Aim

Deep infection following endoprosthetic replacement (EPR) of long bones is a devastating complication occurring in 15% of musculoskeletal tumour patients. The recently published PARITY Trial demonstrated that extending antibiotic prophylaxis from 24 hours to 5 days does not reduce infection rates. However, questions remain about the optimal antibiotic choice and dose.

Primary malignant bone and soft tissue tumours often occur in the lower extremities of active individuals including children, teenagers and young adults. Survivors routinely face long-term physical disability. Participation in sports is particularly important for active young people but the impact of sarcoma treatment is not widely recognised and clinicians may be unable to provide objective advice about returning to sports. We aimed to identify and summarise the current evidence for involvement in sports following treatment of lower limb primary malignant bone and soft tissue tumours.

A comprehensive search strategy was used to identify relevant studies combining the main concepts of interest: (1) Bone/Soft Tissue Tumour, (2) Lower Limb, (3) Surgical Interventions and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors. Customised data extraction and quality assessment tools were used.

22 studies were selected, published between 1985 – 2020, and comprising 1005 patients. Fifteen studies with data on return to sports including 705 participants of which 412 (58.4%) returned to some form of sport at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing and amputation; none of these were able to identify a difference in sports participation or ability.

Return to sports is important for patients treated for musculoskeletal tumours, however, there is insufficient published research to provide good information and support for patients. Future prospective studies are needed to collect better pre and post-treatment data at multiple time intervals and validated clinical and patient sports participation outcomes such as type of sports participation, level and frequency and a validated sports specific outcome score, such as UCLA assessment. In particular, more comparison between limb sparing and amputation would be welcome.

Aims

The proximal tibia (PT) is the anatomical site most frequently affected by primary bone tumours after the distal femur. Reconstruction of the PT remains challenging because of the poor soft-tissue cover and the need to reconstruct the extensor mechanism. Reconstructive techniques include implantation of massive endoprosthesis (megaprosthesis), osteoarticular allografts (OAs), or allograft-prosthesis composites (APCs).

Aims

Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery.

Background

Myxofibrosarcomas are malignant soft tissue tumours that often present as painless slowly growing masses in the extremities of older males. Locally infiltrative growth means risks of local recurrence is high. Management emphasises negative surgical margins and adjuvant therapy. The aim of this retrospective case series was to review our experience of this tumour, and make recommendations about a minimum resection margin and how best to utilise the expertise of the multidisciplinary team.

Background

Membrane type 1 matrix metalloproteinase (MT1-MMP) plays a role in the progression of several common solid cancers. Given that osteosarcoma features extensive local invasion and haematogenous metastases, we hypothesised that osteosarcoma cells utilise MT1-MMP to drive these processes. Moreover, since hypoxia regulates MT1-MMP expression in breast cancer we investigated the effects of hypoxia on MT1-MMP expression in osteosarcoma cells.

Aims

Solitary plasmacytoma of bone is a locally aggressive lesion seen by sarcoma teams. Some patients progress to myeloma. Local therapy decisions can be complex. This study reviews the experience of this condition in a single centre with a view to informing future treatment.

Introduction and aims

Solitary fibrous tumours (SFT) are rare soft tissue sarcomas. Challenges in management include the variation in anatomical location and uncertain malignant potential. We retrospectively reviewed our experience with the aim of formulating guidelines on appropriate treatment.

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.

Introduction

Aseptic loosening is the most common mode of failure of massive endoprostheses. Introduction of Hydroxyapatite coated collars have reduced the incidence of aseptic loosening. However bone growth is not always seen on these collars.

Introduction

We aimed to determine the extent of osseous integration of the hydroxyapatite collars of tumour endoprostheses implanted in our unit.

Introduction

Angiosarcomas are rare aggressive sarcomas of vascular endothelial origin. These tumours have the potential to be multicentric and are associated with high rates of local recurrence, which makes treatment challenging. The gold-standard is that these patients are managed in specialist centres by a multidisciplinary team. We present our experience of managing patients with angiosarcoma in the North of England Bone and Soft Tissue Tumour Service and a review of the literature.

Aims

Malignant tumours of the foot and ankle are rare, but easily missed. NICE guidelines for bone and soft tissue tumours may be less appropriate for the foot and ankle than elsewhere. The purpose of this study was to identify the clinical features and treatment of malignant tumours arising in the foot and ankle to see if guidelines should be modified.

