Thirty-day Postoperative Complications After Surgery For Metastatic Long Bone Disease Are Associated With Higher Mortality at 1 Year.
转移性长骨疾病手术后 30 天的术后并发症与 1 年时较高的死亡率相关。
- 作者列表："Bindels BJJ","Thio QCBS","Raskin KA","Ferrone ML","Lozano Calderón SA","Schwab JH
BACKGROUND:The benefits of surgical treatment of a metastasis of the extremities may be offset by drawbacks such as potential postoperative complications. For this group of patients, the primary goal of surgery is to improve quality of life in a palliative setting. A better comprehension of factors associated with complications and the impact of postoperative complications on mortality may prevent negative outcomes and help surgeons in surgical decision-making. QUESTIONS/PURPOSES:(1) What is the risk of 30-day postoperative complications after surgical treatment of osseous metastatic disease of the extremities? (2) What predisposing factors are associated with a higher risk of 30-day complications? (3) Are minor and major 30-day complications associated with higher mortality at 1 year? METHODS:Between 1999 and 2016, 1090 patients with osseous metastatic disease of the long bones treated surgically at our institution were retrospectively included in the study. Surgery included intramedullary nailing (58%), endoprosthetic reconstruction (22%), plate-screw fixation (14%), dynamic hip screw fixation (2%), and combined approaches (4%). Surgery was performed if patients were deemed healthy enough to proceed to surgery and wished to undergo surgery. All data were retrieved by manually reviewing patients' records. The overall frequency of complications, which were defined using the Clavien-Dindo classification system, was calculated. We did not include Grade I complications as postoperative complications and complications were divided into minor (Grade II) and major (Grades III-V) complications. A multivariate logistic regression analysis was used to identify factors associated with 30-day postoperative complications. A Cox regression analysis was used to assess the association between postoperative complications and overall survival. RESULTS:Overall, 31% of the patients (333 of 1090) had a postoperative complication within 30 days. The following factors were independently associated with 30-day postoperative complications: rapidly growing primary tumors classified according to the modified Katagiri classification (odds ratio 1.6; 95% confidence interval, 1.1-2.2; p = 0.011), multiple bone metastases (OR 1.6; 95% CI, 1.1-2.3; p = 0.008), pathologic fracture (OR 1.5; 95% CI, 1.1-2.0; p = 0.010), lower-extremity location (OR 2.2; 95% CI, 1.6-3.2; p < 0.001), hypoalbuminemia (OR 1.7; 95% CI, 1.2-2.4; p = 0.002), hyponatremia (OR 1.5; 95% CI, 1.0-2.2; p = 0.044), and elevated white blood cell count (OR 1.6; 95% CI, 1.1-2.4; p = 0.007). Minor and major postoperative complications within 30 days after surgery were both associated with greater 1-year mortality (hazard ratio 1.6; 95% CI, 1.3-1.8; p < 0.001 and HR 3.4; 95% CI, 2.8-4.2, respectively; p < 0.001). CONCLUSION:Patients with metastatic disease in the long bones are vulnerable to postoperative adverse events. When selecting patients for surgery, surgeons should carefully assess a patient's cancer status, and several preoperative laboratory values should be part of the standard work-up before surgery. Furthermore, 30-day postoperative complications decrease survival within 1 year after surgery. Therefore, patients at a high risk of having postoperative complications are less likely to profit from surgery and should be considered for nonoperative treatment or be monitored closely after surgery. LEVEL OF EVIDENCE:Level III, therapeutic study.
背景: 手术治疗四肢转移的益处可能被潜在的术后并发症等缺点所抵消。对于这组患者，手术的首要目标是改善姑息性环境下的生活质量。更好地理解与并发症相关的因素和术后并发症对死亡率的影响可能会预防负面结果，并帮助外科医生进行手术决策。 问题/目的 :( 1) 四肢骨性转移性疾病手术治疗后 30 天并发症的风险如何？(2) 哪些诱发因素与 30 天并发症的高风险相关？(3) 轻微和严重的 3 0 天并发症是否与 1 年时较高的死亡率相关？ 方法: 在 1999 ~ 2016 之间，患者 1090 例，骨性转移性疾病长骨的行手术治疗，在我们的机构回顾性纳入研究.手术包括髓内钉固定 (58%) 、假体内重建 (2 2% )) 、钢板螺钉固定 (14%) 、动力髋螺钉固定 (2% )) 和联合入路 (4%)。如果患者被认为健康到可以进行手术并希望接受手术，则进行手术。通过手动查看患者记录检索所有数据。计算使用Clavien-Dindo分类系统定义的并发症的总体频率。我们不包括 ⅰ 级并发症，因为术后并发症和并发症分为轻微 (ⅱ 级) 和重大 (ⅲ-ⅴ 级) 并发症。采用多变量logistic回归分析确定与术后 30 天并发症相关的因素。采用Cox回归分析评估术后并发症与总生存率之间的关系。 结果: 总体而言，31% 的患者 (333 例中的 1090 例) 在术后 30 天内出现并发症。以下因素与术后 30 天并发症独立相关: 根据改良Katagiri分类的快速生长原发肿瘤 (比值比 1.6; 95% 置信区间，1.1-2.2; p = 0.011) 、多发骨转移 (OR 1.6; 95% CI，1.1-2.3; p = 0.008) 、病理性骨折 (OR 1.5;95% CI，1.1-2.0; p = 0.010) 、下肢位置 (OR 2.2; 95% CI，1.6-3.2; p < 0.001) 、低白蛋白血症 (OR 1.7; 95% CI，1.2-2.4; p = 0.002) 、低钠血症 (OR 1.5; 95% CI，1.0-2.2; p = 0.044) 和白细胞计数升高(OR 1.6; 95% CI，1.1-2.4; p = 0.007)。术后 30 天内的次要和主要术后并发症均与较高的 1 年死亡率相关 (风险比 1。6; 95% CI，1。3-1.8; p < 0.00 1 和HR 3.4; 95% CI，分别为 2.8-4.2; p < 0.00 1)。 结论: 长骨转移性疾病患者易发生术后不良事件。在选择手术患者时，外科医生应仔细评估患者的癌症状况，几个术前实验室值应作为手术前标准检查的一部分。此外，术后 30 天的并发症降低了术后 1 年内的生存率。因此，术后并发症风险高的患者不太可能从手术中获益，应考虑非手术治疗或术后密切监测。 证据级别: III级，治疗性研究。
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.