[Total hip arthroplasty for metastatic Merkel cell carcinoma]

Isolated Tibial Metastasis from Merkel Cell Carcinoma

Merkel cell carcinoma is a rare but aggressive neuroendocrine tumor of the skin with high propensity for local, regional and distant soft tissue metastasis not only at initial presentation but also after timely and satisfactory wide-margin surgery. Bone metastases account for 10% of all cases and have been reported involving the calvarium, facial bones and spine related to the head and neck preferential location of this soft tissue malignancy. Appendicular skeletal dissemination is uncommon with only a few cases reported in the radiological literature. We present a case of isolated tibial metastasis from Merkel cell carcinoma occurring 19 months after a technically adequate head and neck tumor resection and lymphadenectomy.

[Centromedullary nailing of the femur for bone metastasis: clinical and radiological evaluation using the Tokuhashi score in 24 patients]

PURPOSE OF THE STUDY

Pluridisciplinary management of patients with metastasis to the femur is well defined, but the choice between palliative surgery or abstention must be decided on the basis of a few evaluated prognostic criteria. We report a series of 24 cases of metastasis to the weakened or fractured femur which was evaluated with the Tokuhashi score and treated by surgery.

MATERIAL AND METHODS

Sixteen women and eight men, mean age 71 years (58-89) underwent centromedullary nailing of the femur. These patients had metastases from breast cancer (n = 13 of the 16 women). Twenty of the 24 patients also had other metastases. The Tokuhasi score was > 6 in 16/24 patients. Fourteen patients had pain which did not respond to morphine. Thirteen had fractures and eleven weakened femurs. Time to surgery was six days (1-15). A full nail was inserted in four patients and a reconstruction nail in twenty.

RESULTS

Operative time was 93 minutes (57-123). Blood loss was 200 ml (150-350). There were no intraoperative complications (fat embolism) excepting increased comminution. Hospital stay was 23 days (8-55). Survival was 148 days (8-510) for patients with fractures and 272 days (12-730) for patients with weakened femurs. Eight patients with a fractured femur died (six within the first three postoperative weeks), two among those with preventive nailing. On average, weight bearing among the surviving patients with nailing for fracture was achieved on the 57th postoperative day (30-90). Only six patients required morphine early after surgery. Centromedullary nailing successfully relieved pain in all patients with an isolated metastasis. Mean survival in patients with a Tokuhashi score < 3 was 2.1 months. It was 17 months in those whose score was > 6.

CONCLUSION

Centromedullary nailing for fractured or weakened femur due to metastasis is a useful therapeutic solution for patients with short life expectancy. With this technique, antalgesics can be reduced while preserving independence as long as possible. The Tokuhashi score is easy to establish. If it is less than 3, centromedullary nailing should not be attempted due to the short expected survival.