Surgical outcomes of extracorporeal irradiation and re-implantation in extremities for high grade osteosarcoma: A retrospective cohort study and a systematic review of the literature

PURPOSE: To assess the failure rate and mode failure of high-grade osteosarcoma patients who received extracorporeal irradiation and re-implantation (ECIR) in extremities. PATIENTS AND METHODS: For the cohort study, patients who had received ECIR at a single institution between January 1996 and December 2014 were retrospectively evaluated. Characteristics of failure and time to failure were recorded and analyzed. In addition, a systematically search of published literatures regarding the use of ECIR for osteosarcoma was conducted. Failure rates and modes of failure were determined from the pooled data. RESULTS: In the cohort study, the overall reconstruction failure was 46% (23 of 50 cases) of which 6% were due to mechanical failure, and 40% were due to non-mechanical failure. In the systematic review, 164 cases reached the criteria for analysis (50 diaphysis, 97 osteochondral of lower extremity, 6 knee resection, and 11 proximal humerus resection). Among those cases, overall failure rate was 29.9% (49 of 164 cases) of which 7.9% were due to mechanical failure, and 22.0% to non-mechanical failure. Diaphyseal resection with intercalary re-implantation had a significantly lower failure rate than osteochondral reconstruction of lower extremity (OR: 2.7, p < 0.02), and knee extra-articular resection osteochondral re-implantation (OR: 10.5, p < 0.01). CONCLUSIONS: Diaphyseal resection and extracorporeal irradiation of intercalary re-implantation offer the most promising outcome among other type of reconstructions. Availability of graft, fewer structural complications, and biological permanence are advantages of this reconstruction method.