Venous thromboembolismafter surgical treatment of non-spinal skeletal metastases : An underdiagnosed complication

Introduction and aim: Venous thromboembolism (VTE) is a severe complication associated both with major orthopaedic surgery and cancer. However, survival and postoperative complications of skeletal metastases despite their thrombogenic potential, have received little attention in both the clinical management and research setting. This single-centre observational cohort study aimed to evaluate the incidence and impact of VTE in association with cancer surgery targeted to the management of fractures secondary to skeletal metastases. Methods: Data were collected retrospectively from the medical database. We included consecutive 306 patients operated for 343 non-spinal skeletal metastases during a 15-year period (1999-2014). The incidence of VTE and its risk factors were assessed using binary logistic regression analysis. Kaplan-Meier and Cox regression analyses were used to evaluate variables affecting survival. Results: The rate of symptomatic VTE was 10% (30/306) during the 3-month postoperative period, while 79% received thromboprophylaxis. Fatal pulmonary embolism (PE) rate was high, 3.3% (10/306) after surgery. Intraoperative oxygen saturation drop, pulmonary metastases and intramedullary nailing were independent risk factors for VTE. Indicators of decreased survival were lung cancer, intramedullary nailing, multiple skeletal and pulmonary metastases, anaemia, leukocytosis, and PE. Conclusion: Relationship between fractures secondary to skeletal metastases and VTE needs further clinical attention. Whether the survival of patients with fractures secondary to skeletal metastases can be improved by targeted thromboprophylactic means should be studied further. (C) 2016 Elsevier Ltd. All rights reserved.Peer reviewe

Raajojen ja lantion luustoetäpesäkkeiden kirurginen hoito - ei enää pelkkää palliaatiota

English summar

The clinical significance of magnetic resonance imaging of the hand : an analysis of 318 hand and wrist images referred by hand surgeons

Magnetic resonance imaging (MRI) is a common diagnostic tool in hand surgery. However, there is limited knowledge on the kind of findings that are relevant in treatment planning. We analysed the findings and utility of arm, wrist, metacarpal, and finger MRIs taken in a tertiary hand surgery clinic of 318 consecutive images from 316 patients referred by a hand surgeon or hand surgeon resident. Ganglions (28%), findings on the extensor carpi ulnaris tendon (18%) and on the triangular fibrocartilage (18%) were the most common findings and increased with patient age; the clinical significance of these findings was minimal. The correlation between the clinical scaphoid shift test or the fovea sign test and MRI was also non-significant. Despite findings on MRI, the diagnosis remained unsolved in 76 (24%) cases. However, MRI had a role in reassuring the patient, and in 70% of the cases, further follow-up was unnecessary. This study demonstrates that the indications for wrist and hand MRI must be considered thoroughly and interpretation of the MRI report requires knowledge.Peer reviewe

Revision rate of reconstructions in surgically treated diaphyseal metastases of bone

Introduction: Skeletal metastases can weaken the bone, necessitating surgery, and surgical treatment options vary. The aim of this study was to investigate the revision rate of reconstructions in surgically treated diaphyseal skeletal metastases. Materials and methods: Between 2000 and 2018 at Helsinki and Tampere university hospitals in Finland, a total of 164 cases with diaphyseal skeletal metastases were identified from a prospectively maintained database. Tumor location was humerus, femur, and tibia in 106 (65%), 53 (32%), and 5 (3.0%) cases, respectively. A total of 82 (50%) cases were treated with intramedullary nailing (IMN), 73 (45%) with IMN and cementation, and 9 (5%) with another technique. Results: In the upper extremity, implant survival (IS) was 96.4% at 1, 2, and 5 years; in the lower extremity, it was 83.8%, 69.1%, and 57.6% at 1, 2, and 5 years, respectively. Lower extremity IS for impending lesions was 100% at 1, 2, and 5 years, and in cases operated for true pathologic fracture, it was 71.6%, 42.9%, and 21.5% at 1, 2, and 5 years, respectively. In IMN cases without cement, the complication rate was 16% (13/82) when compared to 6% (4/73) in IMN cases with cementation. Discussion: We would advocate for early intervention in patients with metastatic bone disease affecting the femur rather that watchful waiting with the risk for fracture and the need for urgent intervention. However, this choice must be balanced against the underlying risk of surgical intervention in a potentially fragile population with often limited prognoses.Peer reviewe

