, 5 had a locally controlled disease and 5 patients were disease free.

The median OS estimated was 18 months (76%, 49% at one, two years). The median PFS was 9 months (28%, 17% at one, two years).

Materials and Methods

Twenty-nine patients with 32 thoracic nodes metastases were treated with SBRT in our institution. Toxicities and response were assessed. Overall Survival (OS) and Progression Free Survival (PFS) were evaluated.

Conclusions

SBRT is an efficient treatment for thoracic node metastases.

The Role of Local Therapy for Oligometastatic Prostate Cancer: Should We Expect a Cure?

The role of local treatment in oligometastatic prostate cancer remains contentious. Treatment of the prostate in metastatic disease may confer benefit, but prospective data are lacking. With improvements in treatments, aggressive strategies directed at metastases have increasingly become of clinical interest. Current evidence suggests good local control can be achieved; however, further data are required to determine overall cancer outcomes. This article evaluates the evidence available and consider whether local treatment of oligometastatic disease is a feasible, safe, and a positive strategy in this disease cohort. Cure should not be expected, although prolonged disease and treatment-free survival may be observed.

Stereotactic/hypofractionated body radiation therapy as an effective treatment for lymph node metastases from colorectal cancer: an institutional retrospective analysis

OBJECTIVE

The colorectal cancer (CRC) might present loco-regional recurrence, including lymph-node metastasis. Stereotactic body radiotherapy (SBRT) is a non-invasive and well-tolerated ablative treatment. Aim of the present study is to evaluate efficacy and toxicity of SBRT with volumetric modulated arc therapy (VMAT) in this setting.

METHODS

35 patients presenting a total of 47 nodal recurrences from CRC, treated with VMAT-SBRT from 2008 to 2015, were selected. About three fourth of the treatments delivered 45 Gy in 6 daily fractions. End-points were the detection of toxicities, overall survival (OS), local control (LC), disease progression free incidence (DPFI) and disease free survival (DFS). Tumour response was assessed according to the RECIST criteria.

RESULTS

Only Grade 1 and 2 toxicities were recorded. Median follow-up was 15 months (range 2-68). Local relapse was reported in 6 patients, regional relapse in 10 patients. Complete remission was reported in 20 cases (53%), partial remission in 14 (37%). Rates of LC at 1, 2 and 3 years were 85.3, 75.0 and 75.0%, respectively. At 1 year the actuarial OS was 100%, at 2 and 3 years was 81.4%. Median DFS was estimated in 16 months, with an incidence of 69.4, 33.3 and 19.4% at 1, 2 and 3 years, respectively.

CONCLUSION

The use of the VMAT-SBRT in lymph-node recurrence of CRC could prevent severe complications and achieve satisfying rates of disease control. Advances in knowledge: The use of VMAT-SBRT is a viable approach for lymph-node recurrence of CRC.

Oligometastatic prostate cancer: definitions, clinical outcomes, and treatment considerations

The oligometastatic state has been proposed as an intermediate stage of cancer spread between localized disease and widespread metastases. With improvements in diagnostic modalities such as functional imaging, oligometastatic prostate cancer is being diagnosed with greater frequency than ever before. Furthermore, the paradigm for treatment of advanced prostate cancers is shifting toward a more aggressive approach. Many questions surround the understanding of the process and consequences of oligometastasis, meaning that the contemporary literature offers a wide variety of definitions of oligometastatic prostate cancer. Until genomic data exist to provide a biological component to the definition of oligometastatic disease, a clinical diagnosis made on the basis of up to five extrapelvic lesions is reasonable for use. Retrospective studies suggest that interventions such as radical prostatectomy and local or metastasis-directed radiotherapy can be performed in the metastatic setting with minimal risk of toxic effects. These therapies seem to decrease the need for subsequent palliative interventions, but insufficient data are available to draw reliable conclusions regarding their effect on survival. Thus, a protocol for clinicians to manage the patient presenting with oligometastatic prostate cancer would be a useful clinical tool.

VERO® radiotherapy for low burden cancer: 789 patients with 957 lesions

Purpose

The aim of this retrospective study is to evaluate patient profile, feasibility, and acute toxicity of RadioTherapy (RT) delivered by VERO® in the first 20 months of clinical activity.

