Moon Bryan S, Dunbar Dwayne J, Lin Patrick P, Satcher Robert L, Bird Justin E, Lewis Valerae O
Department of Orthopaedic Oncology, MD Anderson Cancer Center, Unit 1448, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
Clin Orthop Relat Res. 2017 Jan;475(1):212-217. doi: 10.1007/s11999-016-5069-8. Epub 2016 Nov 1.
Patients with primary bone and soft tissue sarcoma are at risk for skeletal metastases. Although uncommon, these metastases can result in impending or pathologic fractures. Intramedullary nailing traditionally has been an accepted form of palliative treatment for patients with metastatic carcinoma, but we could find no studies that report specifically on intramedullary nailing of metastatic sarcoma lesions.
QUESTIONS/PURPOSES: We asked: (1) What is the survival of patients with an impending or pathologic fracture from a sarcoma metastasis? (2) What proportion of patients treated with intramedullary nailing subsequently underwent a revision procedure or nail removal during their lifetimes?
Between 1996 and 2014, we performed 40 intramedullary nailing procedures in 34 patients with multifocal metastases from sarcomas who showed signs or symptoms of impending fracture or who presented with a pathologic fracture. All of these patients are accounted for, either through the time of death or to the present, and all are included at a mean of 13 months (range, 0.3-86 months) in this retrospective study. During the study period, we generally applied the same surgical indications for patients with nailing of metastatic sarcoma lesions as we did for patients with metastatic carcinoma; in general, we used intramedullary nailing (with or without cement) rather than resection for diaphyseal lesions with less cortical destruction and no substantial soft tissue mass or metadiaphyseal lesions that could be adequately supplemented with cementation. The goal was to use this approach when it would allow immediate weightbearing, or in patients whose medical conditions were such that a more-extensive procedure seemed unsafe. During the same period, an additional 58 patients underwent resection procedures for metastatic sarcomas to long bones because they either did not meet the above indications, had a solitary resectable metastasis, or because of surgeon preference; these patients were excluded from this study. The median age of the patients was 52 years (range, 27-81 years). Eleven patients with 11 impending or pathologic fractures were documented to have received either preoperative or postoperative radiation therapy and 29 patients received some form of chemotherapy.
Thirty (88%) patients died during the period of observation, at a median of 5 months (range, 0.3-80 months) after surgery. Twenty-nine patients (85%) underwent no additional surgery and retained their original intramedullary nail. One patient (3%) underwent nail removal for infection, and four patients (12%) underwent further surgical revision secondary to local progression.
Patients with an impending or pathologic fracture from multifocal metastatic sarcoma to a long bone have a dismal prognosis, but they may gain short-term benefit from surgical fixation with the goal of reducing pain and maintaining mobility. Although we have no group for comparison, such as treating with radiotherapy alone or resection and an endoprosthesis, our findings suggest that use of intramedullary nails is helpful for providing fixation that in most instances lasts for the lifetime of patients with multifocal bone metastases from sarcomas.
Level IV, therapeutic study.
原发性骨与软组织肉瘤患者存在发生骨转移的风险。虽然这种转移并不常见，但可导致即将发生的骨折或病理性骨折。髓内钉固定术传统上一直是转移性癌患者姑息治疗的一种公认形式，但我们未找到专门报道转移性肉瘤病灶髓内钉固定术的研究。
问题/目的：我们提出以下问题：（1）因肉瘤转移而面临即将发生的骨折或病理性骨折的患者的生存率如何？（2）接受髓内钉固定术治疗的患者在其一生中随后接受翻修手术或取出内固定钉的比例是多少？
1996年至2014年期间，我们对34例患有肉瘤多灶性转移且出现即将发生骨折的体征或症状或已发生病理性骨折的患者进行了40次髓内钉固定手术。所有这些患者均已随访至死亡或直至目前，在这项回顾性研究中，他们的平均随访时间为13个月（范围为0.3 - 86个月）。在研究期间，我们对转移性肉瘤病灶进行髓内钉固定术的患者通常采用与转移性癌患者相同的手术指征；一般来说，对于皮质破坏较轻且无大量软组织肿块的骨干病灶或可通过骨水泥充分填充的干骺端病灶，我们采用髓内钉固定术（有或无骨水泥）而非切除术。目标是在该方法允许立即负重时使用，或在患者病情使其无法进行更广泛手术的情况下使用。同一时期，另有58例患者因不符合上述指征、有孤立的可切除转移灶或因外科医生的偏好而接受了转移性肉瘤至长骨的切除术；这些患者被排除在本研究之外。患者的中位年龄为52岁（范围为27 - 81岁）。11例有即将发生的骨折或病理性骨折的患者记录接受了术前或术后放疗，29例患者接受了某种形式的化疗。
30例（88%）患者在观察期内死亡，中位死亡时间为术后5个月（范围为0.3 - 80个月）。29例（85%）患者未接受额外手术，保留了原有的髓内钉。1例（3%）患者因感染取出内固定钉，4例（12%）患者因局部进展接受了进一步的手术翻修。
因多灶性转移性肉瘤至长骨而面临即将发生的骨折或病理性骨折的患者预后不佳，但他们可能从手术固定中获得短期益处，目标是减轻疼痛和维持活动能力。尽管我们没有可供比较的组，如单独放疗或切除及植入假体治疗组，但我们的研究结果表明，使用髓内钉有助于提供固定，在大多数情况下，对于患有肉瘤多灶性骨转移的患者来说，这种固定可维持终身。
IV级，治疗性研究。
