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Surgical Management of Bone Metastases: Quality of Evidence and Systematic Review

  • Bone and Soft Tissue Sarcomas
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Surgical management of metastatic bone disease (MBD) is typically reserved for lesions with the highest risk of fracture. However, the high risk of perioperative complications associated with surgery may outweigh the benefits of improved pain and/or function. The goal of this study was to (1) assess the quality of current evidence in this domain; (2) confirm that surgical management of metastases to the long bones and pelvis/acetabulum provides pain relief and improved function; and (3) assess perioperative morbidity and mortality rates.

Methods

We conducted a systematic review of the literature for clinical studies that reported pain relief and function outcomes, as well as perioperative complications and mortality, in patients with MBD to the long bones and/or pelvis/acetabulum treated surgically. Multiple databases were searched up to January 2012. Pooled weighted proportions are reported.

Results

Forty-five studies were included in the final analysis, with 807 patients. All included studies were level IV with ‘moderate’ overall quality of evidence using the Methodological Index for Non-Randomized Studies scale. Pain relief following surgical management of metastases was 93, 91, and 93 % in the humerus, femur, and pelvis/acetabulum, respectively. Maintained or improved function after surgery was seen in 94, 89, and 94 % in the humerus, femur, and pelvis/acetabulum, respectively. Perioperative complications and mortality were 17 and 4 %, respectively.

Conclusions

Despite the inherent limitations of the current evidence, a benefit for the surgical management of bone metastases to the long bones and pelvis/acetabulum is evident; however, there is still substantial risk of perioperative morbidity and mortality that should be considered.

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References

  1. Virk MS, Lieberman JR. Tumor metastasis to bone. Arthritis Res Ther. 2007;9 Suppl 1:S5.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Harrington KD. Metastatic disease of the spine. J Bone Joint Surg Am. 1986;68(7):1110–1115.

    CAS  PubMed  Google Scholar 

  3. Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev. 2001;27(3):165–176.

    Article  CAS  PubMed  Google Scholar 

  4. Bauer HC. Controversies in the surgical management of skeletal metastases. J Bone Joint Surg Br. 2005; 87(5):608–617.

    Article  CAS  PubMed  Google Scholar 

  5. Nathan SS, Chan L, Tan WL, Tan I, Go M, Chuah B, et al. The need for a system of prognostication in skeletal metastasis to decide best end-of-life care: a call to arms. Ann Acad Med Singapore. 2010;39(6): 476–81.

    PubMed  Google Scholar 

  6. Wedin R. Surgical treatment for pathologic fracture. Acta Orthop Scand. 2001;72(302): 21–29.

    Google Scholar 

  7. Mirels H. Metastatic disease in long bones: a- proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989; (249): 256–64.

    PubMed  Google Scholar 

  8. Harrington KD. Impending pathologic fractures from metastatic malignancy: evaluation and management. Instr Course Lect. 1986;35:357–381.

    CAS  PubMed  Google Scholar 

  9. Damron TA, Morgan H, Prakash D, Grant W, Aronowitz J, Heiner J. Critical evaluation of Mirels’ rating system for impending pathologic fractures. Clin Orthop Relat Res. 2003;415 Suppl: S201–7.

    Article  PubMed  Google Scholar 

  10. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–716.

    Article  PubMed  Google Scholar 

  11. Atesok K, Liebergall M, Sucher E, Temper M, Mosheiff R, Peyser A. Treatment of pathological humeral shaft fractures with unreamed humeral nail. Ann Surg Oncol. 2007;14(4):1493–1498.

    Article  PubMed  Google Scholar 

  12. Chan D, Carter SR, Grimer RJ, Sneath RS. Endoprosthetic replacement for bony metastases. Ann R Coll Surg Engl. 1992;74(1):13–18.

    CAS  PubMed Central  PubMed  Google Scholar 

  13. Chin HC, Frassica FJ, Hein TJ, et al. Metastatic diaphyseal fractures of the shaft of the humerus. The structural strength evaluation of a new method of treatment with a segmental defect prosthesis. Clin Orthop Relat Res. 1989;248:231–239.

    PubMed  Google Scholar 

  14. Franck WM, Olivieri M, Jannasch O, Hennig FF. An expandable nailing system for the management of pathological humerus fractures. Arch Orthop Trauma Surg. 2002;122(7):400–405.