Methods

Inclusion criteria: 1) adult patients; 2) limited volume cancer (M0 or oligometastatic); 3) small extracranial lesions; 4) treatment between April 2012 and December 2013 and 5) written informed consent. Two techniques were employed: intensity modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT). Toxicity was evaluated using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer (RTOG/EORTC) criteria.

Results

Between April 2012 and December 2013, 789 consecutive patients (957 lesions) were treated. In 84% of them one lesion was treated and in 16% more than one lesion were treated synchronously/metachronously; first radiotherapy course in 85%, re-irradiation in 13%, and boost in 2% of cases. The treated region included pelvis 46%, thorax 38%, upper abdomen 15%, and neck 1%. Radiotherapy schedules included <5 and >5 fractions in 75% and 25% respectively. All patients completed the planned treatment and an acceptable acute toxicity was observed.

Conclusions

RT delivered by VERO® was administrated predominantly to thoracic and pelvic lesions (lung and urologic tumours) using hypofractionation. It is a feasible approach for limited burden cancer offering short and well accepted treatment with favourable acute toxicity profile. Further investigation including dose escalation and other available VERO® functionalities such as real-time dynamic tumour tracking is warranted in order to fully evaluate this innovative radiotherapy system.

[Radiotherapy for intrathoracic metastases]

Indication, doses, and technique of radiotherapy, for intrathoracic metastases are presented. The recommendations for delineation of the target volumes and organs at risk are detailed.

[Not Available]

OLIGOMETASTASIS AND OLIGOPROGRESSION

Oligometastic progression (or solitary metastases) can justify ablative treatment for metastatic treatment. When such a strategy is discussed, it is important to notice that definition of oligometastases is not consensual both in terms of clinical presentation than on the biological basis. Does a specific biological background truly exist and are there markers that could predict for additional occult disease and its oligo or polymetastatic profile in individuals with demonstrated oligometastasis. This article provides a summary of the state of the art in this field and highlights some current areas of controversies.

Curative Stereotactic Robotic Radiotherapy Treatment for Extracranial, Extrapulmonary, Extrahepatic, and Extraspinal Tumors: Technique, Early Results, and Toxicity

We investigated the technique, early results and toxicity of curative stereotactic radiotherapy with the CyberKnife® (Accuray Incorporated, Sunnyvale, California, USA) in 15 extracranial, extrapulmonary, extrahepatic, and extraspinal tumors. Fourteen tumors were located close to the bowel or esophagus. The PTV = GTV + 2–5 mm. The dose to the tumors varied from 10 fractions of 4 Gy up to 3 fractions of 20 Gy (median dose/fraction: 7 Gy; median number of fractions: 6), and depended on the proximity of the bowel. A small volume of the bowel was allowed to receive a dose of 6 Gy/fraction. The dose to the PTV was prescribed to the 75–85% isodose line. With a median follow up of 18 months, the 2-year local control and overall survival was 100%. Due to our flexible fractionation schedules, we were able to prescribe the dose to at least 90% of the PTV (median 95%) without increasing the dose to the bowel > 6 Gy/fraction. Five acute side effects were seen in four patients: two patients had transient grade 1 lymph edema in the leg, one patient complained of grade 1 pain in the abdomen and diarrhea, and one patient complained of grade 1 radiation dermatitis. Late toxicity such as grade 1 rectal bleeding, grade 1 diarrhea, grade 2 painful subcutaneous fibrosis, grade 2 pain in a surgical scar on the abdominal wall and an asymptomatic occlusion of the ureter was observed. Curative stereotactic radiotherapy treatment with the CyberKnife for extracranial, extrapulmonary, extrahepatic, and extraspinal, locally recurrent or solitary metastatic tumors is feasible and results in excellent local control and survival with low acute and late toxicity. A small volume of the bowel is able to tolerate a dose of 6 Gy per fraction for a maximum of 6 fractions.

Radiotherapy cannot prolong overall survival of young prostate cancer patients with bone metastases

BACKGROUND

Patients with prostate cancer is commonly diagnosed with bone metastases. With the growing use of prostate-specific antigen testing, the frequency of prostate cancer has progressively increased in patients younger than 70 years. Radiotherapy is recognized for its effect on local control of bone metastases, but whether it could prolong overall survival is still controversial.

