Research Article: Surgery of skeletal metastases in 306 patients with prostate cancer

Date Published: February 8, 2012

Publisher: Informa Healthcare

Author(s): Rüdiger J Weiss, Jonathan A Forsberg, Rikard Wedin.


Skeletal metastases are common in patients with prostate cancer, and they can be a source of considerable morbidity. We analyzed patient survival after surgery for skeletal metastases and identified risk factors for reoperation and complications.

This study included 306 patients with prostate cancer operated for skeletal metastases during 1989–2010. Kaplan-Meier analysis was used to calculate survival. Cox multiple regression analysis was performed to study risk factors, and results were expressed as hazard ratios (HRs).

The median age at surgery was 72 (49–94) years. The median survival after surgery was 0.5 (0–16) years. The cumulative 1-, 2-, and 3-year survival after surgery was 29% (95% CI: 24–34), 14% (10–18), and 8% (5–11). Age over 70 years (HR 1.4), generalized metastases (HR 2.4), and multiple skeletal metastases (HR 2.3) resulted in an increased risk of death after surgery. Patients with lesions in the humerus (HR 0.6) had a lower death rate. The reoperation rate was 9% (n = 31). The reasons for reoperation were deep wound infection (n = 10), hematoma (n = 7), material (implant) failure (n = 3), wound dehiscence (n = 3), increasing neurological symptoms (n = 2), prosthetic dislocation (n = 2), and others (n = 4).

This study involves the largest reported cohort of patients operated for skeletal lesions from prostate cancer. Our survival data and analysis of predictors for survival help to set appropriate expectations for the patients, families, and medical staff.

Partial Text

This study involved a consecutive series of patients with prostate cancer who were operated for skeletal metastases from 1989 through 2010. Only patients who had their primary operation at our hospital were included in the study. All data are based on the Karolinska Skeletal Metastasis Register (Wedin and Bauer 2005). This quality-control database prospectively collects individual-based information for cancer patients admitted to the Karolinska University Hospital in Stockholm. The criterion for inclusion is surgical treatment of skeletal metastases. Data on patient identity, age, sex, primary tumor, location of metastases, type of metastases (single skeletal, multiple skeletal, or generalized), surgical procedures (method of fixation and type of implant), and postoperative complications are registered. Generalized metastases are defined as skeletal metastases in combination with visceral metastases. Pathological fractures were defined as skeletal metastases resulting in a dislocation (kyphosis or loss of height for vertebral fractures).

We identified 306 patients who met the inclusion criteria; these patients underwent 358 surgical procedures. No patients were excluded from analysis. 16% of the patients had more than 1 site of surgery. The median age at surgery was 72 (49–94) years. Most subjects (62%) were aged 70 years or older. At surgery, most patients had multiple skeletal metastases (73%) followed by generalized metastases (20%) (Table 1).

Decision making regarding management of skeletal metastases is influenced by factors such as expected duration of survival, overall medical condition, rehabilitation potential, and type of operation required. The goal is to relieve pain and improve function for the maximum amount of time. Patients with a short life expectancy may not benefit from surgery due to rapid deterioration of health and difficulties in managing the postoperative rehabilitation. Some authors have argued that a postoperative lifespan of at least 2 months is required for surgery to be beneficial in extremity metastases (Harrington et al. 1976) and a postoperative lifespan of 3–6 months for spinal lesions (Cybulski et al. 1987, Atanasiu et al. 1993, Tomita et al. 1994). However, these time points are highly debated, and the decision to offer surgery remains patient-specific.