Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors

Hashimoto,Kazuhiko; Nishimura,Shunji; Ito,Tomohiko; Kakinoki,Ryosuke; Goto,Koji

doi:10.3892/mco.2024.2763

Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors

Authors:
- Kazuhiko Hashimoto
- Shunji Nishimura
- Tomohiko Ito
- Ryosuke Kakinoki
- Koji Goto
View Affiliations

Affiliations: Department of Orthopedic Surgery, Kindai University Hospital, Osakasayama, Osaka 589‑8511, Japan
Published online on: July 16, 2024 https://doi.org/10.3892/mco.2024.2763
Article Number: 65
Copyright: © Hashimoto et al. This is an open access article distributed under the terms of Creative Commons Attribution License.

Metrics: Total Views: 0 (Spandidos Publications: | PMC Statistics: )

Metrics: Total PDF Downloads: 0 (Spandidos Publications: | PMC Statistics: )

Cited By (CrossRef): 0 citations Loading Articles...

Abstract

As managing pathological fractures of the extremities can be difficult, the present study aimed to present a treatment algorithm for lower extremity bone malignancies. A total of 38 patients with impending and pathological fractures were treated at the Department of Orthopedic Surgery in Kindai University Hospital. Age, sex, fracture site, type of primary malignancy, number of metastases, pre‑fracture Eastern Cooperative Oncology Group performance status (ECOG‑PS) score, adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score, outcomes, follow‑up period and the MSTS scores and ECOG‑PS were compared in cases of primary malignant tumors and those cases of metastatic malignant tumors were retrospectively surveyed. Post‑treatment MSTS scores in cases of impending and pathological fractures were compared between intramedullary nail fixation and non‑intramedullary nail fixation procedures. Disease sites included the sub‑trochanteric femur in 10 patients, trochanteric femur in 8, femoral diaphysis in 7, femoral neck in 5, bilateral trochanteric femur in 3, proximal tibia in 3 and distal femur in 2 patients. A total of 10 patients had metastases between 3‑20 sites. The median pre‑fracture ECOG‑PS score was 1. Adjuvant radiotherapy was administered to 5, chemotherapy to 8 and radiotherapy with chemotherapy to 10 patients. Surgical procedures included intramedullary nails in 18 patients, tumor arthroplasty in 4, plate fixation in 3, artificial head replacement in three, compression hip screw (CHS) in 3, conservative treatment in 2, bilateral intramedullary nail fixation in 2 and artificial bone stem with combined intramedullary nail and plate fixation, right‑sided artificial head replacement and left‑sided CHS in 1 patient each. The MSTS score was 19.9±8.95 for intramedullary nail fixation and 24.3±7.45 for other procedures, with a negative association between the MSTS score and pre‑fracture ECOG‑PS. The median follow‑up period was 8 months. The outcomes were as follows: Alive with disease, 23 patients; continued disease‑free, 1 patient; and dead due to disease, 14 patients. The 1‑year postoperative overall survival rate was 60.5%. Moreover, the group with metastatic malignant tumors, which had significantly worse ECOG‑PS, had significantly lower MSTS scores than the group with primary malignant tumors. The authors' treatment algorithm for malignant bone tumors of the lower extremity was shown to be useful.

