Aim

To identify factors leading to the success or failure of extracorporeal irradiation and re-implantation of bone (ECIR).

Aim

To determine the overall survival of patients with Pelvic Ewing's Sarcoma treated in our unit and to identify prognostic factors in pelvic primaries that could be used to select patients who would most likely benefit from high intensity treatment.

Introduction

The aim of this study was to investigate the results of a series of cases from a single institution with respect to local disease control and patient survival to determine prognostic factors.

Neoadjuvant chemotherapy for osteosarcoma improves outcomes for the majority, but if the chemotherapy does not work then the dilemma often arises as to whether to do limb salvage with a marginal (or worse) margin of excision or to do an amputation. If limb salvage is carried out with a close margin, does post operative radiotherapy make any difference? This study aims to address these questions.

The outcome for patients with Ewing's sarcoma recurrence is poor. Local recurrences occur in 8%-25%of these patients. The aim of the study was to analyze the patients who had a local recurrence to identify factors predicting the local recurrence and if it could be prevented

Bone and Soft Tissue Sarcomas represent approximately 1% of all malignant tumours. Delays in diagnosis are frequent and the average size of Sarcomas at diagnosis has averaged 10cm for many years. In 1999 guidance was produced by NICE with the aim of leading to the earlier diagnosis of common cancers – including Sarcomas. We have attempted to analyze whether this guidance has had any impact on either the size of the tumours at diagnosis or the symptom duration prior to diagnosis experienced by the patients.

Data for patients referred to the Royal Orthopaedic Hospital in Birmingham between 1992 and 2007 with Bone Sarcomas (n=1592) and Soft Tissue Sarcomas (n=2004) were analysed to determine the effect of the guidance. For Bone Sarcomas the mean size of the tumours decreased from 11.2cm prior to the guidance to 10.7cm after the guidance but the change was not statistically significant (p=0.09). The mean duration of symptoms increased from 18 to 21.2 weeks (p=0.01). For Soft Tissue Sarcomas, mean size fell from 10.8cm to 9.5cm (p<0.001), however the duration of symptoms actually increased from 27.3 to 32.1 weeks (p=0.01). Statistical modelling using restricted cubic splines confirmed these trends in the data.

These results show that whilst there may have been a slight improvement in the size at diagnosis of Soft Tissue Sarcomas, overall most patients still experience a long delay between the onset of symptoms and diagnosis and commencement of treatment. It is difficult to conclude that the early diagnosis guidance produced in 1999 has had a significant effect on the basis of this study. Strategies to improve awareness of the symptoms and clinical features of Bone and Soft Tissue Sarcomas are still urgently required.

Introduction

Recently a great deal of interest has emerged in new techniques for resection of bone tumours, such as the use of computer guided surgery, joint sparing prostheses and epiphysiolysis. However, all the techniques may require narrower margins at resection than the traditional Enneking wide margins. The aim of the study was to look at the effect of width and tissue at surgical margins, together with the use of adjuvant therapy on locally recurrent disease and disease free survival.

To evaluate functional and oncological outcomes following resection of primary malignant bone tumours.

Primary malignant tumours of the sacrum are rare, arising from bony or neural elements, or bone marrow in haematological malignancies.

Management of these lesions is dictated by anatomical considerations and the behaviour of tumours. The three key issues which arise are the adequacy of tumour resection, mechanical stabilisation and the need for colostomy.

A retrospective review of the surgical management of primary malignant sacral tumours from 2004 - 2009.

The study included 46 patients (34 males, 12 females) with an average age of 49 (range 7 – 82). Median duration of symptoms before presentation was 26 months.

10 patients had inoperable tumours at presentation. 6 patients had chemotherapy. 2 patients opted for palliative radiotherapy. 1 patient was unfit for surgery.

25 patients (54%) underwent surgical resection. 8 underwent instrumented stabilisations with fibula strut graft vs. 17 uninstrumented.

Colostomy was performed in 10 patients (40%). Mean follow post-operatively was 19.0 months.

Wound healing problems were present in 5/25 (20%). There was no difference in infection rates between definitive surgery with and without colostomy. Mechanical failure of stabilisation was noted in 75%. There was one peri-operative death.

Local recurrence occurred in 12%(3/25) of operated patients although follow-up period was noted to be short.

