Perioperative considerations in patients with metastatic bone disease

Correlation of the Neutrophil-to-lymphocyte and Platelet-to-lymphocyte Ratios with Postoperative Complications and Survival in Surgery for Bone Metastasis of the Appendicular Skeleton

Objective  To analyze, in cases of long-bone metastases, the incidence of postoperative complications and survival of up to 1 year, correlating them with the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Methods  Review of 160 medical records of patients who underwent surgery for bone metastases in the appendicular skeleton. We determined epidemiological characteristics and NLR and PLR values, which were correlated with survival and complications. Results  Women represented 64.5% of the sample, and 62.6% presented primary breast tumor. The proximal femur was the most affected bone. The median survival was of 13.2 months, and the 1-year survival rate, of 34.7%. Tumor resection with endoprosthesis was the most common surgery. The postoperative complication rate was of 10%, and the mean time until occurrence was of 27.9 (range: 0-140) days. We observed a significant association between neutrophil levels and postoperative complications ( p  = 0.04): for every increase of 100 neutrophils, the risk of postoperative complications increased by 1%. The mean NLR and PLR values were of 5.3 (range: 0.2-30.7) and 199.7 (range: 32.1-676.7) respectively. Patients with NLR ≥ 2 ( p  < 0,001) showed a decrease in survival from 92,3 to 62,5% in the third month, and from 61,5 to 31,3% in the first year. Those with PLR ≥ 209 ( p  < 0.001) showed a decrease in survival from 69 to 59.3% in the third month, and from 40.2 to 25.9% in the first year. Conclusion  There was no positive association regarding the NLR and PLR and postoperative complications. However, we noted a strong correlation involving elevated NLR and PLR levels and reduced life expectancy starting from the third postoperative month.

The perioperative management of skeletal metastases

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

EARLY COMPLICATIONS IN THE ORTHOPEDIC TREATMENT OF BONE METASTASES

Objective: To assess the early complications in the orthopedic treatment of metastatic bone lesions and the factors associated with these complications. Method: There were assessed, retrospectively, 64 patients that underwent surgical treatment for bone metastases, analyzing the complications that occurred in the pre-operative and early post- operative period and associating them with the tumor origin, type of procedure done, the need of blood reposition before the surgery, the need of new surgical procedures and the mortality due to the complications. Results: Early complications in the treatment were observed in 17 (26.6%) patients, of which six (35.2%) ended up dying due to these complications. Regarding the type, 15 (23.8%) cases were due to surgical complications, four (6.3%) clinical and three (4.7%) patients showed clinical and surgical complications. There was no significant difference in the frequency of complications or mortality when assessed the type of reconstruction or affected region. The tumors with a renal origin needed more blood reposition and showed a bigger frequency of complications. Conclusion: The complications occurred in 26.6%. The complications are not related to the kind of treatment performed or to the region affected. The renal origin tumors showed a higher risk of hemorrhage.

Radionuclide bone imaging: an illustrative review

Bone scintigraphy with technetium-99m-labeled diphosphonates is one of the most frequently performed of all radionuclide procedures. Radionuclide bone imaging is not specific, but its excellent sensitivity makes it useful in screening for many pathologic conditions. Moreover, some conditions that are not clearly depicted on anatomic images can be diagnosed with bone scintigraphy. Bone metastases usually appear as multiple foci of increased activity, although they occasionally manifest as areas of decreased uptake. Traumatic processes can often be detected, even when radiographic findings are negative. Most fractures are scintigraphically detectable within 24 hours, although in elderly patients with osteopenia, further imaging at a later time is sometimes indicated. Athletic individuals are prone to musculoskeletal trauma, and radionuclide bone imaging is useful for identifying pathologic conditions such as plantar fasciitis, stress fractures, "shin splints," and spondylolysis, for which radiographs may be nondiagnostic. A combination of focal hyperperfusion, focal hyperemia, and focally increased bone uptake is virtually diagnostic for osteomyelitis in patients with nonviolated bone. Bone scintigraphy is also useful for evaluating disease extent in Paget disease and for localizing avascular necrosis in patients with negative radiographs. Radionuclide bone imaging will likely remain a popular and important imaging modality for years to come.