Metástasis falángica en dedo anular derecho en paciente con antecedente de cáncer de colon etapa IV

Objetivo: Reportar un caso clínico de acrometástasis de cáncer de colon. Materiales y Métodos: Se obtiene información de la ficha clínica electrónica. Se realiza revisión de literatura, utilizando los términos "acrometastasis", "metástasis óseas", "metástasis en la mano", "metástasis en falanges". Resultados: Se presenta el caso de un paciente con antecedente de cáncer de colon sigmoides etapa IV sometido a resección de metástasis hepáticas, quimioterapia y radioterapia. Consulta por lesión ulcerada en dedo anular derecho, cuya biopsia indica metástasis de adenocarcinoma de colon. Se realiza amputación transfalángica proximal con biopsia que confirma diagnóstico. Discusión: Las metástasis en mano dan cuenta del 0,0070,2% de todas las metástasis a distancia. Se presentan como aumento de volumen doloroso de aspecto granulomatoso o asociado a ulceración con empeoramiento progresivo. El tratamiento tiene por objetivo el manejo del dolor y la preservación de la funcionalidad de la extremidad. Conclusión: El adenocarcinoma de colon, raramente, da metástasis falángicas. Corresponden a una manifestación tardía de la enfermedad con una alta tasa de mortalidad a 6 meses asociada. Se deben considerar como diagnóstico diferencial en pacientes oncológicos.

Objective: To report a clinical case of achrometastases of colon cancer. Materials and methods: Information is obtained from the electronic medical record. A literature review is performed, using the terms "achrometastases", "bone metastases", "hand metastases", "phalangeal metastases". Results: We present the case of a patient with a history of stage IV sigmoid colon cancer who underwent resection of liver metastases, chemotherapy and radiotherapy. Consultation due to an ulcerative lesion on the right ring finger, whose biopsy indicated colon adenocarcinoma metastases. Proximal transphalangeal amputation is performed with biopsy confirming diagnosis. Discussion: Hand metastases account for 0.007-0.2% of all distant metastases. They present as a painful increase in volume with a granulomatous appearance or associated with progressively worsening ulceration. The treatment aims to manage pain and preserve the functionality of the limb. Conclusion: Colon adenocarcinoma rarely gives phalangeal metastases. They correspond to a late manifestation of the disease with a high associated 6-month mortality rate. They should be considered as a differential diagnosis in cancer patients.

Intervencionismo para el control del dolor por metástasis óseas / Interventionism for pain control due bone metastases

Objetivo: El dolor óseo por cáncer óseo o metástasis es un dolor de difícil manejo asociado a dolor incidental. Hay distintas estrategias quirúrgicas para su tratamiento, sin embargo, no todos los pacientes con metástasis óseas pueden beneficiarse de un tratamiento quirúrgico. La presente revisión bibliográfica tiene como objetivo identificar terapias intervencionales mínimamente invasivas para el control del dolor por metástasis óseas. Métodos: Revisión bibliográfica acerca de terapias intervencionales para el control del dolor por metástasis óseas utilizando la base de datos PubMed (www.pubmed.gov) y el motor de búsqueda Google (www.google.cl). Tipos de participantes: Pacientes con metástasis óseas dolorosas de cualquier tumor primario. Tipos de intervenciones: Bloqueos anestésicos, bloqueos neurolíticos, terapias ablativas, cementoplastías. Resultados: Se obtuvieron 384 resultados que incluyeron revisiones sistemáticas, revisiones bibliográficas, ensayos clínicos controlados, series de casos y reporte de casos. Todos los artículos relevantes en inglés y español se incluyeron para su análisis. Conclusión: Las metástasis óseas son un evento común en los pacientes con cáncer, y el dolor óseo es un dolor de difícil manejo asociado a dolor incidental. Se han desarrollado terapias intervencionales no invasivas o mínimamente invasivas para tratar el dolor, mejorar la calidad de vida y la funcionalidad, disminuir el consumo de fármacos, y reducir el tamaño del tumor. La gran mayoría ha demostrado ser terapias seguras y eficaces, con pocos eventos adversos y de rápida resolución, y que si son combinadas mejoran los resultados.

Objective: Bone pain from bone cancer or metastasis is a pain that is difficult to manage associated with incidental pain. There are different surgical strategies for its treatment, however, not all patients with bone metastases can benefit from a surgical treatment. This literature review aims to identify minimally invasive interventional therapies for the control of pain due to bone metastasis. Methods: Literature review of interventional therapies for the control of pain due to bone metastases was done using the PubMed database (www.pubmed.gov) and the Google search engine (www.google.cl). Types of participants: Patients with painful bone metastases from any primary tumor. Types of interventions: Anesthetic blocks, neurolytic blocks, ablative therapies, cementoplasties. Results: We obtained 384 results that included systematic reviews, literature reviews, controlled clinical trials, case series and case reports. All relevant articles in English and Spanish were included for analysis. Conclusion: Bone metastases are a common event in cancer patients, and bone pain is a difficult-to-manage pain associated with incidental pain. Non-invasive or minimally invasive interventional therapies have been developed to treat pain, improve quality of life and functionality, decrease drug use, and reduce tumor size. The vast majority therapies have been shown to be safe and effective ones, with few adverse events and rapid resolution, and that if combined they improve the outcomes.