METHODS

A total of 113 prostate cancer patients (<70y) with bone metastases were retrospectively analyzed. The Kaplan-Meier method was used for survival analysis with log-rank test. Multivariate analysis was performed to find the prognostic factors with the COX regression model.

RESULTS

The 1-, 2-, 3-, 5-, 7- and 10-year survival rates were 97.14, 82.86, 62.61, 38.76, 25.83 and 13.84 % respectively in the radiotherapy group, and 92.75, 73.91, 54.66, 36.63, 26.03 and 17.85 % respectively in the non-radiotherapy group, which showed no significant difference. Multivariate COX regression showed the overall survival was associated with alkaline phosphatase when bone metastases occurred and the number of bone metastases.

CONCLUSION

With the advances in life-prolonging treatment of metastatic prostate cancer, radiotherapy may not be the first choice for young bone metastatic prostate cancer patients in order to improve survival.

Cryosurgery/cryoablation in musculoskeletal neoplasms: history and state of the art

The field of cryosurgery began nearly 40 years ago with the open application of liquid nitrogen to ablate tumors. Recent developments in imaging and cryoprobe technology allow for percutaneous ablation of tumors. Computed tomography (CT)-guided cryoablation has particular use in treating musculoskeletal neoplasms because of the ability to image the lethal ice zone around both bone and soft tissue structures. This manuscript will review the development, indications, and results of cryoablation as applied to musculoskeletal neoplasms. This technique holds promise for the treatment of benign conditions as well as the palliation and durable treatment of musculoskeletal metastases; it is not commonly indicated in the curative treatment of primary malignant bone or soft tissue sarcomas.

The negative prognostic impact of bone metastasis with a tumor mass

OBJECTIVE

Typically, bone metastasis causes osteolytic and osteoblastic lesions resulting from the interactions of tumor cells with osteoclasts and osteoblasts. In addition to these interactions, tumor tissues may grow inside bones and cause mass lesions. In the present study, we aimed to demonstrate the negative impact of a tumor mass in a large cohort of patients with bone metastatic cancer.

METHODS

Data from 335 patients with bone metastases were retrospectively reviewed. For the analysis, all patients were divided into three subgroups with respect to the type of bone metastasis: osteolytic, osteoblastic, or mixed. The patients were subsequently categorized as having bone metastasis with or without a tumor mass, and statistically significant differences in median survival and 2-year overall survival were observed between these patients (the median survival and 2-year overall survival were respectively 3 months and 16% in patients with a tumor mass and 11 months and 26% in patients without a tumor mass; p<0.001).

RESULTS

According to multivariate analysis, the presence of bone metastasis with a tumor mass was found to be an independent prognostic factor (p=0.011, hazard ratio: 1.62, 95% confidence interval: 1.11-1.76). Bone metastasis with a tumor mass was more strongly associated with osteolytic lesions, other primary diseases (except for primary breast and prostate cancers), and spinal cord compression.

CONCLUSION

Bone metastasis with a tumor mass is a strong and independent negative prognostic factor for survival in cancer patients.

Oligometastases in prostate cancer: restaging stage IV cancers and new radiotherapy options

There are various subgroups of patients with metastatic prostate cancer: polymetastatic, oligometastatic, or oligo-recurrent cancers whose progression follows different courses and for whom there are different treatment options. Knowledge of tumor dissemination pathways and different genetic and epigenetic tumor profiles, as well as their evolution during disease progression, along with new diagnostic and therapeutic advances has allowed us to address these situations with local ablative treatments such as stereotactic body radiation therapy or stereotactic radiosurgery. These treatments provide high rates of local control with low toxicity in metastatic spread for primary cancers including those of pulmonary, digestive, and renal origin, while these types of treatments are still emerging for cancers of prostatic origin. There are several retrospective studies showing the effectiveness of such treatments in prostate cancer metastases, which has led to the emergence of prospective studies on the issue and even some phase II studies intended to prevent or delay systemic treatments such as chemotherapy. Here we collect together and review these past experiences and the studies currently underway. These types of radiotherapy treatments redefine how we approach extracranial metastatic disease and open up new possibilities for combination therapy with new systemic treatment agents.

