Increased incidence of bone metastases in hepatocellular carcinoma

Unusual extrahepatic metastatic site of hepatocellular carcinoma with post-therapy disseminating metastases presenting as a primary soft tissue sarcoma: case report

Introduction and importance

Hepatocellular carcinoma (HCC) is a highly malignant primary hepatic tumor. However, extrahepatic metastatic sites of HCC with post-therapy dissemination of metastases mimicking primary soft tissue sarcomas with rib metastases are extremely rare.

Case presentation

The authors report a unique case of hepatitis B virus (HBV)-positive HCC with bilateral lung involvement and widespread right-flank soft tissue and rib metastases. The pathological diagnosis after surgical resection confirmed extrahepatic HCC metastasis. Subsequently, adjuvant-targeted and immune-checkpoint inhibitor therapies were still initiated.

Clinical discussion

Extrahepatic HCC metastasis, which initially presents at distant sites, is uncommon. HCC commonly metastasizes to the lungs, bones, lymph nodes, kidneys, adrenal glands, and peritoneum/omentum. HCC with aggressive post-scheduled adjuvant therapy to the lungs and hypochondriac soft tissue with rib metastasis is very rare and has a poor prognosis.

Conclusion

Although most patients with HCC have disseminated extrahepatic metastases, primary HCC should still be treated. Thus, a review of the history and imaging, histopathology, and immunohistochemical findings is crucial for the definite and differential diagnosis of this tumor.

Skull Metastasis With Orbital Invasion as a Primary Manifestation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a common worldwide cancer with a poor prognosis despite treatment advancements. Patients typically exhibit signs and symptoms pertaining to the liver. Extrahepatic metastasis of HCC is documented to be as low as 5% of cases. Bone metastasis ranks third following lungs and regional lymph nodes. The typical locations for bone metastasis include the vertebral column, pelvis, femora, and ribs, with skull metastasis, being reported in less than 1.6% of cases. Herein, we describe a case of HCC presenting with skull metastases and orbital invasion as the initial manifestation.

Effects of Clinical and Tumor Characteristics on Survival in Patients with Hepatocellular Carcinoma with Bone Metastasis

Background

Advanced hepatocellular carcinoma (HCC) generally has a dismal prognosis. Bone metastases from HCC are infrequent, with a poorer prognosis. However, the survival influencing factors are not yet well understood.

Aim

The aim of the present study was to assess the clinical features and tumor characteristics of HCC patients with bone metastasis.

Methods

A cohort of 170,576 adult patients with HCC was studied using the National Cancer Database (NCDB) spanning from 2010 to 2019, and within this group, 5285 patients (3.1%) were diagnosed with bone metastasis. We performed the Kaplan-Meier method to calculate the median overall survival (OS). We included demographics (age at diagnosis, gender, race, insurance status), comorbidity score, and treatment characteristics.

Results

Of a total of 5285 HCC patients with bone metastasis, 86.2% were male and 61.2% were non-Hispanic white. Most patients (55.1%) were below 65, and 89% had a total Charlson-Deyo comorbidity score of under 3. Among patients with known tumor grade, 24.8% had well-differentiated tumors, and 36.1% had poorly differentiated tumors. Chemotherapy was administrated to 39.5% of patients. In univariate analysis, patients with well-differentiated tumors had better OS compared to poorly differentiated tumors (5.4 months vs 3.0 months, p = 0.001). Patients who received single or multiagent chemotherapy were significantly associated with improved OS compared to patients who did not receive chemotherapy (7.0 and 8.5 months vs 1.94 months, respectively). We also found mortality difference between age, comorbidity scores, facility types and race groups.

Conclusion

In this cohort analysis of NCDB data, we found better OS in treatment receipt, lower tumor grade, younger age, non-Hispanic Black and Hispanic race, treatment at academic facility and lower comorbidity score in HCC patients with bone metastasis. The study results may have a consequential impact on the treatment decisions for HCC patients with bone metastasis.

Image-Guided Ablation Therapies for Extrahepatic Metastases from Hepatocellular Carcinoma: A Review

The most common sites of extrahepatic metastases from hepatocellular carcinoma (HCC) are the lungs, intra-abdominal lymph nodes, bones, and adrenal glands, in that order. Although systemic therapies are a common treatment for patients with extrahepatic metastases, local ablative therapies for the extrahepatic metastatic lesions can be performed in selected patients. In this article, the literature on image-guided thermal ablation for metastasis to each organ was reviewed to summarize the current evidence. Radiofrequency ablation was the most commonly evaluated technique, and microwave ablation, cryoablation, and percutaneous ethanol injection were also utilized. The local control rate of thermal ablation therapy was relatively favorable, at approximately 70-90% in various organs. The survival outcomes varied among the studies, and several studies reported that the absence of viable intrahepatic lesions was associated with improved survival rates. Since only retrospective data from relatively small studies has been available thus far, more robust studies with prospective designs and larger cohorts are desired to prove the usefulness of thermal ablation for extrahepatic metastases from HCC.

Pituitary metastasis of hepatocellular carcinoma as the initial presentations: a case report and review of the literature

Background

Extrahepatic metastasis of hepatocellular carcinoma (HCC) is common. However, pituitary metastasis of HCC is extremely rare. Our case may be helpful to extend the understanding of the disease.

Case presentation

A 65-year-old man presented to the outpatient department for unexplained headache and ptosis for 1 month. Brain imaging showed a slight enhancement tumor in the pituitary fossa, and the endocrinological assessment showed normal results. We considered the tumor as a non-functioning pituitary adenoma before surgery. Then, the tumor was resected by an endonasal endoscopic transsphenoidal approach. The histopathological examination results revealed the pituitary metastasis of HCC. Additional abdominal imaging revealed tumors were located in the left and right liver lobes with portal vein invasion and bilateral ilium metastases. After multidisciplinary cooperation, the patient chose chemotherapy.

Conclusion

We report a case of HCC metastasis to the pituitary gland that initially presented with neurological symptoms. We should consider the possibility of pituitary metastasis in HCC patients.

