British Association of Surgical Oncology Guidelines: The management of metastatic bone disease in the United Kingdom

Team Approach: Management of Pathologic Fractures

»

Optimal care for pathologic fractures centers on the use of a multidisciplinary team; thus, whenever there is a concern for pathologic fracture and proper workup is unable to be performed, prompt referral to a center equipped to manage these injuries should occur.

»

Fixation strategies for pathologic fractures must take into account patient characteristics, cancer subtypes, and overall goals of treatment.

»

As the treatments of cancers improve, patient life expectancy with disease will improve as well. This will lead to an increase in the incidence of impending or completed pathologic fractures. The broader subspecialties of orthopaedics must be aware of general principles in the diagnosis and management of these injuries.

Translational Strategies to Target Metastatic Bone Disease

Metastatic bone disease is a common and devastating complication to cancer, confounding treatments and recovery efforts and presenting a significant barrier to de-escalating the adverse outcomes associated with disease progression. Despite significant advances in the field, bone metastases remain presently incurable and contribute heavily to cancer-associated morbidity and mortality. Mechanisms associated with metastatic bone disease perpetuation and paralleled disruption of bone remodeling are highlighted to convey how they provide the foundation for therapeutic targets to stem disease escalation. The focus of this review aims to describe the preclinical modeling and diagnostic evaluation of metastatic bone disease as well as discuss the range of therapeutic modalities used clinically and how they may impact skeletal tissue.

Metastatic bone disease: new quality performance indicator development

OBJECTIVES

Patients with metastatic bone disease (MBD) should receive the same standard of care regardless of which centre they are treated in. The aim was to develop and test a set of quality performance indicators (QPIs) to evaluate care for patients with MBD referred to orthopaedics.

METHODS

QPIs were adapted from the literature and ranked on feasibility and necessity during a modified RAND/Delphi consensus process. They were then validated and field tested in a retrospective cohort of 108 patients using indicator-specific targets set during consensus.

RESULTS

2568 articles including six guidelines were reviewed. 43 quality objectives were extracted and 40 proceeded to expert consensus. After two rounds, 18 QPIs for MBD care were generated, with the following generating the highest consensus: 'Patients with high fracture risk should receive urgent assessment' (combined mean 6.7/7, 95% CI 6.5 to 6.8) and 'preoperative workup should include full blood tests including group and save' (combined mean 6.7/7, 95% CI 6.5 to 6.9). In the pilot test, targets were met for 5/18 QPIs (mean 52%, standard deviation 22%). The median deviation from projected target was -14% (interquartile range -11% to -31%, range -74% to 11%). The highest scoring QPI was 'adults with fractures should have surgery within 7 days' (target 80%:actual 92%).

CONCLUSIONS

The published evidence and guidelines were adapted into a set of validated QPIs for MBD care which can be used to evaluate variation in care between centres. These QPIs should be correlated with outcome scores to determine whether they can act as predictors of outcome after surgery.

The effects of metastatic lesion on the structural determinants of bone: Current clinical and experimental approaches

Metastatic bone disease is incurable with an associated increase in skeletal-related events, particularly a 17-50% risk of pathologic fractures. Current surgical and oncological treatments are palliative, do not reduce overall mortality, and therefore optimal management of adults at risk of pathologic fractures presents an unmet medical need. Plain radiography lacks specificity and may result in unnecessary prophylactic fixation. Radionuclide imaging techniques primarily supply information on the metabolic activity of the tumor or the bone itself. Magnetic resonance imaging and computed tomography provide excellent anatomical and structural information but do not quantitatively assess bone matrix. Research has now shifted to developing unbiased data-driven tools that can predict risk of impending fractures and guide individualized treatment decisions. This review discusses the state-of-the-art in clinical and experimental approaches for prediction of pathologic fractures with bone metastases. Alterations in bone matrix quality are associated with an age-related increase in skeletal fragility but the impact of metastases on the intrinsic material properties of bone is unclear. Engineering-based analyses are non-invasive with the capability to evaluate oncological treatments and predict failure due to the progression of metastasis. The combination of these approaches may improve our understanding of the underlying deterioration in mechanical performance.

Multimodal Treatment of Bone Metastasis-A Surgical Perspective

Over the past decades there has been an increase in the incidence of cancer worldwide. With the advancement in treatment, patient survival has improved in tandem with the increasing incidence. This, together with the availability of advanced modern diagnostic modalities, has resulted in more cases of metastatic bone disease being identified. Bone metastasis is an ongoing problem and has significant morbidity implications for patients affected. Multimodal treatment strategies are required in dealing with metastatic bone disease, which include both surgical and non-surgical treatment options. In the multidisciplinary team, orthopedic surgeons play an important role in improving the quality of life of cancer patients. Surgical intervention in this setting is aimed at pain relief, restoration of function and improvement in functional independence. In selected cases with resectable solitary metastasis, surgical treatment may be curative. With the advancement of surgical technique and improvement in implant design and manufacture, a vast array of surgical options are available in the modern orthopedic arena. In the majority of cases, limb salvage procedures have become the standard of care in the treatment of metastatic bone disease. Non-surgical adjuvant treatment also contributes significantly to the improvement of cancer patient care. A multidisciplinary approach in this setting is of paramount importance.

