In 2004 the Scottish Sarcoma Network (SSN) was established with the aim of optimising management of patients with sarcoma. Clinical, radiological, oncological and pathological details of all bone and soft tissue sarcomas presenting in Scotland are registered and cases discussed in a multi-centre, tele-link multidisciplinary team (MDT) forum. The aim of this study was to establish any difference in referral patterns, time to specialist review, preoperative MRI scanning and appropriate biopsy before and after establishment of the Scottish Sarcoma Network in Grampian. A database was established of all patients presenting with sarcomas of the trunk or extremity in Grampian between 1991 and 2010. One hundred and fifty eight patients were randomly selected, 79 (50%) presenting prior to the establishment of the Scottish Sarcoma Network. Since the initiation of the Scottish sarcoma network we found that the median time of referral to review by the sarcoma service has improved from 19.5 days to 10 days (P=0.016). There has been an increase in the number of patients referred from other specialities while the number of general practice has remained fairly constant. This has resulted in a slight increase in the median total patient journey from 35 days to 41 days, this does not reach statistical significance. A greater number of patients are undergoing pre biopsy MRI scan, 53 (67%) before 2004 and 68 (86%) after (P=0.009). More patients are also undergoing appropriate biopsy 45(57%) before the network and 62(79%) after. The creation of the Scottish Sarcoma Network has had a positive impact on the care of sarcoma patients presenting in Grampian

Bone and soft tissue sarcoma is an uncommon. Benign swellings are, however, common. An approach to tertiary referral is required to accommodate the need for specialist interpretation of all concerning referrals, while maintaining an acceptable time to diagnosis and management. We aim to describe a new tertiary sarcoma service, utilising modern communication technology and the “virtual clinic” model through a multidisciplinary approach. All suspected musculoskeletal sarcoma cases are discussed, with available history and imaging, in a virtual clinic by a multidisciplinary team within a week of referral. Clinic decisions allow either immediate discharge, progress to further investigation, or clinic appointment. Data from the first thousand patients was prospectively collected for initial management decision, and final intervention, and in 625 for waiting time. Almost one third of patients were discharged from the virtual clinic without physical appointment. 45% were sent for further investigation prior to first clinic appointment. Of 625 patients with referral data, mean waiting time was 5.1 days to virtual clinic. For malignant bone and soft tissue tumours, not requiring neoadjuvant treatment, median time to surgery from virtual clinic review was 37 and 47 days respectively. Through a virtual clinic approach to tertiary sarcoma care, almost a third of referrals have been managed quickly without need for an unnecessary appointment. For 45% of patients the first appointment will be after all necessary investigations have been performed to facilitate rapid decision making. This enables shorter clinic waiting times and rapid transition from first referral to definitive management

The modified Glasgow Prognostic Score (mGPS) is a validated prognostic indicator in various carcinomas as demonstrated by several meta-analyses. The mGPS includes pre-operative CRP and albumin values to calculate a score from 0–2 that correlates with overall outcome. Scores of 2 are associated with a poorer outcome. Our aim was to assess if the mGPS is reliable as a prognostic indicator for soft tissue sarcoma (STS) patients. All patients with a STS diagnosed during years 2010–2014 were identified using our prospectively collected MSK oncology database. We performed a retrospective case note review examining demographics, preoperative blood results and outcomes (no recurrence, local recurrence, metastatic disease and death). 94 patients were included. 56% were female and 53% were over 50 years. 91% of tumours were high grade (Trojani 2/3) and 73% were >5cm. 45 patients had an mGPS score of 0, 16 were mGPS 1 and 33 were mGPS 2. On univariate analysis, an mGPS of 0 or 2 was statically significant with regards to outcome (p=0.012 and p=0.005 respectively). We have demonstrated that pre-treatment mGPS is an important factor in predicting oncological outcome. A score of 0 relates to an improved prognosis whilst a score of 2 relates to an increased risk of developing metastases and death. mGPS as a prognostic indicator was not affected by either the tumour size or grade. We believe that a pre-operative mGPS should be calculated to help predict oncological outcome and in turn influence management. Further work is being undertaken with a larger cohort

