Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?

Hoban, Katie A.; Downie, Samantha; Adamson, Douglas; MacLean, James G.; Cool, Paul; Jariwala, Arpit

doi:10.1016/j.jseint.2022.03.006

Cited by 9 publications

(7 citation statements)

References 21 publications

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“…There is also interobserver variability in the Mirels grading system. Previous studies have demonstrated only moderate interobserver variability (kappa = 0.580, 95% CI = 0.395 to 0.765) for grading upper-extremity lesions 3,8 , which may have affected our overall Mirels scores. Thus, our recommendation to use a Mirels score of ‡8 for metastatic humeral lesions should be viewed with caution.…”

Section: Discussionmentioning

confidence: 84%

“…In contrast, the traditional Mirels definition of impending pathological fracture (≥9 points) that was developed on the basis of lower-extremity lesions had lower sensitivity and specificity. Hoban et al 8 also suggested using a lower Mirels cutoff for the upper extremity, but recommended a score of ≥7. We suspect that the difference in recommended cutoffs is due to the populations studied.…”

Section: Discussionmentioning

confidence: 99%

“…Long bones in the upper extremity, such as the humerus, have different load-bearing requirements, undergo torsional and bending forces rather than compression forces, and have cortical densities that may confer differences in fracture risk compared with bones in the lower limb 7 . To our knowledge, only 2 studies have investigated the validity of the Mirels scoring system in the upper extremity 3 , 8 . Both studies showed that a Mirels score of ≥9 had a low predictive value, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.55 (95% confidence interval [CI], 0.51 to 0.59, p = 0.057), sensitivity of 14%, and specificity of 73% 3 , 8 .…”

mentioning

confidence: 99%

“…To our knowledge, only 2 studies have investigated the validity of the Mirels scoring system in the upper extremity 3 , 8 . Both studies showed that a Mirels score of ≥9 had a low predictive value, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.55 (95% confidence interval [CI], 0.51 to 0.59, p = 0.057), sensitivity of 14%, and specificity of 73% 3 , 8 . However, those studies were underpowered as a result of their small sample sizes.…”

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confidence: 99%

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Predicting Pathological Fractures at Metastatic Humeral Lesions

et al. 2023

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Background:The humerus is the second most common site of metastatic disease involving long bones, yet it is still unclear which patients are at high risk for a fracture and may require prophylactic surgical fixation. The goal of this study was to assess the validity of the Mirels score to predict fractures of metastatic lesions in the humerus.Methods:We performed a retrospective electronic chart review of patients with humeral metastases at our institution (2005 to 2021), with 188 patients meeting the inclusion criteria. Sixty-one of the patients developed a fracture during follow-up. The metastatic humeral lesions were scored according to the Mirels rating system and additional radiographic criteria (cortical breach, location within the humerus, number of lesions). The predictive value of each Mirels score cutoff for fracture was assessed using sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and multivariate logistic regression. Survivorship until fracture was analyzed for each Mirels score cutoff using Kaplan-Meier curves and the log-rank test. Significance was set at p < 0.01.Results:There were no significant differences in age, sex, side of the lesion, type of malignancy, and radiation dose between the groups with and without fracture (all p > 0.01). A Mirels score of ≥8 points had the best predictive profile, with sensitivity of 83.6%, specificity of 79.5%, and AUC of 0.82 (95% confidence interval [CI], 0.75 to 0.88, p < 0.01). A logistic regression model also demonstrated that a Mirels score of ≥8 (odds ratio = 5.8, 95% CI = 1.9 to 18.2, p < 0.01) and a cortical breach (odds ratio = 21.0, 95% CI = 5.7 to 77.2, p < 0.01) were significant predictors of pathological fracture. No other radiographic characteristics were found to be significant predictors of fracture.Conclusions:This study indicated that a Mirels score of ≥8 points had the best predictive profile for anticipating fractures at a metastasis in the humerus. This is in contrast to the traditional Mirels definition of an impending pathological fracture that is used for the lower extremity, a score of ≥9. Additionally, the presence of a cortical breach was a significant predictor of fracture risk.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Predicting Pathological Fractures at Metastatic Humeral Lesions

et al. 2023

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“…It happened because more than half of the samples (72.7%) in the upper extremities had lesions that are more than 2/3 of the cortex, while only 42.1% of the samples in the lower extremities and only 33.3% of the samples in the trochanteric area were larger than 2/3 of the cortex. Hoban et al ( 2022) stated that the lesion size had a significant relationship with the incidence of pathological fractures (p <0.001) (23) . For the type of lesion variable, it was found that there was a correlation between the lytic type lesions in upper extremities with the incidence of pathological fractures (p = 0.003).…”

Section: Discussionmentioning

confidence: 99%

Correlation Analysis of The Risk Factors for Pathological Fracture Using Mirels’ Classification in Long Bone Metastatic Disease

Safira¹,

Setiawati²,

Edward³

et al. 2022

IJRP

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Background: Pathological fracture is one of the consequences from MBD, which can worsen the prognosis and can deplete the quality of patients' lives. Looking at those effects, predicting the pathological fracture in MBD patients needs to be done. Objective: Determine the correlation of risk factors for pathological fractures in long bone metastatic disease and determine the accuracy of the Mirels' scoring system. Method: This was a retrospective research based on the medical record data and x-ray photos of patients with long bone metastases at Dr. Soetomo General Academic Hospital in 2019-2021. We determined the correlation of risk factors by using the likelihood-ratio test. Result: Of the total of 39 long bone metastases cases, there were 28 cases (71.79%) followed by pathological fracture, and 11 of them (28.21%) were not. From the calculation of Mirels' score, 36 cases had scores of ≥ 9 (impending), and 3 of them had scores of 8 (borderline). Most metastases were located in the lower extremities (48.7%), sized >2/3 cortex (48.7%), lytic type (79.5%), and with functional pain (82.1%). %). Conclusion: There was a correlation between the location of upper extremity lesions sized > 2/3 cortex, lytic type, and functional pain with the incidence of fracture (p < 0,05) and the percentage of Mirel's scoring system accuracy in predicting the incidence of pathological fractures was 66.67%.

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