转移性癌症患者姑息性大截肢的适应证和结果。
Indications and outcomes of palliative major amputation in patients with metastatic cancer.
机构信息
Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA; Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA.
出版信息
Surg Oncol. 2022 Mar;40:101700. doi: 10.1016/j.suronc.2021.101700. Epub 2021 Dec 30.
BACKGROUND
Patients with stage IV cancer often experience diminished quality of life and pain. Although palliative amputation (PA) can reduce pain, it is infrequently performed because of the morbidity associated with amputation and the limited life expectancy in this population. Here, we describe the indications for PA in patients with stage IV carcinoma or sarcoma and discuss their clinical courses and outcomes. We hypothesized that PA would be associated with reduced pain and improved quality of life in these patients.
METHODS
We retrospectively reviewed medical records of all patients who underwent major amputation (proximal to the ankle or wrist) for metastatic sarcoma or carcinoma from January 1995 to April 2021. We excluded patients who underwent amputation for indications other than palliation. Cox proportional hazards regression analysis was used to determine factors associated with survival after PA.
RESULTS
Twenty-six patients underwent PA (11 for carcinoma, 15 for sarcoma). The most common indications for PA were pain (all patients) and fungating tumor (16 patients). PA was the initial surgery in 7 patients. Forequarter amputations were the most common procedure (6 patients). All patients reported reduced pain after PA, with the mean (±standard deviation) visual analog pain score (on a 10-point scale) decreasing from 5.7 ± 2.9 preoperatively to 0.43 ± 1.3 postoperatively (p < 0.001). The mean preoperative ECOG score was 1.9 ± 0.2 compared with 1.3 ± 0.1 postoperatively (p < 0.001). Fourteen patients were fitted for prostheses (6 upper extremity, 8 lower extremity). Two patients had local recurrence, both within 6 months after PA. The mean survival time after PA was 13 ± 12 months, and mean follow-up was 28 ± 29 months. Mean survival time after PA was not significantly different between patients with sarcoma (11 ± 11 months) versus carcinoma (15 ± 14 months) (p = 0.51). Adjuvant chemotherapy was positively associated with survival; no other factors were associated with survival.
CONCLUSIONS
PA was associated with significantly reduced pain in all patients with stage IV cancer. PA should be considered for those with intractable pain, fungating tumors, or symptoms that diminish quality of life.
LEVEL OF EVIDENCE
Level III.
背景
IV 期癌症患者常经历生活质量下降和疼痛。虽然姑息性截肢（PA）可以减轻疼痛，但由于与截肢相关的发病率以及该人群的预期寿命有限，因此很少进行。在这里，我们描述了 IV 期癌或肉瘤患者行 PA 的适应证，并讨论了他们的临床过程和结果。我们假设 PA 会降低这些患者的疼痛并改善生活质量。
方法
我们回顾性分析了 1995 年 1 月至 2021 年 4 月间所有因转移性肉瘤或癌接受主要截肢（踝关节或腕关节以上）的患者的病历。我们排除了因姑息治疗以外的其他适应证而行截肢的患者。使用 Cox 比例风险回归分析确定与 PA 后生存相关的因素。
结果
26 例患者接受了 PA（11 例为癌，15 例为肉瘤）。PA 的最常见适应证为疼痛（所有患者）和外生肿瘤（16 例）。7 例患者首次接受 PA。前肩部截肢是最常见的手术（6 例）。所有患者报告 PA 后疼痛减轻，平均（±标准差）视觉模拟疼痛评分（10 分制）从术前的 5.7±2.9 降至术后的 0.43±1.3（p<0.001）。术前 ECOG 评分平均为 1.9±0.2，术后为 1.3±0.1（p<0.001）。14 例患者适配了义肢（6 例上肢，8 例下肢）。2 例患者在 PA 后 6 个月内发生局部复发。PA 后平均生存时间为 13±12 个月，平均随访时间为 28±29 个月。PA 后肉瘤（11±11 个月）与癌（15±14 个月）患者的平均生存时间无显著差异（p=0.51）。辅助化疗与生存呈正相关；其他因素与生存无关。
结论
PA 可显著减轻所有 IV 期癌症患者的疼痛。对于那些疼痛剧烈、有外生肿瘤或症状降低生活质量的患者，应考虑行 PA。
证据水平
III 级。
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