View Figures

View References

1	Hoshi M, Iwai T, Oebisu N, Shimatani A, Takada N and Nakamura H: Pathological fracture of a solitary bone cyst in the calcaneus: A case series and literature review. Arch Orthop Trauma Surg. 143:1155–1162. 2023.PubMed/NCBI View Article : Google Scholar
2	Salunke AA, Chen Y, Tan JH, Chen X, Khin LW and Puhaindran ME: Does a pathological fracture affect the prognosis in patients with osteosarcoma of the extremities?: A systematic review and meta-analysis. Bone Joint J. 96 B:1396–1403. 2014.PubMed/NCBI View Article : Google Scholar
3	Urakawa H, Tsukushi S, Hosono K, Sugiura H, Yamada K, Yamada Y, Kozawa E, Arai E, Futamura N, Ishiguro N and Nishida Y: Clinical factors affecting pathological fracture and healing of unicameral bone cysts. BMC Musculoskelet Disord. 15(159)2014.PubMed/NCBI View Article : Google Scholar
4	Fontanella C, Fanotto V, Rihawi K, Aprile G and Puglisi F: Skeletal metastases from breast cancer: Pathogenesis of bone tropism and treatment strategy. Clin Exp Metastasis. 32:819–833. 2015.PubMed/NCBI View Article : Google Scholar
5	Scorianz M, Gherlinzoni F and Campanacci DA: Metastases to the long bones: Algorithm of treatment. In: Management of bone metastases. Denaro V, Di Martino A and Piccioli A (eds). Springer, Berlin, pp93-102, 2019.
6	Scully SP, Ghert MA, Zurakowski D, Thompson RC and Gebhardt MC: Pathologic fracture in osteosarcoma: Prognostic importance and treatment implications. J Bone Joint Surg Am. 84:49–57. 2002.PubMed/NCBI
7	Chung LH, Wu PK, Chen CF, Weng HK, Chen TH and Chen WM: Pathological fractures in predicting clinical outcomes for patients with osteosarcoma. BMC Musculoskelet Disord. 17(503)2016.PubMed/NCBI View Article : Google Scholar
8	Hage WD, Aboulafia AJ and Aboulafia DM: Incidence, location, and diagnostic evaluation of metastatic bone disease. Orthop Clin North Am. 31:515–528. 2000.PubMed/NCBI View Article : Google Scholar
9	Piccioli A, Spinelli MS and Maccauro G: Impending fracture: A difficult diagnosis. Injury. 45 (Suppl 6):S138–S141. 2014.PubMed/NCBI View Article : Google Scholar
10	Blagden SP, Charman SC, Sharples LD, Magee LR and Gilligan D: Performance status score: Do patients and their oncologists agree? Br J Cancer. 89:1022–1027. 2003.PubMed/NCBI View Article : Google Scholar
11	Enneking WF, Dunham W, Gebhardt MC, Malawar M and Pritchard DJ: A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 286:241–246. 1993.PubMed/NCBI
12	Hu YC, Lun DX and Wang H: Clinical features of neoplastic pathological fracture in long bones. Chin Med J (Engl). 125:3127–3132. 2012.PubMed/NCBI
13	Angelini A, Trovarelli G, Berizzi A, Pala E, Breda A, Maraldi M and Ruggieri P: Treatment of pathologic fractures of the proximal femur. Injury. 49 (Suppl 3):S77–S83. 2018.PubMed/NCBI View Article : Google Scholar
14	Guzik G: Oncological and functional results after surgical treatment of bone metastases at the proximal femur. BMC Surg. 18(5)2018.PubMed/NCBI View Article : Google Scholar
15	Ji Y, Wu Y and Li J: Use of three-dimensional-printed custom-made prosthesis to treat unicondylar femoral defect secondary to pathological fracture caused by giant cell tumor. J Int Med Res. 49(3000605211025347)2021.PubMed/NCBI View Article : Google Scholar
16	Johnson NA, Uzoigwe C, Venkatesan M, Burgula V, Kulkarni A, Davison JN and Ashford RU: Risk factors for intramedullary nail breakage in proximal femoral fractures: A 10-year retrospective review. Ann R Coll Surg Engl. 99:145–150. 2017.PubMed/NCBI View Article : Google Scholar