Purpose. To investigate the prognostic effect of surgical margins in soft tissue sarcoma on Local Recurrence (LRFS), Metastasis (MFS) and Disease Free Survival (DFS). Patients and Methods. This is a retrospective, single center study of 105 consecutive patients operated with curative intent. Quality of surgery was rated according to the International Union Against Cancer classification (R0/R1) and a modification of this classification (R0M/R1M) to take into account growth pattern and skip metastases in margins less than 1mm. Univariate and multivariate analysis was done to identify potential risk factors. Kaplan-Mayer estimated cumulative incidence for LRFS, MFS and DFS were calculated. Survival curves were compared using Log rank tests. Results. Estimated LRFS was 0.64 [0.52;0.76] at 5 years following R1 surgery, 0.9 [0.85;0.95] following R0 (p=0.023), 0.64 [0.519;0.751] following R1M surgery and 0.92 [0.87;0.96] following R0M (p=0.01). The R status was associated with DFS (p=0.028), but not MFS (p=0.156). The RM status was associated with both outcomes (p=0.001 and p=0.007). Multivariate analysis showed an independent association with LRFS for RM status (HR 6.77 [1.78–25.7], p=0.005), with DFS for RM status (HR 2.83 [1.47–5.43], p=0.001) and Grade (HR=3.17 [1.38–7.27], p=0.003) and with MFS for Grade (HR=3.96 [1.50–10.5], p=0.006). Conclusions. In Soft Tissue Sarcoma, surgical margins are the strongest prognostic factor for LRFS. In this study, taking growth pattern and skip metastases into account for margins less than 1mm increased prognostic significance of surgical margins for LRFS, DFS and MFS

Brachial plexus tumours (BPT) and peripheral nerve sheath tumours (PNST) are largely benign in nature, with malignant tumours being rare and presenting significant surgical challenges. Excision of benign tumours may relieve pain and other symptomology. This retrospective study analysed data from 138 PNST and 92 BPT patients managed by a single consultant orthopaedic or plastic surgeon experienced in nerve tumour surgery between January 1999 to December 2019. The most common benign tumours were schwannomas and neurofibromas, with sarcomas being the most common malignant tumour. In the PNST group 30 patients were managed by observation only. Twenty patients underwent trucut biopsy, 21 patients underwent biopsy and surgical excision and 56 patients underwent surgical excision only. There were nine complications, with two significant neurological deficits requiring further surgical intervention. No recurrence of tumours occurred in this group. In the BPT group 16 patients were managed by observation only. Seven patients underwent trucut biopsy, 16 patients biopsy and surgical excision and 44 BPT patients underwent surgical excision only. Sixteen patients had complications with two significant complications requiring urgent further surgical intervention. Seven patients had recurrence of tumours which presented as metastases, with three patients requiring further surgery to remove recurrence of tumours. BPT patients are more complex and present with both benign and malignant lesions and are therefore more prone to complications due to the complex nature of the surgery and higher recurrence rate of tumours than PNST. Benign tumours in both groups can be safely managed conservatively if patients’ symptomology is acceptable

Introduction. Primary malign tumors and solitary metastatic lesions of the thoracic and thoracolumbar spine are indications for radical en bloc resections. Extracompartimental tumor infiltration makes the achievement of adequate oncological resection more difficult and requires an extension of the resection margins. We present a retrospective clinical study of patients that underwent chest wall resection in combination with vertebrectomy due to sarcomas and solitary metastases for assessing the clinical outcome especially focusing on onco-surgical results. Method. From 01/2002 to 01/2009 20 patients (female/male: 8/12; mean age: 52 (range of age: 27–76yrs)) underwent a combined en bloc resection of chest wall and vertebrectomy for solitary primary spinal sarcoma and metastatic lesions. The median follow-up was 20,5 (3–80) months. Histological analysis revealed 17 primary tumors and 3 solitary metastatic lesions. In the group of primary tumors 10 sarcomas, 1 giant cell tumor, 2 PNET, 1 histiocytoma, 1 aggressiv fibrous dysplasia, 1 pancoast tumor and 1 plasmocytoma were histologically documented. We included 1 rectal carcinoma, 1 breast cancer metastases and 1 renal cell carcinoma. All patients underwent a chestwall resection en bloc with multilevel (1/2/3/4 segments: n=4/6/6/4) hemi (n=7) or total vertebrectomy (n=13) with subsequent defect reconstruction. Reconstruction of the spinal defect following total resections was accomplished by combined dorsal stabilization and carbon cage interposition. The chest wall defects were closed with a goretex ® -patch. One patient also received a musculocutaneus latissimus dorsi flap. Results. The surgical margins were R0 in 19 (wide in 14, marginal in 5) and one R1 resection. Marginal/R1 resections were due to extracompartimental sarcoma invasion (spinal canal) and dural involvement. In these patients postoperative radiotherapy was performed. Surgical complications requiring revision occurred in 1 patient due to injury of the ductus thoracicus and persisting chylothorax. Temporary subileus or mild pneumonia appeared in 3 patients. No superficial/deep infection or neurological deficits (except those related to oncologically required dissection of thoracic nerve roots) were observed. At follow up 2 patients died due to the disease after 7,5 months. Local recurrences were seen in 3 patients at median 24 months (13–43). Pulmonary metastases necessitating polychemotherapy were seen in 7 patients after median 17 months (7–44). Conclusion. Despite the only midterm follow up, the combined en bloc resection of chest wall and multilevel en bloc spondylectomy/hemivertebrectomy is a challenging but safe and effective technique in order to achieve adequate margins and local control in selected with spinal sarcomas extending to the dorsolateral chest wall

