Surgical treatment for pathologic fracture

Aim To evaluate epidemiology, prognosis and diagnostics in metastatic bone dise ase and identify risk factors for failure after operation for pathologic fr acture. Patients The study was based on patients treated for skeletal metastases, myeloma or lymphoma between 1986 and 1998 at the Oncology Service, Department of Orth opedics, Karolinska Hospital and on patients diagnosed with symptomatic ske letal metastases 1989-1994 in the Stockholm Region. Epidemiology 641 breast cancer patients were diagnosed with symptomatic skeletal metasta ses 1989-1994. Based upon 1100 new primary breast cancer cases yearly, the overall risk of developing symptomatic skeletal metastases was 10-15%. One out of 5 patients with skeletal metastases required surgical treatment for skeletal complications. Prognosis The survival rate after surgical treatment for skeletal complications was 0 .3 at 1 year and 0.008 at 3 years. Multivariate analysis based on 619 patie nts showed that complete pathologic fracture and soft tissue metastases wer e negative prognostic variables for 1-year survival after operation. Solita ry skeletal metastasis, breast, prostate, kidney cancer, myeloma, and lymph oma were positive variables. Diagnosis Fine Needle Aspiration Biopsy (FNAB) was and to which extent information ab out primary site of the metastatic carcinoma could be gained. There were 80 patients with metastatic carcinoma, 14 with lymphoma, and 16 with myeloma. FNAB offered correct diagnosis in 9 of 10 patients and also provided guida nce in the search for the primary lesions. Hence, 27 of 30 myeloma or lymph omas were diagnosed by FNAB and in half of the patients with metastatic car cinoma the site of the primary tumor could be ascertained. For patients wit h a suspected skeletal metastasis the search for the primary tumor may pref erably start with FNAB. Surgical treatment Risk factors for failure after operation for pathologic fractures were iden tified in 192 patients treated for 228 metastatic lesions of the long bones . 26 out of 228 procedures (11%) lead to failures necessitating reoperation . Long survival after surgery was the most important risk factor for failur e of the reconstruction. Kidney cancer was the primary tumor associated wit h the highest rate of reoperations. Reoperations were more common in the fe mur than in the humerus. Reconstructions based on prosthetic as opposed to osteosynthetic devices appeared safer. There was a tendency for a high reop eration rate in hospitals with few treated patients. Conclusion To decrease the risk of reoperation, it is important to identify patients w ith a long expected survival. Patients with a good prognosis should be cons idered for wide resection and reconstruction as applied in primary malignan t bone tumors.