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PREVENTION OF PATHOLOGICAL

FRACTURE
AUDIT RESULTS & NEW STANDARDS & GUIDELINES
14TH NOVEMBER 2013
PREVENTION OF PATHOLOGICAL FRACTURE (PPF) GUIDELINE DEVELOPMENT GROUP
DR MARIA DEBATTISTA
PAULA HORTON
SUSAN HOWARTH
BARBARA HUMPHRIES
DR ANDREW KHODABUKUS

JOANNE REYNOLDS
DR JENNY SMITH
MR PAUL COOL
DR AZMAN IBRAHIM

SESSION OUTLINE
Overview
Existing Standards & Audit
Results
Updated Standards &
Guidelines POWERPOINT
Mr Paul Cool
- External
PRESENTATION
Review
JULY 2012

V1.0

PROVENANCE

April 2005 initial guidelines produced

3rd May 2012 Review meeting of MCPCNAG,


majority quorate vote to review guidelines

Meetings of membership of Prevention of


Pathological Fracture (PPF) guideline development
group

POWERPOINT
PRESENTATION

17th July 2012


25th September 2012
13th November 2012
11th June 2013
12th September 2013
16th October 2013 JULY 2012
4th November 2013

V1.0

Presentation of Literature Review on

4th

July 2013

LITERATURE REVIEW
Main changes to evidence
base:
Mirels Score
upgraded to Level 2+ evidence

Denosumab licensed for PPF


Breast cancer
and solid tumours if
POWERPOINT
bisphosphonates would otherwise
PRESENTATION
be prescribed
JULY
2012
Not used in
prostate
cancer
Level 1+ Evidence
V1.0

POWERPOINT
EXISTING PRESENTATION
STANDARDS & AUDIT

RESULTS

JULY 2012
V1.0

DATA COLLECTION
Period
13th February 2013 26th April
2013
Collection Method
POWERPOINT
Case Note Audit
Evaluation ofPRESENTATION
Professional
Practice
Disseminated to all ICNs
JULY 2012

V1.0

EVALUATION OF PROFESSIONAL
PRACTICEPOWERPOINT
PRESENTATION
CASE NOTE
REVIEW
JULY 2012
V1.0

DEMOGRAPHICS
EVALUATION OF PROFESSIONAL PRACTICE

38 Responses
8 ICNs
CNS 21 (55%), Doctors 17 (45%)

POWERPOINT
PRESENTATION
JULY 2012
V1.0

DEMOGRAPHICS
CASE NOTE REVIEW

69 Responses
6 ICNs, CNS 22 (32%), Doctors 37 (68%)

POWERPOINT
PRESENTATION
JULY 2012
V1.0

DEMOGRAPHICS
CASE NOTE REVIEW

POWERPOINT
PRESENTATION
JULY 2012
V1.0

DEMOGRAPHICS
CASE NOTE REVIEW

POWERPOINT
PRESENTATION
JULY 2012
V1.0

DEMOGRAPHICS
CASE NOTE REVIEW

N = 68

POWERPOINT
PRESENTATION
JULY 2012
V1.0

Total
Responses
= 157 as
multiple
metastases
in some

9 (13%)
had bone
pain and no
known
metastases

DEMOGRAPHICS
CASE NOTE REVIEW

Pain

Location of Pain

62 responses
4 had missing data

100%
43.5%
12.9%
3.2%
0%

one pain
two
three
four
five

30
25

24 (36%)
21 (32%)

20

19 (29%)

15
12 (18%)
10 (15%)

10

POWERPOINT
PRESENTATION
5
0

JULY 2012
V1.0

5 (8%)
4 (6%)
3 (5%) 2

Reports of bone pain should be promptly and


appropriately investigated following British
Association of Surgical Oncology (BASO)
Guidelines. [Grade D]

POWERPOINT
PRESENTATION
STANDARD
1
JULY 2012
V1.0

Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 3 23

Level 4 Expert Opinion

ASSESSMENT

BRITISH ASSOCIATION OF SURGICAL ONCOLOGY GUIDELINES


Level of clinical
suspicion of
metastatic disease

Clinical Features

Known cause for pain.


Minimal

Resolves well usually 2 3


weeks from onset

Action

Normal outpatients review. Return to GP if resolution


not complete
Plain radiograph.

Low

Probable cause known. Good


resolution over 4 6 weeks.

