C women in the US2 and comprises 23y0

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1 PROPHYLACTIC INTERNAL FIXATION OF THE FEMUR IN METASTATIC BREAST CANCER RODNEY K. BEALS, MD, GRANT D. LAWTON, MD,+ AND WILLIAM E. SNELL, MD~ Three hundred and thirty-eight patients with breast cancer have been reviewed. About half of the patients with skeletal metastases developed femoral involvement, usually bilateral. Certain impending femcial fractures can be presaged, and in these patients prophylactic internal fixation has reduced the incidence of pathologic fractures in femora so affected by metastatic disease from 32% to 9%. ANCER OF THE BREAST AFFECTS 6% OF ALL C women in the US2 and comprises 23y0 of all newly detected cancer. Although radiographic evidence of bone metastases is reported in 20-60% of affected patients:, 7, lo, 1623 incidence at autopsy has been reported as high as 85%.13 Most bony lesions are lytic. In our combined series, 94 femora were involved with metastatic disease. Pain relief from treatment of these lesions by irradiation or hormone therapy is frequently excellent; however, only four lesions (4%) reossifed. Thus, patients with a good pain response remain in jeopardy of fracture. Approximately half of the patients with bone metastases will develop femoral metastases,and about half of these patients will eventually sustain a fracture.5.23 MATERIAL Our first series,22 reported in 1962, comprised 1 I8 patients hospitalized for metastatic breast cancer during the 5-year period at the University of Oregon Medical School Hospital. Sixty-nine (58%) of these patients, all of whom were treated by our general surgery colleagues, developed skeletal metastases, and 60 femora of 32 patients were involved. Fifteen of these patients sustained 19 pathologic fractures. Since some of these fractures were predictable, prophylactic internal fixation for selected cases was begun in From the Department of Orthopedic Surgery, University of Oregon Medical School, Portland, Oregon. Associate Professor. T Resident. t Professor and Head. Received for publication April 26, The present report, our second series, is a review of the years , during which 220 patients were seen with breast cancer. Since this second group includes outpatients as well as inpatients, only 35 (16%) demonstrated skeletal metastases, and 34 femora of 20 patients were involved (Table 1). Five affected femora in this series were treated by prophylactic internal fixation, and 3 other patients sustained pathologic fractures (Table 2). PREDICTABILITY OF FRACTURES Retrospective evaluation of the 19 fractures in the first series reveaied that over half (58%) were predictable. Fractures were found to occur when a well-defined metastatic lytic lesion of 2.5 cm in diameter involved the femoral cortex or when a lesion of this size was painful, regardless of its bony location (Fig. 1). Occasionally, borderline cases of diffusely involved femora may fracture, but these are not clearly predictable. In the first series, 8 femora did not meet these criteria but nevertheless did fracture. Eleven other femora did fulfill the above criteria and did, in fact, fracture. In the second series, 24 femora with metastases did not fit these criteria and did not fracture. Of the 10 other femora that did fulfill these criteria, 3 did fracture, 5 were pinned prophylactically, and 2 did not fracture. These 2 were in patients non-ambulatory for reasons other than femoral involvement. All 3 femora that did fracture fulfilled the predictive criteria for fracture, but were not secured prior to the event. One patient refused surgery, and the other 2 experienced their frac-

