骨肉瘤患者肺部不确定性质结节的临床转归与预后

Clinical outcome and prognosis of indeterminate pulmonary nodules in patients with osteosarcoma

目的探讨骨肉瘤患者不确定性质肺结节(indeterminate pulmonary nodules,IPN)的发生率、临床及影像学特征、临床转归以及预后。方法回顾性收集2011年1月至2021年1月于东部战区总医院骨肿瘤中心收治的合并IPN骨肉瘤患者69例,男47例、女22例,年龄19(7,60)岁。统计患者发现IPN前无病间期、化疗反应、复发或非肺部转移病史、IPN出现化疗间期以及IPN影像学特征,包括IPN的数量、位置、密度、边界清晰度及转归。根据IPN最后转归分为转移组与良性结节组,采用χ2检验比较两组间临床特征及IPN影像学特征与结节恶变转归的相关性。统计患者生存情况,采用Kaplan-Meier检验比较临床及影像学单因素与总生存期的相关性,采用Cox风险回归模型进行生存相关的多因素分析。结果211例骨肉瘤患者中69例发生肺部IPN,发生率为32.7%(69/211)。69例患者中45例(65.2%)IPN诊断为转移灶,24例(34.8%)IPN诊断为良性结节。69例患者随访时间为1~124个月,中位随访时间43个月。至末次随访,41例(59.4%)存活,28例(40.6%)死亡。总生存时间41.0(20.0,65.0)个月,发现IPN后生存时间25.0(10.0,43.0)个月。转移性结节组和良性结节组中肺部结节密度(P<0.001)、边界(P=0.002)以及化疗效果(P<0.001)的差异有统计学意义。多因素生存分析显示化疗效果是影响患者总生存期的独立因素[HR=0.05,95%CI(0.01,0.26)]。边界清晰度[HR=0.12,95%CI(0.02,0.93)]和化疗效果[HR=0.06,95%CI(0.01,0.29)]是影响IPN诊断后生存期的独立因素。结论合并IPN的骨肉瘤患者预后较差,化疗效果差是患者总生存期以及诊断IPN后生存期的独立危险因素,IPN边界清晰是患者诊断IPN后生存期的独立危险因素。

Objective To explore the incidence,clinical characteristics,imaging features,clinical outcome and prognosis of indeterminate pulmonary nodules(IPN)in patients with osteosarcoma.Methods A total of 69 patients of osteosarcoma with IPN in lung treated in the Bone tumor Center of Eastern Theater General Hospital from January 2011 to January 2021 were collected retrospectively,there were 47 males and 22 females,with a median age of 19 years old(range 7-60 years old).The clinical characteristics including disease-free interval,the chemotherapy response,with recurrence/non-pulmonary,IPN presence before/during/after chemotherapy and imaging features of IPN including number of IPN,location of IPN,density of IPN,boundary clarity of IPN and outcome.The patients were divided into the metastasis pulmonary nodules group and the benign nodules group according to the final outcome of IPN.Further,χ2 test was performed for comparison of the clinical and imaging characteristics between the two groups.The survival of patients was counted and the correlation between single factor and survival was compared by Kaplan-Meier test,and multivariate survival analyses were performed using Cox proportional hazards regression models.Results Sixty-nine cases occurred IPN in 211 patients with osteosarcoma,with an incidence of 32.7%.Of the 69 patients,45 patients(65.2%)with IPN were diagnosed as metastases,and 24 patients(34.8%)with IPN were diagnosed as benign nodules.Follow-up length ranged from 1 to 124 months,with the median follow up time 43 months.To the end of follow-up,41 patients(59.4%)remained alive and 28 patients(40.6%)had died.The median survival time was 41.0(20.0,65.0)months and the median survival time after diagnosis of IPN was 25.0(10.0,43.0)months.There were significant differences in lung nodule density(P<0.001),boundary(P=0.002),history of recurrence/extra-pulmonary metastasis(P=0.023)and chemotherapeutic effect(P<0.001)between the metastasis pulmonary nodules group and the benign nodules group.Multivariate survival analysis showed that chemotherapeutic effect was an independent factor affecting the overall survival of patients[HR=0.048,95%CI(0.01,0.26)].Boundary definition[HR=0.12,95%CI(0.02,0.93)]and chemotherapeutic effect[HR=0.06,95%CI(0.01,0.29)]were independent factors influencing survival after diagnosis of IPN.Conclusion Osteosarcoma patients with IPN have a poor prognosis.The poor effect of chemotherapy is an independent risk factor for the overall survival time of those patients and the survival time after diagnosis of IPN.The boundary definition of IPN is an independent risk factor for the survival time after diagnosis of IPN.