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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. 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. 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). 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.
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313
CLINICS 2006;61(4):313-20
Department of Orthopedics and Traumatology Faculty of Medicine,
University of São Paulo /SP, Brazil.
Email: olapcama@uol.com.br
Received for publication on January 16, 2006
Accepted for publication on April 19, 2006
ORIGINAL RESEARCH
PROGNOSTIC FACTORS IN PATHOLOGIC
FRACTURES SECONDARY TO METASTATIC TUMORS
Douglas Kenji Narazaki, Carlos Coelho de Alverga Neto, André Mathias Baptista,
Marcelo Tadeu Caiero Olavo Pires de Camargo
Narazaki DK, Alverga Neto CC, Baptista AM, Caiero MT, Camargo OP. Prognostic factors in pathologic fractures secondary
to metastatic tumors. Clinics. 2006;61(4):313-20.
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.
KEYWORDS: Pathological fractures. Neoplasia. Metastasis. Prognosis. Surgery.
INTRODUCTION
According to data issued by the Brazilian Ministry of
Health in 2002, neoplasias are the second most frequent,
well-defined cause of mortality in Brazil, the first being
cardiocirculatory system diseases.
Metastatic disease is the main cause of death among
cancer patients, the third most common site of metastases
being the bone, after liver and lungs. Breast, lung, thyroid,
prostate, and kidney tumors are most likely to metastasize
to bone. Approximately 50% of all patients dying from can-
cer have bone metastases.1
New oncologic treatments available allow these patients’
survival times to increase, and the oncologic orthopedist
must be able to evaluate and treat the different complica-
tions secondary to bone metastases. These problems include
pain, pathologic fractures, and medullary compression.2
Pathologic fractures cause a sharp decrease in the qual-
ity of life of these patients and increase their mortality. Or-
thopedic advances in osteosynthesis and endoprosthesis
have benefited prevention and treatment of such fractures.
Other beneficial adjuvant treatments include, locally, the
use of cement and radiotherapy and, systemically, chemo-
therapy, radiotherapy, and hormone therapy.2-6
The sites that are most affected by bone metastases in-
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CLINICS 2006;61(4):313-20Prognostic factors in pathologic fractures secondary
Narazaki DK et al.
clude the vertebral column, hip, ribs, femur, and skull.
Pathologic fractures occur in 9% to 29% of patients with
bone metastases.7,8 The average survival of patients with
metastatic disease secondary to breast, prostate, and lung
adenocarcinoma is 34 months, 24 months, and 4 months,
respectively.8,9
In bone metastases caused by renal cell carcinoma, pa-
tients with limb, not axial skeleton, injuries have longer
survival times (i) when there is a disease-free interval
longer than 2 years between nephrectomy and the onset of
metastases, (ii) when there is a single, versus multiple, bone
injury, and (iii) when there is an absence of metastasis at
early disease diagnosis.10
In bone metastases secondary to breast adenocarcinoma,
the only significant prognostic factors are the presence of
associated visceral metastases and duration of symptoms
less than 3 months, determining shorter survival.6,9
With the increase in the global survival of patients with
bone metastasis, it is important to establish defined
protocols for clinical and surgical approaches aiming to
improve the quality of local control of the bone injury, even
before the occurrence of a pathologic fracture, and to main-
tain such stabilization for many years.
The objective of our study was to determine the prog-
nostic factors of pathologic fractures caused by metastatic
tumors of various origins treated in our Service.
Determining which patients have a better prognosis is
important, since this will determine the choice of surgical
treatment type. Patients with a better expectation of sur-
vival require a more aggressive treatment with wide and
marginal resection of the bone tumor associated with
endoprosthesis + cement or osteosynthesis + graft/cement
and postoperative radiotherapy. This approach is necessary
because patients with longer survival, typically greater than
2 years, present higher failure indexes of the synthetic ma-
terial when used alone, without tumor resection.1,4,5,7-12,14
However, patients with low expectations for survival may
benefit from a less aggressive, less morbid treatment with
internal fixation using interlocking nails associated with
adjuvant radiotherapy.
METHODS
This is a retrospective study enrolling 112 patients
treated for pathologic fractures secondary to metastatic
tumors between April 1994 and December 2004 in our
Service. It is important to emphasize that the best inclu-
sion criterion is histological confirmation of metastatic
tumor, not merely the presence of the clinical tumor. This
means that all patients undergoing conservative treatment
were biopsied.
Data were obtained from medical dossiers and from a
review of slices of histopathological samples from the meta-
static bone tumor.
The treatment strategy for each patient depended upon
factors such as the prognosis of the primary disease and
the injury size and site. Therefore, metastatic tumors with
poor prognosis and difficult surgical access were treated
conservatively with radiotherapy and chemotherapy, while
metastatic tumors with good prognosis, large injury caus-
ing instability of the segment, and easy surgical access were
treated surgically.
