Surgical management options for long-bone metastasis

Abstract

Bone metastases are difficult to treat surgically, necessitating a multidisciplinary approach that must be applied to each patient depending on the specifics of their case. The main indications for surgical treatment are a lack of response to chemotherapy, radiation therapy, hormone therapy, immunotherapy, and bisphosphonates which is defined by persistent pain or tumor progression; the risk of imminent pathological bone fracture; and surgical treatment for single bone metastases. An important aspect of choosing the right treatment for these patients is accurately estimating life expectancy. Improved chemotherapy, postoperative radiation therapy, and sustainable reconstructive modalities will increase the patient's life expectancy. The surgeon should select the best surgical strategy based on the primary tumor and its characteristics, the presence of single or multiple metastases, age, anatomical location, and the functional resources of the patient. Preventive osteosynthesis, osteosynthesis to stabilize a fracture, resections, and reconstructions are the main surgical options for bone metastases. Resection and reconstruction with a modular prosthesis remain the generally approved surgical option to restore functionality, increase the quality of life, and increase life expectancy. Preoperative embolization is necessary, especially in the case of metastases of renal or thyroid origin. This procedure is extremely important to avoid complications, with a major impact on survival rates.

Keywords: bone metastasis; impending fractures; resection reconstruction.

Figure 1

Extensive locoregional acromial metastasis in a 61-year-old female secondary to breast adenocarcinoma, the patient presenting with multiple metastasis at diagnosis.

Figure 2

(A) Solitary proximal left femur metastasis with an impending fracture in a 74-year-old male secondary to renal carcinoma. (B) Intraoperative image secondary to resection and measurements for the final prosthesis. (C) Postoperative image of the resection reconstruction with a modular tapered, fluted stem.

Figure 3

(A) Preoperative anterior-posterior image of the pelvis of a 68-year-old woman with bilateral subtrochanteric pathological fractures secondary to a cervical neoplasm, recently treated on the left side with a cephalointramedullary nail. (B) Postoperative image of the right femur after fracture fixation with a long cephalointramedullary nail.

Figure 4

(A) A 60-year-old patient previously known to have a subtrochanteric fracture on the pathological bone secondary to breast carcinoma initially treated with a cephalointramedullary nail that failed, later replaced with this plate that also failed. (B) Intraoperative resected segment and prosthetic measurements. (C) Postoperative X-ray after resection and reconstruction with a long modular fluted stem.

Figure 5

(A) Preoperative X-ray of a 56-year-old male diagnosed with a solitary proximal humerus metastasis secondary to renal carcinoma. (B) Preoperative angiography and embolization of the tumor were performed prior to resection to limit intraoperative blood loss. (C) Intraoperative image of the tumor resection and intraoperative measurements. (D) Postoperative image of the modular prosthesis used after tumor resection.

Figure 6

(A) Solitary metastasis of the proximal femur secondary to breast carcinoma in a 46-year-old female. (B) Intraoperative image of the tumor resection. (C) Postoperative x-ray of the modular prosthesis used for reconstruction of the proximal femur.