17	Kosygan KP, Mohan R and Newman RJ: The Gotfried percutaneous compression plate compared with the conventional classic hip screw for the fixation of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 84:19–22. 2002.PubMed/NCBI View Article : Google Scholar
18	Willeumier JJ, van der Linden YM, van de Sande MAJ and Dijkstra PDS: Treatment of pathological fractures of the long bones. EFORT Open Rev. 1:136–145. 2017.PubMed/NCBI View Article : Google Scholar
19	Swanson KC, Pritchard DJ and Sim FH: Surgical treatment of metastatic disease of the femur. J Am Acad Orthop Surg. 20:56–65. 2000.PubMed/NCBI View Article : Google Scholar
20	Dijstra S, Wiggers T, van Geel BN and Boxma H: 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. 160:535–542. 1994.PubMed/NCBI
21	Wedin R and Bauer HC: Surgical treatment of skeletal metastatic lesions of the proximal femur: Endoprosthesis or reconstruction nail? J Bone Joint Surg Br. 87:1653–1657. 2005.PubMed/NCBI View Article : Google Scholar
22	Harvey N, Ahlmann ER, Allison DC, Wang L and Menendez LR: Endoprostheses last longer than intramedullary devices in proximal femur metastases. Clin Orthop Relat Res. 470:684–691. 2012.PubMed/NCBI View Article : Google Scholar
23	Moore J, Isler M, Barry J and Mottard S: Major wound complication risk factors following soft tissue sarcoma resection. Eur J Surg Oncol. 40:1671–1676. 2014.PubMed/NCBI View Article : Google Scholar
24	Goryń T, Pieńkowski A, Szostakowski B, Zdzienicki M, Ługowska I and Rutkowski P: Functional outcome of surgical treatment of adults with extremity osteosarcoma after megaprosthetic reconstruction-single-center experience. J Orthop Surg Res. 14(346)2019.PubMed/NCBI View Article : Google Scholar
25	Roudier MP, True LD, Higano CS, Vesselle H, Ellis W, Lange P and Vessella RL: Phenotypic heterogeneity of end-stage prostate carcinoma metastatic to bone. Hum Pathol. 34:646–653. 2003.PubMed/NCBI View Article : Google Scholar
26	Ganesh K and Massagué J: Targeting metastatic cancer. Nat Med. 27:34–44. 2021.PubMed/NCBI View Article : Google Scholar
27	Mavrogenis AF, Pala E, Romagnoli C, Romantini M, Calabro T and Ruggieri P: Survival analysis of patients with femoral metastases. J Surg Oncol. 105:135–141. 2012.PubMed/NCBI View Article : Google Scholar
28	Chandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu A and Buckley L: Modular endoprosthetic replacement for tumours of the proximal femur. J Bone Joint Surg Br. 20:108–112. 2009.PubMed/NCBI View Article : Google Scholar
29	Saad F, Lipton A, Cook R, Chen YM, Smith M and Coleman R: Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer. 110:1860–1867. 2007.PubMed/NCBI View Article : Google Scholar
30	Mirels H: Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 249:256–264. 1989.PubMed/NCBI
31	Hashimoto K, Nishimura S, Ito T, Kakinoki R and Goto K: Treatment algorithm for metastatic malignancies in the lower extremities. Mol Clin Oncol. 21(51)2024.PubMed/NCBI View Article : Google Scholar
32	Gharibi A, La Kim S, Molnar J, Brambilla D, Adamian Y, Hoover M, Hong J, Lin J, Wolfenden L and Kelber JA: ITGA1 is a pre-malignant biomarker that promotes therapy resistance and metastatic potential in pancreatic cancer. Sci Rep. 7(10060)2017.PubMed/NCBI View Article : Google Scholar
33	Mariean CR, Tiucă OM, Mariean A and Cotoi OS: Cancer Cachexia: New insights and future directions. Cancers (Basel). 15(5590)2023.PubMed/NCBI View Article : Google Scholar
34	Law ML: Cancer cachexia: Pathophysiology and association with cancer-related pain. Front Pain Res (Lausanne). 3(971295)2022.PubMed/NCBI View Article : Google Scholar