Patients were analyzed according to sex, age, site of
bone metastasis, visceral metastases, origin of primary
tumor, treatment type, serum hemoglobin, and sur-
vival.3,4,6,10,14,15
Later, a statistical study was performed using the Log
Rank test, Breslow test, Tarone-Ware test, and the Kaplan-
Meier life-table of survival, a descriptive procedure to
evaluate the distribution of time-dependent variables. Thus,
it is possible to compare the distribution by levels, or pro-
duce a separate analysis for each layer.4,10
RESULTS
Of the 112 patients studied, 53 (47%) were men and
59 (53%) were women. Figure 1 displays the age distribu-
tion of patients: 33 were aged between 50 and 59 years,
while the range of the entire population was 20-88 years).
Primary tumors (Figure 2) were (in descending order)
breast (29 patients), undetermined origin (18), prostate (16),
lung (15), thyroid (7), kidney (6), collum uteri (5),
esophagus (4), bowel (4), pharynx (3), myometrium (2),
skin (2), stomach (1), liver (1), larynx (1), and ovary (1).
Figure 3 displays the sites of pathological fracture by
segment, as follows: the lower limbs, 63 patients (47%);
spine, 40 patients (30%); upper limbs, 16 patients (12%);
and pelvic girdle, 14 patients (11%). In the extremities (Fig-
ure 4), the most affected site was the femur (59 patients,
Figure 1- Distribution by age range
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CLINICS 2006;61(4):313-20 Prognostic factors in pathologic fractures secondary
Narazaki DK et al.
44%) followed by the humerus (15 patients, 11%). In the
spine, the most affected portion was the lumbar area (22
patients, 17%); followed by the thorax (10 patients, 7.5%);
sacrum, (10 patients, 4.5%) and cervical spine (2 patients,
1.5%). The pelvic girdle was affected in 11 patients (8.3%)
and the scapula in 2 patients (1.5%).
We observed that 15% of patients presented metastases
in other organs, and that the most affected site was the lung
(59%), followed by liver (15%), as shown in Figure 5.
The treatment administered to all 112 patients ranged
from clinical only to clinical and surgical. Forty-one percent
were treated clinically only, with immobilizations and/or rest
associated with radiotherapy, chemotherapy, hormone
therapy, and/or biphosphonates. Fifty-nine percent underwent
surgical treatment in addition to clinical treatment. Regard-
ing surgical treatment of the extremities (Figure 6), 45 pa-
tients had endoprostheses (66%), 9 had osteosyntheses
(13%), 3 had amputations (4.4%), 2 had external fixators
(3%), and 1 had a Girdlestone arthroplasty (1.5%). Concern-
ing the spine, 4 patients underwent instrumentation with the
Hartshill rectangle (5.8%), 2 had pediculate screws (3%), and
2 had Harrington-Luque instrumentation (3%).
The endoprostheses employed were as follows: 41 par-
tial hip, 1 total hip, 1 total knee, 1 partial shoulder, and 1
humeral diaphyseal endoprosthesis.
Serum hemoglobin laboratory tests showed that 99% of
the patients presented Hb >7 g/dL.
We were able to obtain survival data for 43 out of the
112 patients: 33 had died and 10 were still alive at the end
of the study. These patients were analyzed using the
Kaplan-Meier life-table, a descriptive procedure to exam-
ine the distribution of time-dependant variables, which al-
lows comparisons of the distribution by levels; or, a sepa-
rate analysis for each stratum was produced.
Therefore, initially, we evaluated the distribution of sur-
vival time according to the levels of each study variable. Vari-
ables analyzed included sex, age at diagnosis, treatment type,
fracture site, primary tumor, and metastases in other organs:
Sex
Of these 43 patients, 20 were men and 23 were women.
Eighteen of the 20 men had died and 2 were alive. Fifteen
Figure 2- Distribution by primary tumor
Figure 3- Distribution according to fracture site per segment
Figure 4- Distribution according to site of pathological fractures per bone.
Figure 5- Distribution according to the site of non-bone metastases
Figure 6- Distribution according to type of surgery
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CLINICS 2006;61(4):313-20Prognostic factors in pathologic fractures secondary
Narazaki DK et al.
of the 23 women had died and 8 were alive. The mean sur-
vival time among men was 24.2 months and among women
31.7 months; however, this was not a significant difference
(P > 0.05). (Table 1)
Age at diagnosis
The distribution by age at diagnosis shows a larger
number of patients within the fifth life decade, totaling 15
patients. The age range (Table 2) with longest survival time
was between 20 and 39 years (mean 90.6 months); followed
by the 6th decade (35.3 months), 4th decade (30.3 months),
5th decade (26.1 months), 7th decade (9.5 months), and 8th
decade (5.7 months); however, this distribution did not ex-
hibit significant differences (P > 0.05).
Initial bone injury
The most common site of pathologic fracture (Table 3)
was the femur (17 patients, 15 died and 2 are alive). The next
most common were the vertebral column (15 patients, 10 died
and 5 are alive); humerus (5 patients, all died); pelvic girdle
(3 patients, 1 died and 2 are alive); and tibia (2 patients, 1
died and 1 is alive). The longest survival time was observed
for patients with pathologic vertebral column fractures (mean
52.1 months), and the shortest survival times were observed
for patients with pathologic humeral fractures (12.4 months).
Again, no significant differences were found (P > 0.05).
