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Spodeck D, Guder W, Streitbürger A, Dudda M, Podleska LE, Nottrott M, Hardes J. Pathological Fractures in Benign Bone Lesions - Diagnosis and Therapy. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:69-78. [PMID: 35882354 DOI: 10.1055/a-1850-2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Most tumour-related pathological fractures occur in patients with bone metastases. However, in mostly younger patients, a pathological fracture can be due to both a benign or a malignant bone tumour. Making the correct diagnosis from among these two differential diagnoses is enormously important. If the tumour is malignant, treating the fracture inevitably leads to tumour cell contamination and can significantly worsen the oncological situation. The aim of this review article is firstly to provide the reader with diagnostic assistance in the case of suspected pathological fractures, and secondly to focus on the treatment of pathological fractures occurring with benign bone tumours. METHODS This is a non-systematic review of the diagnosis and treatment of pathological fractures in benign bone tumours or tumour-like lesions, based on an electronic PubMed database search. We also present our own procedures, in particular for ruling out a malignant bone tumour. RESULTS AND DISCUSSION Whenever a fracture occurs in the absence of sufficient traumatic force, the possibility of a pathological fracture should always be considered. As well as taking a general history for a possible primary tumour, it is particularly important to ask the patient whether they had any pain before the fracture occurred. If the findings from clinical examination or conventional radiological imaging give rise to suspicion of a pathological fracture, an MRI of the affected skeletal section with contrast medium should be carried out before commencing any fracture treatment. A CT scan is also helpful for accurately assessing bone destruction. If a malignant or locally aggressive benign bone tumour such as giant cell tumour (GCT) or aneurysmal bone cyst (ABC) cannot be definitively ruled out through imaging, a biopsy is essential. The bone biopsy must always be carried out on the assumption that the histological work-up will reveal a malignant bone tumour; it must therefore be performed according to strict oncological criteria. If the radiological diagnosis is unambiguous, e. g., a juvenile bone cyst (JBC) or a non-ossifying fibroma (NOF), conservative treatment of the fracture can be considered, depending on the location. In the presence of a locally aggressive benign bone tumour such as a GCT or ABC, curettage of the tumour must be carried out as well as treating the fracture. With GCT in particular, neoadjuvant therapy with denosumab prior to curettage and osteosynthesis or en bloc resection of the tumour should be considered, depending on the extent of the tumour. CONCLUSION Pathological fractures, especially in younger patients, should not be overlooked. Only after a malignant or benign locally aggressive bone tumour has been definitively ruled out should fracture treatment be performed. In the presence of a locally aggressive bone tumour, as well as treating the fracture, it is usually necessary to perform curettage of the tumour - also en bloc resection, where applicable, in the case of a GCT. Depending on the location, benign, non-aggressive tumours can be treated conservatively if necessary.
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Affiliation(s)
- Daniel Spodeck
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Wiebke Guder
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Essen, Deutschland
| | - Arne Streitbürger
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Essen, Deutschland
| | - Marcel Dudda
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Universität Duisburg-Essen, Duisburg, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Lars Erik Podleska
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Essen, Deutschland
| | - Markus Nottrott
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Essen, Deutschland
| | - Jendrik Hardes
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Essen, Deutschland
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Fan Y, Zhang B, Guo L, Yao W. Long bone shaft metastasis: a comparative study between cement filling and intercalary prosthesis. World J Surg Oncol 2023; 21:374. [PMID: 38037167 PMCID: PMC10687828 DOI: 10.1186/s12957-023-03242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Metastatic bone lesions in the extremities can cause severe pain and pathological fractures, significantly affecting patients' quality of life. Timely intervention and effective management of long bone metastases can positively influence patient outcomes, including survival rates and subsequent treatment options. OBJECTIVE The objective of this study is to compare the efficacy and associated complications of two surgical reconstruction techniques and propose a more effective limb reconstruction approach for long bone metastases. METHODS A retrospective study was conducted on 28 patients with complete clinical data who underwent a surgical procedure for long bone metastases of the extremities in our department between January 2017 and June 2022. The patients were divided into two groups based on their surgical methods. In group 1, the affected bones were curetted and filled with cement, then secured with plates or intramedullary nails. In group 2, the affected bone segments were completely removed and replaced with custom intercalary prostheses. Various factors, including general patient information, surgical details, surgical effectiveness, and common complications, were compared and analyzed. RESULTS There were no significant differences in general patient information between the two groups, including age, gender, surgical site, and primary tumor type. The operative times were 115.37 min for group 1 and 108.90 min for group 2, respectively (p > 0.05). However, intraoperative blood loss differed significantly between the groups, with 769 ml in group 1 and 521 ml in group 2 (p < 0.05). The postoperative MSTS scores were 91% for group 1 and 92% for group 2 (p > 0.05). Postoperative complications included two cases of internal fixation failure and three cases of tumor recurrence in group 1, resulting in a 33% incidence rate, while group 2 experienced a 15% incidence rate with two cases of internal fixation failure. CONCLUSION The results of this study suggest that both surgical techniques are effective for the treatment of long bone metastases of the extremities. However, the custom intercalary prostheses technique in group 2 showed a lower incidence of complications and less intraoperative blood loss. Therefore, it may be a more effective limb reconstruction approach for long bone metastases. Further studies with larger sample sizes are needed to confirm these findings.
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Affiliation(s)
- Yichao Fan
- Department of Bone and Soft Tissue Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, China
| | - Boya Zhang
- Department of Bone and Soft Tissue Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, China
| | - Liangyv Guo
- Department of Bone and Soft Tissue Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, China
| | - Weitao Yao
- Department of Bone and Soft Tissue Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, China.
