Introduction: The Literature is divisive in regards to the superiority of Core versus Incision biopsy in the diagnosis of Soft Tissue Tumour. The Aim of the study is to compare the accuracy of Trucut biopsy and open Incision Biopsy.

Methods: This was a retrospective review of case notes and pathology records. Between January 2006 and June 2007, 34 Trucut biopsies were performed without imaging guidance in an outpatient setting and 57 incision biopsies were performed as an inpatient on patients referred with a soft tissue mass to our service. In each case the accuracy of biopsy in providing a diagnostic sample, in determining the tumour type and the histological grade of tumour were calculated. For each biopsy method we compared the diagnosis after biopsy with the final diagnosis after excision. The proportion of diagnostic biopsies was calculated, as were the sensitivity and specificity of each technique in providing a diagnosis. Fisher’s exact test was used to test for differences in the techniques.

Results: In this series there were 41 soft tissue sarcomas, 8 metastatic adenocarcinoma soft tissue deposits, 7 lymphomas, 1 non soft tissue sarcoma, 32 benign soft tissue tumours and 1 infection. 33/34 Trucut biopsies and 55/57 open biopsies provided the final histological diagnosis (p=1). There was no statistical difference between the techniques in the accuracy of identifying the type and grade of soft tissue sarcoma

Discussion: Trucut biopsy is equivalent to incision biopsy in its accuracy of diagnosing soft tissue tumours. Biopsy in an outpatient setting for appropriate tumours is cost effective and likely shortens the time to diagnosis. Our results are comparable to published data from other centres.

Introduction: The Two Week Waiting Time (2wwt) Standard, which requires that patients with suspected cancer referred by general practitioners should be seen within 2 weeks, was introduced in 2000. We reviewed the performance of this standard with regards to proportion of patients seen and tumour detection rates.

Methods and Results: We reviewed all the referrals sent as “two week waiters” from January 2004 to December 2005, to our bone and soft tissue sarcoma service. These referrals were evaluated for

Whether or not the referral met established referral guidelines for bone and soft tissue tumours

This was compared with the total number of referrals to the unit and their tumour detection rates.

A total of 40 patients were referred as “two week waiters” in the given time period. They were seen on an average of 8 days following the referral. Of the 40 patients, four patients had soft tissue metastasis from a primary tumour elsewhere, and six had primary malignant soft tissue tumours. 12 had a benign bone/ soft tissue tumour. 18 (45%) patients had a non neoplastic pathology (6 Muscle tear/ herniation; 4 ganglion/bursa; 2 lumps that disappeared)

During the same period a total of 515 patients were referred by other routes.

Conclusion: Only 10 of 40 patients referred under the 2-week rule had malignant tumours. The majority of referrals to our service do not fall under this rule. Significant numbers of referral under the 2wwt standard are not in line with the referral guidelines. It is our impression that the 2-week rule, whilst highlighting the need of these patients to be seen urgently may distort clinical priorities and disadvantage patients referred from other sources.

Case Report: Metastatic deposits in the proximal femur commonly result in pathological fracture. Conventionally these fractures are treated surgically, by internal fixation or arthroplasty. The emphasis in treating these fractures is on restoring stability to the proximal femur and relieving pain. We present two cases in which pathological fractures of the proximal femur secondary to metastatic renal carcinoma were treated conservatively with excellent functional outcomes. In both cases, the medical condition of the patient precluded surgery. A 68 year old male with a subcapital fracture of the proximal femur was treated with bedrest and mobilisation. At 6 months he was able to mobilise with crutches, swim, and had returned to almost all normal activities despite non-union of the fracture.

A 63 year old male had a pathological fracture of the proximal femur treated by DCS fixation. The fracture failed to unite and the plate fractured. Despite this the patient was able to walk with crutches, pain free. Discussion: After a pathological fracture of the proximal femur conservative management can lead to satisfactory analgesia, function and therefore quality of life.

Introduction: Short term pain or discomfort after a knee replacement (TKR) is not uncommon, and is usually attributed to the surgical procedure. In this case report, we describe an unusual cause of knee pain following total knee replacement, and remind the reader of the need for a thorough assessment.

