Approximately of the patients who developed

Approximately 50% of the patients who developed BM during their palliative disease course received BM-related radiotherapy and/or surgery; 12% of the patients received both therapy options. Our data confirms that the majority of patients with BM will respond to a low course of radiotherapy with good pain relief and only a proportion of these patients will appear in the trauma department with a pathological fracture requiring stabilization [10]. Patients who received radiotherapy or surgery for BM had a median survival after the procedures of 14 months. Patients with BM who received radiotherapy and/or surgery had a significantly improved MDS compared to patients who had not (27.5 vs. 19.5 months). Undoubtedly, through the introduction of a new generation of effective agents with safer profiles in the last 20 years (e.g., endocrine therapy: third-generation aromatase inhibitors, fulvestrant; chemotherapy: taxanes, capecitabine, liposomal doxorubicin, gemcitabine, vinorelbine; immunotherapy: trastuzumab) and of course, through considerable advances in supportive care, longer survival times could be achieved. In our study cohort, the median survival after palliative surgery for BM was 13.5 months; this is considerably higher compared to a cohort of BC patients who received surgical treatment for BM in Sweden during 1989 and 1994 in which the survival rate was 8 months [6]. Furthermore, bone-targeted agents such as bisphosphonates and denosumab which have become a standard of care for patients with BM lead to a significant reduction in the incidence of, and time to skeletal related events and bone pain [11–13]. These advances in systemic palliative therapy increasingly allow the application of chronic disease treatment concepts in metastatic BC (definition of chronic disease and its therapy approach: long-lasting or recurrent diseases which require a long 4 mu of treatment, supervision, observation or care; they are caused by non-reversible pathological alterations, leave residual disability, and can be altered but not be cured by various therapies [14,15]; both chronic non-malignant diseases and longer metastatic disease courses require periodic therapy to control progressive course, and symptoms can be treated using strategies that permit stabilization with treatment regimens that have limited cumulative toxicity). One cannot assess exactly the impact of non-systemic locoregional procedures for BM on increased survival rates in metastatic BC. In our study, we have deliberately foregone drawing conclusions regarding the impact of palliative radiotherapy and/or surgery on survival and reported this data in a descriptive manner. In addition to the retrospective approach of our study, there is a high degree of heterogeneity within the entire cohort and the described particular subgroups, which would make any analysis regarding palliative non-systemic therapy for bone metastases and prognostic impact more than debatable. On the other hand, it can be clearly stated that in the cases in which palliative therapy results in longer survival times, and thus the palliative therapy concepts resemble those of a chronic disease, non-systemic locoregional therapy for BM, in particular radiotherapy, is an established part of the overall multimodal palliative therapy course. Radiotherapy is effective even when the disease becomes refractory to systemic therapy because ionizing radiation alters cell function in all viable cells within the radiation field. On the one hand, tumor shrinkage will enable osteoblastic repair, on the other hand, the decrease of osteoclast activity might be responsible for the success of radiotherapy [16]. In order to further improve the overall care of patients with BM, a multidisciplinary approach between oncologists on the one hand and radiooncologists and orthopedic surgeons on the other hand is required [10,17].
Conclusions
Conflict of interest statement
Case presentation A 50 year old female machinist presented to our general orthopaedic outpatients׳ department with a 5 month history of right groin and buttock pain of spontaneous onset. She had a background history of hypertension and biopsy-proven sarcoidosis. The pain radiated to the right knee and had progressively worsened over the preceding month. She had not experienced any constitutional symptoms, had no previous malignancies, and had been on a daily dose of 20mg prednisone and 150mg azathioprine for 4 years as part of her treatment for sarcoidosis.