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Thompson AL, Grenald SA, Ciccone HA, Mohty D, Smith AF, Coleman DL, Bahramnejad E, De Leon E, Kasper-Conella L, Uhrlab JL, Margolis DS, Salvemini D, Largent-Milnes TM, Vanderah TW. Morphine-induced osteolysis and hypersensitivity is mediated through toll-like receptor-4 in a murine model of metastatic breast cancer. Pain 2023; 164:2463-2476. [PMID: 37326644 PMCID: PMC10578422 DOI: 10.1097/j.pain.0000000000002953] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 06/17/2023]
Abstract
ABSTRACT The propensity for breast cancer to metastasize to bone is coupled to the most common complaint among breast cancer patients: bone pain. Classically, this type of pain is treated using escalating doses of opioids, which lack long-term efficacy due to analgesic tolerance, opioid-induced hypersensitivity, and have recently been linked to enhanced bone loss. To date, the molecular mechanisms underlying these adverse effects have not been fully explored. Using an immunocompetent murine model of metastatic breast cancer, we demonstrated that sustained morphine infusion induced a significant increase in osteolysis and hypersensitivity within the ipsilateral femur through the activation of toll-like receptor-4 (TLR4). Pharmacological blockade with TAK242 (resatorvid) as well as the use of a TLR4 genetic knockout ameliorated the chronic morphine-induced osteolysis and hypersensitivity. Genetic MOR knockout did not mitigate chronic morphine hypersensitivity or bone loss. In vitro studies using RAW264.7 murine macrophages precursor cells demonstrated morphine-enhanced osteoclastogenesis that was inhibited by the TLR4 antagonist. Together, these data indicate that morphine induces osteolysis and hypersensitivity that are mediated, in part, through a TLR4 receptor mechanism.
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Affiliation(s)
- Austen L. Thompson
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Shaness A. Grenald
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Haley A. Ciccone
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Dieter Mohty
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Angela F. Smith
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Deziree L. Coleman
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Erfan Bahramnejad
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Erick De Leon
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | - Logan Kasper-Conella
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | | | - David S. Margolis
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
- Orthopaedic Surgery, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Daniela Salvemini
- Department of Pharmacology and Physiology and Henry and Amelia Nasrallah Center for Neuroscience, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Tally M. Largent-Milnes
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
- Comprehensive Pain and Addiction Center, University of Arizona, Tucson, AZ, United States
| | - Todd W. Vanderah
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
- Comprehensive Pain and Addiction Center, University of Arizona, Tucson, AZ, United States
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Barik S, Raj V, Kumar V. Pathological fracture in prior diagnosed malignancies: A dilemma. Injury 2023; 54:110817. [PMID: 37268531 DOI: 10.1016/j.injury.2023.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/12/2023] [Indexed: 06/04/2023]
Affiliation(s)
- Sitanshu Barik
- Department of Orthopedics, All India Institute of Medical Sciences, Deoghar, India.
| | - Vikash Raj
- Department of Orthopedics, All India Institute of Medical Sciences, Deoghar, India
| | - Vishal Kumar
- Department of Orthopedics, All India Institute of Medical Sciences, Deoghar, India
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Wänman J, Kjartansdóttir S, Wolf O, Sundkvist J, Wennergren D, Mukka S. Age, sex, primary tumor type and site are associated with mortality after pathological fractures: an observational study of 1453 patients from the Swedish Fracture Register. J Orthop Surg Res 2023; 18:150. [PMID: 36859299 PMCID: PMC9976455 DOI: 10.1186/s13018-023-03620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/15/2023] [Indexed: 03/03/2023] Open
Abstract
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.
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Affiliation(s)
- Johan Wänman
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden.
| | - Sonja Kjartansdóttir
- grid.8761.80000 0000 9919 9582Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Wolf
- grid.8993.b0000 0004 1936 9457Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jonas Sundkvist
- grid.12650.300000 0001 1034 3451Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - David Wennergren
- grid.8761.80000 0000 9919 9582Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sebastian Mukka
- grid.12650.300000 0001 1034 3451Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
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Minimally invasive plate osteosynthesis with locking plate for metastatic humeral fractures. J Orthop Sci 2022; 27:1309-1314. [PMID: 34579991 DOI: 10.1016/j.jos.2021.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Limited reports have examined the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) with a locking plate (LP) in metastatic humeral fractures. Therefore, this study aimed to evaluate the effectiveness of MIPO in the treatment of metastatic humeral fractures. METHODS Patients who underwent MIPO for metastatic humeral fractures were included in this study. Data on patient demographics, new Katagiri score, operative time, amount of blood loss, bone union rate, range of motion (ROM) of the shoulder and elbow, and perioperative complications were obtained. RESULTS Twelve patients (seven men and five women) with 14 fractures were included in this study. The median operative time was 92.6 ± 28.9 min (range, 57-175 min) and the median amount of intraoperative blood loss was 106.1 ± 109.5 g (range, 10-330 g). No patient required surgery-related transfusion. The median duration of acquisition of active elbow ROM of>100° and active shoulder flexion of >90° were 8.9 ± 6.6 days (range, 1-30 days) and 17.5 ± 13.0 days (range, 6-47 days), respectively. The mean follow-up period was 10.0 ± 9.0 months (range, 1-33 months). There were no complications, and no patient required any further surgery for the affected humerus until death. CONCLUSION MIPO using an LP provided acceptable functional outcomes in advanced-stage cancer patients with metastatic humeral fractures during their limited lifetime.
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Bouthors C, Laumonerie P, Crenn V, Prost S, Blondel B, Fuentes S, Court C, Mazel C, Charles YP, Sailhan F, Bonnevialle P. Surgical treatment of bone metastasis from osteophilic cancer. Results in 401 peripheral and spinal locations. Orthop Traumatol Surg Res 2022; 108:103193. [PMID: 34954014 DOI: 10.1016/j.otsr.2021.103193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Peripheral and spinal bone metastases arise mainly from 5 osteophilic cancers: lung, prostate, kidney, breast and thyroid. Few studies combined results for the two types metastatic location (peripheral and spinal). Therefore we performed a multicenter retrospective study of surgically managed peripheral and spinal bone metastases to assess: (1) global function at a minimum 1 year's follow-up and; (2) factors affecting survival. HYPOTHESIS Global function is improved by surgery, with acceptable survival. MATERIAL AND METHOD Between 2015 and 2016, 386 patients were operated on in 11 centers for 401 metastases: 231 peripheral, and 170 spinal. Mean age was 62.6±12.5 years in the 212 female patients (54%) versus 66.4±11.5 years in the 174 males (46%) (p=0.001). Pre- to postoperative comparison was made on pain on VAS (visual analog scale), WHO (World Health Organization) score, Karnofsky score, walking and global upper-limb function. Survival was estimated at 4 years' follow-up. RESULTS The most frequent locations were in the femur (n=146, 36%) and thoracic spine (n=107, 27%). The primary cancer was revealed by the metastasis in 82 patients (21%). There were 55 general complications (14%) and 48 local complications (12%). Twenty-one patients (5.4%) died during the first month. VAS and Karnofsky sores improved: respectively, 6.6±2.3 vs. 3.4±2.1 (p<0.001) and 65±14 vs. 72±20 (p=0.01). Walking, upper-limb function and Frankel grade improved in respectively 49/86 (57%), 19/29 (66%) and 31/84 (37%) patients. Median survival was 13.3 months (95% CI: 10.8-17.1), and was related to the primary (log-rank, p<0.001): lung 6.5 months (95% CI: 5.2-8.9), prostate 11.1 months (95% CI: 5.3-43.6), kidney 12.9 months (95% CI: 8.4-22.6), breast 26.5 months (95% CI: 19.0-34.0), and thyroid 49.0 months (95% CI: 12.2-NA). On multivariate analysis, independent factors for death comprised internal fixation rather than prosthesis (OR=2.20; 95% CI: 1.59-3.04 (p<0.001)), high preoperative ASA score (OR=1.78; 95% CI: 1.40-2.28 (p<0.001)), preoperative chemotherapy (OR=1.26; 95% CI: 1.13-1.41 (p<0.001)) and major visceral metastasis (lung, brain, liver) (OR=11.80; 95% CI: 5.21-26.71 (p<0.001)). CONCLUSION Although function improved only slightly, pain relief and maintained autonomy suggest enhanced comfort in life, confirming the study hypothesis only partially. Factors affecting survival and clinical results argue for preventive surgery when possible, before general health status deteriorates. LEVEL OF EVIDENCE IV; retrospective observational.