Surgery of non-spinal skeletal metastases in renal cell carcinoma

Background and purpose - Surgery for metastases of renal cell carcinoma has increased in the last decade. It carries a risk of massive blood loss, as tumors are hypervascular and the surgery is often extensive. Preoperative embolization is believed to facilitate surgery. We evaluated the effect of preoperative embolization and resection margin on intraoperative blood loss, operation time, and survival in non-spinal skeletal metastases of renal cell carcinoma. Patients and methods - This retrospective study involved 144 patients, 56 of which were treated preoperatively with embolization. The primary outcome was intraoperative blood loss. We also identified factors affecting operating time and survival. Results - We did not find statistically significant effects on intraoperative blood loss of preoperative embolization of skeletal non-spinal metastases. Pelvic localization and large tumor size increased intraoperative blood loss. Marginal resection compared to intralesional resection, nephrectomy, level of hemoglobin, and solitary metastases were associated with better survival. Interpretation - Tumor size, but not embolization, was an independent factor for intraoperative blood loss. Marginal resection rather than intralesional resection should be the gold standard treatment for skeletal metastases in non-spinal renal cell carcinoma, especially in the case of a solitary lesion, as this improved the overall survival.Peer reviewe

Kirurgisesti hoidetut ei-spinaaliset luustoetäpesäkkeet

TAUSTA Syövän hoito on hyvin kehittynyttä, mutta osalla potilaista tauti lopulta leviää. Luusto on yksi yleisimmistä syövän leviämispaikoista keuhkojen ja maksan jälkeen. Luustoetäpesäkkeitä hoidetaan kipulääkityksin ja sädetyksellä, mutta joskus voimakas kipu tai patologinen murtuma edellyttää kirurgista hoitoa. Kirurgiset tekniikat vaihtelevat yksinkertaisimmista naulauksista isoihin resektioihin ja tuumoriproteesien laittoon. Potilaan eliniän arvioiminen on tärkeää valittaessa eri hoitolinjojen välillä. Tämä on ensimmäinen väitöskirja luustoetäpesäkkeiden kirurgisesta hoidosta Suomessa. POTILAAT JA MENETELMÄT Tutkimus perustuu laajaan skandinaaviseen rekisteriin syöpäpotilaista, jotka ovat joutuneet leikkaukseen luuston etäpesäkkeen vuoksi (Scandinavian Sarcoma Group Skeletal Metastases Registry). Ensimmäisessä tutkimuksessa tarkasteltiin tietoja kaikista rekisterissä olevista 1107 leikatusta potilaasta. Toisessa tutkimuksessa vertailtiin eloonjäämistä neljässä yleisimmässä luustoetäpesäkkeitä aiheuttavassa syövässä, rinta-, keuhko-, eturauhas- ja munuaissyövässä. Kolmannessa tutkimuksessa fokus oli munuaissyövässä ja leikkausta edeltävässä embolisaatiohoidossa. Neljännessä tutkimuksessa tutkittiin leikkauksen jälkeisten tromboembolisten komplikaatioiden yleisyyttä. TULOKSET Patologinen murtuma oli ensimmäinen merkki syövästä 14 %:lla potilaista. Kokonaiseloonjääminen ortopedisen leikkauksen jälkeen oli 58 % kuuden kuukauden kohdalla, 41 % vuoden kohdalla ja vain 2 % viiden vuoden kohdalla. Primaaridiagnoosin, etäpesäketaakan ja yleistilan perusteella voidaan karkeasti arvioida eloonjäämisennustetta. Munuaissyövässä marginaalinen resektio yksittäisten etäpesäkkeiden kohdalla voi ennustaa parempaa selviytymistä. Isot etäpesäkkeet aiheuttivat enemmän leikkauksenaikaista verenvuotoa, mutta yllättäen leikkausta edeltävästä embolisaatiohoidosta ei ollut tilastollista hyötyä. Raportoituja komplikaatioita oli vähän, mutta riski vakaviin tromboembolisiin komplikaatioihin on merkittävä. YHTEENVETO Potilaita pitää hoitaa yksilöllisesti. Eloonjäämisennuste leikkauksen jälkeen on riippuvainen primaaridiagnoosista, etäpesäketaakasta ja leikkausmarginaaleista. Tarvitsemme lisää yhteistyötä ortopedien, onkologien, hematologien ja radiologien kanssa, jotta tulevaisuudessa voitaisiin tehdä tarkempia hoitosuunnitelmia, ja estää komplikaatioita, jotka voivat johtaa ennenaikaiseen kuolemaan.BACKGROUND The cancer burden is increasing, and although the treatment of different primary cancers has become very specialized and effective, the disease will eventually disseminate in some patients. Metastatic disease is the leading cause of death in cancer patients, with bone as one of the most common sites of metastasis after the lungs and liver. Skeletal metastases can dramatically decrease patients´ quality of life due to sharp pain and pathological fracture. Treatment of skeletal metastases is most often non-surgical, but when surgery is needed it varies from simple excisions to excessive resections and reconstructions with prostheses. Estimating survival is important in choosing the scope of treatment. This is the first thesis concerning surgical treatment of non-spinal skeletal metastases in Finland. PATIENTS AND METHODS Patient data for the first and second study were based on the Scandinavian Sarcoma Group Skeletal Metastases Registry, world’s largest metastases registry. A total of 1195 operated non-spinal skeletal metastases in 1107 patients were included in the first study. The scope of the second study was to study factors affecting survival in bone-seeking cancers, investigating patients with breast, lung, prostate, and kidney cancer. In the third study, the focus was on skeletal metastases in renal cell carcinoma and the effects of pre-operative embolization. In the fourth study, the focus was on venous thromboembolic events among patients who underwent surgery for pathological fractures. RESULTS In 14% of patients, skeletal complications were the first sign of cancer. The overall patient survival rate after operating on metastases was 58% at 6 months, 41% at 1 year, and 2% after 5 years. Primary cancer, metastatic load, and overall health status could robustly estimate the survival. A scoring system was developed to improve to estimate the survival. Marginal resection in solitary metastases in renal cell carcinoma increased survival compared to the intralesional surgery. Larger tumours had more intra-operative bleeding but, unexpectedly, we did not find pre-operative embolization beneficial. Reported complications were few, but there was an increased risk of thromboembolic events, which can be fatal. CONCLUSION Survival depends on the primary tumour, metastatic load and surgical margins. Surgical treatment should be well designed. We need further collaboration between radiologists, oncologists, surgeons, and hematologists and in the future, we hope to create more accurate clinical practice guidelines and prevent complications, which can lead to premature death

