Вопросы гематологии/онкологии и иммунопатологии в педиатрии. 2021; 20: 116-124
Симультанные билатеральные торакотомии у пациентов с остеосаркомой и двусторонним метастатическим поражением легких: опыт НМИЦ ДГОИ им. Дмитрия Рогачева
https://doi.org/10.24287/1726-1708-2021-20-4-116-124Аннотация
Остеосаркома (ОС) – самая частая первичная опухоль костей у детей и взрослых. Выявление отдаленных метастазов на момент постановки диагноза ОС имеет место у 15–20% пациентов. Более чем в 80% случаев метастазы локализуются в легких и наиболее часто являются причиной болезньассоциированной смерти пациентов с ОС. Излечение от ОС возможно только в случае достижения полной хирургической ремиссии в легких путем проведения оперативного вмешательства с мануальной пальпацией, обнаружением и удалением всех определяемых метастазов. Среди специалистов, занимающихся торакальной хирургией, общепринятым является проведение клиновидной резекции паренхимы с патологическими очагами, позволяющей сохранить больший объем ткани легкого, по показаниям – выполнение лобэктомии или пульмонэктомии. При этом единого мнения в отношении выбора оперативного доступа при проведении метастазэктомии нет. В настоящее исследование включены 24 пациента, которым в период с февраля 2018 г. по май 2021 г. в отделении онкологии и детской хирургии НМИЦ ДГОИ им. Дмитрия Рогачева проведены симультанные билатеральные торакотомии. Данное исследование одобрено независимым этическим комитетом и утверждено решением ученого совета НМИЦ ДГОИ им. Дмитрия Рогачева. Восемнадцати пациентам операция проведена первично в рамках комбинированного протокольного лечения, 6 – в рецидиве заболевания. У 66,7% пациентов, оперированных первично, по результатам компьютерной томографии и последующих операций количество очагов было недооценено. Только у 3 пациентов и в 21,1% удаленных метастазов выявлена IV степень посттерапевтического патоморфоза. Медиана срока возобновления системного противоопухолевого лечения после билатеральной торакотомии составила 12 дней. У 2 пациентов отмечалась метастатическая прогрессия в легких на терапии и непосредственно после завершения протокольного лечения. При катамнестическом наблюдении 2 пациента умерли от прогрессии ОС, 3 – живы с признаками болезни. У 33,3% пациентов, оперированных первично, развились метастатический (n = 6) и локальный (n = 1) рецидивы.
Список литературы
1. Meyers P.A., Heller G., Healey J.H., Huvos A., Applewhite A., Sun M., et al. Osteogenic sarcoma with clinically detectable metastasis at initial presentation. J Clin Oncol 1993; 11 (3): 449–53.
2. Kager L., Zoubek A., Potschger U., Kastner U., Flege S., Kempf-Bielack B., et al. Primary metastatic osteosarcoma: presentation and outcome of patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols. J Clin Oncol 2003; 21 (10): 1535–41.
3. Bacci G., Rocca M., Salone M., Balladelli A., Ferrari S., Palmerini E., et al. High grade osteosarcoma of the extremities with lung metastases at presentation: treatment with neoadjuvant chemotherapy and simultaneous resection of primary and metastatic lesions. J Surg Oncol 2008; 98 (6): 415–20.
4. Miller B.J., Cram P., Lynch C.F., Buckwalter J.A. Risk factors for metastatic disease at presentation with osteosarcoma: an analysis of the SEER database. J Bone Joint Surg Am 2013; 95 (13): е89.
5. Chen F., Miyahara R., Bando T., Okubo K., Watanabe K., Nakayama T., et al. Prognostic factors of pulmonary metastasectomy for osteosarcomas of the extremities. Eur J Cardiothorac Surg 2008; 34 (6): 1235–9.
6. Ferrari S., Briccoli A., Mercuri M., Bertoni F., Picci P., Tienghi A., et al. Postrelapse survival in osteosarcoma of the extremities: prognostic factors for long-term survival. J Clin Oncol 2003; 21 (4): 710–5.