Primary tumor
Regarding primary tumors (Table 4), we observed a
higher incidence of breast tumors (9 patients, 5 dead and
4 alive), followed by lung tumors (7 cases, 6 dead and 1
alive), prostate tumors (6 cases, all dead) and thyroid (5
cases, 2 dead and 3 alive). Other tumors comprised 16 cases
(14 dead and 2 alive). Patients with breast tumors had the
longest survival time (mean 43.3 months), followed by thy-
roid (25.1 months), prostate (21.5 months), and lung (17.4
months, the shortest survival times); however, no signifi-
cant differences were found (P > 0.05).
Non-bone metastasis
The 11 cases with non-bone metastases had survival
times of 32 months. The 32 cases without non-bone
metastases had a mean survival time of 28.4 months. There
was no significant difference between these mean survival
times (P > 0.05) (Table 5).
Treatment type
Of the 43 patients, 16 underwent exclusively clinical
treatments. Eleven of them died and 5 are alive. Twenty-
seven patients underwent clinical and surgical treatment;
22 died and 5 are alive. Longer survival times (Table 6)
Table 4- Days of survival by primary tumor site
Primary Total Alive Dead Average of
tumor site Survival
Breast 9 5 4 1300
Prostate 6 6 0 646
Lung 7 6 1 525
Thyroid 5 2 3 753
Other 16 14 2 755
Overall 43 33 10 970
Table 3- Days of survival by location of the bone metastasis
Metastasis Total Alive Dead Average days
location of survival
Girdle 3 1 2 843
Spine 15 10 5 1565
Femur 17 15 2 594
Tibia 2 1 1 501
Humerus 5 5 0 374
Overall 42 32 10 981
Table 2- Days of survival by age
Age Total Alive Dead Average days
of survival
20/39 3 1 2 2718
40/49 7 5 2 911
50/59 15 11 4 784
60/69 7 6 1 1061
70/79 8 8 0 286
80/89 3 2 1 172
Overall 43 33 10 970
Table 1- Days of survival by sex
Sex Total Alive Dead Average days
of survival
Female 23 15 8 951
Male 20 18 2 725
Overall 43 33 10 970
Table 5- Days of survival by presence of non-bone metastasis
Non-bone Total Alive Dead Average days
metatasis of survival
No 32 24 8 853
Yes 11 9 2 962
Overall 43 33 10 970
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CLINICS 2006;61(4):313-20 Prognostic factors in pathologic fractures secondary
Narazaki DK et al.
were observed among clinically treated patients (mean:
34.1 months). Those surgically treated had a survival time
of 28.3 months. There were no significant differences be-
tween these mean survival times (P > 0.05).
Surgical type
Regarding surgically treated patients (Tables 7 and 8;
Figure 7), 16 had endoprostheses (14 dead, 2 alive); 9 had
osteosynthesis (6 dead, 3 alive); 1 had an amputation
(dead); and 1had an external fixator (dead). Patients treated
with osteosynthesis had longer survival times (mean: 47.8
months), followed by endoprosthesis (21.6 months). These
means were significantly different (P < 0.05).
DISCUSSION
Although we obtained survival data from only 43 of the
112 patients studied, it was important to analyze both groups,
since the larger sample allows us to know whether the profile
of patients treated at the Instutute of Orthpedics and Trauma
of Hospital das Clínicas, São Paulo University Medical School
is similar to that of the population studied in international lit-
erature. This allowed us to reduce our sample bias.
Based on the 112 patients, we observed an agreement
with reported data in terms of incidence of primary tumors
that metastasize mostly to the bone, ie, breast, prostate, lung,
and thyroid primary tumors.12 The most affected age range
was the 5th decade. The incidence of diagnosed non-bone
metastases was 15%, the lung being the most common.
The most affected site in the patients treated in our
Service were the lower limbs (47%), more specifically the
femur, and this differs from most reported studies.2,3 A pos-
sible explanation is that vertebral column fractures are less
frequently referred to the Tumor Group of our Service and/
or they are underdiagnosed.
Surgical treatment was performed in most patients
(59%), although it is more indicated for pathological femo-
ral and humeral fractures. Exclusively clinical treatment
was the most indicated for pathological fractures of the ver-
tebral column and pelvic girdle (41%).
Among surgically treated patients, more endoprostheses
were performed (66%) than any other type of procedure
because there was higher incidence of proximal femoral
pathological fractures (44%).
Currently, interlocking nails are preferred over
endoprostheses in cases of proximal femoral pathological
fractures, due to their lower morbidity in cases with less
destruction of bone matrix. This procedure is invariably
supplemented by postoperative radiotherapy.1,2,7
Hemoglobin was not a relevant datum in our study be-
cause only 1 patient in our sample had Hb < 7g/dL.
