Skip to main content
SpringerLink
Log in

Metastases to the Long Bones: Algorithm of Treatment

  • Chapter
  • First Online:
Management of Bone Metastases

Abstract

Metastases of the long bones represent a frequent clinical condition.

Multiple treatment options are available, ranging from the more aggressive resections and arthroplasty to palliative care and from long-lasting reconstruction to minimally invasive therapies.

When selecting a treatment, it is paramount to consider not only the mechanical characteristics of the lesions but also the tumoral behavior, medical state, and expected survival of the patient. In addition, other factors should be taken into account: the presence of a single metastatic lesion, the site in the long bone (diaphysis or metaepiphysis), mechanical stability (impending or pathological fracture), and the effectiveness of nonsurgical therapies.

Several prognostic criteria were assessed in the last 20 years and, being familiar with them may help in treatment selection.

An algorithm of treatment has been the objective to guide the decision-making process in a multidisciplinary approach to metastasis of the long bones.

A collaboration between the orthopedic surgeon, the oncologist, and the radiotherapist leads to the best choice of treatment for the different scenarios.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 129.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Li S, Peng Y, Weinhandl ED, et al. Estimated number of prevalent cases of metastatic bone disease in the US adult population. Clin Epidemiol. 2012;4:87–93.

    PubMed  PubMed Central  Google Scholar 

  2. Ibrahim T, Farolfi A, Mercatali L, et al. Metastatic bone disease in the era of bone-targeted therapy: clinical impact. Tumori. 2013;99:1–9.

    Article  CAS  PubMed  Google Scholar 

  3. Saad F, Lipton A, Cook R, et al. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer. 2007;110:1860–7.

    Article  PubMed  Google Scholar 

  4. Hansen BH, Keller J, Laitinen M, et al. The Scandinavian Sarcoma Group skeletal metastasis register. Survival after surgery for bone metastases in the pelvis and extremities. Acta Orthop Scand. 2004;75:11–5.

    Article  CAS  Google Scholar 

  5. Bohm P, Huber J. The surgical treatment of bony metastases of the spine and limb. J Bone Joint Surg Br. 2002;84B:521–9.

    Google Scholar 

  6. Katagiri H, Takahashi M, Wakai K, et al. Prognostic factors and scoring system for patients with skeletal metastasis. J Bone Joint Surg Br. 2005;87-B:698–703.

    Article  Google Scholar 

  7. Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents. In: MacLeod CM, editor. Evaluation of chemotherapeutic agents. New York: Columbia University Press; 1949. p. 191–205.

    Google Scholar 

  8. Nathan SS, Healey JH, Mellano D, et al. Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care. J Clin Oncol. 2005;23:6072–82.

    Article  PubMed  Google Scholar 

  9. Conill C, Verger E, Salamero M. Performance status assessment in cancer patients. Cancer. 1990;65:1864–6.

    Article  CAS  PubMed  Google Scholar 

  10. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–55.

    Article  CAS  PubMed  Google Scholar 

  11. Forsberg JA, Eberhardt J, Boland PJ, et al. Estimating survival in patients with operable skeletal metastases: an application of a Bayesian belief network. PLoS One. 2011;6:e19956.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Forsberg JA, Wedin R, Bauer H, et al. External validation of the Bayesian Estimated Tools for Survival (BETS) models in patients with surgically treated skeletal metastases. BMC Cancer. 2012;12:493.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Forsberg JA, Sjoberg D, Chen QR, et al. Treating metastatic disease: which survival model is best suited for the clinic? Clin Orthop Relat Res. 2013;471:843–50.

    Article  PubMed  Google Scholar 

  14. Capanna R, Campanacci DA. The treatment of metastasis in appendicular skeleton. J Bone Joint Surg Br. 2001;83:471–81.

    Article  CAS  PubMed  Google Scholar 

  15. Rougraff BT. Diagnosis of bone metastases evaluation of the patient with carcinoma of unknown origin metastatic to bone. Clin Orthop Relat Res. 2003;415S:S105–9.

    Article  Google Scholar 

  16. Fuchs B, Trousdale RT, Rock MG. Solitary bony metastasis from renal cell carcinoma. Significance of surgical treatment. Clin Orthop Rel Res. 2005;431:187–92.

    Article  Google Scholar 

  17. Althausen P, Althausen A, Jennings LC, et al. Prognostic factors and surgical treatment of osseous metastases secondary to renal cell carcinoma. Cancer. 1997;80:1103–9.

    Article  CAS  PubMed  Google Scholar 

  18. Durr HR, Maier M, Pfahler M, et al. Surgical treatment of osseous metastases in patients with renal cell carcinoma. Clin Orthop Rel Res. 1999;367:283–90.