Percutaneous management of bone metastases: State of the art.

Interventional radiology is playing an increasingly important role in the local treatment of bone metastases; this treatment is usually done with palliative intent, although in selected patients it can be done with curative intent. Two main groups of techniques are available. The first group, centered on bone consolidation, includes osteoplasty/vertebroplasty, in which polymethyl methacrylate (PMMA) is injected to reinforce the bone and relieve pain, and percutaneous osteosynthesis, in which fractures with nondisplaced or minimally bone fragments are fixed in place with screws. The second group centers on tumor ablation. tumor ablation refers to the destruction of tumor tissue by the instillation of alcohol or by other means. Thermoablation is the preferred technique in musculoskeletal tumors because it allows for greater control of ablation. Thermoablation can be done with radiofrequency, in which the application of a high frequency (450 Hz-600 Hz) alternating wave to the tumor-bone interface achieves high temperatures, resulting in coagulative necrosis. Another thermoablation technique uses microwaves, applying electromagnetic waves in an approximate range of 900 MHz-2450 MHz through an antenna that is placed directly in the core of the tumor, stimulating the movement of molecules to generate heat and thus resulting in coagulative necrosis. Cryoablation destroys tumor tissue by applying extreme cold. A more recent, noninvasive technique, magnetic resonance-guided focused ultrasound surgery (MRgFUS), focuses an ultrasound beam from a transducer placed on the patient's skin on the target lesion, where the waves' mechanical energy is converted into thermal energy (65 °C-85 °C). Treatment should be planned by a multidisciplinary team. Treatment can be done with curative or palliative intent. Once the patient is selected, a preprocedural workup should be done to determine the most appropriate technique based on a series of factors. During the procedure, protective measures must be taken and the patient must be closely monitored. After the procedure, patients must be followed up.

Calidad de vida en pacientes con metástasis óseas por cáncer de próstata tratados con ácido zoledrónico / Quality of life in patients suffering from bone metastasis due to prostate cancer treated with zoledronic acid

Introducción: El ácido zoledrónico mejora la calidad de vida en pacientes con metástasis óseas por cáncer prostático. Objetivo: Evaluar la calidad de vida relacionada con la salud con el cuestionario EORTC QLQ-BM22 en pacientes con metástasis óseas por cáncer prostático tratados con ácido zoledrónico. Métodos: Se realizó un estudio prospectivo-descriptivo de 71 pacientes con cáncer prostático metastásico a hueso tratados en el servicio de oncología del Hospital Clínico Quirúrgico "Hermanos Ameijeiras" con: edades 18-80 años, ECOG<3, expectativa de vida >6 meses, y seguimiento de al menos doce meses. Se administró ácido zoledrónico cada 21-28 días. Se aplicó la escala visual análoga y el módulo EORTC QLQ-BM22. Resultados: Los pacientes tenían una mediana de 71 años de edad, Gleason ≥ 8: en 57,7 % de los pacientes, PSA al diagnóstico ≥ 20 ng/mL: 70,4 por ciento, ECOG 1: 67,6 por ciento, y estadio IV como presentación inicial: 50,7 por ciento. Metástasis óseas sin toma visceral: 84,5 por ciento, en vértebras 36,6 por ciento, <3 sitios 66,2 por ciento, y metástasis óseas blásticas 60,6 por ciento. Eventos esqueléticos relacionados previos al ácido zoledrónico 7,9 por ciento (fractura), y posteriores, 5,6 por ciento (radioterapia anti-álgica). A doce meses, acorde a la escala visual análoga, se alcanzó respuesta completa: 71 por ciento, y parcial: 29 por ciento (p<0,05). Luego de la aplicación del módulo EORTC QLQ-BM22, se comprobó disminución significativa tanto en la escala de síntomas como en la funcional, independientemente de otros factores. Conclusiones: Los tratamientos específicos para cáncer prostático combinado a zoledrónico mejoran significativamente el dolor y calidad de vida relacionada con la salud en pacientes con metástasis óseas(AU)