National guidelines recommend that trauma centres have a designated consultant for managing metastatic bone disease (MBD). No such system exists in Scotland. We compared MBD cases in a trauma hospital to a national bone tumour centre to characterise differences in management and outcome. Consecutive patients with metastatic proximal femoral lesions referred to a trauma unit and a national sarcoma centre were compared over a seven-year period (minimum follow-up one year). From Jan 2010-Dec 2016, 195 patients were referred to the trauma unit and 68 to the tumour centre. The trauma unit tended to see older patients (mean 72 vs. 65 years, p<0001) with cancers of poorer prognosis (e.g. 31% 61/195 vs. 13% 9/68 lung primary, p<0.001). Both units had similar operative rates but patients referred to the tumour centre were more likely to have endoprosthetic reconstruction (EPR 44% tumour vs. 3% trauma centre, p<0.001). Patients with an EPR survived longer than those with other types of fixation (81% 17/21 vs. 31% 35/112 one-year survival, p<0.001). Patients undergoing EPR were more likely to have an isolated metastasis (62% 13/21 vs. 17% 4/24, p<0.001). One patient from each centre had a revision for failed metalwork. There was a difference in caseload referred to both units, with the tumour centre seeing younger patients with a better prognosis. Patients suitable for endoprostheses were more likely to have isolated metastatic disease and a longer survival after surgery. An MBD pathway is required to ensure such patients are identified and referred for specialist management where appropriate

Sacral tumours are rare and can present difficult diagnostic and therapeutic challenges even at an early diagnosis. Surgical resection margins have a reported prognostic role in local recurrence and improved survival. Successful management is achieved within a specialist multidisciplinary service and involves combination chemotherapy, radiotherapy and surgery. We present our experience of patients with sacral tumours referred to our unit, who underwent total and subtotal sacrectomy procedures. Materials and Methods. Between 1995 and 2010, we identified twenty-six patients who underwent a total or subtotal sacrectomy operation. Patients were referred from around the United Kingdom to our services. We reviewed all case notes, operative records, radiological investigations and histopathology, resection margins, post operative complications, functional outcomes and we recorded long-term survival outcomes. Patients who were discharged to local services for continued follow up or further oncological treatment were identified and information was obtained from their general practitioner or oncologist. We reviewed the literature available on total sacrectomy case series, functional outcomes and soft tissue reconstruction. Results. We reviewed 26 patients, 16 male and 10 female, with a mean age at presentation of 53.4 years (range 11–80 years). Duration of symptoms ranged from 2 weeks to 6 years; lower back pain and sciatica were amongst the most common presenting features. Histological diagnoses included chordoma, Ewing's, malignant peripheral nerve sheath tumour, chondromyxoid fibroma, spindle cell sarcoma, synovial sarcoma, chondrosarcoma. A combined approach was used in two-thirds of patients and most of these patients had a soft tissue reconstruction with pedicled vertical rectus myocutaneous flap. Complications were categorised into major and minor and subdivided into wound, bladder and bowel symptoms. Wound complications and need for further intervention were more common amongst the patient group who did not have simultaneous soft tissue reconstruction at operation. All patients had a degree of bladder dysfunction in the early postoperative period. We present survivorship curves including recurrence and development of metastases. Conclusion. Total sacrectomy procedures carry a high risk of associated morbidity but can improve survival amongst specific groups of patients. They present challenges in diagnosis and management, but must be referred to a specialist service, that will instigate appropriate investigations and treatment regimes within a multidisciplinary setting. The expansion of services from other specialties required for the postoperative and ongoing rehabilitation plays an important role in overall management and appropriate pathways to coordinate these services are necessary

