Surgery for skeletal metastases in lung cancer

Background and purpose

Most lung cancer patients with skeletal metastases have a short survival and it is difficult to identify those patients who will benefit from palliative surgery. We report complication and survival rates in a consecutive series of lung cancer patients who were operated for symptomatic skeletal metastases.

Methods

This study was based on data recorded in the Karolinska Skeletal Metastasis Register. The study period was 1987–2006. We identified 98 lung cancer patients (52 females). The median age at surgery was 62 (34–88) years. 78 lesions were located in the femur or spine.

Results

The median survival time after surgery was 3 (0–127) months. The cumulative 12-month survival after surgery was 13% (95% CI: 6–20). There was a difference between the survival after spinal surgery (2 months) and after extremity surgery (4 months) (p = 0.03). Complete pathological fracture in non-spinal metastases (50 patients) was an independent negative predictor of survival (hazard ratio (HR) = 1.8, 95% CI: 1–3). 16 of 31 patients with spinal metastases experienced a considerable improvement in their neurological function after surgery. The overall complication rate was 20%, including a reoperation rate of 15%.

Interpretation

Bone metastases and their subsequent surgical treatment in lung cancer patients are associated with high morbidity and mortality. Our findings will help to set appropriate expectations for these patients, their families, and surgeons.Lung cancer has become one of the most common cancers worldwide and is the predominant cause of death among cancer patients. The American Cancer Society estimated that almost 160,000 patients would die from lung and bronchus cancer in the USA in 2009 (Jemal et al. 2009). Some authors have stated that lung cancer is one of the most important challenges in oncology at the present time (Boyle and Dresler 2005).Historically, about one third of all lung cancer patients are found to have bone metastases during the course of the disease. Symptoms and events of skeletal origin such as pain, pathological fractures, spinal cord compression with paraparesis, and hypercalcemia are common complications. The decline in quality of life and eventual death of these patients can be explained to some extent by skeletal complications and their treatment (Coleman 1997).Lung cancer patients with skeletal events have a short expected survival; however, some case reports have involved patients who survived several years after pathological fractures (Agarwala and Hanna 2005, Hirano et al. 2005). A major problem in selecting patients for surgery is to avoid operating on those who are likely to die very soon after surgery. Although several features help to identify patients with long survival (Bauer and Wedin 1995, Tomita et al. 2001), it is still difficult to identify those who will die early.We analyzed a consecutive series of lung cancer patients who were operated on for skeletal metastases at our department, to determine the complications and reoperation rates after surgery and to identify risk factors for early death.