Introduction: Zoledronic Acid improves the quality of life of patients suffering from prostate cancer. Objectives: To assess the health-related quality of life using EORTC QLQ-BM22 questioner in patients suffering from prostate cancer, treated with zoledronic acid. Method: A prospective-descriptive study was carried out in 71 patients suffering from prostate cancer involving bones, with ages ranging between 18 and 80 years, and who were treated in the oncology service at Hermanos Ameijeiras Hospital. The ECOG was less than 3, life expectancy> 6 months, and follow-up of at least twelve months. Zoledronic acid was administered every 21-28 days. The visual analog scale and EORTC QLQ-BM22 module were applied. Results: The patients had median age of 71 years, Gleason ≥ 8: in 57.7% of the patients, PSA at diagnosis ≥ 20 ng / mL: 70.4%, ECOG 1: 67.6 percent, and stage IV as initial presentation: 50.7 percent. Bone metastases without visceral intake: 84.5 percent, in vertebrae 36.6 percent, <3 sites 66.2 percent, and blast bone metastases 60.6 percent. Skeletal events related to zoledronic acid before 7.9 percent (fracture), and after 5.6 percent (anti-allergic radiotherapy). At twelve months, according to the visual analog scale, a complete response was achieved, 71 percent, and a partial response, 29 percent (p <0.05). After the application of EORTC QLQ-BM22 module, a significant decrease was found in both the symptom and functional scales, regardless of other factors. Conclusions: Specific treatments for prostate cancer combined with zoledronic significantly improve pain and health-related quality of life in patients with bone metastases(AU)

Aporte de las imágenes híbridas spect/ct para el diagnóstico diferencial de lesiones óseas malignas y benignas en pacientes con cáncer de mama. Nuestra experiencia / Contribution of the spect/ct hybrid images for the differential diagnosis of malignant and benign bone lesions in patients with breast cancer. Our experience

Objetivo El objetivo del presente trabajo es evaluar el valor adicional del spect/ct sobre el Centellograma de Cuerpo Entero (cce) y la spect en pacientes con cáncer de mama con mínimo dos estudios: tiempo inicial (i) y evolución (e). Material y método Se evaluaron retrospectivamente 208 lesiones en 186 pacientes. Se realizaron imágenes: cce, spect y spect/ct del esqueleto axial con 99mTcmdp y equipo híbrido Infinia Hawkeye 4 GE. Las lesiones se caracterizaron del siguiente modo: benigna (b); maligna (m); y equívocas: probablemente benigna (pb) y probablemente maligna (pm). Resultados spect/cti clasificó 197/208 lesiones (94,7%), specti 155/208 (74,5%) y ccei 130/208 (51%). Los tres métodos coincidieron inicialmente en 138 lesiones: 106 b (77%), 23 m (17%) y 9 equívocas (6%), y en la evolución en 155: 110 b (71%), 44 m (28%), 1 equívoca (1%). La sensibilidad, especificidad y exactitud inicial para diagnóstico de metástasis (incluyendo como malignas las lesiones probablemente malignas) fueron 92/70/51% (ccei), 100/78/75% (specti) y 100/97/95% (spect/cti). Diferencias de a pares: ccei vs specti y spect/cti para sensibilidad (p<0,05) y specti y ccei vs spect/cti especificidad y exactitud (p<0,001). Conclusiones El aporte de spect/ct incrementó la precisión y certeza diagnóstica para diferenciar las lesiones benignas, malignas y equívocas. Su utilización debería ser rutinaria en la detección de metástasis óseas en pacientes con carcinoma de mama

Objective To assess the additional value of spect/ct on whole-body scintigraphy (wbs) and spect in patients with breast cancer, with a minimum of two tests: start time (i) and assessment (e). Materials and method Retrospective assessment of 208 lesions in 186 patients. Images were taken by wbs, spect and spect/ct of the axial skeleton with 99mTc- mdp and hybrid equipment Infinia Hawkeye 4 GE. Characterization of the lesions: benign (b), malignant (m) and equivocal: likely to be benign or malignant. Results By using spect/cti, 197/208 lesions (94.7%), specti 155/208 (74.5%) and wbsi 130/208 (51%) were classified. The three methods initially coincided on 138 lesions: 106 b (77%), 23 m (17%) and 9 equivocal (6%); and on assessment on 155: 110 b (71%), 44 m (28%), 1 equivocal (1%). The initial sensitivity, specificity and accuracy for the diagnosis of metastases (including as malignant those lesions which were likely to be so) were as follows: 92/70/51% (wbsi), 100/78/75% (specti) and 100/97/95% (spect/cti). Differences by pairs: wbsi vs specti and spect/cti for sensitivity (p<0,05) and specti and wbsi vs spect/cti for specificity and accuracy (p<0,001). On assessment 99%. Conclusions The contribution of spect/ct has increased diagnostic accuracy and certainty to differentiate benign, malignant and equivocal lesions. It should be used routinely for the detection of bone metastases in patients with breast cancer

Role of 18F-FDG PET/CT in the detection of primary malignancy in patients with bone metastasis of unknown origin. / Papel de la PET/TC con 18F-FDG en la detección del tumor primario en pacientes con metástasis óseas de origen desconocido.

