1 / 50

Pathologic Fractures – Metastasis

Pathologic Fractures – Metastasis. Orthopedic Surgery Grand Round 7 th February 2013 Dr. J.W. Kinyanjui Registrar Ward 6D. Outline. Introduction Epidemiology Pathophysiology Clinical evaluation Management. Introduction. Fracture through abnormal bone

lovey
Download Presentation

Pathologic Fractures – Metastasis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pathologic Fractures – Metastasis Orthopedic Surgery Grand Round 7th February 2013 Dr. J.W. Kinyanjui Registrar Ward 6D

  2. Outline • Introduction • Epidemiology • Pathophysiology • Clinical evaluation • Management

  3. Introduction • Fracture through abnormal bone • Minor trauma or during normal activity • 5th decade most prevalent • Metastases 2nd most common cause of pathologic fractures • F: breast and lungs – 80% • M: prostate and lungs – 80% • 10% - no primary tumor found

  4. Epidemiology – incidence at autopsy Primary Site% metastasis to Bone Breast 50-85 Lung 30-50 Prostate 50-70 Hodgkin’s 50-70 Kidney 30-50 Thyroid 40 Melanoma 30-40 Bladder 12-25

  5. Pathophysiology • Most spread is hematogenous • Few tumors due to contiguous spread • Most common osteolytic via osteoclast stimulation • Prostate – commonly osteoblastic • Breast – mixed • Theories explaining predilection of bone for metastasis

  6. Paget’s fertile soil hypothesis • 1889 • Sites of secondary growths are not a matter of chance • Some organs provide a more fertile environment for the growth of certain metastases • Example: breast cancer to liver, Krukenberg tumor • Prostate cancer to bone • Hart and fielder later proved this using radioactive labelling

  7. Ewing’s circulation theory • 1928 • Metastatic deposits dependent on route of blood and lymph flow • Organs though to be passive receptacles • Organs with prominent venous systems have more secondaries • Baston plexus of spine responsible for prostate secondaries

  8. Red marrow theory • In descending order of frequency: • Spine • Pelvis • Ribs • Proximal appendicular skeleton • Marrow sinusoids more susceptible to tumor cell penetration • Sudden change from arterioles to sinusoids favours tumor cell entrapment • Ewing’s and Paget’s theories not mutually exclusive

  9. Molecular level • Cells from primary enter blood vessels • Attachment and penetration of basement membrane, neovascularisation • Type 1 collagen shown to be chemotactic to tumor cells • RANK ligand produced by tumor cells stimulating osteoclast activity • PTHrP produced by breast and lung cancer cells stimulates osteoclasts • Prostate cancer cells produce BMPs, IGF1, TGFβ2 which stimulate osteoblasts

  10. Clinical evaluation: History • Pain – most common, preceding fracture, night, constant, dull, aggravated by activity • Trauma – usually minimal for type of fracture • Constitutional – anorexia, night sweats, weight loss, fatigue • Previous cancer • Carcinogen – smoking, radiation, occupational toxins

  11. Factors suggesting pathologic fracture • Spontaneous fracture • Minor trauma • Pain at site preceeding fracture • Multiple recent fractures • Age > 45 yrs • Prior history of malignancy

  12. Associated problems • Lowered Quality of life: • Debilitating pain • Immobility • Neurologic deficits – spine mets • Anaemia • Hypercalcemia

  13. Hypercalcemia • Neurologic: headache, confusion, irritability, blurred vision • Gastrointestinal: anorexia, nausea, vomiting, abdominal pain, constipation, weight loss • Musculoskeletal: fatigue, weakness, joint and bone pain, unsteady gait • Urinary:nocturia, polydypsia, polyuria, urinary tract infections

  14. Clinical evaluation: examination • Local: mass, deformity, tenderness, contiguous skeleton, neurologic exam • Systemic: cachexia, pallor, lymphadenopathy, entire skeletal system • Primary: breast, thyroid, prostate, lung, pelvic

  15. Clinical evaluation: Laboratory • TBC – anaemia of chronic disease • Calcium – elevated • Alkaline phosphatase – elevated, non specific • Tumor markers – PSA, CEA, CA125, TFTs • N-telopeptide + C-telopeptide – markers of bone destruction, determine extent of skeletal involvement, assess response to bisphosphonates

  16. Imaging: plain radiographs • Enneking’s questions: • Location: diaphysis, metaphysis, epiphysis, cortical or medullary • Effect: osteoblastic vs. osteolytic or mixed • Reaction: sclerotic rim, periosteal reaction, codman triangle • Isolated avulsion of lesser trochanter – imminent femoral neck fracture

