Surgical Treatment Of Metastatic Disease Research Articles

Predictors for quality of life, pain and functional outcomes after surgical treatment of metastatic disease in the spine

BackgroundWhile predictors for postoperative survival in spine tumour patients have been identified, there is limited evidence for predictors of postoperative Quality of Life (QoL), pain and functional outcome. MethodsOne hundred and fifty-three consecutive patients, who had undergone surgery for symptomatic spinal metastases between June 2016 and April 2019, were interviewed preoperatively and during follow-ups at three, six and 12 months using the EQ-5D-3L, COMI, and ODI questionnaires. Differences in means exceeding the specific Minimal Clinically Important Difference (MCID) values were considered clinically significant. ResultsThirty-three percent of the patients were reported dead after 12 months. Only one metastasis compared to multiple metastases has 7.9 the Odds for an improved EQ-5D-3L score at three months. No neoadjuvant metastatic irradiation has 6.8 the Odds for the improvement at that time against performed radiation. A preoperative ODI score between 50.1 and 100 has 22.0 times the odds compared to the range from 0 to 50 for an improved EQ-5D-3L after three months, and 12.5 times the odds in favour of improved COMI after three months, and 13.6 times the odds for improvement of ODI at the three-month follow-up. A preoperative COMI score ranging from 5.0 to 10 has 21 times the odds of a COMI between 0 and 5 for an improved EQ-5D-3L score and 11 times the odds for an improved ODI after 12 months. Other predictors showed no statistically significant improvement. ConclusionAn improvement in QoL, pain and spinal function after 12 months can be predicted by a subjective preoperative poor health condition. Impaired spinal function before surgery, a singular metastasis and no previous irradiation is predictive of improved spinal function and quality of life three months after surgery.

Spine

The April 2023 Spine Roundup360 looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.

The Influence of Hospital Characteristics on Patient Survival in Surgically Managed Metastatic Disease of Bone: An Analysis of the SEER-Medicare Linked Database.

We investigated whether patients receiving surgical treatment for metastatic disease of bone (MDB) at hospitals with higher volume, medical school affiliation, or Commission on Cancer accreditation have superior outcomes. Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 9413 patients surgically treated for extremity MDB between 1992 and 2014 at the age of 66 years or older. Cox proportional hazards models were used to calculate the hazards ratios (HR) for 90-day and 1-year mortality and 30-day readmission according to the characteristics of the hospital where bone surgery was performed. We observed no notable differences in 90-day mortality, 1-year mortality, or 30-day readmission associated with hospital volume. Major medical school affiliation was associated with lower 90-day (HR: 0.88, 95% confidence interval [CI]: 0.80-0.96) and 1-year (HR: 0.92, 95% CI: 0.87-0.99) mortality after adjustments for demographic and tumor characteristics. Surgical treatment at Commission on Cancer accredited hospitals was associated with significantly higher risk of death at 90 days and 1 year after the surgery. This effect appeared to be driven by lung cancer patients (1-year HR: 1.17, 95% CI: 1.07-1.27). Our findings suggest surgical management of MDB at lower-volume hospitals does not compromise survival or readmissions. There may be benefit to referral or consultation with an academic medical center in some tumor types or clinical scenarios.

Outcomes after Surgical Treatment of Metastatic Disease in the Adrenal Gland; Valuable for the Patient?

