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Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma

Timothy A Damron, MD
Jeffrey A Bogart, MD
Mark Bilsky, MD
Section Editors
Reed E Drews, MD
Thomas F DeLaney, MD
Janet Abrahm, MD
Raphael E Pollock, MD
Deputy Editor
Diane MF Savarese, MD


Bone metastases are a common manifestation of distant relapse from many types of solid cancers, especially those arising in the lung, breast, and prostate. Bone involvement can also be extensive in patients with multiple myeloma, and bone may be a primary or secondary site of disease involvement in patients with lymphoma. (See "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma" and "Primary lymphoma of bone".)

Among patients with advanced malignancy, bone metastases represent a prominent source of morbidity [1,2]. Skeletal-related events (SREs) due to bone metastases include pain, pathologic fracture, hypercalcemia, and spinal cord compression. Across a wide variety of tumors with bone involvement, the frequency of SREs can be reduced through use of osteoclast inhibitors such as bisphosphonates or denosumab. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors" and "The use of osteoclast inhibitors in patients with multiple myeloma".)

A fracture that develops through an area of bone pathology is termed a pathologic fracture. In some cases, the extent of bone destruction is such that a fracture is imminent, but not complete (termed an impending fracture). Pathologic fractures can be secondary to a benign lesion (eg, Paget disease, giant cell tumor of bone, hemangioma) or a malignant tumor, which may be a primary bone tumor (osteosarcoma, chondrosarcoma, lymphoma) or metastatic carcinoma, multiple myeloma, or lymphoma. The goals of treatment, regardless of underlying etiology, are to minimize morbidity and maximize function and skeletal integrity. For most patients with a completed or impending pathologic fracture of a long bone, this will necessitate surgical fixation. (See "Clinical manifestations and diagnosis of Paget disease of bone" and "Giant cell tumor of bone" and "Osteosarcoma: Epidemiology, pathogenesis, clinical presentation, diagnosis, and histology" and "Chondrosarcoma" and "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma".)

This topic review will cover the epidemiology, clinical presentation, imaging evaluation, and therapeutic options for a complete or impending pathologic fracture in patients with metastatic cancer, multiple myeloma, and lymphoma. An overview of the epidemiology, clinical presentation, diagnosis, and therapeutic options for bone metastases in general, issues related to pathologic fractures in Paget disease and in patients with a primary bone tumor such as osteosarcoma, and the use of radiation therapy for the management of painful bone metastases without a pathologic fracture are discussed elsewhere. (See "Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis" and "Treatment of Paget disease of bone", section on 'Role of surgery' and "Giant cell tumor of bone", section on 'Surgery' and "Bone sarcomas: Preoperative evaluation, histologic classification, and principles of surgical management", section on 'Patient selection' and "Radiation therapy for the management of painful bone metastases".)


Bone is one of the most common sites of distant metastases from cancer and is particularly common in multiple myeloma. Among visceral cancers, breast, prostate, lung, thyroid, and kidney cancer account for 80 percent of all skeletal metastases, but many other primary malignant tumors can spread to bone including multiple myeloma, lymphoma, uterine leiomyosarcoma, and hepatocellular and uterine carcinomas. (See "Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis", section on 'Epidemiology'.)

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Literature review current through: Nov 2017. | This topic last updated: Oct 06, 2016.
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