If negative: no action.
If positive: follow advice regarding the need for
orthopaedic assessment.
Plain radiographs, serum calcium and bone scan
within 10 working days. Review one week later.

Moderate

No clear cause for pain which is


persistent but not progressive.

If all negative, review in 8 weeks if symptomatic.


If one or more tests positive, follow advice regarding
the need for orthopaedic assessment.

No identified cause for pain.


High

Night pain, severe and/or


progressive pain.

Neurological symptoms and


signs.

Plain radiographs, serum calcium and bone scan


within 10 working days. Review one week later.
If all negative but suspicion high, review in 1 week
(appendicular skeleton). If pain in spine then arrange
MRI
If one or more tests positive, follow advice regarding
the need for orthopaedic assessment.

Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of
metastatic bone disease in the United kingdom. Eur J Surg Oncol 1999: 25: 3 23

STANDARD 1
EVALUATION OF PROFESSIONAL PRACTICE

What awareness is there of the BASO criteria?


How would you assess risk of bone disease and fracture?
25
21
20

15

POWERPOINT
PRESENTATION
11

10

5 JULY 2012

V1.0
0
Unsure/Seek further help Scoring System

Clinical assessment

STANDARD 1
EVALUATION OF PROFESSIONAL PRACTICE

What awareness is there of the BASO criteria?

What guidelines are you aware of that assess risk of


bone disease and pathological fracture?
None/Don't Know

12

Mirels

12

Harrington
Hartington

POWERPOINT
6
4
PRESENTATION
3

MCCN Guidelines
NICE
BASO
Trust Policy

MSCC Guidelines

1
0

JULY 2012
V1.0

10

12

14

STANDARD 1
CASE NOTE REVIEW
WAS THE RISK OF METASTATIC BONE DISEASE ASSESSED?
0

10

Yes - risk assessed as probable metastaic disease but


not graded as one of options below

15

20

25

30

28.8%(19)

Yes - risk assessed according to BASO Guidelines as


"minimal"

0.0% (0)

Yes - risk assessed according to BASO Guidelines as


"low"

0.0% (0)

POWERPOINT
PRESENTATION

Yes - risk assessed according to BASO Guidelines as


"moderate"

0.0% (0)

Yes - risk assessed according to BASO Guidelines as


"high"

0.0% (0)

JULY 2012

No/Not documented

37.9%(25)

V1.0

Not applicable-already known to have metastatic disease


in the area(s) of pain

37.9%(25)

STANDARD 1
CASE NOTE REVIEW
What investigations has the patient had up to this assessment
date?
40
35 (57%)
35

34 (55%)

33 (53%)
30 (48%)

30

25
22 (36%)

POWERPOINT
PRESENTATION

20

15

10

JULY 2012
5

V1.0
0
MRI scan

CT scan

Ca2+ & Alk Phos

Plain radiograph (x-ray

Isotope bone scan

STANDARD 1
CASE NOTE REVIEW
What new investigations were organised after SPC assessment?
30

25

24 (39%)

20

15

14 (23%)

POWERPOINT
PRESENTATION

10 (16%)

10

8 (13%)

8 (13%)

5 (8%)

JULY 2012
2

2
1

V1.0

0
No-all
appropriate

MRI scan

Ca2+ & Alk


Phos

Plain
radiograph (xray)

No - patient
too unwell

CT Scan

Isotope bone
scan

No-reason
unclear

No-low
severity/risk

STANDARD 1
CASE NOTE REVIEW
What prompted these investigations to be ordered or advised?
30

28 (45%)

28 (45%)

25

20

15

POWERPOINT
PRESENTATION

10

12 (19%)

8 (13%)

JULY 2012

3 (5%)

3 (5%)

V1.0

0
Not applicable

Increased pain

Pain on weightbearing

Pain at night

Results of other
investigations

Other symptoms or
reasons

Standard 1
Reports of bone pain
should be promptly
and appropriately
investigated following
British Association of
Surgical Oncology
(BASO) Guidelines.
[Grade D]

Low knowledge of
BASO guidelines
Clinical reasoning is
better

POWERPOINT
PRESENTATION
JULY 2012
V1.0

Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 3 23

Patients presenting with a lesion due to metastatic


bone disease must be discussed with an
oncologist for consideration of further therapy
(e.g. hormonal manipulation, bisphosphonates,
chemotherapy, radiotherapy) regardless of
orthopaedic intervention. [Grade C]