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Affiliation(s)
- Charlie Bouthors
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France.
| | - Pierre Laumonerie
- Département de Chirurgie Orthopédique, Hôpital Pellegrin, Place Amélie Raba Léon, 33000 Bordeaux, France
| | - Vincent Crenn
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France
| | - Solène Prost
- Service de Neurochirurgie, Hôpital de la Timone, 264, Rue Saint Pierre, 13005 Marseille, France
| | - Benjamin Blondel
- Service de Neurochirurgie, Hôpital de la Timone, 264, Rue Saint Pierre, 13005 Marseille, France
| | - Stéphane Fuentes
- Service de Neurochirurgie, Hôpital de la Timone, 264, Rue Saint Pierre, 13005 Marseille, France
| | - Charles Court
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Christian Mazel
- Département de Chirurgie Orthopédique, Institut Montsouris, 42, Boulevard Jourdan, 75014 Paris, France
| | - Yann-Philippe Charles
- Service de Chirurgie du Rachis, Hôpital de Hautepierre, Avenue Molière, 67200 Strasbourg, France
| | - Fréderic Sailhan
- Service d'Orthopédie, Hôpital Cochin, 27, Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Paul Bonnevialle
- Département Universitaire d'Orthopédie Traumatologie, Hôpital Pierre Paul Riquet, Place Baylac, 31052 Toulouse Cedex, France
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- Société Française de Chirurgie Orthopédique et Traumatologique, SOFCOT, 56, Rue Boissonade, 75014 Paris, France
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Musculoskeletal Metastasis From Soft-tissue Sarcomas: A Review of the Literature. J Am Acad Orthop Surg 2022; 30:493-503. [PMID: 35320120 DOI: 10.5435/jaaos-d-21-00944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/13/2022] [Indexed: 02/01/2023] Open
Abstract
Soft-tissue sarcomas are a rare and extremely heterogeneous group of cancers, representing <1% of all human malignancies. The lungs are the most common site of distant metastasis, followed by the bone, lymph nodes, liver, brain, and subcutaneous tissue. Clinical experience suggests that skeletal metastasis is part of the natural history affecting the prognosis and quality of life in these patients. Approximately 2.2% of patients have skeletal metastasis at diagnosis. However, up to 10% will develop skeletal metastasis after a mean interval of 21.3 months. Although systemic therapy with conventional chemotherapy remains the primary treatment modality for those with metastatic sarcoma, increased survival has been achieved in selected patients who receive multimodality therapy, including surgery, for their metastatic disease. The 5-year overall survival of patients with isolated bone metastases was 41.2% (26.9% to 54.9%), which decreased to 32.9% (21.2% to 45.1%) in the setting of combined bone and lung metastases. Moreover, the resection of the primary soft-tissue sarcoma is a predictor of survival, resulting in a 58% decrease in mortality after surgery (hazard ratio, 0.42, P = 0.013). Understanding the effect of these metastases on patient survival may influence imaging, surveillance, and treatment decisions.
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Wu C, Zeng B, Deng J, Shen D, Wang X, Tan L, Liu X, Qiu G. Custom design and biomechanical clinical trials of 3D-printed polyether ether ketone femoral shaft prosthesis. J Biomed Mater Res B Appl Biomater 2022; 110:2006-2014. [PMID: 35297154 DOI: 10.1002/jbm.b.35055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 02/10/2022] [Accepted: 03/03/2022] [Indexed: 01/18/2023]
Abstract
During the surgical resection and reconstruction of a pathological femoral fracture, the removal of the femoral tumor leaves a large bone defect. Thus, it is necessary to reconstruct the defect and perform internal fixation. Polyether ether ketone (PEEK) has been widely used in spinal fusion and cranioplasty given its excellent biomechanical properties, biocompatibility, and stability. The typical design method of femoral prosthesis is based on the contralateral mirror image model (M-model), and we propose a novel method for designing femoral prosthesis, which is based on the cross section and centerline of the mirrored femur (C-model). In this study, the femoral shaft prostheses based on two models were manufactured using fused deposition modeling technology, and we use mechanical test and finite element analysis (FEA) to reveal the differences in mechanical properties of the two models. The mechanical results showed that the maximum loading force and yield strength were increased by 3% and 6% in the C-model prosthesis compared with the M-model prosthesis, respectively. In FEA, the results indicate that the C-model prosthesis could reduce the stress concentration by 5.4%-10.9% compared to the M-model prosthesis. Finally, the 3D-printed PEEK femoral shaft prosthesis based on C-model was implanted, no early complications occurred. Postoperative radiological examination indicated that the prosthesis and the femoral osteotomy end were closely matched and fixed well.
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Affiliation(s)
- Chao Wu
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China.,Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Baifang Zeng
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China.,Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiayan Deng
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Danwei Shen
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Xiangyu Wang
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
| | - Lun Tan
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
| | - Xin Liu
- Health Management Center, Zigong Fourth People's Hospital, Zigong, China
| | - Guigang Qiu
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
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Kendal JK, Heard BJ, Abbott AG, Moorman SW, Saini R, Puloski SKT, Monument MJ. Does surgical technique influence the burden of lung metastases in patients with pathologic long bone fractures? BMC Musculoskelet Disord 2022; 23:102. [PMID: 35101024 PMCID: PMC8802478 DOI: 10.1186/s12891-022-05067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery. METHODS Retrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher's exact tests, and Kaplan-Meier survival analyses. RESULTS Patients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4-49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p < 0.001). CONCLUSIONS In this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival. LEVEL OF EVIDENCE III, therapeutic study.
