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Review Question - QID 213057

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QID 213057 (Type "213057" in App Search)
A 70-year-old man is scheduled to undergo a procedure to address a symptomatic left proximal femur solitary lesion. Plain radiographs are depicted in Figure A and histopathology in Figure B. Which of the following procedures is associated with improved survivorship in this patient?
  • A
  • B

Radiation therapy

6%

137/2432

Chemotherapy

6%

148/2432

Intramedullary stabilization

16%

386/2432

Wide resection and proximal femoral replacement

71%

1729/2432

Open reduction internal fixation with plates and screws

1%

21/2432

  • A
  • B

Select Answer to see Preferred Response

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Wide resection and proximal femur replacement (PFR) is the best treatment option for a metastatic lesion in the proximal femur from renal cell carcinoma (RCC) and has been demonstrated to increase overall survivorship.

Similar to primary sarcoma of bone, wide resection and PFR is the treatment modality recommended for metastatic RCC to avoid implant-related complications, decrease tumor recurrence, and increase overall survival rates. Fixation with a plates, screws, or an intramedullary nail has been shown to have a higher rate of implant-related complications, particularly with local tumor progression or recurrence, leading to a higher rate of revision surgery.

Hwang et al. performed a study to determine the clinico-pathological factors predicting survival in patients who underwent wide resection and endoprosthetic replacement for RCC. They reported an increased risk of death in patients with multiple skeletal metastases, one or more visceral metastases, and local recurrence. They concluded that given the low risk of revision surgery after endoprosthetic replacement, patients with multiple skeletal and visceral metastases should be considered for wide resection and endoprosthetic replacement, much like patients with solitary bone lesions and no visceral metastases.

Laitinen et al. performed a study to identify prognostic factors for reconstruction survival of skeletal metastases in RCC and the nature of the reconstruction-related complications. They reported that primary endoprosthetic replacement for RCC had the best survivorship. Decreased survival after endoprosthetic replacement was associated with previous surgical intervention, preoperative radiotherapy, and intralesional resection margins.

Szendroi et al. performed a study to identify prognostic factors and survivorship of patients with RCC. They reported that survival was significantly improved if the lesions were solitary, had a low Fuhrman grade, were late in onset, with radical surgery performed at the time of surgery. They reported 75% survival at 1 year and 35.5% at 5 years after wide resection and endoprosthetic replacement for solitary lesions, however, 0% survivorship at 5 years if lesions were multiple or if a radical resection was not performed at the time of endoprosthetic replacement. They recommended radical resection and endoprosthetic replacement in late-onset solitary metastatic lesions with a low Fuhrman grade.

Figure A demonstrates an expansive lytic lesion in the left proximal femur. Figure B demonstrates a histological section of RCC, with the characteristic clear cell and pseudoalveolar pattern.

Incorrect Answers:
Answer 1: Radiation therapy has not been shown to increase survival rates for a metastatic RCC lesion to the proximal femur.
Answer 2: Chemotherapy has not been shown to increase survival rates for a metastatic RCC lesion to the proximal femur.
Answer 3: Fixation with an intramedullary nail has been shown to have a higher rate of implant-related complications and a higher rate of revision surgery.
Answer 5: Open reduction with plates and screws has been shown to have a higher rate of implant-related complications and a higher rate of revision surgery.

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