POWERPOINT
PRESENTATION
STANDARD
2
JULY 2012
V1.0

STANDARD 2
EVALUATION OF PROFESSIONAL PRACTICE

ORTHOPAEDIC

ONCOLOGY

POWERPOINT
PRESENTATION
JULY 2012
V1.0

STANDARD 2
EVALUATION OF PROFESSIONAL PRACTICE

Summary (from additional comments made


on questionnaire responses)
Referral to an oncologist is likely to arise from a
combination of factors, primarily severe pain with
radiological evidence of metastatic disease at that
site.
POWERPOINT
Location is also
a factor. Spinal disease,
particularly where
there is suspicion of impending
PRESENTATION
cord compression, is more likely to result in a
2012
referral thanJULY
either
upper or lower limb disease
V1.0
(74% compared to 55/56% respectively)

STANDARD 2
CASE NOTE REVIEW
What discussions took place when investigations were completed?
25
23 (64%)

20

15

11 (31%)
10

POWERPOINT
PRESENTATION
7 (19%)

JULY 2012
V1.0

1 (2.8%)

0
Orthopaedic surgeon

Oncologist

None

Missing Data

Standard 2
Patients presenting
with a lesion due to
metastatic bone
disease must be
discussed with an
oncologist for
consideration of
further therapy (e.g.
hormonal
manipulation,
bisphosphonates,
chemotherapy,
radiotherapy)
regardless of
orthopaedic
intervention. [Grade
C]

Evaluation of
professional practice
less than 100%
Case note analysis
64%
POWERPOINT
But
impact of poor
performance
status
PRESENTATION
(affecting 35% of
sample)
JULY 2012

V1.0

If there is evidence of significant risk of a


pathological fracture, orthopaedic review should
be urgently sought and the patient seen within
one week. [Grade D]

POWERPOINT
PRESENTATION
STANDARD
3
JULY 2012
V1.0

Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 3 23
British Orthopaedic Association Working Party on Metastatic Bone Disease. Metastatic Bone Disease: A Guide to Good Practice. London.
2001.

STANDARD 3
CASE NOTE REVIEW
ALL DISCUSSED WITH
ORTHOPAEDICS

WHEN THERE WAS AN OVERT


RISK GRADING

N = 11
N=1
Hospital 9 (82%),
Community 1 (9%), Hospice Mirels of 8 graded by
1 (95)
ortho SHO
5 clearly discussed with
Discussed within 1 week
them within 1 week, 6 had
missing data
Offered IM nail but patient
POWERPOINT
Outcome
declined

PRESENTATION

4 (36%) had treatment


4 (36%) none needed
JULY 2012
2 (18%) poor PS
1 (9%) patient declined op

V1.0

Standard 3
If there is evidence of
significant risk of a
pathological fracture,
orthopaedic review
should be urgently
sought and the
patient seen within
one week. [Grade D]

From data all had an


urgent orthopaedic
review
Hospital bias?

POWERPOINT
PRESENTATION
JULY 2012
V1.0

When a fracture is likely to occur, prophylactic


fixation, appropriate to the site of the lesion,
should be performed prior to treatment with
radiotherapy. [Grade D]

POWERPOINT
PRESENTATION
STANDARD
4
JULY 2012
V1.0

Source: Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathological fracture. Clin
Orthop Rel Res 1989; 249: 256-264.

STANDARD 4
EVALUATION OF PROFESSIONAL PRACTICE

Orthopaedic procedures in last 12 months


Procedure

Number of responses
4
(2 bilateral, 1 post fracture on 1 side)

Femoral nail

1
(after fracture)

Total hip replacement


Nail of humerus
Vertebroplasty
Amputation

NOS IM nail

3
POWERPOINT
(1 offered post fracture)
2
PRESENTATION
(1 post spinal fracture)
JULY 2012

1
V1.0

Other comments usually too poorly to have treatment

STANDARD 4
EVALUATION OF PROFESSIONAL PRACTICE
Do you think there is a minimal likely
prognosis needed for referral to an
orthopaedic surgeon to be appropriate?

If so how long should that prognosis be?

