Metastatic Carcinoma and Myeloma of the Femur
Publication Date: October 1, 2020
RECOMMENDATIONS
Imaging and Clinical Findings
In the absence of reliable evidence, it is the opinion of the workgroup that the combination of imaging findings and lesion-related pain is predictive of risk of pathologic femur fracture. There is no reliable evidence to suggest that MRI is a strong predictor of femur fracture. (★)
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Efficacy of Bone Modifying Agents (BMAs)
In the absence of reliable evidence, it is the opinion of the workgroup that the use of BMAs may assist in reducing incidence of femur fractures in patients with metastatic carcinoma or multiple myeloma and bone lesions. (★)
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Dosage Response of BMAs
Clinicians should consider decreasing the frequency of zoledronic acid dosing to 12 weeks (compared to the standard 4-week interval), as this is associated with non-inferior SRE outcomes and similar adverse event rates in patients with metastatic carcinoma or multiple myeloma. Clinicians should consider long-term use of BMAs to reduce skeletal related events in patients with multiple myeloma. (★★★★)
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BMAs for Various Diagnoses
In the absence of reliable evidence, it is the opinion of the workgroup that BMAs should be considered in patients with metastatic carcinoma or multiple myeloma with bone lesions at risk for fracture regardless of tumor histology. (★)
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Imaging Findings and Atypical Fractures
In the absence of reliable evidence, it is the opinion of the workgroup that imaging findings of lateral cortical thickening may be associated with increased atypical femur fracture risk. (★)
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Efficacy of Radiation Therapy
Clinicians should consider the use of radiation therapy to decrease the rate of femur fractures in patients with metastatic carcinoma or multiple myeloma lesions who are deemed at increased risk based on the combination of imaging findings and lesion-related pain. (★★★)
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Radiation Therapy and Prophylactic Femur Stabilization
In the absence of reliable evidence, it is the opinion of the workgroup that clinicians may consider the use of radiation therapy in patients undergoing prophylactic femur stabilization to reduce pain, improve functional status, and reduce the need for further intervention. (★)
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Radiation Therapy after Resection and Reconstruction
In the absence of reliable evidence, it is the opinion of the workgroup that radiation therapy may be considered after resection and reconstruction to reduce pain, improve functional status, and reduce the need for further intervention in patients with residual tumor, or those at increased risk of tumor recurrence. (★)
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Multi-Fraction Radiation Treatment
Clinicians should consider the use of multi-fraction in lieu of single fraction radiation treatment to reduce the risk of fracture in patients with metastatic carcinoma in the femur. (★★★)
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Estimating Survival and Reconstruction Method
In the absence of reliable evidence, it is the opinion of the workgroup that surgeons utilize a validated method of estimating survival of the patient in choosing the method of reconstruction. Longer survival estimates may justify more durable reconstruction methods such as arthroplasty, if clinically appropriate. (★)
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Long Stem Hemiarthroplasty
Long Stem Hemiarthroplasty In the absence of reliable evidence, it is the opinion of the workgroup that when treating a femoral neck fracture with hemiarthroplasty, use of a long stem can be associated with increased intra-operative and post-operative complications and should only be used in patients with additional lesions in the femur. (★)
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Cephalomedullary Nailing
In the absence of reliable evidence, it is the opinion of the workgroup that there is no advantage to routine use of cephalomedullary nails for diaphyseal metastatic lesions as there does not appear to be a high frequency of new femoral neck lesions following intramedullary nailing. (★)
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Arthroplasty
Clinicians may consider arthroplasty to improve patient function and decrease the need for post-operative radiation therapy in patients with pathologic fractures from metastatic carcinoma in the femur. (★★)
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Recommendation Grading
Disclaimer
Overview
Title
Treatment of Metastatic Carcinoma and Myeloma of the Femur
Authoring Organizations
American Society for Radiation Oncology
American Society of Clinical Oncology
Musculoskeletal Tumor Society
Publication Month/Year
October 1, 2020
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Target Patient Population
Patients with metastatic or myelomatous lesions of the femur regardless of age, sex, race, ethnicity, education, or socioeconomic status
Target Provider Population
Orthopaedic surgeons, oncologists, radiation oncologists and primary care physicians
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening
Diseases/Conditions (MeSH)
D001859 - Bone Neoplasms, D009140 - Musculoskeletal Diseases
Keywords
musculoskeletal tumor, orthopaedic oncology, myelomatous lesions