Treatment of Metastasis in the Appendicular Skeleton

Moura, Marcio

doi:10.1055/s-0041-1729597

Marcio Moura Address for correspondence Marcio Moura, MD, PhD, Rua da Paz, 195 - room 120, Centro, Curitiba, PR, 80060-160, Brazil (e-mail: mm.tumorosseo@gmail.com).

Department of Orthopedics, Federal University of Paraná, Curitiba, PR, Brazil

http://orcid.org/0000-0001-6169-1106

Address for correspondence Marcio Moura, MD, PhD, Rua da Paz, 195 - room 120, Centro, Curitiba, PR, 80060-160, Brazil (e-mail: mm.tumorosseo@gmail.com).

Conflito de Interesse

O autor declara não haver conflito de interesses.

Figures (3)
Tables (2)

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Fig. 1
45-year-old patient, fall from own height at home, shows a perceptual litic lesion in the region near the fracture. The incorrect interpretation of the image led to surgical treatment as a conventional fracture, submitted to fixation with plate and sliding pin without cement, which evolved with loosening because there was no consolidation due to metastatic disease. The patient could not walk for months, being treated with chemotherapy. Finally, the tumor was resected and replaced by unconventional endoprosthesis, allowing early ambulation.

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Fig. 2
Patient, 39 years old, liver transplant due to hepatitis, develops hepatocarcinoma before transplantation, which was diagnosed in the pathologic piece, post-transplant, and presented with proximal nonfemur bone metastasis and pulmonary metastasis, with criteria for preventing the fracture but with reserved prognosis, submitted to surgery for impediment with medullary nail, but had response in pulmonary lesions and progress in bone lesions, being submitted to resection and replacement by endoprosthesis, complemented with radiotherapy due to previous contamination in the placement of the intramedullary nail in the femur. The patient survived for 3 years and 4 months after a reversal to endoprostheses.

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Fig. 3
Male patient, 59 years old, presents with pain in the proximal region of the thigh. The initial treatments were for trochanteric bursitis. Evolving with disability, he is hospitalized, and a perceptual litic lesion in the intertrochanteric region of the proximal femur is diagnosed. At staging, it is seen that it is a single lesion originated from renal neoplasia, which was submitted to resection and replacement by endoprosthesis, with local control without the need for radiotherapy. The patient is alive after 3 years due to new treatment modalities for renal cancer; he developed heterotopic ossification around the prosthesis, with autonomy for daily routine.

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Table 1
Mirel’s point scale for prophylactic fixation of pathological fracture impediments¹¹11 Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989;(249):256-264

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Table 2
Suggestion of orthopedic treatment for the impediment and treatment of pathological fracture, in order of higher frequency of occurence

Affected site	Preventing pathologic fracture^* * PMMN bone cement can be used at surgical discretion.	Treating pathologic fracture
1. Proximal femur2. Femur diaphysis3. Distal femur	1. Cephalomedullary nail or partial prothesis 2. Cephalomedullary nail 3. Retrograde rod or plate/screw	1. a: head/neck: partial hip arthroplasty (PHA) long rod with cement. b: inter trochanter: endoprosthesis or long IM rod with PMMN 2. IM rod with PMMN/diafiseal endoprosthesis 3. Distal femur endoprosthesis or plate/screw with PMMN
1. Proximal humerus 2. Humeros diaphysis 3. Distal humerus	1. Long plate and/or long IM rod 2. IM rod 3. Plate/screw	1. Endoprostheses of proximal humerus or plate/screw with PMMN 2. IM rod with PMMN/diafiseal endoprosthesis 3. Partial elbow or total endoprosthesis. plate/screw with PMMN
1. Proximal tibia 2. Tibia diaphysis 3. Distal tibia	1. Plate/screw 2. IM nail 3. Plate/screw	1. Pate/screw with PMMN or proximal tibia endoprostheses 2. IM rod with PMMN/diafiseal endoprosthesis 3. Plate/screw with PMMN or arthrodesis with structural graft or amputation
1. Proximal ulna 2. Ulna diaphysis 3. Distal ulna	1. Olecranon plate 2. Plate/screw and or flexible rod 3. Plate/screw	1. Plate/screw with PMMN or elbow endoprostheses 2. Plate/screw with PMMN or flexible rod with PMMN 3. Plate/screw with PMMN or resection
1. Proximal radial 2. Radio diaphysis 3. Distal radial	1. Plate/screw or radial head arthroplasty 2. Plate/screw or flexible rod 3. Distal radial plate	1. Screw plate with PMMN or thread replacement 2. Screw plate and/or flexible rod with PMMN 3. Plate/screw with PMMN or resection with arthrodesis of the structural graft handle
1. Proximal fibula 2. Fibula diaphysis 3. Distal fibula	1. Nonsurgical 2. Nonsurgical 3. Plate/screw or dry	1. Nonsurgical 2. Nonsurgical 3. Plate/screw with PMMN or arthrodesis with structural graft

[1] Address for correspondence Marcio Moura, MD, PhD, Rua da Paz, 195 - room 120, Centro, Curitiba, PR, 80060-160, Brazil (e-mail: mm.tumorosseo@gmail.com).

Score	1	2	3
Location	Upper limb	Lower limb	Peri trochanteric
Pain	Mild	Moderate	Strong
Size	<1/3	<2/3	>2/3
Feature	Blastic	Mixed	Lytic

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Treatment of Metastasis in the Appendicular Skeleton

Abstract