The aim of the study was to compare measures of the quality of
life (QOL) after resection of a chordoma of the mobile spine with
the national averages in the United States and to assess which factors
influenced the QOL, symptoms of anxiety and depression, and coping
with pain post-operatively in these patients. A total of 48 consecutive patients who underwent resection of
a primary or recurrent chordoma of the mobile spine between 2000
and 2015 were included. A total of 34 patients completed a survey
at least 12 months post-operatively. The primary outcome was the
EuroQol-5 Dimensions (EQ-5D-3L) questionnaire. Secondary outcomes were
the Patient-Reported Outcome Measurement Information System (PROMIS)
anxiety, depression and pain interference questionnaires. Data which
were recorded included the indication for surgery, the region of
the tumour, the number of levels resected, the status of the surgical
margins, re-operations, complications, neurological deficit, length
of stay in hospital and rate of re-admission.Aims
Patients and Methods
The aim of the study was to investigate the controversial issue
of whether the pelvic ring should be reconstructed following resection
of the sarcomas of the ilium. From our database, we identified 64 patients who underwent excision
of a tumour involving the ilium between 1976 and 2015. A total of
35 underwent complete resection, of whom 24 were reconstructed with
a non-vascularised fibula graft, and four with extracorporeal irradiation
and reimplantation. A total of 29 patients had a partial resection.
The mean follow-up was 9.2 years (1.1 to 25.6). Functional outcomes
were assessed using the Toronto Extremity Salvation Score (TESS)
at final follow-up. In all, 32 patients (50%) had a chondrosarcoma.Aims
Patients and Methods
Due to the complex anatomy of the pelvis, limb-sparing resections
of pelvic tumours achieving adequate surgical margins, can often
be difficult. The advent of computer navigation has improved the
precision of resection of these lesions, though there is little
evidence comparing resection with or without the assistance of navigation. Our aim was to evaluate the efficacy of navigation-assisted surgery
for the resection of pelvic bone tumours involving the posterior
ilium and sacrum. Using our prospectively updated institutional database, we conducted
a retrospective case control study of 21 patients who underwent
resection of the posterior ilium and sacrum, for the treatment of
a primary sarcoma of bone, between 1987 and 2015. The resection
was performed with the assistance of navigation in nine patients
and without navigation in 12. We assessed the accuracy of navigation-assisted
surgery, as defined by the surgical margin and how this affects
the rate of local recurrence, the disease-free survival and the
effects on peri-and post-operative morbidity. Aims
Patients and Methods
We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells. We seeded mouse skeletal muscle cells C2C12 on the hydroxyapatite/calcium sulphate biomaterial and the phenotype of the cells was analysed. To mimic surgical conditions with leakage of extra cellular matrix (ECM) proteins and growth factors, we cultured rat bone cells ROS 17/2.8 in a bioreactor and harvested the secreted proteins. The secretome was added to rat muscle cells L6. The phenotype of the muscle cells after treatment with the media was assessed using immunostaining and light microscopy.Objectives
Materials and Methods
Giant cell tumours (GCTs) of the small bones
of the hands and feet are rare. Small case series have been published but
there is no consensus about ideal treatment. We performed a systematic
review, initially screening 775 titles, and included 12 papers comprising
91 patients with GCT of the small bones of the hands and feet. The
rate of recurrence across these publications was found to be 72%
(18 of 25) in those treated with isolated curettage, 13% (2 of 15)
in those treated with curettage plus adjuvants, 15% (6 of 41) in
those treated by resection and 10% (1 of 10) in those treated by
amputation. We then retrospectively analysed 30 patients treated for GCT
of the small bones of the hands and feet between 1987 and 2010 in
five specialised centres. The primary treatment was curettage in
six, curettage with adjuvants (phenol or liquid nitrogen with or
without polymethylmethacrylate (PMMA)) in 18 and resection in six.