By analyzing the subgroup formed by 43 patients for
whom survival data was available, we found that sex, age,
primary tumor, site affected, non-bone metastasis, and clini-
cal versus surgical treatment variables are not good pre-
dictors for survival. We found that the evidence of visceral
metastasis in patients with pathological fractures does not
necessarily mean a poorer prognosis, nor does the fracture
site or the primary tumor. A possible explanation for this
Table 8. Statistical analysis for the different types of surgery,
as specified in Table 7.
chi-square df P
Log Rank (Mantel-Cox) 13.193 3 0.004
Breslow (Generalized Wilcoxon) 11.572 3 0.009
Tarone-Ware 12.284 3 0.006
Table 7- Days of survival by type of surgical treatment
Surgery Total Alive Dead Average days
of survival
Amputation 1 1 0 19
Endoprothesis 16 14 2 648
External Fixation 1 1 0 22
Osteosynthesis 9 6 3 1435
Overall 27 22 5 850
Table 6- Days of survival by type of treatment: surgical vs
clinical
Treatment Total Alive Dead Average day
type of survival
Surgical 27 22 5 850
Clinical 16 11 5 1025
Overall 43 33 10 970
Figure 7 - Survival functions
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CLINICS 2006;61(4):313-20Prognostic factors in pathologic fractures secondary
Narazaki DK et al.
would be the fact that the fracture itself represents a strong
determinant for survival decrease in this population.
However, the type of surgery performed was signifi-
cantly associated with length of survival, which supported
our hypothesis that surgery type would be the largest de-
terminant of survival decrease in these cancer patients. Pa-
tients who received an endoprosthesis (mean survival time,
21.6 months) had worse prognoses than those undergoing
osteosynthesis (mean survival time, 47.8 months). This may
be explained either by the higher severity of proximal
femoral fractures that were more frequently treated with
endoprostheses, or by the fact that the surgical technique
employed in osteosynthesis is less aggressive, produces less
morbidity, and is more prone to rehabilitation than the tech-
nique involving an endoprosthesis.
CONCLUSION
We conclude that the treatment of choice for pathologi-
cal diaphyseal femoral and proximal femoral fractures is
internal fixation using interlocking medullary nailing,
which is less aggressive to soft tissue and patients.
This is also shown by the current international litera-
ture;1,2,7 the profile of the population in this study was simi-
lar to those in other studies.1,4,5,7-14
Whenever it can be indicated, osteosynthesis with inter-
locking nails for pathological fractures is more compatible
with patients’ survival, since it reduces hospital stay, rehabili-
tation time, surgical time and bleeding, and makes it possible
to stabilize the entire femur, compared to endoprostheses.2,14
RESUMO
Narazaki DK, Alverga Neto CC, Baptista AM, Caiero MT,
Camargo OP. Fatores prognósticos nas fraturas patológicas
por tumores metastáticos.Clinics. 2006;61(4):313-20.
OBJETIVO: As fraturas patológicas por metástase óssea
determinam uma queda abrupta na qualidade de vida dos
pacientes com neoplasias malignas e também aumentam
sua mortalidade. Os avanços ortopédicos de osteossíntese
e endopróteses têm beneficiado a prevenção e tratamento
dessas fraturas. O objetivo de nosso estudo é determinar
quais são os fatores prognósticos dessas fraturas patológicas
tratadas no nosso serviço.
CASUÍSTICA E MÉTODOS: Foram estudados 112
pacientes tratados com fraturas patológicas secundárias a
tumores metastáticos entre abril de 1994 e dezembro de
2004, no nosso serviço. Os pacientes foram analisados
319
CLINICS 2006;61(4):313-20 Prognostic factors in pathologic fractures secondary
Narazaki DK et al.
quanto ao sexo, idade, local de metástase óssea, metástases
viscerais, origem do tumor primário, tipo de tratamento,
hemoglobina sérica e sobrevida.
RESULTADOS: O local mais acometido foi o fêmur
(44%), o tumor primário mais freqüente foi o câncer de
mama (25%), o tratamento cirúrgico mais realizado foi a
endoprótese não convencional (66%). As variáveis sexo,
idade, tumor primário, local acometido, mestástase não-
óssea e tratamento clínico versus cirúrgico não são bons
preditores para sobrevida. Os pacientes operados com
endoprótese (21,6 meses) apresentaram pior prognóstico
que os pacientes submetidos à osteossíntese (47,8 meses).
DISCUSSÃO E CONCLUSÃO: Os pacientes submetidos
à osteossíntese, com uma técnica cirúrgica menos mórbida
e de reabilitação mais precoce, apresentaram maior
sobrevida em relação aos pacientes submetidos à
endopróteses. Observamos que nossa casuística é seme-
lhante à internacional, na qual aparece como tumor
primário mais freqüente o de mama, os de origem
indeterminada, próstata e pulmão.
UNITERMOS: Fraturas patológicas, Neoplasias, Metás-
tases, Prognóstico, Cirurgia.
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... treated surgically. 2 Intramedullary nailing (IMN) is an effective procedure to prophylactically or therapeutically stabilize the bone and prevent additional fracture. 3 Owing to the limited life expectancy of these patients, the goal of this surgical procedure was to improve the patient's quality of life by reducing pain and increasing functional mobility. ...
