Management

 

Femur met

 

Goals

 

1.  Maintain function

2.  Reduce pain

3.  Prevent or treat pathological fracture

 

Pathological fracture

 

Groot et al, CORR 2022

- Retrospective cohort study 1064 patients who had femoral nailing for completed pathological fracture vs prophylaxis

- 90 day survival rate same

- 1yr survival rate worse in completed (38%) vs prophylactic (46%)

- Completed pathological fractures associated with more blood loss, more transfusions, longer anaesthetic times and more re-operations (OR 2.5)

- No difference in 30d complication rate

 

Mirels prediction system for pathological fracture

 

Mirels CORR 1989 

- quantify risk of pathological fracture

- weighted scoring system

- non fracture group mean score 7

- fracture group mean score 10

- score of 9 fracture risk 33%

 

Four risk factors

  1 2 3
Site Upper limb Lower limb Peritrochanter
Pain Mild Moderate Mechanical
Lesion Blastic Mixed Lytic
Size < 1/3 1/3 - 2/3 2/3

 

Guidelines

 

Suggest surgical intervention score 9 or more

- 7 or less: radiotherapy

- 8: fracture risk is 15%

 

Validity

 

Howard et al Bone Joint J 2018

- reliability of Mirels

- moderate inter-rater and intra-rater reliability

 

CT based structural rigidity analysis (CTRA)

 

Damron et al CORR 2016

- 125 patients compared CTRA with Mirels

- CTRA more sensitive (100% v 67%) and specific (61% v 48%)

 

Management

 

Aims

 

1. Appropriate patient selection / estimate life expectancy

2. Stabilize fracture / metastasis and allow full weight bearing

3. Radiotherapy

 

Estimate life expectancy

 

Need to live longer than time for recovery from the operation (> 6 - 8 weeks)

 

Estimates

 

Forsberg et al PLoS One 2011

- www.PATHFx.org.

- online Bayesian Belief Network

- estimates 1, 3, 6, 12, 18 and 24 month survival in patients undergoing surgery for skeletal metastases

- 10 prognostic factors

- age / sex / type of cancer / visceral mets / number of bony mets / lymph nodes mets / path # / Hb / WCC

 

Anderson et al CORR 2020

- 208 patients

- updated PATHFx version 3.0 model demonstrates external validity

 

Karnofsky performance scale

 

Ranges from 100 (full function) to 0 (death)

- 80 - 100%: able to work

- 50 - 70%: unable to work, able to live at home, mostly independantly

- 30 - 40%: unable to care for self

- 20%: very sick, active supportive treatment required

- 10%: moribund

 

Results

 

Razvi et al Ann Palliat Med 2019

- 170 patients metastatic disease

- estimated clinical survival using Karnofsky

- 75% over-estimated by average 19 weeks

 

Surgical fixation

 

Obtain stability / allow load bearing / prevent fracture / obtain union

 

Location specific

 

See www.boneschool.com/metastasis/specific management

 

Radiotherapy

 

Nonoperative

 

Chow et al Radiother Oncol 2019

- meta-analysis of single versus multiple radiotherapy / fractions

- no increased efficacy with multiple regimens

- good pain relief

 

Postoperative

 

Typically minimum 2 weeks post surgery to minimize wound healing complications

 

Ramadan et al Cancers 2023

- systematic review of postoperative radiotherapy after surgery for metastasis

- reduces local recurrence and provides effective pain relief

 

Kraus et al Adv Radiat Oncol 2021

- postoperative radiotherapy

- no difference between single or multiple regimens

 

Pre-operative Arterial Embolization

 

Indications

- renal cell carcinoma

- thyroid carcinoma

 

Results

 

Rossi et al Radiol Med 2013

- embolisation of RCC metastasis in 107 patients

- success in 96%

- all patients had variable ischemic pain for 2 - 4 day

 

Pazionis et al CORR 2014

- 41 cases with embolization prior to surgery compared to 41 cases without

- embolization reduced blood loss, transfusion, and surgical times

 

Shoulder Renal Cell CarcinomaShoulder RCC EmbolisationShoulder RCC Embolisation 2

 

RCC femur 1RCC femur 2RCC femur 3

 

Medical treatment

 

Bisphosphonates

 

O'Carrigan et al Cochrane Database Syst Review 2017

- bisphosphonates in breast cancer

- 44 RCT's and 37,000 patients

- reduce risk of skeletal metastasis, reduce bone pain, and increase overall survival

 

Denosumab (monoclonal antibody to RANKL)

 

Pagnotti et al Cells 2022

- denosumab

- evidence reduces hypercalcaemia of bony metastasis

- can slow bony metastasis progression