Commentary & Perspective on
"Pathologic Fracture in Osteosarcoma:
Prognostic Importance and Treatment Implications"
By Sean P. Scully, MD, PhD et al.

Commentary & Perspective by
Dempsey S. Springfield, MD*,
Leni and Peter W. May Department of Orthopaedic Surgery,
Mount Sinai Medical Center, New York, NY

Twenty years ago the standard of care for a patient with an osteosarcoma was to amputate the affected extremity; limb-salvage was an exceptional treatment. In 2001, it is the exception that a child loses a limb as part of the treatment regimen for an osteosarcoma. This dramatic change is attributable to improvements in surgical technique (both resection and reconstruction), imaging methods (first, computed tomography and later, magnetic resonance imaging), and survival rates of patients treated with adjuvant chemotherapy, particularly preoperative or "neoadjuvant" chemotherapy. Today, patients who are advised to have an amputation are those who have tumors that extend into all surrounding compartments with encasement of the neurovascular bundle, or those who have had local recurrence after a limb-sparing operation.

Patients with a pathologic fracture, particularly those who present with a fracture before the diagnosis of osteosarcoma has been made, are often advised to have an amputation. This recommendation is made on the basis of the assumption that a limb-sparing resection in these patients would have an unacceptably high risk of local recurrence, and thus might jeopardize patient survival.

Early in our experience with limb-sparing procedures, the orthopaedic oncologic community recognized that an operation to resect the tumor but spare the limb was associated with an incidence of local recurrence higher than that following an amputation (this is especially true when the low rate of local recurrence after an amputation with radical margins is compared with the rate after a limb-sparing resection), but because there was no significant difference in overall survival, it was thought that an increased rate of local recurrence in patients who had limb-sparing surgery was acceptable¹. Presently, the orthopaedic oncologic community is undecided on the question of whether a pathologic fracture through an osteosarcoma increases the risk of either local recurrence after a limb-sparing resection or death.

Scully and colleagues gathered retrospective data from members of the Musculoskeletal Tumor Society in an attempt to determine whether the presence of a pathologic fracture in an osteosarcoma has prognostic significance with regard to rates of local recurrence or survival. They concluded that patients with an osteosarcoma who sustain a pathologic fracture, whether treated with an amputation or a limb-sparing resection, have an increased risk of local recurrence and death compared with patients who do not have a fracture. In this retrospective study, patients who had limb-sparing resections were most likely selected for these procedures because they had "favorable" tumor and fracture patterns. Patients whose fractures healed during the chemotherapy period had a better prognosis than did those whose fractures did not heal. This observation suggests that the response of the tumor to chemotherapy is important in determining the prognosis in terms of local recurrence and death.

The conclusions of Scully and colleagues confirm the results of previous studies involving small numbers of patients from single surgeons or institutions. The data in this study represent many institutions, a variety of chemotherapeutic protocols, and the experience of different surgeons with varying philosophies regarding limb-sparing resection in patients with osteosarcoma and a pathologic fracture. Their combined results support the concept of resecting the osteosarcoma and sparing the limb, at least in those patients whose tumors are otherwise amenable to a limb-sparing resection. These findings suggest that orthopaedic oncologists can use their current criteria to make decisions about what to advise a patient and his or her family regarding the choice of limb-sparing resection versus amputation.

The psychological outcomes of patients who have a limb-sparing resection are not much better than those of patients who have an amputation². Limb-sparing resection is associated with an increased risk of local recurrence, more perioperative morbidity, a longer recovery period, and the likelihood of additional operations when compared with the outcomes of amputation. Therefore, it is not appropriate to take undue risk to save a limb. The younger the patient, the more difficult it is to successfully control the tumor while salvaging a functional extremity; sometimes an amputation is the correct choice of treatment for a patient. But, for the appropriate patient, Scully and colleagues have provided support in this study for the concept that, in patients with a pathologic fracture in an osteosarcoma, limb-sparing surgery can be safely performed.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68:1331-7.
2. Weddington WW Jr, Segraves KB, Simon MA. Psychological outcomes of extremity sarcoma survivors undergoing amputation or limb salvage. J Clin Oncol. 1985;3:1393-9.