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Becktell K, Chen Y, Yasui Y, Phelan R, Armstrong GT, Link M, Oeffinger K, Snyder C, Daw N, Weil B, Weldon C, Chow EJ, Schwartz CL. Long-term outcomes among survivors of childhood osteosarcoma: A report from the Childhood Cancer Survivor Study (CCSS). Pediatr Blood Cancer 2024:e31189. [PMID: 39010279 DOI: 10.1002/pbc.31189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/05/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024]
Abstract
PURPOSE Treatment strategies for osteosarcoma evolving between 1970 and 1999 improved 5-year survival and continue as standard of care today. This report evaluates the impact of these evolving therapies on long-term health outcomes. METHODS Five-year survivors of childhood osteosarcoma in CCSS treated from 1970 to 1999 were evaluated for late (>5 years from diagnosis) mortality, chronic health conditions (CHCs), and health status using piecewise-exponential and logistical models. Comparisons were made between survivors and siblings without cancer, and among survivors examining historical and current standard chemotherapies (e.g., methotrexate/doxorubicin/cisplatin [MAP] vs. others), specific chemotherapy agents and surgical approaches (amputation vs. limb salvage [LS]). Models were evaluated adjusting for attained age, sex, race, ethnicity, and age at diagnosis. RESULTS A total of 1257 survivors of osteosarcoma were followed on average for 24.4 years. Twenty-year all-cause late mortality was 13.3% (95% confidence interval [CI]: 11.7%-14.9%) overall and 11.7% (95% CI: 6.9%-16.5%) for the subset treated with MAP plus LS. Survivors were at higher risk of CHCs (rate ratio [RR] 3.7, 95% CI: 3.2-4.3) than the sibling cohort, most notably having more serious cardiac, musculoskeletal, and hearing CHCs. Within the survivor cohort, the risk of severe CHCs was twice as high with MAP versus no chemotherapy (RR 2.1, 95% CI: 1.3-3.4). Compared with primary amputation, serious musculoskeletal CHCs were higher after LS (RR 6.6, 95% CI: 3.6-13.4), without discernable differences in health status. CONCLUSION Contemporary osteosarcoma therapy with MAP plus LS, while improving 5-year disease-free survival, continues to be associated with a high burden of late mortality, CHCs, and health status limitations.
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Affiliation(s)
- Kerri Becktell
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Yan Chen
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Rachel Phelan
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Michael Link
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin Oeffinger
- Department of Medicine and Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Claire Snyder
- Departments of Medicine, Oncology, and Health Policy & Management, Johns Hopkins Schools of Medicine and Public Health, Baltimore, Maryland, USA
| | - Najat Daw
- Department of Pediatrics, Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brent Weil
- Department of Surgery, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Christopher Weldon
- Department of Surgery, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Cindy L Schwartz
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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McChesney GR, Al Farii H, Singleterry S, Lewis VO, Moon BS, Satcher RL, Bird JE, Lin PP. Can Periprosthetic Joint Infection of Tumor Prostheses Be Controlled With Debridement, Antibiotics, and Implant Retention? Clin Orthop Relat Res 2024:00003086-990000000-01672. [PMID: 38991232 DOI: 10.1097/corr.0000000000003184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/17/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Two-stage revision for periprosthetic joint infection (PJI) in patients who have undergone segmental replacement of the distal femur or proximal tibia after tumor resection can be associated with considerable morbidity, pain, and risk of complications because the procedure often results in removal of long, well-fixed stems from the diaphysis. A less-aggressive surgical approach, such as debridement, antibiotics, and implant retention (DAIR), may be attractive to patients and surgeons because of less morbidity, but the likelihood of eradicating infection in comparison to the traditional two-stage revision is not well established for oncology patients. Furthermore, the relative risk of subsequent amputation for DAIR versus two-stage revision has not been defined for this population. QUESTIONS/PURPOSES (1) How does DAIR compare with two-stage revision in terms of infection control for patients with distal femoral or proximal tibial segmental modular endoprostheses? (2) Is DAIR as an initial procedure associated with an increased risk of amputation compared with two-stage revision for infection? METHODS From the longitudinally maintained orthopaedic oncology surgical