L. Wan, C. Tu, S. Li, Z. Li, Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China L. Wan, C. Tu, S. Li, Z. Li, Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China L. Wan, Division of Engineering in Medicine, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Cambridge, MA, USA.
Clin Orthop Relat Res. 2019 Nov;477(11):2508-2518. doi: 10.1097/CORR.0000000000000846.
Regional lymph node involvement is thought to be rare in patients with chondrosarcoma, but its actual prevalence is unclear. Additionally, it is often not considered when prognostic factors are analyzed in patients with chondrosarcoma. However, it has been well established that lymph node involvement is a poor prognostic marker in patients with many types of bone and soft tissue sarcoma, including rhabdomyosarcoma, osteosarcoma, and Ewing's sarcoma. Although lymph node metastases are rare among all sarcoma types, it is important to consider whether lymph node metastases should be assessed in patients with chondrosarcoma because these metastases may impact survival.
QUESTIONS/PURPOSES: (1) What is the reported prevalence of regional lymph node involvement in patients with chondrosarcoma? (2) Do patients who have chondrosarcomas with regional lymph node involvement have different clinicopathologic presentations and survival than patients without regional lymph node involvement? (3) Is regional lymph node involvement independently associated with prognosis in patients with chondrosarcoma?
The data of patients with chondrosarcoma registered in the Surveillance Epidemiology and End Results database (SEER) (1988-2015) were analyzed for the reported prevalence of regional lymph node involvement and its relationship with clinicopathologic features and the 5-year overall survival rate. From 1988 to 2015, 5528 patients with chondrosarcoma were registered in the SEER database. After screening by the inclusion criterion-chondrosarcoma as the first primary tumor, diagnosis with histology confirmation, patients with active followup and available information about regional node status-3374 patients met the inclusion criteria and were analyzed. Demographics and clinicopathologic data were compared using chi-square or Fisher's exact tests. Logistic regression analysis was used to assess the adjusted odds ratio. The overall survival rate was estimated with Kaplan-Meier curves and log-rank tests. Univariate and multivariate analyses of overall survival were performed with Cox proportional hazard models. In addition, a series of sensitivity analyses were performed to assess the robustness of the final Cox proportional hazard model.
Forty-four patients (1.3%) were recorded in the database as having regional lymph node involvement at the time of the primary diagnosis. Lymph node metastases were more likely to be reported in an extraskeletal primary site (3% [13 of 426] versus 1% [31 of 2948], adjusted odds ratio [OR] = 2.9, 95% CI, 1.5-5.8; p = 0.003) for bone primary sites and tumors with maximum diameter ≥ 8 cm (2% [26 of 1045] versus 1% [10 of 1075], adjusted OR = 2.9, 95% CI, 1.3-6.3; p = 0.008) and poorer differentiation (4% [24 of 608] versus 1% [14 of 2308], adjusted OR = 4.0, 95% CI, 2.0-8.2; p < 0.001), and in those with distant metastases (7% [14 of 203] versus 1% [30 of 3148], adjusted OR = 3.5, 95% CI, 1.7-7.1, p = 0.001). The 5-year overall survival rates of patients with and without regional lymph node involvement were 28% (95% CI, 15-42%) and 77% (95% CI, 75-78%), respectively (p < 0.001). After controlling for age, sex, race, grade, metastatic status, size, and histologic subtype, the presence of regional lymph node involvement was associated with poorer survival (hazard ratio, 2.20; 95% CI, 1.50-3.24; p < 0.001); this finding was confirmed in several sensitivity analyses.
The prevalence of regional lymph node involvement in patients with chondrosarcoma was 1.3% in the SEER database. Although chondrosarcomas are rare, patients with chondrosarcomas who have regional node metastases have a poorer prognosis than those who have not reported to have them. This may underrepresent the true proportion of patients with lymph node metastases given the inaccuracies of reporting in this database, but we believe these findings indicate that clinicians should examine patients more carefully for chondrosarcoma with lymph node metastases. Future studies are needed to assess potential treatment strategies to improve the prognosis of these patients.