A case of bone metastasis of hepatocellular carcinoma: Mallory hyaline bodies can lead to the correct cytological diagnosis

Hepatocellular carcinoma (HCC) accounts for most primary tumors of the liver. Although bone metastasis does not occur in a high percentage of patients, bone metastasis is often found first, which leads to the diagnosis of HCC. In this report, we describe a case of bone metastasis from HCC in which bone lesions were detected incidentally, and in which a cytological diagnosis was difficult to make. The patient was a 78-year-old man with a history of renal dysfunction after orthopedic surgery. He underwent a thorough examination after a bone tumor was incidentally found on abdominal CT. Plasmacytoma was suspected. Fine needle aspiration cytology revealed irregular clusters of medium-to-large atypical epithelioid polygonal cells with relatively abundant eosinophilic, somewhat granular cytoplasm, and indistinct cell borders, which led to a diagnosis of malignancy. Histologically and immunohistochemically, the tumor was diagnosed as bone metastasis of HCC. Re-examination of the cytological specimen revealed characteristic Mallory hyaline bodies (MHBs). Immunohistochemistry using a cell transfer method revealed that they were positive for low molecular weight cytokeratin, Cam5.2, in a densely granular fashion. In this case, the cytological diagnosis of HCC was difficult to make due to the unclear cytoplasmic borders and absence of bile pigment. However, the identification of MHBs can potentially guide me to the correct cytological diagnosis.

Extrahepatic metastasis of hepatocellular carcinoma: A Malaysian case series

Introduction: Hepatocellular carcinoma (HCC) is a primary malignancy which arises from hepatocytes. It is the sixth most commonly diagnosed cancer and the third leading cause of cancer death worldwide in 2020. It predominantly metastasizes via the hematogenous route. However, there are possibility of distant metastasis via the lymphatic and bone dissemination in a few of HCC cases. Case Series: We report two atypical cases of HCC with distant metastasis to cervical lymph node and bone in Malaysia. The first case reported is a HCC case of extrahepatic metastasis to cervical lymph node and the second case is a HCC case of extrahepatic metastasis to right femur. Conclusion: The patients with atypical site of distant metastasis from HCC have poor prognosis. Overall physical examination should be done to prevent overlook for all the patients with HCC.

Large Oncosome-Loaded VAPA Promotes Bone-Tropic Metastasis of Hepatocellular Carcinoma Via Formation of Osteoclastic Pre-Metastatic Niche

Tumor-derived extracellular vesicles (EVs) function as critical mediators in selective modulation of the microenvironment of distant organs to generate a pre-metastatic niche that facilitates organotropic metastasis. Identifying the organ-specific molecular determinants of EVs can develop potential anti-metastatic therapeutic targets. In the current study, large oncosomes (LOs), atypically large cancer-derived EVs, are found to play a crucial role in facilitating bone-tropic metastasis of hepatocellular carcinoma (HCC) cells by engineering an osteoclastic pre-metastatic niche and establishing a vicious cycle between the osteoclasts and HCC cells. Transmembrane protein, VAMP-associated protein A (VAPA), is significantly enriched on LOs surface via direct interaction with LOs marker αV-integrin. VAPA-enriched LOs-induced pre-metastatic education transforms the bone into a fertile milieu, which supports the growth of metastatic HCC cells. Mechanically, LOs-delivered VAPA integrates to plasma membrane of osteoclasts and directly interacts with and activates neural Wiskott-Aldrich syndrome protein (N-WASP) via dual mechanisms, consequently resulting in ARP2/3 complex-mediated reorganization of actin cytoskeleton in osteoclasts and osteoclastogenesis. Importantly, treatment with N-WASP inhibitor 187-1-packaged LOs (LOs/187-1) dramatically abolishes the inductive effect of VAPA-enriched LOs on pre-metastatic niche formation and precludes HCC bone metastasis. These findings reveal a plausible mechanism for bone-tropism of HCC and can represent a potential strategy to prevent HCC bone metastasis.

Epidemiology of spinal metastases, metastatic epidural spinal cord compression and pathologic vertebral compression fractures in patients with solid tumors: A systematic review

Introduction

Spinal metastases (SM) are a frequent complication of cancer and may lead to pathologic vertebral compression fractures (pVCF) and/or metastatic epidural spinal cord compression (MESCC). Based on autopsy studies, it is estimated that about one third of all cancer patients will develop SM. These data may not provide a correct estimation of the incidence in clinical practice.

Objective

This systematic review (SR) aims to provide a more accurate estimation of the incidence of SM, MESCC and pVCF in a clinical setting.

Methods

We performed a SR of papers regarding epidemiology of SM, pVCF, and MESCC in patients with solid tumors conform PRISMA guidelines. A search was conducted in the PubMed and Web of Science database using the terms epidemiology, prevalence, incidence, global burden of disease, cost of disease, spinal metastas*, metastatic epidural spinal cord compression, pathologic fracture, vertebral compression fracture, vertebral metastas* and spinal neoplasms. Papers published between 1975 and august 2021 were included. Quality was evaluated by the STROBE criteria.

Results

While 56 studies were included, none of them reports the actual definition used for MESCC and pVCF, inevitably introducing heterogenity. The overall cumulative incidence of SM and MESCC is 15.67% and 2.84% respectively in patients with a solid tumor. We calculated a mean cumulative incidence in patients with SM of 9.56% (95% CI 5.70%-13.42%) for MESCC and 12.63% (95% CI 7.00%-18.25%) for pVCF. Studies show an important delay between onset of symptoms and diagnosis.

Conclusions

While the overall cumulative incidence for clinically diagnosed SM in patients with a solid tumor is 15.67%, autopsy studies reveal that SM are present in 30% by the time they die, suggesting underdiagnosing of SM. Approximately 1 out of 10 patients with SM will develop MESCC and another 12.6% will develop a pVCF. Understanding these epidemiologic data, should increase awareness for first symptoms, allowing early diagnosis and subsequent treatment, thus improving overall outcome.

Emerging Perspectives of Bone Metastasis in Hepatocellular Carcinoma

Recent evidence suggests the global incidence and mortality of hepatocellular carcinoma (HCC) are increasing. Although the highest incidence of HCC remains entrenched in WHO regions with high levels of HBV-HCV infection, the etiology of this disease is rapidly changing to include other lifestyle risk factors. Extrahepatic metastasis is a frequent feature of advanced HCC and most commonly locates in the lungs and bone. Bone metastasis in HCC (HCC-BM) signals a more aggressive stage of disease and a poorer prognosis, simultaneously HCC-BM compromises the function and integrity of bone tissue. HCC induced osteolysis is a prominent feature of metastasis that complicates treatment needed for pathologic fractures, bone pain and other skeletal events like hypercalcemia and nerve compression. Early detection of bone metastases facilitates the treatment strategy for avoiding and relieving complications. Although recent therapeutic advances in HCC like targeting agents and immunotherapy have improved survival, the prognosis for patients with HCC-BM remains problematic. The identification of critical HCC-BM pathways in the bone microenvironment could provide important insights to guide future detection and therapy. This review presents an overview of the clinical development of bone metastases in HCC, identifying key clinical features and identifying potential molecular targets that can be deployed as diagnostic tools or therapeutic agents.

