Limb salvage versus amputation in patients with osteosarcoma of the extremities: an update in the modern era using the National Cancer Database

Abstract

Background Historically, amputation was the primary surgical treatment for osteosarcoma of the extremities; however, with advancements in surgical techniques and chemotherapies limb salvage has replaced amputation as the dominant treatment paradigm. This study assessed the type of surgical resection chosen for osteosarcoma patients in the twenty-first century. Methods Utilizing the largest registry of primary osteosarcoma, the National Cancer Database (NCDB), we retrospectively analyzed patients with high grade osteosarcoma of the extremities from 2004 through 2015. Differences between patients undergoing amputation and patients undergoing limb salvage are described. Unadjusted five-year overall survival between patients who received limb salvage and amputation was assessed utilizing Kaplan Meier curves. A multivariate Cox proportional hazard model and propensity matched analysis was used to determine the variables independently correlated with survival. Results From a total of 2442 patients, 1855 underwent limb salvage and 587 underwent amputation. Patients undergoing amputation were more likely to be older, male, uninsured, and live in zip codes associated with lower income. Patients undergoing amputation were also more likely to have larger tumors, more comorbid conditions, and metastatic disease at presentation. After controlling for confounders, limb salvage was associated with a significant survival benefit over amputation (HR: 0.70; p < 0.001). Although this may well reflect underlying biases impacting choice of treatment, this survival benefit remained significant after propensity matched analysis of all significantly different independent variables (HR: 0.71; p < 0.01). Conclusion Among patients in the NCDB, amputation for osteosarcoma is associated with advanced age, advanced stage, larger tumors, greater comorbidities, and lower income. Limb salvage is associated with a significant survival benefit, even when controlling for significant confounding variables and differences between cohorts.

Predictors and Treatment Outcomes of Pediatric Osteosarcoma in Diverse Socioeconomic Backgrounds in Southeast Asia: A Retrospective Multicenter Study

“…In addition, amputation is more often performed among metastatic patients in LMIC (Pakos et al, 2009;Noor et al, 2014). While significantly superior outcomes were observed in our patients who underwent limb salvage surgery than amputation, this finding may be confounded by the improved supportive care and adjuvant therapy in Singapore and Thailand in our study (Evans et al, 2020;Qi et al, 2020). Nonetheless, amputation may still be appropriate in resource-limited contexts, as it effectively lowers the rate of local recurrence (Nakamura et al, 2020) while preserving adequate functional outcomes and quality of life (Solooki et al, 2018).…”

“…Amputation is typically preferred over limb salvage for patients with older age, advanced stage, large tumor size, comorbidities and low socioeconomic status (Evans et al, 2020), such as in LMC. In addition, amputation is more often performed among metastatic patients in LMIC (Pakos et al, 2009;Noor et al, 2014).…”

Trends in Tumor Site-Specific Survival of Bone Sarcomas from 1980 to 2018: A Surveillance, Epidemiology and End Results-Based Study

“…For osteosarcoma patients, the 5-year CSS rate was 51.0%, 61.6%, 61.8% and 60.5%, in the 1980s, 1990s, 2000s, and 2010s, respectively. Historically, limb amputation was the main treatment for non-metastatic osteosarcoma, with a poor 5-year survival rate of less than 20% [18,19]. Since the 1970s, chemotherapy advancements such as Adriamycin, cis-platin, and methotrexate have increased the prevalence of limb salvage surgery and elevated the 5-year survival rate to more than 50% [20].…”

Joint-preservation surgery for bone sarcoma in adolescents and young adults

“…OS (7) 4 Classification of joint-preservation surgery using distraction osteogenesis. Type I: diaphyseal reconstruction.…”