Figure 1. Kaplan-Meier survival analysis demonstrates disease-free survival between propensity-matched patients with sarcoma who underwent metastasectomy and patients who received only medical management without metastasectomy. At-risk patients are shown along the x axis. (PM, pulmonary metastasectomy)

AAOS Now

Published 8/2/2022
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Brandon May

Pulmonary Metastasectomy Improves Survival in Patients with Sarcoma and Lung Metastases

A study suggests that pulmonary metastasectomy is associated with significantly greater rates of disease-free survival (DFS) than the use of medical management alone in patients with sarcoma and lung metastases.

The findings of the study were presented at the AAOS 2022 Annual Meeting by Linus Lee, BE, of the department of orthopaedic surgery at Rush University Medical Center in Chicago.

According to Mr. Lee and colleagues, metastasectomy and chemotherapy are often used for the treatment of advanced sarcoma, yet some data suggest metastasectomy is more cost-effective than chemotherapy for improving short-term survival in these patients. Although available data indicate that the five-year survival of patients who undergo pulmonary metastasectomy for sarcoma can range from 15 percent to 50 percent, the study investigators noted that no randomized, controlled trial data exist to support the use of pulmonary metastasectomy for metastatic sarcoma.

To address the current research gap, Mr. Lee and investigators retrospectively assessed the outcomes of 565 patients with sarcoma and confirmed isolated pulmonary metastasis who underwent either pulmonary metastasectomy (n = 59) or medical management alone (n = 202). The researchers compared the treatment groups with respect to survival.

Patient data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 to 2015. The investigators used 1:4 propensity score matching to select pulmonary metastasectomy and medically managed groups. Additionally, the study used a multivariable Cox proportional hazards model to assess prognostic factors of DFS.

Prior to propensity-matching, there were significant differences between the surgical and nonsurgical groups in terms of median age (45 years versus 52 years, respectively; P <0.001). there were no significant differences between the treatment groups after propensity-matching in regard to baseline characteristics.>

In the matched pulmonary metastasectomy group, surgery was performed for advanced osteosarcoma (32.2 percent), leiomyosarcoma (18.6 percent), and chondrosarcoma (8.5 percent). Most of the matched pulmonary metastasectomy and medically managed patients received neoadjuvant and/or adjuvant chemotherapy (76.3 percent versus 74.8 percent, respectively). After matching, however, a higher proportion of patients in the pulmonary metastasectomy group received radiation to the primary site compared with the nonmetastasectomy group (39.0 percent versus 17.8 percent, respectively).

The median follow-up period was 31 months. In all matched patients, the overall median DFS was 22 months. The median one-, three-, and five-year DFS estimates were 65.1 percent, 31.2 percent, and 17.5 percent, respectively (Figure 1).

After pulmonary metastasectomy, the median DFS was 32 months versus 20 months in patients who underwent only medical management (P = 0.032). According to the multivariable Cox proportional hazards model, factors associated with improved DFS included metastasectomy (hazard ratio [HR] = 0.536; P = 0.008) and chemotherapy (HR = 0.569; P = 0.021). In contrast, negative prognostic factors included age (HR = 1.016; P = 0.001) and high-grade sarcoma (HR = 1.893; P = 0.023).

In a subgroup analysis of patients who underwent only pulmonary metastasectomy, the median DFS was significantly longer in males than in females (P = 0.021) and in patients with bone sarcoma compared with patients with soft-tissue sarcoma (P = 0.014).

Although the data in the study were collected from various hospitals, the retrospective nature of the analysis as well as the small number of patients in the pulmonary metastasectomy group represent limitations of the research. Additionally, the investigators noted that they lacked baseline patient data such as pulmonary reserve or comorbid diseases, as well as data on progression of initial disease with systemic medical therapy.

The researchers wrote, “Until randomized clinical trials for treatment of pulmonary metastasis in sarcoma are successfully completed,” pulmonary metastasectomy “should be considered an effective treatment strategy in select patients” with sarcoma and lung metastases.

Mr. Lee’s coauthors of “Pulmonary Metastasectomy in Bone and Soft Tissue Sarcoma with Metastasis to the Lung” are Charles Gusho, BS; Christopher Seder, MD; Nicolas Lopez-Hisijos, DO; Alan Blank, MD; and Marta Batus, MD.

Brandon May is a freelance writer for AAOS Now.