Metastatic bone cancer: Consideration for optimal dose fractionation in radiation therapy

The bones are one of the most common sites for metastatic cancer spread. Unfortunately, there is no current known cure for many people affected by bone metastasis. Therefore, the treatment intent for radiotherapy remains a palliative objective, whereby treatments are meant to provide pain relief and alleviate symptoms. However, some debate has arisen in recent decades regarding the most appropriate dose prescription pertaining to dose protraction and fractionation. By delivering a larger dose in fewer fractions, patients can spend less time at the hospital and more time with loved ones. Additionally, many dose prescriptions were prioritized to be shortened during the COVID-19 pandemic, which may offer retrospective data on the treatment outcomes from providing shortened courses of radiotherapy.

Advancing Treatment of Bone Metastases through Novel Translational Approaches Targeting the Bone Microenvironment

Bone metastases represent a lethal condition that frequently occurs in solid tumors such as prostate, breast, lung, and renal cell carcinomas, and increase the risk of skeletal-related events (SREs) including pain, pathologic fractures, and spinal cord compression. This unique metastatic niche consists of a multicellular complex that cancer cells co-opt to engender bone remodeling, immune suppression, and stromal-mediated therapeutic resistance. This review comprehensively discusses clinical challenges of bone metastases, novel preclinical models of the bone and bone marrow microenviroment, and crucial signaling pathways active in bone homeostasis and metastatic niche. These studies establish the context to summarize the current state of investigational agents targeting BM, and approaches to improve BM-targeting therapies. Finally, we discuss opportunities to advance research in bone and bone marrow microenvironments by increasing complexity of humanized preclinical models and fostering interdisciplinary collaborations to translational research in this challenging metastatic niche.

The homogeneity and heterogeneity of occurrence, characteristics, and prognosis in hepatocellular carcinoma patients with synchronous and metachronous bone metastasis

Purpose: Based on the one of the largest hepatocellular carcinoma (HCC) population with bone metastasis (BM) from the single center in Tianjin, China, the present study aimed to investigate the risk and survival of synchronous bone metastasis (sBM) and metachronous bone metastasis (mBM) in HCC, and to reveal characteristics and related factors of HCC patients with bone metastasis.

Methods: HCC patients with bone metastasis between 2009 and 2017 from Tianjin Medical University Cancer Institute & Hospital, Tianjin, China, were involved. Chi-square test/ Fisher's exact test and Logistic regression were used to estimate the risk factors of bone metastasis in HCC. Kaplan-Meier method was used to estimate the survival of HCC patients, and the Log-rank test was used to analyze the survival of HCC patients. The prognostic factors of HCC patients with BM were identified via Kaplan-Meier method and multivariable COX regression model.

Results: Among 4421 HCC patients, 128 patients with BM were identified. Of the 128 patients with BM, 77 patients (60.16%) were with sBM and 51 patients (39.84%) were with mBM. The incidence of sBM in HCC was 1.74% at initial diagnosis. The most common metastatic site of sBM was rib, followed by lumbar, thoracic, and sacral. The median latency time from HCC diagnosis to mBM was six months. The most common site of mBM was thoracic, followed by lumbar, sacral and rib. Alcohol-drinking history (P=0.027), numbers (P=0.023) and size (P=0.008) of intrahepatic tumor, lymph node metastasis (P<0.001), serum ALP (P=0.004) and HGB (P=0.004) level were found to be correlated with the occurrence of BM. The overall survival between non-BM and BM were statistically different (P=0.028).

Conclusion: The incidence of sBM in HCC was 1.74% at initial diagnosis. The median latency time from HCC diagnosis to mBM was 6 months. The characteristics between occurrence and prognosis showed significant difference between sBM and mBM. Early identification of high-risk BM population was essential for the improvement of both quality of life and prognosis. The revealed related factors can potentially guide sBM and mBM identification and early diagnosis in HCC.

A Trigeminal Neuropathy From an Inactive Hepatocellular Carcinoma

Breast, lung, prostate, thyroid, and kidney carcinomas are the primary tumors that are known to have bony metastasis. Hepatocellular carcinoma (HCC) frequently involves the lung and lymph nodes and less commonly the osseous system. Numbness/persistent pain in the distribution of the trigeminal nerve is more likely a neuropathy. The causes are idiopathic(common), unintentional injury to the trigeminal nerve during surgery or trauma, blood vessel pressing the trigeminal nerve, tumor infiltration, multiple sclerosis, and stroke. Unresolved facial pains after conventional treatment should prompt additional investigation to rule out other causes. In this case, we report a trigeminal neuropathy of rare cause, which is a solitary metastasis from an inactive HCC involving the osseous structures.

Progress of Phototherapy Applications in the Treatment of Bone Cancer

Bone cancer including primary bone cancer and metastatic bone cancer, remains a challenge claiming millions of lives and affecting the life quality of survivors. Conventional treatments of bone cancer include wide surgical resection, radiotherapy, and chemotherapy. However, some bone cancer cells may remain or recur in the local area after resection, some are highly resistant to chemotherapy, and some are insensitive to radiotherapy. Phototherapy (PT) including photodynamic therapy (PDT) and photothermal therapy (PTT), is a clinically approved, minimally invasive, and highly selective treatment, and has been widely reported for cancer therapy. Under the irradiation of light of a specific wavelength, the photosensitizer (PS) in PDT can cause the increase of intracellular ROS and the photothermal agent (PTA) in PTT can induce photothermal conversion, leading to the tumoricidal effects. In this review, the progress of PT applications in the treatment of bone cancer has been outlined and summarized, and some envisioned challenges and future perspectives have been mentioned. This review provides the current state of the art regarding PDT and PTT in bone cancer and inspiration for future studies on PT.

A Rare Occurrence of Scalp Metastasis in Hepatocellular Carcinoma: Case Report

Hepatocellular carcinoma (HCC) is the most prevalent primary liver malignancy and the fifth most common cancer worldwide. Extrahepatic spread in this type of cancer is most commonly seen in the lungs and lymph nodes and less commonly in the skeletal system. Skull metastases are exceedingly rare, with an incidence of 0.5 to 1.6% reported to date. We report a similar case of a middle-aged Asian male patient with parietal scalp swelling that was initially diagnosed as meningioma. Surgical resection was performed at a local facility. The abdominal computed tomography scan did not reveal any primary or metastatic lesion. After much deliberation, multiparametric magnetic resonance imaging was requested that showed multiple lesions in the liver. Metastatic scalp lesion should be considered a differential diagnosis in HCC regardless of liver symptoms.