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Affiliation(s)
- Joseph K Kendal
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Bryan J Heard
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Annalise G Abbott
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Scott W Moorman
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Raghav Saini
- Northern Ontario School of Medicine, Thunder Bay, Canada
| | - Shannon K T Puloski
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Michael J Monument
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada. .,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada. .,Foothills Medical Center, McCaig Tower, 3134 Hospital Drive N. W, Calgary, Alberta, Canada.
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11
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Karaca O, Balaban K, Yildiz Y. Metastasis of submandibular Adenoid cystic carcinoma to the femur bone causing pathological fracture: A case report. SANAMED 2022. [DOI: 10.5937/sanamed0-40661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction: Adenoid cystic carcinoma (ACC) is a rare head and neck malignancy and is likely to be diagnosed in the major salivary glands. It's also known for its slow clinical course and prolonged survival unless no distant metastasis occurs. Even after a long period from the detection of the primary tumor, metastasis to the lung, brain, liver, and bone has a tendency to occur. Case presentation: We report a 53-year-old man who presented with a pathological femur fracture thirteen years after the presentation of submandibular ACC. Our patient reported an improved patient-reported outcome after undergoing resection hemiarthroplasty for his bone metastasis. Conclusion: We tried to accentuate the importance of periodical visits for the probability of distant metastasis and the work-up if it's necessary in such a rare case. It should be kept in mind that proper management of bone metastasis may lead to improvements in the quality of life.
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12
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Raad M, Puvanesarajah V, Wang KY, McDaniel CM, Srikumaran U, Levin AS, Morris CD. Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database. Clin Orthop Relat Res 2022; 480:57-63. [PMID: 34356036 PMCID: PMC8673988 DOI: 10.1097/corr.0000000000001908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/30/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Racial disparities in outcomes after orthopaedic surgery have been well-documented in the fields of arthroplasty, trauma, and spine surgery; however, little research has assessed differences in outcomes after surgery for oncologic musculoskeletal disease. If racial disparities exist in the treatment of patients with pathologic long bone fractures, then they should be identified and addressed to promote equity in patient care. QUESTIONS/PURPOSES (1) How do wait times between hospital admission and operative fixation for pathologic fractures of long bones differ between Black and non-Hispanic white patients, after controlling for confounding variables using propensity score matching? (2) How does the proportion of patients with 30-day postoperative complication differ between these groups after controlling for confounding variables using propensity score matching? METHODS Using the National Surgical Quality Improvement Program database, we analyzed 828 patients who underwent fixation for pathologic fractures from 2012 to 2018. This database not only provides a large enough sample of pathologic long bone fracture patients to conduct the present study, but also it contains variables such as time from hospitalization to surgery that other national databases do not. After excluding patients with incomplete data (4% of the initial cohort), 775 patients were grouped by self-reported race as Black (12% [94]) or white (88% [681]). Propensity score matching using a 1:1 nearest-neighbor match was then used to match 94 Black patients with 94 white patients according to age, gender, BMI, American Society of Anesthesiologists physical status classification, anemia, endstage renal disease, independence in performing activities of daily living, congestive heart failure, and pulmonary disease. The primary outcome of interest was the number of days between hospital admission and operative fixation, which we assessed using a Poisson regression and report as an incidence risk ratio. The secondary outcomes were the occurrences of major 30-day postoperative adverse events (failure to wean off mechanical ventilation, cerebrovascular events, renal failure, cardiovascular events, reoperation, death), minor 30-day adverse events (reintubation, wound complications, pneumonia, and thromboembolic events), and any 30-day adverse events (defined as the pooling of all adverse events, including readmissions). These outcomes were analyzed using a bivariate analysis and logistic regression with robust estimates of variance and are reported as odds ratios. Because any results on disparities rely on rigorous control of other baseline demographics, we performed this multivariable approach to ensure we were controlling for confounding variables as much as possible. RESULTS After controlling for potentially confounding variables such as age and gender, we found that Black patients had a longer mean wait time (incidence risk ratio 1.5 [95% CI 1.1 to 2.1]; p = 0.01) than white patients. After controlling for confounding variables, Black patients also had greater odds of having any postoperative adverse event (OR 2.1 [95% CI 1.1 to 3.8]; p = 0.02), including readmission (OR 3.3 [95% CI 1.5 to 7.6]; p = 0.004). CONCLUSION The racial disparities in pathologic long bone fracture care found in our study may be attributed to fundamental racial biases, as well as systemic socioeconomic disparities in the US healthcare system. Identifying and eliminating the racial, socioeconomic, and sociocultural biases that drive these disparities would improve care for patients with orthopaedic oncologic conditions. One possible way to reduce these disparities would be to implement standardized surgical care pathways for pathological long bone fractures across different institutions to minimize variation in important aspects of care, such as time to surgical fixation. Further insight is needed on the types of standardized care pathways and the implementation mechanisms that are most effective. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Kevin Y. Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Claire M. McDaniel
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Adam S. Levin
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Carol D. Morris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
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13
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Ban J, Fock V, Aryee DNT, Kovar H. Mechanisms, Diagnosis and Treatment of Bone Metastases. Cells 2021; 10:2944. [PMID: 34831167 PMCID: PMC8616226 DOI: 10.3390/cells10112944] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 12/24/2022] Open
Abstract
Bone and bone marrow are among the most frequent metastatic sites of cancer. The occurrence of bone metastasis is frequently associated with a dismal disease outcome. The prevention and therapy of bone metastases is a priority in the treatment of cancer patients. However, current therapeutic options for patients with bone metastatic disease are limited in efficacy and associated with increased morbidity. Therefore, most current therapies are mainly palliative in nature. A better understanding of the underlying molecular pathways of the bone metastatic process is warranted to develop novel, well-tolerated and more successful treatments for a significant improvement of patients' quality of life and disease outcome. In this review, we provide comparative mechanistic insights into the bone metastatic process of various solid tumors, including pediatric cancers. We also highlight current and innovative approaches to biologically targeted therapy and immunotherapy. In particular, we discuss the role of the bone marrow microenvironment in the attraction, homing, dormancy and outgrowth of metastatic tumor cells and the ensuing therapeutic implications. Multiple signaling pathways have been described to contribute to metastatic spread to the bone of specific cancer entities, with most knowledge derived from the study of breast and prostate cancer. However, it is likely that similar mechanisms are involved in different types of cancer, including multiple myeloma, primary bone sarcomas and neuroblastoma. The metastatic rate-limiting interaction of tumor cells with the various cellular and noncellular components of the bone-marrow niche provides attractive therapeutic targets, which are already partially exploited by novel promising immunotherapies.
