Although most surgeons and patients choose internal fixation of fractures as the most effective and expedient way to control pain and restore function, external fixation is occasionally successful. It is particularly suitable for (1) patients with extensive localized disease that cannot be immobilized by internal means; (2) preterminal patients in whom analgesic modalities such as narcotics or rhizotomy can control symptoms, or (3) patients in whom infection, nadir sepsis, pneumonia, or other temporary medical problems prevent surgery. These nonoperative measures can be used in the hospital and translate well to outpatient, home, or hospice care sitations. Stabilization of a fracture requires control of the proximal and distal fracture fragments.
The secondary metastatic deposit should be excised under most circumstances. Treatment options consists of intralesional excision, wide excision, or other excision method plus a surgical adjuvant.
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Intralesional therapy either occurs at the time of biopsy or as a planned intervention. Once the biopsy confirms metastatic disease, a decision must be made whether to remove all gross disease, in essence debulking the tumor, or to rely on external radiation and systemic therapy to control the lesion. The surgeon must anticipate this eventuality and discuss the treatment options with other members of the oncology team. Only in this way is it possible to prepare the patient and his or her family appropriately before surgery. The variety of treatment options and contingencies make such a discussion and education process difficult. It is the benchmark of clinical skill to guide a patient and family through the decision-making process. Judgment, sensitivity, and skill are needed to integrate the biopsy process with overall tumor management. It is far more than a technical surgical exercise. The combination of tumor removal and bone stabilization best meets the goals of diagnosis, pain relief, and functional restoration. This is particularly so because biopsy further disrupts already weak bone and the structural restoration process is long and undependable.
Intralesional curettage of tumor in and around the fracture site is the principal strategy. It is important in several respects. Tumors have a high degree of vascularity so extensive hemorrhage occurs frequently. When the lesional tissue can be removed back to normal bone, the tumor vessels can contract, seal off, and stop the bleeding. Tumor removal is therefore important in controlling hemorrhage. Eliminating the gross tumor achieves an immediate “partial response” that could take weeks to achieved by other methods. Furthermore, it identifies the remaining structural bone. The resultant defect can be filled much more effectively with methylmethacrylate cement. This gives better tumor control and long-term stability to the fractured bone.
Extralesional excision can be accomplished by either marginal or wide excision. The appeal of complete local excision is obvious. It is the most effective way to achieve local tumor control. It obviates the need for adjuvant radiotherapy and is the fastest, most effective way to eliminate the biologic contribution to pain while correcting the structural deficiency. Isolated solitary metastases should be evaluated for potential resectability. Occasional cures are reported following resection of bone metastases, but they are infrequent. Radical ablative surgery is usually not appropriate. Dispensable bones such as fibula, iliac wing, ribs, clavicle, and scapula are the most appropriate for excision. Occasionally, solitary metastases in the femur, ischium, proximal humerus, and phalanges provide opportunities to cure the patient. Long intervals between primary tumor presentation and the development of a secondary deposit auger well for cancer respectability. Patients with a long projected survival, such as those with renal or thyroid cancers, are the most suitable to undergo radical excision of metastases. Unfortunately, the sacroiliac region and spine are common sites for “solitary” metastases. The tumors are large and bulky, and the surgery is dangerous. Plasmacytomas should be considered for resection. Even if systemic disease later develops, some clinicians contend that survival may be prolonged in surgically resected cases. Isolated thyroid lesions, particularly follicular or papillary carcinomas, are more effectively treated by resection than by radiation, according to Niederle.
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Surgical adjuvants are helpful whether intralesional or excisional procedures are considered. Preoperative angiography and tumor embolization greatly reduce blood flow and intraoperative hemorrhage. This is also helpful in reducing the hypervascularity around the tumor. Marcove pioneered the use of cryosurgery in metastatic disease. Cryosurgery extends the surgical margin without causing an immediate disruption in the surrounding bone structure. Liquid nitrogen freezes and sterilizes the host bed when the temperature is reduced to below -30C°. Typically, three freeze-thaw cycles, achieving approximately 70% to 80% tumor kill from each cycle would be performed. Although long-term cure had been reported for renal and lung cancers by Marcove, the goal is local tumor control for the short and intermediate term. This is particularly suited for cancers that have failed to respond to systemic treatment, local radiation therapy, or both and in which local tumor progression is expected. Tumor control can prevent destabilization of the internal fixation device. Radiation therapy is the principal surgical adjuvant. It should be delivered to the entire surgical field and extend the length of any internal fixation device.