Parapharyngeal metastasis in hepatocellular carcinoma-a rare entity

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. It most commonly metastasizes haematogenously to the lungs and bones, less commonly via lymphatics to lymph nodes. However, metastasis to the parapharyngeal space has yet to be reported. This is the first clinical report of the treatment of parapharyngeal metastasis from HCC. The case of a 46-year-old man who was found to have a parapharyngeal soft tissue mass during routine follow-up 12 years post deceased-donor liver transplantation for hepatitis B-related HCC is reported here. This was investigated and diagnosed to be metastatic HCC. He underwent excision of the parapharyngeal metastasis, followed by adjuvant radiotherapy. Parapharyngeal metastasis is a rare occurrence in HCC. It is important to be cognizant of the possibility of disease spread to this location in order to ensure early detection and treatment. Surgical excision with adjuvant radiotherapy should be considered to achieve disease control.

Extrahepatic metastases from hepatocellular carcinoma: multimodality image evaluation

The most prevalent primary malignancy of the liver is hepatocellular carcinoma (HCC); its poor prognosis is mainly related to intrahepatic recurrence and extrahepatic metastases. However, survival from HCC has improved due to better control of the primary tumor, the development of newer treatment modalities, including liver transplant, together with advances in imaging techniques. Therefore, the significance of patient management as corresponds with distant metastases has increased; since the proper evaluation and detection of extrahepatic metastases is crucial to optimize potential therapy for patients. Conventional imaging like CT, MRI play crucial rule in patient's diagnosis and qualifying for a certain type of therapy. More recently, a molecular imaging tool with radiolabeled deoxyglucose and fluorocholine has proved its promising value as a complementary tool to conventional studies. In this review, the frequent sites of metastases and HCC spread are discussed as well as the imaging findings as seen by both conventional imaging techniques and by molecular imaging tools, namely 18F-Choline PET/CT, and FDG PET. The implications of guiding treatment planning have also been discussed.

A Shock-Like Pain and Inability to Ambulate: Thoracic Spinal Cord Compression from Hepatocellular Carcinoma

Hepatocellular carcinoma commonly metastasizes to organs, but there are few reports of vertebral metastases causing cord compression. Here, we present a case of thoracic cord compression in a patient with advanced hepatocellular carcinoma. Providers' and patient's awareness of this risk is important, as this is an oncological emergency.

Hepatocellular Carcinoma: First Manifestation as Solitary Humeral Bone Metastasis

Hepatocellular carcinoma (HCC) most commonly presents with abdominal pain or mass, fever of unknown etiology, weight loss, and decompensation of known liver disease or at an asymptomatic stage through surveillance. Rarely, presenting symptoms can be exclusively related to extrahepatic metastases. Herein, we write a case of a patient with no known liver disease, presenting with a pathological fracture of the proximal humerus bone secondary to a massive solitary metastasis from HCC. This case represents an unusual appendicular skeletal metastasis in a patient with unknown primary HCC, successfully treated with sorafenib. The prognosis of HCC patients with extrahepatic metastasis is poor, and in the presence of bone metastases, the mean survival rate is severely reduced. However, the multikinase inhibitor sorafenib has been the standard of treatment. Recently, there has been developments of other therapeutic class of drugs (i.e., immune check inhibitors), which have shown promising benefits and better side effect profiles. Still, there is a need for further studies, owing to challenges in recognizing cellular and molecular markers.

Nationwide Patterns of Pathologic Fractures Among Patients Hospitalized With Bone Metastases

OBJECTIVES

Pathologic fractures from bone metastases can significantly affect quality-of-life, although it is unclear which patients may be at high risk of this outcome. We aim to determine risk factors for pathologic fracture among patients admitted with bone metastases and to evaluate the association of pathologic fracture with clinical and economic outcomes.

METHODS

The Healthcare Cost and Utilization Project National Inpatient Sample was queried for all patients hospitalized with bone metastases in 2016. Baseline differences between patients with and without pathologic fractures were assessed by χ and analysis of variance testing. Multivariable logistic regression was used to identify factors associated with fractures.

RESULTS

In 2016, 272,275 hospital admissions were associated with a diagnosis of bone metastases, of which 11,960 (4.4%) had a primary diagnosis of pathologic fracture. Patients with pathologic fractures had a longer length-of-hospital-stay (mean 7.5 vs. 6.4 d; P<0.001) and higher cost-of-hospital-stay (mean $23,611 vs. $15,942; P<0.001) compared to patients without pathologic fractures. Primary cancers associated with increased likelihood of pathologic fracture included liver and intrahepatic bile duct (odds ratio [OR] 2.34; 95% confidence interval [CI], 1.65-3.32), multiple myeloma (OR 1.94; 95% CI, 1.31-2.86), and kidney and renal pelvis cancer (OR 1.89; 95% CI, 1.50-2.37).

CONCLUSIONS

Nearly 5% of hospitalizations with bone metastases presented with a concomitant pathologic fracture, which was associated with longer inpatient stay and higher cost. Patients with hepatobiliary, renal cell carcinoma, or multiple myeloma, had a higher likelihood of pathologic fracture. These groups may benefit from increased outpatient monitoring, prophylactic stabilization, or early irradiation.

Diagnostic and prognostic nomograms for bone metastasis in hepatocellular carcinoma

Background

Bone metastasis (BM) is one of the common sites of hepatocellular carcinoma (HCC), and the prognosis of BM patients is worse than patients without it. Our study aimed to identify predictors and prognostic factors of BM in HCC patients and develop two nomograms to quantify the risk of BM and the prognosis of HCC patients with BM.

Methods

We retrospectively reviewed the data of patients who were diagnosed as HCC between 2010 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database. Independent predictors for BM from HCC patients were determined by the univariate and multivariate logistic regression analysis. Independent prognostic factors for HCC patients with BM were identified by univariate and multivariate Cox regression analysis. Two nomograms were established and evaluated by calibration curves, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA).

Results

Nine thousand and forty-seven patients were included. The independent risk factors of BM in newly diagnosed HCC patients are sex, grade, T stage, and N stage. The independent prognostic factors for HCC patients with BM are radiotherapy, chemotherapy, and lung metastasis. The AUC of diagnostic nomogram were 0.726 in the training set and 0.629 in the testing set. For the prognostic nomogram, the AUCs of 6-, 9-, and 12-months were 0.753, 0.799, and 0.732 in the training set and 0.698, 0.770, and 0.823 in the validation set. The calibration curve and DCA indicated the good performance of the nomogram.

Conclusions

Two nomograms were established to predict the incidence of BM in HCC patients and the prognosis of HCC patients with BM, respectively. Both nomograms have satisfactory accuracy, and clinical utility may benefit for clinical decision-making.

Superior Sagittal Sinus Tumor Eroding through the Skull: An Unfamiliar Presentation of Hepatocellular Carcinoma and Literature Review

Background

Hepatocellular carcinoma (HCC) most commonly develops in patients with liver cirrhosis caused by hepatitis C and B virus. HCC is the most common cause of death in people with cirrhosis. The lungs, bone, and lymph nodes are frequent sites of metastasis of HCC.

