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Team Approach: Emergencies in Patients with Skeletal Metastases

Levin, Adam S., MD1; Alcorn, Sara R., MD, MPH1; Neuman, Brian J., MD1; Meyer, Christian F., MD, PhD1

doi: 10.2106/JBJS.RVW.18.00036
Team Approach Review Articles

  • » Understanding the potential complexities and emergencies involved in the management of skeletal metastases, as well as the role of a carefully coordinated multidisciplinary care team to help to mitigate and manage these concerns, is essential in preventing potentially devastating complications when treating these patients.
  • » A standardized algorithm, including serum and urine laboratory analysis and advanced imaging studies, can help to confirm the diagnosis for patients who have an osseous lesion without a previously proven malignancy with skeletal metastases. The order and timing of the various studies are often dictated by the urgency of the patient’s clinical care.
  • » The optimal clinical management strategy may be dictated by the tumor’s responsiveness to radiation or systemic therapy options, as well as the patient’s functional needs and anticipated duration of survival. Early engagement and communication among all members of the clinical care team are critical to the efficient coordination of systemic therapy, radiation therapy, and orthopaedic surgical management of each patient with metastatic disease.
  • » Hypercalcemia of malignancy may present a medical emergency in patients with skeletal metastatic disease, and its prompt recognition and multidisciplinary treatment is critical to patient survival.
  • » Radiation therapy can provide excellent pain relief and may preclude the need for surgical intervention for many osseous metastases. However, for lesions treated with both radiation and a surgical procedure, wound-healing complications may ensue. Similarly, some systemic therapy modalities may impair wound-healing during the postoperative period. Thoughtful coordination and planning, along with continued communication, are key to the successful multidisciplinary management of these complex patients.

1Department of Orthopaedic Surgery (A.S.L. and B.J.N.), Department of Radiation and Molecular Radiation Sciences (S.R.A.), Sidney Kimmel Comprehensive Cancer Center (C.F.M.), The Johns Hopkins School of Medicine, Baltimore, Maryland

E-mail address for A.S. Levin:

Investigation performed at the Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins School of Medicine, Baltimore, Maryland

Disclosure: There was no source of external funding for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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