The December 2022 Oncology Roundup. 360. looks at: Is high-dose radiation therapy associated with early revision with a cemented endoprosthesis?; Neoadjuvant chemotherapy and endoprosthetic reconstruction for lower extremity sarcomas: does timing impact complication rates?; Late amputation after treatment for lower extremity sarcoma; Osteosarcoma prediagnosed as another tumour: a report from the Cooperative Osteosarcoma Study Group; The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur: a 21st century perspective

The October 2023 Oncology Roundup. 360. looks at: Are pathological fractures in patients with osteosarcoma associated with worse survival outcomes?; Spotting the difference: how secondary osteosarcoma manifests in retinoblastoma survivors versus conventional cases; Accuracy of MRI scans in predicting intra-articular joint involvement in high-grade sarcomas around the knee; Endoprosthetic reconstruction for lower extremity soft-tissue sarcomas with bone involvement; Local relapse of soft-tissue sarcoma of the extremities or trunk wall operated on with wide margins without radiation therapy; 3D-printed, custom-made prostheses in patients who had resection of tumours of the hand and foot; Long-term follow-up for low-grade chondrosarcoma; Evaluation of local recurrence and diagnostic discordance in chondrosarcoma patients undergoing preoperative biopsy; Radiological scoring and resection grade for intraosseous chondrosarcoma

To determine if rates of local recurrence and metastasis differ in upper versus lower extremity sarcomas. Prospectively collected data relating to patients undergoing limb-sparing surgery for extremity soft tissue sarcoma between January 1986 and April 1997 were analysed. Local recurrence-free and metastasis-free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model. Of 480 eligible patients, 48 (10. 0%) had a local recurrence and 131 (27. 3%) developed metastases. Median follow-up of survivors was 4. 8 years (0. 1 to 12. 9). There were 139 upper and 341 lower extremity tumours. Upper extremity tumours were more often treated by unplanned excision before referral (89 vs 160, p< 0. 001) and were smaller (6. 0cm vs 9. 3cm, p< 0. 000). Lower extremity tumours were more often deep to or involving the investing fascia (280 vs. 97, p< 0. 003). The distribution of histological types differed in each extremity. Fewer upper extremity tumours were treated with adjuvant radiotherapy (98 vs. 289, p< 0. 000). The 5-year local recurrence-free rate was 82% in the upper and 93% in the lower extremity (p< 0. 002). Local recurrence was predicted by surgical margin status (hazard ratio 3. 16, p< 0. 000) but not extremity (p=0. 127) or unplanned excision before referral (p=0. 868). The 5-year metastasis-free rate was 82% in the upper and 69% in the lower extremity (p< 0. 013). Metastasis was predicted by high histological grade (hazard ratio 17. 28, p< 0. 000), tumour size in cm (hazard ratio 1. 05, p< 0. 001) and deep location (hazard ratio 1. 93, p< 0. 028) but not by extremity (p=0. 211). Local recurrence is more frequent after treatment for upper compared with lower extremity sarcomas. Variation in the use of radiotherapy and differences in histological type may be contributory. Metastasis is more frequent after treatment for lower extremity sarcomas because tumours tend to be large and deep

Aims

The standard of surgical treatment for lower limb neoplasms had been characterized by highly interventional techniques, leading to severe kinetic impairment of the patients and incidences of phantom pain. Rotationplasty had arisen as a potent limb salvage treatment option for young cancer patients with lower limb bone tumours, but its impact on the gait through comparative studies still remains unclear several years after the introduction of the procedure. The aim of this study is to assess the effect of rotationplasty on gait parameters measured by gait analysis compared to healthy individuals.

Introduction: Limb preserving surgery in children with bone sarcoma remains a significant challenge as most are expected to survive their disease and put significant functional loads on their reconstructed limbs. The most common reconstructions used for children with lower limb sarcomas are endoprosthetic replacements and rotationplasty. This study aimed to investigate and compare differences in the complications and functional outcomes between these two methods of reconstruction. Methods: This is a retrospective case control study of 12 rotationplasty patients and 12 patients who received EPR. Patients were selected at random from records provided by both centres and matched according to age at diagnosis, sex, site of disease and date of surgery. The Musculoskeletal Tumour Society (MSTS) score was used to evaluate functional outcome, and surgical complications were assessed qualitatively. Results: Five patients (42%) treated with endoprostheses experienced some form of post-operative surgical complication compared to three patients (25%) treated with rotationplasty and one patient from each group required an amputation to treat the complications. The average MSTS score was 22.7 in the EPR cohort and 18.9 in rotationplasty patients. This difference was statistically significant (p=0.05). Discussion: The study showed that patients who received EPR suffered more surgical complications than rotationplasty patients. However the results demonstrated superior functional outcomes in patients who received EPR. These results suggest that the functional benefit historically attributed to rotationplasty has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology. Conclusion: Our experience shows that patients with EPR are more likely to suffer more surgical complications but have similar, if not better functional outcomes compared to rotationplasty

