Ibrahim Ishaq, Haughom Bryan D, Fillingham Yale, Gitelis Steven
Rush Medical College, Rush University, 600 S Paulina Street, Chicago, IL, 60612, USA.
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
Clin Orthop Relat Res. 2016 Mar;474(3):719-30. doi: 10.1007/s11999-015-4292-z.
Non-Hodgkin's lymphoma (NHL) of bone is a rare musculoskeletal malignancy accounting for fewer than 7% of bone cancers. Traditionally, we have treated patients who have NHL of bone with chemotherapy and radiation therapy, but the role of radiotherapy in disease management and patient functional outcomes after treatment have not been well studied. We investigated the survival advantage of radiotherapy in a large cohort of patients with NHL of bone and assessed associated patient complications of radiotherapy.
QUESTIONS/PURPOSES: The objective of this study was to compare patients treated for NHL of bone with and without radiation in terms of (1) overall survival; (2) pretreatment complications; (3) posttreatment complications; and (4) functional outcomes using the Musculoskeletal Tumor Society (MSTS) score.
A retrospective analysis of all patients with biopsy-proven NHL of bone diagnosed at our institution between 1985 and 2013 was undertaken; 70 patients met our criteria for inclusion with minimum followup of 6 months (median, 55 months; range, 10-219 months). Overall survival at 5 and 10 years was estimated and compared between two groups of patients: one group treated with systemic therapy alone (chemotherapy, rituximab; 46 patients [66%]) and the other with combined modality therapy (systemic therapy and radiotherapy; 24 patients [34%]). During the period in question, indications for radiotherapy included bulky disease, an abbreviated course of systemic therapy, and an incomplete response to systemic therapy. Patients not meeting these criteria generally received systemic therapy alone. With the available sample size, it was estimated that a difference in survival of approximately 30% would have to be present for detection with 80% power (α = 0.05, β = 0.2, n = 70, Δ = 30%). Pretreatment and posttreatment complications occurring in both patient groups were retrospectively reviewed with special emphasis on fracture healing after treatment. MSTS scores were obtained for 45 patients with appendicular tumors at a median followup of 42 months (range, 10-215 months).
With the data available, no difference in Kaplan-Meier survivorship was observed between patients treated with and without radiation at 5 years (98%; 95% confidence interval [CI], 93%-100% versus 95%; 95% CI, 85%-100%; p = 0.281). Patients who were treated with radiation were more likely to experience problems with fracture healing (relative risk [RR], 12.8; 95% CI, 1.8-89.8; p = 0.01). Similarly, patients treated with radiation were at a higher risk for fracture in the posttreatment period (five of 24 versus no radiation zero of 46; RR, 20.7; 95% CI, 1.2-359.0; p = 0.0375). MSTS scores were poorer in patients treated with radiation (75% versus 91%; p = 0.034) attributable in part to a higher incidence of bony complications in this group after treatment.
Based on the numbers of patients in our study, we could not demonstrate a survival advantage with radiation use. Rather, radiotherapy may be associated with orthopaedic complications occurring during and after treatment. Larger, prospective studies are necessary to definitively establish whether radiation is necessary for the treatment of patients with lymphoma of bone.
Level III, therapeutic study.
骨非霍奇金淋巴瘤（NHL）是一种罕见的肌肉骨骼恶性肿瘤，占骨癌的比例不到7%。传统上，我们对骨NHL患者采用化疗和放疗进行治疗，但放疗在疾病管理中的作用以及治疗后患者的功能结局尚未得到充分研究。我们调查了放疗在一大群骨NHL患者中的生存优势，并评估了放疗相关的患者并发症。
问题/目的：本研究的目的是比较接受和未接受放疗的骨NHL患者在以下方面的情况：（1）总生存率；（2）治疗前并发症；（3）治疗后并发症；以及（4）使用肌肉骨骼肿瘤学会（MSTS）评分的功能结局。
对1985年至2013年在我们机构确诊的所有经活检证实的骨NHL患者进行回顾性分析；70例患者符合纳入标准，随访时间至少6个月（中位数为55个月；范围为10 - 219个月）。估计并比较两组患者的5年和10年总生存率：一组仅接受全身治疗（化疗、利妥昔单抗；46例患者[66%]），另一组接受综合治疗（全身治疗和放疗；24例患者[34%]）。在所述期间，放疗的指征包括肿块较大、全身治疗疗程缩短以及对全身治疗反应不完全。不符合这些标准的患者通常仅接受全身治疗。根据可用样本量估计，要以80%的检验效能（α = 0.05，β = 0.2，n = 70，Δ = 30%）检测到生存差异，生存差异需达到约30%。回顾性分析两组患者治疗前和治疗后的并发症，特别关注治疗后的骨折愈合情况。对45例四肢肿瘤患者进行了MSTS评分，中位随访时间为42个月（范围为10 - 215个月）。
根据现有数据，接受放疗和未接受放疗的患者在5年时的Kaplan - Meier生存率无差异（98%；95%置信区间[CI]，93% - 100%对95%；95% CI，85% - 100%；p = 0.281）。接受放疗的患者骨折愈合出现问题的可能性更大（相对风险[RR]，12.8；95% CI，1.8 - 89.8；p = 0.01）。同样，接受放疗的患者在治疗后发生骨折的风险更高（24例中有5例，未接受放疗的46例中无；RR，20.7；95% CI，1.2 - 359.0；p = 0.0375）。接受放疗患者的MSTS评分较低（75%对91%；p = 0.034），部分原因是该组治疗后骨并发症发生率较高。
基于我们研究中的患者数量，我们未能证明放疗具有生存优势。相反，放疗可能与治疗期间及治疗后发生的骨科并发症相关。需要更大规模的前瞻性研究来明确放疗对于骨淋巴瘤患者的治疗是否必要。
III级，治疗性研究。