Five polyostotic conditions that general orthopedic surgeons should recognize (or should not miss)

General orthopedic surgeons frequently encounter patients with conditions affecting multiple bones. It is important to recognize common polyostotic diseases. This article describes five polyostotic conditions: Multipe Enchondromatosis (Ollier Disease and Maffucci syndrome), Multiple Hereditary Exostosis (Diaphyseal Aclasis), Fibrous Dysplasia (McCune-Albright syndrome and Mazabraud syndrome), Paget's Disease of bone (Osteitis Deformans), and Skeletal Metastases. This is a survey of the clinical, pathologic and radiographic features that assist in diagnosing these conditions. Also, an overview of the laboratory findings, treatment, follow-up, and prognosis is presented. Recognizing these diseases will aid in prompt and accurate diagnosis and appropriate referral and therapy.

Oligometastatic breast cancer: a shift from palliative to potentially curative treatment?

A distinctive subset of metastatic breast cancer is represented by the so called 'oligometastatic' disease, characterized by single/few detectable metastatic lesions. A more aggressive multidisciplinary approach can be considered in this patient population: available data report favorable results of 'radical' local therapy for limited metastatic disease at least in a subset of selected patients. Selection bias and the retrospective nature of data do not allow for generalization of the results: the use of such approaches must be individualized and managed within a multidisciplinary team of dedicated specialists. Improvement in surgical and radiation techniques, development of new tools to deliver local chemotherapy, and new procedures (i.e. cryosurgery, laser and microwave ablation) mandate careful evaluation of such single and combined modalities in controlled clinical trials. A more accurate identification of patients with limited metastases and better definition of treatment endpoints will also allow correct patient selection for locally aggressive therapies. This paper focusses on local treatment of the primary tumor and of the most frequent distant disease sites in the presence of oligometastatic disease.

[Solitary spinal metastases. Is aggressive surgical management justified?]

Advances in oncological and surgical therapies have led to a significant increase in life expectancy of cancer patients and also prolonged survival of patients with isolated or multiple metastases. Among the skeletal manifestations the spine is the most often affected site. Using novel imaging techniques with higher resolution and use of metabolic signatures, the screening of cancer patients has improved considerably. Consequently, the diagnosis of metastases is becoming increasingly more sensitive. Therefore, but also due to more effective polychemotherapy protocols, singular or solitary metastases are more frequently observed either in the early stages or as a result of a controlled malignant tumor entity (stable disease). The questions whether a solitary metastasis really exists (illusion or reality?) and its radical oncological and surgical treatment as a circumscribed singular tumor manifestation, is really relevant for the overall prognosis, remains controversial. However, it seems evident that a biologically favorable underlying tumor biology, radical treatment of the primary tumor and a long metastasis-free interval are valid predictors of a good oncological outcome. In the presence of a solitary metastasis under these circumstances (typical example: solitary metastasis of renal cell carcinoma many years after radical tumor nephrectomy) a radical surgical procedure (en bloc spondylectomy) can significantly improve the long-term prognosis of this patient group in combination with adjuvant chemotherapy and/or radiotherapy. However, a thorough evaluation of the overall survival prognosis, a detailed and complete staging followed by a treatment consensus in the interdisciplinary tumor board has to precede any therapeutical decisions.

Stereotactic body radiotherapy for oligo-recurrence within the nodal area from colorectal cancer

Recurrence of colorectal cancer (CRC) often presents as solitary metastases, oligometastases or oligo-recurrence. Surgical resection became the preferred treatment for patients with CRC lung and hepatic metastases. However, surgical treatment for oligo-recurrence within nodal area is not a widely accepted treatment due to due to their relative rarity and high postoperative morbidity. Stereotactic body radiotherapy (SBRT) is one of the emerging radiation treatment techniques in which a high radiation dose can be delivered to the tumor. High-dose SBRT can ablate the tumor with an efficacy similar to that achieved with surgery, especially for small tumors. However, there have been very few studies on SBRT for oligo-recurrence within nodal area, although several studies have evaluated the role of SBRT in the treatment of liver and lung metastases from CRC. This article reviews the current clinical status of and treatment methods for oligo-recurrence within nodal area from CRC, with particular emphasis on SBRT.