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

Pediatric patients with lower extremity sarcoma often experience long lasting restrictions concerning physical activity and walking due to the required off-loading of the limb and other consequences of surgeries. Activity promotion during treatment in addition to physiotherapy could improve patients’ activity levels and walking capabilities. In the present study we investigated the ambulatory activity of 31 pediatric patients (13.7 ± 3.1 years, 1.63 ± 0.15 m, 51.9 ± 15 kg, 19.3 ± 3.7 kg/m2) with Osteosarcoma or Ewing sarcoma at the lower limb using the StepWatch™ Activity monitor (SAM; Orthocare Innovations, USA). Sixteen patients regularly underwent supervised exercise interventions during inpatient stays, 15 did not receive any additional intervention. Step activities were measured for seven consecutive days during home stays at five different points in time, to determine a possible transfer of activity to everyday life. Patients without intervention assembled considerably less steps than those in the intervention group. Before surgery they reached 25.4% of the intervention group (total n=16), six weeks after surgery 40% (total n= 8), after three months 46% (total n=10), after six months 72% (total n=13) and after one year 90%. However differences only reached significance at the first measurement. Data presented must be considered as preliminary. Not all patients could be measured at all appointments due to impaired walking ability. Nevertheless activity promoting interventions during inpatient stays seem to have a positive influence on patients’ daily walking activity. Though the differences between the groups are not significant they are considerable. Especially during treatment – as reflected by the first three measurements- patients could benefit from additional interventions exceeding typical therapy regimes. Interventions should be individualized to the patients’ capabilities. Conclusions concerning tumor location or surgical procedures are not yet possible. Future research should furthermore concentrate on the effects of activity promotion on other fields of well-being

The December 2022 Research Roundup³⁶⁰ looks at: Halicin is effective against Staphylococcus aureus biofilms in vitro; Synovial fluid and serum neutrophil-to-lymphocyte ratio: useful in septic arthritis?; Transcutaneous oximetry and wound healing; Orthopaedic surgery causes gut microbiome dysbiosis and intestinal barrier dysfunction; Mortality in alcohol-related cirrhosis: a nationwide population-based cohort study; Self-reported resistance training is associated with better bone microarchitecture in vegan people.

Purpose. Rotationplasty was first described in 1930 by Borggreve for treatment of limb shortening with knee ankylosis after tuberculosis. In 1948, Van Nes described its use for management of congenital defects of the femur and in the 1980s, Kotz and Salzer reported on patients with malignant bone tumors around the knee treated by rotationplasty as an alternative to above-knee amputation. Currently, rotationplasty is one of the options for surgical management of lower extremity bone sarcomas in skeletally immature patients but alternative limb salvage techniques, such as the use of expandable endoprosthesis, are also available. Despite rather satisfactory functional results have been uniformly associated with rotationplasty, concern still exists about the potential psychological impact of the new body imagerelated to the strange appearance of the rotated limb. Results of rotationplasty for sarcomas of the distal femur over a 20-year period were analyzed, focusing on long-term survival, function, quality of life and mental health. Method. Retrospective study of 73 children who had a rotationplasty performed at two institutions between 1984 and 2007 for a bone sarcoma of the distal femur; 42 males and 31 females, mean age at surgery 8.7 yrs (range 3–17). Four patients were converted to transfemoral amputation due to early vascular complication; 25 eventually died of their disease (mean survival 34 months, range 4–127). The 46 remaining survivors were evaluated for updated clinical outcome, MSTS score, gait analysis, SF-36 score, quality of life interview and psychological assessment at mean follow-up of 15 yrs (range 3–23). Results. Overall survival was 64%. All the survivors were disease-free at last follow-up. Four patients required hardware revision for nonunion and subsequently healed. Three patients refused participation in the long-term follow-up study. Mean MSTS score was 79 (range 64–88). SF-36 score was obtained in 35 patients (age > 16); male patients showed a trend toward greater activity and vitality. Compared to age-group norms, rotationplasty scores were lower for physical activity level (p <0.05) and higher for general health perception (p = 0.05) and mental health (p < 0.05). Conclusion. Rotationplasty remains a durable reconstructive option with good long-term function and acceptable psychological impact for children with bone sarcomas of the distal femur

Objective

Clinical studies of patients with bone sarcomas have been challenged by insufficient numbers at individual centres to draw valid conclusions. Our objective was to assess the feasibility of conducting a definitive multi-centre randomised controlled trial (RCT) to determine whether a five-day regimen of post-operative antibiotics, in comparison to a 24-hour regimen, decreases surgical site infections in patients undergoing endoprosthetic reconstruction for lower extremity primary bone tumours.