Patients and Methods

We present a case of solitary skull metastasis as the first symptom of HCC. A literature review with regard to HCC skull metastasis was undertaken.

Results

This patient had HCC based on chronic hepatitis C. He presented with an erosive lesion masquerading as a scalp lipoma resulting in hepatocellular carcinoma with retrograde reflux and sinus metastases. The lesion was ultimately resected, but the patient died within one week from liver failure. Seventeen similar cases were found in the literature. Median age of the patients was 58 years with 95% being male and 35% having viral hepatitis. Surgery was the preferred treatment with chemotherapy and radiation being other options. Outcome was acceptable but baseline liver disease is a limiting factor.

Discussion

Cranial metastases of HCC are rare but should be considered in patients with chronic hepatitis C presenting with scalp skin lesions.

Female sex is associated with a lower risk of bone metastases and favourable prognosis in non-sex-specific cancers

Background

The objectives were to investigate the disparity in the prevalence of bone metastases (BM) between the sexes and to assess the effect of female sex on the development and prognosis of BM.

Methods

Cases of invasive non-sex-specific cancers diagnosed between 2010 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) program were used. The prevalence of BM was calculated by combining the prevalence of BM among different cancers. Multivariable logistic regression and proportion hazard regression were conducted to investigate the effect of female sex, and the results were pooled by meta-analysis.

Results

The pooled prevalence of BM among male and female patients was 2.3% (95% CI: 1.6–3.2%) and 1.8% (95% CI: 1.2–2.6%), respectively. The pooled prevalence of BM dramatically decreased for patients aged 11–40 years old, plateaued for patients aged 41–90 years old and increased for patients aged > 90 years old in both male and female patients. Meta-analysis suggested that female sex had a protective effect on the development of BM (pooled OR = 0.80; 95% CI: 0.75–0.84; p < .001) and a favourable prognosis for respiratory system cancers (pooled HR = 0.81; 95% CI: 0.71–0.92; p < .001). However, no significant associations existed for other cancers. Male non-sex-specific cancer patients and those with male-leaning genetic variations or hormonal status have a greater likelihood of developing BM than female patients.

Conclusions

Female sex was associated with fewer BM in various non-sex-specific cancers, and the effect was constant with changes in age. Female sex showed a protective effect exclusively on the prognosis of respiratory system cancers.

Prognostic factors in hepatocellular carcinoma patients with bone metastases

Purpose

To identify the prognostic factors that could influence survival and to compare prognoses of the patients with the number of the risk factors that might assist in the adequate management of hepatocellular carcinoma (HCC) patients with bone metastases that showed a heterogeneous range of survival.

Materials and Methods

A total of 41 patients, treated with radiotherapy (RT) for bone metastases from HCC from 2014 to 2017, were enrolled retrospectively. Survival was determined by the Kaplan–Meier method from the start of the RT for metastatic bone lesions. Pre-RT clinical features were evaluated and their influences on survival were analyzed. The significant factors were considered to compare survivals according to the number of prognostic factors.

Results

Median follow-up was 6.0 months (range, 0.5 to 47.0 months). The median overall survival was 6.5 months, and the 1-year and 2-year survival rates were 35.5% and 13.5%, respectively. Multivariate analysis revealed that the Child-Pugh class A group, alpha-fetoprotein increased more than 30 ng/mL, and HCC size of more than 5 cm were associated with worse overall survival. The median survivals in HCC with none, 1, 2, and 3 of the aforementioned risk factors were 19.5, 9.0, 2.5, and 1.0 months, respectively (p < 0.05).

Conclusion

Our results show that the overall survivals were significantly different according to the number of the risk factors among HCC patients with bone metastases who showed various lengths of survival.

A randomized trial of conventional fraction versus hypofraction radiotherapy for bone metastases from hepatocellular carcinoma

External beam radiotherapy (EBRT) has been reported to be effective in palliating painful bone metastases, but the optimal fractions and doses for treating bone metastases from hepatocelluar carcinoma (HCC) are not established. This study aimed to compare toxicity and efficacy for conventional fraction versus hypofraction schedules. From January 2009 through December 2014, 183 patients with HCC bone metastases were randomly assigned to conventional fraction EBRT (Group A) or hypofraction radiotherapy (Group B). Study outcomes were pain relief, response rate and duration, overall survival, and toxicity incidence. Median follow-up time was 9.3 months. Response times were 6.7 ± 3.3 fractions in Group A and 4.1 ± 1.2 fractions in Group B (p <0.001). Pain relief rates were 96.7% and 91.2% in Group A and B, respectively (p=0.116). Time to treatment failure for Group A was significantly longer than Group B (p=0.025). Median overall survival was similar between two groups (p=0.628). Toxicity incidence in both groups was minimal, with no significant differences observed.

In conclusion, hypofractionated radiotherapy is safe for patients with HCC bone metastases and may achieve earlier pain relief compared to conventional radiotherapy. This protocol should be considered for patients with shorter predicted survival times.

Bad to the Bone: The Role of the Insulin-Like Growth Factor Axis in Osseous Metastasis

Bone metastases are a frequent complication of cancer that are associated with considerable morbidity. Current treatments may temporarily palliate the symptoms of bone metastases but often fail to delay their progression. Bones provide a permissive environment because they are characterized by dynamic turnover, secreting factors required for bone maintenance but also stimulating the establishment and growth of metastases. Insulin-like growth factors (IGF) are the most abundant growth factors in bone and are required for normal skeletal development and function. Via activation of the IGF-1 receptors (IGF-1R) and variant insulin receptors, IGFs promote cancer progression, aggressiveness, and treatment resistance. Of specific relevance to bone biology, IGFs contribute to the homing, dormancy, colonization, and expansion of bone metastases. Furthermore, preclinical evidence suggests that tumor cells can be primed to metastasize to bone by a high IGF-1 environment in the primary tumor, suggesting that bone metastases may reflect IGF dependency. Therapeutic targeting of the IGF axis may therefore provide an effective method for treating bone metastases. Indeed, anti-IGF-1R antibodies, IGF-1R tyrosine kinase inhibitors, and anti-IGF-1/2 antibodies have demonstrated antitumor activity in preclinical models of prostate and breast cancer metastases, either alone or in combination with other agents. Several studies suggest that such treatments can inhibit bone metastases without affecting growth of the primary tumor. Although previous trials of anti-IGF-1R drugs have generated negative results in unselected patients, these considerations suggest that future clinical trials of IGF-targeted agents may be warranted in patients with bone metastases.