    CAS  PubMed  Google Scholar 

  15. Kim JH, Kang HG, Kim JR, Lin PP, Kim HS. Minimally invasive surgery of humeral metastasis using flexible nails and cement in high-risk patients with advanced cancer. Surg Oncol. 2011;20(1):e32–7.

    Article  PubMed  Google Scholar 

  16. Kumta SM, Quintos AD, Griffith JF, Chow LT, Wong KC. Closed retrograde nailing of pathological humeral fractures. Int Orthop. 2002;26(1):17–19.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  17. Kunec JR, Lewis RJ. Closed intramedullary rodding of pathologic fractures with supplemental cement. Clin Orthop Relat Res. 1984;188:183–186.

    PubMed  Google Scholar 

  18. Lin J, Hou SM, Hang YS, Chao EY. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop Relat Res. 1997;342:147–155.

    Article  PubMed  Google Scholar 

  19. Moehring HD. Closed flexible intramedullary fixation for pathologic lesions in the long bones. Orthopaedics. 1984;7(5): 829–834.

    CAS  Google Scholar 

  20. Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg Am. 1996;78(6):891–896.

    CAS  PubMed  Google Scholar 

  21. Tome J, Carsi B, Garcia-Fernandez C, Marco F, Lopez-Duran Stern L. Treatment of pathologic fractures of the humerus with seidel nailing. Clin Orthop Relat Res. 1998;(350):51–55.

    PubMed  Google Scholar 

  22. van der Hulst RR, van den Wildenberg FA, Vroemen JP, Greve JW. Intramedullary nailing of (impending) pathologic fractures. J Trauma. 1994;36(2):211–215.

    Article  PubMed  Google Scholar 

  23. Algan SM, Horowitz SM. Surgical treatment of pathologic hip lesions in patients with metastatic disease. Clin Orthop Relat Res. 1996;332:223–231.

    Article  PubMed  Google Scholar 

  24. Assal M, Zanone X, Peter RE. Osteosynthesis of metastatic lesions of the proximal femur with a solid femoral nail and interlocking spiral blade inserted without reaming. J Orthop Trauma. 2000;14(6):394–397.

    Article  CAS  PubMed  Google Scholar 

  25. Broos P, Reynders P, van den Bogert W, Vanderschot P. Surgical treatment of metastatic fracture of the femur improvement of quality of life. Acta Orthop Belg. 1993;59 Suppl 1:52–56.

    PubMed  Google Scholar 

  26. Chien SH, Hung SH, Cheng YM, et al. Surgical treatment of pathologic fracture of the femur. Kaohsiung J Med Sci. 1997;13(9):556–561.

    CAS  PubMed  Google Scholar 

  27. Ciesielczyk B. Palliative intramedullary fixation of pathological fractures in the terminal period of tumoral disease. Orthop Traumatol Rehabil. 2003;5(3):331–334.

    Google Scholar 

  28. Faisham WI, Zulmi W, Biswal BM. Metastatic disease of the proximal femur. Med J Malaysia. 2003;58(1):120–124.

    CAS  PubMed  Google Scholar 

  29. Favorito PJ, McGrath BE. Impending or completed pathologic femur fractures treated with intramedullary hip screws. Orthopedics. 2001;24(4):359–363.

    CAS  PubMed  Google Scholar 

  30. Giannoudis PV, Bastawrous SS, Bunola JA, Macdonald DA, Smith RM. Unreamed intramedullary nailing for pathological femoral fractures. good results in 30 cases. Acta Orthop Scand. 1999;70(1):29–32.

    Article  CAS  PubMed  Google Scholar 

  31. Gibbons CE, Pope SJ, Murphy JP, Hall AJ. Femoral metastatic fractures treated with intramedullary nailing. Int Orthop. 2000;24(2):101–103.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  32. Hamada K, Naka N, Tamiya H, Ozaki R, Outani H, Fujimoto T, et al. Intercalary endoprosthetic reconstruction for impending pathological fractures in patients with femoral diaphyseal bone metastases. Euro J Orthop Surg Traumatol. 2009;19:547–551.