Case Report: A 76 year-old male presented with pain in the knee and shin seven months following a TKR on the same side. The pain was dull, aching and constant in nature. There was no other significant past medical history. Pre-operative and immediate postoperative radiographs did not reveal any other abnormality. Clinical examination revealed no evidence of infection, and the motion in the knee ranged from 0–100 degrees. Radiographs revealed a lytic lesion in the proximal tibia just distal to the tibial prosthesis. Further investigations confirmed a diagnosis of renal carcinoma with bone metastases, with one of the lesions appearing in the proximal tibia. The lesion was treated with intralesional curettage, cementing and plate osteosynthesis. The knee pain improved and the mobility was restored. Follow-up radiographs at 6 months showed no evidence of local recurrence.

Discussion: Knee pain following TKR may be attributed to the surgery or the knee implant. However, it is important to keep an open mind about the diagnosis. Local hyperaemia in the metaphysis of proximal tibia following TKR may have resulted in the seeding of metastasis. We elected for primary stabilization of the metastasis with cement and plate, rather than revision of the tibial component with a long intramedullary stem. As a result, rehabilitation was rapid and the risks of revision of the knee prosthesis were avoided.

Introduction and aims: Despite advances in local therapy, there is an ongoing risk of local recurrence after treatment for soft tissue sarcoma. Early detection of local recurrence with MRI scanning may improve outcomes for patients. The purpose of this retrospective study was to evaluate the usefulness of routine postoperative MRI scans in diagnosing clinically occult local recurrence after surgery for trunk and extremity soft tissue sarcomas.

Material and Methods: We reviewed the clinical and radiology records of all patients who underwent surgery for trunk or extremity soft tissue sarcoma in our service with the potential for 3 years of follow up. We looked at the number of postoperative MRI scans performed, the indications for the scans (routine or clinical suspicion of recurrence) and the scan results.

Results: Between 1998 and 2003, 151 patients met the inclusion criteria. The mean age was 59 (17 – 94) years. The diagnosis was liposarcoma in 37%, malignant fibrous histiocytoma in 17%, and leiomyosarcoma in 15%. Reflecting differences in practice between consultants, 79 patients had routine postoperative MRI scans, 8 patients had MRI scans following clinical suspicion of a local recurrence, and 64 patients did not have a postoperative MRI scan. Of 79 patients undergoing a total of 354 routine postoperative scans, 2 had detection of a local recurrence not suspected clinically. This represents a cost of £55,224 per recurrence detected. Of the 8 patients who underwent MRI scanning for a clinical suspicion of local recurrence, 4 had a local recurrence confirmed on scanning.

Conclusions: Most local recurrences are detected clinically. The cost of detecting local recurrence of a trunk or extremity soft tissue sarcoma by MRI scanning is high. The benefit of earlier detection over clinical examination is not known.

Introduction: Brown tumours occur as a complication in patients with renal failure, due to secondary hyperparathyrodism. In these patients brown tumours commonly regress if the primary cause is treated. We present a rare case of recalcitrant brown tumour with unusual presentation and symptom complex requiring surgical intervention.

Case Report: 14-year-old girl with blindness presented with pain in the proximal tibia. Radiographs revealed a lytic lesion in the proximal tibia. Biopsy of the lesion showed osteoclast rich stroma. Blood investigations indicated renal impairment, and secondary hyperparathyroidism. She underwent repeated dialysis treatment, and her renal parameters and parathormone levels were brought back to within normal limits. However, there was no evidence of regression of the lesion. Hence, intralesional curettage of the brown tumour was performed while still maintaining her on regular dialysis. This resulted in complete healing of the brown tumour with no recurrence at latest follow-up. She recently had a renal transplant as a definitive treatment for her renal failure.

Conclusion: The patient in our case has got renal retinal dysplasia which resulted in juvenile renal failure and retinal pigmentary degeneration. The renal failure resulted in secondary hyperparathyroidism leading to the formation of bone tumour in the proximal tibia. Eventhough temporarily the renal parameters were restored to within normal limits, this tumour did not regress in size, and hence required surgical intervention. This case highlights the importance of detailed thorough investigations to find the primary cause and syndrome associated with juvenile renal failure which presented with only a bony abnormality.

