Soft tissue tumor recurrence after intramedullary stabilization of impending pathologic fractures

This article describes the cases of 3 patients who were treated for impending pathologic fractures with intramedullary stabilization who developed soft tissue tumor recurrence along the surgical tract site postoperatively, with confirmed histologic diagnoses consistent with each of their prior-known metastatic primaries. This sequela of treatment can lead to additional surgical procedures, longer recovery, and a delay in further systemic treatment, which negatively affects patient outcomes and survival. This can occur despite the use of adjuvant radiation therapy to the surgical site. Between June 2008 and July 2010, our institution surgically treated 71 pathologic (or impending) fractures, of which 52 were femoral nails and 19 were humeral nails. Three of these patients sustained soft tumor tissue recurrence along the surgical tract. Due to the unfavorable long-term prognoses for patients with metastatic disease, these surgeries are palliative and not curative in nature. The purpose of this article is to draw attention to this sequala and heighten awareness for physicians who treat inpending or pathologic fractures. It is difficult to make strong recommendations based on a series of 3 patients, but some general principles can be used. We recommend copious intraoperative irrigation of the wound sites and consideration for routine surveillance with physical examination and prompt imaging and biopsy if any suspicion for local soft tissue recurrence arises. Our approach includes fine-needle aspiration of suspicious lesions followed by resection. The plastic surgery team is consulted pre- or intraoperatively if the resection defect cannot be closed primarily. The patient is also referred back to a medical oncologist for consideration of systemic chemotherapy because soft tissue tumor recurrence is a sign of progressive disease.