0022-534 7/92/1483-0784$03.00/0 Vol. 148, 784-787, September 1992
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
TREATMENT OF OSSEOUS METASTASES SECONDARY TO RENAL CELL CARCINOMA ERIC M. SMITH, ELROY D. KURSH, JOHN MAKLEY
AND
MARTIN I. RESNICK*
From the Division of Urology and Department of Orthopedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
ABSTRACT
Osseous metastases occur in 25 to 50% of the patients with metastatic renal cell carcinoma. We retrospectively reviewed our experience with 14 patients who underwent 20 palliative orthopedic procedures for treatment of bony metastases secondary to renal cell carcinoma. Of the patients 6 presented after nephrectomy (group 1) and 8 presented initially with osseous metastases (group 2). Only 1 of the group 2 patients underwent adjunctive nephrectomy. Overall, 5 of 14 patients (36%) presented with fracture and 9 of 14 (64%) presented with impending fracture. Five patients required multiple procedures. A total of 7 lesions had been previously treated with external radiation. Of the 20 orthopedic procedures 17 (85%) resulted in significant functional improvement and 18 (90%) resulted in significant relief of pain. There were 4 major complications in the series, including 2 culminating in amputation. Average survival after palliative orthopedic procedures was 22 months (range 7 to 64 months) with a 1-year survival rate of 58%. Orthopedic palliation of osseous metastases from renal cell carcinoma is effective, and our experience indicates that the majority of renal cancer patients with bone metastases will survive long enough to benefit from palliative orthopedic procedures. KEY WORDS:
carcinoma, renal cell; kidney neoplasms; neoplasm metastasis; bone neoplasms
limb was recovered, moderate if there was partial use or a prosthetic device was required for function (for example use of a walker), or poor if no function was recovered. Pain relief was rated good if no analgesics were required after the initial postoperative period, moderate if occasional use of analgesics was required or poor if pain was unrelieved or worsened by the procedure.
More than 17,000 new patients with renal cell carcinoma will be diagnosed in the United States this year. Of these patients up to 90% will eventually have metastases and 25 to 50% of this group will have osseous metastases. 1• 2 Therefore, the paramount concern of the clinician who cares for these unfortunate patients should be palliation but the management of painful and disabling bone metastases is often difficult. We retrospectively reviewed our experience with 14 renal carcinoma patients with osseous metastases who underwent 20 palliative orthopedic procedures to evaluate the effectiveness of this approach.
RESULTS
MATERIALS AND METHODS
The charts of 14 patients who presented to our institution from 1981 to 1989 with bone metastases from renal cell carcinoma requiring orthopedic procedures were reviewed. Eight patients who had osseous metastases but who did not undergo orthopedic procedures other than biopsy were excluded. Presentation of the metastatic lesion was classified as pain with impending fracture or fracture. Radiographic criteria for impending fracture were a painful lytic destructive lesion involving greater than 2.5 cm of the cortex, a lytic lesion greater than 50% of the cross-sectional diameter of the bone and pain unrelieved by radiation therapy. Metastatic evaluation at presentation included a chest x-ray, liver function tests, alkaline phosphatase, bone scan and head computerized tomography. In 1 patient alkaline phosphatase was not obtained. Diagnosis of metastatic renal carcinoma was confirmed pathologically for each lesion at the time of orthopedic repair via excisional biopsy in 12 patients. Two patients underwent diagnostic needle aspiration before repair. The patients were divided into 2 groups: group 1 included 6 patients who presented with osseous metastases after nephrectomy and group 2 consisted of 8 patients who initially presented with bone metastases. The effectiveness of palliative orthopedic procedures was graded according to the level of function and pain relief after the initial postoperative period. Function was considered good if full use of the affected Accepted for publication January 31, 1992. *Requests for reprints: Division of Urology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, Ohio 44106.
Mean patient age was 61 years (range 41 to 79). There were 8 men and 6 women. Robson stage at presentation of the renal cell cancer was I (tumor confined to capsule) in 1 patient, II (tumor confined to Gerota's fascia) in 1 and IV (distant metastases) in 12. Overall, 5 of 14 patients (36%) presented with a fracture and 9 (64%) presented with impending fracture. The average age of the patients presenting with a pathological fracture was no different from that of all patients. Only 5 of 13 patients (39%) had an elevated alkaline phosphatase at presentation (3 of 5 in group 1 and 2 of 8 in group 2). Of 14 patients 10 had multiple osseous and visceral metastases when the osseous metastases were discovered. A total of 6 patients (43 % ) suffered pulmonary metastases during the course of the disease, and 3 (21 %) presented with pulmonary and osseous metastases. The 6 group 1 patients (43%) who presented after nephrectomy were an average age of 61 years, and presented at an average of 30 months (range 3 to 72 months) after nephrectomy. Only 1 of these patients presented with a pathological fracture. Of the 8 group 2 patients (57%) who presented initially with osseous metastases 1 underwent nephrectomy and 1 underwent tumor embolization. No renal surgery was required for palliation in the remaining 6 patients. The average age of this group was also 61 years. Four of these patients (51 %) presented with a pathological fracture. The location of the osseous metastases requiring surgery is noted in table 1. The femur was the most common bone affected, followed by the humerus. These 2 sites accounted for 16 of the 20 metastases (80%) requiring surgical intervention. The orthopedic procedures performed and their outcomes are also summarized in table 1. A total of 20 procedures was performed on 14 patients: 9 (62%) underwent a single proce-
784
RENAL
TREA~Cl½E!"
