Does surgical technique influence the burden of lung metastases in patients with pathologic long bone fractures?

Joseph K Kendal,Shannon K T Puloski,Bryan J Heard,Annalise G Abbott,Raghav Saini,Michael J Monument,Scott W Moorman

doi:10.1186/s12891-022-05067-5

Abstract

BackgroundThe aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery.MethodsRetrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher’s exact tests, and Kaplan-Meier survival analyses.ResultsPatients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4–49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p < 0.001).ConclusionsIn this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival.Level of evidenceIII, therapeutic study

Highlights

The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or open reduction and internal fixation (ORIF) (Arthro/ ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery
En bloc resection and reconstruction with a large tumour endoprosthesis may be indicated for patients with solitary metastatic disease, whereas intramedullary nail (IMN) fixation may be a preferred strategy in a patient with multiple sites of bony metastasis and a short life expectancy
The primary objective of this study was to determine if the surgical fixation of pathological fractures using IMN significantly increases the incidence of new metastatic disease to the lungs compared to arthroplasty and ORIF techniques (Arthro/ORIF) (Fig. 1)

Summary

Introduction

The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery. Surgical management of metastatic long bone fractures, using various surgical techniques and implants (indicated by lesion size, matrix, location, and degree of bone destruction), is an effective, typically palliative intervention that can significantly improve patient quality of life, including pain and mobility [5, 6]. While striving for these goals, surgical decision making in this patient population must include patient-oriented life expectancy, timely surgical care, health economics and implant longevity in the context of persistent bone pathology. Further research in this latter priority is critical to ensure orthopaedic practices are evolving with advances in other therapeutic domains of cancer care

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