Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study

Sam Yeol Chang; Hyoungmin Kim; Se-Jun Park; Bong-Soon Chang; Chong-Suh Lee; Choon-Ki Lee

doi:10.4184/jkss.2019.26.4.117

Journal List > J Korean Soc Spine Surg > v.26(Suppl 1) > 1142092

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Chang, Kim, Park, Chang, Lee, and Lee: Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study

Original Article

Journal of Korean Spine Surg 2019;26(4):117-125.

Published online: 31 December 2019

DOI: https://doi.org/10.4184/jkss.2019.26.4.117

Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study

Sam Yeol Chang, M.D.^∗, Hyoungmin Kim, M.D., Ph.D.^∗,, Se-Jun Park, M.D.^†, Bong-Soon Chang, M.D.^∗, Chong-Suh Lee, M.D.^†, Choon-Ki Lee, M.D.^∗

^∗Department of Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, Korea

^†Department of Orthopedic Surgery, College of Medicine, Sungkyunkwan University, Seoul, Korea

Corresponding author: Hyoungmin Kim, M.D., Ph.D. ORCID ID: Sam Yeol Chang: https://orcid.org/0000-0003-4152-687X Hyoungmin Kim: https://orcid.org/0000-0002-4500-9653 Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 03080 Korea TEL: +82-2-2072-0357, FAX: +82-2-764-2718 E-mail: hmkim21@gmail.com

Received 14 August 201929 August 2019 Accepted 26 September 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

A retrospective multi-center study.

Objectives

To analyze oncological outcomes according to the resection type and surgical margin following surgical treatment for primary spinal sarcoma.

Summary of Literature Review

Previous studies using registry databases have shown that surgery and negative margins were associated with improved survival for primary spinal sarcoma. However, few studies have comprehensively analyzed the clinical significance of the resection type and surgical margin for the oncological outcomes of this rare malignancy.

Materials and Methods

We retrospectively reviewed consecutive patients who underwent surgical resection for primary spinal sarcoma between 1997 and 2016 at two tertiary medical centers. Overall survival and the occurrence of local recurrence and distant metastasis were compared between the groups using Kaplan-Meier curve analysis and the log-rank test.

Results

Thirty-three patients (21 males, 12 females) with a mean age of 45.1 years and a median follow-up of 36 months were included. There were 13 (39.4%) chondrosarcomas, 12 (36.4%) osteosarcomas, and eight different histological diagnoses. The cohort was categorized into four groups: 1) total en bloc resection with a negative margin (n=12; 36.4%), 2) total en bloc resection with a positive margin: (n=5; 15.2%), 3) total piecemeal resection (n=12; 36.4%), and 4) subtotal resection (n=4; 12.1%). Total en bloc resection with a negative margin was associated with improved overall survival (p=0.030) and less distant metastasis (p=0.025) and local recurrence (p=0.004).

Conclusions

Achieving a negative margin through total en bloc resection, although technically demanding, improves oncological outcomes in primary spinal sarcoma.

Keywords: Primary spinal sarcoma, En bloc resection, Survival, Recurrence, Metastasis

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Fig. 1.

Distribution of patients according to the type of surgical resection and surgical margin.

Fig. 2.

Kaplan-Meier survival curve of the total cohort showing an improvement in overall postoperative survival in patients who underwent total en bloc resection and had a negative margin

Fig. 3.

(A) Kaplan-Meier survival curve for local recurrence showing significantly less recurrence in patients who underwent total en bloc re-section with a negative margin (p=0.004, log-rank test). (B) Kaplan-Meier survival curve for distant metastasis showing significantly less metastasis in patients who underwent total en bloc resection with a negative margin (p=0.025, log-rank test).

Fig 4.

(A–D) A 63-year-old woman was diagnosed with osteosarcoma at the T7 level, which encased the descending thoracic aorta over the T5–8 levels. (E, F) The patient underwent total en bloc resection of the tumor, combined with replacement of the descending thoracic aorta by a thoracic surgeon. The postoperative X-ray is shown. (G, H) The specimen from the operation is shown. The patient experienced transient paraplegia due to spinal cord infarction, and currently ambulates using a walker. The patient had no evidence of disease after 4 years of follow-up.