Mechanical stabilisation for extensive lesions in the sacrum are particularly challenging in tumour surgery. Despite radiological failure in 7/8 instrumented stabilisations, patients were relatively asymptomatic and only 1/8 required revision stabilisation surgery.

Ethics approval: None: Audit Interest Statement: None

Introduction

The pelvis has always been a difficult area for surgeons, with high complication rates from surgery and the perception of poor oncological outcomes. The aim of the study was to look at the surgical and oncological outcomes of pelvic tumours treated at our centre.

There is currently no standard follow up protocol for patients who have been diagnosed with and treated for high-grade osteosarcoma. We therefore investigated the possibility of creating a risk based follow-up protocol for patients with primary osteosarcomas.

313 patients diagnosed with primary osteosarcomas were studied. The identified risk factors for local recurrence included poor necrosis, inadequate margins and high risk tumour site in the bone. The risk factors for metastases were poor necrosis, inadequate margins, extra-compartmental stage and tumour size ≥5cm.

The risk of local recurrence and/or metastases within three years of diagnosis increases as the number of risk factors increase. Patients were grouped according to their number of risk factors. The cumulative risk of metastases for patients with 0, 1, 2, 3 and 4 risk factors is 0%, 12%, 21%, 54% and 60% respectively (p=<0.0001). Risk of local recurrence for patients with 0, 1, 2 and 3 risk factors is 5%, 14%, 25% and 20% respectively (p=0.0025).

Our investigation shows that by grouping patients together according to their number of identified risk factors, it is possible to identify groups of patients that are most at risk. This information can be used to design an evidence based follow up protocol which would have important implications for clinical practice.

Introduction

Bone tumours rarely involve the joint surface as cartilage is thought to be a good barrier to tumour spread. When the tumour does cross the surface the surgeon is faced with the dilemma of whether to amputate the limb, resect it without reconstruction or reconstruct with an implant. This paper aims to investigate the oncological and functional outcomes of patients undergoing an extra-articular resection and reconstruction with an endoprosthesis.

Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment.

We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery.

Eight patients had localised disease and were all treated with open synovectomy and excision of the lesion, with no evidence of recurrence. Twenty patients had diffuse disease, eight treated arthroscopically and twelve with open total synovectomy. Nineteen patients (95%) had recurrence on MRI, however, only five (25%) had evidence of clinical recurrence.

There were no significant complications following arthroscopic synovectomy. Open synovectomy, in contrast, was associated with three wound infections and two thrombo-embolisms. Three patients had Complex regional pain syndrome.

We believe diffuse disease should be treated with arthroscopic synovectomy which is associated with minimal morbidity and can be repeated to maintain disease control. Radiotherapy is helpful in very aggressive cases. TKR was used when there was associated articular erosion.

Objectives

To assess the affects of a delay in diagnosis on the survival rates of Bone Sarcoma (BS) using size and symptom duration as measures of delay.

Solitary plasmacytomas in the appendicular skeleton are rare monoclonal expansions of plasmacytoid cells. They are two main hazards; local destruction of bone with resultant loss of function and possible fracture, and progression to Myeloma.

Between February 1988 and July 2005 seven patients (4 male, 3 female) were treated for solitary plasmacytoma with surgical resection and endoprosthetic reconstruction. The median age was 46.7 (35-75). The site was: distal humerus (2), proximal humerus (2) proximal femur (2) proximal tibia (1). Three patients had sustained a pathological fracture. Five patients had received pre-operative radiotherapy and three received post-operative radiotherapy. Mean follow-up is 8.6 years. Two cases became infected at 2 and 5 years post-operatively and have had revisions of their endoprosthesis. Both remain functional at 18 and 15 years. No patient has suffered a local recurrence. Two patients have progressed to multiple Myeloma but no patients have died. Literature review shows that the progression of solitary bone plasmacytoma to Myeloma is around 53% despite radiotherapy, in an average period of 2-4 years. With resection and endoprosthetic reconstruction, the progression in this series has been 28% despite an average follow up of 8.6 years.

Although the numbers are small, due to the rarity of the condition, surgical resection and endoprosthetic reconstruction reduces disease progression than radiotherapy alone. This produces far superior results compared to the intramedullary nailing of the long bones for this condition. Endoprosthetic reconstruction after resection should be given consideration in cases of solitary plasmacytoma of the appendicular skeleton when there is extensive bone destruction present. The optimal timing of local radiotherapy to be combined with surgery is still to be established.