50%
45%
45%
40%
Last Days of
life
31%

35%

Weeks
38%

30%
24%

25%

21%
20%
15%

10%

POWERPOINT
PRESENTATION
JULY 2012

Months
31%

5%

V1.0
0%
Yes

No

Unsure

STANDARD 4
CASE NOTE REVIEW

N=3
IM Nail of humerus, IM nail of femur,
curettage and cementoplasty of femur
1 had radiotherapy, 2 did not due to
performancePOWERPOINT
status

PRESENTATION
JULY 2012
V1.0

Standard 4
When a fracture is
likely to occur,
prophylactic fixation,
appropriate to the
site of the lesion,
should be performed
prior to treatment
with radiotherapy.
[Grade D]

All had consideration


re: radiotherapy

POWERPOINT
PRESENTATION
JULY 2012
V1.0

Following any orthopaedic intervention


(prophylactic stabilisation or fracture
management) a patient must be discussed with
an oncologist regarding the possibility of further
therapy. [Grade D]

POWERPOINT
PRESENTATION
STANDARD
5
JULY 2012
V1.0

Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 3 23

STANDARD 5
EVALUATION OF PROFESSIONAL PRACTICE

What oncological treatments to reduce risk of pathological


fractures have your patients received in the last 12 months?
Treatment

Percentage

Single Fraction Radiotherapy

86.8%

Multiple fraction Radiotherapy

73.7%

Bisphosphonate Therapy

92.1%

Denosumab
Other

POWERPOINT
23.7%
PRESENTATION
10.5%
JULY 2012
V1.0

STANDARD 5
EVALUATION OF PROFESSIONAL PRACTICE
Do you think there is an appropriate
minimal prognosis for referral to an
oncologist?

If so how long should that prognosis be?

45%
40%

> 3 months
8%

39%
36%

35%
30%

1-3 months
30%

25%
20%
15%
9%

10%

POWERPOINT
PRESENTATION
JULY 2012

5%

V1.0
0%
Yes

No

Unsure

Few weeks
62%

STANDARD 5
CASE NOTE REVIEW

N=3
IM Nail of humerus, IM nail of femur,
curettage and cementoplasty of femur
1 already on biologic agent, 2 did not due
to performance
status
POWERPOINT

PRESENTATION
JULY 2012
V1.0

Standard 5
Following any
orthopaedic
intervention
(prophylactic
stabilisation or
fracture
management) a
patient must be
discussed with an
oncologist regarding
the possibility of
further therapy.
[Grade D]

All had consideration


re: chemotherapy

POWERPOINT
PRESENTATION
JULY 2012
V1.0

REVISED GUIDELINES FOR


THE PREVENTION OF
PATHOLOGICAL FRACTURES
IN PALLIATIVE
POWERPOINT
CARE

PRESENTATION
JULY 2012
V1.0

1.GENERAL PRINCIPLES (1)

Bone is one of the commonest sites of metastatic


disease. The most likely primary tumours to spread
to bone are breast, bronchus, kidney, thyroid and
prostate. The axial skeleton (skull, ribs, spine and
pelvis) is more likely to develop metastatic disease
than the appendicular skeleton. l

The major associated morbidities of bone metastases


include pain (the most common symptom occurring
in 70% of patients), pathological fractures (occurring
in 8-30% of patients) and hypercalcaemia.2, 3

POWERPOINT
Advances in hormonal
treatments, use of
PRESENTATION

bisphosphonates and chemotherapy treatments have


JULY 2012
meant that the prognosis of patients with bone
metastases, without visceral metastatic disease,
V1.0 has
greatly improved. 4

1.GENERAL PRINCIPLES (2)

Survival rates for people with bone metastases vary


depending on the primary tumour type. In breast
cancer, median survival is 24 months with a 5-year
survival rate of 20% and in prostate cancer there is a
5-year survival rate of 25% and a median survival of
40 months5.

Prediction of pathological fractures before the event


is a relevant clinical problem. Prophylactic fixation of
long bone metastases is generally easier for the
surgeon and less traumatic for the patient.
Therefore, prophylactic fixation of long bones prior
to radiotherapy should be considered. Stabilisation
of impending pathological fractures is likely to result
in shorter hospital stays, with patients more likely to
9
be discharged to their
JULYown
2012 homes.