Simple SummaryAdrenal glands are common dissemination sites for metastases of various solid tumors. The rapid development of new treatment strategies, such as targeted therapy and immunotherapy for different cancer types, has led to increased metastatic adrenalectomies. Therefore, clear communication between oncologists and adrenal gland specialists has become increasingly important to outweigh surgical risks versus oncological advantages of adrenalectomies in these patients. This study assesses trends in diagnosis, type of surgery, and short-term and long-term surgical outcomes of patients who underwent metastatic adrenalectomy. We included a total of 95 patients with an adrenal metastasis of non-adrenal primary tumors, most often colorectal or lung cancer, who underwent (minimal invasive) adrenalectomy. 37.9% of the patients experienced one or more complications after adrenalectomy. Within our patient cohort, an increased demand for metastatic adrenalectomy was observed over the past years, which might be associated with the rise of targeted- and immunotherapy. Our data aims to assist multidisciplinary teams with weighing the pros and cons of resection of the metastasized adrenal gland of cancer patients.The adrenal glands are common dissemination sites for metastasis of various solid tumors. Surgical treatment is often recommended because targeted therapies and immunotherapy are frequently ineffective for adrenal metastasis. We report the experience with short-term and long-term surgical outcomes of patients undergoing surgery for adrenal metastasis in two hospitals. A retrospective, multicenter study was performed to analyze patient characteristics, tumor-related data, perioperative outcomes, and oncological outcomes. Postoperative complications that occurred within 30 days were scored according to the Clavien Dindo classification. Metastatic adrenalectomy was performed in 95 patients. We observed an increase from an average of 3 metastatic adrenalectomies per year between 2001–2005 to 10 between 2015–2019. The most frequent underlying malignancies were colorectal and lung cancer. In 55.8%, minimal invasive adrenalectomy was performed, including six conversions to open surgery. A total of 37.9% of patients had postoperative complications, of which ileus or gastroparesis, wound problems, pneumonia, and heart arrhythmias were the most occurring complications. Improved cancer care has led to an increased demand for metastatic adrenalectomy over the past years. Complication rates of 37.9% are significant and cannot be neglected. Therefore, multidisciplinary teams should weigh the decision to perform metastatic adrenalectomy for each patient individually, taking into account the drawbacks of the described morbidity versus the potential benefits.

The effect of health insurance on racial disparities in patients with isolated colorectal liver metastases

Presenter: Anastasios Mitsakos MD | East Carolina University Background: Resection of colorectal liver metastases (CRLM) is associated with improved overall survival compared to palliative chemotherapy in patients with stage IV colorectal cancer. Prior literature has demonstrated that Black patients are less likely to undergo surgical treatment for metastatic disease compared to patients of other races. However, little is known about the impact of health insurance on racial disparities. The primary aim of this study was to evaluate the potential effect of health insurance status on racial disparities in receipt of surgical therapy in patients with CRLM. Methods: A retrospective cohort study of patients diagnosed with stage IV colorectal cancer with CRLM in the absence of extrahepatic metastatic disease was performed using the National Cancer Database (NCDB) (2006-2016). The primary outcome of interest was receipt of surgical therapy for hepatic metastatic disease. Multivariable logistic regression (MVR) was performed to evaluate the association of race and health insurance status with the odds of surgical resection. A two-way interaction term was incorporated in the MVR to evaluate the potential heterogeneity of race effect across insurance status. Results: A total of 6,002 patients were included: 70.5% White, 16.7% Black, 6.6% Hispanic, and 6.2% Other race. Rates of resection were lower among Black compared to White patients (17.7% vs. 22.0%), as were rates of systemic chemotherapy (72.0% vs. 75.1%) and multimodality therapy (40.1% vs. 44.9%). By MVR, Black patients had lower odds of undergoing resection for CRLM compared to White patients (OR 0.81, 95% CI 0.67-0.99). No difference was observed among patients of Hispanic or Other races compared to White patients. Uninsured patients were also less likely to undergo resection compared to patients with private health insurance (OR 0.53, 95% CI 0.36-0.76). No statistically significant difference in the odds of resection was observed among other health insurance categories. On MVR of race stratified by health insurance status, only Black patients with Medicare insurance had decreased odds of undergoing surgical therapy for CRLM compared to their White counterparts (OR 0.55, 95% CI 0.38-0.78). No difference in odds of resection was observed among patients of any other race or health insurance category. [Table] Conclusion: Black patients with CRLM have lower odds of receipt of resection for CRLM compared to White patients, particularly among the Medicare-insured population. Further investigation is warranted to better understand racial disparities in the Medicare population and develop implementation strategies to address them.

Utility of the Current Procedural Terminology Codes for Prophylactic Stabilization for Defining Metastatic Femur Disease.

