bims-rebome 2026-08-30 papers

bims-rebome

Biomed News

on Management of bone metastases

Issue of 2026–08–30
twelve papers selected by
Alberto Selvanetti, Azienda Ospedaliera San Giovanni Addolorata

Human Versus Machine: Concordance and Conflict in Spinal Metastasis Management.
Deep Learning Versus LASSO-Based Machine Learning for 1-Year Survival After Surgery for Spinal Metastases: A JASA Multicenter Prospective Cohort Analysis.
SURVIVAL PREDICTORS IN CANCER PATIENTS WITH BONE METASTASIS: RETROSPECTIVE COHORT SINGLE-CENTER STUDY.
Prophylactic dexamethasone for the prevention of radiation-induced pain flare in patients with bone metastases: a meta-analysis.
18F-FDG PET/CT-Informed Multidisciplinary Reassessment Modifies Surgical Strategy in Patients with Metastatic Bone Disease: Exploratory Predictors of Decision Change in an Orthopedic Oncology Board.
Association between time from cancer diagnosis to surgery for femoral metastasis and overall survival among patients with malignancy.
Intratumoral Heterogeneity-aware Imaging Biomarkers for Bone Metastasis Risk Stratification in Breast Cancer.
Oxycodone combined with pulsed radiofrequency for refractory cancer pain from spinal metastases: a randomized controlled study.
Surviving Cancer, Lacking Support: The Hidden Burden of Modern Radiation Oncology in the Treatment of Oligometastatic Disease.
Can Orthopaedic Oncologists Agree on What Is and Is Not a Pathologic Fracture?
Breast Cancer Metastases Presenting as Musculoskeletal Complaints.
The Prevalence, Risk Factors for Bone Metastases Development and Prognosis in Gastric Cancer Patients: A Population-based Study.

Clin Spine Surg. 2026 Aug 17.

Human Versus Machine: Concordance and Conflict in Spinal Metastasis Management.

Elie Najjar, Rawan Masarwa, Ahmed A Hassan, Sotiris Karatzoglou, Rodrigo Muscogliati, Khalid Salem, Nasir A Quraishi.

   STUDY DESIGN: Retrospective concordance analysis.
OBJECTIVE: To evaluate the concordance between ChatGPT-4 and a spinal multidisciplinary team (MDT) in management decisions for metastatic spinal disease and to explore the potential role of large language models (LLMs) as decision-support tools in oncologic spine care.
SUMMARY OF BACKGROUND DATA: Management of metastatic spinal disease requires multidisciplinary input balancing neurological preservation, mechanical stability, and systemic prognosis. Frameworks such as the Spine Instability Neoplastic Score (SINS) and the NOMS model guide decisions, but variability persists. Artificial intelligence tools like ChatGPT may standardize reasoning, yet their concordance with expert MDTs remains unexplored in this context.
METHODS: A retrospective analysis was performed on 100 anonymized adult cases referred to a spinal MDT for spinal metastases with suspected instability or metastatic spinal cord compression (MSCC). Ten additional cases were used to calibrate the model input. Each case summary, including demographics, tumor histology, SINS, Karnofsky Performance Scale, and Tokuhashi estimates, was presented identically to ChatGPT-4 (OpenAI, March 2025 snapshot) and the MDT. Management recommendations: surgical versus palliative (noncurative therapy including radiotherapy, systemic treatment, or best supportive care) were compared using Cohen κ, and discordant cases underwent qualitative analysis.
RESULTS: ChatGPT and the MDT were concordant in 86% of cases (κ=0.66, P<0.001), indicating substantial agreement. Concordant recommendations included surgery in 26% and palliative care in 60%. Discordance occurred in 14% of cases, typically involving younger patients or rare tumor histologies. ChatGPT emphasized mechanical instability and high SINS scores, whereas the MDT weighted systemic prognosis more heavily.
CONCLUSIONS: ChatGPT-4 achieved substantial concordance with expert MDT decision-making in metastatic spinal disease. While it aligned well in structurally clear-cut cases, discordance in prognostically complex scenarios underscores the need for prognosis-aware, dynamically validated AI models. These findings support AI as an adjunct-not a replacement-for multidisciplinary clinical workflows.