    Article  Google Scholar 

  33. Hattori H, Mibe J, Matsuoka H, Nagai S, Yamamoto K. Surgical management of metastatic disease of the proximal femur. J Orthop Surg (Hong Kong). 2007;15(3):295–298.

    CAS  Google Scholar 

  34. Karachalios T, Atkins RM, Sarangi PP, Crichlow TP, Solomon L. Reconstruction nailing for pathological subtrochanteric fractures with coexisting femoral shaft metastases. J Bone Joint Surg Br. 1993;75(1):119–122.

    CAS  PubMed  Google Scholar 

  35. Katagiri H, Sato K, Takahashi M, Sugiura H, Yamamura S, Iwata H. Use of adriamycin-impregnated methylmethacrylate in the treatment of tumor metastases in the long bones. Arch Orthop Trauma Surg. 1997;116(6–7):329–333.

    Article  CAS  PubMed  Google Scholar 

  36. Keating JF, Burke T, Macauley P. Proximal femoral replacement for pathological fracture. Injury. 1990;21(4):231–233.

    Article  CAS  PubMed  Google Scholar 

  37. Korkala OL, Karaharju EO. Metastatic fractures of long bones. Int Orthop. 1991;15(2):105–109.

    CAS  PubMed  Google Scholar 

  38. Maccauro G, Liuzza F, Scaramuzzo L, et al. Percutaneous acetabuloplasty for metastatic acetabular lesions. BMC Musculoskelet Disord. 2008;9:66.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Madhusudhan TR, Shetty SK, Ramesh B, Smith IC. Cannulated interlocking titanium prosthesis in pathological proximal femoral fractures: a prospective study. Euro J Orthop Surg Traumatol. 2009;19:315–319.

    Article  Google Scholar 

  40. Maniscalco P, Urgelli S, Rivera F, Bertone C, Lazzeroni L. The CLOS MB intramedullary nail for the treatment of pathological femoral shaft lesions. Acta Biomed. 2002;73(1–2):7–10.

    PubMed  Google Scholar 

  41. Nargol AV, Port A, Seif-Asaad SS. Pathological fractures of the proximal femur treated with the variwall reconstruction nail. Injury. 1996;27(5):307–309.

    Article  CAS  PubMed  Google Scholar 

  42. Rompe JD, Eysel P, Hopf C, Heine J. Metastatic instability at the proximal end of the femur. comparison of endoprosthetic replacement and plate osteosynthesis. Arch Orthop Trauma Surg. 1994;113(5):260–264.

    Article  CAS  PubMed  Google Scholar 

  43. Samsani SR, Panikkar V, Venu KM, Georgiannos D, Calthorpe D. Breast cancer bone metastasis in femur: surgical considerations and reconstruction with long gamma nail. Eur J Surg Oncol. 2004;30(9):993–997.

    Article  CAS  PubMed  Google Scholar 

  44. Santori FS, Ghera S, de Palma F, de Chiara N. Treatment of pathological fractures and impending pathological fractures of the femur with ender nails. Orthopaedics. 1984;7(2):269–274.

    CAS  Google Scholar 

  45. Voggenreiter G, Assenmacher S, Klaes W, Schmit-Neuerburg KP. Pathological fractures of the proximal femur with impending shaft fractures treated by THR and cemented intramedullary nailing: a report of nine cases. J Bone Joint Surg Br. 1996;78(3):400–403.

    CAS  PubMed  Google Scholar 

  46. Weikert DR, Schwartz HS. Intramedullary nailing for impending pathological subtrochanteric fractures. J Bone Joint Surg Br. 1991;73(4):668–670.

    CAS  PubMed  Google Scholar 

  47. Broos P, Vanderspeeten K. Our first experiences with the unreamed femoral nail (UFN). Acta Chir Belg. 1997;97(1):27–32.

    CAS  PubMed  Google Scholar 

  48. Samsani SR, Panikkar V, Georgiannos D, Calthorpe D. Subtrochanteric metastatic lesions treated with the long gamma nail. Int Orthop. 2003;27(5):298–302.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  49. Aboulafia AJ, Buch R, Mathews J, Li W, Malawer MM. Reconstruction using the saddle prosthesis following excision of primary and metastatic periacetabular tumors. Clin Orthop Relat Res. 1995;314:203–213.