Extracorporeal irradiation and re-implantation of a bone segment is a technique employed in bone sarcoma surgery for limb salvage in the setting of reasonable bone stock. There is neither consensus nor rationale given for the dosage of irradiation used in previous studies, with values of up to 300Gy applied. We investigated the influence of extracorporeal irradiation on the elastic and viscoelastic properties of bone. Bone specimens were extracted from mature cattle and subdivided into thirteen groups; twelve groups exposed to increasing levels of irradiation and a control group. The specimens, once irradiated, underwent mechanical testing in saline at 37°C. Mechanical properties were calculated by experimental means which included Young's Modulus, Poisson's Ratio, Dissipation Factor, Storage Modulus, Loss Modulus and Dynamic Modulus. These were all obtained for comparison of the irradiated specimens to the control group. We found there to be a statistically significant increase in Poisson's ratio after increasing irradiation doses up to 300Gy were applied. However, there was negligible change in all other mechanical properties of bone that were assessed. Therefore, we conclude that the overall mechanical effect of high levels of extracorporeal irradiation (300Gy) is minute, and can be administered to reduce the risk of malignancy recurrence

A systematic literature review of distraction osteogenesis (DO) for the primary reconstruction of bone defects following resection of primary malignant tumours of long bones (PMTLB) is presented. Fewer than 50 cases were identified. Most reports relate to benign tumours or secondary reconstructive procedures. The outcomes of our own series of 7 patients is also presented (4 tibiae, 3 femora). All patients had isolated bone lesions without metastases and were assessed through the hospital sarcoma board. Mean follow-up was 59 months (17–144). Mean age was 42 years. Final histologic diagnoses were 3 chondrosarcoma, 2 malignant fibrous histiocytoma, 1 adamantinoma and 1 malignant intraosseous nerve sheath tumour. Mean bone defect after resection was 13.1cm (10–17) and bone transport was the reconstruction method in all. There was one local recurrence of tumour six months post-resection, necessitating amputation. Mean frame index for remaining cases was 30.9 days/cm (15.7–41.6). Complications included pin infection, docking site non-union, premature corticotomy union, soft-tissue infection and minor varus deformity. Six cases remain tumour-free with united, well-aligned bones and good long-term function. We conclude DO provides an effective biologic reconstruction option in select cases of PMTLB

Introduction. Dedifferentiated chondrosarcoma (D.C.) has a very poor prognosis. The efficacy of chemotherapy is still debated. Aim of this study was to evaluate the survival of patients with D.C. and to evaluate possible prognostic factors. Methods. Between 1990 and 2006, 109 patients were treated for D.C.: 55 males and 54 females, mean age of 59.6 years. In 81 cases tumor was located in the extremities and in 28 cases in the trunk. The most frequent dedifferentiation was in osteosarcoma (53.2%) followed by spindle cell sarcoma (21%), malignant fibrous histiocytoma (13.8%), fibrosarcoma (6.4%). All patients received surgery and mostly, limb salvage with tumor resection and implantation of a megaprosthesis or allograft (65 patients). Chemotherapy was given to 43 patients. Results. 16 patients (15.5%) were Ned at a mean followup of 10 yrs, 8 patients Ned1 after treatment of relapse, 1 patient AWD at 4.7 yrs, 77 patients DWD at a mean time of 1.6 yrs, 1 patient dead for other causes and 6 patients lost to followup were excluded. The overall survival of patients was 15%. There was significant difference in survival between patientens with D.C. of the trunk and those with D.C. of the extremities (p=0.0156). There was no significant difference in survival with chemoterapy and surgery or with surgery only (p=0.1115). Conclusion. The prognosis for patients with D.C. remains dismal. Surgery with wide margins is the principal treatment for this condition. There was no statistical evidence of any beneficial effect from chemotherapy

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions.

There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection.

The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants.

We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement.

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group).

We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury.

The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups.

The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.