Posted: Mar 29 2020 #(C101412) RESIDENTES HOSPITAL SÃO RAFAEL

Impending Pathologic Fracture Proximal Femur in 51F

HPI

This is a 51 y/o female with metastatic bone disease due to breast cancer. She first began having right hip pain three months ago. At that time, she received 30 Gy in 5 fractions to the right proximal femur. Unfortunately, her pain returned, and she now has pain with ambulation. She is unable to sleep due to the pain, and is using crutches and a wheelchair. She is completing her last cycle of conventional chemotherapy, and is scheduled to begin a clinical trial next month involving experimental targeted therapy. She has been receiving denosumab infusions monthly since being diagnosed with metastatic bone disease, four months ago. STAGING T2N1M1 Breast Cancer ER/PR(+), HER2(-) 3 of 5 axillary lymph nodes were positive for metastatic disease 2cm metastatic lesion in the liver, treated with ablation, three months ago 1cm pulmonary nodules, stable for approximately three months. Biopsy-proven metastatic lesions to the spine (T9, L1, L4), and right proximal femur. PROGNOSIS PATHFx Survival Estimate (see blue plot on right): 6 months: 60% 12 months: 50% 18 months: 30% During the interview, she became quite tearful. Her goal is to go to the park and play with her two young children and feels she cannot do so currently.

PMH

She is a lawyer, who now works part time to focus on her cancer treatment. Her husband, who is present with her today, works full time, and is very supportive. Seasonal allergies

She has an antalgic gait, and is unable to bear weight on the right lower extremity without pain. Her right hip ROM is subnormal (F90°, ER45°, IR0°) compared to the contralateral hip (F110°, ER55°, IR10°) She has a positive resisted straight leg raise against gravity, and pain at the extremes of internal and external rotation.

Poll

1 of 13

1. What would be your PRIMARY method to determine the risk of developing a pathologic fracture?

I would not determine risk of pathologic fracture - it does not change my management

93/1225

Mirels' score

50%

615/1225

Harington's criteria

35/1225

Presence of functional pain (pain with weight-bearing) alone

63/1225

Degree of cortical involvement and/or presence of a stress reaction on imaging

81/1225

Combination of imaging findings and functional pain

20%

251/1225

Outside my area of expertise - best if I don't vote

87/1225

2. What would be your PRIMARY method to determine the patient's survival prognosis?

I would not determine prognosis - it does not change my management

112/1130

Consult medical oncology

46%

528/1130

MSTS (Enneking) Staging System

10%

113/1130

AJCC Staging System

44/1130

Bauer Score / Karolinska Method

18/1130

Tomita classification

26/1130

PATHFx

112/1130

van der Linden Score

5/1130

Outside my area of expertise - best if I don't vote

15%

172/1130

3. Given her diagnosed metastatic breast cancer, would you need a biopsy to finalize your treatment plan?

No - Type of tumor does not change my management

56%

640/1138

Yes - Preoperatively

11%

136/1138

Yes - Intraoperative frozen

28%

319/1138

Outside my area of expertise - best if I don't vote

43/1138

4. How would you manage this patient?

Manage myself - Nonoperative

12/1101

Manage myself - Operative

59%

660/1101

Refer it out

40/1101

Refer it to orthopaedic oncologist at my institution

32%

362/1101

Outside my area of expertise - best if I don't vote

27/1101

5. If you choose Operative management, what technique would you use?

I would not choose Operative management

7/1115

Open Reduction and Internal Fixation (ORIF)

42/1115

Cephalomedullary Nail (CMN) fixation

77%

867/1115

Arthroplasty

14%

163/1115

Outside my area of expertise - best if I don't vote

36/1115

6. If you choose Cephalomedullary nail (CMN) fixation, what nail length would you use?

I would not choose CMN fixation

39/1088

Short nail

30/1088

Intermediate nail

72/1088

Long nail

84%

915/1088

Outside my area of expertise - best if I don't vote

32/1088

7. If you choose Cephalomedullary nail (CMN) fixation, would you add curettage and cementation of the lesion?

I would not choose CMN fixation

37/1080

No - I would not

61%

661/1080

Yes - I would

31%

339/1080

Outside my area of expertise - best if I don't vote

43/1080

8. If you choose Arthroplasty, which type would you perform?

I would not choose Arthroplasty

53%

566/1055

Standard length hemiarthroplasty

16/1055

Long-stem hemiarthroplasty

11%

119/1055

Proximal femoral replacement hemiarthroplasty

10%

107/1055

Standard length total hip arthroplasty

11/1055

Long-stem total hip arthroplasty

101/1055

Proximal femoral replacement total hip arthroplasty

98/1055

Outside my area of expertise - best if I don't vote

37/1055

9. If you choose Arthroplasty, would you cement the femoral component?

I would not choose Arthroplasty

50%

516/1012

No - I would not use cement

45/1012

Yes - I would use cement

41%

425/1012

Outside my area of expertise - best if I don't vote

26/1012

10. In general, how long would you wait after PREoperative radiotherapy is administered (assuming 30 Gray was delivered), before you would perform CMN?

I would not choose CMN

25/982

I would not wait - perform immediately

28%

276/982

1 week

47/982

2 week

19%

191/982

3 weeks

97/982

4 weeks

12%

121/982

6 weeks

10%

99/982

Outside my area of expertise - best if I don't vote

12%

126/982

11. In general, how long would you wait after PREoperative radiotherapy is administered (assuming 30 Gray was delivered), before you would perform Arthroplasty?

I would not choose Arthroplasty

47%

433/917

I would not wait - perform immediately

14%

132/917

1 week

13/917

2 weeks

10%

94/917

3 weeks

42/917

4 weeks

61/917

6 weeks

55/917

Outside my area of expertise - best if I don't vote

87/917

12. Assuming you do an CMN, how long would you wait before you administered POSToperative radiation, assuming 30 Gray was to be delivered?

I would not do postoperative radiation

47/937

I would not wait - perform immediately

21%

197/937

1 week

31/937

2 weeks

34%

319/937

3 weeks

11%

105/937

4 weeks

76/937

6 weeks

55/937

Outside my area of expertise - best if I don't vote

11%

107/937

13. The patient returns at 8 months with inability to bear weight. (Post-procedure P1 - 8 months). PATHfx now shows a survival probability of 40% at 3 months. How would you manage this complication?

Refer it out

79/895

Perform Revision to Open Reduction and Internal Fixation (ORIF)

36/895

Perform Revision to Cephallomedullary nail (CMN) fixation

15%

135/895

Perform Revision to Arthroplasty

28%

259/895

Perform Palliative Care

36%

326/895

Outside my area of expertise - best if I don't vote

60/895

2 months

Post-procedure P1

8 months

Post-procedure P1

Post-procedure P2

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