We evaluated the rate of complications and recurrence as well as
the factors that influenced their functional outcome. At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence
was 50% (n = 3) in those patients treated with isolated curettage,
22% (n = 4) in those treated with curettage plus adjuvants and 17%
(n = 1) in those treated with resection (p = 0.404). The only complication
was pain in one patient, which resolved after surgical removal of remnants
of PMMA. We could not identify any individual factors associated
with a higher rate of complications or recurrence. The mean post-operative
Musculoskeletal Tumor Society scores were slightly higher after
intra-lesional treatment including isolated curettage and curettage
plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to
30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted
in the cure for all patients and is therefore a reasonable treatment
for both primary and recurrent GCT of the small bones of the hands
and feet. Cite this article:
Resection of a primary sarcoma of the diaphysis
of a long bone creates a large defect. The biological options for reconstruction
include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods
of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent
biological reconstruction of a diaphyseal defect after resection
of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4).
Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised
fibular autograft. Either method could have been used for any patient in
the study. The mean follow-up was 52 months (12 to 259). Oncological,
surgical and functional outcome were evaluated. Kaplan–Meier analysis
was performed for graft survival with major complication as the
end point. At final follow-up, eight patients had died of disease. Primary
union was achieved in 40 patients (75%); 22 (42%) with a vascularised
fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A
total of 32 patients (60%) required revision surgery. Kaplan–Meier
analysis revealed a mean survival without complication of 36 months
(0.06 to 107.3, Both groups seem to be reliable biological methods of reconstructing
a diaphyseal bone defect. Vascularised autografts require more revisions
mainly due to problems with wound healing in distal sites of tumour,
such as the foot. Cite this article:
Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh. A total of 18 patients (14 men, four women) underwent total or partial quadriceps resection for soft-tissue sarcoma of the thigh between 2002 and 2014. The number of resected quadriceps was surveyed, knee extension strength was measured with the Biodex isokinetic dynamometer system (affected side/unaffected side) and relationships between these were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D) score and the Short Form 8 were used to evaluate post-operative function and examine correlations with extension strength. The cutoff value for extension strength to expect good post-operative function was also calculated using a receiver operating characteristic (ROC) curve and Fisher’s exact test.Objectives
Methods
Osteosarcoma of the pelvis is a particularly difficult tumour
to treat as it often presents late, may be of considerable size
and/or associated with metastases when it presents, and is frequently
chondroid in origin and resistant to chemotherapy. The aim of this study was to review our experience of managing
this group of patients and to identify features predictive of a
poor outcome. Between 1983 and 2014, 121 patients, (74 females and 47 males)
were treated at a single hospital: 74 (61.2%) patients had a primary
osteosarcoma and 47 (38.8%) had an osteosarcoma which was secondary
either to Paget’s disease (22; 18.2%) or to previous pelvic irradiation
(25; 20.7%). The mean age of those with a primary osteosarcoma was 29.3 years
(nine to 76) and their mean follow-up 2.9 years (0 to 29). The mean
age of those with a secondary sarcoma was 61.9 years (15 to 85)
and their mean follow-up was one year (0 to 14). A total of 22 patients with a primary sarcoma (52.4%) and 20
of those with a secondary sarcoma (47.6%) had metastases at the
time of presentation. Aims
Patients and Methods
The aim of this study was to define the incidence
of venous thromboembolism (VTE) and risk factors for the development
of deep-vein thrombosis (DVT) after the resection of a musculoskeletal
tumour. A total of 94 patients who underwent resection of a musculoskeletal
tumour between January 2003 and December 2005 were prospectively
studied. There were 42 men and 52 women with a mean age of 54.4
years (18 to 86). All patients wore intermittent pneumatic compression
devices and graduated compression stockings. Ultrasound examination
of the lower limbs was conducted to screen for DVT between the fifth
and ninth post-operative days. DVT was detected in 21 patients (22%). Of these, two were symptomatic
(2%). One patient (1%) had a fatal pulmonary embolism. Patients
aged ≥ 70 years had an increased risk of DVT (p = 0.004). The overall incidence of DVT (both symptomatic and asymptomatic)
after resection of a musculoskeletal tumour with mechanical prophylaxis
was high. It seems that both mechanical and anticoagulant prophylaxis
is needed to prevent VTE in patients who have undergone the resection
of a musculoskeletal tumour. Cite this article:
The purpose of this study was to develop a prognostic model for
predicting survival of patients undergoing surgery owing to metastatic
bone disease (MBD) in the appendicular skeleton. We included a historical cohort of 130 consecutive patients (mean
age 64 years, 30 to 85; 76 females/54 males) who underwent joint
arthroplasty surgery (140 procedures) owing to MBD in the appendicular
skeleton during the period between January 2003 and December 2008.
