Survival improved after pathologic fracture
- Prior to 1970: 7.2 months
- Currently: 18.8 months
- Breast 22.6 months
- Prostate 29.3 months
- Kidney: 11.8 months
- Survival time with vertebral metastases as the first skeletal site involved may be slightly higher compared with appendicular lesions
Palliative control in metastatic disease:
- Small-cell lung cancer
- Ewing’s sarcoma
- Embryonal rhabdomyosarcoma
- Choriocarcinoma
- Testicular carcinomas
- Several types of lymphoma
- Also in: breast, gastric, endometrial, neuroblastoma, pancreatic islet-cell carcinoma, sarcomas (several types), some head & neck carcinomas
- No/little benefit in: colorectal, melanoma, hypernephroma, bladder, cervical, hepatoma, pleomorphic carcinoma
Guidelines
- (1) More effect on small tumors
- (2) More effective at maximal doses
- (3) More effect with multi-drug regimens
- (4) Optimal effects with combinations with different side effects
- (5) ? XRT or surgery to enhance tx/hormonal therapy:
- Breast (better response if estrogen receptor +[also better survival])(better response with bony than visceral metastases)
-
- Tamoxifen
-
- Multiagent tx: cyclophosphamide, methotrexate, fluorouracil, vincristine, prednisone (CMFVP, CMF, CFP), adriamycin (FAC)
- Prostate (orchiectomy and systemic estrogens)
- Thyroid (I131 to suppress TSH)
- Kidney
-
- Interferon
-
- 20-25% regression (esp lung lesions)
- Endometrium
- Seminal vesicle
- Lymphomas
- Leukemia
- (Melanoma)(Chondrosarcoma)
Nutritional care to maximize immune response and assist wound healing
Benefits of chemo- and hormonal therapy
- Tumor growth inhibition
- Regression with pain relief, bone repair, recovery of myelo- and erythropoiesis
Nonoperative management should be supervised with orthopaedic consultation
Prevention of metastases
- Bisphosphonates: improve bone pain, functional level, and fracture rate; potentially may prevent development of bony metastases
-
- Bind to hydroxyapatite to inhibit their resorption
-
- Clodronate (PO or IV)
-
- ? pain (delayed), ? need for XRT, and 32% ? risk of fx
-
- Pamidronate (IV)
-
- ? fx risk, hypercalcemia, pain, delayed "skeletal complications", less decline in func-tional status (no ? in survival or vertebral fx rate)
-
- Inhibits osteoclasts
Pathologic fxs treated nonoperatively often fail to unite
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