Introduction

The Two Week Waiting Time 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.

Introduction and Aims: Morbid obesity (BMI> 40) has been shown to cause increased perioperative morbidity and poorer long-term implant survivorship following total knee arthroplasty (TKA). The aim of this study was to determine the impact of morbid obesity on patient-reported outcomes following TKA.

Methods: Patients undergoing primary TKA were invited to complete questionnaires preoperatively and one year after surgery. Questionnaires include the WOMAC and SF-36 health status measures, demographics, self-reported comorbid medical conditions, height and weight. At follow-up, satisfaction with results of TKA is included. Patients were categorised by their preoperative BMI categories as ideal weight (20–25), overweight (> 25–30), obese (> 30–40) or morbidly obese (> 40). We used multivariate analysis to adjust for known significant correlates of WOMAC and SF-36, namely age, gender and comorbid medical conditions. Adjusted mean scores for each assessment were compared by BMI category.

Results: A total of 769 patients were included in the study which included 27 morbidly obese, 280 obese, 314 overweight and 148 ideal weight patients. Morbidly obese patients when compared with non-obese patients had significantly worse preoperative WOMAC pain and function and a trend for worse SF36 scores (Vitality significantly worse, p=0.04). There was no significant difference between the BMI categories at one year for WOMAC or SF-36 scores (trend for the Physical Functioning score to be lower, p=0.052). Morbidly obese patients were all satisfied with pain relief after surgery but were less satisfied with functional results when compared to the non-obese groups.

Discussion: This study shows that morbidly obese patients report significantly worse health status prior to TKA but their post-operative improvement is greater than the non-obese population. Although morbid obesity should not be an absolute contraindication to TKA, patients should be carefully selected balancing the risk of perioperative complications and earlier failure against the demonstrated marked improvement in quality of life.

Introduction: The workload of a bone and soft tissue tumour (BSTT) multidisciplinary team (MDT) is varied. Only a proportion of the workload attracts specific funding from the National Commissioning Group (NCG) but many patients who do not have primary malignant bone tumours are also seen and treated. We analysed the workload of our supra-regional BSTT MDT to determine the variety of conditions seen, the proportion that does not attract specific funding and the expertise required to run the service.

Methods: A prospective database was used to identify all new patients discussed at our weekly BSTT MDT meetings between 2004 and 2008 inclusively. Patients were divided by diagnosis into eight categories and further identified as to whether or not they attracted funding under NCG regulations.

Results: 1743 new patients were identified of which 83 were excluded. Of the remaining 1660, 65% were non-sarcoma and 50% were benign. 31% of the malignant workload was non-sarcoma. Only 9% of treated patients were eligible for NCG funding. Of those requiring surgery, the orthopaedic team managed 93% of benign and 77% of malignant cases; general, plastic, or thoracic surgical teams managed the remainder.

Discussion: NCG funds the management of all malignant primary bone tumours and the investigation and/or treatment of other selected conditions; the majority of our workload does not qualify. Despite fluctuations in the total workload, the ratio of benign to malignant cases remains relatively constant. An effective MDT requires expertise across many specialties.

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’ in 2005. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological biopsy was required for diagnosis and consider the current 2ww impact on services in our centre.

Materials and Methods: Two hundred and nine patients were referred under 2ww to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records.

Results: Malignancy was diagnosed in 41(20%) patients. This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%). 63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was required in 108 (52%) patients.

Discussion and Conclusion: 15% of 2ww referrals to our centre have a primary bone or soft tissue sarcoma but over half of all 2ww patients require biopsy for diagnosis creating additional strains on resources under the 32- and 62-day rule. Emphasis is placed on obtaining a rapid diagnosis, to ease pressure on time to treatment, utilising a ‘one-stop clinic’ approach for biopsies of accessible tumours where applicable. The availability of timely radiological resources, facilitated by an MDT involving a designated coordinator (‘patient-tracker’), is key to ensure treatment is not delayed for any cancer patient regardless of referral route. Our centre is 100% compliant for waiting times for sarcoma according to the Department of Health 2008 data.

Introduction: Well-differentiated liposarcomas have a tendency to recur locally but do not metastasise unless dedifferentiation occurs. In this study, a tumour superficial to the deep fascia of the trunk or limb is termed an atypical lipoma (AL) and one deep to fascia, a lipoma-like liposarcoma (LL) reflecting increased difficulty in wide local excision.