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Introduction Despite the benefits of intramedullary nailing (IMN) of impending or pathologic fractures in oncologic patients, literature on patient-reported outcomes (PROs) is scarce in patients treated with carbon fiber (CF) nails. Our study compared postoperative PROs after IMN with CF or titanium implants. Methods We conducted a retrospective propensity score–matched cohort study of patients treated at our institution with CF or titanium nails for impending or pathologic fractures from metastatic bone disease. Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form (SF) Physical, Mental, and Physical Function 10a scores were collected. Pain was assessed using visual analog scale (VAS). Absolute and differential scores were compared between groups. Results We included 207 patients, 51 treated with CF and 156 with titanium nails. One month postoperatively, patients had a one-point decrease in the pain VAS score while PROMIS scores did not improve. At 3 months, PROMIS SF Physical and SF 10a scores improved from preoperative values. Six months postoperatively, median PROMIS SF Physical, SF Mental, and SF 10a scores were higher than preoperative scores. Absolute and differential PROMIS and pain VAS scores were similar between groups at the 6-month and 1-year marks. Conclusion Patient-reported outcomes were similar after intramedullary nailing with either CF or titanium implants.
... The cost for the care of SRE involves the resources allocated during the initial phase of treatment (i.e., emergency care at the hospital) and medical appointments after discharge. In the case of pathologic fractures (Table 2), the cost associated with physiotherapy sessions is added, and its estimate was generated with data published in various articles 2,6,36,37,39 and with the unit costs of a specialty appointment and a physiotherapy session at tertiary care level 35 and the costs of certain IMSS diagnosis-related groups (DRG), 38 updated for inflation. The costs for each one of the other three types of SRE (Table 3) were estimated as the sum of the cost of the corresponding DRG 38 and the product obtained by multiplying the frequency of specialty appointments reported by Body et al. 2 and the unit cost of a specialty appointment at IMSS tertiary care level 35 . ...
... Because the efficacy of treatment options available to cancer patients has improved, so has the patient's average life expectancy following a cancer diagnosis [1]. Metastatic bone disease results in weakened and pathologic bone prone to a painful fracture, with considerable implications for patient quality of life (QoL), functionality and mortality [2,3]. As such, metastatic long bone fractures cause a significant health care burden and are associated with poor functional outcomes and reduced life expectancy [3]. ...
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Background Pathological fractures are challenging in orthopedic surgery and oncology, with implications for the patient’s quality of life, mobility and mortality. The efficacy of oncological treatment on life expectancy for cancer patients has improved, but the metastatic pattern for bone metastases and survival is diverse for different tumor types. This study aimed to evaluate survival in relation to age, sex, primary tumor and site of the pathological fractures. Methods All pathological fractures due to cancer between 1 September 2014 and 31 December 2021 were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, tumor type, fracture site and mortality were collected. Results A total of 1453 patients with pathological fractures were included (48% women, median age 73, range 18–100 years). Unknown primary tumors were the most common primary site (n = 308). The lower extremities were the most common site of pathological fractures. Lung cancer had the shortest median survival of 78 days (range 54–102), and multiple myeloma had the longest median survival of 432 days (range 232–629). The site at the lower extremity had the shortest (187 days, range 162–212), and the spine had the longest survival (386 days, range 211–561). Age, sex, primary type and site of the pathological fractures were all associated with mortality. Interpretation Age, sex, primary tumor type and site of pathological fractures were associated with survival. Survival time is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival.
... Because the e cacy of treatment options available to cancer patients has improved, so has the patient's average life expectancy following a cancer diagnosis [1]. Metastatic bone disease results in weakened and pathologic bone prone to a painful fracture, with considerable implications for patient quality of life (QoL), functionality and mortality [2][3]. As such, metastatic long bone fractures cause a signi cant health care burden and are associated with poor functional outcomes and reduced life expectancy [3]. ...
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Background Pathological fractures are challenging in orthopedic surgery and oncology, with implications for the patient’s quality of life, mobility and mortality. The efficacy of oncological treatment on life expectancy for cancer patients has improved, but the metastatic pattern for bone metastases and survival is diverse for different tumor types. This study aimed to evaluate survival in relation to age, sex, primary tumor and site of the pathological fractures. Methods All pathological fractures due to cancer between 1 September 2014 and 31 December 2021 were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, tumor type, fracture site and mortality were collected. Results 1,453 patients with pathological fractures were included (48% women, median age 73, range 18-100 years). Unknown primary tumors were the most common primary site (n=308). The lower extremities were the most common site of pathological fractures. Lung cancer had the shortest median survival of 78 days (range 54-102) and multiple myeloma had the longest median survival of 432 days (range 232-629). The site at the lower extremity had the shortest (187 days, range 162-212) and the spine had the longest survival (386 days, range 211-561). Age, sex, primary type and site of the pathological fractures were all associated with mortality. Interpretation Age, sex, primary tumor type and site of pathological fractures significantly impact survival. Survival time is short and correlated to primary tumor type, with lung cancer as the strongest negative predictor of survival.
... With the increase in the global life expectancy of patients with bone metastasis, it is crucial to determine the appropriate protocols aiming to improve the quality of patients life. This has to be done even before the occurrence of a pathologic fracture, and to preserve such stabilization for the rest of their life (6). ...
... The rods or plates should be long in order to protect all the affected bone. 13,14 A study by Narazaki et al. 15 shows that survival in patients treated with intramedullary nail without bone cement had a better survival than those treated with endoprostheses, because they were less bitten surgeries. ...