Background: Giant-cell tumour (GCT) of bone is a benign but aggressive tumour, usually treated by radical surgical curettage. Surgical treatment of GCT involving the ischium is associated with a high local recurrence rate. We describe a case in which serial arterial embolisation and bisphosphonate treatment resulted in radiological healing of the tumour. So far we have avoided surgical treatment.

Case Report: A 40-year-old lady was referred to the bone tumour unit following a fall. A plain radiograph of the pelvis revealed a lytic lesion in the ischium, extending into the posterior column of the acetabulum and associated with a pathological fracture. Biopsy confirmed a diagnosis of GCT. Given the anatomic location, the tumour was treated with serial arterial embolisation and intravenous zoledronate infusions. Follow up at one-year shows healing of the lesion, with no radiological evidence of recurrence. The patient has so far avoided surgery.

Discussion: Serial arterial embolisation has been described in the treatment of giant cell tumours in anatomical regions where surgery is likely to be associated with significant morbidity, such as the sacrum. There is a sound theoretical basis for the use of bisphosphonates in this disease; they have been shown to cause apoptosis of the osteoclast-like giant cells and interfere with osteoclast recruitment. As far as we are aware this is the first case described in which embolisation and bisphosphonate treatment appears to have led to healing and stabilisation of the lesion. The durability of this response remains uncertain.

Aims: Bone and soft tissue tumours not infrequently arise from the chest wall. Resection may require removal of ribs and reconstruction using mesh, biological materials such as lyophylised pig skin and muscle flaps. The purpose of this study was to review the experience of our multidisciplinary team in the management of chest wall resections for bone and soft tissue tumours. Patients and methods: This was a retrospective review of patient records. Between 2001 and 2005, 20 patients of mean age 50.3 years (13 to 92) underwent resections involving the chest wall. Ten were male.

Results: The diagnosis was chondrosarcoma in 8, osteosarcoma in 3, PNET/Ewings in 2, MPNST in 2, sarcoma NOS in 2, and one each of leiomyosarcoma, pleomorphic MFH, and metastatic renal carcinoma. 15 patients underwent rib resection, four sternal resections and one tumour of the clavicle was removed with the underlying rib. In 3 cases a latissimus dorsi flap was used as part of the chest wall reconstruction. The surgical margins were intralesional in 5, marginal in 11 and wide in 4 cases. Two patients died following a complication of treatment. Four patients died at a mean of 6 months (4 to 8 months) from metastatic disease. Two patients had local recurrence. At a mean follow up of 26 months (4 to 58) twelve patients were alive without evidence of disease, and two were alive with metastatic disease.

Conclusion: Chest wall resection for malignant bone or soft tissue tumours is feasible and can be achieved safely. However, there is a significant mortality rate associated with this procedure. This procedure demonstrates par excellence the value of multidisciplinary team working. Local anatomical constraints may mean that achieving a wide surgical margin is not always possible.

Purpose: The purpose of this study was to determine the rate of clinically detected deep venous thrombosis and pulmonary embolism in patients with trunk or extremity bone or soft tissue sarcomas.

Patients and methods: The clinical records of patients with a confirmed diagnosis of primary bone or soft tissue sarcoma presenting between 1998 and 2003 were reviewed. Data relating to clinical features, risk factors for thromboembolism and clinical thromboembolic events were retrieved.

Results: 252 patients were identified. 94 had a diagnosis of primary bone sarcoma and 158 a diagnosis of primary soft tissue sarcoma. The mean age was 53 (range 15 to 94); 137 (54%) were male.

37 patients were suspected clinically of having a deep venous thrombosis, 10 of which were confirmed radiologically, giving a rate of 4%. Nine patients had a suspected pulmonary embolism, 2 of which were confirmed radiologically and one of whom died of pulmonary embolism, giving an overall rate of fatal pulmonary embolism of 0.4%. All patients with thromboembolic events had lower extremity tumours and all were surgical patients. However, the majority of thromboembolic events (6 of 10 deep venous thromboses and 2 of 3 pulmonary embolisms) occurred prior to surgery.

