Lanier Claire M, Johnson Adam G, Razavian Niema B, Farris Joshua C, Hughes Ryan T
Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Radiation Oncology, Middlesex Hospital, Middletown, CT, USA.
Cureus. 2022 Dec 21;14(12):e32778. doi: 10.7759/cureus.32778. eCollection 2022 Dec.
Introduction In patients with metastatic disease involving weight-bearing bones, postoperative radiotherapy (PORT) is commonly administered following surgical stabilization of an impending or confirmed pathologic fracture to reduce the risk of a seeded local recurrence. The goal was to re-evaluate the beneficial effect of PORT in a modern cohort of patients and determine any potential clinical predictors of skeletal-related events (SREs) which were defined as a pathologic fracture or the necessity for radiation or surgery to the affected bone. Methods Consecutive patients undergoing surgical stabilization of metastatic disease to weight-bearing bones of the extremities between 2012 and 2019 were reviewed. Patient, disease, and treatment factors were abstracted. The cumulative incidence of SREs was determined using competing risks methodology; overall survival (OS) was estimated using the Kaplan-Meier method. Results A total of 82 patients were identified, 74% of whom had undergone intramedullary nail fixation and 26% internal fixation or replacement. The femur was the most commonly involved bone (94%). A majority (78%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 1-2. Bone-strengthening agents were given to 38% and PORT to 54%. The median PORT dose was 30 Gy in 10 fractions and the median percent coverage of surgical hardware was 100% (range, 25-100). SREs occurred in 10 of 82 patients. There were no differences between no RT and RT groups for the two-year cumulative incidence of SREs (8.2% vs 11.5%, p=0.59) or two-year cumulative incidence of local failure (10.8% vs 4.6%, p=0.53). The only identified predictors of SREs were the use of bone-strengthening agents (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.05-1.06, p=0.06) and malnutrition (HR 3.69, 95% CI 0.91-14.93, p=0.07). For patients treated with PORT, a biologically effective dose or percent coverage of surgical hardware was not associated with SREs. Conclusion In this series, the addition of PORT following surgery for metastatic disease involving weight-bearing bones does not significantly affect the rate of SREs. The use of bone-strengthening agents appears protective, and malnourished patients appear particularly at high risk for future SRE.
引言 在患有累及负重骨的转移性疾病的患者中，术后放疗（PORT）通常在即将发生或已确诊的病理性骨折手术固定后进行，以降低种植性局部复发的风险。目的是重新评估PORT在现代患者队列中的有益效果，并确定骨骼相关事件（SREs）的任何潜在临床预测因素，SREs定义为病理性骨折或对受累骨进行放疗或手术的必要性。方法 回顾了2012年至2019年间接受四肢负重骨转移性疾病手术固定的连续患者。提取患者、疾病和治疗因素。使用竞争风险方法确定SREs的累积发生率；使用Kaplan-Meier方法估计总生存期（OS）。结果 共确定了82例患者，其中74%接受了髓内钉固定，26%接受了内固定或置换。股骨是最常受累的骨（94%）。大多数（78%）患者东部肿瘤协作组（ECOG）体能状态为1-2。38%的患者接受了骨强化剂治疗，54%接受了PORT。PORT的中位剂量为30 Gy，分10次给予，手术硬件的中位覆盖百分比为100%（范围，25%-100%）。82例患者中有10例发生了SREs。未接受放疗组和放疗组在SREs的两年累积发生率（8.2%对11.5%，p=0.59）或局部失败的两年累积发生率（10.8%对4.6%，p=0.53）方面没有差异。唯一确定的SREs预测因素是骨强化剂的使用（风险比[HR]0.22，95%置信区间[CI]0.05-1.06，p=0.06）和营养不良（HR 3.69，95%CI 0.91-14.93，p=0.07）。对于接受PORT治疗的患者，生物学有效剂量或手术硬件的覆盖百分比与SREs无关。结论 在本系列研究中，对累及负重骨的转移性疾病手术后加用PORT对SREs发生率没有显著影响。骨强化剂的使用似乎具有保护作用，营养不良的患者未来发生SREs的风险似乎特别高。