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Resumo As metástases ósseas podem evoluir com eventos (dor, fraturas e compressão) com os quais o cirurgião ortopédico irá se depararar independentemente da sua subespecialidade. Os conhecimentos cirúrgicos acumulados são predicativos para a prevenção de fraturas iminentes, assim como de fraturas patológicas. Apresentaremos um guia para avaliar e conduzir de forma adequada um paciente com implante ósseo para cirurgiões que não sejam especialistas na área.
... With respect to the prevalence of CRAB symptoms in myeloma patients, few studies have identified the answer to this question. One study that included 113 patients found that the frequency of CRAB symptoms among their study population was: hypercalcemia (6%), renal failure (29%), anemia (57%), and bone disease (68%) [7]. Another study comprising 170 patients showed that among patients with symptomatic MM, 74% presented with CRAB symptoms, 20% presented with non-CRAB manifestations, and 6% had evidence of both clinical features [8]. ...
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Multiple myeloma is a devastating illness with a hallmark of end-organ damage. The clinical presentation of multiple myeloma often includes the involvement of CRAB (hypercalcemia, renal failure, anemia, bone lesions) symptoms. We present a case of a patient who did not exhibit the typical presentation of multiple myeloma making her case unique and her diagnosis more difficult. In addition to the CRAB criteria, typical symptomatology includes constipation, pain, fatigue, and peripheral sensory issues. The purpose of this case report is to bring awareness to both multiple myeloma and this particular presentation. The patient is a 71-year-old female with a past medical history of hypertension, hypothyroidism, and rheumatoid arthritis who presented with a chief complaint of right shoulder pain. The patient’s initial labs were significant for a total protein of 9.3, albumin of 3.4, corrected calcium of 9.3, hemoglobin 10.6 (with baseline near 11-12), and creatinine of 1.0 (baseline of 1.0). The patient’s right upper extremity X-rays were significant for a right humeral fracture. The patient had a serum kappa/lambda ratio of 15.94. Bone marrow biopsy revealed 50% kappa-restricted cells, consistent with a diagnosis of multiple myeloma. The patient’s subsequent bone survey and CT scan were negative for any additional lesions. The patient had subsequent radiation therapy followed by maintenance therapy with bortezomib, lenalidomide, and dexamethasone with improvement in her symptoms. MM is a complex pathophysiological disease and equally as complex in diagnosis as the presentation is varied and sometimes obscure as noted in the case presented here. Although bone lytic lesions are part of the CRAB criteria, it is rare for them to present in patients with MM in an isolated manner with no corresponding lab abnormalities. With this case, we aim to shed light upon an atypical presentation of MM, notably one that solely involves a pathological fracture in a non-axial distribution.
... Within the proximal femur, about 50% of lesions occur in the femoral neck, 20% in the per-trochanteric region, and 30% in the subtrochanteric region. The breast, prostate, and lungs are the most common origin of proximal femoral metastases [1,2]. ...
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Background and purpose Proximal femur is a common site for metastasis, it has a significant impact on patient’s quality of life, and traditional treatment aims at protecting as much as possible from the femur. However, recent studies have demonstrated increased rate of complications and questioned the need for long stem in this high-risk group. Our purpose is to determine whether standard-length femoral stem is noninferior to long femoral stem in the treatment of proximal femoral metastasis. Patients and methods Between 2019 and 2021, we prospectively included 24 patients with proximal femoral metastasis leading either to impending or pathological fractures (5 and 19 cases, respectively). We included patients with lesions due to metastasis, lymphoma, or multiple myeloma. Patients were quasi-randomized based on their order of presentation into two groups based on the femoral stem length, cemented standard (group 1) and long (group 2) femoral stem. Oncological complications, survival, stem complications, and functional outcomes were recorded and analyzed using SPSS 25. Results 24 patients were included in the final analysis, 13 case in group 1 and 11 in group 2, and mean age 57.6 years. Mean follow-up duration was 10 months, and 11 patients died of the whole-study population with mean survival of (10.85 ± 2.23, 8.82 ± 3.6) months in group 1, 2, respectively. The complication rate was higher in the standard group; however, this difference did not reach statistical significance. No difference was found between study groups regarding functional outcomes, except for VAS at 6 months which was higher in standard group. Conclusion We believe that the ubiquitous use of long stem in the management of proximal femoral metastasis should be questioned considering the expected patient survival and low rate of complications associated with the use of standard stem. Clinicaltrials.gov registration number NCT04660591.
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Objetivo: Evaluar económicamente el denosumab en comparación con un escenario mixto de ácido zoledrónico o no tratamiento si existe contraindicación a dicho agente por enfermedad renal grave (Mix AZ/No Trt) en pacientes con tumores sólidos (TS) con metástasis ósea. Método: Análisis de costo-efectividad basado en un modelo Markov, con horizonte temporal de por vida y bajo perspectiva del Instituto Mexicano del Seguro Social. Se evaluaron las frecuencias de eventos relacionados con esqueleto (ERE) y los costos asociados con adquisición de medicamentos, infusión de AZ, manejo de rutina, atención de ERE y tratamiento de eventos adversos serios. Resultados: En el caso base, denosumab resultó dominante sobre Mix AZ/No Trt, con ahorro promedio de $2,494 pesos y 0.781 ERE evitados por paciente. Si AZ se administra cada 12 semanas, denosumab no sería dominante, pero sí costo-efectivo. El denosumab fue dominante o costo-efectivo en 74.7% de las simulaciones. Conclusiones: En pacientes con TS con metástasis ósea, denosumab representa una intervención dominante o al menos costo-efectiva frente al Mix AZ/No Trt.