Introduction:Cohorts from the electronic health record are often defined by the Current Procedural Terminology (CPT) codes. The error prevalence of CPT codes for patients receiving surgical treatment of metastatic disease of the femur has not been investigated, and the predictive value of coding ontologies to identify patients with metastatic disease of the femur has not been adequately discussed.Methods:All surgical cases at a single academic tertiary institution from 2010 through 2015 involving prophylactic stabilization of the femur or fixation of a pathologic fracture of the femur were identified using the CPT and International Classification of Disease (ICD) codes. A detailed chart review was conducted to determine the procedure performed as documented in the surgical note and the patient diagnosis as documented in the pathology report, surgical note, and/or office visit notes.Results:We identified 7 CPT code errors of 171 prophylactic operations (4.1%) and one error of 71 pathologic fracture fixation s(1.4%). Of the 164 prophylactic operations that were coded correctly, 87 (53.0%) had metastatic disease. Of the 70 pathologic operations that were coded correctly, 41 (58%) had metastatic disease.Discussion:The error prevalence was low in both prophylactic stabilization and pathologic fixation groups (4.1% and 1%, respectively). The structured data (CPT and ICD-9 codes) had a positive predictive value for patients having metastatic disease of 53% for patients in the prophylactic stabilization group and 58% for patients in the pathologic fixation group. The CPT codes and ICD codes assessed in this analysis do provide a useful tool for defining a population in which a moderate proportion of individuals have metastatic disease in the femur at an academic medical center. However, verification is necessary.

Functional and survival outcomes in patients undergoing surgical treatment for metastatic disease of the spine.

Retrospective review of a prospective database. Spine metastasis has been shown to occur in 40% of cancer patients with an annual incidence of over 18,000 cases in North America alone. In this study, we sought to explore the functional and survival outcomes of patients undergoing surgical treatment for metastatic disease of the spine. A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 55 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status was assessed through patient's ambulatory status. Patient and tumor characteristics were analyzed and regression analyses were performed. Renal cell carcinoma (RCC) was the most common subtype encountered (27.3%). Excluding patients who had spinal metastasis at time of diagnosis, the median time to spinal metastasis from cancer diagnosis was 2.5 years. Median overall survival (OS) time was 1.8 years post diagnosis and 1.6 years post-surgical intervention. Age and tumor subtype were independent predictors of death (P<0.05). Post-surgical intervention, only 3.6% of patients were unable to ambulate-an improvement from 12.7% seen in the immediate preoperative period, P=0.0253. However, at the time of final follow-up, this number had risen to nearly 37%, P<0.0001. Spinal metastasis portends a debilitating prognosis. Ambulatory status is improved or maintained in the post-surgical period. However, long-term outlook remains dismal with median survival at only 1.8 years following diagnosis of spinal metastasis and ambulatory status declining precipitously at the time of final follow-up.

Therapeutic approach in oligometastatic gastric and esophageal cancer

The therapeutic approach to patients with oligometastatic gastric cancer and esophageal cancer is currently undergoing ashift towards amore aggressive therapy including surgical resection. In the current GermanS3 guidelines surgical treatment of metastatic disease is not recommended; however, nowadays interdisciplinary tumor boards have to evaluate such patients increasingly more often. On an individual basis a radical surgical resection of the primary tumor and the metastases is considered and performed in patients who respond well to multimodal chemotherapy concepts. In this review article the currently available data from the literature are discussed and afoundation for individually extended surgical approaches is presented. Together with the currently available results of the FLOT 3 study and the mostly retrospective studies, it seems to be possible to identify patients who would profit from such an aggressive treatment. In the future randomized prospective studies, such as the RENAISSANCE/FLOT 5 study and the GASTRIPEC study will have to evaluate whether an aggressive surgical therapy within multimodal therapy concepts of metastatic gastric and esophageal carcinomas is warranted.

Improved outcomes of colorectal cancer patients with liver metastases in the era of the multidisciplinary teams.

The use of multidisciplinary teams (MDTs), which address colorectal cancer treatment planning through weekly regular group meetings, was begun in October 2007. We analyzed and compared the outcomes of colorectal cancer patients with metastatic disease before and after the era of MDTs. From 2001 to 2010, 1075 patients who presented with stage IV disease and were treated in Taipei Veterans General Hospital were enrolled in the study. Among these patients, 439 (40.8%) were diagnosed after MDTs had been established. The percentage of patients receiving surgical treatment for metastatic disease was calculated and compared before and after MDTs were established, and the survival rate was compared using a log-rank test, with a significance of P < 0.05. A significantly improved survival rate in patients with stage IV disease was observed after establishment of MDTs, with the 3-year survival rate increasing from 25.6 to 38.2% (P < 0.001). Based on multivariate analysis, establishment of a MDT was an independent prognostic factor in patients with stage IV disease (hazard ratio = 0.74, 95% confidence interval = 0.624∼0.866, P < 0.001). The percentage of liver resection in patients with liver metastasis increased from 19.6 to 35.2% after the establishment of MDTs, whereas the percentage of lung resection in patients with lung metastasis remained stationary from 12.4 to 14.3%. In the era of MDTs, intensive cooperation between different specialists has increased the referral rate for metastasectomy, resulting in significantly improved outcomes of colorectal patients in initial stage IV disease.

