Survival, Recurrence, and Function After Epiphyseal Preservation and Allograft Reconstruction in Osteosarcoma of the Knee
Survival, Recurrence, and Function After Epiphyseal Preservation and Allograft Reconstruction in Osteosarcoma of the Knee
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DOI：
10.1007/s11999-014-4028-5
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发表时间：
2015-05-01
影响因子：
4.2
通讯作者：
Farfalli, German L.
中科院分区：
文献类型：
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作者：
Aponte-Tinao, Luis;Ayerza, Miguel A.;Farfalli, German L.
骨肿瘤切除保肢已成为标准治疗。最近，保留骨骺的间质肿瘤切除术已被用作骨肉瘤患者的替代方案。该手术维持了正常的关节功能，并避免了与骨关节同种异体移植物或内假体相关的一些并发症;然而，分析肿瘤结局的长期研究很少，据我们所知，局部复发率较高的问题尚未得到解决。（2）局部复发率和肢体存活率，特别是剩余骨骺的复发率;（3）骨科并发症的发生频率，以及，（4）对35例膝关节周围骨肉瘤患者行关节间肿瘤切除术后的功能恢复情况进行分析1991年至2008年期间在我中心接受治疗的股骨远端和胫骨近端患者，接受了保留骨骺的切除术和椎间同种异体移植物重建术。最短随访时间为5年，除非死亡提前发生（平均9年;范围1-16年），无患者失访。在研究期间，我们的这种方法的适应症包括无转移的患者，对新辅助化疗有临床和影像学反应，计划在骨中手术切缘宽度为10 mm后，可获得至少1 cm厚的残余骨骺，16%（223例中的35例）符合这些适应症的患者使用这种方法治疗。通过病历回顾，我们确定了患者的总生存率、肿瘤并发症（如局部复发和肿瘤进展）、肢体生存率和骨科并发症（包括感染、骨折和骨不连）。使用Kaplan-Meier方法估计存活率。采用肌肉骨骼肿瘤协会（MSTS）-93评分系统评价患者功能，5年和10年的总生存率为86%（95%CI，73%-99%）。5名患者死于疾病。没有患者在剩余的骨骺中发生局部复发，但3例患者（9%; 95% CI，0%-19%）在软组织中发生局部复发。5年和10年时的肢体存活率为97%（95% CI，89%-100%）。19例患者（54%）记录了通过额外手术治疗的并发症，包括3例局部复发、2例感染、11例骨折和3例骨不连。在这19名患者中，有10名患者的同种异体移植物被取出。在35例研究患者中，只有5例（14%）因并发症失去了最初保留的骨骺。最终随访时平均功能评分为26分（范围10-30分，评分越高表示结果越好），尽管该系列的复发率很高，但样本量小意味着即使少一两次复发也可能导致更有利的百分比。因此，未来需要更大规模的研究来确定这是否是一种安全的方法，也许应该将骨骺保留与其他可能的方法进行比较，包括内假体重建和/或骨关节同种异体移植。
Bone tumor resections for limb salvage have become the standard treatment. Recently, intercalary tumor resection with epiphyseal sparing has been used as an alternative in patients with osteosarcoma. The procedure maintains normal joint function and obviates some complications associated with osteoarticular allografts or endoprostheses; however, long-term studies analyzing oncologic outcomes are scarce, and to our knowledge, the concern that a higher local recurrence rate may be an issue has not been addressed.We wanted to assess (1) the overall survival in patients treated with this surgical technique; (2) the percentage of local recurrence and limb survival, specifically the incidence of recurrence in the remaining epiphysis; (3) the frequency of orthopaedic complications, and, (4) the functional outcomes in patients who have undergone intercalary tumor resection.We analyzed all 35 patients with osteosarcomas about the knee (distal femur and proximal tibia) treated at our center between 1991 and 2008 who had resection preserving the epiphysis and reconstruction with intercalary allografts. Minimum followup was 5 years, unless death occurred earlier (mean, 9 years; range, 1-16 years), and no patients were lost to followup. During the study period, our indications for this approach included patients without metastases, with clinical and imaging response to neoadjuvant chemotherapy, that a residual epiphysis of at least 1 cm thickness could be available after a surgical margin width in bone of 10 mm was planned, and 16% of patients (35 of 223) meeting these indications were treated using this approach. Using a chart review, we ascertained overall survival of patients, oncologic complications such as local recurrence and tumor progression, limb survival, and orthopaedic complications including infection, fracture, and nonunion. Survival rates were estimated using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system.Overall survival rate of the patients was 86% (95% CI, 73%-99%) at 5 and 10 years. Five patients died of disease. No patient had a local recurrence in the remaining bony epiphysis, but three patients (9%; 95% CI, 0%-19%) had local recurrence in the soft tissue. The limb survival rate was 97% (95% CI, 89%-100%) at 5 and 10 years. Complications treated with additional surgical procedures were recorded for 19 patients (54%), including three local recurrences, two infections, 11 fractures, and three nonunions. In 10 of these 19 patients, the allograft was removed. Only five of the total 35 study patients (14%) lost the originally preserved epiphysis owing to complications. The mean functional score was 26 points (range, 10-30 points, with a higher score representing a better result) at final followup.Although the recurrence rate was high in this series, the small sample size means that even one or two fewer recurrences might have resulted in a much more favorable percentage. Because of this, future, larger studies will need to determine whether this is a safe approach, and perhaps should compare epiphyseal preservation with other possible approaches, including endoprosthetic reconstruction and/or osteoarticular allografts.Level IV, therapeutic study.