POWERPOINT
PRESENTATION

V1.0

The prevention and management of pathological


fractures should be within the context of a multidisciplinary team. 5,10

2. GUIDELINES
POWERPOINT
PRESENTATION
JULY 2012
V1.0

2.1 Investigation of bone pain (1)

Pain may be described as a dull ache to a deep


intense pain; pain at rest; pain exacerbated by weight
bearing and importantly, pain which is worse at night.
2 Patients should be encouraged to report skeletal
symptoms promptly.4

Bone pain may be due to structural damage,


periosteal irritation, nerve entrapment or secretion of
chemical mediators causing osteolysis e.g.
prostaglandins and cytokines. These mediators
activate both osteoclasts and nociceptors.2

POWERPOINT
The clinical conundrum is to determine which pains
are due to new or existing
metastatic disease and
PRESENTATION

which of these lesions may progress to a pathological


JULY 2012
fracture. As such, reports of bone pain should be
investigated following the British Association V1.0
of
Surgical Oncology (BASO) Guidelines (see Table 2.1).
10 [Level 4]

BASO GUIDELINES FOR THE INVESTIGATION OF


BONE PAIN10 [LEVEL 4]
Level of clinical suspicion of
metastatic disease

Clinical features

Action

Minimal

Known cause for pain.


Resolves well usually 2-3
weeks from onset.

Low

Probable cause known. Good


resolution over 4-6 weeks.

Moderate

No clear cause for pain which


is persistent but not
progressive.

Normal outpatient review.


Return to GP if resolution not
complete.
Plain radiograph. If negative:
no action.
If positive: follow advice
regarding the need for
orthopaedic assessment.
Plain radiographs, serum
calcium and bone scan within
10 working days. Review one
week later.
If all negative, review in 8
weeks if symptomatic.
If one or more tests positive,
follow advice regarding the
need for orthopaedic
assessment.
Plain radiographs, serum
calcium and bone scan within
10 working days. Review one
week later.
If all negative but suspicion
high, review in 1 week
(appendicular skeleton). If
pain in spine, then arrange
V1.0
MRI.
If one or more tests positive,
then follow advice regarding
need for orthopaedic
assessment.

POWERPOINT
PRESENTATION
High

No identified cause for pain.


2012and / or
NightJULY
pain, severe
progressive pain.
Neurological symptoms and
signs.

2.1 Investigation of bone pain (2)

Plain radiographs should be of the entire bone,


including the joint above and below the site of pain.
Specific radiographs should be centralised over the
painful area in an AP and lateral view.
Bone metastases may be described as osteolytic (bone
appears less dense on imaging), osteoblastic (where
bone looks denser or whiter on imaging) or mixed in
nature.4 [Level 4]
Any plain radiograph report that details the presence of
a lytic lesion in a long bone should be discussed with a
radiologist regarding its size and degree of cortical
involvement, if not already stated. 7, 8, 10[Level 4]
Plain radiographs are relatively insensitive at detecting
bone metastases.19 Thus if clinical suspicion is high
JULY 2012 further imaging is
and radiographs are normal,
warranted. This should be an isotope scan if the
V1.0
appendicular skeleton is suspected, and an MRI
if the
spine is potentially involved.19

POWERPOINT
PRESENTATION

2.1 Investigation of bone pain (3)

Areas of increased uptake in any long bones on an


isotope bone scan should be followed up by plain
radiographs of the whole bone in two planes at 90 to
each other, to assess for size and cortical
involvement.10 [Level 4]

Patients with symptomatic bone metastases should


be referred urgently to an orthopaedic clinic or be
discussed at a site-specific multidisciplinary team
meeting if they have any of the following:

POWERPOINT
PRESENTATION
Structurally significant
bone destruction.

JULY 2012
Uncertainty whether
the destruction is
significant.
V1.0
Pain of sudden onset (or change in character)
that is exacerbated by movement.10 [Level 4]

PREDICTION OF PATHOLOGICAL
FRACTURE

Clinical features of impending pathological fracture


include pain on movement, persistent pain and
increasing pain. Pain in an area which has already
been treated with radiotherapy, but has not
responded, may also be considered as a clinical
indicator of possible impending fracture.7,8
The risk of a pathological fracture occurring, and
therefore the need to consider prophylactic
fixation, may be assessed using either Mirels
scoring system (for use in long weight bearing
bones) or Harrington's classic definitions (use
restricted to the proximal femur).7
In Mirels scoring system
(Table 32.2) [Level 2+], the
JULY 2012
maximum possible score is 12. If a lesion scores 8
V1.0
or above, then prophylactic fixation is
recommended prior to radiotherapy.