OBJECTIVE: The present study investigates the role of 18F-FDG PET/CT in the detection of primary malignancy in patients with bone metastasis of unknown primary origin (BMUO). MATERIAL AND METHODS: This retrospective study considered histopathological examination findings or clinical follow-up data as the standard reference in the diagnosis of primary tumors, and results were compared with results of PET/CT scans. RESULTS: The study included 100 patients with BMUO (74 males, 26 females, mean age 61 years). The primary origin was identified in 92 of the 100 patients. Adenocarcinoma was the most common histopathological subtype in patients in whom the primary origin of tumor was detected (65.2%). The most common primary tumor was lung carcinoma (n=52) followed by prostate (n=13), breast (n=7), colon (n=4), gastric (n=3), ovarian (n=2), renal cell (n=2), adrenal (n=1), thyroid (n=1), endometrial (n=1) and parotid (n=1) carcinoma, hepatobiliary cancers (n=2), leiomyosarcoma (n=2) and maxillary sinus tumor (n=1). The numbers of patients in whom PET/CT showed true positive, true negative, false positive (FP) and false negative (FN) results were 72, 7, 8 and 13, respectively. The sensitivity, specificity, accuracy and detection rate of PET/CT in detecting the primary tumor were 84.7%, 46%, 79% and 72%, respectively. The overall survival was significantly lower in lung cancer group when compared to non-lung cancer group, whereas it was significantly higher in prostate cancer group than in non-prostate cancer group. CONCLUSIONS: PET/CT, as a non-invasive method, can be preferred as the first choice in the detection of primary tumor in patients with BMUO.

Four years of clinical experience with Radium-223 for the treatment of castration-resistant prostate cancer. / Cuatro años de experiencia clínica con radio-223 para el tratamiento del cáncer de próstata resistente a la castración.

PURPOSE: Radium-223 is an alpha-emitting radiopharmaceutical that significantly prolongs overall survival in patients with castration-resistant prostate cancer and symptomatic bone metastases. We report a retrospective analysis of our clinical experience with Radium-223 in the first 68 patients treated. METHODS: The incidence of hematologic, gastrointestinal, and other adverse events was identified, including events that led to treatment discontinuation or delay. Alterations in bone pain and prostate-specific antigen and serum alkaline phosphatase levels were evaluated. Bone scan changes were identified and correlated with the clinical course. RESULTS: Sixty-eight patients were included in the study. The median number of radium-223 injections was 5 (range 1-6), with 69% of patients receiving 5 to 6 injections. The most common side effects were digestive alterations in 24 patients, anemia in 7 patients, and thrombocytopenia in 5 patients. Clear downward trends in serum alkaline phosphatase were seen, that were less clear in prostate-specific antigen. Mean serum alkaline phosphatase decreased from baseline in 77% of the patients, and prostate-specific antigen in less than 40%. The majority of patients (62) experienced an improvement in bone pain intensity or no increase in bone pain intensity. No prostate-specific antigen flare phenomenon was noted. CONCLUSIONS: Radium-223 was generally well tolerated and there were no safety concerns. The adverse events were mild and manageable. A decline in serum alkaline phosphatase was more common than a decline in prostate-specific antigen. Monitoring changes in serum alkaline phosphatase dynamics may be useful.

Relevance of radium-223 in hospital clinical practice from a medical oncologist point of view. / Importancia del radio-223 en la práctica hospitalaria. Visión del oncólogo médico.

Currently, there are several options available for the treatment of metastatic castration resistant prostate cancer (mCRPC), however evidence on the optimal treatment sequence is lacking. 223Ra is the first targeted alpha therapy that has shown an improvement in overall survival in mCRPC patients. This drug specifically targets bone lesions, so there is a window of opportunity for the administration of 223Ra previous to the development of visceral metastases. This should be taken into account to design the therapeutic strategy for mCRPC patients. It is necessary, therefore, to review the different approaches in routine clinical practice, to define best practices for patient selection and on-treatment monitoring.

Prognosis and treatment of acrometastases: Observational study of 35 cases treated in a single institution. / Pronóstico y tratamiento de las acrometástasis: estudio observacional de 35 casos tratados en un único centro.