[Novel irradiation techniques in the treatment of solid tumours. Radiotherapy for metastases]

Novel developments in percutaneous radiotherapy, such as positron emission tomography/computed tomography, adaptive radiation planning, intensity modulation radiotherapy and intensity modulated arc therapy (RapidArc), as well as the newer generation of image control (cone-beam computed tomography) and image guided radiotherapy ensure increased dosages of planning target volume and clinical target volume of solid tumours without damaging surrounding tissues and providing maximal protection. By raising the dosages of planned target volume and clinical target volume, these novel technical developments have created new indications in the treatment of solid tumours. With the aid of the cone-beam computed tomography and image guided radiotherapy the organ metastasis (lung, liver, spinal cord) and the primary tumour can be treated safety and effectively. Hypofractionation, dose escalation and the use of stereotactic devices can probably decrease radiation damage. The authors review the most common forms of evidence-based fractionation schemes used in irradiation therapy.

Oligometastasis as a predictor for occult disease

Oligometastasis can be defined as a state of limited metastases that is potentially amenable to ablative local therapy; the success of such therapy depends on whether or not additional occult metastases exist. A model is presented here to predict occult metastases given detectable oligometastases. Predictions were based on Bayes' theorem, in conjunction with descriptions of the statistical distributions for the sizes and numbers of hematogenous metastases. The background probability for occult metastases in individuals with oligometastases increased markedly with relatively minor increases in metastatic potential. With each additional metastasis detected the chance of further occult metastases increased. These latter increases were incremental and proportionately smaller with the more metastatic tumors. Long disease free intervals had a major effect to decrease in the probability of further occult disease. Demonstration of oligometastases depends heavily upon the sensitivity of radiological imaging techniques, where the proportion of detectable metastases relates to the position of the distribution of metastasis growth times with respect to the detection threshold. Given the limitations of radiological methods, and the possibility that the oligometastases detected may be the only disease, an aggressive approach appears indicated.

Stereotactic body radiotherapy for solitary spine metastasis

A clear consensus has not been established regarding the best treatment for solitary bone metastasis. Here, we reviewed the medical records of patients with a controlled primary malignancy who had only solitary spine metastasis without metastasis to the extraspinal bone or viscera and underwent treatment between April 2007 and December 2012 with stereotactic body radiosurgery using CyberKnife, with a total dose of 24 Gy in three to four fractions. During that time, there were only four cases. This was effective in each case, and all the four patients had no local failure and remained alive at a median follow-up of 68 months (range, 64 to 80 months). Although our experience is limited, this study suggests that stereotactic body radiotherapy could be a feasible, safe, effective, and noninvasive alternative treatment for solitary spine metastasis in patients who are medically inoperable or unsuitable for surgery.

Outcome of surgical resection of symptomatic cerebral lesions in non-small cell lung cancer patients with multiple brain metastases

OBJECTIVE

Patients with symptomatic brain metastases secondary to mass effect are often candidates for surgery. However, many of these surgical candidates are also found to have multiple asymptomatic tumors. This study aimed to determine the outcome of surgical resection of symptomatic brain metastases followed by chemotherapy or radiotherapy (RT) for the remnant asymptomatic lesions in non-small cell lung cancer (NSCLC) patients with multiple brain metastases.

METHODS

We conducted a retrospective review of the medical records of 51 NSCLC patients with symptomatic multiple brain metastases who underwent surgical resection, of whom 38 had one or more unresected asymptomatic lesions subsequently treated with chemotherapy and/or RT. Thirteen patients underwent resection of all metastatic lesions.

RESULTS

Median survival for overall patient population after surgical resection was 10.8 months. Median survival for patients with surgical resection of all brain metastases was not significantly different with patients who underwent surgical resection of only symptomatic lesions (6.5 months vs. 10.8 months; p=0.97). There was no statistically significant difference in survival according to the number of tumors (p=0.86, 0.16), or post-surgical treatment modalities (p=0.69).

CONCLUSION

The survival time of NSCLC patients with multiple brain metastases after surgery for only symptomatic brain metastases is similar to that of patients who underwent surgery for all brain metastases. The remaining asymptomatic lesions may be treated with chemotherapy or radiotherapy. The optimal treatment modality, however, needs to be defined in prospective trials with larger patient cohort.

