CONSERVATIVE SURGERY FOR SARCOMA OF LIMB BONES: AN ANALYSIS OF 498 CASES

Abstract

Purpose: Between January 1975 and December 2000, 498 cases of sarcoma of limb bones were treated by our multi-disciplinary team. Mean patient age was 27.1 years. Mean tumour size was 13.1 cm. Histology revealed osteosarcoma (n= 231), chondrosarcoma (n=118), Ewing sarcoma (n=104), MFH (n= 25), fibrosarcoma (n=12) and diverse tumours (n=8). The most frequent localisations were: femur (n=203), pelvis (n=98), tibia (n=86), humerus (n=60). Metastasis was present in 64 cases when first seen by our team. The histological resection was wide in 295 cases, marginal in 185 and contaminated in 18. Adjuvant treatment was adapted to patient age, histology and tumour localisation. Postoperative radiotherapy (34 to 50 Gy) was given for certain adults with osteosarcoma or Ewing tumours who had little histological response to preoperative chemotherapy or who had a marginal or contaminated resection.

Results: Median follow-up was 12 years. Two hundred fifty-two patients were living and disease free, eight were still under treatment, and 238 had died of their disease or treatment complications. There were 35 cases of local relapse, most of them (n=26) in referred patients, particularly after insufficiently effective chemotherapy. Complications were mainly deep infections (n=42). Secondary amputation was required for 24 patients (5%). Functional outcome at last follow-up was excellent in 52% of the patients, good in 35%, fair in 7% and unsatisfactory in 6%. Outcome depended basically on tumour size and localisation and deteriorated with infectious complications and radiotherapy.

Conclusion: 1. In our series, conservative surgery was performed in 95% of the cases, even for large tumours with fractures or for young children. 2. Functional outcome was better after conservative surgery: more than 85% excellent or good function. 3. Risk of local relapse was 2% for patients seen for initial diagnosis of high-grade malignant sarcoma. For patients with low-grade malignant tumours, or those who could not be given effective chemotherapy, the risk of local relapse was higher. 4. Radiotherapy improved local control for Ewing sarcomas and mesenchymatous chondro-sarcomas but its effect could not be assessed for the other tumours. As most of the secondary amputations and most of the poor functional results were observed in patients given complementary radiotherapy, this therapeutic modality, should, in our opinion, be avoided. 5. Preoperative chemotherapy being potentially dangerous for poor responders when the preoperative phase is continued too long, we advocate one month of preoperative chemotherapy for osteosarcoma and six weeks for Ewing sarcoma. This should be sufficient to allow conservative surgery (reduced tumour size) and chemotherapy (precise dose and protocols).