  17. Osteolytic, diaphysealmedullary, periosteal reaction

  18. Osteoblastic mets to bone

  19. Codman triangle

  20. Osteolytic lesion in lesser trochanter

  21. Radiology: CT scans • Most sensitive for detecting bone destruction • Determines extent of cortical involvement • Also used to search for primary lesion in pelvis, abdomen or chest

  22. Mixed lesion in lung mets

  23. Radiology: MRI • Most sensitive for assessment of the anatomic extent of a lesion • Most adequate for spinal metastases to determine neurologic structure involvement • Can determine extraosseous spread of a mass

  24. Bone scanning • Technetium-99m (99m Tc) bone scanning: • Sensitive for detection of occult lesions • Assessment of the biologic activity of lesions • Identification of other sites • Assessing response to therapy

  25. Biopsy • Indicated to rule out primary tumor of bone • Immunohistochemistry can determine primary • Biopsy at fracture site complicated by bleeding and callus formation • Needle vsincisional • Oncological surgical principles adhered to • Cultures to rule out infection

  26. Impending pathologic fractures • Prophylactic stabilisation before radiotherapy can be performed for pain • Radio and chemotherapy without stabilisation also an option • Decision to stabilise difficult • Mirel’s criteria useful to determine which lesions at high risk of fracture

  27. Mirel’s criteria Size is the diameter of cortex involved on plain radiographs A score of 8 or more is an indication for prophylactic stabilisation

  28. Advantages • Prophylactic stabilisation: • Shorter hospital stay • More immediate pain relief • Faster and less complex surgery • Quicker return to premorbid function • Improved survival

  29. Management objectives • Decrease pain • Restore function • Maintain/restore mobility • Limit surgical procedures • Minimize hospital time • Early return to function (immediate weightbearing)

  30. Non operative management • Bisphosphonates – modifies bone resorption by osteoclasts, shown to reduce risk of skeletal metastasis • Hematologic – correction of anaemia, coagulopathy, DVT prophylaxis • Hypercalcemia – hydration, calcium restriction, bisphosphonates, mithramycin • Analgesia • Radiation – most useful in spinal metastases

  31. Radiotherapy • Used to reduce pain secondary to bone metastases • Partial in 80%. Complete in 50 – 60% • Halts progression of bony destruction • Allows healing of an impending pathologic fracture • Postoperative local tumor control

  32. Bracing • Patients with limited life expectancies, severe comorbidities, small lesions, or radiosensitive tumors • Upper extremity lesions particularly amenable • Adjuvant radiotherapy of suscepible tumors required

  33. Operative: principles • Durable, weight bearing impalnts needed • PPMA augmentation of construct useful incl. prosthesis • Bone graft less useful due to prolonged healing time • Prophylacticallystabilise as much bone as possible • Anticipate hemorrhage due to neovascularisation • Thus tourniquet, preoperative embolisation

  34. Upper extremity • Scapula, clavicle – non operative • Proximal humerus – prosthesis (long stem), intramedullary nail with multiple screws • HumerusDiaphysis – locked IM nail > plating • Distal humerus – prosthesis, retrograde flexible IM nails > bicondylar plating • Forearm – Rare. IM nails or plating

  35. Lower extremity • Acetabular – reconstruction with appropriate prosthesis • Femoral neck – hemi- or THR. Cemented. Long stem • Intertrochanteric – recon nail or prosthesis > DHS • Subtrochanteric – locked IM nail • Femur shaft – locked IM nail preferably cephalomedullary • Around the knee – locked plating > retrograde nailing

  36. Spinal fractures • Commonly present with compression fracture • MRI to differentiate from osteoporosis • Lesion involving body and pedicle sparing disc highly suggestive • Radiotherapy, steroids if no neurodeficits or impending fracture

  37. Spinal fractures • Surgery: • Progression of disease after radiation • Neurologic compromise • Impending fracture • Spinal instability due to pathologic fracture • Progressive deformity due to pathologic fracture • Options: • Minimally invasive kyphoplasty/vertebroplasty • Decompression and instrumentation

  38. Controversies and future trends • Optimal length of femoral component of THR • Criteria for impeding fracture • Wide resection of solitary metastases – RCC • Radiofrequency ablation • Cryotherapy • Acetabuloplasty – percutaneous PMMA injection • RANK L modification • Angiogenesis inhibitors

  39. Summary • Diagnosis and treatment requires a multidisciplinary approach • Aggressive surgical treatment relieves pain, restores function, and facilitates nursing care • Biopsy all solitary lesions or refer appropriately • Understand tumor biology and tailor treatment

  40. THANK YOU

More Related