Stereotactic body radiotherapy for oligometastases

The management of metastatic solid tumours has historically focused on systemic treatment given with palliative intent. However, radical surgical treatment of oligometastases is now common practice in some settings. The development of stereotactic body radiotherapy (SBRT), building on improvements in delivery achieved by intensity-modulated and image-guided radiotherapy, now allows delivery of ablative doses of radiation to extracranial sites. Many non-randomised studies have shown that SBRT for oligometastases is safe and effective, with local control rates of about 80%. Importantly, these studies also suggest that the natural history of the disease is changing, with 2-5 year progression-free survival of about 20%. Although complete cure might be possible in a few patients with oligometastases, the aim of SBRT in this setting is to achieve local control and delay progression, and thereby also postpone the need for further treatment. We review published work showing that SBRT offers durable local control and the potential for progression-free survival in non-liver, non-lung oligometastatic disease at a range of sites. However, to test whether SBRT really does improve progression-free survival, randomised trials will be essential.

Calcitriol: a better option than vitamin D in denosumab-treated patients with kidney failure?

Denosumab has been proven to be at least as effective with respect to zoledronic acid in preventing skeletal-related events in patients with bone metastases from solid tumors. Although denosumab can be considered to have a more favorable toxicity profile compared to zoledronic acid in terms of kidney toxicity and flu-like symptoms, hypocalcemia is twice as frequent with denosumab. Importantly, denosumab is not metabolized by the kidney and it may be employed even in patients with severe kidney failure. Like zoledronic acid, denosumab is administered with oral calcium and vitamin D. As conversion of vitamin D to its active form is progressively impaired with a creatinine clearance < 70 ml/min, we speculate that calcitriol may be a better option than vitamin D in denosumab-treated patients with impaired kidney function.

Volumetric modulated arc therapy with flattening filter free beams for isolated abdominal/pelvic lymph nodes: report of dosimetric and early clinical results in oligometastatic patients

BACKGROUND

SBRT is a safe and efficient strategy to locally control multiple metastatic sites. While research in the physics domain for Flattening Filter Free Beams (FFF) beams is increasing, there are few clinical data of FFF beams in clinical practice. Here we reported dosimentric and early clinical data of SBRT and FFF delivery in isolated lymph node oligometastatic patients.

METHODS

Between October 2010 and March 2012, 34 patients were treated with SBRT for oligometastatic lymph node metastasis on a Varian TrueBeam(TM) treatment machine using Volumetric Modulated Arc Therapy (RapidArc). We retrospectively evaluated a total of 25 patients for isolated lymph node metastases in abdomen and/or pelvis treated with SBRT and FFF (28 treatments). Acute toxicity was recorded. Local control evaluation was scored by means of CT scan and/or PET scan.

RESULTS

All dosimetric results are in line with what published for the same type of stereotactic abdominal lymph node metastases treatments and fractionation, using RapidArc. All 25 FFF SBRT patients completed the treatment. Acute gastrointestinal toxicity was minimal: one patient showed Grade 1 gastrointestinal toxicity. Three other patients presented Grade 2 toxicity. No Grade 3 or higher was recorded. All toxicities were recovered within one week. The preliminary clinical results at the median follow up of 195 days are: complete response in 12 cases, partial response in 11, stable disease in 5, with an overall response rate of 82%; no local progression was recorded.

CONCLUSIONS

Data of dosimetrical findings and acute toxicity are excellent for patients treated with SBRT with VMAT using FFF beams. Preliminary clinical results showed a high rate of local control in irradiated lesion. Further data and longer follow up are needed to assess late toxicity and definitive clinical outcomes.

Review and uses of stereotactic body radiation therapy for oligometastases

In patients with proven distant metastases from solid tumors, it has been a notion that the condition is incurable, warranting palliative care only. The term "oligometastases" was coined to refer to isolated sites of metastasis, whereby the entire burden of disease can be recognized as a finite number of discrete lesions that can be potentially cured with local therapies. Stereotactic body radiation therapy (SBRT) is a novel treatment modality in radiation oncology that delivers a very high dose of radiation to the tumor target with high precision using single or a small number of fractions. SBRT is the result of technological advances in patient and tumor immobilization, image guidance, and treatment planning and delivery. A number of studies, both retrospective and prospective, showed promising results in terms of local tumor control and, in a limited subset of patients, of survival. This article reviews the radiobiologic, technical, and clinical aspects of SBRT for various anatomical sites.