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A number of risk factors based upon mostly retrospective surgical data, have been formulated in order to identify impending pathological fractures of the femur from low-risk metastases. We have followed up patients taking part in a randomised trial of radiotherapy, prospectively, in order to determine if these factors were effective in predicting fractures. In 102 patients with 110 femoral lesions, 14 fractures occurred during follow-up. The risk factors studied were increasing pain, the size of the lesion, radiographic appearance, localisation, transverse/axial/circumferential involvement of the cortex and the scoring system of Mirels. Only axial cortical involvement >30 mm (p = 0.01), and circumferential cortical involvement >50% (p = 0.03) were predictive of fracture. Mirels' scoring system was insufficiently specific to predict a fracture (p = 0.36). Our results indicate that most conventional risk factors overestimate the actual occurrence of pathological fractures of the femur. The risk factor of axial cortical involvement provides a simple, objective tool in order to decide which treatment is appropriate.
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BACKGROUND The objective of this article was to assess the occurrence of symptomatic bone metastases in a defined population of patients with breast carcinoma and to characterize the clinical outcome with reference to surgical treatment for pathologic fracture or neurologic deficit.METHODS The authors identified all patients in the Stockholm Breast Cancer Database (population base 1.8 million) with a diagnosis of bone metastases during 1989–1994. These cases were linked with the Stockholm County Council Hospital Discharge Diagnosis Registry that includes information on in-patient care and discharge diagnoses. This enabled us to identify patients who had undergone surgical treatment for their bony metastases at any of the six departments of orthopedics in the region, or who had been treated at the one department of neurosurgery.RESULTSSix hundred forty-one patients with breast carcinoma presented with symptomatic skeletal metastasis during 1989–1994, and 107 (17%) were operated on. Metastases were located in long bones (77), spine (14), and pelvis (6). The median survival postoperatively was 6 months. The total reoperation rate was 0.12. Hip screws and glide-screw plates were associated more often with failure as was location in the distal femur. Pain decreased postoperatively in 77% of the patients, and function improved in 65%.CONCLUSIONS One in 10 patients with breast carcinoma developed symptomatic bone metastases, and one-fifth of these patients required surgery for pathologic fracture or neurologic deficit. There was a high failure rate in those hospitals in which few patients were operated on. Cancer 2001;92:257–62. © 2001 American Cancer Society.
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Bone metastases can present to a number of different specialties and their successful management requires a coordinated approach with good liaison between the specialists. Patients who respond to systemic therapy for their metastases have a good chance of being alive at 3 years, and 20% will be alive at 5 years. This means that it is worth palliating these patients properly. With this in mind, the intention of this document is to try and improve the process of care for women with metastatic bone disease from breast cancer. These guidelines consider all aspects of care from diagnosis to assessment of response to treatment, and describe the Quality Objectives that should be addressed at each stage. The level of available evidence is indicated throughout the document where possible. In considering diagnosis, the guidelines emphasize the value of having a dedicated orthopaedic surgeon specifically linked to each Cancer Unit. The attachment of a dedicated orthopaedic surgeon will ensure that mechanical problems are correctly identified, and that actual or imminent fracture is correctly managed. The latter is particularly important as the management of pathological fractures is not the same as that of traumatic fractures. The orthopaedic surgeon should also act as the liaison between his/her own Unit and the tertiary spinal or neurosurgical centres as necessary. In addition, empowering the radiologist means that the diagnostic process can be accelerated and refined. The place of different investigations in diagnosis, including tumour markers, is discussed. The guidelines emphasize the need for a definitive diagnosis before treatment in the (rare) case of a solitary metastasis. The treatment section discusses orthopaedic management, radiotherapy and systemic treatments (endocrine therapy, chemotherapy and bisphosphonates). The guidelines emphasize the emergency nature of spinal cord compression, describing the need for fast access to assessment and for good liaison between specialists. It is essential that these are available and widely publicized to ensure effective management. The role of radiotherapy in both local pain relief and spinal cord compression is discussed, and various techniques are described. Endocrine therapy and chemotherapy are discussed in relation to the disease-free interval, performance status, extent and site of metastatic disease, and oestrogen receptor status. Specific chemotherapy regimes are not discussed as these are subject to change and local protocols should be followed. The increasing evidence behind the role of bisphosphonates is reviewed. With many unanswered questions about the long-term use of this group of drugs, the guidelines offer a scoring system for deciding which patients might benefit most from long-term bisphosphonate therapy. The guidelines describe the possible ways of assessing response to treatment and the difficulties that may be encountered, including a discussion of the role of tumour markers in assessment of response. A final section looks at palliative care principles in bone pain management, acknowledging the need for continuation of good care throughout the patient's journey, from diagnosis onwards. We very much hope these guidelines will stimulate individuals and institutions to improve the process of delivering care to this group of patients.