7. Bielack S.S., Kempf-Bielack B., Branscheid D., Carrle D., Friedel G., Helmke K., et al. Second and subsequent recurrences of osteosarcoma: presentation, treatment, and outcomes of 249 Consecutive Cooperative Osteosarcoma Study group patients. J Clin Oncol 2009; 27 (4): 557–65.
8. Regal A.M., Reese P., Antkowiak J., Hart T., Takita H. Median sternotomy for metastatic lung lesions in 131 patients. Cancer 1985; 55: 1334–9.
9. De Oliveira-Filho A.G., Neto L.S., Epelman S. Median sternotomy for the resection of bilateral pulmonary metastases in children. Pediatr Surg Int 1998; 13: 560–3.
10. Torre W., Rodriguez-Spiteri N., Sierrasesumaga L. Current role for resection of thoracic metastases in children and young adults – Do we need different strategies for this population? Thoracic Cardiov Surg 2004; 52: 90–5.
11. Harting M.T., Blakely M.L. Management of osteosarcoma pulmonary metastases. Semin Pediatr Surg 2006; 15: 25–9.
12. Zarroug A.E., Hamner C.E., Pham T.H., Houghton S.G., Stavlo P., Moir C.R., et al. Bilateral staged versus bilateral simultaneous thoracotomy in the pediatric population. J Pediatr Surg 2006; 41: 647–51.
13. Häcker F.-M., von Schweinitz D., Gambazzi F. The relevance of surgical therapy for bilateral and/or multiple pulmonary metastases in children. Eur J Pediatr Surg 2007; 17: 84–9.
14. Fuchs J., Seitz G., Ellerkamp V., Dietz K., Bosk A., Müller I., et al. Analysis of sternotomy as treatment option for the resection of bilateral pulmonary metastases in pediatric solid tumors. Surg Oncol 2008; 17: 323–30.
15. Tsai J., Mattei P. Median sternotomy for bilateral pulmonary metastasectomy in children. J Pediatr Surg 2012; 47:1345–8.
16. Abbo O., Guatta R., Pinnagoda K., Joseph J.-M. Bilateral anterior sternothoracotomy (clamshell incision): A suitable alternative for bilateral lung sarcoma. World J Surg Oncol 2014; 12: 233.
17. Huvos A.G. Osteogenic sarcoma: pathologic assessment of preoperative (neoadjuvant) chemotherapy. Pр. 122–128. In: Bone tumors: Diagnosis, treatment and prognosis. Second edition. Philadelphia: W.B. Saunders Co.; 1991.
18. Margaritora S., Cesario A., Galetta D., Kawamukai K., Meacci E., Granone P. Staged axillary thoracotomy for bilateral lung metastases: an effective and minimally invasive approach. Eur J Cardiothorac Surg 1999; 16 (Suppl 1): S37–9.
19. Younes R.N., Gross J.L., Deheinzelin D. Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary? World J Surg 2002; 26: 1112–6.
20. Abel R.M., Brown J., Moreland B., Parikh D. Pulmonary metastasectomy for pediatric solid tumors. Pediatr Surg Int 2004; 20 (8): 630e2.
21. Su W.T., Chewning J., Abramson S., Rosen N., Gholizadeh M., Healey J., et al. Surgical management and outcome of osteosarcoma patients with unilateral pulmonary metastases. J Pediatr Surg 2004; 39 (3): 418–23.
22. Karplus G., McCarville M.B., Smeltzer M.P., Spyridis G., Rao B.N., Davidoff A., et al. Should contralateral exploratory thoracotomy be advocated for children with osteosarcoma and early unilateral pulmonary metastases? J Pediatr Surg 2009; 44 (4): 665–71.
23. Erginel B., Soysal F.G., Keskin E., Kebudi R., Celik A., Salman T. Pulmonary metastasectomy in pediatric patients. World J Surg Oncol 2016; 14: 27.
24. Guye E., Lardy H., Piolat C., Bawab F., Becmeur F., Dyon J.-F., et al. Thoracoscopy and solid tumors in children: a multicenter study. J Laparoendosc Adv Surg Tech A 2007; 17: 825–9.