Pulmonary Oligometastases

Introduction. Pulmonary oligometastases are resected both for diagnostic and therapeutic reasons. The histological features may be nonspecific, resulting in diagnostic difficulties. Design. The authors retrospectively studied the clinical and pathological features of 73 open resections of lung metastases from 64 patients to determine the frequency and types of problems in establishing site of origin. Results. There were 18 primary organ sites, the most frequent being colon (n = 10), head and neck (9 squamous and 6 salivary gland), kidney (n = 7), and soft tissue (n = 7). Unusual histological features included detached alveolar tumor clusters at the periphery (83% of adenocarcinomas), lepidic spread (2 metastatic pancreatic tumors), and entrapped pneumocyte-lined cysts (6 tumors). A majority of squamous carcinomas from the head and neck presented difficulties in regard to excluding a second primary, especially 4 with basaloid features that mimicked primary basaloid lung carcinoma. Other tumors mimicking lung primaries included pancreatic, endometrial, and breast metastases. Germ-cell tumors, sarcomas, melanomas, and sarcomatoid carcinomas presented diagnostic difficulties. Overall, comparison with the primary tumor with or without immunohistochemical studies was performed in 38 of 73 cases (52%). Conclusions. Pulmonary oligometastases comprise a wide range of histological types and often require careful pathological evaluation to determine primary site of origin.

Long-term local control achieved after hypofractionated stereotactic body radiotherapy for adrenal gland metastases: a retrospective analysis of 34 patients

AIMS AND BACKGROUND

To describe feasibility, tolerability and clinical outcomes of stereotactic body radiation therapy (SBRT) in the treatment of adrenal metastases in 34 consecutive cancer patients.

MATERIAL AND METHODS

Between March 2004 and July 2010, a total of 34 consecutive patients, accounting for 36 adrenal metastatic lesions, were treated with SBRT. SBRT treatments were delivered by a Linac Varian 600 with microMLC (3DLine, Elekta, Stockholm, Sweden) and a Linac ELEKTA Precise (Elekta). All 34 patients were clinically and radiologically evaluated during and after completion of SBRT. Following outcomes were taken into account: best clinical response at any time, local control, time to systemic progression, time to local progression, overall survival and toxicity. Survival was estimated by the Kaplan-Meier method and factor potentially affecting outcomes were analyzed with Cox regression analysis.

RESULTS

Total RT doses ranged from 20 Gy in 4 fractions to 45 Gy in 18 fractions (median dose: 32 Gy; median number of fractions: 4). All doses were prescribed to the 95% isodose line. No cases of Grade ≥ 3 toxicity were recorded. At a median follow-up time of 41 months (range, 12-75) 22 patients were alive. Three of 28 lesions (11%) showed complete response, 13/28 (46%) partial response, 10/28 (36%) stable disease and 2/28 (7%) progressed in the treated area. Local failure was observed in 13 cases. Actuarial local control rates at one and two years were 66% and 32%, respectively. Median time to local progression was 19 months. Median survival was 22 months.

CONCLUSION

SBRT in adrenal gland metastasis is feasible without significant acute and late toxicities, with a good rate of local control. New SBRT fractionation schemes and the possibility to combine new systemic approaches should be investigated in order to further increase local control and reduce systemic disease progression.

Stereotactic body radiation therapy for spinal metastases

The goal of this paper is to expose the clinical results and review of the literature of the treatment of spinal metastases with Stereotactic Body Radiation Therapy (SBRT) presenting one case. A spinal metastases from rectal cancer treated with a single dose of 18Gy is presented. The following physics aspects are exposed: Treatment volume, tumor volume marginal doses and maximum doses in organs at risk. Clinical and radiographic follow up is presented. Local control and pain relief after one year of follow up was excellent. In properly selected patients, the treatment of limited metastatic disease with SBRT appears to be feasible and safe.

Resection of secondary pulmonary malignancies in head and neck cancer patients

BACKGROUND

This study aimed to evaluate a single institute's experience with resection of metachronous pulmonary malignancy in patients treated for squamous cell carcinoma of the head and neck.