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Affiliation(s)
- Jozef Ban
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
| | - Valerie Fock
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
| | - Dave N. T. Aryee
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
- Department of Pediatrics, Medical University Vienna, 1090 Vienna, Austria
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
- Department of Pediatrics, Medical University Vienna, 1090 Vienna, Austria
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14
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Mou H, Wang Z, Zhang W, Li G, Zhou H, Yinwang E, Wang F, Sun H, Xue Y, Wang Z, Chen T, Chai X, Qu H, Lin P, Teng W, Li B, Ye Z. Clinical Features and Serological Markers Risk Model Predicts Overall Survival in Patients Undergoing Breast Cancer and Bone Metastasis Surgeries. Front Oncol 2021; 11:693689. [PMID: 34604031 PMCID: PMC8484887 DOI: 10.3389/fonc.2021.693689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background Surgical therapy of breast cancer and bone metastasis can effectively improve the prognosis of breast cancer. However, after the first operation, the relationship between preoperative indicators and outcomes in patients who underwent metastatic bone surgery remained to be studied. Purpose 1. Recognize clinical and laboratory prognosis factors available to clinical doctors before the operation for bone metastatic breast cancer patients. 2. Develop a risk prediction model for 3-year postoperative survival in patients with breast cancer bone metastasis. Methods From 2014 to 2020, patients who suffered from breast cancer bone metastasis and received therapeutic procedures in our institution were included for analyses (n=145). For patients who underwent both breast cancer radical surgery and bone metastasis surgery, comprehensive datasets of the parameters of interest (clinical features, laboratory factors, and patient prognoses) were collected (n=69). We performed Multivariate Cox regression to identify factors that were associated with postoperative outcome. 3-year survival prediction model and nomograms were established by 100 bootstrapping. Its benefit was evaluated by calibration plot, C-index, and decision curve analysis. The Surveillance, Epidemiology, and End Results database was also used for external validation. Results Radiotherapy for primary cancer, pathological type of metastatic breast cancer, lymph node metastasis, elevated serum alkaline phosphatase, lactate dehydrogenase were associated with postoperative prognosis. Pathological types of metastatic breast cancer, multiple bone metastasis, organ metastases, and elevated serum lactate dehydrogenase were associated with 3-year survival. Then those significant variables and serum alkaline phosphatase counts were integrated to construct nomograms for 3-year survival. The C-statistic of the established predictive model was 0.83. The calibration plot presents a graphical representation of calibration. In the decision curve analysis, the benefits are higher than those of the extreme curve. The receiver operating characteristic of the external validation of the model was 0.82, indicating a favored fitting degree of the two models. Conclusion Our study suggests that several clinical features and serological markers can predict the overall survival among the patients who are about to receive bone metastasis surgery after breast cancer surgery. The model can guide the preoperative evaluation and clinical decision-making for patients. Level of evidence Level III, prognostic study.
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Affiliation(s)
- Haochen Mou
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zhan Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Wenkan Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Guoqi Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hao Zhou
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Eloy Yinwang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Fangqian Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hangxiang Sun
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Yucheng Xue
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zenan Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Tao Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Xupeng Chai
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hao Qu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Peng Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Wangsiyuan Teng
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Binghao Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zhaoming Ye
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
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15
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Yang Z, Xie Y, Liu C, Liu X, Song S, Zhang Y, Ge R, Wang B, Yang Z. The clinical value of 18F-fluoroestradiol in assisting individualized treatment decision in dual primary malignancies. Quant Imaging Med Surg 2021; 11:3956-3965. [PMID: 34476181 DOI: 10.21037/qims-20-1364] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/19/2021] [Indexed: 12/29/2022]
Abstract
Background For patients with previously diagnosed dual primary tumors, it is usually difficult to determine the diagnosis and treatment of stage IV recurrence. The study was to explore the influences of 18F-fluoroestradiol positron emission tomography/computed tomography (18F-FES PET/CT) in the diagnosis of estrogen receptor (ER) positive breast cancer combined with other primary tumor with distant metastases. Methods Multidisciplinary team were organized to explore the definite clinical value of 18F-FES PET/CT in stage IV patients suffered from ER-positive breast cancer and another primary tumor synchronously or metachronously. Thirty-two female patients were retrospectively analyzed who underwent 18F-FES PET/CT scans in our center. Before and after reading 18F-FES reports, the team members from department of surgery, oncology and radiotherapy should make decisions of management strategy. Results Totally, the multidisciplinary team completed the management decision-making of the 32 patients before and after 18F-FES PET/CT scans. 87.5% (n=28) of the patients were considered to benefit from 18F-FES reports for diagnosis and treatment decisions. Out of the 28 patients, 7 patients (7/32, 21.9%) were considered to definitely change the management strategies while 12 patients (12/32, 37.5%) was instructive to develop management plans after the scan. The other 9 patients were suggested reassuring decision-making process by 18F-FES PET/CT. Conclusions 18F-FES PET/CT scans have clinical effects on diagnosis and treatment strategies of stage IV patients suffered from ER-positive breast cancer and another primary tumor.
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Affiliation(s)
- Ziyi Yang
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Molecular Imaging Probes, Shanghai, China
| | - Yizhao Xie
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Cheng Liu
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Molecular Imaging Probes, Shanghai, China
| | - Xin Liu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shaoli Song
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Molecular Imaging Probes, Shanghai, China
| | - Yingjian Zhang
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Molecular Imaging Probes, Shanghai, China
| | - Rui Ge
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Biyun Wang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhongyi Yang
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Molecular Imaging Probes, Shanghai, China
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16
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Tsukamoto S, Kido A, Tanaka Y, Facchini G, Peta G, Rossi G, Mavrogenis AF. Current Overview of Treatment for Metastatic Bone Disease. Curr Oncol 2021; 28:3347-3372. [PMID: 34590591 PMCID: PMC8482272 DOI: 10.3390/curroncol28050290] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/13/2021] [Accepted: 08/26/2021] [Indexed: 12/16/2022] Open
Abstract
The number of patients with bone metastasis increases as medical management and surgery improve the overall survival of patients with cancer. Bone metastasis can cause skeletal complications, including bone pain, pathological fractures, spinal cord or nerve root compression, and hypercalcemia. Before initiation of treatment for bone metastasis, it is important to exclude primary bone malignancy, which would require a completely different therapeutic approach. It is essential to select surgical methods considering the patient’s prognosis, quality of life, postoperative function, and risk of postoperative complications. Therefore, bone metastasis treatment requires a multidisciplinary team approach, including radiologists, oncologists, and orthopedic surgeons. Recently, many novel palliative treatment options have emerged for bone metastases, such as stereotactic body radiation therapy, radiopharmaceuticals, vertebroplasty, minimally invasive spine stabilization with percutaneous pedicle screws, acetabuloplasty, embolization, thermal ablation techniques, electrochemotherapy, and high-intensity focused ultrasound. These techniques are beneficial for patients who may not benefit from surgery or radiotherapy.
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Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
- Correspondence: ; Tel.: +81-744-22-3051
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
| | - Giancarlo Facchini
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Giuliano Peta
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Giuseppe Rossi
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 41 Ventouri Street, 15562 Athens, Greece;
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17
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Ononuju U, Hamilton DA, Washington A, Vaidya R. A pituitary cup biopsy is more accurate than reamings for histological diagnosis of intramedullary lesions during nailing of impending and pathologic fractures: a retrospective matched cohort analysis. INTERNATIONAL ORTHOPAEDICS 2021; 45:2735-2740. [PMID: 34401932 DOI: 10.1007/s00264-021-05087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Histologic diagnosis of the lesion is important while intramedullary nailing of a pathologic or impending fracture of a long bone. A biopsy can be performed extramedullary using a targeted sampling device such as a pituitary rongeur or intramedullary from the bone removed from the reamer during preparation of the intramedullary canal. The purpose of this study is to compare a cup pituitary rongeur vs. a reaming biopsy from the intramedullary canal during the treatment of pathologic bone lesions with an intramedullary nail. METHODS An IRB approved retrospective case control study was performed on 46 consecutive patients who underwent an IMN for pathologic fracture or impending pathologic fracture with an obvious lytic lesion with a known metastatic primary. A laryngeal cup pituitary forceps' rongeur was used in 25 patients and the intramedullary reamer as it passed the lesion was used in 21 patients. Histopathology reports were assessed for (1) adequacy of bone sample (defined as containing sufficient bone and marrow-derived tissue to allow complete histological analysis) and (2) tumor tissue diagnosis. A standard approach for IMN was used. RESULTS Twenty-three of 25 cup biopsy cases (92%) had positive pathology that corresponded to the primary cancer. Eleven of 21 reaming cases (52.4%) had positive pathology that corresponded to the primary cancer (p = 0.0117). CONCLUSION The use of an intramedullary cup biopsy forceps is better than reamings to diagnose pathological lesions of impending and pathological fractures in long bones caused by metastatic lesions.
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Affiliation(s)
- Ucheze Ononuju
- Detroit Medical Center, Wayne State University School of Medicine, Detroit, MI, USA
| | - D Alex Hamilton
- Detroit Medical Center, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Rahul Vaidya
- Department of Orthopaedic Surgery, Detroit Medical Center, 5Th Floor Heart Hospital, 311 Mack Avenue, Detroit, MI, 48201, USA.
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18
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Streitbürger A, Nottrott M, Guder W, Podleska L, Dudda M, Hardes J. [Strategic approach to pathological fractures]. Unfallchirurg 2021; 124:687-694. [PMID: 34398277 DOI: 10.1007/s00113-021-01068-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
Pathological tumor-associated fractures are overall rare. They can occur in every age group and every bone. Although tumor-related fractures only form a small proportion of bone fractures, the early recognition of the cause of the fracture and treatment according to oncological guidelines are of enormous importance for affected patients. False treatment is frequently associated with far-reaching negative consequences with respect to the course of the disease. The great challenge is not the expeditious surgical treatment but much more the adequate diagnostics and the incorporation of local fracture treatment into an interdisciplinary overall oncological concept.
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Affiliation(s)
- Arne Streitbürger
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Markus Nottrott
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Wiebke Guder
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Lars Podleska
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Marcel Dudda
- Klinik für Unfall‑, Hand-, und Wiederherstellungschirurgie, Universitätsmedizin Essen, Essen, Deutschland
| | - Jendrik Hardes
- Klinik für Tumororthopädie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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Fracture Risk of Long Bone Metastases: A Review of Current and New Decision-Making Tools for Prophylactic Surgery. Cancers (Basel) 2021; 13:cancers13153662. [PMID: 34359563 PMCID: PMC8345078 DOI: 10.3390/cancers13153662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/16/2021] [Accepted: 07/18/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Long bone metastases are frequently a pivotal point in the oncological history of patients. Weakening of the bone results in pathologic fractures that not only compromise patient function but also their survival. Therefore, the main issue for tumor boards remains timely assessment of the risk of fracture, as this is a key consideration in providing preventive surgery while also avoiding overtreatment. As the Mirels scoring system takes into account both the radiological and the clinical criteria, it has been used worldwide since the 1990s. However, due to increasing concern regarding the lack of accuracy, new thresholds have been defined for the identification of impending fractures that require prophylactic surgery, on the basis of axial cortical involvement and biomechanical models involving quantitative computed tomography. The aim of this review is to establish a state-of-the-art of the risk assessment of long bone metastases fractures, from simple radiologic scores to more complex multidimensional bone models, in order to define new decision-making tools. Abstract Long bone pathological fractures very much reflect bone metastases morbidity in many types of cancer. Bearing in mind that they not only compromise patient function but also survival, identifying impending fractures before the actual event is one of the main concerns for tumor boards. Indeed, timely prophylactic surgery has been demonstrated to increase patient quality of life as well as survival. However, early surgery for long bone metastases remains controversial as the current fracture risk assessment tools lack accuracy. This review first focuses on the gold standard Mirels rating system. It then explores other unique imaging thresholds such as axial or circumferential cortical involvement and the merits of nuclear imaging tools. To overcome the lack of specificity, other fracture prediction strategies have focused on biomechanical models based on quantitative computed tomography (CT): computed tomography rigidity analysis (CT-RA) and finite element analysis (CT-FEA). Despite their higher specificities in impending fracture assessment, their limited availability, along with a need for standardization, have limited their use in everyday practice. Currently, the prediction of long bone pathologic fractures is a multifactorial process. In this regard, machine learning could potentially be of value by taking into account clinical survival prediction as well as clinical and improved CT-RA/FEA data.