25. Boysen P.G. Perioperative management of the thoracotomy patient. Clin Chest Med 1993; 14 (2): 321–33.
Pediatric Hematology/Oncology and Immunopathology. 2021; 20: 116-124
Simultaneous bilateral thoracotomy in patients with osteosarcoma and bilateral pulmonary metastases: the experience of the D. Rogachev NMRCPHOI
https://doi.org/10.24287/1726-1708-2021-20-4-116-124Abstract
Osteosarcoma (OS) is the most common primary bone tumor in children and adults. In 15–20% of patients, distant metastases are detected at the time of diagnosis of OS. In more than 80% of cases, metastases are located in the lungs and are the most common disease-related cause of death in OS patients. OS can only be cured if complete surgical remission (CSR) in the lungs is achieved through surgery involving palpation, identification and resection of all detected metastases. Among thoracic surgeons, it is common practice to perform wedge resection of the affected lung parenchyma as it spares more healthy lung tissue. Lobectomy or pneumonectomy can be carried out if either is indicated in the patient. There is, however, no consensus on the best surgical approach for metastasectomy. Our study includes 24 patients who underwent simultaneous bilateral thoracotomy at the Department of Oncology and Pediatric Surgery of the D. Rogachev NMRCPHOI in the period from February 2018 to May 2021. The study was approved by the Independent Ethics Committee and the Scientific Council of the D. Rogachev NMRCPHOI. Eighteen patients underwent primary surgery as part of combination protocol treatment, and six patients were surgically treated for relapse. In 66.7% of the patients treated with upfront surgery, the number of lesions was underestimated, as evident from computed tomography images and intraoperative findings. Post-treatment necrosis grade IV was detected only in 3 patients, in 21.1% of the resected metastases. The median time from bilateral thoracotomy to systemic anti-cancer therapy reinitiation was 12 days. Two patients experienced progression of metastatic disease in the lungs during and immediately the protocol treatment. At the last follow-up, 3 patients were alive with evidence of disease, and 2 patients had died of OS progression. A total of 33.3% of the patients who had had primary surgery developed metastatic (n = 6) and local (n = 1) relapses.
References
1. Meyers P.A., Heller G., Healey J.H., Huvos A., Applewhite A., Sun M., et al. Osteogenic sarcoma with clinically detectable metastasis at initial presentation. J Clin Oncol 1993; 11 (3): 449–53.
2. Kager L., Zoubek A., Potschger U., Kastner U., Flege S., Kempf-Bielack B., et al. Primary metastatic osteosarcoma: presentation and outcome of patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols. J Clin Oncol 2003; 21 (10): 1535–41.
3. Bacci G., Rocca M., Salone M., Balladelli A., Ferrari S., Palmerini E., et al. High grade osteosarcoma of the extremities with lung metastases at presentation: treatment with neoadjuvant chemotherapy and simultaneous resection of primary and metastatic lesions. J Surg Oncol 2008; 98 (6): 415–20.
4. Miller B.J., Cram P., Lynch C.F., Buckwalter J.A. Risk factors for metastatic disease at presentation with osteosarcoma: an analysis of the SEER database. J Bone Joint Surg Am 2013; 95 (13): e89.
5. Chen F., Miyahara R., Bando T., Okubo K., Watanabe K., Nakayama T., et al. Prognostic factors of pulmonary metastasectomy for osteosarcomas of the extremities. Eur J Cardiothorac Surg 2008; 34 (6): 1235–9.
6. Ferrari S., Briccoli A., Mercuri M., Bertoni F., Picci P., Tienghi A., et al. Postrelapse survival in osteosarcoma of the extremities: prognostic factors for long-term survival. J Clin Oncol 2003; 21 (4): 710–5.
7. Bielack S.S., Kempf-Bielack B., Branscheid D., Carrle D., Friedel G., Helmke K., et al. Second and subsequent recurrences of osteosarcoma: presentation, treatment, and outcomes of 249 Consecutive Cooperative Osteosarcoma Study group patients. J Clin Oncol 2009; 27 (4): 557–65.