POWERPOINT
PRESENTATION

Table 32.2
Score
Clinical
features
Site

Mirels scoring system for the prediction of


pathological fractures 6 [Level 2+]
1
2
3

Pain severity
Type of lesion

Size (Maximum
destruction of cortex
in any view as seen on
plain x-ray)

Upper limb
Mild
Blastic

Lower limb Peritrochanter


ic
Moderate
Functional
Mixed
Lytic

POWERPOINT
<l/3
1/3-2/3
>2/3
PRESENTATION
JULY 2012
V1.0

ANY ONE OF HARRINGTON'S CLASSIC DEFINITIONS


INDICATES A HIGH RISK OF PATHOLOGICAL
FRACTURE IN THE PROXIMAL FEMUR (SEE TABLE
2.3).8 [LEVEL 3].

Table 2.3 Harrington's classic definitions. Risk of a pathological fracture 8 [Level 3]


1. 50% of circumferential cortical bone has been destroyed.
2. Where pain with weight bearing stresses persists, increases or recurs, despite
adequate local irradiation.
3.

POWERPOINT
Lesions in the proximal femur
in excess of 2.5cm in any dimension.
PRESENTATION

4. Lesions in the proximal femur


associated
with avulsion of the lesser trochanter.
JULY
2012
V1.0

2.3 ROLE OF ORTHOPAEDIC SURGEON

A lead orthopaedic surgeon for appendicular


metastatic bone disease should be identified in
each local NHS trust. 4 [Level 4]

Referral to an orthopaedic surgeon is appropriate in


the following situations:
Prophylactic fixation of metastatic deposits
when there is a high risk of fracture i.e.Mirels
score equal or greater than 8 (see Table 32.2) or
the presence of any one of Harrington's classic
definitions (see Table 32.3).
Stabilisation or reconstruction after
pathological fracture.
Decompression of the spinal cord and nerve
JULY 2012
roots and / or stabilisation for spinal
instability. 4 [Level 4] (see Guidelines onV1.0
the
Management of Metastatic Spinal Cord
Compression).

POWERPOINT
PRESENTATION

2.4

RADIOTHERAPY

Radiotherapy has a major role in the treatment of


bone metastases. 70% of patients will achieve pain
relief with palliative external beam radiotherapy. It
may also prevent additional bone destruction, help
to maintain function, prevent neurological
compromise and maintain quality of life.6

Following nailing of a bone, radiotherapy should be


considered by appropriate specialists
within the context of the multidisciplinary team. 5, 11,
12 [Level 2-]

POWERPOINT
PRESENTATION
JULY 2012
V1.0

2.5 OTHER TREATMENT MODALITIES (1)

Bisphosphonates should be considered, where


clinically appropriate, for the prevention of
skeletal related events and treatment of malignant
bone pain in patients with bone metastases
from breast cancer or hormone refractory prostate
cancer, and also patients with multiple
myeloma.13 [Level 1+] Decisions to treat should be
based on an assessment of their general
medical condition and expected survival time (see
Guidelines on the Use of Bisphosphonates in
the Management of Malignant Bone Disease).
[Level 4].

POWERPOINT
PRESENTATION
Radiofrequency ablation
of bone metastases is an

emerging alternativeJULY
therapy
for the
2012
management of bony metastatic disease. Referral to
an appropriate specialist may be beneficial V1.0
for effective pain palliation and local control of
disease. 15 [Level 3]

2.5 OTHER TREATMENT MODALITIES (2)

Percutaneous cementoplasty is indicated for


patients with painful vertebral metastases. It is a
minimally invasive technique involving injection of
polymethylmethacrylate to strengthen a
vertebra. It may provide fast pain relief for patients
when traditional surgical options are considered to
be too invasive. 16,17 [Level 3]
Denosumab is recommended as an option for
preventing skeletal-related events from breast
cancer and from solid tumours, if bisphosphonates
would otherwise be prescribed. It can be used in
poor renal function. It is however not
recommended by NICE for use in prostate cancer,
2012
and carries the risk JULY
of potential
osteonecrosis of
the jaw5. [Level 1+]

POWERPOINT
PRESENTATION
V1.0

2.3 STANDARDS
1. Reports of bone pain should be promptly and
appropriately investigated following British
Association of Surgical Oncology (BASO) Guidelines.10
[Grade D].
2. If there is evidence of significant risk of a pathological
fracture, urgent orthopaedic review should be
considered.4, 10 [Grade D]
3. Following any orthopaedic intervention (prophylactic
stabilisation or fracture management) a patient should
be discussed with an oncologist regarding the
possibility of further therapy.10
[Grade D]
4. Patients presenting with a NEW OR SYMPTOMATIC
lesion due to metastatic bone disease must be
discussed with an oncologist for consideration of
JULY 2012
further therapy (e.g. hormonal manipulation,
bisphosphonates, chemotherapy, radiotherapy)
V1.0
10
regardless of orthopaedic intervention. [Grade C]

