Rikard Wedin

Survival after surgery for spinal and extremity metastases : prognostication in 241 patients

We assessed the survival after surgery in 153 patients with extremity metastases and 88 with spinal metastases. The survival rate for the whole series of 241 patients was 0.30 at 1 year, 0.15 at 2, and 0.08 at 3 years. The 1-year survival rate was the same for the extremity metastases group and the spinal group. Univariate analysis showed that 1-year survival was related to metastatic load, site of primary tumor, and presence of pathologic fracture. Multivariate regression analysis showed that pathologic fracture, visceral or brain metastases, and lung cancer were negative prognostic variables. Solitary skeletal metastases, breast and kidney cancer, myeloma, and lymphoma were positive variables. A prognostication model based on these variables stratified the patients into 3 groups with a 1-year survival ranging from 0.5 to 0.0. These prognostic variables can be used for differentiating the treatment of cancer patients with pathologic fracture or epidural compression.

Failures after operation for skeletal metastatic lesions of long bones

This study was based on 192 patients treated surgically for 228 metastatic lesions of the long bones from 1986 through 1995. The survival rate was 0.3 at 1 year after surgery. The surgical treatment consisted of resection and reconstruction of the involved bone (18), intralesional curettage (133), or stabilization only (77). Reconstruction was achieved by an endoprosthesis in 54 cases, by an osteosynthetic device in 162, by cement only in 10. In two cases no reconstruction was performed. The local failure rate was 11% and the median time to failure was 8 months. Local failure was most frequent in patients with kidney cancer (24%) and in diaphyseal and distal femoral lesions (20%). Among 162 operations involving osteosynthetic devices, 22 (14%) were failures as compared with one of 54 (2%) endoprostheses. Sixty percent of the patients received preoperative or postoperative radiotherapy. Five of the six patients who had surgery for local tumor progression had not received radiotherapy. Eight of 10 nonunions and all five patients who developed a stress fracture had been treated with radiotherapy. It is concluded that endoprosthetic reconstructions are preferable to osteosynthetic devices. The skeletal complications associated with radiotherapy may be circumvented by the use of endoprostheses.

Surgical treatment of skeletal metastatic lesions of the proximal femur: ENDOPROSTHESIS OR RECONSTRUCTION NAIL?

We report positive and negative factors associated with the most commonly-used methods of reconstruction after pathological fracture of the proximal femur. The study was based on 142 patients treated surgically for 146 metastatic lesions between 1996 and 2003. The local rate of failure was 10.3% (15 of 146). Of 37 operations involving osteosynthetic devices, six failed (16.2%) compared with nine (8.3%) in 109 operations involving endoprostheses. Of nine cases of prosthetic failure, four were due to periprosthetic fractures and three to recurrent dislocation. In the osteosynthesis group, three (13.6%) of 22 reconstruction nails failed. The two-year risk of re-operation after any type of osteosynthesis was 0.35 compared with 0.18 after any type of endoprosthetic reconstruction (p = 0.07). Endoprosthetic reconstructions are preferable to the use of reconstruction nails and other osteosynthetic devices for the treatment of metastatic lesions in the proximal third of the femur.

The Scandinavian Sarcoma Group skeletal metastasis register: Survival after surgery for bone metastases in the pelvis and extremities

INTRODUCTION The assessment of the prognosis for the individual patient is important for the choice of surgical treatment of skeletal metastases. In 1999 the Scandinavian Sarcoma Group (SSG) initiated the Skeletal Metastasis Register as a multicentric, prospective study to provide a scientific basis for treatment recommendations. To improve prognostication we analyzed the survival of patients with skeletal metastases surgically treated at 9 SSG centres. PATIENTS AND METHODS 460 patients with an average age of 64 years underwent 501 operations for non-spinal skeletal metastases. 7% were operated for more than one metastasis. Carcinoma of the breast, prostate, kidney and lung were the dominating primary tumors. RESULTS The survival rate was 0.4 at 1 year, 0.3 at 2 years and 0.2 at 3 years. Univariate analysis showed that survival was related to bone localization, skeletal metastatic load, presence of visceral metastases, Karnofsky performance score, primary tumor type, presence of a complete pathological fracture and preoperative hemoglobin content. Multivariate regression analysis showed that pathological fracture, visceral metastases, haemoglobin content < 7 mmol/L and lung cancer were negative prognostic factors for survival. Myeloma was the sole positive prognostic factor for survival.

Surgical treatment for pathologic fracture.

AIM To evaluate epidemiology, prognosis and diagnostics in metastatic bone disease and identify risk factors for failure after operation for pathologic fracture. PATIENTS The study was based on patients treated for skeletal metastases, myeloma or lymphoma between 1986 and 1998 at the Oncology Service, Department of Orthopedics, Karolinska Hospital and on patients diagnosed with symptomatic skeletal metastases 1989-1994 in the Stockholm Region. EPIDEMIOLOGY 641 breast cancer patients were diagnosed with symptomatic skeletal metastases 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 patients showed that complete pathologic fracture and soft tissue metastases were negative prognostic variables for 1-year survival after operation. Solitary skeletal metastasis, breast, prostate, kidney cancer, myeloma, and lymphoma were positive variables. DIAGNOSIS Fine Needle Aspiration Biopsy (FNAB) was assessed in 110 patients for diagnostic accuracy and to which extent information about 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 guidance in the search for the primary lesions. Hence, 27 of 30 myeloma or lymphomas were diagnosed by FNAB and in half of the patients with metastatic carcinoma the site of the primary tumor could be ascertained. For patients with a suspected skeletal metastasis the search for the primary tumor may preferably start with FNAB. SURGICAL TREATMENT Risk factors for failure after operation for pathologic fractures were identified 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 failure of the reconstruction. Kidney cancer was the primary tumor associated with the highest rate of reoperations. Reoperations were more common in the femur than in the humerus. Reconstructions based on prosthetic as opposed to osteosynthetic devices appeared safer. There was a tendency for a high reoperation rate in hospitals with few treated patients. CONCLUSION To decrease the risk of reoperation, it is important to identify patients with a long expected survival. Patients with a good prognosis should be considered for wide resection and reconstruction as applied in primary malignant bone tumors.

