title: Does amputation offer any survival benefit over limb salvage in osteosarcoma patients with poor chemonecrosis and close margins?
abstract: A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence. Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis.
authors.affiliation: Vanderbilt Orthopaedic Institute, 1215 21st Avenue South, Medical Center East, S Tower, Suite 4200, Nashville, Tennessee 37232-8774, USA.
authors.forename: K I A
authors.initials: KI
authors.lastname: Reddy
authors.affiliation: Glasgow Royal Infirmary, 84, Castle Street, Glasgow, G4 0SF, UK.
authors.forename: H
authors.initials: H
authors.lastname: Wafa
authors.affiliation: Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
authors.forename: C L
authors.initials: CL
authors.lastname: Gaston
authors.affiliation: Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
authors.forename: R J
authors.initials: RJ
authors.lastname: Grimer
authors.affiliation: Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
authors.forename: A T
authors.initials: AT
authors.lastname: Abudu
authors.affiliation: Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
authors.forename: L M
authors.initials: LM
authors.lastname: Jeys
authors.affiliation: Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
authors.forename: S R
authors.initials: SR
authors.lastname: Carter
authors.affiliation: Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
authors.forename: R M
authors.initials: RM
authors.lastname: Tillman
mesh_terms: D000293:Adolescent; D000328:Adult; D000671:Amputation, Surgical / Q000379:methods / Q000401:mortality*; D000704:Analysis of Variance; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000627:therapeutic use; D001859:Bone Neoplasms / Q000188:drug therapy / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D035002:Lower Extremity / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D059351:Organ Sparing Treatments / Q000379:methods / Q000401:mortality*; D010020:Osteonecrosis / Q000139:chemically induced / Q000473:pathology; D012516:Osteosarcoma / Q000188:drug therapy / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
keywords: Osteosarcoma; Poor chemonecrosis; Amputation; Limb salvage; Margins; Prognosis; Local recurrence