Complications of bone metastases: surgical management

Patients with metastatic disease to the bone present a management challenge. Of the complications encountered in these patients, the predominant types that require surgical intervention are pathologic or impending fractures and neurologic compromise secondary to cord compression from spinal metastases. A multimodality approach is helpful in caring for these patients, and addressing complications related to bony metastatic disease with timely and appropriate intervention is an important step in optimizing care and quality of life.

This article incorporates information from multiple sources and presents recent reviews of the experience at the Memorial Sloan-Kettering Cancer Center with acetabular reconstruction for metastatic lesions, and with the use of the posterolateral transpedicular approach to address metastatic disease in the spine.

Of 55 patients who underwent reconstruction of the acetabulum for metastatic disease, although there was a 25% incidence of local disease progression, there was only a 9% incidence of late fixation failure. Of the 41 who were evaluable at 3 months, 83% continued to experience significant pain relief, and 50% of nonambulatory patients regained walking ability secondary to the procedure. Of the patients with more than 2 years of follow-up, 86% maintained pain relief and 71% maintained their ability to ambulate and function in their community. The preliminary series of 25 patients managed with a posterolateral transpedicular approach to address metastatic disease in the spine showed excellent tumor control, pain relief, and neurologic preservation with the technique. Particular benefit was obtained for patients with extensive epidural disease in which an anterior approach was contraindicated.

Although a multimodality approach to the treatment of patients with metastatic disease to bone combining appropriate surgical intervention with systemic therapy and radiation can entail a major operative procedure, the overall benefits to a patient's quality of life outweigh the risks in most cases. Clinician awareness of the various therapeutic options and their indications, and aggressive advocacy of quality of life for these patients, can improve the care delivered to people with metastatic disease.