Free Fibula Flap for Restoration of Spinal Stability after Oncologic Vertebrectomy Is Predictive of Bony Union.
- 作者列表："Mericli AF","Boukovalas S","Rhines LD","Adelman DM","Hanasono MM","Chang EI
BACKGROUND:Nonvascular bone grafts larger than 4 cm have a 50 percent nonunion rate in spine surgery. Vascular bone flaps are one potential solution; however, their utility in spine surgery has not been fully elucidated. The authors hypothesized that the addition of a free fibula flap after oncologic vertebrectomy would safely potentiate bone union. METHODS:The authors performed a retrospective analysis, including all patients who underwent oncologic vertebrectomy for a primary bone tumor at their institution from 2002 to 2017. Patients were divided into two groups: those who underwent spinal reconstruction with nonvascularized bone graft and an alloplastic cage (control) and those whose reconstruction was augmented with a free fibula flap. RESULTS:Forty patients were included (free fibula flap, n = 16; control, n = 24). Adjuvant therapies and medical comorbidities were similar between the two groups. Chordoma was the most common abnormality in both groups. The median number of vertebrae resected in the free fibula flap group was two, compared to one in the cage group (p = 0.08). Despite the smaller mean resection size, there were significantly more nonunions (41.7 percent versus 6.3 percent; p = 0.02), instrumentation complications (33.3 percent versus 6.3 percent; p = 0.04), and neurologic complications (25 percent versus 0 percent; p = 0.03) in the control group. Multivariate logistic regression revealed a control reconstruction significantly predictive of nonunion (OR, 57.04; 95 percent CI, 1.17 to 2773; p = 0.04). Free fibula flap patients demonstrated evidence of bony union at a mean of 4.8 months versus 22.4 months in the control group (p < 0.001). CONCLUSIONS:Free fibula flap surgery in spinal reconstruction after oncologic vertebrectomy is safe and effective. Free fibula flap surgery is independently protective against nonunion and is associated with more rapid union compared with the control. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
背景: 在脊柱外科手术中，大于 4 cm的非血管骨移植物有 50% 的骨不连率。血管骨瓣是一种潜在的解决方案; 然而，它们在脊柱手术中的效用尚未完全阐明。作者假设在肿瘤椎体切除术后增加游离腓骨瓣可安全地加强骨愈合。 方法: 作者进行了回顾性分析，包括 2002 年至 2017 年在其机构接受原发性骨肿瘤椎体切除术的所有患者。将患者分为两组: 采用非血管化骨移植和成体笼 (对照) 进行脊柱重建的患者和采用游离腓骨瓣增强重建的患者。 结果: 共纳入 40 例患者 (游离腓骨瓣，n = 16; 对照，n = 24)。两组的辅助治疗和内科合并症相似。脊索瘤是两组中最常见的异常。游离腓骨瓣组切除的椎体中位数为 2 个，而cage组为 1 个 (p = 0.08)。尽管平均切除大小较小，但骨不连明显较多 (41.7% 对 6.3%; p = 0。0 2) 、器械并发症 (33.3% 对 6.3%; p = 0。0 4)，和神经系统并发症发生率 (25% vs 0; p = 0.0 3) 在对照组中。多变量logistic回归显示对照重建显著预测骨不连 (OR，57.04; 95% CI，1.17 ~ 2773; p = 0.04)。游离腓骨瓣患者在平均 4.8 个月时表现出骨性愈合的证据，而对照组为 22.4 个月 (p <0.001)。 结论: 游离腓骨瓣在脊柱肿瘤椎体切除术后重建中的应用是安全有效的。游离腓骨瓣手术独立预防骨不连，与对照相比愈合更快。 临床问题/证据水平: 治疗性，III。
METHODS:OBJECTIVE:Large inoperable sacral chordomas show unsatisfactory local control rates even when treated with high dose proton therapy (PT). The aim of this study is assessing feasibility and reporting early results of patients treated with PT and concomitant hyperthermia (HT). METHODS: :Patients had histologically proven unresectable sacral chordomas and received 70 Gy (relative biological effectiveness) in 2.5 Gy fractions with concomitant weekly HT. Toxicity was assessed according to CTCAE_v4. A volumetric tumor response analysis was performed. RESULTS: :Five patients were treated with the combined approach. Median baseline tumor volume was 735 cc (range, 369-1142). All patients completed PT and received a median of 5 HT sessions (range, 2-6). Median follow-up was 18 months (range, 9-26). The volumetric analysis showed an objective response of all tumors (median shrinkage 46%; range, 9-72). All patients experienced acute Grade 2-3 local pain. One patient presented with a late Grade 3 iliac fracture. CONCLUSION:Combining PT and HT in large inoperable sacral chordomas is feasible and causes acceptable toxicity. Volumetric analysis shows promising early results, warranting confirmation in the framework of a prospective trial. ADVANCES IN KNOWLEDGE: :This is an encouraging first report of the feasibility and early results of concomitant HT and PT in treating inoperable sacral chordoma.
