Background:Due to the relatively advanced age and high mortality rate of patients with high-grade chondrosarcoma (CS), it is important to holistically assess patient- and tumor characteristics in multidisciplinary team and shared decision-making with regard to treatment options. While current prognostic models include multiple tumor and treatment characteristics, the only patient characteristics that are commonly included are age and gender. Based on clinical experience, we believe that factors related to patient preoperative systemic health status such as the American Society of Anesthesiologists (ASA) score may be equally important prognostic factors for overall survival (OS).Methods:A retrospective nationwide cohort study was identified from four specialized bone sarcoma centers in The Netherlands. Patients with a primary CS grade II, III, and dedifferentiated CS were eligible. Prognostic factors including age at presentation, gender, ASA score, CVD, tobacco use, BMI, histological tumor grade, tumor size, pathological fracture, presentation after unplanned excision, type of surgery and surgical margin were evaluated. The outcome measure was OS at the time of surgery. The Kaplan–Meier methodology was employed to estimate OS; a log-rank test was used to assess the difference in survival. To study the impact of prognostic factors on OS, a multivariate Cox proportional hazard regression model was estimated.Results:In total, 249 patients were eligible for this study, and 89 were deceased at the end of follow-up. In multivariate analysis, histological grade (HR 2.247, 95% CI 1.334–3.783), ASA score III (HR 2.615, 95% CI 1.145–5.976, vs. ASA I), and age per year (HR: 1.025, 95% CI 1.004–1.045) were negatively associated with OS. No association was found between tobacco use, BMI, gender or cardiovascular disease and OS in this cohort. Pathological fracture and tumor size were only associated with OS in univariate analysis.Conclusions:This multicenter study is the first on sarcomas to include ASA in a prognostic model. Results show that ASA score as a proxy for patients’ systemic health status should be included when providing a prognosis for patients with a high-grade primary CS, besides the conventional risk factors such as tumor grade and age. Specifically, severe systemic disease (ASA score III) is a strong negative predictor. Conversely, we found no difference in OS between ASA scores I and II. These findings aid multidisciplinary team and shared decision-making with regard to these complex sarcoma patients that often require life-changing surgeries.Level of Evidence:Prognostic level III. See the instructions for authors for the complete description of levels of evidence.
背景：鉴于高级别软骨肉瘤（CS）患者年龄相对较大且死亡率较高，在多学科团队中全面评估患者及肿瘤特征，并就治疗方案进行共同决策至关重要。当前预后模型虽包含多种肿瘤及治疗特征，但通常纳入的患者特征仅有年龄和性别。基于临床经验，我们认为反映患者术前全身健康状况的因素，如美国麻醉医师协会（ASA）评分，可能同样是影响总生存期（OS）的重要预后因素。 方法：本研究为一项回顾性全国队列研究，数据来源于荷兰四家骨肉瘤专科中心。纳入对象为原发II级、III级及去分化软骨肉瘤患者。评估的预后因素包括就诊年龄、性别、ASA评分、心血管疾病史、吸烟史、体重指数、肿瘤组织学分级、肿瘤大小、病理性骨折、非计划切除后就诊情况、手术类型及手术切缘。结局指标为手术时的总生存期。采用Kaplan-Meier法估计总生存期，对数秩检验评估生存差异。为研究预后因素对总生存期的影响，构建了多变量Cox比例风险回归模型。 结果：本研究共纳入249例患者，随访结束时89例死亡。多变量分析显示，组织学分级（HR 2.247，95% CI 1.334–3.783）、ASA评分III级（HR 2.615，95% CI 1.145–5.976，以ASA I级为参照）及年龄（每增加一岁HR：1.025，95% CI 1.004–1.045）与总生存期呈负相关。在本队列中未发现吸烟史、体重指数、性别或心血管疾病与总生存期存在关联。病理性骨折和肿瘤大小仅在单变量分析中与总生存期相关。 结论：本项多中心研究首次在肉瘤预后模型中纳入ASA评分。结果表明，在为高级别原发软骨肉瘤患者提供预后评估时，除肿瘤分级和年龄等传统风险因素外，应纳入作为患者全身健康状况代用指标的ASA评分。具体而言，严重全身性疾病（ASA评分III级）是强烈的负面预测因子。相反，我们发现ASA评分I级与II级患者的总生存期无显著差异。这些发现有助于多学科团队为常需接受重大手术的复杂肉瘤患者制定治疗方案并进行共同决策。 证据等级：预后研究III级。关于证据等级的完整说明请参阅作者须知。
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