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Meynard P, Seguineau A, Laumonerie P, Fabre T, Foltran D, Niglis L, Descamps J, Bouthors C, Lebaron M, Szymanski C, Sailhan F, Bonnevialle P. Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series. Orthop Traumatol Surg Res 2020; 106:1013-1023. [PMID: 32778439 DOI: 10.1016/j.otsr.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/13/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival. HYPOTHESIS The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival. MATERIAL AND METHODS The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy. RESULTS After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]). CONCLUSIONS Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Pierre Meynard
- Centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux cedex, France.
| | - Arthur Seguineau
- Centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux cedex, France
| | - Pierre Laumonerie
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse cedex, France
| | - Thierry Fabre
- Centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux cedex, France
| | - Deborah Foltran
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse cedex, France
| | - Lucas Niglis
- Service d'orthopédie traumatologie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - Jules Descamps
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Charlie Bouthors
- Service de chirurgie orthopédique et traumatologie et du Rachis, hôpital Kremlin-Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Marie Lebaron
- Service de chirurgie orthopédique et traumatologie, hôpital Nord, chemin des Bourrely, 13015 Marseille, France
| | - Christophe Szymanski
- Service de chirurgie orthopédique et traumatologie, hôpital Salengro, avenue du Professeur-Emile-Laine, 59037 Lille, France
| | - Fréderic Sailhan
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Paul Bonnevialle
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse cedex, France
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- Société française de chirurgie orthopédique et traumatologique (SoFCOT), 56, rue Boissonade, 75014 Paris, France
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Lavignac P, Prieur J, Fabre T, Descamps J, Niglis L, Carlier C, Bouthors C, Baron-Trocellier T, Sailhan F, Bonnevialle P. Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases. Orthop Traumatol Surg Res 2020; 106:1025-1032. [PMID: 32763011 DOI: 10.1016/j.otsr.2020.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/07/2020] [Accepted: 03/24/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival. HYPOTHESIS The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies. METHODS Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)]. RESULTS Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer. CONCLUSION Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined. LEVEL OF EVIDENCE IV, retrospective study without control group.
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Affiliation(s)
- Pierre Lavignac
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon 33076 Bordeaux cedex, France
| | - Jules Prieur
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon 33076 Bordeaux cedex, France
| | - Thierry Fabre
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon 33076 Bordeaux cedex, France.
| | - Jules Descamps
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Lucas Niglis
- Service d'orthopédie traumatologie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - Christophe Carlier
- Clinique chirurgicale orthopédique et traumatologique, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - Charlie Bouthors
- Service de chirurgie orthopédique et traumatologie et du rachis, hôpital Kremlin-Bicêtre, 78, rue du Général-Leclerc 94270 Le Kremlin-Bicêtre, France
| | - Thomas Baron-Trocellier
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse Cedex, France
| | - Fréderic Sailhan
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Clinique Arago, groupe Almaviva, 187, rue Raymond-Losserand, 75014 Paris, France
| | - Paul Bonnevialle
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse Cedex, France
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- SOFCOT, 56, rue Boissonade, 75014 Paris, France
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Surgical treatment of tibial metastases: Retrospective, multicenter, observational study of 25 patients. Orthop Traumatol Surg Res 2020; 106:1039-1045. [PMID: 31624032 DOI: 10.1016/j.otsr.2019.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/02/2019] [Accepted: 07/15/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition. HYPOTHESIS We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature. MATERIAL AND METHODS The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient. RESULTS Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment. CONCLUSION Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort. LEVEL OF EVIDENCE IV, retrospective study.
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Crenn V, Carlier C, Gouin F, Sailhan F, Bonnevialle P. High rate of fracture in long-bone metastasis: Proposal for an improved Mirels predictive score. Orthop Traumatol Surg Res 2020; 106:1005-1011. [PMID: 32782175 DOI: 10.1016/j.otsr.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pathologic fracture is the most feared complication in long-bone metastasis. Various radiographic tools are available for identifying at-risk patients and guide preventive treatment. The Mirels score is the most frequently studied and widely used, but has been criticized, many patients not being operated on until the actual fracture stage. We therefore conducted a French national multicenter prospective study: (1) to determine the proportion of patients operated on at fracture stage versus preventively; (2) to compare Mirels score between the two; and (3) to identify factors for operation at fracture stage according to Mirels score and other epidemiological, clinical and biological criteria. HYPOTHESIS Simple discriminatory items can be identified to as to complete the Mirels score and enhance its predictive capacity. MATERIAL AND METHODS A non-controlled multicenter prospective study included 245 patients operated on for non-revelatory long-bone metastasis, comparing patients operated on for fracture versus preventively according to body-mass index (BMI), ASA score, Katagiri score items and the 4 Mirels items. RESULTS One hundred and twenty-six patients (51.4%) were operated on at fracture stage: 106 (84.1%) showed high risk on Mirels score (score>8), and 15 (11.9%) moderate risk (score=8). On multivariate analysis, 4 independent factors emerged: in increasing order, advanced age (OR=1.03; 95%CI 1.01-1.06), VAS pain score>6 (OR=1.47; 95%CI 1.02-2.11), WHO grade>2 (OR=2.74; 95%CI 1.22-6.15), and upper-limb location (OR=5.26; 95%CI 2.13-12.84). DISCUSSION The present study confirmed that more than half of patients with long-bone metastasis are operated on at actual fracture stage, in agreement with the literature. Several studies highlighted the weakness of the Mirels score as a predictive instrument. Comparison between preventive and fracture-stage surgery showed that upper-limb location, intense pain, advanced age and impaired functional status were associated with fracture-stage surgery, and should be taken into account alongside the original Mirels criteria. This improved scoring instrument remains to be validated in a prospective study. LEVEL OF EVIDENCE IV, prospective cohort study without control group.