Primary cancer, pre-operative haemoglobin, fracture Aims
Methods
The aim of this study was to evaluate the prognostic
and therapeutic factors which influence the oncological outcome
of parosteal osteosarcoma. A total of 80 patients with a primary parosteal osteosarcoma
were included in this retrospective study. There were 51 females
and 29 males with a mean age of 29.9 years (11 to 78). The mean follow-up was 11.2 years (1 to 40). Overall survival
was 91.8% at five years and 87.8% at ten years. Local recurrence
occurred in 14 (17.5%) patients and was associated with intralesional
surgery and a large volume of tumour. On histological examination,
80% of the local recurrences were dedifferentiated high-grade tumours.
A total of 12 (14.8%) patients developed pulmonary metastases, of
whom half had either a dedifferentiated tumour or a local recurrence.
Female gender and young age were good prognostic factors. Local
recurrence was a poor prognostic factor for survival. Medullary
involvement or the use of chemotherapy had no impact on survival. The main goal in treating a parosteal osteosarcoma must be to
achieve a wide surgical margin, as inadequate margins are associated
with local recurrence. Local recurrence has a significant negative
effect on survival, as 80% of the local recurrences are high-grade
dedifferentiated tumours, and half of these patients develop metastases. The role of chemotherapy in the treatment of parosteal osteosarcoma
is not as obvious as it is in the treatment of conventional osteosarcoma.
The mainstay of treatment is wide local excision. Cite this article:
Extracorporeal irradiation of an excised tumour-bearing
segment of bone followed by its re-implantation is a technique used
in bone sarcoma surgery for limb salvage when the bone is of reasonable
quality. There is no agreement among previous studies about the
dose of irradiation to be given: up to 300 Gy have been used. We investigated the influence of extracorporeal irradiation on
the elastic and viscoelastic properties of bone. Bone was harvested
from mature cattle and subdivided into 13 groups: 12 were exposed
to increasing levels of irradiation: one was not and was used as
a control. The specimens, once irradiated, underwent mechanical
testing in saline at 37°C. The mechanical properties of each group, including Young’s modulus,
storage modulus and loss modulus, were determined experimentally
and compared with the control group. There were insignificant changes in all of these mechanical properties
with an increasing level of irradiation. We conclude that the overall mechanical effect of high levels
of extracorporeal irradiation (300 Gy) on bone is negligible. Consequently
the dose can be maximised to reduce the risk of local tumour recurrence. Cite this article:
The aim of this study was to define the treatment
criteria for patients with recurrent chondrosarcoma. We reviewed the
data of 77 patients to examine the influence of factors such as
the intention of treatment (curative/palliative), extent of surgery,
resection margins, status of disease at the time of local recurrence
and the grade of the tumour. A total of 70 patients underwent surgery
for recurrent chondrosarcoma. In seven patients surgery was not
a viable option. Metastatic disease occurred in 41 patients, appearing
synchronously with the local recurrence in 56% of cases. For patients
without metastasis at the time of local recurrence, the overall
survival at a mean follow-up after recurrence of 67 months (0 to
289) was 74% (5 of 27) compared with 19% (13 of 50) for patients
with metastasis at or before the development of the recurrence.
