Townsend P W, Smalley S R, Cozad S C, Rosenthal H G, Hassanein R E
Department of Radiation Oncology, University of Kansas Medical Center, Kansas City.
Int J Radiat Oncol Biol Phys. 1995 Jan 1;31(1):43-9. doi: 10.1016/0360-3016(94)E0310-G.
Although orthopedic stabilization is frequently performed for pathological fractures caused by metastatic disease, no data is available to support the value of postoperative radiation therapy (S+RT) in this setting.
We reviewed 64 orthopedic stabilization procedures in 60 consecutive patients with metastatic disease to previously unirradiated weight-bearing bones with pathological or impending pathological fracture (femur 91%). Thirty-five sites that received adjuvant S+RT were compared to 29 sites that were treated with surgery alone (SA). Many potential prognostic variables were evaluated. Endpoints were: functional status (FS) of the extremity (1 = normal pain free use; 2 = normal use with pain, 3 = significantly limited use; 4 = nonfunctional extremity), subsequent orthopedic procedures to the same site, and survival following surgery.
At the univariate level, S+RT (p = 0.02) and prefracture FS (p = 0.04) were the only significant predictors of patients achieving an FS of 1 or 2 after surgery. On multivariate analysis, only postoperative RT was significantly (p = 0.02) associated with attaining FS of 1 or 2 after surgery. The predicted probability of achieving FS 1 or 2 at any time was 53% for S+RT vs. 11.5% or SA (multiple logistic regression, p < 0.01). Evaluation of FS following surgery revealed that S+RT group had significantly better function in the 1-3, 3-6, and 6-12 month postoperative periods (chi-square, p < 0.04 for each time period). Second orthopedic procedures to the same site were more common in the SA group than the S+RT group (log rank, p = 0.03). Actuarial median survival of S group was 3.3 months compared with 12.4 months for the S+RT group (log rank, p = 0.02), confirming the beneficial association with survival shown by the multivariate Cox regression analysis (p = 0.025).
Although this retrospective study is subject to possible biases, several analyses adjusting for numerous prognostic factors uniformly indicate S+RT is the most important factor in patients achieving and maintaining normal functional status (+/- pain). Further, the S+RT group was associated with fewer orthopedic procedures as well as an improved overall survival. The improved survival may be due to (a) more favorable patients being referred for RT (possible section bias), or (b) improved functional status in the S+RT group. This study quantitatively supports the benefit of postoperative RT in this setting.
尽管骨科固定术常用于治疗转移性疾病所致的病理性骨折，但尚无数据支持在此情况下术后放疗（手术加放疗）的价值。
我们回顾了60例连续性转移性疾病患者的64例骨科固定手术，这些患者之前未接受过放疗，发生病理性或即将发生病理性骨折（91%为股骨）。将接受辅助手术加放疗的35个部位与仅接受手术治疗（单纯手术）的29个部位进行比较。评估了许多潜在的预后变量。观察终点包括：肢体功能状态（1 = 正常无痛使用；2 = 正常使用伴疼痛；3 = 使用明显受限；4 = 肢体无功能）、同一部位随后的骨科手术以及术后生存率。
在单因素分析中，手术加放疗（p = 0.02）和骨折前功能状态（p = 0.04）是术后患者达到功能状态1或2的唯一显著预测因素。多因素分析显示，只有术后放疗与术后达到功能状态1或2显著相关（p = 0.02）。手术加放疗组在任何时间达到功能状态1或2的预测概率为53%，而单纯手术组为11.5%（多因素逻辑回归，p < 0.01）。术后功能状态评估显示，手术加放疗组在术后1 - 3个月、3 - 6个月和6 - 12个月的功能明显更好（卡方检验，每个时间段p < 0.04）。同一部位的二次骨科手术在单纯手术组比手术加放疗组更常见（对数秩检验，p = 0.03）。单纯手术组的精算中位生存期为3.3个月，而手术加放疗组为12.4个月（对数秩检验，p = 0.02），这证实了多因素Cox回归分析显示的与生存率的有益关联（p = 0.025）。
尽管这项回顾性研究可能存在偏倚，但多项针对众多预后因素进行调整的分析一致表明，手术加放疗是患者实现并维持正常功能状态（±疼痛）的最重要因素。此外，手术加放疗组的骨科手术较少，总体生存率也有所提高。生存率的提高可能是由于（a）接受放疗的患者病情更有利（可能存在选择偏倚），或（b）手术加放疗组的功能状态得到改善。本研究定量支持了在此情况下术后放疗的益处。