Advanced Hepatocellular Carcinoma with Bone Metastases: Prevalence, Associated Factors, and Survival Estimation

Background

The objective of the present research was to explore the prevalence, risk, and prognostic factors associated with bone metastases (BM) in newly diagnosed hepatocellular carcinoma (HCC) patients.

Material/Methods

From 36 507 HCC patients who were registered in Surveillance, Epidemiology, and End Results (SEER) database, we enrolled 1263 with BM at the initial diagnosis of HCC from 2010 to 2014. Kaplan-Meier curves and log-rank tests were used to estimate overall survival for different subgroups. Univariate and multivariate logistic and Cox regression analyses were performed to identify risk factors and independent prognostic factors for BM.

Results

A total of 1567 (4.29%) HCC patients were detected with BM at initial diagnosis. Male sex, unmarried status, higher T stage, lymph node involvement, intrahepatic metastases, and extrahepatic metastases (lung or brain) were positively associated with BM. The median survival of the patients was 3.00 months (95% CI: 2.77–3.24 months). Marital status and primary tumor surgery were independently associated with the better survival.

Conclusions

A list of factors associated with BM occurrence and the prognosis of the advanced HCC patients with BM were found. These associated factors may provide a reference for BM screening in HCC and guide prophylactic treatment in clinical settings.

Sudden Collapse due to Medullary and Cervical Cord Infarction-An Unusual Presentation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a common cancer worldwide with a great potential for metastatic spread. Hepatocellular carcinoma often arises in people with underlying viral hepatitides or liver cirrhosis and may present in various ways including abdominal pain, liver mass, and signs of hepatocellular decompensation. Many tumors may have metastasized to other organs such as the lungs, lymph nodes, bone, and adrenal glands at the time of diagnosis. However, it is uncommon for HCC to present purely due to its metastasis, such as spinal cord compression from vertebral metastasis. Here, an unusual presentation of a sudden cardiovascular collapse due to medullary and cervical cord infarction from compression of the cervical cord is presented. The importance of clinical investigations, the usefulness of postmortem computed tomography scans, and the examination of the cervical spine and cervical cord in people with no obvious cause of death after standard autopsy procedures are emphasized.

Surgical management of coincidental metastases to upper cervical spine and skull from hepatocellular carcinoma: a case report

Metastases to the skull or upper cervical spine from hepatocellular carcinoma (HCC) are very rare. We herein report a unique case of two-site surgery for both skull and upper cervical spine metastases from HCC. The patient was a 64-year-old man with cervical pain. Computed tomography (CT) revealed osteolytic change related to metastatic cervical spine and occipital bone tumors. Two-stage surgery involving posterior occipitocervical fusion and occipital bone tumor resection was performed. The patient’s pain decreased in severity, and postoperative radiotherapy and chemotherapy could be conducted. The postoperative course was favorable, and the patient exhibited improvement in his activities of daily living. Neither cervical spine X-ray examination nor CT showed any instrumentation failure, such as screw loosening, before the patient died of liver failure 13 months after surgery. Patients with both skull and upper cervical spine metastases from liver cancer may have a markedly unfavorable prognosis. Even in these patients, however, surgery as an aggressive palliative treatment may prolong the survival period or maintain the quality of life as long as the patient’s general condition permits.

The prognostic analysis of different metastatic patterns in advanced liver cancer patients: A population based analysis

Background

The prognostic impact of different distant metastases pattern in liver cancer is unexplored still now. The aim of this study is to analyze the metastasis patterns and prognosis differences for patients with stage IV liver cancers.

Methods

A SEER analysis was performed. Overall survival and cancer-specific survival were calculated by the Kaplan-Meier method. Multivariable Cox regression models were used to further analyze survival outcome and other prognostic factors.

Results

A total of 37526 eligible cases were retrieved in the Surveillance, Epidemiology, and End Results database. Among these patients, stage of IV liver cancer accounted for 14.80% (5555/37526) at initial diagnosis. Patients who suffered bone, brain or lung metastasis occupied 55.61% (3089/5555). Comparing with other two single metastases, the patients with brain metastasis exhibited worst overall survival whose mean of survival was 4.758 months. Multivariate analysis with Cox hazard regression model showed that metastatic site was an independent prognostic factor of overall survival and cancer-specific survival in patients with single metastasis (P<0.05). The results of univariate analysis showed that metastatic pattern was significantly correlated with overall survival (P = 0.038) and cancer-specific survival (P = 0.035) of patients with two sites.

Conclusions

Lung was the most common site of single metastasis for liver cancers. Patients with bone metastasis had best survival outcome comparing with other two distant metastases. Patients with two metastatic sites, where one of them is the lung tends to have a slight trend to a worse outcome.

Hepatocellular Carcinoma with Bone Metastases: Incidence, Prognostic Significance, and Management-Single-Center Experience

BACKGROUND

Hepatocellular carcinoma (HCC) represents one of the most common causes of cancer-related deaths worldwide, with rising incidence in the USA. Bone metastases with HCC, in particular, have an extremely poor prognosis. We present prevalence, treatment, and survival of patients with bone and more specifically spinal metastases from HCC.

METHODS

A retrospective analysis was done at a single tertiary care institution of patients with bone metastases from HCC between January 2005 and December 2015.

RESULTS

Among 1017 patients with HCC, 20 were found to have bone metastases of which 11 had spinal metastases. Seventeen (85%) were male, with median age of 58 years at time of HCC diagnosis. Systemic chemotherapy and sorafenib were used in 12 (60%) patients, and 12 (60%) received radiation therapy. Among patients who did not receive therapy, median survival was 76 days. Median survival after diagnosis of metastasis in patients on sorafenib and radiation were 106 and 100 days, respectively.

CONCLUSION

Bone metastases in HCC are very rare and aggressive. Due to its rarity, optimal treatment strategies are not well defined. Early diagnosis is important for optimal therapy and improved survival.

Establishment of a Disease-Specific Graded Prognostic Assessment for Hepatocellular Carcinoma Patients with Spinal Metastasis

Background/Aims

Hepatocellular carcinoma (HCC) patients with spinal metastasis (SM) show heterogeneous lengths of survival. In this study, we develop and propose a graded prognostic assessment for HCC patients with SM (HCC-SM GPA).

Methods

We previously reported the outcomes of 192 HCC patients with SM who received radiotherapy from April 1992 to February 2012. Prognostic factors that significantly affected survival in that study were used to establish the HCC-SM GPA. Validation was performed using an independent cohort of 63 patients recruited from September 2011 to March 2016.