Neither the type/extent of surgery, site of tumour, nor the resection margins
for the recurrent tumour significantly influenced the overall survival. With limited survival for patients with metastatic disease at
the time of local recurrence (0% for patients with grade III and
de-differentiated chondrosarcoma), palliative treatment, including
local radiation therapy and debulking procedures, should be discussed
with the patients to avoid long hospitalisation and functional deficits. For
patients without metastasis at the time of local recurrence, the
overall survival of 74% justifies an aggressive approach including
wide resection margins and extensive reconstruction.
Endoprosthetic reconstruction following resection of 31 tumours of the proximal femur in 30 patients was performed using a Wagner SL femoral revision stem. The mean follow-up was 25.6 months (0.6 to 130.0). Of the 28 patients with a metastasis, 27 died within a mean follow-up period of 18.1 months (0.6 to 56.3) after the operation, and the remaining patient was excluded from the study 44.4 months post-operatively when the stem was removed. The two patients with primary bone tumours were still alive at the latest follow-up of 81.0 and 130.0 months, respectively. One stem only was removed for suspected low-grade infection 44.4 months post-operatively. The worst-case survival rate with removal of the stem for any cause and/or loss to follow-up was 80.0% (95% confidence interval 44.9 to 100) at 130.0 months. The mean Karnofsky index increased from 44.2% (20% to 70%) pre-operatively to 59.7% (0% to 100%) post-operatively, and the mean Merle d’Aubigné score improved from 4.5 (0 to 15) to 12.0 (0 to 18). The mean post-operative Musculoskeletal Tumour Society score was 62.4% (3.3% to 100%). The Wagner SL femoral revision stem offers an alternative to special tumour prostheses for the treatment of primary and secondary tumours of the proximal femur. The mid-term results are very promising, but long-term experience is necessary.
The August 2013 Oncology Roundup360 looks at: spinal osteosarcoma: all hope is not lost; intralesional curettage for low-grade chondrosarcoma?; isolated limb perfusion is a salvage option; worryingly high infection rates in patients with endoprostheses; how bad is endoprosthetic infection?; operatively treated metastatic disease; and cementoplasty gives immediate pain relief
The aim of this study was to assess a specific
protocol for the treatment of patients with a parosteal osteosarcoma of
the distal femur with limb salvage involving hemicortical resection
and reconstruction using recycled pasteurised autograft and internal
fixation. Between January 2000 and January 2010, 13 patients with
a mean age of 26.5 years (17 to 39) underwent this procedure. All
the tumours were staged according to Enneking’s criteria: there
were eight stage IA tumours and five stage IB tumours. The mean
follow-up was 101.6 months (58 to 142), and mean post-operative
Musculoskeletal Tumour Society functional score was 88.6% (80% to
100%) at the final follow-up. All the patients had achieved bony
union; the mean time to union was 11.2 months (6 to 18). Local recurrence
occurred in one patient 27 months post-operatively. No patient had
a pulmonary metastasis. A hemicortical procedure for the treatment of a parosteal osteosarcoma
is safe and effective. Precise pre-operative planning using MRI
is essential in order to define the margins of resection. Although
it is a technically demanding procedure, gratifying results make
it worthwhile for selected patients. Cite this article:
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. We performed a pilot international multi-centre RCT. We used
central randomisation to conceal treatment allocation and sham antibiotics
to blind participants, surgeons, and data collectors. We determined
feasibility by measuring patient enrolment, completeness of follow-up,
and protocol deviations for the antibiotic regimens. Objective
Methods
The pre-operative differentiation between enchondroma,
low-grade chondrosarcoma and high-grade chondrosarcoma remains a
diagnostic challenge. We reviewed the accuracy and safety of the
radiological grading of cartilaginous tumours through the assessment
of, first, pre-operative radiological and post-operative histological agreement,
and second the rate of recurrence in lesions confirmed as high-grade