Keywords:  ChatGPT; artificial intelligence; decision support; metastatic spinal disease; multidisciplinary team; spinal metastases

DOI:  https://doi.org/10.1097/BSD.0000000000002135
Spine (Phila Pa 1976). 2026 Aug 26.

Deep Learning Versus LASSO-Based Machine Learning for 1-Year Survival After Surgery for Spinal Metastases: A JASA Multicenter Prospective Cohort Analysis.

Sadayuki Ito, Hiroaki Nakashima, Naoki Segi, Jun Ouchida, Yuki Shiratani, Akinobu Suzuki, Hidetomi Terai, Takaki Shimizu, Kenichiro Kakutani, Yutaro Kanda, Hiroyuki Tominaga, Ichiro Kawamura, Masayuki Ishihara, Masaaki Paku, Yohei Takahashi, Toru Funayama, Kousei Miura, Eiki Shirasawa, Hirokazu Inoue, Atsushi Kimura, Takuya Iimura, Hiroshi Moridaira, Hideaki Nakajima, Shuji Watanabe, Koji Akeda, Norihiko Takegami, Kazuo Nakanishi, Hirokatsu Sawada, Koji Matsumoto, Masahiro Funaba, Hidenori Suzuki, Haruki Funao, Tsutomu Oshigiri, Takashi Hirai, Bungo Otsuki, Kazu Kobayakawa, Koji Uotani, Hiroaki Manabe, Shinji Tanishima, Ko Hashimoto, Chizuo Iwai, Daisuke Yamabe, Akihiko Hiyama, Shoji Seki, Yuta Goto, Masashi Miyazaki, Kazuyuki Watanabe, Toshio Nakamae, Takashi Kaito, Narihito Nagoshi, Satoshi Kato, Kota Watanabe, Shiro Imagama, Gen Inoue, Takeo Furuya.

   STUDY DESIGN: Multicenter prospective cohort study; secondary analysis.
OBJECTIVE: To evaluate predictors associated with 1-year survival after surgery for spinal metastases by comparing a comprehensive 50-variable deep learning (DL) model with a previously published 5-variable LASSO-based machine learning (ML) model and applying DL-based permutation feature importance as an exploratory analytic lens.
SUMMARY OF BACKGROUND DATA: Surgical decision-making for spinal metastases requires reliable survival estimates. Traditional scores such as those of Tokuhashi and Tomita and contemporary tools such as SORG and NESMS support prognostication, but performance and calibration may vary across cohorts. A parsimonious 5-variable JASA ML model is clinically practical, whereas DL may help identify prognostic signals embedded in detailed activities of daily living (ADLs), patient-reported outcomes (PROs), and scoring-system components.
METHODS: We analyzed 401 complete-case patients who underwent surgery for spinal metastases at 35 Japanese institutions (2018-2021). A feed-forward neural network incorporating 50 preoperative variables was evaluated using five repeated random 8:2 train-test splits. Accuracy, AUROC, Brier score, and calibration summaries were reported and descriptively compared with the previously published 5-variable LASSO-based ML model.
RESULTS: At 1 year, 269 of 401 patients were alive. The DL model achieved 75.5+/- 3.0% accuracy (95% confidence interval [CI], 71.8%-79.2%), held-out AUROC 0.789 (95% CI, 0.681-0.886), and Brier score 0.214. The ML model achieved 71.8% accuracy (Wilson 95% CI, 67.2%-76.0%) and apparent AUROC 0.762. Because the comparison was descriptive rather than paired, formal statistical superiority was not claimed. DL feature importance highlighted Vitality Index-On and Off Toilet, EQ-5D-5L total score and pain/discomfort, and individual Tokuhashi/Tomita components; the ML-selected Vitality Index-Wake Up item ranked 38th.
CONCLUSIONS: The 50-variable DL model provided reasonable prediction and generated clinically plausible feature-importance hypotheses, but it did not demonstrate a clearly meaningful performance advantage over the simpler 5-variable ML model. DL may be most useful for research-based feature discovery and refinement of future parsimonious prognostic tools, whereas validated simple models remain more practical for bedside prognostication.
LEVEL OF EVIDENCE: 2.