Results

We developed the HCC-SM GPA using the following factors: Eastern Cooperative Oncology Group performance status (0–2, 0 point; 3–4, 1 point), controlled primary HCC (yes, 0 point; no, 2 points), and extrahepatic metastases other than bone (no, 0 point; yes, 1 point). Patients were stratified into low (GPA=0), intermediate (GPA=1 to 2), and high risk (GPA=3 to 4). When applied to the validation cohort, the HCC-SM GPA determined median survival durations of 13.6, 4.8, and 2.6 months and 1-year overall survival rates of 58.3%, 17.8%, and 7.3% for the low-, intermediate-, and high-risk patient groups, respectively (p<0.001).

Conclusions

Our newly proposed HCC-SM GPA successfully predicted survival outcomes.

High dose and compartmental target volume may improve patient outcome after radiotherapy for pelvic bone metastases from hepatocellular carcinoma

PURPOSE

Pelvic bone metastases are difficult to treat because of complex pelvic bone anatomy and the proximity of normal organs. The adequacy of radiation dose and field coverage was evaluated.

PATIENTS AND METHODS

We analyzed 146 cases of pelvic bone metastases from HCC treated with radiotherapy (RT). Bone metastases were confirmed using CT/MRI. Subjective pain response was assessed using the visual analogue scale, and treatment-related toxicity with the Common Terminology Criteria for Adverse Events v3.0. Local failure free survival (LFFS) and overall survival were estimated using the Kaplan-Meier method.

RESULTS

The local control rate was 80.1% and the pain control rate was 68.5%. Compartmental target volume (CTV), encompassing the whole compartment of the involved bone, was found to be a significant factor (1-year LFFS, 78% vs. 50%; p=0.001). Sites of metastasis were categorized as either upper or lower pelvic bone; both categories showed improved local control with CTV. Metastatic lesions that received more than 50 Gy of EQD2 showed more partial response in pain after RT (58% vs. 79%; p=0.007). No patient showed toxicity higher than Grade IV.

CONCLUSION

Compartmental RT targeted to the involved bone was associated with improved local control and LFFS. High-dose radiation was associated with an improved treatment response.

Defining the role of palliative radiotherapy in bone metastasis from primary liver cancer: An analysis of survival and treatment efficacy

Aims and background

Primary liver cancer is the fourth leading cause of cancer-related death worldwide and is still associated with a poor prognosis. Hepatocellular carcinoma and cholangiocarcinoma are known to cause bone metastasis resulting in pain, neurologic impairment and risk of fracture. Palliative radiotherapy is the treatment of choice in symptomatic bone lesions and is usually performed as percutaneous fractionated radiotherapy.

Methods and study design

From June 1987 to December 2009, 41 patients (median age, 64 years) with bone metastasis received radiotherapy in our department. The analyzed patients were treated for 67 sites of bone lesions. We analyzed the applied fractionation schedules and the preferred sites of metastasis and symptoms, evaluated the therapeutic outcome in terms of symptomatic improvement, and described the prognosis of these patients.

Results

Main indication for palliative radiotherapy was pain in 94% of all cases. Most frequent radiation protocols were 10 × 3 Gy (20 patients) and 20 × 2 Gy (19 patients). Median applied overall dose was 39 Gy (range, 4–48 Gy) and median single dose was 2.5 Gy (range, 1.8–4 Gy). The median duration of the radiotherapeutic treatment was 15 days (range, 2–24 days) and in 12 cases treatment was discontinuated. The overall response rate to palliative radiotherapy in bone metastasis was 77%. Median overall survival in both cholangiocarcinoma and hepatocellular carcinoma patients was 4.2 months after initiation of radiotherapy (range, 0.2–38.9).

Conclusions

Considering the poor prognosis of patients with bone metastasis in hepatocellular carcinoma and cholangiocarcinoma, with a poor median survival of 3.7–5.0 months according to our study and existing literature, shorter radiotherapy schedules or even single-fraction irradiation can be considered.

A case report of metastatic hepatocellular carcinoma in the mandible and coracoid process: A rare presentation

RATIONALE

We report a rare case of hepatocellular carcinoma (HCC) with metastases to the mandible and coracoid process of scapula without evidence of lung involvement.

PATIENTS CONCERNS

The patient was diagnosed with HCC, presented 5 months later with right lower tooth pain, swelling over the right mandible area and right shoulder pain.

DIAGNOSES

Histopathological examination of mandible showed findings suggestive of metastatic HCC. Magnetic resonance imaging (MRI) of the right shoulder revealed findings of irregular enhancing lesion at the right coracoid process causing erosion of the coracoid process.

INTERVENTIONS

Patient was subsequently referred for palliative medicine care.

OUTCOMES

He received adequate analgesia.

LESSONS

Oral cavity and scapula metastases from HCC are very rare. Most oral metastases are associated with lung metastases, and they possibly occur by hematogenous route. In our case, the possible pathway of metastasis is an anastomotic network of paravertebral veins that bypasses the pulmonary, inferior caval, and portal venous circulations.

Bone metastases from hepatocellular carcinoma: clinical features and prognostic factors

BACKGROUND

Bone metastases (BMs) from hepatocellular carcinoma (HCC) is an increasingly common disease in Asia. We assessed the clinical features, prognostic factors, and differences in outcomes related to BMs among patients with different treatments for HCC.

METHODS

Forty-three consecutive patients who were diagnosed with BMs from HCC between January 2010 and December 2014 were retrospectively enrolled. The clinical features were identified, the impacts of prognostic factors on survival were statistically analyzed, and clinical data were compared.

RESULTS

The median patient age was 54 years; 38 patients were male and 5 female. The most common site for BMs was the trunk (69.3%). BMs with extension to the soft tissue were found in 14 patients (32.5%). Most (90.7%) of the lesions were mixed osteolytic and osteoblastic, and most (69.8%) patients presented with multiple BMs. The median survival after BMs diagnosis was 11 months. In multivariate analyses, survival after BM diagnosis was correlated with Karnofsky performance status (P=0.008) and the Child-Pugh classification (P<0.001); BM-free survival was correlated with progression beyond the University of California San Francisco criteria (P<0.001) and treatment of primary tumors (P<0.001). BMs with extension to soft tissue were less common in liver transplantation patients. During metastasis, the control of intrahepatic tumors was improved in liver transplantation and hepatectomy patients, compared to conservatively treated patients.

CONCLUSIONS

The independent prognostic factors of survival after diagnosis of BMs were the Karnofsky performance status and Child-Pugh classification. HCC patients developed BMs may also benefit from liver transplantation or hepatectomy.

Cone-beam computed tomography with automated bone subtraction in preoperative embolization for pelvic bone tumors

PURPOSE

To evaluate the usefulness of cone-beam computed tomography with automated bone subtraction (CBCT-ABS) in the preoperative embolization of hypervascular tumors located in the pelvic bone.