Lectin-based biosensors as analytical tools for clinical oncology

The review focus on the use of lectin-based biosensors in the oncology field, and ponders the potentialities of using these devices as analytical tools to monitor the levels of cancer glycobiomarkers in biological fluids, helping in the diagnosis, prognosis and treatment assessment. Several examples of lectin-based biosensors directed for cancer biomarkers are described and discussed, and their potential application in the clinic is considered, taking into account their analytical features, advantages and performance in sample analysis. Technical and practical aspects in the construction process, which are specific for lectin biosensors, are debated, as well as the requirements in sample collection and processing, and biosensor validation. Today's challenges for real implementation of these devices in the clinic are presented, along with the future trends in the field.

The Role of Blood Tumor Marker Measurement (Using a Biochemical Index Score and C-Erbb2) in Directing Chemotherapy in Metastatic Breast Cancer

The role of blood tumor markers in monitoring response in advanced breast cancer is established in endocrine therapy and standard chemotherapy. This study examines marker levels in patients receiving new chemotherapy regimens. Thirty patients were recruited into two multicenter trials in which docetaxel-based regimens were used in 15 patients. The other 15 received doxorubicin-based regimens. Biochemical response calculated from a score using CA15.3, CEA and ESR was compared with UICC response. Marker changes at 2, 4 and 5 months correlated with UICC response at 3, 41/2 and 6 months, respectively (p < 0.03). Eleven patients achieved both clinical/radiological and biochemical response at the end of treatment; markers had not yet returned to below cutoffs in seven, suggesting a possible advantage to continue chemotherapy. No patient showed a biochemical response whilst judged clinically/radiologically progressive. Nineteen patients had progressed either clinically/radiologically or biochemically at six months; of these, eight showed progression assessed earlier by markers so that a median of four cycles of chemotherapy could have been saved. Measurements of serum c-erbB2 showed a correlation with tissue c-erbB2 staining in the primary tumor (p < 0.003). Among the patients with positive tissue staining, sequential changes in serum c-erbB2 completely paralleled initial response.

Bone metastases of the hand

Introduction The aim of this study was to identify patients with malignant hand lesions, establish the proportions of those that were metastases and review their clinical course. Methods A retrospective search of a prospective tumour database was carried out to identify all patients treated at our unit with hand metastases. Patient demographics were recorded including site of primary malignancy, region of the hand involved, management of their metastasis and clinical outcome. Results Overall, 149 patients were identified with a malignant tumour of the hand. Ten had a metastatic lesion. There were 3 women and 7 men with a median age of 68 years (range: 28-91 years) at presentation. All presented with non-mechanical hand pain while four had pain and swelling. The median interval from symptom onset to diagnosis was eight weeks. The minimum follow-up duration was four months. Three patients had no history of malignancy. Of the remaining seven patients, three had other known metastases. Six patients underwent solely palliative radiotherapy. Three patients had amputation. One was treated with surgical excision and radiotherapy. One had an amputation and axillary node clearance. All but one patient had died by the time of the latest follow-up appointment. The median time to death following identification of acrometastases was 18 months. Sites of primary disease were skin (n=4), lung (n=3), kidney (n=2) and neuroendocrine system (n=1). The thumb was the most commonly affected location. Conclusions This study demonstrates that patients presenting with non-mechanical hand pain should be considered to have a malignant process until proved otherwise, particularly in patients with thumb symptoms and a history of prior malignancy.

A review of patterns of practice and clinical guidelines in the palliative radiation treatment of uncomplicated bone metastases

BACKGROUND AND PURPOSE

Single fraction radiation treatment (SFRT) is recommended for its equivalence to multiple-fraction (MF) RT in the palliation of uncomplicated bone metastases (BM). However, adoption of SFRT has been slow.

MATERIALS AND METHODS

Literature searches for studies published following 2014 were conducted using online repositories of gray literature, Ovid MEDLINE, Embase and Embase Classic, and the Cochrane Central Register of Controlled Trials databases.

RESULTS

A total of 32 articles detailing patterns of practice and clinical practice guidelines were included for final synthesis. The majority of organizations have released high level recommendations for SFRT use in treatment of uncomplicated BM, based on evidence of non-inferiority to MFRT. There are key differences between guidelines, such as varying strengths of recommendation for SFRT use over MFRT; contraindication in vertebral sites for SFRT; and risk estimation of pathologic fractures after SFRT. Differences in guidelines may be influenced by committee composition and organization mandate. Differences in patterns of practice may be influenced by individual center policies, payment modalities and consideration of patient factors such as age, prognosis, and performance status.

CONCLUSION

Although there is some variation between groups, the majority of guidelines recommend use of SFRT and others consider it to be a reasonable alternative to MFRT.

