Chang-Yeon Kim MD, MS, Christopher D. Collier MD, Raymond W. Liu MD, Patrick J. Getty MD, Department of Orthopaedics, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, USA.
Clin Orthop Relat Res. 2019 Mar;477(3):596-605. doi: 10.1097/CORR.0000000000000622.
Chondrosarcoma is the second most frequent primary sarcoma of bone and frequently occurs in the pelvis. Surgical resection is the primary treatment with the two main operative modalities being limb-sparing resection and amputation. Contemporary management has trended toward limb-sparing procedures; however, whether this approach has an adverse effect on long-term survival is unclear.
QUESTIONS/PURPOSES: (1) What are the 5- and 10-year survival rates after limb-sparing surgery and amputation? (2) What factors are associated with survival after contemporary surgical management of pelvic chondrosarcoma?
The 2004-2014 National Cancer Database, a nationwide registry that includes approximately 70% of all new cancers in the United States with requirement for 90% followup, was reviewed for patients diagnosed with pelvic chondrosarcoma who had undergone limb-sparing surgery or amputation. To compare survival, patient demographics, tumor attributes, and treatment characteristics were used to generate one-to-one propensity score-matched cohorts. Other factors associated with survival were determined through multivariable Cox regression. Three hundred eighty-five patients (75%) underwent limb-sparing surgery and 131 (25%) underwent amputation. Propensity score matching resulted in two balanced cohorts of 131 patients.
With the numbers available, we could not demonstrate a difference in overall survival between limb-sparing procedures and amputation. The 5-year survivorship was 70% (95% confidence interval [CI], 62%-79%) for limb-sparing surgery versus 70% (95% CI, 62%-79%) for amputation. The 10-year survivorship was 60% (95% CI, 48%-75%) for limb-sparing surgery versus 59% (95% CI, 48%-72%) for amputation. Kaplan-Meier survival analysis did not demonstrate a difference in survival (p = 0.9). Older age (hazard ratio [HR] = 1.029, p < 0.001), higher Charlson/Deyo comorbidity score (HR = 3.039, p = 0.004), higher grade (HR = 2.547, p = 0.005 for Grade 2; HR = 7.269, p < 0.001 for Grade 3; HR = 10.36, p < 0.001 for Grade 4), and positive surgical margins (HR = 1.61, p = 0.039) were associated with decreased survival.
Our findings support the trend toward increased use of limb-sparing surgery for patients with pelvic chondrosarcoma. Orthopaedic oncologists may use our results when counseling their patients regarding treatment options. However, the choice of limb-sparing surgery versus amputation for these challenging patients should still be a highly individualized decision with careful discussion between the patient and the surgeon.
Level III, therapeutic study.
软骨肉瘤是第二常见的原发性骨肉瘤，常发生于骨盆。手术切除是主要的治疗方法，两种主要的手术方式是保肢手术和截肢。当代的治疗方法倾向于保肢手术；然而，这种方法是否对长期生存有不利影响尚不清楚。
问题/目的：（1）保肢手术后和截肢后的 5 年和 10 年生存率是多少？（2）哪些因素与当代骨盆软骨肉瘤的手术治疗后生存有关？
对 2004-2014 年国家癌症数据库进行了回顾性分析，该数据库是一个全国性的登记处，包括美国约 70%的新发癌症病例，需要进行 90%的随访，对接受保肢手术或截肢的骨盆软骨肉瘤患者进行了分析。为了比较生存率，使用患者人口统计学、肿瘤特征和治疗特征来生成一对一的倾向评分匹配队列。通过多变量 Cox 回归确定与生存相关的其他因素。385 例（75%）患者接受了保肢手术，131 例（25%）患者接受了截肢。倾向评分匹配产生了两个平衡的队列，每组 131 例。
根据现有数据，我们无法证明保肢手术与截肢之间的总生存率存在差异。保肢手术的 5 年生存率为 70%（95%置信区间，62%-79%），截肢的 5 年生存率为 70%（95%置信区间，62%-79%）。保肢手术的 10 年生存率为 60%（95%置信区间，48%-75%），截肢的 10 年生存率为 59%（95%置信区间，48%-72%）。Kaplan-Meier 生存分析未显示生存率存在差异（p=0.9）。年龄较大（风险比[HR] = 1.029，p<0.001）、Charlson/Deyo 合并症评分较高（HR = 3.039，p=0.004）、分级较高（HR = 2.547，p=0.005 为 2 级；HR = 7.269，p<0.001 为 3 级；HR = 10.36，p<0.001 为 4 级）和阳性切缘（HR = 1.61，p=0.039）与生存率降低有关。
我们的研究结果支持在骨盆软骨肉瘤患者中增加使用保肢手术的趋势。骨科肿瘤医生在为患者提供治疗方案时可以使用我们的研究结果。然而，对于这些具有挑战性的患者，保肢手术与截肢的选择仍应是一个高度个体化的决定，需要患者和外科医生之间进行仔细的讨论。
III 级，治疗性研究。
