Background. Decisions about local treatment are important in osteosarcoma treatment. The purpose of this study was to review decisions about local treatment in one centre. Methods. This was a retrospective review of the records of all patients with high-grade extremity osteosarcoma presenting to our centre between 1997 and 2008. Particular attention was paid to local control decisions. Results. 54 patients were included, 37 were male. Median age was 18 (4.1 to 71.3 years). The anatomical location was distal femur in 33, tibia in 8, humerus in 7, ankle/foot in 3, fibula in 2 and clavicle in 1. 8 (14.8%) patients had metastases at presentation. 13 (24.1%) patients underwent primary amputation, predominantly in the early years of the series. The remaining 41 patients had limb-sparing surgery, 5 of whom had microscopically positive margins. 21 of 54 (38.8%) had >90% necrosis in the resected tumour. 3 patients had poor necrosis and positive margins. These were a 70 yo intolerant of chemotherapy, who refused amputation, developed LR and metastatic disease; a 15 yo with metastatic disease, who had a secondary amputation and metastatectomy and survived and a 43 yo who developed metastases and LR on chemotherapy. 4 further patients had local recurrence after LSS. All had poor necrosis after chemotherapy but adequate margins. All developed metastatic disease and 3 have died. Overall survival was 60%. 5-year survival without metastatic disease at presentation was 65%. Conclusion. Our series is similar to other centres. Challenges include older patients, poor response to chemotherapy and metastases

Background: For the treatment of osteosarcoma, the significance of the preoperative cisplatin (CDDP) as single agent has not been assessed in conjunction with prognostic value. Purpose: To assess the effect of preoperative CDDP as single agent and its impact on the prognosis of the limb osteosarcoma in the multi-institutional group study. Patients and methods: Forty-seven cases were entered for the study between December 1983 and June 1993 at cooperative institutions. Three cases were eliminated from the study because of presence of lung metastasis at diagnosis. Forty-four cases of stage IIB limb osteosarcoma treated with CDDP as initial preoperative chemotherapy were evaluated in this study. Mean age was 17.1 years old (7–29 yo.), and mean follow up periods of the living patients were 150 months (58–189 mo.). Two to four courses of CDDP (3 mg/kg, mean 2.4 courses) were administered intravenous and/or intraarterial rout as initial preoperative treatment. All the patients underwent postoperative multi-drug combination chemotherapy with CDDP, doxorubicin, with/without HD-MTX. We evaluated the effect of initial preoperative CDDP by synthesizing the results of clinical findings, radiological findings, serum alkaline phosphatase level, and histological findings. Each findings were evaluated into four grades, and final evaluation was done according to our criteria. Results: Favorable response ((Complete response(CR) and Partial response (PR)) were obtained in 25 patients, and poor response (No change (NC) and Progression of the disease (PD)) were obtained in 19 patients. Survival rate of all patients in this study was 59.1%, and 64.0% in patients with CR and PR effects, and 52.6% in NC and PD groups. No statistical differences were found between the groups (p=0.3886). Necrotic ratios were examined in 20 patients, and average necrotic ratio was 74.5 %. Good histological response (%necrosis > 80%) was obtained in 11 patients and poor response was obtained in 9 patients. Survival rate of the patients with good histological response was 72.7%, and 44.4% in patients with poor histological response, with no statistical differences between the groups (p=0.14). Discussion: CDDP has been postulated as one of the most effective chemotherapeutic agents for the treatment of osteosarcoma. In this study, we obtained 57% response rate (25/44) by initial preoperative CDDP administration. In this study, local response to single CDDP treatment is not significant prognostic factor. For treatment planning of neoadjuvant chemotherapy, local response should be evaluated after multi-drug combination preoperative regimen to predict patients¡Ç prognosis