Keywords:  1-year survival; activities of daily living; deep learning; machine learning; patient-reported outcomes; preoperative factors; prognostic tool; spinal metastases; spinal surgery; survival estimate

DOI:  https://doi.org/10.1097/BRS.0000000000005843
Exp Oncol. 2026 08 21. 48(2): 146-151

SURVIVAL PREDICTORS IN CANCER PATIENTS WITH BONE METASTASIS: RETROSPECTIVE COHORT SINGLE-CENTER STUDY.

M Vorobchuk, A Burlaka, A Diedkov.

BACKGROUND: Bone metastasis, a frequent complication in cancer patients, is associated with a significant decline in quality of life and reduced survival. Overall survival prognosis is critical for selecting the optimal treatment strategy, particularly for planning orthopedic surgery in patients with bone metastasis. The aim of the study was to delineate prognostic factors for overall survival in patients with bone metastasis following orthopedic surgery.
MATERIALS AND METHODS: 136 patients with bone metastasis treated at the National Cancer Institute (Ukraine) between 2006 and 2025 were included in a retrospective, single-center cohort study. The effects of the primary tumor type, number of metastases, presence of a pathologic fracture, prior treatment, and type of surgery on overall survival were assessed. Survival was analyzed using the Kaplan-Meier method, and the log-rank test was used for group comparisons. Multivariate Cox regression was used to identify independent prognostic factors.
RESULTS: The median overall survival was 32.8 months. Patients with solitary metastases had significantly better survival than those with multiple metastases (median 44.8 vs 18.4 months; p = 0.021). Pathologic fractures were associated with worse survival (median 25.4 vs 64.6 months; p = 0.014). In multivariate analysis, multiple metastases (HR 1.95; 95% CI 1.18-3.22; p = 0.009) and pathologic fractures (HR 1.82; 95% CI 1.05-3.17; p = 0.034) were identified as independent adverse factors. Combined treatment was associated with a lower risk of death (HR 0.48; 95% CI 0.26-0.91; p = 0.023). The type of surgery was not an independent factor affecting survival.
CONCLUSION: The number of metastases and the presence of a pathologic fracture are key prognostic factors affecting survival in patients with bone metastasis. The results delineating prognostic factors in patients with bone metastasis may be useful for risk stratification and personalized treatment.

DOI: https://doi.org/10.15407/exp-oncology.2026.02.146
Front Oncol. 2026 ;16 1894776

Prophylactic dexamethasone for the prevention of radiation-induced pain flare in patients with bone metastases: a meta-analysis.

Lang Chen, YaJun Wang, Jian Tan, MingLiu He, Han Gou, Xing Chen, YiHui Liu.

   Purpose: This study primarily evaluated the efficacy and safety of prophylactic dexamethasone in preventing radiation-induced pain flare in patients with bone metastases undergoing palliative radiotherapy.
Methods: A systematic search of the PubMed, Embase, and Cochrane databases was conducted to identify prospective randomized controlled trials published up to May 2026. After screening, six studies were ultimately included. A random-effects model was used for pooled analyses, and sensitivity analyses were performed to assess heterogeneity.
Results: A total of 1,833 records were initially identified, and six prospective randomized controlled trials were ultimately included in the final analysis. Pooled analysis demonstrated that prophylactic dexamethasone was associated with a significantly lower risk of radiation-induced pain flare compared with placebo (RR = 0.63, 95% CI: 0.46-0.86). Sensitivity analyses did not identify a clear source of heterogeneity within the dexamethasone group. Adverse events were infrequently reported and were generally mild, with no severe treatment-related complications observed in the included studies.
Conclusion: Prophylactic dexamethasone may reduce the incidence of radiation-induced pain flare in patients with bone metastases undergoing palliative radiotherapy. However, given the limited number of studies and heterogeneity among treatment protocols, these findings should be interpreted cautiously, and further large-scale randomized controlled trials are warranted.