Latest Developments in Surgical and Minimally Invasive Treatment of Metastatic Bone Disease

Surgical treatment of metastatic disease to bone continues to evolve. Advances have been made in diagnosis, improved surgical outcomes, and minimally invasive procedures. Improved prediction of risk for bone fracture continues to evolve with CT-based techniques including structural rigidity analysis and finite element modeling. Improved surgical outcomes have been seen in treatment of proximal femoral pathologic lesions and fractures with the pendulum swinging toward more use of endoprosthetic devices over internal fixation, humeral lesions with a wide variety of techniques, and acetabular lesions with the use of tantalum acetabular cups and augments. Minimally invasive techniques including osteoplasty, radiofrequency ablation, cryoablation, and high-intensity ultrasound offer alternatives to open surgical treatment. Despite this evolution, the goals of treatment remain the same: pain relief, immediate stability, local disease control, and maintenance or restoration of function.

The role of surgery in renal cell carcinoma metastatic to the pancreas: A single-institution experience

s / Pancreatology 13 (2013) e1–e94 e57 old female. Routine follow-up carried out for five years demonstrated a 35 mmmass localized on the body of the pancreas. The tumor was resected by subtotal pancreasectomy. Histopathologically the specimen was also positive to S-100. The feature of the primary cutaneous lesionwas a superficial spreading tumor in accordance with the anatomical Clark level of IV (melanoma invasive to the reticular dermis). The tumor resected from the pancreas showed heavy brownish pigmentation. Melanin pigment was clearly evident in cytoplasms. An immunohistochemical examination revealed that the tumor cells were positive for HMB-45 and S-100 protein. Thepostoperative coursewasuneventful andno chemotherapywasgiven. The follow-up after three years has shown no relapse of the disease. Discussion: The surgical treatment of metastatic disease is still controversial. Furthermore distinction should be carried out properly. Allen & Spitz have established histopathological criteria for the diagnosis of metastatic, as opposed to primary melanoma. Metastatic melanoma of the pancreas is considered to be a sign of disseminated disease at the time of diagnosis and that could be considered a poor prognosis. Conclusion: In this case the long term survival after the operation would suggest the possible role of surgery in the treatment of metastasis of melanoma of the pancreas.

転移巣の手術適応

皮膚悪性腫瘍の治療を行う我々が関わる転移巣には，皮膚悪性腫瘍の所属リンパ節および遠隔転移巣と，内臓悪性腫瘍からの転移性皮膚腫瘍があげられる。皮膚悪性腫瘍の遠隔転移症例では，がん薬物療法をはじめとした全身治療が原則である。しかしながら現在のところそれのみで良好な治療効果を得られることは少なく，主に悪性黒色腫において，適切な症例の選択により転移巣の切除を含めた局所治療を組み合わせることで時に良好な臨床経過が得られることがある。またそれ以外にも，脳転移巣からの出血や消化管転移による腸閉塞などに対して緊急手術が行われることもある。一方内臓悪性腫瘍からの転移性皮膚腫瘍については，原発巣のがん種に応じた全身治療が原則であるために，これまで切除を含めた局所治療という視点での議論は少なかったように思う。本稿では，主に悪性黒色腫の転移巣および内臓悪性腫瘍からの転移性皮膚腫瘍について，手術適応を考察した。