Table 1.

Summary of Osteosarcoma Patients

Case	Gender/Age	Site	Resection type	Surgical Margin	Local recurrence	Distant metastasis	Follow up (month)	Final status
1	M/23	L2	Total, En bloc	Negative	No	No	96	NED
2	M/49	Sacrum	Total, En bloc	Negative	No	No	56	NED
3	F/63	T6-7-8	Total, En bloc	Negative	No	No	48	NED
4	F/71	C4-5-6	Total, En bloc	Negative	No	No	21	NED
5	M/16	T9	Total, En bloc	Positive	No	No	43	NED
6	M/74	T3	Total, En bloc	Positive	No	No	12	NED
7	F/34	Sacrum	Total, En bloc	Positive	Yes	Yes	33	DOD
8	M/65	T11-12	Total, Piecemeal		Yes	No	20	AWD
9	M/9	T10-11	Total, Piecemeal		No	No	27	NED
10	F/60	T12	Subtotal		NA	Yes	36	AWD
11	M/55	T9-10	Subtotal		NA	Yes	41	DOD
12	M/74	L3	Subtotal		NA	Yes	12	DOD

^∗ Abbreviations: NED, ∗no evidence of disease: AWD, alive with disease, ∗DOD, death of disease: NA, not applicable.

Table 2.

Summary of Chondrosarcoma Patients

Case	Gender/Age	Site	Resection type	Surgical Margin	Local recurrence	Distant metastasis	Follow up (month)	Final status
1	F/41	T7	Total, En bloc	Negative	No	No	255	NED
2	F/63	T10-11-12	Total, En bloc	Negative	No	No	20	NED
3	M/32	L2-3	Total, En bloc	Negative	No	No	25	NED
4	F/60	T4-8	Total, En bloc	Negative	No	No	24	NED
5	F/55	T9-10-11	Total, En bloc	Positive	Yes	Yes	36	AWD
6	F/25	L1	Total, Piecemeal		No	No	78	NED
7	M/76	T11	Total, Piecemeal		No	No	51	NED
8	M/71	T9-11	Total, Piecemeal		No	No	6	NED
9	M/48	C4-5	Total, Piecemeal		Yes	Yes	47	AWD
10	M/36	T4-6	Total, Piecemeal		Yes	Yes	41	AWD
11	M/43	L4-5	Total, Piecemeal		Yes	Yes^∗	56	DOD
12	M/48	T9-12	Total, Piecemeal		Yes	Yes	22	DOD
13	M/33	C5	Subtotal		NA	No	47	AWD

^∗ Abbreviations: NED, ∗no evidence of disease: AWD, alive with disease, ∗DOD, death of disease: NA, not applicable.

^∗ The patient had a lung metastasis at the initial presentation of malignancy and was excluded from the survival analysis for the occurrence of distan metastasis.

Table 3.

Summary of Patients with Other Types of Sarcoma

Case	Gender/ Age	Diagnosis	Site	Resection type	Surgical margin	Local recurrence	Distant metastasis	Follow up (month)	Final status
1	F/30	Langerhans cell sarcoma	T12	Total, En bloc	Negative	No	No	33	NED
2	M/60	Spindle cell sarcoma	T12	Total, En bloc	Negative	No	No	24	NED
3	F/40	Rhabdomyosarcoma	Sacrum	Total, En bloc	Negative	No	No	15	NED
4	M/38	Synovial sarcoma	C6-7-T1	Total, En bloc	Negative	No	Yes	47	NED
5	M/10	Epithelioid sarcoma	Sacrum	Total, En bloc	Positive	No	No	27	NED
6	M/37	Leiomyosarcoma	T3	Total, Piecemeal		Yes	Yes	15	AWD
7	F/36	Undifferentiated pleomorphic sarcoma	L5	Total, Piecemeal		Yes	Yes	144	DOD
8	M/16	Ewing's sarcoma	T6	Total, Piecemeal		Yes	Yes	54	DOD

^∗ Abbreviations: NED,∗no evidence of disease: AWD, ∗alive with disease: DOD, death of disease.

^∗ The patient is in NED state after lung metastectomy.

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