Kirurgisesti hoidetut ei-spinaaliset luustoetäpesäkkeet

TAUSTA Syövän hoito on hyvin kehittynyttä, mutta osalla potilaista tauti lopulta leviää. Luusto on yksi yleisimmistä syövän leviämispaikoista keuhkojen ja maksan jälkeen. Luustoetäpesäkkeitä hoidetaan kipulääkityksin ja sädetyksellä, mutta joskus voimakas kipu tai patologinen murtuma edellyttää kirurgista hoitoa. Kirurgiset tekniikat vaihtelevat yksinkertaisimmista naulauksista isoihin resektioihin ja tuumoriproteesien laittoon. Potilaan eliniän arvioiminen on tärkeää valittaessa eri hoitolinjojen välillä. Tämä on ensimmäinen väitöskirja luustoetäpesäkkeiden kirurgisesta hoidosta Suomessa. POTILAAT JA MENETELMÄT Tutkimus perustuu laajaan skandinaaviseen rekisteriin syöpäpotilaista, jotka ovat joutuneet leikkaukseen luuston etäpesäkkeen vuoksi (Scandinavian Sarcoma Group Skeletal Metastases Registry). Ensimmäisessä tutkimuksessa tarkasteltiin tietoja kaikista rekisterissä olevista 1107 leikatusta potilaasta. Toisessa tutkimuksessa vertailtiin eloonjäämistä neljässä yleisimmässä luustoetäpesäkkeitä aiheuttavassa syövässä, rinta-, keuhko-, eturauhas- ja munuaissyövässä. Kolmannessa tutkimuksessa fokus oli munuaissyövässä ja leikkausta edeltävässä embolisaatiohoidossa. Neljännessä tutkimuksessa tutkittiin leikkauksen jälkeisten tromboembolisten komplikaatioiden yleisyyttä. TULOKSET Patologinen murtuma oli ensimmäinen merkki syövästä 14 %:lla potilaista. Kokonaiseloonjääminen ortopedisen leikkauksen jälkeen oli 58 % kuuden kuukauden kohdalla, 41 % vuoden kohdalla ja vain 2 % viiden vuoden kohdalla. Primaaridiagnoosin, etäpesäketaakan ja yleistilan perusteella voidaan karkeasti arvioida eloonjäämisennustetta. Munuaissyövässä marginaalinen resektio yksittäisten etäpesäkkeiden kohdalla voi ennustaa parempaa selviytymistä. Isot etäpesäkkeet aiheuttivat enemmän leikkauksenaikaista verenvuotoa, mutta yllättäen leikkausta edeltävästä embolisaatiohoidosta ei ollut tilastollista hyötyä. Raportoituja komplikaatioita oli vähän, mutta riski vakaviin tromboembolisiin komplikaatioihin on merkittävä. YHTEENVETO Potilaita pitää hoitaa yksilöllisesti. Eloonjäämisennuste leikkauksen jälkeen on riippuvainen primaaridiagnoosista, etäpesäketaakasta ja leikkausmarginaaleista. Tarvitsemme lisää yhteistyötä ortopedien, onkologien, hematologien ja radiologien kanssa, jotta tulevaisuudessa voitaisiin tehdä tarkempia hoitosuunnitelmia, ja estää komplikaatioita, jotka voivat johtaa ennenaikaiseen kuolemaan.BACKGROUND The cancer burden is increasing, and although the treatment of different primary cancers has become very specialized and effective, the disease will eventually disseminate in some patients. Metastatic disease is the leading cause of death in cancer patients, with bone as one of the most common sites of metastasis after the lungs and liver. Skeletal metastases can dramatically decrease patients´ quality of life due to sharp pain and pathological fracture. Treatment of skeletal metastases is most often non-surgical, but when surgery is needed it varies from simple excisions to excessive resections and reconstructions with prostheses. Estimating survival is important in choosing the scope of treatment. This is the first thesis concerning surgical treatment of non-spinal skeletal metastases in Finland. PATIENTS AND METHODS Patient data for the first and second study were based on the Scandinavian Sarcoma Group Skeletal Metastases Registry, world’s largest metastases