Keywords:  bone metastases; dexamethasone; meta-analysis; pain flare; radiotherapy

DOI:  https://doi.org/10.3389/fonc.2026.1894776
J Clin Med. 2026 Aug 20. pii: 6436. [Epub ahead of print]15(16):

18F-FDG PET/CT-Informed Multidisciplinary Reassessment Modifies Surgical Strategy in Patients with Metastatic Bone Disease: Exploratory Predictors of Decision Change in an Orthopedic Oncology Board.

Erkan Akgun, H Emre Tepedelenlioğlu, Serkan Aydin, Turgut Yurdakul, S Sinan Gültekin, H Bilgehan Çevik.

  Background/Objectives: Bone is the third most common site of solid-tumor metastasis, and surgical management spans a wide spectrum from observation to curative en bloc resection in selected patients. 18F-FDG PET/CT has been reported to alter oncologic management in 20% to 45% of patients across diverse settings, yet its specific impact on surgical decision-making within a multidisciplinary orthopedic oncology board (MOOB) reassessment and the predictors of decision change remain undefined. Methods: We retrospectively analyzed consecutive patients with histopathologically confirmed bone metastases evaluated at a tertiary-care MOOB between February 2023 and February 2026. For each patient, the surgical plan was recorded twice: first by the orthopedic team based on available conventional imaging (radiography, computed tomography, magnetic resonance imaging) and then as the final PET/CT-informed MOOB review. This design evaluates changes in decision-making intent after PET/CT-informed multidisciplinary reassessment, rather than the isolated causal effect of PET/CT or actual surgical implementation. Surgical plans were categorized as no surgery, palliative stabilization, palliative resection, or curative-intent resection, and changes were classified as no change, escalation, de-escalation, or cancellation. Results: Among 73 patients (mean age 64.7 ± 12.1 years; 53.4% male), the most frequent primaries were lung (37.0%), breast (21.9%), and renal cell carcinoma (13.7%). Following PET/CT-informed MOOB reassessment, the intended surgical plan changed in 53.4% of cases (p < 0.001), comprising surgery cancellation (27.4%), escalation (17.8%), and de-escalation (8.2%). Patients directed to no surgery increased fourfold (6.8% to 28.8%), and curative resection emerged as a post-reassessment recommendation (0% to 10.9%). SUVmax did not predict overall decision change, but higher SUVmax was associated with cancellation/de-escalation in the directional analysis. In exploratory multivariable analysis, polymetastatic disease (OR 0.051; 95% CI 0.005 to 0.547; p = 0.014), long-bone diaphyseal location (OR 0.133; p = 0.006), and higher Eastern Cooperative Oncology Group (ECOG) performance score (OR 2.109 per point; p = 0.018) independently predicted decision change. Conclusions: PET/CT-informed MOOB reassessment was associated with substantial changes in intended surgical strategy for metastatic bone disease. The findings support careful multidisciplinary integration of metabolic imaging, metastatic burden, anatomic location, and performance status, but should be regarded as hypothesis-generating until validated prospectively with data on treatment delivery and downstream outcomes.

Keywords:  18F-FDG PET/CT; SUVmax; bone metastases; multidisciplinary tumor board; orthopedic oncology; surgical decision-making

DOI:  https://doi.org/10.3390/jcm15166436
Eur J Surg Oncol. 2026 Aug 25. pii: S0748-7983(26)00717-1. [Epub ahead of print]52(11): 112098

Association between time from cancer diagnosis to surgery for femoral metastasis and overall survival among patients with malignancy.

Mojahed Sakhnini, Oded Hershkovich, Raphael Lotan, Geffen Kleinstern.

BACKGROUND: The prognostic significance of the interval between initial cancer diagnosis and development of femoral metastasis requiring surgery remains unclear. This study evaluated the association between this interval and overall survival in patients undergoing surgery for metastatic femoral lesions.
METHODS: A retrospective cohort study was conducted among 314 patients treated surgically for metastatic femoral disease at a single center between 2005 and 2019. The primary exposure was the interval between cancer diagnosis and surgery for femoral metastasis: <1 year, 1-5 years, and >5 years. Data included demographics, tumor type, fracture status (actual versus impending), surgical modality, and Karnofsky performance score. Survival was assessed using Kaplan-Meier analysis, log-rank testing, and multivariable Cox regression adjusting for clinical and demographic variables.
RESULTS: Median overall survival was 10 months (IQR 3-28). Survival differed significantly among diagnostic-interval groups (p < 0.001), with median survivals of 14 months in the <1-year group, 7 months in the 1-5-year group, and 14 months in the >5-year group. In multivariable analysis, a 1-5-year interval was associated with higher mortality compared with <1 year (HR = 1.79, 95% CI 1.31-2.43). Lower Karnofsky performance status and actual versus impending fracture were also independently associated with increased mortality.
CONCLUSIONS: The interval between cancer diagnosis and surgery for femoral metastasis is independently associated with overall survival. Incorporating this readily available clinical variable may serve as a complementary factor in preoperative survival assessment and assist in patient counseling and surgical planning.

DOI: https://doi.org/10.1016/j.ejso.2026.112098
Acad Radiol. 2026 Aug 26. pii: S1076-6332(26)00604-5. [Epub ahead of print]

Intratumoral Heterogeneity-aware Imaging Biomarkers for Bone Metastasis Risk Stratification in Breast Cancer.

Liwei Sun, Weizhi Zhang, Zhengtong Wang, Yunfei Yang, Pei Nie, Wenjian Xu.

   RATIONALE AND OBJECTIVES: Breast cancer carries a substantial long-term risk of bone metastasis, which marks progression to incurable disease and severely compromises patient quality of life. Conventional clinicopathological factors provide limited individualized prognostic resolution, highlighting the need for noninvasive biomarkers capable of capturing tumor biology relevant to bone-specific metastatic progression.
MATERIALS AND METHODS: We systematically compared two commonly used intratumoral heterogeneity (ITH) modeling strategies: feature-level heterogeneity encoding based on tumor radiomics features complexity (ITH1) and habitat-based regional aggregation derived from supervoxel partitioning (ITH2). Prognostic performance for bone metastasis-free survival (BMFS) was also evaluated by global tumor region (GTR) radiomics and vision transformer (ViT)-derived deep learning features. Multidimensional models integrating imaging-derived scores and clinicoradiological variables were constructed and interpreted using SHapley Additive exPlanations (SHAP).
RESULTS: ITH1 consistently outperformed ITH2 in prognostic performance and generalizability, indicating greater robustness in capturing tumor heterogeneity relevant to bone metastasis. Integration of the ITH1 score with GTR radiomics and ViT scores significantly improved BMFS prediction compared with any single modality. The final integrated model incorporating clinicoradiological variables achieved high and stable discrimination across cohorts, with concordance index values ranging from 0.878 to 0.908. SHAP analysis revealed that the ITH1 score contributed most prominently to bone metastasis risk prediction, underscoring the critical role of tumor heterogeneity in bone-specific metastatic risk.
CONCLUSION: Feature-level ITH encoding provides a more informative and robust representation of ITH than habitat-based modeling for predicting breast cancer bone metastasis. Multidimensional integration of ITH, GTR radiomics, and ViT-derived features enables complementary tumor characterization and substantially enhances individualized risk stratification, supporting its potential utility in precision oncology.

Keywords:  Bone metastasis; Breast cancer; ITH; Radiomics; ViT

DOI:  https://doi.org/10.1016/j.acra.2026.08.016
Support Care Cancer. 2026 Aug 24. pii: 896. [Epub ahead of print]34(9):

Oxycodone combined with pulsed radiofrequency for refractory cancer pain from spinal metastases: a randomized controlled study.

L Li, Hj Wang, Xj Wang, Sc Xing, Jh Zhong.

   OBJECTIVES: To assess the clinical efficacy and safety of oxycodone combined with pulsed radiofrequency (PRF) in the treatment of refractory cancer pain (RCP) arising from spinal metastasis.
METHODS: A randomized controlled trial enrolled 60 patients with RCP due to spinal metastases. Participants were randomly allocated to the oxycodone alone group (Group A, n = 30) or the oxycodone combined with PRF group (Group B, n = 30). Primary outcomes comprised pain scores on the Numerical Rating Scale (NRS) and episodes of breakthrough pain at post-treatment time points Secondary endpoints included opioid consumption, immune parameters, quality of life, and adverse event incidence.
RESULTS: Group B had significantly lower NRS scores and fewer 24-h breakthrough pain episodes than Group A at post-treatment time points (p < 0.05). The opioid consumption and 7/30-day drug escalation indices of Group B were significantly lower (p < 0.05), with a lower dose escalation rate (46.67% vs. 73.33%, p = 0.035). Group B exhibited relatively better preserved selected T lymphocyte subset parameters (CD3⁺, CD4⁺ T cell percentages, CD4⁺/CD8⁺ ratio) and quality of life scores (p < 0.05), with a markedly lower overall adverse reaction rate (43.33% vs. 70.00%, p = 0.037) and no serious adverse events observed.
CONCLUSIONS: This exploratory pilot randomized controlled trial indicated that the combination of oxycodone and PRF may contribute to improved pain control, decreased opioid consumption, and attenuated decline in lymphocyte subsets alongside enhanced quality of life in patients with spinal metastasis-related refractory cancer pain. No serious adverse events were documented. The clinical and oncological significance of the observed intergroup differences in T cell indices remains unclear. These preliminary observations require verification in larger prospective trials.

Keywords:  Oxycodone; Pulsed radiofrequency; Refractory cancer pain; Spinal metastases

DOI:  https://doi.org/10.1007/s00520-026-11122-x
Cancers (Basel). 2026 Aug 11. pii: 2584. [Epub ahead of print]18(16):

Surviving Cancer, Lacking Support: The Hidden Burden of Modern Radiation Oncology in the Treatment of Oligometastatic Disease.

Beth Chasty, Agata Rembielak, Richard Berman, Eva Oldenburger.

  The management of oligometastatic disease has undergone a significant paradigm shift over the past two decades. Once considered uniformly incurable, selected patients with metastatic disease can now achieve prolonged progression-free survival, durable disease control, and, in carefully selected cases, long-term remission or cure through metastasis-directed therapies. Advances in stereotactic ablative radiotherapy (SABR), surgery, systemic therapies, and the emerging concept of Curative Oligometastatic Radiotherapy (CORT) have challenged the traditional distinction between curative and palliative treatment. Concurrent developments in imaging, including PET/CT, prostate-specific membrane antigen (PSMA) PET, whole-body MRI, and MR-guided adaptive radiotherapy (MR-linac), together with evolving biomarker research, are improving disease characterisation, refining patient selection, and treatment personalisation. As survival improves, an increasing number of patients are living with durably controlled metastatic cancer and experience long-term physical, psychological, cognitive, functional, and financial consequences of treatment. Despite these challenges, evidence-based survivorship pathways for patients with oligometastatic disease remain poorly defined. Supportive oncology is becoming an essential component of modern radiation oncology rather than an adjunct to cancer treatment. This emerging discipline focuses on optimising symptom control, minimising toxicity, and delivering structured survivorship care. Rather than being limited to end-of-life care, supportive oncology is embedded throughout the patient journey; from diagnosis and treatment selection to prehabilitation, rehabilitation, patient-reported outcome (PRO) monitoring, surveillance for late effects, multidisciplinary follow-up, and long-term survivorship. This review discusses how advances in precision radiotherapy, molecular imaging, biomarkers, and emerging treatment technologies are reshaping the management of oligometastatic disease while simultaneously creating a growing population of long-term survivors with increasingly complex supportive care needs. It highlights the expanding role of supportive oncology in the care of patients with oligometastatic disease, encompassing multidisciplinary symptom management and argues that improvements in disease control must now be matched by the development of evidence-based multidisciplinary survivorship pathways that integrate supportive oncology to optimise quality of life (QoL), functional independence, and patient-centred outcomes. Finally, this review highlights current evidence gaps and proposes future research priorities for developing evidence-based survivorship models for this rapidly expanding patient population.