Discussion: The risk of a clinically apparent thromboembolic event in patients with bone or soft tissue sarcomas is comparable to that in other orthopaedic patients. Risk factors for venous thromboembolism include lower extremity sarcomas and mechanical obstruction of the venous system. Consideration should be given to excluding deep venous thrombosis before surgery.

Purpose: The purpose of this study was to determine how patients with soft tissue sarcoma are followed up in the United Kingdom to inform the development of a prospective clinical trial.

Methods: A list of clinicians (surgeons and oncologists) treating patients with soft tissue sarcomas in the United Kingdom was compiled and a postal survey performed. Reminders were sent to non-responders. The survey included questions about the specialty of the clinician, the grade, membership of specialist societies, perceptions about risk factors for recurrence and the value of follow up and asked specifically about three clinical scenarios.

Results: Of 192 clinicians who were sent the questionnaire, responses were obtained from 155 (81%). 128 of these met the criteria for analysis. In the given clinical scenarios, length of follow up varied from 1 year to lifelong. The total number of clinic visits in 5 years varied from 5 to 30, of chest radiographs from 0 to 24, of chest CT scans from 0 to 10, and of local site imaging from 0 to 13. 88 (84%) agreed that follow up is of benefit. 57 (59%) agreed that it would be reasonable to follow up selected patients in the community. 96 (93%) agreed that a study of follow up protocols would be of value.

Discussion: There is significant variation in follow-up protocols amongst clinicians in the United Kingdom. A prospective study of follow-up protocols is likely to be supported.

Aim: To describe referral pathways and assess delays in order to inform targeting of educational initiatives.

Methods: Anonymised data on all patients with non-gynaecological sarcoma over 2 years (1999–2000), was obtained from the Northern & Yorkshire Cancer Registry.

Results: 362 cases were registered (29 per million). Patients were referred to a maximum of three hospitals. Of 86 managed solely at the first hospital, 13 were treated at a specialist centre. 225 (59.8%) eventually reached a sarcoma specialist centre. Those referred for further treatment were younger compared to those managed at the initial hospital (median age 55–59 vs 65–69 years) p< 0.01, and were symptomatic for a shorter period (292 vs 419 days, NS). Average time between attendance at first and second hospital was 52 days (median 34, range 0–678 days) and between second and third hospitals was 77 days (median 35, range 0–414 days). Onward average referral time by specialty varied from 5 to 93 days.

Conclusion: Evidence suggests that sarcoma treatment is best undertaken by specialist multi-disciplinary teams. However, less than 60% of patients regionally access specialist management, and many experience considerably delay in the referral pathway. Patients referred on from the initial treating hospital tend to be younger and may have had shorter duration of symptoms. Further work is needed to quantify referral delays in primary care. Future guidelines may therefore be usefully targeted both at primary and secondary care.

Objective: To report a rare case of lymphomatous transformation in a Pagetic bone

Methods: A 61yr old lady with an 8yr history of monostotic Paget’s disease affecting her right proximal humerus presented with increasing right arm pain. Initial investigations including plain films, a radioisotope bone scan and MRI scan showed evidence of malignant transformation.

Results: The patient was admitted for an incision biopsy. Initial pathological examination suggested a high grade Paget’s sarcoma. However, further stains and immunohistochemical markers showed bone involvement by a malignant B-cell lymphoma.

Conclusion: Although sarcoma is by far the commonest malignant transformation of Pagetic bone, rare cases of lymphoma must also be considered, especially since the management and prognosis are radically different.

Aim: To explore the relationship between anatomical location in lower extremity soft tissue sarcoma and function as measured by the Musculoskeletal Tumour Society (MSTS 93) rating and Toronto Extremity Salvage Score (TESS).

Methods: 207 patients of median age 54 years (15 to 89) were reviewed. 58 tumours were superficial and 149 deep. Deep tumours were allocated to one of 9 locations based on anatomical compartments.