    Google Scholar 

  19. Jung ST, Ghert MA, Harrelson JM, et al. Treatment of osseous metastases in patients with renal cell carcinoma. Clin Orthop Rel Res. 2003;409:223–31.

    Article  Google Scholar 

  20. Balock KG, Grimer RJ, Carter SR, et al. Radical surgery for the solitary bony metastasis from renal-cell carcinoma. J Bone Joint Surg Br. 2000;82-B:62–7.

    Article  Google Scholar 

  21. Lin PP, Mirza AN, Lewis VO, et al. Patient survival after surgery for osseous metastases from renal cell carcinoma. J Bone Joint Surg Am. 2007;89:1794–801.

    Article  PubMed  Google Scholar 

  22. Casara D, Rubello D, Saladini G, et al. Distant metastases in differentiated thyroid cancer: long-term results of radioiodine treatment and statistical analysis of prognostic factors in 214 patients. Tumori. 1991;77:432–6.

    Article  CAS  PubMed  Google Scholar 

  23. Sampson E, Brierley JD, Le LW, et al. Clinical management and outcome of papillary and follicular (differentiated) thyroid cancer presenting with distant metastasis at diagnosis. Cancer. 2007;110:1451–6.

    Article  PubMed  Google Scholar 

  24. Proye CA, Dromer DH, Carnaille BM, et al. Is it still worthwhile to treat bone metastases from differentiated thyroid carcinoma with radioactive iodine? World J Surg. 1992;16:640–5.

    Article  CAS  PubMed  Google Scholar 

  25. Schlumberger M, Challeton C, De Vathaire F, et al. Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma. J Nucl Med. 1996;37:598–605.

    PubMed  CAS  Google Scholar 

  26. Niederle B, Roka R, Schemper M, et al. Surgical treatment of distant metastases in differentiated thyroid cancer: indication and results. Surgery. 1986;100:1088–97.

    PubMed  CAS  Google Scholar 

  27. Boyle MJ, Hornicek FJ, Robinson DS, et al. Internal hemipelvectomy for solitary pelvic thyroid cancer metastases. J Surg Oncol. 2000;75:3–10.

    Article  CAS  PubMed  Google Scholar 

  28. Durr HR, Muller PE, Lenz T, et al. Surgical treatment of bone metastases in patients with breast cancer. Clin Orthop Rel Res. 2002;396:191–6.

    Article  Google Scholar 

  29. Jimeno A, Amador ML, Gonzalez-Cortijo L, et al. Initially metastatic breast carcinoma has a distinct disease pattern but an equivalent outcome compared with recurrent metastatic breast carcinoma. Cancer. 2004;100:1833–42.

    Article  PubMed  Google Scholar 

  30. Oka H, Kondoh T, Seichi A, et al. Incidence and prognostic factors of Japanese breast cancer patients with bone metastasis. J Orthop Sci. 2006;11:13–9.

    Article  PubMed  Google Scholar 

  31. Koizumi M, Yoshimoto M, Kasumi F, et al. Comparison between solitary and multiple skeletal metastatic lesions of breast cancer patients. Ann Oncol. 2003;14:1234–40.

    Article  CAS  PubMed  Google Scholar 

  32. Weiss RJ, Forsberg JA, Wedin R. Surgery of skeletal metastases in 306 patients with prostate cancer. Indications, complications, and survival. Acta Orthop. 2012;83:74–9.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Cheville JC, Tindall D, Boelter C, et al. Metastatic prostate carcinoma to bone. Clinical and pathologic features associated with cancer-specific survival. Cancer. 2002;95:1028–36.

    Article  PubMed  Google Scholar 

  34. Healey JH, Brown HK. Complications of bone metastases - surgical management. Cancer. 2000;88:2940–51.

    Article  CAS  PubMed  Google Scholar 

  35. Poitout DG, Tropiano P, Clouet D’Orval B, et al. Surgery for bone metastasis of the limbs. In: Poitout DG, editor. Bone metastases medical, surgical and radiological treatment. London: Springer; 2002. p. 97–100.

    Chapter  Google Scholar 

  36. Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop. 1983;178:297–302.

    Google Scholar 

  37. Sim FH. Operative treatment—general considerations. In: Sim FH, editor. Diagnosis and management of metastatic bone disease—a multidisciplinary approach. New York: Raven Press; 1987. p. 161–70.

    Google Scholar 

  38. Ward WG, Holsenbeck S, Dorey FJ, et al. Metastatic disease of the femur: surgical treatment. Clin Orthop Relat Res. 2003;415(Suppl):S230–44.

    Article  Google Scholar 

  39. Harrington KD. The role of surgery in the management of pathologic fractures. Orthop Clin North Am. 1977;8:841.

    Google Scholar 

  40. Mirels M. Metastatic disease in long bones: a proposed scoring system for diagnosis impending pathologic fractures. Clin Orthop. 1989;249:256–64.