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Affiliation(s)
- Vincent Crenn
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France; Physos, Inserm UMR 1238, Faculté de Médecine de Nantes, Rue G. Veil, 44000 Nantes, France.
| | - Christophe Carlier
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France
| | - François Gouin
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France; Physos, Inserm UMR 1238, Faculté de Médecine de Nantes, Rue G. Veil, 44000 Nantes, France; Département de Chirurgie, Centre Léon Bérard, 28, Rue Laennec, 69008 Lyon, France
| | - Fréderic Sailhan
- Hôpital Cochin, 27, Rue du Faubourg-Saint-Jacques, 75014 Paris, France; Clinique Arago, Groupe Almaviva, 187a, Rue Raymond Losserand, 75014 Paris, France
| | - Paul Bonnevialle
- Département Universitaire d'Orthopédie Traumatologie de Toulouse, Hôpital P.P. Riquet, Place Baylac, 31052 Toulouse Cedex, France
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- Société Française de Chirurgie Orthopédique et de Traulatologie (So.F.C.O.T.), 56, rue Boissonnade, 75014 Paris, France
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Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series. Orthop Traumatol Surg Res 2020; 106:997-1003. [PMID: 32273249 DOI: 10.1016/j.otsr.2019.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors. HYPOTHESIS The French data for clinical results, survival and complications are in agreement with the international literature. MATERIALS AND METHOD The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%). RESULTS There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before. CONCLUSION The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture. LEVEL OF EVIDENCE IV, retrospective study without control group.
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Willeumier JJ, van der Wal CWPG, Schoones JW, van der Wal RJ, Dijkstra PDS. Pathologic fractures of the distal femur: Current concepts and treatment options. J Surg Oncol 2018; 118:883-890. [PMID: 30328621 DOI: 10.1002/jso.25218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
Abstract
Pathologic fractures of the distal femur caused by bone metastases are not as common as those in the proximal femur but provide great difficulty to adequately treat. This systematic review shows that insufficient literature exists to draw clinically relevant conclusions for essential questions, such as "what factors indicate an endoprosthetic reconstruction for distal femur pathologic fractures?" Due to paucity of literature in the systematic review, a current concepts review (including treatment flowchart), based on instructional reviews and experience, was also performed.
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Affiliation(s)
- Julie J Willeumier
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - C W P Gerco van der Wal
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert J van der Wal
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - P D Sander Dijkstra
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Kim LD, Bueno FT, Yonamine ES, Próspero JDD, Pozzan G. Bone metastasis as the first symptom of tumors: role of an immunohistochemistry study in establishing primary tumor. Rev Bras Ortop 2018; 53:467-471. [PMID: 30027080 PMCID: PMC6052186 DOI: 10.1016/j.rboe.2018.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/20/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives To determine the role of immunohistochemistry in identifying the primary site of tumors, and in establishing which bones are most frequently involved, their relationship with the primary tumor site, and the rate of pathologic bone fracture as the first symptom of a malignant tumor. Methods A retrospective analysis of all medical records on bone metastases the cases treated between January 2006 and December 2011 at the Department of Orthopedics and Traumatology was performed. Results Immunohistochemistry correctly determined the primary tumor site in 61.2% of cases analyzed. Regarding the metastatic site, the most affected bone was the femur, accounting for 49.6% of the sample. Bone metastasis was the first symptom of the tumor in only 20.2% of patients, and of these, 95% were admitted for pathologic bone fracture. Conclusion The study showed that the primary sites and their incidence rate are consistent with the literature reviewed. It was noted that in this sample, most patients did not present with pathologic bone fracture as the first clinical symptom of neoplastic disease. However, analysis of those patients that had a metastasis as the first clinical symptom revealed that it manifested itself as a pathologic fracture in almost all cases. The immunohistochemical study was consistent with the primary tumor site in most cases, indicating the value of the method in the detection of the primary site.
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Affiliation(s)
- Leandro Duil Kim
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Serviço de Ortopedia e Traumatologia, São Paulo, SP, Brazil
- Corresponding author.
| | - Fabiana Toledo Bueno
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Departamento de Anatomia Patológica, São Paulo, SP, Brazil
| | - Eduardo Sadao Yonamine
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Serviço de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - José Donato de Próspero
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Departamento de Anatomia Patológica, São Paulo, SP, Brazil
| | - Geanete Pozzan
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Serviço de Ortopedia e Traumatologia, São Paulo, SP, Brazil
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Metástase óssea como primeira manifestação de tumores: contribuição do estudo imuno-histoquímico para o estabelecimento do tumor primário. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Casadei R, Drago G, Di Pressa F, Donati D. Humeral metastasis of renal cancer: Surgical options and review of literature. Orthop Traumatol Surg Res 2018; 104:533-538. [PMID: 29654934 DOI: 10.1016/j.otsr.2018.03.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/15/2018] [Accepted: 03/20/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The humerus is the second most common long bone site of metastatic disease from renal cell carcinomas (RCC) after femur. Surgery has an important role in the treatment of these lesions due to renal cell tumor's resistance to chemotherapy and radiotherapy. HYPOTHESIS Prosthetic replacement is an effective and safe solution in treatment of renal humeral metastasis. MATERIAL AND METHODS Fifty-six patients affected by RCC bone metastases of the humerus that underwent a surgical reconstruction were rewised. Thirty-five lesions were localized on proximal third, 12 on the shaft, 9 on distal third. Among proximal 29 were treated with resection and endoprosthetic replacement and 6 with plate and cement. Six diaphyseal lesions were stabilized with intramedullary nailing, 5 with plate and cement and 1 with an intercalary prosthesis. Regarding distal lesions, 7 elbow prostheses and 2 plates and cement were used. RESULTS The average age was 63years. Metastasis was single in 55% of cases, and in 45% metachronous. A pathologic fracture (PF) occurred in 64% of cases. Only 9% of patients had a mechanical complication, 7% an infection and 5% neurological deficit. A local recurrence occurred in 14% of patients. An implant failure has been observed in 10 patients, 5 for mechanical complications, 2 for infections and 3 for local recurrence; of these 7 were treated with a prosthesis and 3 with plate and cement. The mean value of MSTS score was 64%, 63% and 59% respectively in patients with proximal, diaphyseal and distal humerus metastases. DISCUSSION Solitary and metachronous bone metastases have a longer survival. Disease-free interval>2years is another important prognostic factor. Reconstruction with a modular prosthesis is recommended in proximal and distal third. Instead in diaphyseal lesions a closed reduction and fixation with intramedullary locked nailing are preferred. When surgical indications are correctly followed, good oncologic and functional outcomes are obtained, leading to markedly improvement of patients' quality of life. RETROSPECTIVE STUDY Level of evidence: IV.
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Affiliation(s)
- R Casadei
- Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - G Drago
- Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - F Di Pressa
- Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - D Donati
- Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
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