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
TREATMENT OF OSSEOUS METASTASES SECONDARY TO RENAL CELL CARCINOMA ERIC M. SMITH, ELROY D. KURSH, JOHN MAKLEY
AND
MARTIN I. RESNICK*
From the Division of Urology and Department of Orthopedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
ABSTRACT
Osseous metastases occur in 25 to 50% of the patients with metastatic renal cell carcinoma. We retrospectively reviewed our experience with 14 patients who underwent 20 palliative orthopedic procedures for treatment of bony metastases secondary to renal cell carcinoma. Of the patients 6 presented after nephrectomy (group 1) and 8 presented initially with osseous metastases (group 2). Only 1 of the group 2 patients underwent adjunctive nephrectomy. Overall, 5 of 14 patients (36%) presented with fracture and 9 of 14 (64%) presented with impending fracture. Five patients required multiple procedures. A total of 7 lesions had been previously treated with external radiation. Of the 20 orthopedic procedures 17 (85%) resulted in significant functional improvement and 18 (90%) resulted in significant relief of pain. There were 4 major complications in the series, including 2 culminating in amputation. Average survival after palliative orthopedic procedures was 22 months (range 7 to 64 months) with a 1-year survival rate of 58%. Orthopedic palliation of osseous metastases from renal cell carcinoma is effective, and our experience indicates that the majority of renal cancer patients with bone metastases will survive long enough to benefit from palliative orthopedic procedures. KEY WORDS:
carcinoma, renal cell; kidney neoplasms; neoplasm metastasis; bone neoplasms
limb was recovered, moderate if there was partial use or a prosthetic device was required for function (for example use of a walker), or poor if no function was recovered. Pain relief was rated good if no analgesics were required after the initial postoperative period, moderate if occasional use of analgesics was required or poor if pain was unrelieved or worsened by the procedure.
More than 17,000 new patients with renal cell carcinoma will be diagnosed in the United States this year. Of these patients up to 90% will eventually have metastases and 25 to 50% of this group will have osseous metastases. 1• 2 Therefore, the paramount concern of the clinician who cares for these unfortunate patients should be palliation but the management of painful and disabling bone metastases is often difficult. We retrospectively reviewed our experience with 14 renal carcinoma patients with osseous metastases who underwent 20 palliative orthopedic procedures to evaluate the effectiveness of this approach.
RESULTS
MATERIALS AND METHODS
The charts of 14 patients who presented to our institution from 1981 to 1989 with bone metastases from renal cell carcinoma requiring orthopedic procedures were reviewed. Eight patients who had osseous metastases but who did not undergo orthopedic procedures other than biopsy were excluded. Presentation of the metastatic lesion was classified as pain with impending fracture or fracture. Radiographic criteria for impending fracture were a painful lytic destructive lesion involving greater than 2.5 cm of the cortex, a lytic lesion greater than 50% of the cross-sectional diameter of the bone and pain unrelieved by radiation therapy. Metastatic evaluation at presentation included a chest x-ray, liver function tests, alkaline phosphatase, bone scan and head computerized tomography. In 1 patient alkaline phosphatase was not obtained. Diagnosis of metastatic renal carcinoma was confirmed pathologically for each lesion at the time of orthopedic repair via excisional biopsy in 12 patients. Two patients underwent diagnostic needle aspiration before repair. The patients were divided into 2 groups: group 1 included 6 patients who presented with osseous metastases after nephrectomy and group 2 consisted of 8 patients who initially presented with bone metastases. The effectiveness of palliative orthopedic procedures was graded according to the level of function and pain relief after the initial postoperative period. Function was considered good if full use of the affected Accepted for publication January 31, 1992. *Requests for reprints: Division of Urology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, Ohio 44106.
Mean patient age was 61 years (range 41 to 79). There were 8 men and 6 women. Robson stage at presentation of the renal cell cancer was I (tumor confined to capsule) in 1 patient, II (tumor confined to Gerota's fascia) in 1 and IV (distant metastases) in 12. Overall, 5 of 14 patients (36%) presented with a fracture and 9 (64%) presented with impending fracture. The average age of the patients presenting with a pathological fracture was no different from that of all patients. Only 5 of 13 patients (39%) had an elevated alkaline phosphatase at presentation (3 of 5 in group 1 and 2 of 8 in group 2). Of 14 patients 10 had multiple osseous and visceral metastases when the osseous metastases were discovered. A total of 6 patients (43 % ) suffered pulmonary metastases during the course of the disease, and 3 (21 %) presented with pulmonary and osseous metastases. The 6 group 1 patients (43%) who presented after nephrectomy were an average age of 61 years, and presented at an average of 30 months (range 3 to 72 months) after nephrectomy. Only 1 of these patients presented with a pathological fracture. Of the 8 group 2 patients (57%) who presented initially with osseous metastases 1 underwent nephrectomy and 1 underwent tumor embolization. No renal surgery was required for palliation in the remaining 6 patients. The average age of this group was also 61 years. Four of these patients (51 %) presented with a pathological fracture. The location of the osseous metastases requiring surgery is noted in table 1. The femur was the most common bone affected, followed by the humerus. These 2 sites accounted for 16 of the 20 metastases (80%) requiring surgical intervention. The orthopedic procedures performed and their outcomes are also summarized in table 1. A total of 20 procedures was performed on 14 patients: 9 (62%) underwent a single proce-
784
RENAL
TREA~Cl½E!"