Article
Metastatic lesions to bone outnumber primary bone malignancies. Osseous metastases to the tibia tend to be less common than osseous metastases to other long bones. This study examined the treatment options for a population of patients with metastatic disease to the tibia, with surgical intervention being the cornerstone of treatment for the osseous lesion. A multicenter study had 592 patients with metastatic disease to the bone, with 26 lesions occurring in the tibia (4.4%) during a 13-year period. No patient had concurrent metastases distal to the elbow. After confirmation of metastatic disease, treatment consisted of surgical intervention in all patients, including plate osteosynthesis, intramedullary rodding and cementation, endoprosthetic replacement, and in most patients, postoperative radiation therapy. In 96% of patients, the reconstruction outlasted their life expectancy. All patients were satisfied with their reconstruction. Four complications were encountered in the postoperative period, all requiring additional surgery. Aggressive treatment of osseous metastasis is justified in patients with metastatic disease despite a limited life expectancy. Intervention by an orthopaedic oncologist may result in fewer reconstructive failures. Surgical intervention contributes to an improved quality of life and limb function, ease of nursing care, and may help in maintaining patient independence.
Article
Background: The purpose of this study was to analyze the survival of 38 cases of metastatic renal cell carcinoma with secondary osseous metastases treated at the Orthopaedic Oncology Unit of the Massachusetts General Hospital. The survival was analyzed because it seemed to be considerably longer than any reported previously in the literature. Methods: Survival was analyzed with respect to age, gender, site of primary tumor, presence of pathologic fracture, disease free interval, initial presentation with metastasis, solitary versus multiple metastases, and axial versus appendicular metastases. Results: Survival for the entire group was 90% at 6 months, 84% at 1 year, 55% at 5 years, and 39% at 10 years. Age, gender, and presence of pathologic fracture had no influence on survival. Presentation without metastases, long disease free interval between nephrectomy and first metastases, appendicular skeletal location, and solitary metastases were all correlated with longer survival. Conclusions: In the authors' view, patients with the characteristics correlated with longer survival are appropriate candidates for aggressive surgical resection of bone metastasis.
Article
BACKGROUND The purpose of this study was to analyze the survival of 38 cases of metastatic renal cell carcinoma with secondary osseous metastases treated at the Orthopaedic Oncology Unit of the Massachusetts General Hospital. The survival was analyzed because it seemed to be considerably longer than any reported previously in the literature.METHODS Survival was analyzed with respect to age, gender, site of primary tumor, presence of pathologic fracture, disease free interval, initial presentation with metastasis, solitary versus multiple metastases, and axial versus appendicular metastases.RESULTSSurvival for the entire group was 90% at 6 months, 84% at 1 year, 55% at 5 years, and 39% at 10 years. Age, gender, and presence of pathologic fracture had no influence on survival. Presentation without metastases, long disease free interval between nephrectomy and first metastases, appendicular skeletal location, and solitary metastases were all correlated with longer survival.CONCLUSIONS In the authors' view, patients with the characteristics correlated with longer survival are appropriate candidates for aggressive surgical resection of bone metastasis. Cancer 1997; 80:1103-9. © 1997 American Cancer Society.
Article
We have operated on 42 patients with bone metastasis from various primary tumors over the past fourteen years. The number of operated cases of metastasis secondary to thyroid and breast carcinoma was especially high, since patients with such types of cancer have prolonged life expectancies in general. The sites of these operation were as follows: 27 in the spine, 12 in the femur, 2 in the tibia, and 1 in the humerus.
Article
The importance of early, secure, internal fixation in the management of pathologic fractures, especially if bone stock has been severely compromised, is clearly recognized by the orthopedic surgeon. There is virtually no place for denying surgical treatment to the majority of these cases, because it would most probably leave them in a painful, bedridden state. The risks of operative intervention and the use of methylmethacrylate along with fixation devices are justified when analyzing the end results of relief of pain, ambulatory activity, and restoration of function, as well as psychologic benefits. The use of radiotherapy and chemotherapy along with surgery has greatly enhanced the management of this disabled patient population. Fracture healing can take place in the presence of extensive destructive lesions. Survival rates are improving and earlier recognition of skeletal metastasis by newer technology, including bone scanning and computerized axial tomography, is helpful in the overall management of these patients. The goals of treatment can be achieved by proper planning and a multidisciplinary approach to the patient with metastatic skeletal disease.
Article
The authors report their experience in the treatment of metastases in long bones. Between 1980 and 1985, 51 cases were submitted to surgical treatment. They comprised osteolytic lesions in the femur (44), tibia (2), and humerus (5). The most frequent primary tumours were: carcinoma of the breast (37%), lung (25%), kidney (16%), rectum (9%). The remaining 13% were from the prostate gland, bladder, ovaries, uterus, chronic lymphatic leukemia, and haemangiopericytoma. Surgical treatment was supplemented by medication and physiotherapy. The choice of instrumentation (prosthesis, total prosthesis, plates, endomedullary nailing) was based on the site of the metastasis and the general condition of the patient. Palliative surgery in these cases was fully justified by the results in that it achieved the aim we set ourselves, namely to restore these unfortunate patients to as normal a lifestyle as possible.