    PubMed  Google Scholar 

  50. Kunisada T, Choong PF. Major reconstruction for periacetabular metastasis: early complications and outcome following surgical treatment in 40 hips. Acta Orthop Scand. 2000;71(6):585–590.

    Article  CAS  PubMed  Google Scholar 

  51. Nilsson J, Gustafson P, Fornander P, Ornstein E. The Harrington reconstruction for advanced periacetabular metastatic destruction: good outcome in 32 patients. Acta Orthop Scand. 2000;71(6):591–596.

    Article  CAS  PubMed  Google Scholar 

  52. Stark A, Bauer HC. Reconstruction in metastatic destruction of the acetabulum. support rings and arthroplasty in 12 patients. Acta Orthop Scand. 1996;67(5):435–438.

    Article  CAS  PubMed  Google Scholar 

  53. Walker RH. Pelvic reconstruction/total hip arthroplasty for metastatic acetabular insufficiency. Clin Orthop Relat Res. 1993;294:170–175.

    PubMed  Google Scholar 

  54. Wangsaturaka P, Asavamongkolkul A, Waikakul S, Phimolsarnti R. The results of surgical management of bone metastasis involving the periacetabular area: Siriraj experience. J Med Assoc Thai. 2007;90(5):1006–1013.

    PubMed  Google Scholar 

  55. Wright RW, Schwartz HS. Pathologic acetabular fractures: new concepts in surgical management. Semin Arthroplasty. 1994;5(2):95–105.

    CAS  PubMed  Google Scholar 

  56. Lee SH, Kim HS, Kim SR, Park YB, Yoo KH, Lee HM. Functional outcome following surgical treatment of metastatic tumors involving the femur. Orthopaedics. 2000;23(10):1075–1079.

    CAS  Google Scholar 

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Disclosure

Thomas J. Wood, Antonella Racano, Herman Yeung, Forough Farrokhyar, Michelle Ghert, and Benjamin M. Deheshi have no commercial associations to disclose in connection with the submitted article.

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Authors and Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Thomas J. Wood MD, Herman Yeung, Michelle Ghert MD, FRCSC & Benjamin M. Deheshi MD, MSc, FRCSC

  2. Department of Surgery, McMaster University, Hamilton, ON, Canada

    Thomas J. Wood MD, Antonella Racano MSc, Forough Farrokhyar PhD, Michelle Ghert MD, FRCSC & Benjamin M. Deheshi MD, MSc, FRCSC

  3. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

    Forough Farrokhyar PhD

  4. Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada

    Benjamin M. Deheshi MD, MSc, FRCSC

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Correspondence to Benjamin M. Deheshi MD, MSc, FRCSC.

Electronic Supplementary Material

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10434_2014_4002_MOESM1_ESM.tif

A forest plot using a random-effects model for rates of (a) pain relief and (b) improved function following surgical management of MBD of the humerus is shown. The pooled weighted proportion of improved pain and improved range of motion are 93 % (95 % CI 87–97%) and 94 % (95 % CI 88–98 %), respectively. Supplementary material 1 (TIFF 1294 kb)

Supplementary material 2 (TIFF 1304 kb)

10434_2014_4002_MOESM3_ESM.tif

A forest plot using a random-effects model for rates of (a) pain relief and (b) improved function following surgical management of MBD of the femur is shown. The pooled weighted proportion of improved pain and improved ambulation are 91 % (95 % CI 84–97 %) and 89 % (95 % CI 83–94 %), respectively. Supplementary material 3 (TIFF 1998 kb)

Supplementary material 4 (TIFF 2854 kb)

10434_2014_4002_MOESM5_ESM.tif

A forest plot using a random-effects model for rates of (a) pain relief and (b) improved function following surgical management of MBD of the acetabulum/pelvis is shown. The pooled weighted proportion of improved pain and improved ambulation are 93 % (95 % CI 82–99 %) and 94 % (95 % CI 85–99 %), respectively. Supplementary material 5 (TIFF 1148 kb)

Supplementary material 6 (TIFF 1207 kb)

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Wood, T.J., Racano, A., Yeung, H. et al. Surgical Management of Bone Metastases: Quality of Evidence and Systematic Review. Ann Surg Oncol 21, 4081–4089 (2014). https://doi.org/10.1245/s10434-014-4002-1

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