Patient pathway for breast cancer: turning points and future aspirations

Improved survival from breast cancer can be attributed to a number of advances in the patient pathway from screening to advanced disease. The benefit of population screening has been established with national programs implemented. There has been improvement in the methodology of diagnostic assessment, relating to imaging techniques, methods of obtaining histological evidence and evaluation of lymph node status. Sentinel node biopsy is now routine, as is oncoplastic surgery. New forms and improved adjuvant systemic therapies are being explored. The prognosis of breast cancer can be more reliably evaluated to provide individualized information and to personalize treatments. Developments have also been seen in other areas improving the treatment and care of patients with advanced disease.

Mucins and Cytokeratins as Serum Tumor Markers in Breast Cancer

Structural and functional characteristics of mucins and cytokeratins are shortly described. Thereafter, those commonly used in breast cancer as serum tumor markers are considered. First CA15.3, MCA, CA549, CA27.29 mucins and CYFRA21.1, TPA, TPS cytokeratins alone or in association have been examined in different stages and conditions. Then their usefulness in monitoring disease-free breast cancer patients is evaluated. The central role of the established cut-off and critical change, the "early" treatment of recurrent disease and the potential benefit in survival are other issues that have been highlighted and discussed. The successive sections and subsections deal with the monitoring of advanced disease. In them, the current recommendations and the principal findings on using the above mentioned mucins and cytokeratins have been reported. A computer program for interpreting consecutive measurements of serum tumor markers also has been illustrated. The final part of the chapter is devoted to mucins and cytokeratins as markers of circulating and disseminated tumor cells and their usefulness for prognosis.

Metachronous Bilateral Chondroblastoma of the Proximal Part of the Femur with a Pathologic Fracture: A Case Report

CASE

A twenty-two-year-old man presented with metachronous bilateral chondroblastoma of the proximal part of the femur with a pathologic fracture. The pathologic fracture on the right side was treated with tumor resection and total hip arthroplasty. Within forty-three months, the chondroblastoma in the left femoral head was detected and treated with the same protocol as the chondroblastoma on the right side. No metastatic lesion was evident at this time; because of its benign appearance histologically, the lesion was diagnosed as a metachronous lesion.

CONCLUSION

In a patient who has been previously diagnosed with and treated for chondroblastoma, skeletal pain at another site may represent a metachronous lesion.

A cross-sectional survey of the diagnosis and management of bone metastasis in breast cancer patients in Turkey

Purpose

This study aimed to report the practice of managing breast cancer with bone metastasis in Turkey and to determine the adherence to the British Association of Surgical Oncology (BASO) guidelines.

Methods

This multicenter, cross-sectional epidemiological survey was conducted in 38 centers across Turkey. Data from 1,026 breast cancer patients with bone metastases (mean age 54.0 ± 11.9 years) were analyzed.

Results

Over 30 % of patients had a diagnosis of metastatic breast cancer (stage IV) at the time of primary diagnosis. The imaging modalities used for diagnosing bone metastases were bone scintigraphy (57.8 %), radiography (22.8 %), and bone survey (4.4 %). Tumor markers were detected in 94.9 %, and markers of bone metabolism were measured in 90.4 % of patients. A total of 3.5 % of patients underwent surgery for bone metastasis, 26.4 % underwent palliative chemotherapy (most commonly docetaxel + capecitabine), and 56.5 % endured radiotherapy. Most patients (96 %) also received bisphosphonate. Radiography, bone scintigraphy, and CT were the main imaging tools used for postoperative follow-up of bone metastasis. Our results were >95 % in line with the BASO guidelines for the management of bone metastasis, except that interventional procedures, such as biopsy, were applied less frequently in our survey.

Conclusions

The diagnosis and management practices of breast cancer with bone metastasis in Turkey were generally compatible with international guidelines. However, the awareness and knowledge of physicians on the current guidelines should be increased, and equipment for the appropriate interventional procedures should be provided in every clinic to obtain optimal and standard management of bone metastases.

Bisphosphonates and bone metastases: current status and future directions

Since bone metastases in advanced cancer are common and frequently lead to skeletal-related morbid complications, their treatment remains a major challenge in cancer therapy. Bisphosphonates not only significantly decreased the odds ratios for fracture, need for radiotherapy, and incidence of hypercalcemia, but also had proven ability in the preservation of the 3D microstructure of bone that is responsible for bone stability. Bisphosphonates are well tolerated and have a very low incidence of serious side effects. Consequently, bisphosphonates have become the standard of care for the treatment of malignant bone disease. Benefits of bisphosphonate treatment appears to be more pronounced with longer treatment, indicating that they should be continued until no longer clinically relevant. As this advice has substantial implications on resources, it is essential that the use of bisphosphonates is evidence based.

Metastatic bone disease: Have we improved after a decade of guidelines?