Surgical Treatment of Metastatic Disease to the Lung

The presence of distant metastases usually implies disease not amenable to cure through surgical resection. In such cases, chemotherapy is the mainstay of treatment, with surgery or radiation reserved for palliative measures. However, metastases limited to the lung may be resected with resultant prolonged patient survival compared to unresectable, widely disseminated metastases. Isolated pulmonary metastases should therefore not be considered untreatable. In this review, we discuss the pathophysiology of pulmonary metastases. We outline prognostic factors associated with metastases, and propose criteria to help select patients for metastasectomy. Surgical approaches, including various open techniques and video-assisted thoracoscopy, are covered. Surgical issues, including the need for unilateral versus bilateral exploration, the extent of resection to achieve cure, the need for lymph node dissection, and the benefit of repeat operations, are discussed. Finally, we review some of the more common tumors that metastasize to the lungs, and the role of metastasectomy in their treatment. Resection of pulmonary metastases confers a survival benefit to a select group of patients so long as the primary tumor is controlled, metastases are limited to the lungs, the patient can tolerate the operation from a cardiopulmonary standpoint, and the metastases are completely resected.

Surgical Management of Metastatic Disease of the Proximal Femur

To review the surgical treatment for metastatic disease of the proximal femur. Records of 8 patients who underwent endoprosthetic replacement with tumour resection (group 1) and 8 others who underwent intramedullary nailing without tumour resection (group 2) were reviewed. Treatments were based on the disease progression and patient's condition. In groups 1 and 2, the respective mean survival periods were 16 and 4 months. All patients in group 1 regained preoperative mobility, but only one patient in group 2 was able to walk with crutches. This was a retrospective, rather than comparative study of endoprothetic replacement and intramedullary nailing for metastatic disease of the proximal femur. Both procedures are considered palliative, and not curative. The longer survival period in group 1 was mainly due to selection of patients with better preoperative medical status.

P80. Results of Surgical Treatment for Metastatic Disease Involving the Sacrum

P80. Results of Surgical Treatment for Metastatic Disease Involving the Sacrum

One Surgeon's Unabashedly Biased View on Liver Resection

All of us who publish the results of our academic endeavors in peer-reviewed journals, or present our findings at local, regional, national or international meetings, are accustomed to signing disclaimers. Scientific and intellectual integrity requires that our studies be performed free of any conflict of interest on the part of the investigators. However, I have never been required, or even requested, to sign a document or to disclose another important point of conflict: my baseline beliefs and biases. Thus, I will state openly and clearly that as a hepatobiliary surgical oncologist, my biases lead me to agree wholeheartedly with the recommendation for aggressive surgical treatment of colorectal liver metastases whenever feasible, as outlined in the article by Khatri et al, entitled “Extending the Frontiers of Surgical Therapy for Hepatic Colorectal Metastases: Is There a Limit?” Having declared my particular and potentially peculiar proclivity to remove or surgically destroy colon cancer liver metastases, I will explain the background for my bias. Elective liver resection of isolated colorectal cancer metastases provides properly selected patients the best chance for long-term disease-free and overall survival. Nihilistic opponents to surgical treatment of metastatic disease argue that stage IV cancer is a systemic disease that requires treatment with systemic cytotoxic agents and, furthermore, complain that there has never been a prospective, randomized study comparing resection of liver metastases with systemic chemotherapy. Proponents of an aggressive surgical approach, including myself, counter with the extensive literature documenting the outcome of thousands of patients surgically treated, with 5-year overall survival rates of 33% to 58%. Conversely, even in the current era of a dizzying array of combinations of active cytotoxic and biologic agents for colorectal cancer, the complete response rate in patients with liver metastases treated with systemic therapy alone is less than 5%, and 5-year survivorship with systemic agents is still anecdotal. In centers where large numbers of liver resections are performed, the ability to perform complex liver operations safely, with perioperative mortality rates of less than 1% and blood transfusion rates of approximately 5%, would make it impossible, if not unethical, to randomly assign properly selected patients to complete surgical resection versus systemic therapy alone. Several surgical groups have published results defining prognostic factors associated with a higher risk of developing recurrent disease in patients undergoing resection of colorectal cancer liver metastases. I believe the vast majority of surgeons would agree that the patients with the highest probability of a good long-term outcome after surgical treatment of colorectal cancer liver metastases are those with no radiographic or intraoperative evidence of extrahepatic malignant disease. However, it is important not to become too dogmatic because there are subsets of patients who may benefit from aggressive surgical treatment if they have only nodal disease confined to the porta hepatis, a perianastomotic recurrence, or one or two isolated pulmonary metastases also amenable to surgical resection. Patients with diffuse metastatic disease, including peritoneal carcinomatosis, are unlikely to benefit from surgical treatment of their liver metastases, further emphasizing the importance of proper patient selection. For many years, the number of liver metastases was thought to be a critical prognostic determinant, but recent results have also questioned the validity of this premise. Frankly, determination of preoperative prognostic scores or calculation of the statistical probability of the development of recurrent disease is a futile activity because there currently are no clinical or molecular determinants that will predict the future course of a given specific patient who has resectable colorectal cancer liver metastases. Every patient deserves the best treatment possible, so thoughtful but aggressive hepatobiliary surgical oncologists will proceed with resection whenever possible, regardless of the number of tumors or the prognostic score. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 33 NOVEMBER 2

