Renal cell metastases in long bones: reoperation similar whichever operation

Design

Single-institution retrospective cohort

Population

105 patients with 133 renal cell carcinoma long-bone metastases

Primary outcome

Reoperation and overall survival

Effect

Reoperation sHR 1.08 (p = 0.87); mortality HR 2.03 (p = 0.02), solitary metastasis HR 1.54 (p = 0.49)

This single-institution retrospective series reviewed 105 patients with 133 renal cell carcinoma metastases in long bones treated surgically between 2005 and 2022. Patients had either intralesional surgery, such as curettage and fixation, or resection with reconstruction, usually endoprosthetic.

The cumulative incidence of reoperation did not differ (subdistribution HR 1.08, p = 0.87). Reasons differed: after intralesional surgery, reoperation was mostly for recurrence (29%) and pathological fracture (33%); after resection, for recurrence (29%), fracture (14%) and wound infection (14%). Intralesional surgery was associated with higher mortality overall (HR 2.03, p = 0.02), but not among patients with a solitary metastasis (HR 1.54, p = 0.49).

The mortality difference almost certainly reflects who was offered each operation: patients with widespread disease and short expected survival are the ones given a quicker, less morbid procedure. The useful finding is that intralesional surgery did not lead to more returns to theatre, which supports matching the operation to the patient's prognosis and goals rather than defaulting to resection.

• Estimate prognosis and disease burden before choosing between intralesional surgery and resection.
• Consider intralesional fixation for patients with multiple metastases and limited expected survival.
• Consider resection with reconstruction for a solitary metastasis in a patient with good expected survival.
• Plan for heavy bleeding with renal cell metastases; preoperative embolisation is widely used.
• Discuss the case at a multidisciplinary meeting with oncology before operating.

Why it matters

The argument that resection prevents reoperation in renal cell metastases is weaker than often assumed.

Don't overread it

The mortality difference reflects which patients were offered each operation; it does not show intralesional surgery shortens life.

The statistics, in plain English

A subdistribution hazard ratio of 1.08 with p = 0.87 means reoperation rates were effectively the same. The higher mortality after intralesional surgery comes from a retrospective comparison of patients chosen for different operations, so it reflects patient selection at least as much as the procedure.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.