OBJECTIVE: There is a degree of contradiction in the literature about the primary tumour that is most frequently associated with acrometastases, as well as their prognosis and treatment. The aim of this study is to determine the most frequent location of the acrometastases, the most frequent primary tumour according to its location, and to evaluate the surgical options according to the estimated survival. METHODS: A retrospective study on patients diagnosed with acrometastases. The primary tumour, as well as the number, location, symptoms and treatment of the acrometastases and survival rate were collected. RESULTS: 35 acrometastases in 21 patients were reviewed: 4 in the upper limbs and 31 in the lower limbs; the tibia was the most frequently affected bone (N=13). The primary tumour that most frequently produced acrometastases in the lower limb was hypernephroma (19%). In the upper limb lung tumour was more frequent (25%). Eleven patients died (52%); 10 of them had concomitant multiple metastases. The mean survival was 42 months from the diagnosis of acrometastases. CONCLUSION: Acrometastases are more frequently seen in the lower extremities and the most frequent tumour was hypernephroma followed by lung. The treatment of acrometastases depends on the prognosis of the primary tumour, so a multidisciplinary approach is essential. The mean survival in our series did not imply a poorer prognosis for acrometastases, so it is feasible to consider surgical options such as wide resection and reconstruction. A unique acrometastases is a good prognosis signal.

Visualizando Gammagramas Óseos en Colores / Displaying Bone Scans in Color

Resumen En este trabajo se describe el uso de un software para detectar metástasis óseas en gammagramas cuyo funcionamiento está basado en un método cuantitativo. En la investigación se incluyeron cuarenta y tres gammagramas óseos de pacientes con cáncer de próstata, los cuales fueron previamente analizados visualmente por tres especialistas y su diagnóstico se tomó como referencia. Debido a que no todos los huesos de un paciente muestran los mismos tonos de gris, cada uno de los gammagramas se segmentó para su análisis en cuatro regiones: cráneo, hombros, tórax y pelvis. La segmentación se hizo con el fin de obtener intervalos de tonos de gris en cada una de las regiones empleando un proceso estadístico. Para ello se calcularon la media y la desviación estándar de cuatro muestras que contenían cada una cuarenta y tres regiones. Tomando en consideración los intervalos, siete colores fueron asignados a cada región. Mediante los colores fue posible diferenciar los casos sanos e infiltrados en cada región, lo que facilita el diagnóstico. Se muestran ejemplos de los resultados en cada una de las regiones.

Abstract The use of software based on a quantitative method for detecting skeletal metastasis in bone scans is presented. Forty-three bone scans of patients with prostate cancer were previously analyzed visually by three specialists and their diagnosis were taken as a reference. Later, these scans were analyzed by segmenting them into four regions: skull, shoulders, chest, and pelvis. The segmentation was made to obtain intervals of gray levels for each of the regions using a statistical process. Tríese values were found by calculating the mean and standard deviation of four samples containing each forty-three regions. Using these intervals, seven colors were assigned to each region. By means of the colors it is possible to differentiate healthy and infiltrated cases in each region, which may facilitate the diagnosis. Examples of results in each region are shown.

Correlación en el cáncer de próstata entre metástasis óseas, antígeno prostático específico y puntaje gleason / Correlation between bone metastases, specific prostatic antigen and Gleason points in prostate cancer

Introducción: el cáncer de próstata es el más frecuente en la población masculina y la segunda causa de muerte en los hombres mayores de 50 años. Cerca del 23 por ciento de estos pacientes presentan metástasis óseas en el momento del diagnóstico. Objetivos: determinar la aparición de metástasis óseas por gammagrafía en pacientes con cáncer de próstata y la relación que existe entre los niveles de antígeno prostático específico, los resultados de la gammagrafía ósea y el puntaje Gleason. Método: se realizó un estudio observacional, descriptivo, transversal, en pacientes con diagnóstico de cáncer de próstata en el CIMEQ en el período de enero de 2013 a diciembre de 2016. Se excluyeron pacientes que recibieron tratamiento previo para enfermedades prostáticas. Se analizaron variables demográficas, gammagrafías óseas, niveles de PSA, resultados histológicos según Gleasony principales síntomas.Resultados: la edad promedio fue 71,45 años y el color de piel predominante fue el blanco. La gammagrafía ósea demostró metástasis óseas en 55 pacientes, la presencia de estas aumentó proporcionalmente con el nivel de PSA, y con el Gleason. El patrón gammagráfico predominante fue la lesión múltiple con valor promedio de PSA de 66,70 ng/ml. Conclusiones: más del 50 por ciento de la muestra presentó lesiones metastásicas óseas. Los valores de PSA por encima de 20 ng/ml pueden sugerir presencia de metástasis. Pacientes con biopsia de próstata con Gleason de poco grado de diferenciación tienen mayor riesgo de padecer metástasis óseas(AU)

Introduction: prostate cancer is the most frequent in the male population and the second cause of death in older than 50 year-old men. About the 23 por cent of these patients present bone metastases in the moment of the diagnosis. Objective: to determine the appearance of bone metastasis by gammagraphy in patients with prostate cancer and its relation between the levels of specific prostatic antigen, the results of the bone gammagraphy and Gleason points. Method: an observational, descriptive, transverse study was carried out in patients with diagnosis of prostate cancer in CIMEQ in the period from January, 2013 to December, 2016. Patients who received previous treatment for prostatic diseases were excluded. Demographic variables, bone gammagraphy, levels of specific prostatic antigen and histological results according to Gleason and main symptoms were analyzed.Results: the average age was 71,45 years old and the prevailing skin color was white. Bone gammagraphy showed bone metastases in 55 patients, they increased proportionally with the levels of specific prostatic antigen, and Gleason. The gammagraphy pattern that prevailed was the multiple lesion with an average level of specific prostatic antigen of 66,70 ng/ml. Conclusions: more than 50 percent of the sample presented bone metastatic lesions. The values of specific prostatic antigen were higher than 20 ng/ml, which can suggest the presence of metastasis. Patients with biopsy of prostate with Gleason of low differentiation level have higher risk of suffering from bone metastases(AU)

Radium-223 in the treatment of bone metastasis in patients with castration-resistant prostate cancer. Review and procedure. / Radio-223 en el tratamiento de metástasis óseas en pacientes con cáncer de próstata resistente a la castración. Revisión de la literatura y procedimiento.

Bone metastatic disease is the main cause of morbidity / mortality in patients with prostate cancer, presenting frequently as bone pain, pathological fractures or spinal cord compression, which requires early and timely therapy. Although, for the moment, the therapeutic window for its use has not been definitively established, radium-223 (223Ra), an alpha particle emitter, has proved to be an effective therapeutic tool, pre or post-chemotherapy, in patients with castration-resistant prostate cancer with symptomatic bone metastases and absence of visceral metastases, significantly modifying the prognosis of the disease. It is therefore imperative to define the ideal scenarios and the correct protocol for the use of this therapy and thus offer the greatest possible clinical benefit to the patient.

Surgical treatment in bone metastases in the appendicular skeleton. / Tratamiento quirúrgico de las metástasis óseas en el esqueleto apendicular.

INTRODUCTION: Metastatic bone disease is the most common neoplastic process that affects the skeletal system. Eighty percent of bone metastases come from carcinomas of the breast, lung, kidney, thyroid and prostate. The Katagiri scale enables an estimation of the survival of patients based on the presence or absence of visceral metastases, multiple bone metastases and functional status according to the ECOG scale. MATERIAL AND METHODS: A retrospective, descriptive and observational study conducted between March 1, 2013 and June 30, 2015. Thirty-two patients were studied with a diagnosis of metastatic bone disease and who had undergone some type of orthopaedic surgical treatment for pathological fracture or impending fracture. RESULTS: 28 cases (87.5%) presented pathological fracture and 4 cases (12.5%) impending fracture according to the Mirels score. Fifteen cases (46.875%) were treated by placing a central medullary nail + spacer in the long bone diaphysis, 15 cases (46.875%) with modular arthroplasties and 2 patients (6.25%) with forequarter amputation. Eleven patients (34.375%) died during the course of this study, all with a Katagiri greater than or equal to 4. DISCUSSION: The presence of a fracture in previously damaged territory is a catastrophic complication for most cancer patients. A clear understanding of the life expectancy of patients with bone metastases is of great help to prevent errors and failures in treatment.

Radium-223 in the therapeutic sequence of metastatic castration-resistant prostate cancer. / Radio-223 en la secuencia terapéutica del cáncer de próstata resistente a la castración metastásico.

CONTEXT: Radium-223 is an □ -particle transmitter with specific action on bone metastases. The Alpharadin in Symptomatic Prostate Cancer Patients (ALSYMPCA) study showed that radium-223 extended overall survival and delayed the onset of bone events in patients with symptomatic castration-resistant prostate cancer with bone metastases (mCRPC) and without visceral metastases, with a good safety profile. OBJECTIVE: To review the new scientific evidence on radium-223 based on prespecified and post-hoc analyses of the ALSYMPCA study and on early-access programs after the publication of the ALSYMPCA study, thereby providing new data on the management of patients with mCRPC. ACQUISITION OF EVIDENCE: We searched for evidence on PubMed and in the abstracts of international urology and oncology congresses, as well as ongoing clinical trials (ClinicalTrials.gov). SYNTHESIS OF THE EVIDENCE: The results of the reviewed studies offer promising results that will broaden the therapeutic benefits of radium-223 to patients with mild symptoms and those with no symptoms. The results also provide preliminary evidence on the benefit of radium-223 treatment after the failure of docetaxel, enzalutamide or abiraterone or the combination of radium-223 with these agents or other therapeutic agents such as bone-targeted agents and immunotherapy. CONCLUSION: Radium-223 can be a treatment option for patients with mild symptoms and can provide a therapeutic benefit after failure of currently available treatments or in combination with these treatments. This evidence should be corroborated in clinical trials before being added to clinical practice.

Gastric cancer bone metastases together with osteopoikilosis diagnosed using bone scintigraphy and 18F-FDG PET/CT. / Coexistencia de metástasis óseas por cáncer gástrico y osteopoiquilia diagnosticadas mediante gammagrafía ósea y 18F-FDG PET/TC.

The coexistence of different bone diseases in the same patient involves a complex differential diagnosis. A patient is presented who was studied due to a renal mass that showed many sclerotic lesions in spine and limbs in conventional radiology and CT. These lesions were evaluated with 99mTC-HDP bone scintigraphy and 18F-FDG PET/CT, which helped to obtain the definitive pathological diagnosis of osteopoikilosis (OP) co-existing with gastric cancer bone metastases. Of the different imaging scans performed, bone scintigraphy was particularly relevant due to its ability to discriminate between benign and metastatic bone disease.

The value of quantitative analysis in 18F-NaF PET/CT.

AIM: To evaluate the ability of SUVmax to differentiate bone metastases from degenerative lesions, blastic from lytic metastases, as well as to determine the correlation between SUVmax with 18F-NaF and with 18F-FDG. MATERIAL AND METHODS: A review was performed on 115 18F-NaF PET/CT studies. Of the 64 patients with bone metastases, 49 (39 women, 10 men, 61±12 years (16-81)), in whom the PET/CT supported the diagnosis of bone metastases, were selected for analysis. A record was made of the SUVmax of a maximum of ten metastases in each patient (total 172: 141 blastic, 31 lytic), as well as four degenerative lesions (total 188) with the greatest 18F-NaF uptake intensity. Of the 49 patients analyzed, 43 also had a 18F-FDG PET/CT performed in which a record was made of the SUVmax values for 18F-FDG calculated in the locations corresponding to the bone metastases observed in the 18F-NaF PET/CT: 128 metastases (106 blastic, 22 lytic). RESULTS: The mean of the SUVmax values was significantly higher in metastases than in degenerative lesions, 26.8±17.3 vs. 15.3±6.3 (P<0.001) and in blastic than in lytic metastases, 27.9±18.3 vs. 22.1±11.3 (P=0.03). A SUVmax value above 42 always represented metastases, with all values above 49 representing blastic metastases. Using the SUVmax values, it was possible to predict the occurrence of metastases (AUC=0.723; P<0.001; 95% CI=0.671-0.776). The mean of the SUVmax with 18F-NaF was significantly higher in blastic metastases (27.9±18.3 vs. 22.1±11.3, P=0.03), whereas with 18F-FDG it was significantly higher in lytic ones (3.9±3.4 vs. 9.6±3.3; P<0.01). CONCLUSIONS: SUVmax can contribute to the differentiation of metastases from degenerative lesions, and blastic from lytic metastases.

Influence of the location and number of metastases in the survival of metastatic prostatic cancer patients. / Influencia de la localización y del número de metástasis en la supervivencia de los pacientes con cáncer de próstata metastásico.

INTRODUCTION: The prognosis of patients diagnosed with metastatic prostate cancer seems to be modulated by factors such as the number and site of metastases. Our objective is to evaluate survival outcomes according to the number and site of metastases in our series of metastatic patients over the last 15 years. MATERIALS AND METHODS: A retrospective analysis was performed on patients diagnosed between 1998 and 2014. We analyzed overall survival and progression-free survival, depending on the number and location of metastases on patients with newly diagnosed metastatic prostate cancer. Other potential prognostic factors were also evaluated: age, clinical stage, PSA at diagnosis, Gleason, PSA nadir, time till PSA nadir and first-line or second-line treatment after progression. RESULTS: We analyzed a series of 162 patients. The mean age was 72.7yr (SD: 8.5). The estimated median overall survival was 3.9 yr (95% CI 2.6-5.2). The overall survival in patients with only lymph node metastases was 7 yr (95% CI 4.1-9.7), 3.9 (95%CI 2.3-5.5) in patients with only bone metastases, 2.5 yr (95% CI 2-2.3) in lymph nodes and bone metastases, and 2.2 yr (95% CI 1.4-3) in patients with visceral metastases (P<.001). In multivariate analysis, the location of metastasesis significantly associated with overall survival and progression-free survival. The number of metastases showed no association with survival. CONCLUSIONS: The site of metastases has a clear impact on both overall survival and progression-free survival. Patients with only lymph node involvement had a better prognosis. The number of metastases showed no significant impact on survival in our series.

Incidencia de fracturas patológicas por metástasis en el fémur proximal en un hospital de concentración / Incidence of proximal femur pathologic fractures secondary to metastasis in a national reference orthopedic hospital

Resumen: Objetivo: Reportar la incidencia de fracturas en terreno patológico secundarias a metástasis que se presentaron en un hospital de referencia nacional en un período de cinco años. Métodos: Se registraron los ingresos totales a nuestro centro, así como los pacientes que satisficieran la condición de presentar una fractura de fémur proximal en terreno patológico. Con base en información oficial, se calculó el tamaño de población derechohabiente potencial de acuerdo al área de influencia. Con base en los datos se hizo el cálculo de la incidencia anual y de la densidad de incidencia. Resultados: Se identificaron 98 fracturas en 95 individuos. El cálculo de la densidad de incidencia fue de 0.70/100,000 personas durante el período de observación. Se incluyeron 54 sujetos femeninos y 41 masculinos con un promedio de edad de 65.3 años, aunque el rango fue muy variable (de 18 a 90 años). La mayor parte de las personas presentó metástasis por tumores sólidos. De los casos, 29% fue tratado de manera conservadora y el resto requirió tratamiento quirúrgico que incluyó desde osteosíntesis hasta artroplastía protésica. El promedio de estancia hospitalaria fue ligeramente mayor a una semana. Conclusiones: La incidencia reportada es relativamente baja. Encontramos una gran variedad de orígenes y localizaciones anatómicas. No se puede, al momento, generalizar tratamientos o predecir supervivencia.

Abstract: Objective: To report the incidence of pathological fractures secondary to metastasis at a national referral hospital during a 5-year period. Methods: Total admissions to our center were recorded, together with the patients who met the requirement of having a proximal femur fracture in a pathological area. The potential number of beneficiaries was estimated based on official figures and the hospital's area of influence. The annual incidence rate and the incidence density were calculated using the latter data. Results: 98 fractures were identified in 95 patients. The calculated incidence density was 0.70/100,000 population during the observation period. Fifty-four female patients and 41 male patients were included. Mean age was 65.3 years, with a very wide age range (18-90 years). Most patients had metastasis of solid tumors. Twenty-nine percent of patients were treated conservatively and the rest of them required surgery that included from osteosynthesis to prosthetic arthroplasty. The mean length of stay was over one week. Conclusions: The reported incidence of this type of fractures is relatively low. We found a wide variety of anatomical origins and locations. As of now, it is not possible to generalize the treatment or predict the survival.

[Diagnostic performance of bone scintigraphy and (11)C-Choline PET/CT in the detection of bone metastases in patients with biochemical recurrence of prostate cancer]. / Rendimiento diagnóstico de la gammagrafía ósea y la PET/TAC con (11)C-colina en la detección de metástasis óseas en pacientes con recidiva bioquímica de cáncer de próstata.

AIM: To compare bone scan (BS) with (11)C-Choline PET/CT for the detection of bone metastases in patients with biochemical recurrence of prostate cancer (PC). MATERIAL AND METHODS: A total of 169 patients with biochemical recurrence of PC(PSA:2.4-58 ng/ml) who were referred for both exams (0-15 days-in-between) were included. Lesion-detection-rate per patients and lesions were analyzed for both BS and (11)C-Choline PET/CT. Metastasis diagnosis was reached by: biopsy, CT/(18)F-Fluoride PET/MRI confirmation, or evidence of progression in subsequent imaging procedures. RESULTS: A total of 91 lesions were found to be active in BS and/or (11)C-choline PET/CT (40 patients), with 78 of which were metastatic. BS detected 38 blastic, 2 lytic and 10 non-CT-evident lesions. (11)C-Choline PET/CT detected 41 blastic, 4 lytic and 29 non-CT-evident lesions. BS and (11)C-Choline PET/CT sensitivities were 65.4% and 96.1%; specificities ere 38.5 and 92.3% (χ(2) 8.27, p<0.04). Both imaging techniques were negative in 118 patients. Tracer avid lesions were found in 51 patients: with 30/51 being BS and (11)C-Choline PET/CT concordant; in 21/51 patients had discordant lesions (kappa 0.712, p=0.00). Lesions were absolutely discordant in 10/19 patients,: 5 FN BS, 2 FP BS (degenerative changes; dysplasia), 1 FN (11)C-Choline PET/CT (blastic), 1 FP (11)C-Choline PET/CT (degenerative), 1 out of field-of-view lesion with (11)C-Choline PET/CT (tibia alone). (11)C-Choline PET/CT showed extraosseous involvement in 26/51 patients with bone metastases: 9 local recurrences, 5 infra-diaphragmatic-lymph-nodes, 2 supra-diaphragmatic, 5 local and infra-diaphragmatic, 4 infra- and supra-diaphragmatic, 1 supra-diaphragmatic and lung metastases. CONCLUSION: (11)C-Choline PET/CT yielded better sensitivity and specificity than BS for the detection of bone involvement in patients with biochemical recurrence of PC and allowed extraosseous restaging, with an impact in the clinical management of these patients.