POWERPOINT
PRESENTATION

2.4 REFERENCES (1)

Tubiana-Hulin M. Incidence, prevalence and distribution of bone


metastases. Bone 1991; 12(Suppll):S9-S10.
Mercadante S. Malignant bone pain. Pathophysiology and treatment. Pain
1997; 69: 1-18.
Orthoteers Orthopaedic resource. Bone metastases. Available from
www.orthoteers.org Updated 29 May 2009. [Last accessed 1 June 2009]
British Orthopaedic Association Working Party on Metastatic Bone Disease.
Metastatic Bone Disease: A Guide to Good Practice. London. 2001.
NICE (2012) Denosumab for prevention of skeletal related events in adults
with bone metastases from solid tumours Accessed electronically at
http://www.nice.org.uk/nicemedia/live/13939/61129/61129.pdf
Frassica DA. General principles of external beam radiation therapy for
skeletal metastases. Clin Orthop Rel Res 2003; 415 (Suppl): S158-164.
Mirels H. Metastatic disease in long bones. A proposed scoring system for
diagnosing impending pathological fracture. Clin Orthop Rel Res 1989; 249:
256-264.
Harrington KD. Impending pathological fractures from metastatic malignancy:
evaluation and management. Instr Course Lect 1986; 35: 357-381.
Ward WG, Spang J, Howe D,JULY
Gordan
S. Femoral recon nails for metastatic
2012
disease:
Indications, technique and results. AmJOrthop 2000; 29(9 Suppl): 34-42.
V1.0
Breast Specialty Group of the British Association of Surgical Oncology. The
management of metastatic bone disease in the United Kingdom. Eur JSurg
Oncol 1999; 25: 3-23

POWERPOINT
PRESENTATION

2.4 REFERENCES (2)

Saarto T, James R, Tenhunen M, Kouri M. Palliative radiotherapy in the treatment of


skeletal metastases. Eur J Pain 2002; 6(5): 323-330.
Townsend PW, Smalley SR, Cozad SC, Rosenthal HG, Hassanein RES. Role of
postoperative radiation therapy after stabilisation of fractures caused by metastatic
disease. Int J Radiat Oncol Biol Phys 1995; 31: 43-49.
Wong R, Wiffen PJ. Bisphosphonates for the relief of pain secondary to bone
metastases. Cochrane Database of Systematic Reviews 2002. Issue 2. Art
No.:CD002068. DOI:10.1002/14651858. CD002068.
Rosen LS, Gordon D, Tchekmedyian S, Yanaghihara R, Hirsh V, Krzakowski M et al.
Zoledronic acid versus placebo in the treatment of skeletal metastases in patients with
lung cancer and other solid tumours: a phase III double blind randomised trial - the
Zolendronic Acid Lung Cancer and Other Solid Tumour Groups Study Group. J Clin
Oncol 2003; 21(16): 3150-3157.
Thannos L, Mylona S, Galani P, Tzavoulis D, Kalioras V, Tanteles S et al.
Radiofrequency ablation of osseous metastases for the palliation of pain. Skeletal
Radio! 2008; 37: 189-194.
National Institute for Health and Clinical Excellence. Percutaneous cementoplasty
forpalliative treatment of bony malignancies (interventional procedures overview)
January 2006. Available from: www.nice.org.uk/ip304overview. [Last accessed 1 June
2009]
Lieberman I, Reinhardt MK. Vertebroplasty and kyphoplasty for osteolytic vertebral
collapse.
JULY 2012
Clin Orthop Relat Res 2003; 415 (Suppl): S176-186.
Edelyston GA, Gillipsie PJ, Grebbell FS. The radiological demonstration of osseous
metastases: Experimental Observations. CLin Radiol 1967;18:158-62. V1.0
Eastley N, Newey M, Ashford. Skeletal metastases - The role of the orthopaedic and
spinal surgeon. Surg Oncol. 2012 Sep;21(3):216-22.

POWERPOINT
PRESENTATION