Surgery for skeletal metastases in lung cancer

Figures & data

Table 1. 98 lung cancer patients with skeletal metastases

	Total	Males	Females
Number of patients	98	46	52
Median age at diagnosis (years)	62	60	63
range	34–88	43–88	34–84
Smoking status at diagnosis
Former smoker	47	21	26
Current smoker	41	20	21
Never smoker	10	5	5
Histopathology
Non-small cell cancer
Adenocarcinoma	58	25	33
Squamous cell carcinoma	14	8	6
Low differentiated non-small cell cancer	8	4	4
Large cell carcinoma	7	3	4
Small cell cancer	6	3	3
Other cancers	5	3	2
Skeletal metastasis
Femur	46	18	28
Vertebra	31	24	7
Humerus	16	2	14
Other	8	2	6
Type of surgical procedure
Internal fixation	34	10	24
Endoprosthesis	32	11	21
Spinal decompression + instrumentation	17	12	5
Spinal decompression	15	12	3
Other	3	1	2
Preoperative treatment (primary tumor)
Chemotherapy	52	24	28
Radiotherapy	27	10	17
Lobectomy	12	5	7
Postoperative treatment (bone metastasis)
Radiotherapy	59	28	31

Table 2. Pre- and postoperative neurological function in 31 patients with spine metastasis graded according to Frankel

	Preop.	Follow-up
A. Complete paraplegia	2	1
B. No motor function	6	2
C. Motor function useless	14	7
D. Slight motor deficit	6	16
E. No motor deficit	3	5

Table 3. Median survival of lung cancer patients with skeletal metastases. Time in months (range)

	A	B
All	10 (0–168)	3 (0–127)
Males	8 (1–60)	2 (0–59)
Females	10 (0–168)	4 (0–127)
Histopathology
Non-small cell cancer	10 (0–168)	4 (0–127)
Adenocarcinoma	11 (1–168)	4 (0–127)
Squamous cell carcinoma	9 (0–43)	2 (0–18)
Low differentiated non-small cell cancer	8 (1–12)	2 (0–8)
Large cell carcinoma	11 (6–60)	7 (0–59)
Small cell cancer	8 (1–23)	2 (0–3)
Other cancers	5 (1–24)	1 (1–15)
Spinal surgery
All	7 (2–29)	2 (0–15)
Males	7 (2–29)	2 (0–15)
Females	8 (3–20)	1 (1–7)
Extremity surgery
All	10 (0–168)	4 (0–127)
Males	10 (1–60)	3 (0–59)
Females	11 (0–168)	4 (0–127)
Pathological fracture
Complete	8 (0–80)	2 (0–61)
Impending	12 (2–168)	4 (0–127)

A: time between diagnosis of lung cancer and death;

B: time between surgical procedure and death.

Cumulative survival of lung cancer patients after surgery for skeletal metastases, with 95% confidence intervals.

Table 4. Risk of death after surgery for skeletal metastases in lung cancer patients (Cox regression analysis)

Factor	HR	95% CI	p-value
Complete pathological fracture ^a	1.7 ^f	1.1–2.6	0.02
	1.8 ^g	1.0–3.0	0.05
Vertebral skeletal metastasis ^b	1.7 ^f	1.0–2.7	0.03
	1.7 ^g	0.9–3.4	0.1
Hemoglobin level < 10 g/dL ^c	1.9 ^f	1.1–3.4	0.03
	1.8 ^g	0.9–3.7	0.09
Small cell cancer ^d	2.6 ^f	1.2–6.0	0.02
	1.9 ^g	0.8–4.8	0.2
Postoperative radiotherapy (no) ^e	1.7 ^f	1.1–2.6	0.03
	1.6 ^g	0.9–2.9	0.1

Factor versus ^a impending pathological fracture, ^b femur, ^c ≥ 10 g/dL,^d adenocarcinoma, ^e yes;

HR = hazard ratio, ^f unadjusted, ^g adjusted (HRs are adjusted for type of pathological fracture, location of skeletal metastasis, preoperative hemoglobin levels, type of lung cancer, postoperative radiotherapy, age, and sex).

Table 5. Reoperations after surgery for skeletal metastases in lung cancer patients

Sex, age, histology	Localization	Primary operation	Time (months) to and reason for failure	Treatment
F, 57, ^b	Humerus, proximal	Intramedullary nail	5, local tumor progression	Hemiarthroplasty
F, 63, ^c	Humerus, distal	Plate	3, material failure	Plate
F, 62, ^a	Acetabulum	Acetabular reinforcement ring + total joint arthroplasty	1, deep infection	Debridement
F, 62, ^a	Femur, proximal	Total joint arthroplasty	9, periprosthetic fracture	Modular tumor prosthesis
F, 74, ^a	Femur, proximal	Hemiarthroplasty	3, periprosthetic fracture	Modular tumor prosthesis
F, 66, ^a	Femur, trochanteric	Hemiarthroplasty	1, poor initial fixation	Total joint arthroplasty
M, 45, ^a	Femur, trochanteric	Sliding hip screw	1, poor initial fixation	Total joint arthroplasty
F, 73, ^b	Femur, trochanteric	Sliding hip screw	1, poor initial fixation	Exchange of screw
			4, poor bone stock	Total joint arthroplasty
F, 62, ^a	Femur, subtrochanteric	Hemiarthroplasty	0, technical error	Hemiarthroplasty
F, 53, ^a	Femur, distal	Plate	13, non-union + local tumor progression	Plate
M, 56, ^a	Vertebra, thoracic	Decompression	0, paraplegia (hematoma)	Removal of hematoma
M, 55, ^d	Vertebra, thoracic	Decompression + instrumentation	8, local tumor progression	Decompression
F, 48, ^a	Vertebra, thoracic	Decompression + instrumentation	0, poor initial fixation	Reinstrumentation
M, 72, ^b	Vertebra, thoracic	Decompression	1, deep infection	Debridement

^a adenocarcinoma. ^b squamous cell carcinoma. ^c large cell carcinoma. ^d other.

Table 6. Complications after surgery for skeletal metastasis in lung cancer patients

Sex, age, histology	Localization	Primary operation	Time (months) to and reason for failure	Treatment
F, 75, ^a	Femur, distal	Intramedullary nail	0, fatal gastric bleeding	Non-surgical
M, 48, ^c	Vertebra, thoracic	Decompression + instrumentation	0, wound infection	Non-surgical
F, 48, ^b	Vertebra, thoracic	Decompression + instrumentation	0, gastric bleeding	Non-surgical
M, 62, ^d	Vertebra, thoracic	Decompression + instrumentation	0, technical error	Non-surgical
M, 55, ^d	Vertebra, thoracic	Decompression	1, wound infection	Non-surgical

^a adenocarcinoma. ^b large cell carcinoma. ^c small cell lung cancer. ^d other.