The Multi-modal Approach to Metastatic Disease

Abstract

Despite medical and surgical advantages, bone metastases and skeletally- related events such as pathological fractures happen in cancer patients. Even though skeletal metastases and pathological fractures can occur in almost any cancers and sarcomas, about 75% of pathological fractures occur in patients with breast, prostate, lung and kidney cancers and myeloma (Hansen et al., Acta Orthop Scand 75:11–15, 2004; Hansen et al., Acta Orthop 334:85–90, 2009; Ratasvuo et al., Pathological fractures of skeletal metastases – a many sided challenge. A report of 1195 operated metastases. Scandinavian sarcoma group skeletal metastasis registry. Manuscript in preparation, 2011). Skeletal metastases occur in around one-third of patients with these malignancies. Pathological fracture is usually a late manifestation of disease. Pathological fracture causes pain, reduces patients’ functional independence and quality of life if not treated properly. Pathological fractures of the long bones are most common surgical issues in the management of the skeletally-related events. Orthopaedic procedures should be minimally-invasive, producing as little morbidity as possible. However the treatment should aim to be done once and for all and a rapid functional recovery producing maximal pain relief (Ashford, Eur Oncol 5:30–34, 2009; Bauer, J Bone Joint Surg Br 87:608–617, 2005; Clain, Br J Cancer 19:15–29, 1965; Coleman, Clin Cancer Res 12:6243–6249, 2006; Harrington, Cancer 80:1614–1627, 1997; Higinbotham and Marcove, J Trauma 5:792–798, 1965; Weiss and Wedis, Acta Orthop 82:96–101, 2011; Bickels et al., J Bone Joint Surg Am 91:1503–1516, 2009; Fottner et al., BMC Musculoskelet Discord 11:145, 2010; Hansen et al., Acta Orthop Scand 75:11–15, 2004; Hansen et al., Acta Orthop 334:85–90, 2009; Jensen et al., BMC Cancer 24:11–29, 2011; Katagini et al., J Bone Joint Surg Br 87-B:698–703, 2005; Lin et al., J Bone Joint Surg Am 89:1794–1801, 2007; Narazaki et al., Clinics 61:313–320, 2006; Ratasvuo et al., Pathological fractures of skeletal metastases – a many sided challenge. A report of 1195 operated metastases. Scandinavian sarcoma group skeletal metastasis registry. Manuscript in preparation, 2011; Saad et al., Cancer 110:1860–1867, 2007; Wedin et al., Cancer 92:257–262, 2001; Zekri et al., Int J Oncol 19:379–382, 2001). The survival affects the choice of treatment and these issues are discussed later.