Lin P P, Schupak K D, Boland P J, Brennan M F, Healey J H
Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Cancer. 1998 Jun 15;82(12):2356-65.
Surgical resection and adjuvant radiation therapy are standard therapy for soft tissue sarcomas. When the tumor approximates bone, periosteal excision may be necessary. It was hypothesized that periosteal stripping and radiation therapy would increase the rate of pathologic fracture.
The soft tissue sarcoma data base at the Memorial Sloan-Kettering Cancer Center was used to identify a consecutive series of 205 patients who were treated over a 15-year period (1982-1997). All patients had a soft tissue sarcoma of the thigh, which was managed by limb-sparing surgery and radiation therapy. Patients who had bone invasion by tumor or bone resection were not included.
Nine patients, including eight women and one man, developed a femoral fracture in an area of previous radiation and surgery. All nine patients had undergone periosteal excision. The risk of fracture, by Kaplan-Meier survivorship, was 29% at 5 years if the resection included periosteum (P < 0.0001). Cox multiple regression analysis showed that periosteal excision was the only independent prognostic factor for the entire set of 205 patients at risk. However, for the subset of 54 patients who had periosteal stripping, two factors were also found to be prognostically important: female gender (P=0.022) and chemotherapy (P=0.020). The risk of fracture was 47% and 45%, respectively. The treatment of the fractures was difficult. There were four nonunions and three delayed unions.
Periosteal stripping and radiation therapy places the femur at high risk of pathologic fractures, especially for female patients and patients undergoing chemotherapy. When practical, the combination of periosteal stripping and radiation should be avoided.
手术切除及辅助放疗是软组织肉瘤的标准治疗方法。当肿瘤靠近骨骼时，可能需要进行骨膜切除。据推测，骨膜剥离和放疗会增加病理性骨折的发生率。
利用纪念斯隆凯特琳癌症中心的软组织肉瘤数据库，确定了1982年至1997年这15年间连续治疗的205例患者。所有患者均患有大腿软组织肉瘤，采用保肢手术和放疗进行治疗。肿瘤侵犯骨骼或进行骨切除的患者未纳入研究。
9例患者（包括8名女性和1名男性）在先前接受放疗和手术的部位发生了股骨骨折。所有9例患者均接受了骨膜切除。根据Kaplan-Meier生存分析，若切除范围包括骨膜，5年时骨折风险为29%（P<0.0001）。Cox多因素回归分析显示，骨膜切除是205例有风险患者的唯一独立预后因素。然而，对于54例接受骨膜剥离的患者亚组，还发现两个预后重要因素：女性性别（P=0.022）和化疗（P=0.020）。骨折风险分别为47%和45%。骨折的治疗很困难。有4例骨不连和3例延迟愈合。
骨膜剥离和放疗使股骨发生病理性骨折的风险很高，尤其是女性患者和接受化疗的患者。在可行的情况下，应避免骨膜剥离和放疗联合应用。