database at our institution, we identified 69 patients who had been treated for a clinical diagnosis of PJI at the knee between 1993 and 2015. We excluded 32% (22) of patients who did not meet at least one of the major criteria of the Musculoskeletal Infection Society (MSIS) for PJI, 3% (2) of patients who underwent immediate amputation, 3% (2) of patients who had a follow-up time of < 24 months, and 7% (5) of patients who did not have a primary tumor of the distal femur or proximal tibia. The study consisted of 38 patients, of whom eight underwent two-stage revision, 26 underwent DAIR, and four underwent extended DAIR (removal of all segmental components but with retention of stems and components fixed in bone) for their initial surgical procedure. To be considered free of infection, patients had to meet MSIS standards, including no positive cultures, drainage, or surgical debridement for a minimum of 2 years from the last operation. Factors associated with time-dependent risk of infection relapse, clearance, amputation, and patient survival were analyzed using Kaplan-Meier survivorship curves and the log-rank test to compare factors. Association of demographic and treatment factors was assessed using chi-square and Fisher exact tests. RESULTS Continuous infection-free survival at 5 years was 16% (95% CI 2% to 29%) for patients undergoing DAIR compared with 75% (95% CI 45% to 100%) for patients undergoing two-stage revision (p = 0.006). The median (range) number of total surgical procedures was 3 per patient (1 to 10) for DAIR and 2 (2 to 5) for two-stage revision. Twenty-nine percent (11 of 38) of patients eventually underwent amputation. Survival without amputation was 69% (95% CI 51% to 86%) for DAIR compared with 88% (95% CI 65% to 100%) for two-stage revision at 5 years (p = 0.34). The cumulative proportion of patients achieving infection-free status (> 2 years continuously after last treatment) and limb preservation was 58% (95% CI 36% to 80%) for patients initially treated with DAIR versus 87% (95% CI 65% to 100%) for patients first treated with two-stage revision (p = 0.001). CONCLUSION Infection control was better with two-stage revision than DAIR. The chance of eventual clearance of infection with limb preservation was better when two-stage revision was chosen as the initial treatment. However, the loss to follow-up in the two-stage revision group would likely make the true proportion of infection control lower than our estimate. Our experience would suggest that the process of infection eradication is a complex and difficult one. Most patients undergo multiple operations. Nearly one-third of patients eventually underwent amputation, and this was a serious risk for both groups. While we cannot strongly recommend one approach over the other based on our data, we would still consider the use of DAIR in patients who present with acute short duration of symptoms (< 3 weeks), no radiographic signs of erosion around fixed implants, and organisms other than Staphylococcus aureus. We would advocate the extended DAIR procedure with removal of all segmental or modular components, and we would caution patients that there is a high likelihood of needing further surgery. A prospective trial with strict adherence to indications may be needed to evaluate the relative merits of an extended DAIR procedure versus a two-stage revision. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Grant R McChesney
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Humaid Al Farii
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sydney Singleterry
- Neuropsychiatric Institute, Department of Psychiatry, University of Illinois Chicago, Chicago, IL, USA
| | - Valerae O Lewis
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan S Moon
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Robert L Satcher
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Justin E Bird
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick P Lin
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
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Gazendam A, Ghert M. What's New in Musculoskeletal Tumor Surgery. J Bone Joint Surg Am 2023; 105:1929-1936. [PMID: 37874888 DOI: 10.2106/jbjs.23.00833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Aaron Gazendam
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario
| | - Michelle Ghert
- McMaster University, Hamilton, Ontario, Canada
- University of Maryland, Baltimore, Maryland
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Huynh THN, Kuruvilla DR, Nester MD, Zervoudakis G, Letson GD, Joyce DM, Binitie OT, Lazarides AL. Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives. Curr Oncol Rep 2023; 25:1457-1465. [PMID: 37999825 DOI: 10.1007/s11912-023-01475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques. RECENT FINDINGS The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.