Level III, prognostic study.
虽然人们认为软骨肉瘤患者的区域淋巴结受累很少见，但实际的流行率尚不清楚。此外，在分析软骨肉瘤患者的预后因素时，通常不考虑淋巴结受累。然而，已经证实，淋巴结受累是许多类型的骨和软组织肉瘤（包括横纹肌肉瘤、骨肉瘤和尤因肉瘤）患者预后不良的标志。虽然所有肉瘤类型的淋巴结转移都很少见，但重要的是要考虑是否应该评估软骨肉瘤患者的淋巴结转移情况，因为这些转移可能会影响患者的生存。
问题/目的：（1）软骨肉瘤患者的区域淋巴结受累的报告患病率是多少？（2）与没有区域淋巴结受累的患者相比，有区域淋巴结受累的软骨肉瘤患者的临床病理表现和生存情况是否不同？（3）区域淋巴结受累是否与软骨肉瘤患者的预后独立相关？
对监测、流行病学和最终结果（SEER）数据库（1988-2015 年）中登记的软骨肉瘤患者的数据进行分析，以了解区域淋巴结受累的报告患病率及其与临床病理特征和 5 年总生存率的关系。1988 年至 2015 年期间，SEER 数据库中登记了 5528 例软骨肉瘤患者。通过纳入标准-软骨肉瘤作为第一原发肿瘤、组织学证实的诊断、有积极随访和区域淋巴结状态的可用信息，筛选出 3374 例符合纳入标准的患者进行分析。使用卡方或 Fisher 确切检验比较人口统计学和临床病理数据。使用 logistic 回归分析评估调整后的优势比。使用 Kaplan-Meier 曲线和对数秩检验估计总生存率。使用 Cox 比例风险模型进行总生存率的单变量和多变量分析。此外，还进行了一系列敏感性分析，以评估最终 Cox 比例风险模型的稳健性。
数据库中记录了 44 例（1.3%）患者在原发性诊断时存在区域淋巴结受累。淋巴结转移更可能发生在骨外原发性部位（3%[426 例中的 13 例]与 1%[2948 例中的 31 例]，调整后的优势比[OR] = 2.9，95%CI，1.5-5.8；p = 0.003），肿瘤最大直径≥8cm（2%[1045 例中的 26 例]与 1%[1075 例中的 10 例]，调整后的 OR = 2.9，95%CI，1.3-6.3；p = 0.008）和分化较差（4%[608 例中的 24 例]与 1%[2308 例中的 14 例]，调整后的 OR = 4.0，95%CI，2.0-8.2；p < 0.001），以及远处转移（7%[203 例中的 14 例]与 1%[3148 例中的 30 例]，调整后的 OR = 3.5，95%CI，1.7-7.1，p = 0.001）。有和没有区域淋巴结受累的患者的 5 年总生存率分别为 28%（95%CI，15-42%）和 77%（95%CI，75-78%），差异具有统计学意义（p < 0.001）。在控制年龄、性别、种族、分级、转移状态、大小和组织学亚型后，区域淋巴结受累与生存率较差相关（风险比，2.20；95%CI，1.50-3.24；p < 0.001）；这一发现在几项敏感性分析中得到了证实。
SEER 数据库中软骨肉瘤患者的区域淋巴结受累患病率为 1.3%。虽然软骨肉瘤很少见，但有区域淋巴结转移的软骨肉瘤患者的预后比没有报告淋巴结转移的患者差。这可能低估了真正有淋巴结转移的患者比例，因为数据库中的报告存在不准确之处，但我们认为这些发现表明，临床医生应该更仔细地检查有淋巴结转移的软骨肉瘤患者。需要进一步研究以评估潜在的治疗策略，以改善这些患者的预后。
III 级，预后研究。