MATERIALS AND METHODS

This retrospective study included 26 patients with pelvic bone tumors who underwent preoperative embolization between January 2014 and October 2016. A CBCT-ABS scan was taken in a total of 17 patients (CBCT-ABS group), and only a series of digital subtraction angiographies (DSAs) was taken in the remaining 9 patients (DSA group). The percent devascularization, number of angiographic runs, total dose-area product (DAP), fluoroscopy time, interventional procedure time, operative time, and estimated blood loss were compared between the two groups using Mann-Whitney test.

RESULTS

The percent devascularization, interventional procedure time, fluoroscopy time, operative time, and estimated blood loss were not statistically different between the two groups (p > 0.05). On the other hand, the number of angiographic runs in the CBCT-ABS group was significantly lower than that in the DSA group (p = 0.029). The total DAP of the CBCT-ABS group (mean, 17700.7 μGym2) was higher than that of the DSA group (mean, 8939.4 μGym2) (p = 0.002).

CONCLUSIONS

The use of CBCT-ABS during the preoperative embolization of pelvic bone tumors significantly reduces the number of angiographic runs at the cost of an increased radiation dose.

Outcome of Skeletal Reconstructive Surgery for Metastatic Bone Tumours in the Femur

Introduction

The role of surgery in skeletal metastasis is to reduce morbidity and improve the quality of life in terminally ill patients. We report our experience with patients who underwent skeletal reconstructive surgery for metastatic bone tumour of the femur.

Materials and Methods

Twenty nine operations for skeletal metastasis of the femur performed in our centre between 2009 and 2015 were included in this study. We evaluated the choice of implant, complications, survival rate and functional outcome. Fourteen patients were still alive at the time of this report for assessment of functional outcome using Musculoskeletal Tumour Society (MSTS) form.

Results

Plating osteosynthesis with augmented-bone cement was the most common surgical procedure (17 patients) performed followed by arthroplasty (10 patients) and intramedullary nailing (2 patients) There were a total of five complications which were implant failures (2 patients), surgical site infection (2 patients), and site infection mortality (1 patient). The median survival rate was eight months. For the functional outcome, the mean MSTS score was 66%.

Conclusion

Patients with skeletal metastasis may have prolonged survival and should undergo skeletal reconstruction to reduce morbidity and improve quality of life. The surgical construct should be stable and outlast the patient to avoid further surgery.

Outcome after Surgery for Metastases to the Pelvic Bone: A Single Institutional Experience

BACKGROUND

The pelvic bone is the most common site of bone metastases following the axial skeleton. Surgery on the pelvic bone is a demanding procedure. Few studies have been published on the surgical outcomes of metastasis to the pelvic bone with only small numbers of patients involved. This study sought to analyze the complications, local progression and survival after surgery for metastasis to the pelvic bone on a larger cohort of patients.

METHODS

We analyzed 83 patients who underwent surgery for metastases to the pelvic bone between the years 2000 and 2015. There were 41 men and 42 women with a mean age of 55 years. Possible factors that might be associated with complications, local progression and survival were investigated with regard to patient demographics and disease-related and treatment-related variables.

RESULTS

The overall complication rate was 16% (13/83). Advanced age (> 55 years, p = 0.034) and low preoperative serum albumin levels (≤ 39 g/L, p = 0.001) were associated with increased complication rates. In patients with periacetabular disease, the complication rate was higher in those who underwent total hip replacement arthroplasty (THR) than those who did not (p = 0.030). Local progression rate was 46% (37/83). The overall median time to local progression was 26 ± 14.3 months. The median time from local progression to death was 13 months (range, 0 to 81 months). The local progression-free survival was 52.6% ± 6.4% at 2 years and 36.4%± 7.6% at 5 years, respectively. Presence of skip lesions (p = 0.017) and presence of visceral metastasis (p = 0.027) were found to be significantly associated with local progression. The median survival of all patients was 24 months. The 2-year and 3-year survival rates were 52.5% ± 5.9% and 35.6% ± 6%, respectively. Metastasis from the kidney, breast, or thyroid or of hematolymphoid origin (p = 0.014), absence of visceral metastasis (p = 0.017) and higher preoperative serum albumin levels (p = 0.009) were associated with a prolonged survival.

CONCLUSIONS

Advanced age and low serum albumin levels were associated with high complication rates. Local progression after surgery for metastases to the pelvic bone was affected by the presence of skip lesions, not by surgical margins. Primary cancer type, serum albumin level and visceral metastasis influenced survival.

Metastatic fractures of long limb bones

The diagnosis of pathological fracture should be considered routinely in patients with long limb-bone fractures. Investigations must be performed to establish the diagnosis of pathological fracture then to determine that the bone lesion is a metastasis. In over 85% of cases, the clinical evaluation combined with a detailed analysis of the radiographs is sufficient to determine that the fracture occurred at a tumour site. Aetiological investigations establish that the tumour is a metastasis. In some patients, the diagnosis of metastatic cancer antedates the fracture. When this is not the case, a diagnostic strategy should be devised, with first- to third-line investigations. When these fail to provide the definitive diagnosis, a surgical biopsy should be performed. The primaries most often responsible for metastatic bone disease are those of the breast, lung, kidney, prostate, and thyroid gland. However, the survival gains provided by newly introduced treatments translate into an increased frequency of bone metastases from other cancers. The optimal treatment of a pathological fracture is preventive. The Mirels score is helpful for determining whether preventive measures are indicated. When selecting a treatment for a pathological fracture, important considerations are the type of tumour, availability of effective adjuvant treatments, and general health of the patient. Metastatic fractures are best managed by a multidisciplinary team. The emergent treatment should start with optimisation of the patient's general condition, in particular by identifying and treating metabolic disorders (e.g., hypercalcaemia) and haematological disorders. Treatment decisions also depend on the above-listed general factors, location of the tumour, and size of the bony defect. Prosthetic reconstruction is preferred for epiphyseal fractures and internal fixation for diaphyseal fractures.

Osteotropic peptide-mediated bone targeting for photothermal treatment of bone tumors

The treatment of bone tumors is a challenging problem due to the inefficient delivery of therapeutics to bone and the bone microenvironment-associated tumor resistance to chemo- and radiotherapy. Here, we developed a bone-targeted nanoparticle, aspartate octapeptide-modified dendritic platinum-copper alloy nanoparticle (Asp-DPCN), for photothermal therapy (PTT) of bone tumors. Asp-DPCN showed much higher affinity toward hydroxyapatite and bone fragments than the non-targeted DPCN in vitro. Furthermore, Asp-DPCN accumulated more efficiently around bone tumors in vivo, and resulted in a higher temperature in bone tumors during PTT. Finally, Asp-DPCN-mediated PTT not only efficiently depressed the tumor growth but also significantly reduced the osteoclastic bone destruction. Our study developed a promising therapeutic approach for the treatment of bone tumors.