2 KO. 5 FEMUR IN BREAST CANCER - Beah et al TABLE 1. Incidence of Skeletal and Femoral Metastases in Breast Cancer Patients Patients Number of with skeletal with femoral Number of patients metastases metastases affected femora (6 years) (58%) (inpatient breast cancer patients) t (5 years) (16%) (inpatient and outpatient breast cancer patients - TABLE 2. Incidence of Femoral Fracture in Breast Cancer Number of Number of Number of femoral Number of affected patients with prophylactic femoral femora femoral fracture fixation fractures (6 years) (35%) (inpatient breast cancer patients) (5 years) (9%) ([np.itient and outpatient breast,cancer patients) - ~~ ~-. - ture prior to radiographic diagnosis of the lesion (Table 3). PREVENTIVE INTERNAL FIXATION Since 1962, prophylactic internal fixation has been utilized on 8 occasions. Prophylactic n;iiling prevents fracture, decreases morbidity, and lessens the time of hospitalization. This practice has reduced the incidence of fracture in. femora affected by breast cancer in this second series from 32<% to 9% a FIG. 1. Type of metastatic lesion in which fractures are probable. a. cortical involvement; b. with pain. b DISCUSSION Prophylactic internal fixation of the femur involved with metastatic breast cancer was first reported in 1947 by Griessmann and Shuttemeyer who placed Kuntscher nails in two patients.11 Several subsequent reports have also suggested the usefulness of this technique in the management of breast cancer.1, 6, 8,gI 17~22 Prophylactic fixation in other neoplastic disease of bone is also reported to be beneficia1,lv 394, 6.9, 1% 17~20 and preventive internal fixation has been used in non-malignant disease such as fibrous dysplasia and Gaucher's di~ease.1~ Prophylactic internal fixation affords prompt and consistent pain relief. Such fixation provides several advantages over internal fixation after fracture has occurred. The metabolic stress of elective surgery is less than the combined stresses of fracture plus surgery. Morbidity and length of hospitalization are less when preventive fixation is utilized. dncreased activity is well exemplified in Fig. 4. Despite disappearance of the majority of her right femur, she enjoyed a comfortable life

3 1352 CANCER Nouem bey 1971 TABLE 3. Error in Predictability of Fracture I ni pe nd i ng * Subsequent course Other fracture of predicted fractures pred ir ted fractures not predicted Vol. 28 Predicted fractures not occurring (60 femora affected) fractures (34 femora affected) 10 3 fractures 5 prophylactic fixations * Criteria for predicting subsequent fractures are described in text. - and remained mobile in a wheelchair. These benefits are often increased and prolonged when the other forms of treatment lead to tumor regression. Internal fixation does not preclude the use of irradiation either before or after surgery.", Indeed, there may be an advantage in irradiating ii metastatic lesion without fracture. Chondrogenesis, involved in fracture healing, is niore suppressed by irradiation than is osteogenesis, involved in the healing of metastatic lesions.j The decision to utilize prophylactic intcrnal fixation is usu~illy not related to the anticipated survival of the patient. In the first series of patients studied, the average time of survival from the discovery OE femoral metastases was 10 months (Table 4). Although tlccreasetl time of survival follows local recuri'erice and visceral metastases, 110 ciitegoi y of involvement precliitles prophylactic fixation. None of these patients treated by piupliylactic internal fixation has required subsequent hospitalization for complications of their femoral mctast;ises. Theoretical dangers from internal fixation ;ire the spread of tiiiiior sys- FIG. 2 a and b: AS., a 76-year-old woman, with a painful 2.0 x 3.5 cm cortical lesion of midshaft of left fcmur. Treated with Kuntscher nail, resulting in pain relief and prevention of fracture for remaining 7 years.

4 so. 5 FEMUR 1N BREAST CANCER * Beals Ct FIG. 8 a-c: J.O., a 47-year-old wonian with a painful 3.0 x 5.0 cm osteolytic lesion in subtrochanteric region treated with internal fixation and irradiation leading to early resolution of lesion. Five years later, she remains full weight-bearing and asymptomatic. ~eiiiically or within the bone and the conversion of closed tumor to open tumor. These Iiave not been encountered nor have others experienced this problem in metastatic breast tlisease.:i.1i,18.4lthough others have reported mechanical failures of internal fixation devices used in the treatment of neoplastic fractures,li no complications have resulted from any of the several devices used when inserted before fracture had occurred. FIG. 4 a-d. EX., a 59-year-old woman with painful osteolytic lesions greater than 3.1 cm in diameter treated with internal fixation. Four months (c) and one year (d) postoperative demonstrating continued tumor progression and bony destruction. Patient, however, remained painfree, mobile, and out of hospital.