Two hundred and forty-one patients with extremity osteosarcoma presented to our institution between 1989 and August 2002, thirty-six of whom had a pathologic fracture. There were twenty-five limb salvage surgeries and ten primary amputations, with three limb salvage surgeries requiring secondary amputations. One patient had an unresectable tumor and was treated palliatively. At mean follow-up of 96.9 months there was one local recurrence and eighteen patients were alive without disease in the pathologic fracture group. There was no survival difference between the pathologic fracture group with no metastases at presentation and the non-pathologic fracture group with no metastases (119.4 months vs 134.3 months, log rank 0.83, p=0.36). To examine the outcome of osteosarcoma patients that present with a pathologic fracture as compared to those patients without a pathologic fracture. There was no significant difference in the rate of amputation vs limb salvage surgery in osteosarcoma patients that presented with a pathologic fracture as compared to those without. There was no difference in the two groups’ disease-free and overall survival, for those patients that presented without metastatic disease. Presentation with a pathologic fracture in osteosarcoma does not preclude limb salvage surgery and is not a prognostic indicator for decreased survival. Retrospective review of all patients presenting to our institution with extremity osteosarcoma between 1989 and August 2002. There were two hundred and forty-one patients with extremity osteosarcoma, thirty-six of whom presented with a pathologic fracture. In the pathologic fracture group, there were nineteen males and seventeen females. Twenty-five were treated with limb salvage surgery, ten required a primary amputation and one was unre-sectable. Three limb salvage surgery patients required a secondary amputation. Sevenpatients presented with metastatic disease. Twenty-eight of the thirty-six patients received (neo) adjuvant chemotherapy. At last follow-up, eighteen patients were alive no evidence of disease (51.4%), three were alive with disease, eleven were dead of disease and three were deceased from other causes. There was one local recurrence (2.8%). Mean overall survival was 119.4 months (0–147.1) for patients with a pathologic fracture and no metastasis at presentation and 134.3 months (0–172.5) for patients with no pathologic fracture and no metastasis (log rank 0.83, p=0.36)

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. Method. All patients with limb osteosarcoma, no metastases, a poor response to chemotherapy and either a marginal excision or primary amputation were identified from a prospective database. This group were investigated in terms of overall survival and local control. Results. There were 182 patients in this category of whom 60 had an amputation, 105 limb salvage with marginal margins and 17 with an intralesional margin. Local recurrence (LR) arose in 41% of those with an intralesional margin, 22% of those with a marginal margin and 13% of those with an amputation. Radiotherapy was used in 21 of the 122 patients and the risk of LR was the same as in those who did not have radiotherapy. Neither age nor sex of the patient, size or site of the tumour affected the risk of LR. The overall survival for this group was 42% at 10 years. The survival was best in those with marginal margins (38%) than those with an amputation (28%) and worst for those with an intralesional margin (20%). Survival was worst in those who did develop LR, but no worse than in those having amputation. Conclusion. A marginal resection of osteosarcoma with a poor response to chemotherapy leads to a high risk of local recurrence but also carries a poor prognosis. Carrying out an amputation to avoid the risk of LR probably has little survival benefit and the use of radiotherapy remains unclear

Sarcomas account for 10% of cancers occurring in 15–24 year olds. Within this group there is considerable clinical and biological heterogeneity and incomplete understanding of optimal treatments. Most clinical research attention has focused on the management of bone sarcomas, particularly osteosarcoma and Ewing’s tumours. Several factors have been studied which consistently identify patient groups with differing outcomes. Age at diagnosis appears to affect prognosis in Ewing’s tumours but less obviously in localised extremity osteosarcoma. Any underlying biological or treatment delivery variables which may explain these observations have yet to be elucidated. Whether different treatment approaches for bone sarcomas should be adopted for teenagers and young adults (TYA) is unclear and will require systematic prospective evaluation. Soft tissue sarcomas affect all ages. The numerous histiotypes are not evenly distributed across all age ranges. In the progression from childhood through adolescence to adulthood, rhabdomyosarcoma is replaced as the commonest subtype by the many different subtypes recognised by adult oncologists. There is little guidance about appropriate management of ‘adult-type’ soft tissue sarcomas occurring in TYA and this group have not been systematically studied. Their representation within clinical trials may be biased towards those with adverse features. There is considerable variation in practice particularly regarding the use of adjuvant chemotherapy. Few studies address whether specific approaches to treatment are appropriate for TYA with soft tissue sarcoma. In the future, biologists and clinicians familiar with sarcomas affecting TYA and adults need to work together to share understanding and to design rational treatment programmes aimed at improving outcomes for TYA

The December 2012 Trauma Roundup³⁶⁰ looks at: more is not always better, especially when its chemotherapy; new hope for skeletal metastasis; biopsy tracts; intra-operative imaging of sarcomas; curettage with adjuvant therapy; amputation and distal tibial osteosarcoma; and diaphyseal tibial tumours.