on histology. We performed a retrospective review of major long
bone cartilaginous tumours managed by curettage as low grade between
2001 and 2012. A total of 53 patients with a mean age of 47.6 years
(8 to 71) were included. There were 23 men and 30 women. The tumours
involved the femur (n = 20), humerus (n = 18), tibia (n = 9), fibula
(n = 3), radius (n = 2) and ulna (n = 1). Pre-operative diagnoses
resulted from multidisciplinary consensus following radiological
review alone for 35 tumours, or with the addition of pre-operative
image guided needle biopsy for 18. The histologically confirmed diagnosis
was enchondroma for two (3.7%), low-grade chondrosarcoma for 49
(92.6%) and high-grade chondrosarcoma for two (3.7%). Three patients
with a low-grade tumour developed a local recurrence at a mean of 15
months (12 to 17) post-operatively. A single high-grade recurrence
(grade II) was treated with tibial diaphyseal replacement. The overall
recurrence rate was 7.5% at a mean follow-up of 4.7 years (1.2 to
12.3). Cartilaginous tumours identified as low-grade on pre-operative
imaging with or without additional image-guided needle biopsy can
safely be managed as low-grade without pre-operative histological
diagnosis. A few tumours may demonstrate high-grade features histologically,
but the rates of recurrence are not affected. Cite this article:
Skeletal metastases from hepatocellular carcinoma are highly destructive vascular lesions which severely reduce the quality of life. Pre-existing liver cirrhosis presents unique challenges during the surgical management of such lesions. We carried out a retrospective study of 42 patients who had been managed surgically for skeletal metastases from hepatocellular carcinoma affecting the appendicular skeleton between January 2000 and December 2006. There were 38 men and four women with a mean age of 60.2 years (46 to 77). Surgery for a pathological fracture was undertaken in 30 patients and because of a high risk of fracture in 12. An intralesional surgical margin was achieved in 36 and a wide margin in six. Factors influencing survival were determined by univariate and multivariate analyses. The survival rates at one, two and three years after surgery were 42.2%, 25.8% and 19.8%, respectively. The median survival time was ten months (95% confidence interval 6.29 to 13.71). The number of skeletal metastases and the Child-Pugh grade were identified as independent prognostic factors by Cox regression analysis. The method of management of the hepatocellular carcinoma, its status in the liver, the surgical margin for skeletal metastases, the presence of a pathological fracture and adjuvant radiotherapy were not found to be significantly related to the survival of the patient, which was affected by hepatic function, as represented by the Child-Pugh grade.
Atypical cartilaginous tumours are usually treated
by curettage. The purpose of this study was to show that radiofrequency
ablation was an effective alternative treatment. We enrolled 20 patients (two male, 18 female, mean age 56 years
(36 to 72) in a proof-of-principle study. After inclusion, biopsy
and radiofrequency ablation were performed, followed three months
later by curettage and adjuvant phenolisation. The primary endpoint
was the proportional necrosis in the retrieved material. Secondary endpoints
were correlation with the findings on gadolinium enhanced MRI, functional
outcome and complications. Our results show that 95% to 100% necrosis was obtained in 14
of the 20 patients. MRI had a 91% sensitivity and 67% specificity
for detecting residual tumour after curettage. The mean functional
outcome (MSTS) score six weeks after radiofrequency ablation was
27.1 (23 to 30) compared with 18.1 (12 to 25) after curettage (p
<
0.001). No complications occurred after ablation, while two
patients developed a pathological fracture after curettage. We have shown that radiofrequency ablation is capable of completely
eradicating cartilaginous tumour cells in selective cases. MRI has
a 91% sensitivity for detecting any residual tumour. Radiofrequency
ablation can be performed on an outpatient basis allowing a rapid
return to normal activities. If it can be made more effective, it
has the potential to provide better local control, while improving
functional outcome. Cite this article: