Treatment Planning and Fracture Prediction in Patients with Skeletal Metastasis with CT-Based Rigidity Analysis.
OBJECTIVE
Pathologic fractures could be prevented if reliable methods of fracture risk assessment were available. A multicenter prospective study was conducted to identify significant predictors of physicians' treatment plan for skeletal metastasis based on clinical fracture risk assessments and the proposed CT-based Rigidity Analysis (CTRA).


METHODS
Orthopedic oncologists selected a treatment plan for 124 patients with 149 metastatic lesions based on the Mirels method. Then, CTRA was performed, and the results were provided to the physicians, who were asked to reassess their treatment plan. The pre- and post-CTRA treatment plans were compared to identify cases in which the treatment plan was changed based on the CTRA report. Patients were followed for a 4-month period to establish the incidence of pathologic fractures.


RESULTS
Pain, lesion type, and lesion size were significant predictors of the pre-CTRA plan. After providing the CTRA results, physicians changed their plan for 36 patients. CTRA results, pain, and primary source of metastasis were significant predictors of the post-CTRA plan. Follow-up of patients who did not undergo fixation resulted in 7 fractures; CTRA predicted these fractures with 100% sensitivity and 90% specificity, whereas the Mirels method was 71% sensitive and 50% specific.


CONCLUSIONS
Lesion type and size and pain level influenced the physicians' plans for the management of metastatic lesions. Physicians' treatment plans and fracture risk predictions were significantly influenced by the availability of CTRA results. Due to its high sensitivity and specificity, CTRA could potentially be used as a screening method for pathologic fractures.
Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. anazaria@bidmc.harvard.edu.
Ara
A
Nazarian
Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Vahid
V
Entezari
Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
David
D
Zurakowski
Baylor College of Medicine, Houston, Texas.
Nathan
N
Calderon
Baylor College of Medicine, Houston, Texas.
John A
JA
Hipp
Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Juan C
JC
Villa-Camacho
Section of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Patrick P
PP
Lin
Department of Orthopaedic Surgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia.
Felix H
FH
Cheung
Department of Orthopaedic Surgery, Sinai Hospital, Baltimore, Maryland.
Albert J
AJ
Aboulafia
Department of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
Robert
R
Turcotte
Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, Massachusetts.
Megan E
ME
Anderson
Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, Massachusetts.
Mark C
MC
Gebhardt
Department of Orthopaedic Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota.
Edward Y
EY
Cheng
Department of Orthopaedic Surgery, Rhode Island Hospital, Providence, Rhode Island.
Richard M
RM
Terek
Departments of Orthopedic Surgery and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota.
Michael
M
Yaszemski
Department of Orthopaedic Surgery, Upstate Medical University, Syracuse, New York.
Timothy A
TA
Damron
Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Brian D
BD
Snyder
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001859:Bone Neoplasms / Q000000981:diagnostic imaging* / Q000556:secondary; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology; D011446:Prospective Studies; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed