Issues Facing the Established Metastatic Bone Disease Patient: Timing/Indications for Surgery

This chapter explores several challenges faced by clinicians when treating patients with established metastatic disease of bone. The goal is to review general principles and information from other disciplines as they relate to surgical decision-making. The methodology and role of preoperative risk assessment in counseling patients with known metastatic disease are discussed. The difficult challenge of survival prognostication for metastatic bone cancer patients is reviewed with emphasis on available validated prediction models. The influence of disease location and severity, concurrent chemotherapy, and completed or planned radiation therapy upon surgical timing is reviewed with an emphasis on recent evidence and practical applications. The potential consequences of targeted cancer therapies and immunotherapy upon surgical indications, techniques, and complications are discussed. The value of repeat tissue sampling at the time of surgery in patients with established diagnosis is reviewed. The chapter concludes with discussion of mechanisms by which surgical treatment of metastatic bone lesions may improve survival in addition to palliation of symptoms.