Durr et al. (2002)

Durr et al. (2002)
Design: Retrospective case series (prognosis), evidence level: 3
Country: Germany
Inclusion criteria:
None stated
Exclusion criteria:
None stated
Number of patients = 70, age range 31 to 83 years, mean age = 57 years.
Incisional biopsy = 4
Resection of proximal humerus without reconstruction = 1
Dorsal decompression = 11
Dorsal decompression with additional instrumentation = 15
Partial vertebral resection = 3
Tumour resection and implantation of endoprosthesis = 15
Standard hip arthroplasty = 7
Knee endoprosthesis = 1
Intralesional resection with cementation and instrumentation = 12
Acetabular resection and reconstruction = 1

6 patients with a solitary metastasis had wide tumour resection whilst 60 patients had a palliative intralesional or marginal procedure or, in the remaining 4 patients, a biopsy.
Follow up:
The 12 patients alive at the end of the study were followed for a mean of 41.6 months (range: 2–131) median = 34.5 months.
The most common locations of metastases were in the spine (n = 29) and proximal femur (n = 27) with other lesions in the humerus, femoral shaft and pelvis. 17 patients had spinal fractures and 22 had fractures in the extremities (including 15 in the proximal femur). 10 patients had neurological impairment due to spinal cord compression, 6 had thoracic involvement and 4 with lumbar compression.

19 patients had a solitary metastasis, 19 had multiple bone lesions and 32 patients had other visceral involvement.

58 patients had died from their disease by the end of the study. 6 died within 30 days of surgery.

14 patients had post-surgical complications including pulmonary dysfunction (n = 4), cardiac insufficiency (n = 3), neurological impairment (n = 2), post-operative bleeding (n = 2), multi-organ failure (n = 1), deep infection (n = 1), thromboembolus (n = 1), pseudoarthrosis (n = 1) and failure of osteosynthesis (n = 2). Only 3 of these patients had received pre-surgical treatment with RT or chemotherapy.

No patients had local tumour recurrence or progression.

12/19 patients with a solitary metastasis died because of progressive disease; 3 had progressive at the time of publication and 4 were free of tumour (3 of them for > 5 yrs). 5yr survival rate is therefore 39%.

17/19 patients with multiple metastases without visceral involvement died because of progressive disease; 2 patients were alive at the time of publication. 29/32 patients with multiple metastases as part of widespread disease died. 3 patients were alive at the time of publication, all with disease and less than 12 months follow-up.

Overall, the survival rate at 1 year was 59%, after 2 years 36%, after 5 years 13% and 7% after 10 yrs. The most predictive factors for survival were involvement of multiple bone and visceral spread. Patient age and time from diagnosis to surgery were not significantly associated with survival.

Patients receiving chemotherapy before surgery had a significantly worse prognosis than those receiving chemotherapy after surgery.
General comments:
This paper details the experiences of a German centre in its surgical treatment of women with bone metastases due to breast cancer between 1980 and 1998.

This is an observational study without comparators and thus has the usual limitations. Whilst appropriate analysis has been performed i.e. Kaplan Meier survival analysis, Cox regression, survival data are poorly presented i.e. without confidence intervals.

From: Chapter 6, Management of specific problems

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