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New concepts in the surgical treatment of actual and impending pathological fractures in metastatic disease

Published:November 10, 2020DOI:https://doi.org/10.1016/j.injury.2020.11.025

      Highlights

      • There is an increased incidence of bone metastases due to improved of cancer patients survival.
      • “Oligometastases” represents a disease with metastatic localisations in a limited number (3 - 5) in the same body district.
      • Survival of oligometastatic patients is similar to patients with a single metastasis, requiring similar treatment.
      • Optimal implants survival curves should stay above the curves of patients survival.
      • Oligometastatic patients need to be treated with resection and reconstruction instead of using intralesional procedures such as nailing.

      Abstract

      Introduction

      Long bone metastases are a disease of high social importance. The goals of surgical treatment are to relieve pain, maintain or restore joint function, and prevent or treat pathological fractures. “Oligometastases” is a disease with a limited number (3–5) of metastatic lesions in the same body district, where an aggressive treatment can be carried out with “curative” intent. This study aimed to evaluate patients with bone metastases surgically treated to determine how surgical treatment can influence prognosis and quality of life, comparing solitary metastasis, oligometastases, and multiple metastases.

      Patients and Methods

      This is a retrospective analysis of 130 patients with long bone metastases surgically treated between October 2015 and August 2019: 40 patients had solitary metastasis; 38 had less than three metastases (oligometastases), and 52 had multiple metastases. Surgery was resection and reconstruction with a cemented prosthesis (95) or nailing (35).

      Results

      Overall survival was significantly better in patients with solitary metastasis or oligometastases than in those with multiple metastases (p <0.0001). Patients treated with resection and prosthesis had significantly better survival than those treated with nailing (p <0.0001). Implant complications requiring surgical revision occurred in 20 patients treated with prostheses, while no complications occurred in patients treated with nailing.

      Discussion

      Survival of cancer patients has improved in the last two decades, leading to an increase of diagnosed metastases. Patients with oligometastases have a survival similar to those with a single metastasis. Optimal implants survival curves should stay above the curves of patients survival.

      Conclusions

      Since there are no differences in survival, patients with oligometastases should be treated as patients with a solitary lesion, with more aggressive surgery (wide resection and reconstruction with prosthesis). Intramedullary nailing is still indicated in metaphyseal or diaphyseal metastases in patients with advanced disease or poor prognosis when the life expectancy does not overcome the expected survival of the nail, avoiding the need for further surgery.

      Keywords

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