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Affiliation(s)
- Thien Huong N Huynh
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Davis R Kuruvilla
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Matthew D Nester
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | | | | | - David M Joyce
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Odion T Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
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Dieffenbach BV, Murphy AJ, Liu Q, Ramsey DC, Geiger EJ, Diller LR, Howell RM, Oeffinger KC, Robison LL, Yasui Y, Armstrong GT, Chow EJ, Weil BR, Weldon CB. Cumulative burden of late, major surgical intervention in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study (CCSS) cohort. Lancet Oncol 2023; 24:691-700. [PMID: 37182536 PMCID: PMC10348667 DOI: 10.1016/s1470-2045(23)00154-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Multimodal cancer therapy places childhood cancer survivors at increased risk for chronic health conditions, subsequent malignancies, and premature mortality as they age. We aimed to estimate the cumulative burden of late (>5 years from cancer diagnosis), major surgical interventions among childhood cancer survivors, compared with their siblings, and to examine associations between specific childhood cancer treatments and the burden of late surgical interventions. METHODS We analysed data from the Childhood Cancer Survivor Study (CCSS), a retrospective cohort study with longitudinal prospective follow-up of 5-year survivors of childhood cancer (diagnosed before age 21 years) treated at 31 institutions in the USA, with a comparison group of nearest-age siblings of survivors selected by simple random sampling. The primary outcome was any self-reported late, major surgical intervention (defined as any anaesthesia-requiring operation) occurring 5 years or more after the primary cancer diagnosis. The cumulative burden was assessed with mean cumulative counts (MCC) of late, major surgical interventions. Piecewise exponential regression models with calculation of adjusted rate ratios (RRs) evaluated associations between treatment exposures and late, major surgical interventions. FINDINGS Between Jan 1, 1970, and Dec 31, 1999, 25 656 survivors were diagnosed (13 721 male, 11 935 female; median follow-up 21·8 years [IQR 16·5-28·4]; median age at diagnosis 6·1 years [3·0-12·4]); 5045 nearest-age siblings were also included as a comparison group. Survivors underwent 28 202 late, major surgical interventions and siblings underwent 4110 late, major surgical interventions. The 35-year MCC of a late, major surgical intervention was 206·7 per 100 survivors (95% CI 202·7-210·8) and 128·9 per 100 siblings (123·0-134·7). The likelihood of a late, major surgical intervention was higher in survivors versus siblings (adjusted RR 1·8, 95% CI 1·7-1·9) and in female versus male survivors (1·4; 1·4-1·5). Survivors diagnosed in the 1990s (adjusted RR 1·4, 95% CI 1·3-1·5) had an increased likelihood of late surgery compared with those diagnosed in the 1970s. Survivors received late interventions more frequently than siblings in most anatomical regions or organ systems, including CNS (adjusted RR 16·9, 95% CI 9·4-30·4), endocrine (6·7, 5·2-8·7), cardiovascular (6·6, 5·2-8·3), respiratory (5·3, 3·4-8·2), spine (2·4, 1·8-3·2), breast (2·1, 1·7-2·6), renal or urinary (2·0, 1·5-2·6), musculoskeletal (1·5, 1·4-1·7), gastrointestinal (1·4, 1·3-1·6), and head and neck (1·2, 1·1-1·4) interventions. Survivors of Hodgkin lymphoma (35-year MCC 333·3 [95% CI 320·1-346·6] per 100 survivors), Ewing sarcoma (322·9 [294·5-351·3] per 100 survivors), and osteosarcoma (269·6 [250·1-289·2] per 100 survivors) had the highest cumulative burdens of late, major surgical interventions. Locoregional surgery or radiotherapy cancer treatment were associated with undergoing late surgical intervention in the same body region or organ system. INTERPRETATION Childhood cancer survivors have a significant burden of late, major surgical interventions, a late effect that has previously been poorly quantified. Survivors would benefit from regular health-care evaluations aiming to anticipate impending surgical issues and to intervene early in the disease course when feasible. FUNDING US National Institutes of Health, US National Cancer Institute, American Lebanese Syrian Associated Charities, and St Jude Children's Research Hospital.
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Affiliation(s)
- Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Andrew J Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Duncan C Ramsey
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Erik J Geiger
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Krajbich JI. CORR Insights®: What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report. Clin Orthop Relat Res 2023; 481:539-541. [PMID: 35969511 PMCID: PMC9928681 DOI: 10.1097/corr.0000000000002316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/20/2022] [Indexed: 01/31/2023]
Affiliation(s)
- J Ivan Krajbich
- Staff Orthopaedic Surgeon, Shriners Hospital for Children, Portland, OR, USA
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Temple HT. Editorial Comment: Selected Proceedings From the 2021 Musculoskeletal Tumor Society Meeting. Clin Orthop Relat Res 2023; 481:458-459. [PMID: 36758165 PMCID: PMC9928828 DOI: 10.1097/corr.0000000000002568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/04/2023] [Indexed: 02/11/2023]
Affiliation(s)
- H Thomas Temple
- Professor, Department of Orthopaedic Surgery, University of Miami, Miami, FL, USA
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Gazendam A, Ghert M. What’s New in Musculoskeletal Tumor Surgery. J Bone Joint Surg Am 2022; 104:2131-2144. [PMID: 37010478 DOI: 10.2106/jbjs.22.00811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Michelle Ghert
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
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