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Prediction of pathological fracture in patients with lower limb bone metastasis using computed tomography imaging

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Abstract

Lower limb pathological fractures caused by bone metastases can severely impair activities of daily living, so recognizing fracture risk is essential. Medial cortical involvement (MCI) in the proximal femur has been demonstrated to affect bone strength in biomechanical studies, but it has not been investigated in real patients. Between 2012 and 2019, 161 bone metastases with computed tomography (CT) images were retrospectively examined. Twenty-nine fractures were observed including 14 metastases with pathological fractures at the first examination, and prophylactic surgery was performed for 50 metastases. We extracted clinicopathological data using CT images, including patient’s background, MCI in the proximal femur, site, size, circumferential cortical involvement (CCI), pain, and nature of metastasis. Cox proportional hazard regression analyses were performed, and we created integer scores for predicting fractures. We revealed that MCI, CCI, lytic dominant lesion, and pain were significant factors by univariate analyses. By multivariable analysis, MCI and each 25% CCI were significant and integer score 1 was assigned based on hazard ratio. The full score was four points, with MCI in the proximal femur (one point) and ≥ 75% CCI (three points). With integer score two, sensitivity was 88.9% and specificity was 81.2% for predicting fracture within 60 days. In conclusion, MCI and CCI examined by CT images were the risk factors for pathological fracture. CCI ≥ 50% is a widely known risk factor, but in addition, it may be better to consider surgery if MCI in the proximal femur is observed in metastasis with 25–50% CCI.

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Abbreviations

SREs:

Skeletal related events

ADL:

Activities of daily living

QOL:

Quality of life

MCI:

Medial cortical involvement

BMA:

Bone-modifying agent

CT:

Computed tomography

CRP:

C reactive protein

Alb:

Albumin

CCI:

Circumferential cortical involvement

ROC:

Receiver Operating Characteristic

AUC:

Area under the curve

IQR:

Interquartile range

HR:

Hazard ratio

FE method:

Finite element method

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Acknowledgment

We would like to thank Editage (www.editage.jp) for English language editing.

Funding

This work was supported by KAKENHI (Grants-in-Aid for Scientific Research (C)) Grant Number 15K10388.

Author information

Authors and Affiliations

  1. Department of Rehabilitation Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan

    Yusuke Shinoda, Ryoko Sawada, Takahiro Ohki & Nobuhiko Haga

  2. Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan

    Yusuke Shinoda, Ryoko Sawada, Yuki Ishibashi, Toshihide Hirai, Takahiro Ohki, Masachika Ikegami, Hiroshi Kobayashi & Sakae Tanaka

  3. Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan

    Yuki Ishibashi, Toshihide Hirai, Koichi Okajima, Tomotake Okuma & Takahiro Goto

  4. Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan

    Toru Akiyama & Liuzhe Zhang

  5. Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, Faculty of Medicine, The University of Tokyo Hospital, Tokyo, Japan

    Hiroyuki Oka

Authors
  1. Yusuke Shinoda
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  2. Ryoko Sawada
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  3. Yuki Ishibashi
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  13. Takahiro Goto
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  14. Nobuhiko Haga
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  15. Sakae Tanaka
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Contributions

Conception and design of the study: YS, HK; Collection and assembly of data: YS, RS, YI, TA, LZ, TH, MI, KO, TO; Analysis and interpretation of data: YS, HO, HK; Drafting of the article: YS; Critical revision of the article for important intellectual content: TA, HK, TG, ST; Final approval of the article: NH.

Corresponding author

Correspondence to Yusuke Shinoda.

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Conflicts of interest

The authors declare that they have no conflicts of interest regarding the publication of this paper.

Ethical approval

This study was conducted according to the ethical guidelines for epidemiological research laid out by the Japanese Ministry of Education, Culture, Sports, Science and Technology, and the Ministry of Health, Labour and Welfare. The study protocol was included in a comprehensive protocol developed by the Department of Rehabilitation and the Department of Orthopaedic Surgery, the University of Tokyo Hospital. The study was approved by the University of Tokyo Medical Research Center Ethics Committee (approval number: 2373).

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The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

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Shinoda, Y., Sawada, R., Ishibashi, Y. et al. Prediction of pathological fracture in patients with lower limb bone metastasis using computed tomography imaging. Clin Exp Metastasis 37, 607–616 (2020). https://doi.org/10.1007/s10585-020-10053-z

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  • DOI: https://doi.org/10.1007/s10585-020-10053-z

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