Objective

Sarcomas are a rare group of tumours, which pose numerous problems regarding correct diagnosis and appropriate management. This study aimed to examine whether symptom duration and tumour size at diagnosis have changed over time, using size and symptom duration as methods of comparison.

Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records.

A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p < 0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02).

Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.

We performed a retrospective review of 98 patients with malignant tumours of the periacetabular region, treated by resection and endoprosthetic reconstruction between 1971 and 2005 at the Royal National Orthopaedic Hospital, Stanmore and The Royal Orthopaedic Hospital, Birmingham.

The mean age of the patients was 43.6 years (10 to 76). 53 patients (54%) were male. The age distribution demonstrated peaks in the 2nd and 6th decades. The mean follow up was 65 months (2 to 405. The overall 10-year survival rate was 56% (determined by the Kaplan-Meier method).

54 patients (58.1%) had one or more complications. Infection was the most common (30%) with the majority occurring in the first 2 years. Dislocation occurred in 19 (20%) of our patients all in the first year following surgery. All were recurrent with a mean of 2.9 (2 to 6) episodes. Operations performed before 1994 were associated with a dislocation rate of 40.5% and after 1996 the rate was only 3.9% (p < 0.001).

Function was assessed according the Toronto Extremity Salvage Sore (TESS). The overall TESS was 59.4. In patients that had a major complication the TESS was 37.1 but in the group that did not the TESS was 70.3 (p < 0.001).

Men experienced higher rates of death, infection and revision than women (p < 0.05). The local recurrence rate was 31% with high grade tumours associated with higher recurrence rates (p < 0.05). Tumour resection in the ilium is associated with higher rates of infection than tumours located in the periacetabular region alone (p < 0.05).

This method of reconstruction is still associated with high complication rates. Function is good if a major complication can be avoided. The lower dislocation rate more recently is probably the result of improved surgical technique and the use of larger femoral heads.

We have investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures have been documented using a prospective database and review of the implant design records and case records. A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge with most of the latter group having a hydroxyapatite collar at the bone prosthesis junction. The median age of the patients was 24 years (range 13-82 yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow-up of 11 years. The risk of revision for any reason was 17% at 5 years, 34% at 10 years and 58% at 20 years. One in ten patients developed an infection and 42% of these patients eventually required an amputation. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 32% at ten years compared with nil for the rotating hinge knees with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge, and for patients older than 40 years at time of implant.

EPRs are the treatment of choice following resection of tumours. These have been used for 39 years in our institution. There has been concern regarding the long term survival of endoprosthesis; this study investigates the fate of the reconstruction.

Current guidelines suggest that most lumps less than 5cm in size will not be malignant. We reviewed our experiences of small lumps at the Royal Orthopaedic Hospital, Birmingham, in order to try and identify factors associated with malignancy. All referrals to our clinic were included and data on size, symptoms, depth and diagnosis were analysed. We identified 325 patients, with 57 (17.5%) malignant and 268 (82.5%) benign lumps. Size >3cm was the most accurate predictor of malignancy (35.8% malignant vs 9.9% <3cm). 23.6% of lumps reported as increasing size were found to be malignant, compared to 8.6% of those that were not. Pain was found to be a poor predictor of malignancy, with only 15.5% of painful lumps found to be malignant and 18.9% of painless lumps found to be malignant. ‘Size >3cm’ has a sensitivity of 73.6% and a specificity of 56.3%, ‘Depth’ has a sensitivity of 73.6% and a specificity of 30.2%, ‘Increasing in Size’ a sensitivity of 71.4% and a specificity of 56.7% and ‘Pain’ a sensitivity of 33.3% and a specificity of 57.1%. If a lump has none of the above features then one can be 89.5% certain that it is not malignant. If it has 1 feature there is a 16.1% chance of its becoming malignant, 2 features a 58% chance, 3 features an 87% chance and if a lump has all 4 features there is a 93.5% chance of its being found to be malignant.

The main limitation with this study is that the data set is skewed because all lumps referred to the Oncology Department are by their nature suspicious. This study identifies those factors which suggest malignancy in small lumps and provides the basis for carrying out a large, community-based study on all lumps, to identify features associated with malignancy.