Should Postoperative Radiation for Long Bone Metastases Cover Part or All of the Orthopedic Hardware? Results of a Large Retrospective Analysis

Rosen, Daniel B.; Haseltine, Justin M.; Bartelstein, Meredith K.; Flynn, Jessica; Zhang, Zhigang; Yamada, Yoshiya; Schmitt, Adam; Higginson, Daniel S.; Vaynrub, Maksim; Yang, Jonathan T.; Gillespie, Erin F.

doi:10.1016/j.adro.2021.100756

Cited by 7 publications

(11 citation statements)

References 11 publications

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“… 23 , 24 Surgical fixation of the femur involves intraoperative reaming before placement of an intramedullary rod, which disseminates tumor both proximally and distally throughout the femur, and thus may require larger postoperative radiation treatment fields to encompass areas at microscopic risk of disease. 25 , 26 In addition to the increased challenge of target volume delineation postoperatively, the larger field of treatment also precludes the ability to deliver an ablative dose as it is not possible to treat the entire region at risk with 5 fraction SBRT without increased risk of osteonecrosis based on existing constraints. 20 As such, all patients treated at our institution with femur SBRT (defined as 5 fractions or fewer) were treated with radiation as an alternative to surgery after multidisciplinary discussion.…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes Among Patients Treated With Stereotactic Body Radiation Therapy to Femur Metastases for Oligometastatic Disease Control or Reirradiation: Results From a Large Single-Institution Experience

Kwan,

Chen,

Killoran

et al. 2024

Advances in Radiation Oncology

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Section: Discussionmentioning

confidence: 99%

Clinical Outcomes Among Patients Treated With Stereotactic Body Radiation Therapy to Femur Metastases for Oligometastatic Disease Control or Reirradiation: Results From a Large Single-Institution Experience

Kwan,

Chen,

Killoran

et al. 2024

Advances in Radiation Oncology

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“…Rosen et al, 2021 [29] • Coverage of the entire radiation hardware was associated with reduced local recurrence.…”

Section: Study Key Findingsmentioning

confidence: 99%

“…As seen in Table 2 , there are six retrospective studies on PORT for NSBMs [ 24 , 25 , 26 , 27 , 28 , 29 ]. To our knowledge, there are no prospective studies completed to date.…”

Section: Evidence For Post-operative Radiotherapy In Non-spine Bone M...mentioning

confidence: 99%

The Role of Post-Operative Radiotherapy for Non-Spine Bone Metastases (NSBMs)

Ramadan

Arifin

Nguyen

2023

Cancers

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Non-spine bone metastases (NSBMs) can cause significant morbidity and deterioration in the quality of life of cancer patients. This paper reviews the role of post-operative radiotherapy (PORT) in the management of NSBMs and provides suggestions for clinical practice based on the best available evidence. We identified six retrospective studies and several reviews that examined PORT for NSBMs. These studies suggest that PORT reduces local recurrence rates and provides effective pain relief. Based on the literature, PORT was typically delivered as 20 Gy in 5 fractions or 30 Gy in 10 fractions within 5 weeks of surgery. Complete coverage of the surgical hardware is an important consideration when designing an appropriate radiation plan and leads to improved local control. Furthermore, the integration of PORT in a multidisciplinary team with input from radiation oncologists and orthopedic surgeons is beneficial. A multimodal approach including PORT should be considered for an NSBM that requires surgery. However, phase III studies are needed to answer many remaining questions and optimize the management of NSBMs.

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“…A more modern institutional series of patients treated with surgery followed by PORT with or without bone-strengthening agents have seemed to confirm these findings [11][12][13]. Thus, after surgical fixation, most guidelines recommend consideration of PORT to the involved bone in order to eradicate microscopic disease and reduce the risk of local recurrence and/or hardware failure [14][15][16][17]. However, some patients are not referred for RT consultation, usually at the discretion of the surgeon for various reasons, including the perception of limited risk of local failure, poor prognosis, distance from radiation facility/lack of transportation, or patient preference.…”

Section: Introductionmentioning

confidence: 99%

Skeletal-Related Events After Surgery With or Without Radiotherapy for Bone Metastases to Weight-Bearing Bones

Lanier¹,

Johnson²,

Razavian³

et al. 2022

Cureus

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In patients with metastatic disease involving weight-bearing bones, postoperative radiotherapy (PORT) is commonly administered following surgical stabilization of an impending or confirmed pathologic fracture to reduce the risk of a seeded local recurrence. The goal was to re-evaluate the beneficial effect of PORT in a modern cohort of patients and determine any potential clinical predictors of skeletal-related events (SREs) which were defined as a pathologic fracture or the necessity for radiation or surgery to the affected bone. MethodsConsecutive patients undergoing surgical stabilization of metastatic disease to weight-bearing bones of the extremities between 2012 and 2019 were reviewed. Patient, disease, and treatment factors were abstracted. The cumulative incidence of SREs was determined using competing risks methodology; overall survival (OS) was estimated using the Kaplan-Meier method. ResultsA total of 82 patients were identified, 74% of whom had undergone intramedullary nail fixation and 26% internal fixation or replacement. The femur was the most commonly involved bone (94%). A majority (78%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 1-2. Bone-strengthening agents were given to 38% and PORT to 54%. The median PORT dose was 30 Gy in 10 fractions and the median percent coverage of surgical hardware was 100% (range, 25-100). SREs occurred in 10 of 82 patients. There were no differences between no RT and RT groups for the two-year cumulative incidence of SREs (8.2% vs 11.5%, p=0.59) or two-year cumulative incidence of local failure (10.8% vs 4.6%, p=0.53). The only identified predictors of SREs were the use of bone-strengthening agents (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.05-1.06, p=0.06) and malnutrition (HR 3.69, p=0.07). For patients treated with PORT, a biologically effective dose or percent coverage of surgical hardware was not associated with SREs. ConclusionIn this series, the addition of PORT following surgery for metastatic disease involving weight-bearing bones does not significantly affect the rate of SREs. The use of bone-strengthening agents appears protective, and malnourished patients appear particularly at high risk for future SRE.

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Should Postoperative Radiation for Long Bone Metastases Cover Part or All of the Orthopedic Hardware? Results of a Large Retrospective Analysis

Abstract: Should post-operative radiation for long bone metastases cover part or all of the orthopaedic hardware? Results of a large retrospective analysis,

Cited by 7 publications

References 11 publications

Clinical Outcomes Among Patients Treated With Stereotactic Body Radiation Therapy to Femur Metastases for Oligometastatic Disease Control or Reirradiation: Results From a Large Single-Institution Experience

Clinical Outcomes Among Patients Treated With Stereotactic Body Radiation Therapy to Femur Metastases for Oligometastatic Disease Control or Reirradiation: Results From a Large Single-Institution Experience

The Role of Post-Operative Radiotherapy for Non-Spine Bone Metastases (NSBMs)

Skeletal-Related Events After Surgery With or Without Radiotherapy for Bone Metastases to Weight-Bearing Bones

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