Thoracolumbar spine: surgical treatment of metastatic disease

Spinal metastases are likely to become an increasingly common clinical problem as advances in cancer management continue to improve the life expectancy for patients with various neoplastic conditions. The role of surgery is controversial, largely because of a lack of controlled clinical studies comparing the many available treatment modalities. Evolving techniques of spinal instrumentation and reconstruction have allowed the radical resection of metastatic vertebral lesions, and provided effective treatment for painful instability secondary to pathologic vertebral collapse. The current state of surgical treatment for metastatic thoracolumbar disease is discussed, including indications for surgery, options for the surgical approach, and techniques for reconstruction and stabilization. Innovative minimally invasive surgical strategies are also addressed.

Surgical treatment of metastatic disease: are the number of metastases a limit for surgical resection of lung metastases

Surgical treatment of metastatic disease: are the number of metastases a limit for surgical resection of lung metastases

The surgical treatment of metastatic disease of the spine

Background and purpose: The spine is the commonest site for skeletal metastases. The majority of patients with spinal metastases can be managed conservatively, at least initially, but a significant number will develop complications, either neurological or mechanical, requiring surgical intervention. This paper emphasizes the need for a spinal surgeon to be involved early in the care of these patients. Materials and methods: Forty-two patients undergoing surgery for metastatic disease of the spine between January 1995 and June 1997 were reviewed. Thirty-five of the patients had ‘instability’ pain secondary to pathological vertebral fracture, 25 of whom also had radicular pain secondary to nerve root compression. Six patients had radicular pain but no symptoms of instability. Two of these patients had symptoms of spinal claudication and one further patient had symptoms of spinal claudication alone. Forty of the patients had evidence of thecal compression on magnetic resonance imaging scans and 29 had neurological signs. According to the grading of Frankel (Paraplegia 7 (1969) 179), 14 had a major neurological deficit and 15 had a minor neurological deficit. All patients underwent decompression of the cord or nerve roots and spinal stabilization, 25 via a posterior approach, 15 via an anterior approach and two combined. Results: Post-operatively pain improved in 38 of the 42 patients (90%), the neurological deficit in 20 of the 29 patients with a deficit (69%) and the ambulatory ability in 25 of the 32 patients (78%) with very restricted mobility. Conclusions: Identification of the cause of a patient's symptoms allows appropriate surgical intervention with favourable results.

Surgical treatment of metastatic disease of the femur.

Nearly every malignant neoplasm has been described as having the capability to metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed annually, more than 50% will eventually demonstrate skeletal metastasis. Advances in systemic and radiation therapy have led to a considerable improvement in the prognosis of patients with metastatic disease. As a result, orthopaedic surgeons are being asked with increasing frequency to evaluate and treat the manifestations of skeletal metastases. The femur is commonly the site of large impending lesions and complete pathologic fractures. Although the health status of some patients may preclude operative intervention, established pathologic fractures of the femur and metastatic lesions deemed likely to progress to imminent fracture generally should be treated surgically. A rational approach to selection of the proper treatment for these problems includes consideration of the patient's overall medical condition and the type, location, size, and extent of the tumor. Treatment principles are the same regardless of location. A construct should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patient's expected lifetime. All areas of weakened bone should be addressed at the time of surgery in anticipation of disease progression. To minimize disease progression and possible implant or internal fixation failure, postoperative external-beam irradiation should be considered.