Metastatic Carcinoma and Myeloma of the Femur

Publication Date: September 30, 2020
Last Updated: March 14, 2022

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

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

September 30, 2020

Last Updated Month/Year

October 23, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this clinical practice guideline is to provide medical, radiation, and surgical providers with a practical and vetted set of recommendations regarding the management of patients with metastatic or myelomatous lesions of the femur. The goal is not to dictate patient care in all cases, but to provide guidance based on a systematic review of published information and consensus expert opinion.

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

Surgeons, medical oncologists, radiation oncologists, and primary care physicians

PICO Questions

  1. In patients with metastatic carcinoma or multiple myeloma lesions in the femur, which imaging modalities, i.e. x-ray, MRI, CT or PET/CT, offer reliable predication of the rate of pathologic fracture?

  2. In patients with metastatic carcinoma or multiple myeloma lesions in the femur, is there a reduction in the rate of SREs (including femur fractures) with use of bone modifying agents?

  3. In patients with metastatic carcinoma or multiple myeloma, is modifying dosage or duration of treatment with bone modifying agents associated with a change in the rate of atypical femur fracture, osteonecrosis of the jaw, hypocalcemia, or renal insufficiency?

  4. In patients with metastatic carcinoma or multiple myeloma treated with bone modifying agents, does the tumor histology correlate with reduction in rate of skeletal related events (SREs)?

  5. In patients with metastatic carcinoma or multiple myeloma lesions in the femur treated with bone modifying agents, does the tumor histology correlate with reduction in rate of femur fracture?

  6. In patients with metastatic carcinoma or multiple myeloma lesions in the femur treated with bone modifying agents, are there reliable radiological (on bone scan, X-ray, CT, or MRI) or clinical findings that indicate an increased risk of atypical (“brittle bone”) fractures?

  7. In patients with metastatic carcinoma or multiple myeloma lesions in the femur, does radiation therapy modify the rate of fracture?

  8. In patients with metastatic carcinoma or multiple myeloma lesions in the femur undergoing prophylactic femur stabilization, what are the benefits (reduced fracture rate, pain, further intervention, etc.) associated with radiation of the femur following surgery?

  9. In patients with metastatic carcinoma or multiple myeloma lesions in the femur treated with resection and reconstruction, what are the benefits (reduced fracture rate, pain, further intervention, etc.) associated with radiation of the femur following surgery?

  10. In patients with metastatic carcinoma or multiple myeloma lesions in the femur, is the rate of fracture or subsequent intervention affected by single fraction vs multi-fraction radiation of the femur?

  11. In patients with metastatic carcinoma or multiple myeloma lesions in the femur treated with radiation therapy, are there tumor histologies, clinical features, or therapeutic interventions associated with improved outcomes (reduced fracture rate, pain, further intervention, etc.)?

  12. In patients with metastatic carcinoma or multiple myeloma lesions in the femur, are there reliable imaging findings (bone scan, X-ray, CT, PET/CT, or MRI) and/or clinical characteristics (e.g. nature of pain, primary diagnosis) that indicate an increased risk of pathologic fracture without prophylactic surgery versus patients without those findings or characteristics?

  13. In patients with metastatic carcinoma or multiple myeloma lesions in the femur, are there imaging findings (bone scan, X-ray, CT, or MRI) and/or clinical characteristics (e.g. nature of pain, primary diagnosis, survival estimates at diagnosis) that predict poor outcomes with internal fixation (plate or IM rod)?

  14. In patients with metastatic carcinoma or multiple myeloma lesions in the femur with pathologic fractures of the femoral neck, is it preferable to perform long or short stem hemiarthroplasty with respect to preventing future femur fractures and perioperative morbidity?

  15. In patients with metastatic carcinoma or multiple myeloma lesions in the femur with pathologic fractures of the femoral diaphysis, is it preferable to perform standard or cephalomedullary nailing?

  16. In patients with metastatic carcinoma or multiple myeloma lesions in the femur with pathologic fractures of the intertrochanteric or peritrochanteric femur, does arthroplasty result in improved outcomes versus treatment with internal fixation (plating or IM rod)?

  17. In patients with metastatic carcinoma or multiple myeloma lesions in the femur with pathologic fractures of the intertrochanteric or subtrochanteric region, are clinical characteristics, i.e. tumor histology, or predicted survival estimate at diagnosis, related to outcomes after internal fixation (plating or IM rod)?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services, Operating and recovery room

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

Supplemental Methodology Resources

Evidence Tables