Methods: We prospectively collected data for 87 well-differentiated liposarcomas excised at our institution from 1998–2008. Data was recorded on a multidisciplinary team database and verification was undertaken using patient records. Any radiological investigation performed was determined retrospectively. Primary excisions performed elsewhere were excluded. The aim was to produce recommendations on the clinical and radiographical post-operative management of these common tumours.

Results: LL was seen in 74 patients and AL in 13 (mean age 58 years, mean follow up 5 years). The mean size of LL excisional biopsy was 148mm and 54mm for AL (p< 0.05). There were no AL recurrences. Five LL (7%) locally recurred within a mean of 5 years (range 2–10 years). All were deeply related to neurovascular structures (4 thigh-marginal/complete excisions and 1 upper arm-piecemeal excision). One recurrence was detected by MRI from 26 LL patients (35%), the other four being clinically suspected prior to re-scanning. During follow up, a chest radiograph was performed in 21 LL patients (27%) and no metastases were detected.

Discussion: Patients with a completely excised superficial AL need no routine follow up. Follow up of LL is determined by the patient, the tumour size and the location. The routine use of interval MRI to detect local recurrence of uncomplicated LL is not necessary. MRI provides ‘base-line’ post-operative information where a neurovascular bundle was closely related to the tumour or excision was incomplete. Chest radiographs are not indicated in screening for metastases in these tumours unless locally recurrent.

Introduction: Sarcomas are best treated in designated treatment centres. A previous study identified the delays in referral patterns for the years 1999–2000 in Northern and Yorkshire region. The aim of this study was to identify the changes in referral pathways of all non-gynaecological sarcoma patients in view of the NICE guidelines.

Methods: Anonymous data for all non-gynaecological sarcoma patients from year 2000 – 2004 was obtained from the Northern & Yorkshire Cancer Registry.

Results: 1180 of 1430 cases registered in three cancer networks, were selected. The Northern Cancer Network catered to 532 patients. 86.2% of all patients were treated in a designated sarcoma centre compared to 59.8% in the previous study. Of the 504 patients whose dates of first report are available, 39 patients were referred within 2 weeks. 626 of 1180 (53%) patients were diagnosed within two weeks of attending the first hospital. Of the 948 referred to the second hospital, 195 (20.5%) were seen within two weeks of attendance at the first hospital, with an average 56 and median of 38 days. The median age for those referred and otherwise was 55. Of the 631 referred to a third hospital, 187 (29.6%) were seen within two weeks, (average 45 days). The number of patients (Range 1 – 307) seen in each specialty and time taken for referral (range 14 to 127 days) were tallied to denote their efficiencies.

Conclusions: There was a statistically significant increase in referral rates to specialist centres. Age had no influence in referrals, contrary to the previous study. Time delays within specialties show an unchanged trend, with a few exceptions. Further studies into the actual events are needed to unmask the deficient areas.

Introduction: The Plastic Surgery challenge in groin sarcoma is often twofold involving restoration of integrity to the lower abdominal wall and provision of durable soft tissue cover for the groin and perineum.

Methods: This is a retrospective review of consecutive patients undergoing groin sarcoma excision with plastic surgery involvement over the last 7 years. The referral patterns of these patients, histological types, margins and details of reconstructions performed were analysed. Information was also gathered regarding adjuvant therapy, recurrences and survival.

Results: Thirteen patients were included in this review. In twelve out of the thirteen patients initial biopsies/explorations were performed by either General Surgeons or Urologists. Ten of these biopsies were incompletely excised. On average 4.4 months elapsed between initial biopsy and referral to the Regional Sarcoma Service.

The most frequently performed reconstruction was a rectus abdominis musculo-cutaneous flap. Six patients developed post operative complications.

Complete/adequate surgical margins were achieved in seven patients. A further five patients had margins designated as “narrow” or “marginal”.

Six patients received post operative radiotherapy based on the multidisciplinary clinic review. Three patients were referred for radiotherapy but did not receive treatment. Five patients developed recurrences and four of these patients died.

Discussion: Groin sarcomas represent a surgical and logistical challenge.

The anatomical topography makes complete surgical excision difficult without available reconstructive techniques and complication rates can be high.

Referral of these patients to the regional sarcoma service is often delayed whilst exploration or biopsy is performed. This delay can persist even after a diagnosis of sarcoma has been made. Communication with colleagues in other centres may be the key to improving this side of management.