• Wang Zhiyu, Zhang Rui, Wang Shuai, and Zhao Hui.
• Department of Internal Oncology, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, China.
• Lancet. 2016 Oct 1; 388 Suppl 1: S42.

BackgroundAs life expectancy improves in patients with lung cancer and bone metastases, effective surgical treatment to relieve pain and improve quality of life and neurological function is increasingly needed. Indications for surgery in patients with bone metastases are controversial. We aimed to assess a protocol for the surgery of patients with lung cancer and bone metastases.MethodsWe developed a surgical protocol for both spinal and appendicular metastases. According to the aim of surgery, eligible patients were placed into four classes (class 1: solitary metastatic bone lesion; class 2: spinal cord compression or pathological fracture; class 3: impending fracture; and class 4: severe pain after medical treatment or radiation). We assessed mobility and neurological functions 1 day before and 1 week, 1 month, 3 months, and 6 months after surgery with the visual analog scale for pain (VAS; scale 1-10), Karnofsky performance status scale (KPS), mobility scale with a score of 0 representing no limitation, a score of 1 representing limitation without the need for orthopaedic aids, a score of 2 representing limitation necessitating orthopaedic aids, and a score of 3 representing bedridden operative technique. Kaplan-Meier analysis was used to calculate survival. This study was approved by the ethics committee of the Sixth People's Hospital, Shanghai Jiao Tong University. Written informed consent was provided by the patient or their legal guardian.FindingsBetween Jan 1, 2005 and Jan 1, 2014, 134 patients underwent surgery (49 spine lesions and 86 appendicular skeleton lesions; one patient was operated in both lumbar and pelvis). VAS decreased after surgery (mean score 6·58 [SD 1·12] before vs 5·33 [1·38] at 1 week, 4·39 [1·35] at 1 month, 3·71 [1·29] at 3 months, and 3·99 [1·02] at 6 months, all p<0·0001 vs baseline). KPS and mobility scale scores were decreased 1 week after surgery (KPS 69·2 [SD 8·8] vs 65·4 [9·1], p=0·0012; mobility scale score (0/1/2/3) 32/47/34/21 vs 19/43/48/23, p<0·0001), and returned to preoperative levels at 1 month for appendicular surgery (KPS 67·2 [10·1] and mobility 21/34/19/11) or 3 months for spinal surgery (KPS 70·8 [11·7] and mobility 21/13/11/4). Mobility scale scores increased at 3 months and 6 months after surgery (48/46/26/12 at 3 months, p<0·0001; 54/39/21/6 at 6 months, p<0·0001). Frankel classification in patients with spinal metastases also improved at 3 months and 6 months after surgery (D/C/B/A from 17/5/3/4 to 12/4/3/2 and 19/0/0/1; p=0·0234 and p=0·0114), as did Musculo-Skeletal Tumor Society rating scale (MSTS) scores in patients with appendicular metastases (from 14·8 [6·1] 1 week after surgery to 20·3 [5·8] at 1 month, 24·1 [4·3] at 3 months, and 22·6 [5·5] at 6 months; all p<0·05 vs 1 week postoperative). The amounts of blood loss in spinal surgery were larger than appendicular surgery (mean 1620 mL [SD 1078] vs 571 mL [775]; p<0·0001). Median overall survival time after surgery was 13·5 months [SD 0·8]. Survival time in the group aimed at radical cure (Class 1: 27·0 months [3·5]) was significantly longer than the other three group (Class 2: 12·6 months [1·0]; Class 3: 13·1 months [1·0]; Class 4: 9·6 months [0·7]; p<0·0001).InterpretationAppropriate surgery provides pain relief, improvement of quality-of-life, and increased neurological function with an acceptably low rate of complications. Our protocol enabled physicians to identify patients with lung cancer and bone metastases who might be candidates for radical surgery.FundingNational Natural Science Foundation of China Grant (81201628).Copyright © 2016 Elsevier Ltd. All rights reserved.

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