5 ~ ~, 1354 CANCER November 1971 Vol. 28 This series includes only patients with metastatic breast cancer, and many of the above conclusions may not be applicable to patients with metastatic disease from other organ systems. In these other neoplasms, fractures are predicted less accurately, closed tumor has been converted to open tumor, and survival time from the discovery of metastases is often different. TABLE 4. Survival after Discovery of Femoral Metastases Sites affected Femur and other bones Femur and other bones plus local breast recurrence Femur and other bones plus viscera Femur and other bones plus local recurrence and viscera Averaee Average survival 14.6 mo mo. 9.0 mo. 7.0 mo mo. 1. Altman, H.: Metallic fixation for pathologic fracture and impending fracture of long bones. J. Znt. Coll. Surg. 19: , American Cancer Society. Cancer Facts and Fig-' ures, Bennish, E. L.. and Hammond, G.: Treatment of actual and imminent pathological fractures of the femur by intramedullary nailing. Surg. Clin. N. Amer. 35: , Bonarigo, B. C., and Rubin, P.: Nonunion of pathological fracture after radiation therapy. Radiology 88:88!3-893, Bouchard, J.: Skeletal metastases in carcinoma of the breast. Amer. J. Roentgen. 54: , Bremner, R. A., and Jelliffe, A. M.: The management of pathological fracture of the major long bones from metastatic cancer. J. Bone Joint Surg. 40- B: , Coley, B. L., and Higinbotham, N. L.: Diagnosis and treatment of metastatic lesions in bone. Instructional Course Lecture. Arncr. Acad. Orthop. Surg. 7:18-25, REFERENCES 8. Coran, A. G., Banks, H. H., Aliapoulios. M. A., and Wilson, R. E.: The management of pathologic fracture in patients with metastatic carcinoma of the breast. Surg. Gynec. Obstet. 127: , Francis, K. C.: Prophylactic internal fixation of metastatic oseous lesions. Cancer 13:75-76, Garland, L. H., Baker, M., Picard, Jr.. W. H., and Sisson, M. A.: Roentgen and steroid hormone therin mammary cancer metastatic to bone. JAMA 11 : , Griessmann, H., and Shuttemeyer, W.: Weitere Erfahrungen mit der Marknagelung nach Kuntscher an der Chirurgishen Universitatsklinik Kiel, , Chirurg, 17-18, April Haagensen, C. D.: Carcinoma of the breast. American Cancer Society Jaffe, H. L.: Tumoun and Tumorous Conditions of the Bones and Joints. Philadelphia, Lee and Febiger, Johnson, E. W.: Intramedullary fixation of pathological fractures. JAMA , Lehmann, 0.: Problems of pathological fractures. Bull. Hosfi. Joint Dis. 12:90-102, McLaughlin, H.: Intramedullary fixation of pathological fractures. CIin. Orthop. 2: , Parrish, F. F., and Murray, J. A.: Surgical treatment for secondary neoplastic fractures. J. Bone Joint SUT~. 52-A: , Peltier, L. F.: Theoretical hazards in the treatment of pathologic fractures by the Kuntschner intramedullary nail. Surgery a , Peltier, L. F., and Nice, C. M.: Irradiation of bone lesions in the presence of metallic intramedullary fixation. Radiology 56: , Phelan, J. T.: Treatment of pathologic fractures of the long bones from metastatic and primary cancer. Cancer 21: , Roth, 0. R.: Supervoltage radiotherapy and in- tramedullary fixation in the management of athological fractures of long bones. Maryland Mcd. J.~Sl&Sll Snell. W. E., and Beals, R. K.: Femoral metastases and fractures from breast cancer. Surg, Gynec. Obstet , Zimskind. P. D.. and Surver. T. M.: Metastasis to bone from carcinoma of the briast. Clin. Orthop. 11 : , 1958.