Prevention of Pathologic Fractures After Soft Tissue Sarcomas by the Spread of Awareness

R. Lor Randall, MD, FACS

Pathologic fractures are a collective complication experienced by many patients after the development of soft tissue sarcoma. However, awareness needs to be spread among medical oncologists through the guidance of orthopaedic oncologists to help prevent the occurrence of pathologic fractures, according to R. Lor Randall, MD, FACS.

“Unfortunately, there is not a lot of research other than retrospective analyses to describe the incidence of the fracture rates among these patients. We want to get out that this is something we do not need additional research for, but we need to raise awareness and make sure these patients are seen by an orthopaedic oncologist or that they are considered for a prophylactic stabilization,” said Randall.

In an interview with OncLive, Randall, oncologist, professor and chair, department of orthopaedic surgery, and endowed chair of orthopaedic surgery at UC Davis Health, discussed the occurrence, treatment, and prevention methods of pathologic fractures in patients with soft tissue sarcomas.

OncLive: Could you give some background to pathologic fractures in patients with soft-tissue sarcomas?

Randall: Soft tissue sarcomas represent at least 10,000 to 15,000 cases a year. The majority of those are in the extremity and are large and deep-seated. The main treatment for this is surgery and radiation plus or minus chemotherapy. When we do conduct the resection of these tumors they are often [removed from] the femur. Many of these sarcomas are butting against the femur and sometimes envelop the femur.

After radiation the surgeon will conduct a dissection and remove the tumor off of the femur in an attempt to get it in a negative margin. In doing so you revascularize the femur and the bone has been radiated. Sometimes the femur has also seen cytotoxic chemotherapy so the bone can never be remodeled and is at risk for pathologic fracture.

Pathologic fracture is very subtle, and it is important to bring it up to medical oncologists. Medical oncologists are following their patients and if their patients are complaining of thigh aching, they often start looking at the patient's back. What is actually happening is that the femur is stressing to the point of breaking. Radiographs usually look normal and an MRI might show a single abnormality in the femur, but the oncologist remains unaware and they may make a referral to a spine surgeon or an orthopaedic surgeon who does not know these facts.

After a pathologic fracture, the bone never heals. You could insert a rod and try to realign the femur but now you are looking at a [risk of] nonunion or infections. This is a huge life changer and the incidence of it is for patients who have a large, deep-seated, soft-tissue sarcoma who have undergone radiation and surgery plus or minus chemotherapy. The incidence of these fractures is anywhere from 15% to 50% by 10 years.

The message we want to get to a medical oncologist is if they are doing any surveillance on soft-tissue sarcomas and the patients are having any sort of vague thigh pain they need to think about an impending fracture and get that patient to an orthopaedic oncologist immediately. If the orthopaedist is involved in the care from the beginning, which is not always the case, the surgeon will sometimes do a prophylactic stabilization or a preventative stabilization to share the load of the femur and prevent it from breaking.

Could you speak to the data released by the Journal of Clinical Oncology that shows pathological fractures are linked to inferior overall survival (OS) in adults with osteosarcoma?

That would intuitively support the idea that with a pathologic fracture you will probably end up compromising the margin on the tumor and make local control more precarious. Therefore, what you are really seeing is the effect of local contamination from the pathologic fracture and not the pathologic fracture itself.

Are there certain types of patients that might be more prone to pathologic fractures?

For any large spindle cell sarcoma, across all histologic subtypes involving the pericardium of the femur, oncologists should [converse with] an orthopaedic oncologist for the consideration of stabilization upfront or in a delayed manner. Some orthopaedic oncologists, if a patient has a stage III soft-tissue sarcoma, will conduct the prophylactic stabilization contemporaneously with the resection. That is what I often did in my early practice.

Now, if I think the patient is reliable, I do not commit them to prophylactic stabilization at the time of their resection. I will usually do it in a delayed manner, if and when they develop symptoms but that is up to the individual oncologist.

Why do you think there has been a lack of awareness from the medical oncologist perspective?

We have known about this for 20 years, if not longer, and we are still seeing [a lack of awareness]. They are thinking about important issues like OS, disease-free survival, and how patients are doing from an oncologic standpoint. These patients may barely have pain, but many patients also experience pain from the radiation and the scarring. Oncologists are busy and they do not think about these issues nor should they necessarily. However, there should be awareness and there needs to be someone whose focal length is on [identifying pathologic fractures] and teasing out the concerns of these patients.

Surgery alone can compromise the bone and put it at risk, but it becomes much higher with the addition of radiation and chemotherapy. You need to be all that much more vigilant if a patient is getting multimodality therapy.