Chondrosarcoma of the Pelvis
Prognostic Factors and Survival
Analysis at 10-20 Years
Matthew J. Seidel, MD
Patrick P. Lin, MD
Valerae O. Lewis, MD
Christopher P.Cannon, MD
Alan W. Yasko, MD
Literature
Author/Yr #Pts Follow-up 10-Yr Surv Pelvic only?
Comment
Pring 2001 64 12 yr med97% (gr1), 75%(gr2), 14%(DD)
YFew High-Grade (1-gr 3, 7-DD)
Berg 2001 69 13 yr mean 67% NNot all resected; sacrum, spine included
Mochizuki 2000
135 3.9 yr mean 65% NShort f/u, data by stage, sacrum included
Ozaki 1997 31 5.5 yr med 45% YShort f/u, small #pts, data by stage
Sheth 1996 67 9.6 yr med -- YRecurrent tumors included
Goal of Study
• Define long-term oncologic outcome and prognostic factors for chondrosarcoma arising in the pelvic bones
Study Design
• Pelvic chondrosarcoma • Surgically treated with curative intent• Minimum 5 year f/u for living patients
– 5 year potential f/u for deceased patients
• Exclusion:– Sacral epicenter– Recurrent presentation– Metastatic presentation– Prior resection/surgery (other than biopsy)
Data Collection
• Retrospective medical record review including operative, pathology, and radiology reports– Demographics
– Tumor grade, size, location, physical characteristics
– Surgical type and margins
– Timing and location of local recurrence and metastasis
• Long-term data from clinical follow-up, phone call, or letter
Statistics
• Kaplan-Meier survival– Disease-specific survival
– Local recurrence-free survival
– Distant relapse-free survival
• Log rank (determine difference between KM curves)
• Chi-square or Fisher’s exact test
101 Patients
• Collection period: 1948-2000
• Follow-up: 5 to 45 years– Overall median 6 year
follow-up
– Living patients: median 13 year follow-up
• 31 female, 70 male
Overall Survival
• Status At Last Follow-up– 41 NED
– 1 AWD
– 45 DOD
– 13 DOC
– 1 DUC
Grade
• 34 Low
• 24 Intermediate
• 27 High
• 16 Dedifferentiated
Epicenter
• Ilium: 57
• Pubis: 24
• Acetabulum: 10
• Ischium: 10
Tumor Characteristics
• Mean Size: 18.5 cm– Range 3 to 25 cm
• Extra-osseous extension in 91 (90%)
Surgical
• Surgery Type– Amputation: 37– Limb salvage: 64
• Surgical Margins– Negative: 56– Positive: 42– Not Specified: 3
Disease-Specific Survival
5-Year 10-year 20-Year
Low 88% 85% 72%
Intermediate 70% 45% 45%
High 42% 39% 35%
Disease-Specific Survival
5-Year 10-year 20-Year
Low 88% 85% 72%
Intermediate 70% 45% 45%
High 50% 45% 38%
DD31%(15 mo)
31% ---
DSS: Prognostic VariablesVariable Prognostic P-value
Dedifferentiated Y <.0001
High Grade Y .0001
Cross Midline Y .0004
Displace Bladder Y .001
Local Recurrence Y .007
Intermediate Grade Marginal .07
Size >=10 cm Marginal .08
Amputation (vs. LSS) Marginal .08
Extra-osseous extension
N .11
Positive Margin N .13
Epicenter N .45
Effect of LR On DSS
• Significant decrease in survival for patients with LR
• P=.007
Follow-up (months)
6005004003002001000
Survival
1.0
.8
.6
.4
.2
0.0
No LR
LR
Effect of LR On DSSLow Grade
• Significant survival difference
• P=.003
Effect of LR On DSS Intermediate Grade
• Marginal significance• P=.08
Effect of LR On DSSHigh Grade
• Not Significant • P=0.42
Results – Local Recurrence
• 35 Local Recurrences– Mean time 29 months– Range 3 to 120 months
• 91% (32/35) occurred within five years• 3 Local Recurrence after five years
– 84 months (low-grade)– 108 months (intermediate-grade)– 120 months (low-grade)
Results – Local Recurrence
• 68% of LR (23/34) associated with positive resection margins
Negative Margin
(56)
Positive Margin
(42)
LR 10 (17.9%) 23 (54.8%)P=.002
No LR 46 (82.1%) 19 (45.2%)
Local Recurrence-Free Survival
5-Year 10-year 20-Year
Low 73% 66% 66%
Intermediate 49% 37% 37%
High 63% 63% 63%
LR – Prognostic VariablesVariable Prognostic P-Value
Positive Margin Y .0002
Cross Midline Y .007
Displace Bladder Y .001
Size >= 10cm Marginal .06
Pubis Epicenter Marginal .06
Non-Pubis Epicenter N .12
High-Grade N .19
Extra-osseous extension N .25
Dedifferentiated N .35
Surgery (Amp vs LSS) N .91
Results - Metastasis
• 28 Metastasis– Mean time 22 months– Range 1-114 months
• Location– Lung most common (27)– Other locations: liver (4), brain (2), spine (2),
kidney (1), heart (1), pericardium (1), humerus (1), lymph node (1), scalp (1)
Results - Metastasis
• 93% (26/28) metastasis occurred in first four years
• Two metastasis occurred after four years– 74 months (low-grade; LR at 23, 36, 41
months)– 114 months (intermediate-grade; LR at 108
months)
Results - Metastasis
• 26/28 (93%) DOD at last follow-up– Median time 9 months
• 2/28 (7%)– DOC (1): NED 5 years after wedge resection at 24 mo
– AWD(1): alive 4 years, wedge resection pending
• Metastasis has a significant negative effect on DSS (p<.0001)
Distant Relapse-Free Survival
5-Year 10-year 20-Year
Low 91% 88% 88%
Intermediate 76% 61% 61%
High 51% 46% 46%
DR-Prognostic Variables
Variable Prognostic (Y/N) P-Value
Amputation Y .0004
Dedifferentiated Y .002
High-Grade Y .002
Displaced Bladder Y .02
Size >= 10 cm Marginal .08
Local Recurrence N .19
Positive Margin N .30
Extra-osseous extension N .43
Cross Midline N .55
Location N .68
Study Limitations
• Diminishing number of patients at 20 years– 39% >10 yr f/u– 17% >20 yr f/u
• Changes in mode and quality of radiographic imaging over study period
• Vagaries of histological grading
• Limited long-term radiographic imaging
Conclusions
• Long term follow-up data show LR or metastasis can occur beyond five years
• No first LR or metastasis was seen after 10 years
Conclusions
• Local Recurrence has a significant negative effect on long term survival – Most pronounced for low and intermediate
grade tumors.
• Metastasis overwhelmingly resulted in death
Conclusions
• Significant prognostic factors at late follow-up are unchanged from short-term follow-up data– Disease-specific survival– Local recurrence-free survival– Distant relapse-free survival
Conclusions
• Evidence-based post-operative surveillance strategy should include at least 10 year follow-up after initial resection