Chapters Transcript General Principles and Role of Surgery: Extremities and Pelvis Course: NYU Langone Orthopedics Webinar: Multimodal Management of Skeletal Metastases - A Rational Approach Thanks for having me. Um, I'm gonna give kind of the orthopedic view of metastatic disease in the, uh, extremities and pelvis. Um, some of these stats, Doctor Fabri already mentioned, but I think It's worth repeating because again, it kind of puts the problem into perspective that there are over, you know, 8 million Americans who are currently alive with cancer. It's a very common diagnosis with more than a million diagnoses a year. It's the second leading cause of death. And as Dr. Fabri mentioned, the skeletal system is the 3rd most common site to develop metastatic disease. So, Depending on the numbers and the studies that you read, up to 20 to even 50% of patients at some point in their treatment or the course of their disease will develop a metastatic disease to the bone. Uh, hence, orthopedic surgeons are often called on to see and evaluate these problems and potentially perform surgery, uh, which is gonna be the kind of the gist of my short talk here is trying to figure out if we can, who, who would be, first of all, you know, make the correct diagnosis and then who would benefit from surgical intervention. As has already been mentioned, the skeletal system is the 2nd or 3rd most common site of metastatic disease, and metastatic disease has a variable radiologic appearance. Um, these are just examples of different, uh, X-ray appearances of mixed and uh the bottom left blastic prostate metastatic disease versus very lytic lesions that come from lung and renal cancer and very permitive lesions that destroy the bone. So, although these patients can be quite ill and develop the um problems such as hypercalcemia, which has been mentioned as orthopedists, our main, main concern, although uh there are others, is the structural support of the bone, and who would really benefit from surgical intervention. Um, one thing, I know there's a lot of orthopedic surgeons on the call tonight, so one thing that's a common presentation to an orthopedic surgeon is somebody who comes into the office, uh, with an unknown primary of bone. So anytime we see a patient over the age of 40 who comes in maybe to a general orthopedist who gets an X-ray for their complaints of pain, and they see a destructive lesion of bone, anybody over the age of 40, we have to in the back of our minds think that this could be potentially metastatic disease. 2nd on the list, and we treat it's treated similar to metastatic disease would be multiple myeloma, and then 3rd on the list would be some sort of primary tumor of bone. So these are not unusual circumstances. In fact, already twice this week, I've seen a couple of patients who came into me with uh a destructive lesion that is concerning for metastatic disease, and it's our job as orthopedists or as orthopedic oncologist to kind of develop a rational treatment approach to these patients in terms of uh workup and then uh potential surgery. Believe it or not, the history is the most important fact, and even orthopedic surgeons still do take good histories, at least I do. These two patients that I mentioned this week in my office, both have remote histories of cancer. One had lung cancer, uh, treated more than 15 years ago. The other had breast cancer treated more than 10 years ago and were essentially discharged from follow-up by their, uh, oncologist. Um, which is, I think, appropriate, but just to point out that, you know, these patients think that their disease is most likely cured, which, uh, I don't know, we're still in the process of working them up, but the point is that the history is the most important part as orthopedists, physical exam. Examinations can also uh detect tumors. It's reasonable to ask women when their last mammogram was or men when their last PSA count was, because again, for patients that don't have identified primary disease, uh, working up the unknown primary is uh important. Laboratory analysis has already been mentioned. Obviously, the calcium level, uh, these patients can have uh symptomatic hypercalcemia, which is potentially deadly problem due to the cardiac arrhythmias, so you want to consider that and to uh differentiate multiple myeloma from metastatic bone disease from the solid organ, serum protein electrophoresis is done, uh, to differentiate those problems. Obviously, for a radiographic standpoint, you're gonna have a plain X-ray of the limb. Uh, uh, it's been mentioned a whole body bone scan can identify multiple other lesions which may help with surgical planning and diagnostic making. And really the thing that um helps us the most is uh a CT of the chest abdomen and pelvis, which can identify in these patients with unknown primaries up to a third of the tumors, uh, usually an unknown lung primary and occasionally an unknown, uh, kidney, renal cell mass, uh, and others as well. So, once we've made the diagnosis of metastatic disease, uh, the question becomes who really would benefit from surgery? And that's a, uh, a very tough clinical question to uh answer because there are nuances and I think we're gonna talk about some of those in our case-based presentations here later in the, in the present in the talk. Uh, but upper extremity lesions, lower extremity lesions, really the best thing that we have is something called Morell's criteria, which I'm gonna explain on the next slide, which basically takes a, uh, set of uh clinical uh parameters and uh finds, uh, gives them a score in which we can help to identify patients that are more at risk. This was an old study. It was retrospective in nature. It included a lot of different types of tumors, so it was not, um, in terms of today's world, the best uh science, however, it has been repeated and uh been verified to be the best clinical. that we have. So I want to briefly walk us through this. So, basically, the four parameters are the site of the lesion, um, and the amount of pain that patient's having, the type of lesion that the patient, uh, presents with, and then the actual size of the lesion. And each of these is given a clinical score of 12, or 3. Upper limbs, because they're non-weight bearing bones get a lower score than things that are around the hip and the pero anderic region. Pain, which arguably is very subjective finding, uh, is scored from mild to functional. That, so from mild to uh functional pain, and then the type of the lesion. So metastatic lesions from prostate, uh, cancer or breast cancer can often be very blastic, uh, versus things that are more uh primitive. Or lytic that often come from lung or uh renal cell cancer and then the size. And each of these is given a, a clinical score and obviously the higher the score, the more at risk for fracture the patient is and the more inclined we are to recommend some sort of surgical intervention. So for operative fixation, operative management, what are our principles? Anytime we see destruction near a major joint, mainly the hip or potentially the knee or should. uh, where it's gonna be difficult to reconstruct, um, um, from like a trauma from a trauma standpoint, we do resections and replacements, uh, for more diaphyseal lesions, these can be treated with some sort of intramedullary implant, usually an intramedullary nail, and then treated, uh, adjunctively with methylmethacylate. We aggressively use this and as mentioned, oftentimes these patients will receive. Post-operative radiation, uh, to try to uh keep their disease from progressing. So here's an example of somebody with a, a proximal femur lesion in the femoral neck with destruction. This would be a difficult, and this is renal cell cancer, which is generally not responsive to radiation treatments. So this is somebody that would likely benefit from some sort of uh resection and reconstruction, which was done here with uh hemiarthroplasty. Here's an example of somebody with a subtrochanteric permutated lesion from uh metastatic prostate cancer. Again, had functional amounts of uh pain and the disease extended down to the diaphysis of the femur and was treated with a cephalomeddullary implant that spans the entire bone um to try to prevent distal extension of a fracture. Uh, we're gonna have an example in our case presentations about femoral diaphysis, which are treated similarly for patients with, uh, uh, a significant amount of pain and bone destruction as seen here, the posterior cortex. Uh, these also are treated with uh antegrade femoral nails to try to uh prevent pathological fracture or if they sustained a fracture to go ahead and, and treat the actual fracture. Supracondylar and condylar fixation is often done with a plate and methylmethacylate cement reconstruction. Again, for patients that have gone on to sustain a pathological fracture, sometimes they need a large megarosthesis, as shown here on the uh on the bottom right. Pelvic fixation is uh quite, quite, uh, intense. Uh, these patients have to have uh um good life expectancies, but for patients that have significant amount of periocetabular involvement, large pelvic reconstructions with a hybrid total hip arthroplasty can be beneficial. And then here are examples of uh treatment of the proximal humerus where there's diaphysele lesion and then a lesion with destruction in the proximal humerus, uh with uh treated with various implants, um, namely intramedullary nails can be used for the dihyy uh lesion and then a proximal humeral resection and replacement for the patient with the uh destruction near the actual glinohumeral joint. Thank you. Published July 17, 2024 Created by Related Presenters Timothy Rapp, MD View full profile
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