Advancements in Skeletal Tumour Management: Linking Metastatic Biology With Surgical Reconstruction

Skeletal tumours, particularly metastatic bone disease, represent a significant clinical challenge due to their complex biological behaviour and impact on structural integrity and patient function, with improved cancer survival contributing to increased skeletal involvement requiring integrated management. The objective of this review is to examine the evolving relationship between metastatic biology and surgical reconstruction, with emphasis on translational insights for clinical decision-making. A structured narrative review was conducted using PubMed, Scopus, and Web of Science to identify literature published between 2015 and 2025, employing predefined search terms including "bone metastasis", "tumour microenvironment", "skeletal tumours", "MRI", "PET/CT", "radiomics", "targeted therapy", "immunotherapy", and "orthopaedic reconstruction". Studies were screened through title and abstract review followed by full-text assessment, with inclusion criteria prioritising peer-reviewed clinical studies, systematic reviews, and translational research relevant to molecular mechanisms, imaging, systemic therapies, and reconstructive strategies; methodological quality and relevance were appraised qualitatively, and findings were synthesised using a thematic integrative framework. Current evidence highlights tumour-bone interactions, including chemokine-mediated homing and RANK/RANKL pathway dysregulation, as key drivers of disease progression, while advances in imaging and radiomics improve diagnostic accuracy and prognostication; comparative analysis indicates that MRI provides superior local tumour delineation, whereas PET/CT enables assessment of metabolic activity and systemic disease burden, thereby informing surgical planning. Systemic therapies influence tumour biology and surgical timing, and innovations in endoprosthetic and biological reconstruction have expanded limb-salvage options. Key outcomes of this synthesis demonstrate that integrating molecular pathways, imaging-derived biomarkers, and treatment response parameters into surgical decision-making enhances prognostic stratification, optimises intervention timing, and improves functional outcomes, although heterogeneity in study design limits standardisation. This review moves beyond descriptive synthesis by providing a clinically oriented integrative framework linking metastatic biology, radiological phenotype, and reconstructive strategy selection, supporting personalised, multidisciplinary care and improved clinical outcomes in orthopaedic oncology.