Results: Treatment of superficial tumours did not lead to significant changes in MSTS (mean 90.6% vs 93.0%, p=0.566) or TESS (mean 86.4% vs 90.9%, p=0.059). Treatment of deep tumours lead to significant reductions in MSTS and TESS (mean 86.9% vs. 83.0%, p=0.001. mean 83.0% vs. 79.4%, p=0.015). There were no significant differences in MSTS and TESS when overall scores were compared by anatomical location. Exploratory analysis of MSTS subscales showed groin tumours were more painful than others, and posterior calf tumours had the lowest scores for gait. TESS subscales analysis suggested groin and buttock tumours were associated with difficulty sitting, and groin tumours were associated with difficulty dressing. Further exploratory analysis suggested “conservative” surgical excision of low-grade liposarcomas in all locations was associated with a significant decrease in functional scores.

Conclusion: There is significant variation in MSTS and TESS subscale scores when anatomical locations are compared. The “conservative” surgery used in the treatment of low-grade fatty tumours in all locations has a significant impact on functional scores.

The soft tissue sarcomas (STS) are a diverse collection of malignant tumours of the connective tissues arising from the primitive mesoderm and ectoderm. While the primary treatment of most is surgery, chemotherapy can be offered to patients presenting with locally advanced or metastatic disease although sarcomas are resistant to the majority of anticancer drugs. The reasons for this are not fully understood but it is thought that p53 abnormalities and mdm2 overexpression may be involved. Samples from twenty eight adult patients with soft tissue sarcomas have been analysed for p53 mutations in exons 4 to 9 both by denaturing high performance liquid chromatography (dHPLC) and by direct automated sequencing. By sequencing we found mutations in 7/28 patients, giving a mutation rate of 25%. 4/6 were point mutations in exons 5, 7 and 8 and the remaining three were deletions in exons 4, 7 and 8. Six of these samples gave abnormalities in dHPLC analysis with a concordance rate of 97.5% between the sequencing and dHPLC data. Thirty nine and forty samples have been assessed by immunohistochemistry for p53 and mdm2 expression respectively. Do7 antibody which recognises the N terminus of p53 and F4-14 which recognises the carboxy-terminus of mdm2 were used. Immunohistochemistry was scored semiquantitatively by two independent observers and the results scored accordingly: low (< 20%), intermediate (20–80%) and high (> 80%). The initial results showed that 23/40 (58%) of patients were high staining for mdm2 in contrast to only 15/39 (38%) of patients for p53. All patients with deletions in p53 had intermediate staining for mdm2. 2/3 of these had intermediate staining for p53 and 1/3 had high staining for p53. One patient with a point mutation had high staining for both p53 and mdm2 but the other two have yet to be analysed by immunohistochemistry. These results confirm the overexpression of mdm2 in STS. Future experiments are planned using fluorescent in situ hydridisation (FISH) to determine whether MDM2 amplification is one of the mechanisms involved in mdm2 overexpression.

To assess the performance of calcium sulphate pellets as a bone graft substitute in an Orthopaedic Oncology practice using clinical and radiological outcomes.

Between 1998 and 2001, calcium sulphate pellets were used in cavitary defects in 38 procedures in 34 patients with bone tumours. In 29 calcium sulphate pellets were used alone, in 8 allograft and in 1 autograft bone was added. The diagnosis was unicameral bone cyst in 13, giant cell tumour in 11, non-ossifying fibroma in 2, chondroblastoma in 2, benign fibrous histiocytoma in 2 and another pathology in 8 procedures. The femur was involved in 12 procedures, the humerus in 8, the radius in 5, the tibia in 4, the fibula in 3, the calcaneus in 2, and one procedure each in the tarsal cuboid, a metatarsal, the talus, and the middle phalanx of a finger.

Median follow up was 14 months (3 to 48). Seven patients had wound complications. Pellets had absorbed completely in 26/28 (93%) evaluable procedures by 3 months. Healing of the defect occurred in 24/28 (86%) evaluable procedures by 6 months. In 6 cases, the healed defect contained cystic areas simulating local recurrence. In 3 cases, there was collapse of the defect.

In cavitary defects, calcium sulphate pellets reliably absorb. Some patients have wound complications, especially where the cavity is relatively superficial. The pellets do not provide mechanical stability where there is attenuated cortical bone. Cysts within the healed defect may simulate recurrence.