    Google Scholar 

  41. Damron TA, Morgan H, Prakash D, et al. Critical evaluation of Mirels’ rating system for impending pathological fractures. Clin Orthop Rel Res. 2003;415(Suppl):S201–7.

    Article  Google Scholar 

  42. Patel B, DeGroot H. Evaluation of the risk of pathologic fractures secondary to metastatic bone disease. Orthopedics. 2001;24:612–7.

    PubMed  CAS  Google Scholar 

  43. Van der Linden YM, Dijkstra PDS, Kroon HM, et al. Comparative analysis of risk factors for pathological fracture with femoral metastases. Results based on a randomized trial of radiotherapy. J Bone Joint Surg Br. 2004;86B:566–73.

    Article  Google Scholar 

  44. Tanck E, van Aken JB, van der Linden YM, et al. Pathological fracture prediction in patients with metastatic lesions can be improved with quantitative computed tomography based computer models. Bone. 2009;45:777–83.

    Article  PubMed  Google Scholar 

  45. Keyak JH, Kaneko TS, Rossi SA, et al. Predicting the strength of femoral shafts with and without metastatic lesions. Clin Orthop Rel Res. 2005;439:161–70.

    Article  Google Scholar 

  46. Keyak JH, Kaneko TS, Tehranzadeh J, et al. Predicting proximal femoral strength using structural engineering models. Clin Orthop Relat Res. 2005;437:219–28.

    Article  Google Scholar 

  47. Derikx LC, van Aken JB, Janssen D, et al. The assessment of the risk of fracture in femora with metastatic lesions: comparing case-specific finite element analyses with predictions by clinical experts. J Bone Joint Surg Br. 2012;94:1135–42.

    Article  CAS  PubMed  Google Scholar 

  48. Piccioli A, Maccauro G, Rossi B, et al. Surgical treatment of pathologic fractures of humerus. Injury. 2010;41:1112–6.

    Article  PubMed  Google Scholar 

  49. Piccioli A, Maccauro G, Scaramuzzo L, et al. Surgical treatment of impending and pathological fractures of tibia. Injury. 2013;44:1092–6.

    Article  CAS  PubMed  Google Scholar 

  50. Piccioli A, Ventura A, Maccauro G, et al. Local adjuvants in surgical management of bone metastases. Int J Immunopathol Pharmacol. 2011;24:129–32.

    Article  CAS  PubMed  Google Scholar 

  51. Jacofsky DJ, Haidukewych JH. Management of pathologic fractures of the proximal femur state of the art. J Orthop Trauma. 2004;18:459–69.

    Article  PubMed  Google Scholar 

  52. Capanna R, Scoccianti G, Campanacci DA, et al. Surgical technique: extraarticular knee resection with prosthesis-proximal tibia-extensor apparatus allograft for tumors invading the knee. Clin Orthop Relat Res. 2011;469:2905–14.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Harvey N, Ahlmann ER, Allison DC, et al. Endoprostheses last longer than intramedullary devices in proximal femur metastases. Clin Orthop Rel Res. 2012;470:684–91.

    Article  Google Scholar 

  54. Steensma M, Boland PJ, Morris CD, et al. Endoprosthetic treatment is more durable for pathologic proximal femur fractures. Clin Orthop Relat Res. 2012;470:920–6.

    Article  PubMed  Google Scholar 

  55. Lackman RD, Hosalkar HS, Ogilvie CM, et al. Intralesional curettage for graves II and III Giant cell tumors of bone. Clin Orthop. 2005;438:123–7.

    Article  PubMed  Google Scholar 

  56. Quint U, Muller RT, Muller G. Characteristics of phenol. Arch Orthop Trauma Surg. 1998;117:43–6.

    Article  CAS  PubMed  Google Scholar 

  57. Gage AA, Baust JG. Mechanisms of tissue injury in cryosurgery. Cryobiology. 1998;37:171–86.

    Article  CAS  PubMed  Google Scholar 

  58. Marcove RC, Lyden JP, Huvos AG, et al. Giant cell tumors treated by cryosurgery. A report of twenty-five cases. J Bone Joint Surg Am. 1973;55A:1633.

    Article  Google Scholar 

  59. Baust JG, Gage AA. The molecular basis of cryosurgery. BJU Int. 2005;95:1187–91.

    Article  PubMed  Google Scholar 

  60. Robinson D, Halperin N, Nevo Z. Two freezing cycles ensure interface sterilization by cryosurgery during bone tumor resection. Cryobiology. 2001;43:4–10.

    Article  CAS  PubMed  Google Scholar 

  61. Dijkstra S, Wiggers T, Van Geel BN, et al. Impending and actual pathological fractures in patients with bone metastases of the long bones—a retrospective study of 233 surgically treated fractures. Eur J Surg. 1994;160:535–42.