Objectives

Guidelines for the management of patients with metastatic bone disease (MBD) have been available to the orthopaedic community for more than a decade, with little improvement in service provision to this increasingly large patient group. Improvements in adjuvant and neo-adjuvant treatments have increased both the number and overall survival of patients living with MBD. As a consequence the incidence of complications of MBD presenting to surgeons has increased and is set to increase further. The British Orthopaedic Oncology Society (BOOS) are to publish more revised detailed guidelines on what represents ‘best practice’ in managing patients with MBD. This article is designed to coincide with and publicise new BOOS guidelines and once again champion the cause of patients with MBD.

Methods

A series of short cases highlight common errors frequently being made in managing patients with MBD despite the availability of guidelines.

Results

Despite guidelines for the management of patients with MBD being available for more than a decade basic errors in management continue to be made, affecting patient survival and quality of life.

Conclusions

It is hoped that by publicising the new BOOS guidelines the management of patients with MBD will improve over the next decade, significantly more than it has over the last decade.

1st International consensus guidelines for advanced breast cancer (ABC 1)

The 1st international Consensus Conference for Advanced Breast Cancer (ABC 1) took place on November 2011, in Lisbon. Consensus guidelines for the management of this disease were developed. This manuscript summarizes these international consensus guidelines.

The perioperative management of skeletal metastases

Bone metastasis is a common problem affecting a significant proportion of patients with metastatic cancer. Bone metastasis can present in a number of ways and the patients may need surgical stabilisation of their lesions. There are many important considerations in the care of these patients that need to be borne in mind including their increased anesthetic risks and potential risk of complications. There are continuous developments in the prevention, diagnosis and treatment with advances in imaging, orthopaedic technique and medication, particularly radiopharmaceuticals and cytotoxic, endocrine treatments with newer treatments based around the tumour cell-osteoclast interaction. Having a better understanding of these considerations and developments is important in allowing the optimisation of the care of the patient with bone metastasis.

Optimizing pain relief in a specialized outpatient palliative radiotherapy clinic: contributions of a clinical pharmacist

PURPOSE

Bone metastases are the most common cause of cancer pain, with palliative radiotherapy (RT) the mainstay of treatment. However, relief from RT may be delayed, incomplete, or short-lived and therefore optimized pharmacologic therapy is essential. Our objective was to describe the contribution of the clinical pharmacist (CP) to an outpatient palliative RT clinic.

METHODS

The Edmonton Symptom Assessment System, an 11-point scale for measuring nine symptoms, and other validated screening tools were administered, and a medication history performed by the CP. Baseline CP assessment also included opioid toxicity, need for supportive medications, and drug interactions. Anonymized clinical information was collected prospectively and descriptive statistics were compiled including themes of counselling performed by the CP.

RESULTS

The CP reviewed 114 patients over 140 clinic visits (01/2007-12/2008). Median age was 68.3 years, 68.4% were male and 36.8% had prostate cancer. All symptoms improved or stabilized in ≥ 80% by 4 weeks. Median pain score was 6/10 (SD 2.6) at baseline, and 2.1/10 (SD 2.4) by week 4. Average morphine equivalent daily dose was 76.8 mg at baseline and 44.5 mg at week 4. CP assessment included screening for opioid toxicity (87.9%), recommending a change in analgesic (28.9%), and liaison with the community pharmacy (17.1%). Medication counselling took place in 84.3% of visits, on bowel routine (85.6% of the time), opioids (82.2%), and hydration (40.7%).

CONCLUSIONS

The CP plays a key role in holistic patient assessment and optimization of pharmacologic therapy, contributing to improved symptom control of patients receiving palliative RT.

The Need for a System of Prognostication in Skeletal Metastasis to Decide Best End-of-life Care – A Call to Arms

Introduction: The near terminal patient with skeletal metastasis may suitably be palliated with an intramedullary nail whereas another patient with good survival potential may benefit from a more extensive resection and reconstructive procedure. In a previous study by the senior author (Nathan et al, 2005), life expectancy in patients operated on for bone metastases correlated with clinical and haematological parameters in a normogram. We performed a cross-cultural comparison to validate this normogram. Materials and Methods: We randomly selected 73 patients who had undergone surgery for metastatic bone disease between 28 December 2000 and 11 March 2009. The time to deaths was recorded from hospital records and telephone interviews. Multiple parameters including clinical, radiological and haematological were evaluated for significant prognostic value using Kaplan-Meier survivorship analysis. Statistically significant parameters were entered into a Cox regression model for statistically independent significance. A multi-tier prediction of survival was performed by workers from various levels of seniority. Results: At the time of analysis, there were 40 deaths (55%). Median survival was 15.8 (95% CI, 7.9 to 23.7) months. Kaplan-Meier analysis showed that low haemoglobin (P = 0.0000005), presence of lymph node metastases (P = 0.00008), multiple bone metastases (P = 0.003), presence of visceral metastases, (P = 0.007), low lymphocyte count (P = 0.02) and low serum albumin (P = 0.02) were significantly associated with poor survival. By Cox regression analysis, presence of visceral metastases (P = 0.002), presence of lymph node metastases (P = 0.0002) and low haemoglobin (P = 0.01) were shown to be independent factors in the re diction of survival. Survivorship readings were superimposed onto the previous normogram and found to be similar. Independent blinded use of the normogram allowed good prediction of survival. There was a tendency to underestimate survival when patients survived beyond 1 year of skeletal metastasis. Conclusion: Our findings are similar to that of the previous study in showing a relationship between the above-mentioned parameters and survival. This is despite differences in patient demographic characteristics and management protocols. Use of the tools may allow better siting of most appropriate surgery in metastatic bony disease. Key words: Metastasis, Prognosis, Skeletal, Survival

Efficacy of clodronate, pamidronate, and zoledronate in reducing morbidity and mortality in cancer patients with bone metastasis: a meta-analysis of randomized clinical trials

BACKGROUND

Complications from skeletal-related events (SREs) constitute a challenge in the care of patients with metastatic bone disease (MBD) that originated from any type of malignancy.

OBJECTIVE

The purpose of this article was to compare the efficacy of clodronate, pamidronate, and zoledronate with that of placebo in reducing morbidity and overall mortality in cancer patients with MBD.

METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched (from inception to January 2009) to retrieve randomized clinical trials that evaluated the bisphosphonates of interest. The search included articles published in English, French, Italian, Portugese, and Spanish. Patients with a definite (ie, biopsy-proven) diagnosis of MBD were included in the analysis. We extracted and combined data from studies that reported the number of patients with SREs and mortality data. A random-effects, meta-analytic model was applied in all calculations. The Jadad scale was used to assess the quality of study reporting.

RESULTS

The literature search identified 62 potential full-text studies; 44 of these studies were excluded and 18 were evaluated. The mean (SD) quality of reporting of the included studies was 57.8% (22.6%), or 2.89/5 (1.1/5). Each of the 3 drugs was found to be more effective than placebo in preventing all SREs in cancer patients with MBD. The relative risk of developing SREs was 0.70 (95% CI, 0.61-0.81; N = 1211) for zoledronate, 0.81 (95% CI, 0.73-0.91; N = 2251) for pamidronate, and 0.87 (95% CI, 0.75-1.00; N = 681) for clodronate. However, no clear advantage of one drug over the others was observed (CIs overlapped substantially). None of the bisphosphonates was more beneficial than placebo in reducing the number of deaths in the course of the trials (P = NS).

CONCLUSION

Clodronate, pamidronate, and zoled-ronate were associated with reductions in morbidity in cancer patients with MBD with regard to preventing SREs, but were not associated with a reduction in overall mortality.

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is 18,002 pounds at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.

Orthopedic surgery implications of breast cancer

Breast cancer is the most common malignancy and the second leading cause of death in women. The metastatic involvement of bone denotes disease progression and decreased survival. Controversy exists regarding the exact pathophysiologic mechanism of metastasis and the different pathways that determine an osteoblastic versus osteoclastic bone compromise. Several breakthrough advances in imaging techniques aid in the detection, staging and follow-up of bone metastases. Although usually responsive to hormonal therapy and pharmacologic interventions, skeletal metastases often require some type of surgical intervention. Orthopedic surgeons should establish an active role in the multidisciplinary treatment of patients with breast cancer.

Can computerised tomography replace bone scintigraphy in detecting bone metastases from breast cancer? A prospective study

BACKGROUND

The aim of this study was to determine whether bone scans (BS) can be avoided if pelvis was included in CT thorax and abdomen to detect bony metastases from breast cancer.

MATERIALS AND METHODS

Results of 77 pairs of CT (thorax, abdomen, and pelvis) and BS in newly diagnosed patients with metastatic breast cancer (MBC) were compared prospectively for 12 months. Both scans were blindly assessed by experienced radiologists and discussed at multidisciplinary team meetings regarding the diagnosis of bone metastases.

RESULTS

CT detected metastatic bone lesions in 43 (98%) of 44 patients with bone metastases. The remaining patient had a solitary, asymptomatic bony metastasis in shaft of femur. BS was positive in all patients with bone metastases. There were 11 cases of false positive findings on BS.

CONCLUSION

Our findings suggest routine BS of patients presenting with MBC is not required if CT (thorax, abdomen, and pelvis) is performed.

Endocrine therapy for breast cancer: an overview

Endocrine therapy for breast cancer has been established in the adjuvant treatment for primary disease and in the treatment of advanced disease. The ER remains the best predictor of response although other factors exist and need to be identified. Pharmacological manipulation has been replacing ablative procedures. Tamoxifen used to be the most popular agent of choice and promising new agents include the pure anti-oestrogens and the third generation selective aromatase inhibitors. Ongoing and future studies will optimise treatment in established areas and will exploit its potential roles in preoperative use and chemoprevention.

Prognostic factors in pathologic fractures secondary to metastatic tumors

OBJECTIVE

Pathological fractures caused by metastases sharply decrease the quality of life and increase mortality rates for patients with malignant neoplasias. Orthopedic advances in osteosynthesis and endoprosthesis have been beneficial in the prevention and treatment of such fractures. The objective of our study was to determine which prognostic factors for pathologic fractures treated in our Service were significant.

METHOD

This was a retrospective study enrolling 112 patients treated for pathologic fractures secondary to metastatic tumors between April 1994 and December 2004 in our Service. Patients were analyzed according to sex, age, bone metastasis site, visceral metastases, origin of primary tumor, treatment type, serum hemoglobin, and survival.

RESULTS

The most affected site was the femur (44%), the most frequent primary tumor was breast cancer (25%); the most frequently employed surgical treatment was unconventional endoprosthesis (66%). Sex, age, primary tumor, site affected, non-bone metastasis, and clinical versus surgical treatment variables were not good predictors for survival. The only significant predictor was the type of surgery employed. Patients who received an endoprosthesis presented a worse prognosis (21.6 months) than patients undergoing osteosynthesis (47.8 months).

CONCLUSION

Patients undergoing osteosynthesis, with a less morbid surgical technique and earlier rehabilitation, had longer survival times than patients who received endoprostheses. Our case series is similar to international ones, where the most frequent primary tumor is breast tumor, followed by tumors of undetermined origin, prostate, and lung tumors.

Cost effectiveness of bisphosphonates in the management of breast cancer patients with bone metastases

BACKGROUND

Bisphosphonates are recommended to prevent skeletal related events (SREs) in patients with breast cancer and bone metastases (BCBM). However, their clinical and economic profiles vary from one agent to the other.

MATERIALS AND METHODS

Using modeling techniques, we simulated from the perspective of the UK's National Health Service (NHS) the cost and quality adjusted survival (QALY) associated with five commonly-used bisphosphonates or no therapy in this patient population. The simulation followed patients into several health states (i.e. alive or dead, experiencing an SRE or no SRE, and receiving first or second line therapy). Drugs costs, infusion costs, SREs costs, and utility values were estimated from published sources. Utilities were applied to time with and without SREs to capture the impact on quality of life.

RESULTS

Compared to no therapy, all bisphosphonates are either cost saving or highly cost-effective (with a cost per QALY < or = 6126 pounds sterlings). Within this evaluation, zoledronic acid was more effective and less expensive than all other options.

CONCLUSIONS

Based on our model, the use of bisphosphonates in breast cancer patients with bone metastases should lead to improved patient outcomes and cost savings to the NHS and possibly other similar entities.

Breast carcinoma bone metastasis first presenting to single middle phalanx

Phalangeal bone metastasis is rare. Breast cancer is known to metastasise to bone but rarely to fingers. This case presents the first site of breast cancer metastasis found on a single proximal phalanx causing pain and affecting hand function. For surgical symptomatic treatment the patient had a ray resection. Post-operatively the patient was pain free with excellent hand function.

Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care

PURPOSE

Life expectancy is routinely used as part of the decision-making process in deciding the value of surgery for the treatment of bone metastases. We sought to investigate the validity of frequently used indices in the prognostication of survival in patients with metastatic bone disease.

METHODS

The study prospectively assessed 191 patients who underwent surgery for metastatic bone disease. Diagnostic, staging, nutritional, and hematologic parameters cited to be related to life expectancy were evaluated. Preoperatively, the surgeon recorded an estimate of projected life expectancy for each patient. The time until death was recorded.

RESULTS

Kaplan-Meier survival analyses indicated that the survival estimate, primary diagnosis, use of systemic therapy, Eastern Cooperative Oncology Group (ECOG) performance status, number of bone metastases, presence of visceral metastases, and serum hemoglobin, albumin, and lymphocyte counts were significant for predicting survival (P < .004). Cox regression analysis indicated that the independently significant predictors of survival were diagnosis (P < .006), ECOG performance status (P < .04), number of bone metastases (P < .008), presence of visceral metastases (P < .03), hemoglobin count (P < .009), and survival estimate (P < .00005). Diagnosis, ECOG performance status, and visceral metastases covaried with surgeon survival estimate. Linear regression and receiver-operator characteristic assessment confirmed that clinician estimation was the most accurate predictor of survival, followed by hemoglobin count, number of visceral metastases, ECOG performance status, primary diagnosis, and number of bone metastases. Nevertheless, survival estimate was accurate in predicting actual survival in only 33 (18%) of 181 patients.

CONCLUSION

A better means of prognostication is needed. In this article, we present a sliding scale for this purpose.

Medical management of skeletal metastasis

This article discusses general principles of medical management of bone metastases, including diagnosis and follow-up; management of specific symptoms; options for systemic treatment, including bisphosphonates; specific details about each cancer type; and future directions in therapy.

Management of pathologic fractures of the proximal femur: state of the art

Metastases to bone are the most common cause of a destructive lesion of the skeleton in an adult. The proximal femur is the most commonly affected bone with metastatic disease in the appendicular skeleton. A systematic approach to patient management is critical, so as to avoid complications that will delay systemic therapy. The orthopedic traumatologist is often the first physician to see the patient with a pathologic fracture. As a result, the surgeon must be aware of the indications for resection versus internal fixation, as well as options for reconstruction. Polymethyl methacrylate and curettage can be useful in the appropriately selected patient. Postoperative external beam irradiation can significantly reduce disease progression and subsequent loss of fixation. A multidisciplinary approach to this patient group will help optimize prognosis as well as function. This article reviews the evaluation, management, and complications of treatment of pathologic fractures of the proximal femur, with an emphasis on metastatic disease and multiple myeloma.

Managing cancer-related skeletal events with bisphosphonates

Bone metastases cause considerable morbidity. This article discusses the benefits of bisphosphonates, which are now well established in the treatment of skeletal complications across a wide range of tumour types.

Clinical and economic issues in the treatment of advanced breast cancer with bisphosphonates

An ideal palliative therapy for bone metastases would successfully reduce skeletal complications in several thousands of breast cancer patients. Second- and third-generation bisphosphonates are effective in reducing the overall skeletal complication rate and the time to first skeletal complication. Nevertheless, not enough evidence supports their benefit on quality of life. Furthermore, bisphosphonates are expensive (up to 775 US dollars per month, 2002 value) and cost-effectiveness evaluations have been limited to pamidronate (pamidronic acid). In economic evaluations of pamidronate, resulting incremental dollar per quality-adjusted life year gained ranged from cost savings to 108,000 US dollars per quality-adjusted life year. The data were quite sensitive to quality-of-life estimates and country-specific cost values. Because of the wide range of the cost-effectiveness ratio, it is uncertain whether the universal prescription of bisphosphonates in this setting represents an efficient use of healthcare resources. Probably, country- and drug-specific policies might increase the efficiency of this treatment. Further outcomes research is required to assess these agents more fully.

General principles of external beam radiation therapy for skeletal metastases

Radiation therapy plays a major role in the treatment of patients with bone metastases. The primary goals of treatment include pain relief and relief of neurologic symptoms, if present. Approximately 70% of patients will achieve pain relief with palliative external beam radiotherapy. Improvement in the severity of pain may occur within as few as 48 to 72 hours of initiation of therapy, but in some patients significant relief of pain may not occur for 4 weeks after completion of therapy. Treatment schemes ranging from 800 cGy in a single treatment to 3000 cGy in 10 treatments have not been shown to result in major differences in outcome. Treatment decisions must be individualized based on factors such as the patient's performance status, life expectancy, location of the lesion, and size of area to be treated. External beam radiotherapy is recommended after surgical treatment of pathologic fractures or impending fractures to decrease the need for a second surgical procedure and improve the patient's functional outcome. External beam radiotherapy continues to be an important component of the palliative treatment of bone metastases. Its integration with newer therapeutic modalities such as vertebroplasty and radiofrequency ablation currently is being studied.

Bone metastases from breast carcinoma: histopathological - radiological correlations and prognostic features

The aim of this study was to identify factors that may be associated with the development of bone metastases in patients with metastatic breast carcinoma and to see if any of these factors had a bearing on subsequent survival. In total, 492 patients presented to the Nottingham City Hospital with metastatic breast carcinoma between July 1997 and December 2001. Of these, 267 patients had bone metastases at presentation with metastatic disease, 91 patients in this group had bone as their only site of metastatic disease. Sites of first presentation of metastatic disease were prospectively recorded, as were histological features of the primary tumour (tumour type, histological grade, lymph node stage, tumour size and oestrogen receptor (ER) status). The radiological features of the bone metastases, the metastasis-free interval and serological tumour marker levels at presentation with metastases were all recorded. There was a significant association between the development of bone metastases and lower grade tumours (P=0.019), ER-positive tumours (P<0.0001) and the lymph node stage of the primary tumour (P=0.047). A multivariate analysis found that metastasis-free interval, additional sites of metastatic disease other than bone, ER status and serological tumour marker levels all independently contributed to survival from time of presentation with bone metastases.

The clinical and cost considerations of bisphosphonates in preventing bone complications in patients with metastatic breast cancer or multiple myeloma

The bisphosphonates are potent inhibitors of osteoclast-mediated bone resorption and are now the treatment of choice for the management of hypercalcaemia of malignancy. The incidences of hypercalcaemia and other skeletal complications (bone pain, pathological fracture) remain high despite apparent responses to systemic therapy, with particularly high event rates in women with advanced skeletal metastases of breast cancer. This review focuses on studies addressing the long-term efficacy of bisphosphonates to reduce skeletal complications in breast cancer (5 studies) and multiple myeloma (4 studies), with particular reference to controlled studies of sufficient magnitude and duration to allow confidence in the estimation of efficacy. Bearing in mind the limitations of differences in trial design and the lack of direct studies comparing drugs, adequate exposure to a bisphosphonate reduces the incidence of skeletal complication by 30 to 40% in both breast cancer and multiple myeloma. Oral clondronate and intravenous pamidronate have similar efficacy in both diseases, but the duration of efficacy may differ between drugs. Both agents have shown intriguing survival benefits in subgroups of patients. The numbers needed to treat (NNT) to prevent a skeletal complication during one year are lowest in metastatic skeletal disease in breast cancer (NNT < 8) but also compare very favourably with other disease for patients with recurrent nonskeletal breast cancer or multiple myeloma (NNTs 7 to 31 depending on the complication to be prevented). Treatment costs of both breast cancer and multiple myloma are driven by inpatient and outpatient hospital visits so that bisphosphonate regimens should be developed that reduce both. Further research is required to determine if subgroups of patients can be better identified that will derive particular benefit, or perhaps no benefit at all, from bisphosphonate therapy. It is not known whether more potent bisphosphonates will deliver greater clinical efficacy in the future.

Current treatment modalities of breast-cancer patients in Alexandria, Egypt

Despite great advances in the treatment of breast cancer during recent years, many breast cancer patients still do not receive appropriate treatment. Data were collected during a 1-year period from nine general hospitals aiming at evaluating the quality of care delivered to breast cancer patients in Alexandria, Egypt. A total of 565 breast cancer patients were involved. The highest frequency of cases was diagnosed in stage II followed by stage III. Patey's modified radical mastectomy was the most commonly performed operation (82.65% of cases), regardless of the clinical stage or health facilities. Hormonal receptor status was rarely performed. There was no consensus regarding the type of systemic therapy (hormonal, chemotherapy or combined) to be administered for each clinical stage and menopausal status. Concerning postoperative radiotherapy, it was invariably the rule, regardless of the clinical stage. We conclude that, despite some improvement over the last few years (shorter diagnostic delay, larger use of standard classifications, and less radical surgery), the quality of management of breast cancer in Egyptian general hospitals is still not satisfactory.

Detection of occult disease in breast cancer using fluorodeoxyglucose camera-based positron emission tomography

An isolated increase of blood tumor marker CA 15.3 in breast cancer is considered a sensitive indicator for occult metastatic disease but by itself is not sufficient for initiating therapeutic intervention. We investigated the potential of camera-based positron emission tomography (PET) imaging using [18F]-fluorodeoxyglucose (FDG) to detect clinically occult recurrences in 132 female patients (age, 35-69 years) treated for breast cancer, all presenting with an isolated increase in blood tumor marker CA 15.3 without any other evidence of metastatic disease. FDG results were correlated to pathology results or to a sequentially guided conventional imaging method. One hundred nineteen patients were eligible for correlations. Positive FDG scans were obtained for 106 patients, including 89 with a single lesion and 17 with 2 or more lesion. There were 92 true-positive and 14 false-positive cases, 10 of which became true positive within 1 year. Among the 13 negative cases, 7 were false negative and 6 were true negative. Camera-based PET using FDG has successfully identified clinically occult disease with an overall sensitivity of 93.6% and a positive predictive value of 96.2%. The smallest detected size was 6 mm for a lymph node metastasis (tumor to nontumor ratio, 4:2). FDG camera-based PET localized tumors in 85.7% of cases suspected for clinically occult metastatic disease on the basis of a significant increase in blood tumor marker. A positive FDG scan associated with an elevated CA 15.3 level is most consistent with metastatic relapse of breast cancer.

The use of blood tumour markers in the monitoring of metastatic breast cancer unassessable for response to systemic therapy

The role of blood tumour markers is established in the monitoring of response to systemic therapy for patients with metastatic breast cancer assessable by UICC criteria. This paper examines the use of marker measurements (in the form of a previously devised biochemical index score comprising CA15.3, CEA and ESR) in patients with metastatic lesions unassessable for response by UICC criteria. Of 218 patients with metastatic breast cancer treated over a 2-year period in the Nottingham Breast Unit, 43 patients (20%) had unassessable disease and 36 of them with blood marker results available were studied. Eighty-six per cent of patients were biochemically assessable. All patients who achieved biochemical response remained unassessable by UICC criteria. Twenty-two patients progressed initially or subsequently (after an initial biochemical response), either biochemically or by UICC criteria. Biochemical assessment completely paralleled UICC assessment in all eight patients who progressed by both assessments. Biochemical progression occurred ahead of UICC assessment in four of them with a median lead-time of 4.5 months. Biochemical assessment by blood tumour markers is useful in patients with metastatic breast cancer unassessable for response to systemic therapy. These findings need to be confirmed in a larger patient series.

Metastatic bone disease and tumour-induced hypercalcaemia: the role of bisphosphonates

Tumour-induced hypercalcaemia (TIH) is the most common metabolic disorder associated with cancer, and if left untreated is associated with a low survival rate. Bisphosphonates are potent inhibitors of bone resorption. They have emerged as the standard method of treatment for TIH and a new form of medical therapy for bone metastases in addition to current treatments. Newer forms of bisphosphonates are 100-1000 times more potent than pamidronate, the current gold standard. One of these third generation bisphosphonates, zoledronic acid (Zometa, Novartis Pharmaceuticals) has already been shown to provide more effective treatment of TIH than pamidronate. Ongoing research is aimed at choosing the optimum route, type of bisphosphonate and combination therapy to inhibit the development of bone metastases and TIH.