Keywords:  cancer survivorship; metastasis-directed therapy; oligometastatic disease; precision radiation oncology; quality of life; stereotactic ablative radiotherapy (SABR); supportive oncology

DOI:  https://doi.org/10.3390/cancers18162584
Clin Orthop Relat Res. 2026 Aug 25.

Can Orthopaedic Oncologists Agree on What Is and Is Not a Pathologic Fracture?

Arianna Dalamaggas, Abigail Grothe, Yumeng Gao, Felsafa Wodajo, Nicholas Tedesco, Adam Levin, Benjamin J Miller.

BACKGROUND: Orthopaedic oncologists have not agreed on a common definition of pathologic fracture despite abundant reports on diagnosis and management. A standard definition is important for treatment decisions, outcomes assessment, and administrative categorization; therefore, it is first necessary to understand areas of agreement and disagreement on the imaging findings exclusively before considering nonradiologic features of pathologic fracture.
QUESTIONS/PURPOSES: (1) Based on images (radiographs, CT scans, and MRIs), to what degree do orthopaedic oncologists agree on whether or not a pathologic fracture is present? (2) What imaging features lead orthopaedic surgeons to believe that a pathologic fracture is present?
METHODS: We developed a survey of images from 20 patients with metastatic bone disease and distributed them to 30 orthopaedic oncologists holding committee or leadership positions in the Musculoskeletal Tumor Society (MSTS). Images were reviewed twice, at least 6 months apart. Each question consisted of a PowerPoint slide of a patient with metastatic bone disease, with representative plain radiographs, CTs, and MRIs when available. On the first survey, there was only one question for each patient scenario: "Is there a pathologic fracture?" Respondents were asked to respond simply "yes" or "no." In the second survey, consisting of the same PowerPoint slides in a different order, we asked the participants to provide additional insight and rationale behind their decision for each case regarding whether or not there was a fracture to further investigate areas of differences in interpretation or assessment. The Fleiss kappa (κ) was used to evaluate interrater agreement, and the Cohen kappa assessed intrarater agreement for the binary classification of pathologic fractures. The strength of agreement was classified on an interval scale based on a kappa value from 0.0 to 1.0.
RESULTS: The Fleiss kappa for interrater reliability was 0.54 (p < 0.001) for the first survey, indicating moderate agreement, and 0.64 (p < 0.001) for the second, reflecting substantial agreement according to established definitions of agreement. The Fleiss kappa was 0.47 (p < 0.001) for the description of imaging findings, reflecting moderate agreement. We found that nearly every surgeon agreed that images from patients with a complete visible fracture line or bone displacement represented a pathologic fracture. Similarly, patients whose images showed bone erosion but no obvious complete cortical disruption were determined not to represent a pathologic fracture. The areas of major disagreement among orthopaedic oncologists in image interpretation occurred when there was (1) a cortical perforation with a soft tissue component from the underlying tumor, (2) a severely compromised cortex without a clear discontinuity, or (3) an incomplete fracture line or callus in a portion of the cortex.
CONCLUSION: Often raters agreed on the imaging findings but drew opposite conclusions regarding whether a pathologic fracture was present based on sets of images that replicate common clinical scenarios. This disproportionality of responses is too great to have common language for communication and clear surgical indications. This indicates that further review and consensus aimed at agreement on imaging findings based on these data are needed to allow for a clear definition of a pathologic fracture that can be universally applied. Our findings have stimulated early work for a multispecialty consensus project within the MSTS, which aims to classify skeletal lesions for use in clinical communication, research, and registries.
LEVEL OF EVIDENCE: Level IV, diagnostic study.

DOI: https://doi.org/10.1097/CORR.0000000000004101
Cureus. 2026 Jul;18(7): e113298

Breast Cancer Metastases Presenting as Musculoskeletal Complaints.

Eric Chun-Pu Chu, Lucina Ng.