Surgical treatment for skeletal breast cancer metastases

The objective of this article was to assess the occurrence of symptomatic bone metastases in a defined population of patients with breast carcinoma and to characterize the clinical outcome with reference to surgical treatment for pathologic fracture or neurologic deficit.

Insight opinion to surgically treated metastatic bone disease: Scandinavian Sarcoma Group Skeletal Metastasis Registry report of 1195 operated skeletal metastasis.

The number of cancer patients living with metastatic disease is growing. The increased survival has led to an increase in the number of cancer-induced complications, such as pathologic fractures due to bone metastases. Surgery is most commonly needed for mechanical complications, such as fractures and intractable pain. We determined survival, disease free interval and complications in surgically treated bone metastasis. Data were collected from the Scandinavian Skeletal Metastasis Registry for patients with extremity skeletal metastases surgically treated at eight major Scandinavian referral centres between 1999 and 2009 covering a total of 1195 skeletal metastases in 1107 patients. Primary breast, prostate, renal, lung, and myeloma tumors make up 78% of the tumors. Number of complications is tolerable and is affected by methods of surgery as well as preoperative radiation therapy. Overall 1-year patient survival was 36%; however, mean survival was influenced by the primary tumor type and the presence of additional visceral metastases. Patients with impending fracture had more systemic complications than those with complete fracture. Although surgery is usually only a palliative treatment, patients can survive for years after surgery. We developed a simple, useful and reliable scoring system to predict survival among these patients. This scoring system gives good aid in predicting the prognosis when selecting the surgical method. While it is important to avoid unnecessary operations, operating when necessary can provide benefit.

Prognostic role of en-bloc resection and late onset of bone metastasis in patients with bone-seeking carcinomas of the kidney, breast, lung, and prostate: SSG study on 672 operated skeletal metastases.

In metastatic disease, decisions regarding potential surgery require reliable data about the patients survival. In this study, we evaluated different prognostic factors and their impact in four common primary tumors causing bone metastases.

Complications and survival after surgical treatment of 214 metastatic lesions of the humerus

BACKGROUND The humerus is the second most common long-bone site of metastatic bone disease. We report complications, risk factors for failure, and survival of a large series of patients operated on for skeletal metastases of the humerus. MATERIALS AND METHODS This study was based on 208 patients treated surgically for 214 metastatic lesions of the humerus. Reconstructions were achieved by intramedullary nails in 148, endoprostheses in 35, plate fixation in 21, and by other methods in 10. RESULTS The median age at surgery was 67 years (range, 29-87 years). Breast cancer was the primary tumor in 31%. The overall failure rate of the surgical reconstructions was 9%. The reoperation rate was 7% in the proximal humerus, 8% in the diaphysis, and 33% in the distal part of the bone. Among 36 operations involving an endoprosthesis, 2 were failures (6%) compared with 18 of 178 osteosynthetic devices (10%). In the osteosynthesis group, intramedullary nails failed in 7% and plate fixation failed in 22%. Multivariate Cox regression analysis showed that prostate cancer was associated with an increased risk of failure after surgery (hazard ratio, 7; P < 0.033). The cumulative survival after surgery was 40% (95% confidence interval [CI] 34-47) at 1 year, 21% (95% CI, 15-26) at 2 years, and 16% (95% CI, 12-19) at 3 years. CONCLUSIONS Our method of choice is the cemented hemiprosthesis for pathologic proximal humeral fractures and interlocked intramedullary nail for lesions in the diaphysis. Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate.

Surgery for skeletal metastases in lung cancer

Background and purpose Most lung cancer patients with skeletal metastases have a short survival and it is difficult to identify those patients who will benefit from palliative surgery. We report complication and survival rates in a consecutive series of lung cancer patients who were operated for symptomatic skeletal metastases. Methods This study was based on data recorded in the Karolinska Skeletal Metastasis Register. The study period was 1987–2006. We identified 98 lung cancer patients (52 females). The median age at surgery was 62 (34–88) years. 78 lesions were located in the femur or spine. Results The median survival time after surgery was 3 (0–127) months. The cumulative 12-month survival after surgery was 13% (95% CI: 6–20). There was a difference between the survival after spinal surgery (2 months) and after extremity surgery (4 months) (p = 0.03). Complete pathological fracture in non-spinal metastases (50 patients) was an independent negative predictor of survival (hazard ratio (HR) = 1.8, 95% CI: 1–3). 16 of 31 patients with spinal metastases experienced a considerable improvement in their neurological function after surgery. The overall complication rate was 20%, including a reoperation rate of 15%. Interpretation Bone metastases and their subsequent surgical treatment in lung cancer patients are associated with high morbidity and mortality. Our findings will help to set appropriate expectations for these patients, their families, and surgeons.