8. Regal A.M., Reese P., Antkowiak J., Hart T., Takita H. Median sternotomy for metastatic lung lesions in 131 patients. Cancer 1985; 55: 1334–9.
9. De Oliveira-Filho A.G., Neto L.S., Epelman S. Median sternotomy for the resection of bilateral pulmonary metastases in children. Pediatr Surg Int 1998; 13: 560–3.
10. Torre W., Rodriguez-Spiteri N., Sierrasesumaga L. Current role for resection of thoracic metastases in children and young adults – Do we need different strategies for this population? Thoracic Cardiov Surg 2004; 52: 90–5.
11. Harting M.T., Blakely M.L. Management of osteosarcoma pulmonary metastases. Semin Pediatr Surg 2006; 15: 25–9.
12. Zarroug A.E., Hamner C.E., Pham T.H., Houghton S.G., Stavlo P., Moir C.R., et al. Bilateral staged versus bilateral simultaneous thoracotomy in the pediatric population. J Pediatr Surg 2006; 41: 647–51.
13. Häcker F.-M., von Schweinitz D., Gambazzi F. The relevance of surgical therapy for bilateral and/or multiple pulmonary metastases in children. Eur J Pediatr Surg 2007; 17: 84–9.
14. Fuchs J., Seitz G., Ellerkamp V., Dietz K., Bosk A., Müller I., et al. Analysis of sternotomy as treatment option for the resection of bilateral pulmonary metastases in pediatric solid tumors. Surg Oncol 2008; 17: 323–30.
15. Tsai J., Mattei P. Median sternotomy for bilateral pulmonary metastasectomy in children. J Pediatr Surg 2012; 47:1345–8.
16. Abbo O., Guatta R., Pinnagoda K., Joseph J.-M. Bilateral anterior sternothoracotomy (clamshell incision): A suitable alternative for bilateral lung sarcoma. World J Surg Oncol 2014; 12: 233.
17. Huvos A.G. Osteogenic sarcoma: pathologic assessment of preoperative (neoadjuvant) chemotherapy. Pr. 122–128. In: Bone tumors: Diagnosis, treatment and prognosis. Second edition. Philadelphia: W.B. Saunders Co.; 1991.
18. Margaritora S., Cesario A., Galetta D., Kawamukai K., Meacci E., Granone P. Staged axillary thoracotomy for bilateral lung metastases: an effective and minimally invasive approach. Eur J Cardiothorac Surg 1999; 16 (Suppl 1): S37–9.
19. Younes R.N., Gross J.L., Deheinzelin D. Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary? World J Surg 2002; 26: 1112–6.
20. Abel R.M., Brown J., Moreland B., Parikh D. Pulmonary metastasectomy for pediatric solid tumors. Pediatr Surg Int 2004; 20 (8): 630e2.
21. Su W.T., Chewning J., Abramson S., Rosen N., Gholizadeh M., Healey J., et al. Surgical management and outcome of osteosarcoma patients with unilateral pulmonary metastases. J Pediatr Surg 2004; 39 (3): 418–23.
22. Karplus G., McCarville M.B., Smeltzer M.P., Spyridis G., Rao B.N., Davidoff A., et al. Should contralateral exploratory thoracotomy be advocated for children with osteosarcoma and early unilateral pulmonary metastases? J Pediatr Surg 2009; 44 (4): 665–71.
23. Erginel B., Soysal F.G., Keskin E., Kebudi R., Celik A., Salman T. Pulmonary metastasectomy in pediatric patients. World J Surg Oncol 2016; 14: 27.
24. Guye E., Lardy H., Piolat C., Bawab F., Becmeur F., Dyon J.-F., et al. Thoracoscopy and solid tumors in children: a multicenter study. J Laparoendosc Adv Surg Tech A 2007; 17: 825–9.
25. Boysen P.G. Perioperative management of the thoracotomy patient. Clin Chest Med 1993; 14 (2): 321–33.
