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For example, instead of trying to fix a fracture of the distal femur, as would be done ordinarily, a pathological fracture might be treated with prosthetic knee replacement as the index procedure. Taken together, there may be a need for much more bone cement than usual.Īlso, athough it is ordinarily beneficial to try a simple method initially, reserving extensive treatment only if the simple attempts fails, patients with pathologic fractures might benefit from more definitive, albeit larger, surgeries at the outset. Also, because a key part of many cancer surgeries is to remove the cancer from the bone, surgery may create large defects. Normal bone healing processes are impeded in pathologic fracture (due to local and systemic factors) and routine healing cannot be relied open. The patient might need preoperative chemotherapy, and surgery might need to be delayed until low blood counts have rebounded. The timing of surgery and the care needed before and after must be coordinated with medical and radiation oncologists, among other providers. (Metastatic renal cell carcinoma, for example, is notorious for its tremendous vascularity, and without preoperative embolization, surgery is especially difficult and dangerous.) Also, radiation or tumor embolization might be needed. The timing and selection of any surgical procedures should consider the effect of chemotherapy on wound healing and immunosuppression. Patients with metastatic disease will frequently be on chemotherapy protocols for their primary diagnosis. (There are at least three reasons this is very, very bad. It is especially disastrous to fix one lesion with a plate or rod that ends right above a new lesion. It is also important to get full length films of the involved bone. In the case of a solitary lesion, it might be necessary to perform a biopsy. Primary versus metastatic disease are treated very differently. Even if there is a known primary, it is possible that a lesion might represent new, second cancer (especially if there is a lone "solitary" lesion in the bone). Patients with pathologic fractures may need a more extensive diagnostic work up, including bone scans to exclude additional lesions and possibly a tissue biopsy to confirm the diagnosis. Fracture fixation has the benefit of markedly reducing pain, and thus is often performed even in patients with advanced cancers. It is essential to talk with the patient, the family and the other oncologic providers regarding the patient’s wishes and prognosis. Patients with a very short life expectancy may prefer not to have their fractures treated beyond palliative care. Nonetheless, there are important differences that distinguish the management of a cancer-related pathologic fracture from the treatment of ordinary fractures, including the following: Treatment of pathologic fractures draws on many of the techniques that have been developed for the treatment of ordinary fractures in normal bone. Treatment of cancer-related pathologic fracture takes into consideration the nature of the specific type of cancer, the chemotherapy or radiation therapies available for adjuvant treatment, the need for further diagnostic evaluation to diagnose the source of disease, as well as the wishes of patients in palliative treatment (which may differ significantly from how a fracture would ‘normally’ be treated’). Osteoblastic lesions have abnormal bone architecture: thus, these bones are prone to fracture, even though one might say “more bone is present.”įinally, the management of cancer-related fractures often involves coordination with medical subspecialties that will also treat the patient. Lesions can also be osteoblastic (characterized by increased bone formation, as seen with metastases from prostate cancer) or mixed osteoblastic/osteolytic. The fracture pattern is also often different: pathological fractures have a transverse fracture pattern, while higher energy fractures are typically spiral or comminuted.įurther, skeletal metastases from carcinomas are typically osteolytic: the tumor cells in the bone increase osteoclast activity, eroding the bone and causing pain, fractures, and sometimes hypercalcemia. Pathologic fractures are typically low energy (as it does not take much force to break weak bone). The major difference between treating cancer-related pathologic fractures and treating ordinary fractures is based on the loss of skeletal integrity and strength caused by the presence of cancerous tissue in bone. (Primary bone tumors, such as osteogenic sarcoma, are comparatively rare.) Most occurrences of cancer in bone are metastatic lesions, that is, cancer that has spread from a different location, such as lung or breast, and traveled to the bone in question. Figure 1: Pathological fracture of the humerus in a patient with metastasis of renal cell carcinoma, from Wikipedia
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