Reddy K I A, Wafa H, Gaston C L, Grimer R J, Abudu A T, Jeys L M, Carter S R, Tillman R M
Vanderbilt Orthopaedic Institute, 1215 21st Avenue South, Medical Center East, S Tower, Suite 4200, Nashville, Tennessee 37232-8774, USA.
Glasgow Royal Infirmary, 84, Castle Street, Glasgow, G4 0SF, UK.
Bone Joint J. 2015 Jan;97-B(1):115-20. doi: 10.1302/0301-620X.97B1.33924.
A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence. Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis.
骨肉瘤对化疗反应不佳（坏死率≤90%）会导致生存率降低和局部复发风险增加，尤其是在切除边缘较窄的情况下。我们评估了在化疗反应不佳的患者中，截肢相对于切缘狭窄的保肢手术（LSS）是否具有生存获益。我们仅分析了肢体骨肉瘤、化疗反应不佳且LSS切缘狭窄（边缘性/病损内）或一期截肢的患者：纳入了360例患者（36例LSS（病损内切缘）、197例LSS（边缘性切缘）和127例截肢）。LSS病损内切缘术后13例（36%）出现局部复发，LSS边缘性切缘术后39例（20%）出现局部复发。接受截肢的患者未出现局部复发。所有患者的五年生存率为41%（95%置信区间（CI）35%至46%），但LSS边缘性切缘治疗的患者为46.2%（95%CI 38%至53%），截肢治疗的患者为36.3%（95%CI 27%至45%），LSS病损内切缘治疗的患者为28%（95%CI 14%至44%）。LSS后首先出现局部复发的患者与未出现局部复发的一期截肢患者生存率相同。40例患者使用了预防性辅助放疗，但在预防局部复发方面没有明显效果。尽管截肢提供了更好的局部控制，但对于这些总体预后较差的患者，与LSS边缘性切缘相比，截肢并没有明显的生存获益。