registry. A total of 1195 operated non-spinal skeletal metastases in 1107 patients were included in the first study. The scope of the second study was to study factors affecting survival in bone-seeking cancers, investigating patients with breast, lung, prostate, and kidney cancer. In the third study, the focus was on skeletal metastases in renal cell carcinoma and the effects of pre-operative embolization. In the fourth study, the focus was on venous thromboembolic events among patients who underwent surgery for pathological fractures. RESULTS In 14% of patients, skeletal complications were the first sign of cancer. The overall patient survival rate after operating on metastases was 58% at 6 months, 41% at 1 year, and 2% after 5 years. Primary cancer, metastatic load, and overall health status could robustly estimate the survival. A scoring system was developed to improve to estimate the survival. Marginal resection in solitary metastases in renal cell carcinoma increased survival compared to the intralesional surgery. Larger tumours had more intra-operative bleeding but, unexpectedly, we did not find pre-operative embolization beneficial. Reported complications were few, but there was an increased risk of thromboembolic events, which can be fatal. CONCLUSION Survival depends on the primary tumour, metastatic load and surgical margins. Surgical treatment should be well designed. We need further collaboration between radiologists, oncologists, surgeons, and hematologists and in the future, we hope to create more accurate clinical practice guidelines and prevent complications, which can lead to premature death

Insight opinion to surgically treated metastatic bone disease: Scandinavian Sarcoma Group Skeletal Metastasis Registry report of 1195 operated skeletal metastasis.

To access publisher's full text version of this article click on the hyperlink at the bottom of the pageThe number of cancer patients living with metastatic disease is growing. The increased survival has led to an increase in the number of cancer-induced complications, such as pathologic fractures due to bone metastases. Surgery is most commonly needed for mechanical complications, such as fractures and intractable pain. We determined survival, disease free interval and complications in surgically treated bone metastasis. Data were collected from the Scandinavian Skeletal Metastasis Registry for patients with extremity skeletal metastases surgically treated at eight major Scandinavian referral centres between 1999 and 2009 covering a total of 1195 skeletal metastases in 1107 patients. Primary breast, prostate, renal, lung, and myeloma tumors make up 78% of the tumors. Number of complications is tolerable and is affected by methods of surgery as well as preoperative radiation therapy. Overall 1-year patient survival was 36%; however, mean survival was influenced by the primary tumor type and the presence of additional visceral metastases. Patients with impending fracture had more systemic complications than those with complete fracture. Although surgery is usually only a palliative treatment, patients can survive for years after surgery. We developed a simple, useful and reliable scoring system to predict survival among these patients. This scoring system gives good aid in predicting the prognosis when selecting the surgical method. While it is important to avoid unnecessary operations, operating when necessary can provide benefit