METHODS:BACKGROUND:National guidelines recommend screening and treatment for cancer-related bone disease and continued monitoring of bone-modifying agents. It is unclear whether a standardized screening tool is utilized to identify eligible patients and ensure appropriate supportive care is implemented. The purpose of this study was to evaluate current prescribing practices and optimize management of bone-modifying agents. METHODS:A retrospective chart review was performed to identify patients who received hormone deprivation therapy or had bone metastases through Hematology/Oncology or Urology clinics from 1 November 2016 to 31 October 2017. The primary endpoints of this study were the incidence of completed baseline dual-energy X-ray absorptiometry (DEXA) scan for patients on hormone deprivation therapy and percent of patients started on a bone-modifying agent for the prevention of skeletal-related events secondary to bone metastasis. Secondary endpoints included percent of patients with dental examinations prior to initiation, adequate calcium and vitamin D supplementation, incidence of osteonecrosis of the jaw or flu-like symptoms and education, and percent of bisphosphonate doses appropriately adjusted based on renal function. RESULTS:A total of 375 patients were assessed for baseline DEXA scans and bone-modifying therapy. Of the 226 patients on hormone deprivation therapy, 111 (49%) patients were appropriately screened with a DEXA scan prior to initiation of hormone deprivation therapy. Among the 149 patients with bone metastases, only 94 (63.1%) patients were started on a bone-modifying agent. CONCLUSIONS:Opportunities have been identified to optimize management of patients with cancer-related bone disease. Implementation of standardized tools may increase the rate of appropriate screening and initiation of bone-modifying therapy when warranted.
METHODS:PURPOSE:Low skeletal muscle mass has been associated with poor prognosis in patients with advanced lung cancer. However, little is known about the relationship between skeletal muscle mass and overall survival in patients with bone metastases from lung cancer. The objective of the present study was to evaluate the prognostic value of low trunk muscle mass in predicting overall survival in these patients. METHODS:The data from 198 patients who were diagnosed with bone metastases from lung cancer from April 2009 to May 2017 were retrospectively reviewed. The areas of the psoas and paravertebral muscles were measured at the level of the third lumbar vertebra on computed tomography scans taken at the time nearest to the diagnosis of bone metastasis. Muscle area was evaluated for male and female cohorts separately using different cutoff points. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS:The overall survival of patients in the lowest quartile for psoas muscle area or paravertebral muscle area was significantly shorter than that of patients above the 25th percentile for muscle area (p < 0.001). Multivariate analyses showed that paravertebral muscle mass (hazard ratio, 1.73; 95% confidence interval, 1.17-2.56; p = 0.006), epidermal growth factor receptor-targeted therapy, and performance status were independent prognostic factors. CONCLUSIONS:Low paravertebral muscle mass was associated with shorter survival, independently of known prognostic factors.