METHODS

Sixty-three consecutive patients treated curatively for head and neck squamous cell carcinoma underwent surgical resection of malignant lung lesions. Survival was estimated and potential prognostic factors investigated.

RESULTS

The median overall survival for the total group was 22.2 months. Fifty-one patients (81 per cent) had one lung lesion, while the remainder had multiple lesions (range, two to seven). In the 63 patients, 35 lobectomies, 4 pneumonectomies and 24 wedge resections were performed. For patients with pulmonary squamous cell carcinoma (n = 52), the three-year survival rate was 35 per cent (95 per cent confidence interval, 22-48); for patients with resected adenocarcinoma (n = 10), it was 50 per cent (95 per cent confidence interval, 18-75). The overall five-year survival rate was 30 per cent (95 per cent confidence interval, 19-42).

CONCLUSION

In patients treated curatively for head and neck squamous cell carcinoma, resection of secondary pulmonary cancer is associated with favourable long term overall survival, especially for patients with adenocarcinoma lesions.

Predictors of local control after single-dose stereotactic image-guided intensity-modulated radiotherapy for extracranial metastases

PURPOSE

To report tumor local control after treatment with single-dose image-guided intensity-modulated radiotherapy (SD-IGRT) to extracranial metastatic sites.

METHODS AND MATERIALS

A total of 126 metastases in 103 patients were treated with SD-IGRT to prescription doses of 18-24 Gy (median, 24 Gy) between 2004 and 2007.

RESULTS

The overall actuarial local relapse-free survival (LRFS) rate was 64% at a median follow-up of 18 months (range, 2-45 months). The median time to failure was 9.6 months (range, 1-23 months). On univariate analysis, LRFS was significantly correlated with prescription dose (p = 0.029). Stratification by dose into high (23 to 24 Gy), intermediate (21 to 22 Gy), and low (18 to 20 Gy) dose levels revealed highly significant differences in LRFS between high (82%) and low doses (25%) (p < 0.0001). Overall, histology had no significant effect on LRFS (p = 0.16). Renal cell histology displayed a profound dose-response effect, with 80% LRFS at the high dose level (23 to 24 Gy) vs. 37% with low doses (≤22 Gy) (p = 0.04). However, for patients who received the high dose level, histology was not a statistically significant predictor of LRFS (p = 0.90). Target organ (bone vs. lymph node vs. soft tissues) (p = 0.5) and planning target volume size (p = 0.55) were not found to be associated with long-term LRFS probability. Multivariate Cox regression analysis confirmed prescription dose to be a significant predictor of LRFS (p = 0.003).

CONCLUSION

High-dose SD-IGRT is a noninvasive procedure resulting in high probability of local tumor control. Single-dose IGRT may be effectively used to locally control metastatic deposits regardless of histology and target organ, provided sufficiently high doses (> 22 Gy) of radiation are delivered.

Survival of patients with skeletal metastases from hepatocellular carcinoma after surgical management

Skeletal metastases from hepatocellular carcinoma are highly destructive vascular lesions which severely reduce the quality of life. Pre-existing liver cirrhosis presents unique challenges during the surgical management of such lesions. We carried out a retrospective study of 42 patients who had been managed surgically for skeletal metastases from hepatocellular carcinoma affecting the appendicular skeleton between January 2000 and December 2006. There were 38 men and four women with a mean age of 60.2 years (46 to 77). Surgery for a pathological fracture was undertaken in 30 patients and because of a high risk of fracture in 12. An intralesional surgical margin was achieved in 36 and a wide margin in six. Factors influencing survival were determined by univariate and multivariate analyses. The survival rates at one, two and three years after surgery were 42.2%, 25.8% and 19.8%, respectively. The median survival time was ten months (95% confidence interval 6.29 to 13.71). The number of skeletal metastases and the Child-Pugh grade were identified as independent prognostic factors by Cox regression analysis. The method of management of the hepatocellular carcinoma, its status in the liver, the surgical margin for skeletal metastases, the presence of a pathological fracture and adjuvant radiotherapy were not found to be significantly related to the survival of the patient, which was affected by hepatic function, as represented by the Child-Pugh grade.