    Google Scholar 

  62. Capanna R, De Biase P, Sensi L. Minimally invasive techniques for treatment of metastatic cancer. Orthopade. 2009;38:343–7.

    Article  CAS  PubMed  Google Scholar 

  63. Carrafiello G, Laganà D, Pellegrino C, et al. Ablation of painful metastatic bone tumors: a systematic review. Int J Surg. 2008;6:S47–52.

    Article  PubMed  Google Scholar 

  64. Choi J, Raghavan M. Diagnostic imaging and image-guided therapy of skeletal metastases. Cancer Control. 2012;19:10212.

    Article  Google Scholar 

  65. Callstrom MR, Charboneau JW, Goetz MP, et al. Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem. Skelet Radiol. 2006;35:1–15.

    Article  Google Scholar 

  66. Lee JH, Stein M, Roychowdhury S. Percutaneous treatment of a sacral metastasis with combined embolization, cryoablation, alcohol ablation and sacroplasty for local tumor and pain control. Interv Neuroradiol. 2013;19:250–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Capanna R. A new system for classification and treatment of long bone metastases. In: Instructional course lecture – EFORT, 1998.

    Google Scholar 

  68. Piccioli A, Campanacci DA, Daolio P, et al. Linee Guida SIOT. Gruppo di Studio SIOT sulle metastasi ossee. Trattamento delle metastasi ossee nello scheletro appendicolare. GIOT. 2014;40:1–15.

    Google Scholar 

  69. Gruppo di Studio SIOT sulle Metastasi Ossee. Linee Guida SIOT. Il trattamento dell metastasi ossee. 2008.

    Google Scholar 

  70. Attar S, Steffner RJ, Avedian R, et al. Surgical intervention of nonvertebral osseous metastasis. Cancer Control. 2012;19:113–21.

    Article  CAS  PubMed  Google Scholar 

  71. Theriault RL, Theriault RL. Biology of bone metastases. Cancer Control. 2012;19:92101.

    Article  Google Scholar 

  72. Zou X, Zou L, He Y, et al. Molecular treatment strategies and surgical reconstruction for metastatic bone diseases. Cancer Treat Rev. 2008;34:527–38.

    Article  CAS  PubMed  Google Scholar 

  73. Eastley N, Newey M, Ashford RU. Skeletal metastases and the role of the orthopaedic and spinal surgeon. Surg Oncol. 2012;21:216–22.

    Article  PubMed  Google Scholar 

  74. Malvija A, Gerrand C. Evidence for orthopaedic surgery in the treatment of metastatic bone disease of the extremities. A review article. Palliat Med. 2012;26:788–96.

    Article  Google Scholar 

  75. Yu HM, Tsai Y, Hoffe SE. Overview of diagnosis and management of metastatic disease to bone. Cancer Control. 2012;19:84–91.

    Article  PubMed  Google Scholar 

  76. Capanna R, De Biase P, Campanacci DA. A new protocol of surgical treatment of long bone metastases. Ortop Traumatol Rehabil. 2003;5:271–5.

    PubMed  Google Scholar 

  77. Ibrahim T, Flamini E, Fabbri L, et al. Multidisciplinary approach to the treatment of bone metastases: osteo-oncology center, a new organizational model. Tumori. 2009;95:291–7.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Orthopaedic Oncology and Reconstructive Unit, Careggi University Hospital, Florence, Italy

    Maurizio Scorianz & Domenico A. Campanacci

  2. Orthopedic and Traumatology Unit, Gorizia General Hospital, Gorizia, Italy

    Franco Gherlinzoni

  3. Department of Surgery and Translational Medicine, University of Florence, Florence, Italy

    Domenico A. Campanacci

Authors
  1. Maurizio Scorianz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Franco Gherlinzoni
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Domenico A. Campanacci
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Domenico A. Campanacci .

Editor information

Editors and Affiliations

  1. Department of Orthopaedics and Trauma Surgery, University Campus Bio-Medico of Rome, Rome, Italy

    Vincenzo Denaro

  2. Department of Orthopaedics and Trauma Surgery, University Campus Bio-Medico of Rome, Rome, Italy

    Alberto Di Martino

  3. General Direction of Health Program, National Ministry of Health of Italy, Rome, Italy

    Andrea Piccioli

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Scorianz, M., Gherlinzoni, F., Campanacci, D.A. (2019). Metastases to the Long Bones: Algorithm of Treatment. In: Denaro, V., Di Martino, A., Piccioli, A. (eds) Management of Bone Metastases. Springer, Cham. https://doi.org/10.1007/978-3-319-73485-9_9

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-73485-9_9

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-73484-2

  • Online ISBN: 978-3-319-73485-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation