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In Journal of orthopaedic research : official publication of the Orthopaedic Research Society

Metastatic breast, prostate, lung and other cancers often affect bone, causing pain, increasing fracture risk, and decreasing function. Management of metastatic bone disease (MBD) is clinically challenging when there is potential but uncertain risk of pathological fracture. Management of MBD has become a major focus within orthopedic oncology with respect to fracture and impending fracture care. If impending skeletal related events (SREs), particularly pathologic fracture, could be predicted, increasing evidence suggests that prophylactic surgical treatment improves patient outcomes. However, current fracture risk assessment and radiographic metrics do not have high accuracy and have not been combined with relevant patient survival tools. This review first explores the prevalence, incidence, and morbidity of MBD and associated SREs for different cancer types. Strengths and limitations of current fracture risk scoring systems for spinal stability and long bone fracture are highlighted. More recent CT-based structural rigidity analysis (CTRA) and finite element (FE) analysis methods offer advantages of increased specificity (true negative rate), but are limited in availability. Other fracture prediction approaches including parametric response mapping (PRM) and positron emission tomography/computed tomography (PET/CT) measures show early promise. Substantial new information to inform clinical decision-making includes measures of survival, clinical benefits, and economic analysis of prophylactic treatment compared to after-fracture stabilization. Areas of future research include use of Big Data and machine learning to predict SREs, greater access and refinement of CTRA/FE approaches, combination of clinical survival prediction tools with radiographically based fracture risk assessment, and net benefit analysis for fracture risk assessment and prophylactic treatment. This article is protected by copyright. All rights reserved.

Damron Timothy A, Mann Kenneth A


CT, Metastatic bone disease, Mirels, PET, SPECT, bone metastases, bone prophylaxis, carcinoma, clinical decision making, femur, finite element, fracture prediction, fracture risk, impending pathological fracture, machine learning, myeloma, pathologic fracture, prophylactic stabilization, skeletal related events, spine, structural rigidity analysis