  Breast cancer often metastasizes to the bone, leading to musculoskeletal symptoms that may mimic benign conditions. Patients with undiagnosed or recurrent malignancies may initially present to first-contact providers, including chiropractors, with non-specific spinal or musculoskeletal pain. Here, we extend the series with two additional cases, highlighting risks of delayed diagnosis, the role of imaging, and chiropractic care. In Case 1, a 62-year-old woman with a history of breast carcinoma presented with progressive left-sided sciatica-like symptoms (pain radiating from the sacroiliac region to the lower extremity), revealing progressive metastases on MRI (e.g., L5 vertebral collapse with retropulsion and severe stenosis) and PET/CT (e.g., new intraspinal extensions at C2, T2, and T4). Multidisciplinary intervention, including radiotherapy, targeted therapy (letrozole, palbociclib, denosumab), and conservative chiropractic management, reduced Visual Analog Scale (VAS) pain scores from 7/10 to 3/10 and improved quality of life from 58/100 to 86/100. In Case 2, a 44-year-old woman presented with constant lumbar pain (7/10 intensity), leading to the discovery of multilevel vertebral collapses (e.g., C7, T3, T5, T8, and L2) and abnormal marrow signals on MRI, confirmed as invasive ductal carcinoma via biopsy and PET/CT. These cases underscore the need for vigilance in patients with an oncologic history presenting with musculoskeletal pain. These clinical outcomes highlight the synergy of an interdisciplinary management model, where primary oncology therapies (radiotherapy and systemic targeted agents) successfully achieve metabolic and structural stabilization of the metastatic lesions, while concurrent, low-force supportive chiropractic care safely focuses on mechanical symptom mitigation and preserving the patient's quality of life.

Keywords:  bone metastases; breast cancer; breast cancer survivors; chiropractic; chiropractor; musculoskeletal pain; sciatica

DOI:  https://doi.org/10.7759/cureus.113298
Asian Pac J Cancer Prev. 2026 Aug 01. pii: 92325. [Epub ahead of print]27(8): 2999-3011

The Prevalence, Risk Factors for Bone Metastases Development and Prognosis in Gastric Cancer Patients: A Population-based Study.

Thanh Tung Hoang, Tuan Anh Bui, Manh Hung Nguyen, Cong Vinh Dang, Ha Trung Nguyen, Tuan Dat Tran, Hoang Anh Dang, Ngoc Thang Pham, Tien-Manh Hoang.

   OBJECTIVE: The objective of the present study was to explore the prevalence, risk and prognostic factors for bone metastases (BM) developement in patients with initial gastric cancer (GC).
METHODS: A total of 30,817 patients with GC in the Surveillance, Epidemiology and End Results (SEER) database, diagnosed from 2010 to 2016, were used to investigate the incidence and associated risk factors for BM developments using multivariate logistic regression. Among those, 1397 and 1121 BM patients were selected to identify independent prognostic factors for BM overall survival (OS) and cancer-specific survival (CSS) using multivariate Cox regression respectively.
RESULT: A total of 1397 (4.53%) GC patients were diagnosed with BM at initial diagnosis. Younger age (<60 years), white race, cardia cancer, signet ring cell, higher grade, tumor size between 2.1 and 4.0 cm, the presence of regional lymph nodes (RLN) metastases, brain metastases, liver metastases, and lung metastases were positively associated with BM development. Conversely, a lower T stage was negatively associated with BM development compared to the T4 stage. The median survival time for GC patients with BM decreased dramatically to 5 months. The presence of RLN metastases was an independent predictor of worse overall survival and cancer-specific survival. Conversely, T2 stage and chemotherapy were associated with better overall survival and cancer-specific survival. Additionally, patients with cardia cancer had favorable cancer-specific survival.
CONCLUSION: The prognosis of gastric cancer patients with BM was dismal. Our findings of several risk factors for BM development and prognostic factors for BM patients could be useful for clinical surveillance and individualized treatment.

Keywords:  Bone metastases; Gastric cancer; Prevalence; Prognostic factor; risk factor

DOI:  https://doi.org/10.31557/APJCP.2026.27.8.2999