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Slump J, Ferguson PC, Wunder JS, Griffin AM, Hoekstra HJ, Liu X, Hofer SOP, O'Neill AC. Patient, tumour and treatment factors affect complication rates in soft tissue sarcoma flap reconstruction in a synergistic manner. Eur J Surg Oncol 2017; 43:1126-1133. [PMID: 28222969 DOI: 10.1016/j.ejso.2017.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/11/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Flap reconstruction plays an essential role in the management of soft tissue sarcoma, facilitating wide resection while maximizing preservation of function. The addition of reconstruction increases the complexity of the surgery and identification of patients who are at high risk for post-operative complications is an important part of the preoperative assessment. This study examines predictors of complications in these patients. METHODS 294 patients undergoing flap reconstruction following sarcoma resection were evaluated. Data on patient, tumour and treatment variables as well as post-operative complications were collected. Bivariate and multivariate regression analysis was performed to identify independent predictors of complications. Analysis of synergistic interaction between key patient and tumour risk factors was subsequently performed. RESULTS A history of cerebrovascular events or cardiac disease were found to be the strongest independent predictors of post-operative complications (OR 14.84, p = 0.003 and OR 5.71, p = 0.001, respectively). Further strong independent tumour and treatment-related predictors were high grade tumours (OR 1.91, p = 0.038) and the need for additional reconstructive procedures (OR 2.78, p = 0.001). Obesity had significant synergistic interaction with tumour resection diameter (RERI 1.1, SI 1.99, p = 0.02) and high tumour grade (RERI 0.86, SI 1.5, p = 0.01). Comorbidities showed significant synergistic interaction with large tumour resections (RERI 0.91, SI 1.83, p = 0.02). CONCLUSION Patient, tumour and treatment-related variables contribute to complications following flap reconstruction of sarcoma defects. This study highlights the importance of considering the combined effect of multiple risk factors when evaluating and counselling patients as significant synergistic interaction between variables can further increase the risk of complications.
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Davidson D, Barr RD, Riad S, Griffin AM, Chung PW, Catton CN, O'Sullivan B, Ferguson PC, Davis AM, Wunder JS. Health-related quality of life following treatment for extremity soft tissue sarcoma. J Surg Oncol 2016; 114:821-827. [PMID: 27634326 DOI: 10.1002/jso.24424] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/15/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES The primary objective of this study was to estimate the change in health-related quality of life (HRQL) 1 year following treatment for extremity soft tissue sarcoma (STS), measured by the EQ-5D. Secondary objectives included determining clinical variables associated with HRQL at 1 year, estimating the proportion with a clinically important difference (CID) in HRQL, and evaluating variability within EQ-5D domains. METHODS Patients over the age of 16 years, treated for a localized extremity STS, were included. The EQ-5D change score from pre-treatment to 1-year follow-up was determined. The association of clinical variables with EQ-5D scores was estimated using a linear regression model. The proportion of patients with a CID in HRQL score was determined. A vector analysis of the EQ-5D domains was undertaken. RESULTS The mean EQ-5D change score was 0.02. Age, sex, disease status, and initial EQ-5D score were associated with EQ-5D score at 1 year. There was a CID improvement in 32% and a deterioration in 24%. The anxiety and depression domain demonstrated the most change between baseline and 1 year after treatment. CONCLUSION Most patients maintain a high level of HRQL following treatment for extremity STS. J. Surg. Oncol. 2016;114:821-827. © 2016 2016 Wiley Periodicals, Inc.
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Chui MH, Kandel RA, Wong M, Griffin AM, Bell RS, Blackstein ME, Wunder JS, Dickson BC. Histopathologic Features of Prognostic Significance in High-Grade Osteosarcoma. Arch Pathol Lab Med 2016; 140:1231-1242. [PMID: 27552092 DOI: 10.5858/arpa.2015-0389-oa] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context .- In osteosarcoma treated with neoadjuvant chemotherapy the extent of tumor necrosis on resection is considered an indicator of treatment response, and this has been shown to correlate with survival in most but not all studies. Objective .- To identify additional histologic variables of prognostic significance in high-grade osteosarcoma. Design .- Slides of pretreatment biopsy and primary postneoadjuvant chemotherapy resections from 165 patients with high-grade osteosarcoma were reviewed. Univariate (Kaplan-Meier) and multivariate (Cox regression) analyses were performed to identify clinical and histomorphologic attributes associated with overall survival. Results .- Univariate analyses confirmed the prognostic significance of metastatic status on presentation, primary tumor size, anatomic site, and histologic subtype. Additionally, the identification of lymphovascular invasion, 10% or more residual viable tumor, and 10 or more mitoses per 10 high-powered fields assessed in posttreatment resections were associated with poor survival, retaining significance in multivariate analyses. Based on results from multivariate analysis, we developed a prognostic index incorporating primary tumor size and site, and significant histologic features assessed on resection (ie, lymphovascular invasion status, mitotic rate, and extent of viable tumor). This scoring system segregates patients into 3 risk categories with significant differences in overall survival and retained significance in an independent validation set of 42 cases. Conclusions .- The integration of clinical and microscopic features improves prognostication of patients with osteosarcoma.
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Carvallo PI, Griffin AM, Ferguson PC, Wunder JS. Response to letter to the editor re Carvallo et al.: Salvage of the proximal femur following pathological fractures involving benign bone tumors. J Surg Oncol 2016; 114:255. [PMID: 27332668 DOI: 10.1002/jso.24286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 04/29/2016] [Indexed: 11/10/2022]
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Traub F, Singh J, Dickson BC, Leung S, Mohankumar R, Blackstein ME, Razak AR, Griffin AM, Ferguson PC, Wunder JS. Efficacy of denosumab in joint preservation for patients with giant cell tumour of the bone. Eur J Cancer 2016; 59:1-12. [PMID: 26990281 DOI: 10.1016/j.ejca.2016.01.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/05/2016] [Accepted: 01/13/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Giant cell tumour of the bone (GCTB) is an aggressive osteolytic primary tumour. GCTB is rich in osteoclast-like giant cells and contains mononuclear cells that express RANK ligand (RANKL), a key mediator of osteoclast activation. The potential therapeutic effect of denosumab was investigated with special reference to its role in joint preservation. METHODS In this prospective non-randomised study patients with GCTB received denosumab for 6-11 months preoperatively. Serial radiographs and biopsy and resection tumour specimens were used to monitor response to denosumab. RESULTS All 20 patients experienced pain relief in the first month of treatment. All patients demonstrated a positive radiographic response with improved subchondral and cortical bone which allowed intralesional tumour resection and preservation of the joint and articular surface in 18 cases. Histological examination following denosumab revealed rarely detectable osteoclast-like giant cells. There was an obvious increase in osteoid matrix and woven bone which showed rare RANK staining amongst the mononuclear cells and only focal RANKL positivity. At median 30 months follow-up after resection, local tumour recurrence occurred in three patients. CONCLUSION Denosumab provides favourable and consistent clinical, radiographic and pathologic responses which facilitates less aggressive surgical treatment, especially joint preservation. However, the local recurrence rate for GCTB following resection does not seem to be affected by denosumab and remains a concern.
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Mollon B, Griffin AM, Ferguson PC, Wunder JS, Theodoropoulos J. Combined arthroscopic and open synovectomy for diffuse pigmented villonodular synovitis of the knee. Knee Surg Sports Traumatol Arthrosc 2016; 24:260-6. [PMID: 25308157 DOI: 10.1007/s00167-014-3375-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 10/01/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE There are few reports detailing recurrence rates or functional outcomes after combined arthroscopic and open synovectomy to treat diffuse pigmented villonodular synovitis (DPVNS) of the knee. METHODS Patients with DPVNS of the knee treated with combined synovectomy, followed for a minimum of 12 months at a tertiary orthopaedic oncology centre, were identified. We extracted data pertaining to demographics, complications, clinical outcomes and recurrence. Functional status was evaluated prospectively using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society (MSTS) 1987 and 1993 surveys. Data were reported descriptively as mean (SD) unless otherwise specified. RESULTS Fifteen patients [80% female; mean age 38.9 (SD 14.2) years] representing 15 knees were treated with combined synovectomies and followed for 81 (SD 55) months. Posterior arthroscopy was utilized in 73% of patients. External beam radiation was utilized post-operatively in 73% of patients. Two patients (13%) experienced symptomatic disease recurrence. The mean post-operative knee range of motion was 1° (range 0-10°) to 115° (range 90-135°). TESS and MSTS 1987/1993 scores all suggested excellent patient function. Post-operative complications included one posterior wound dehiscence, one case of femoral condyle avascular necrosis and one patient with lymphedema. CONCLUSIONS Combined synovectomy resulted in a low rate of symptomatic disease recurrence and good to excellent functional outcomes for diffuse PVNS of the knee. A literature review identified this as largest case series focusing on combined synovectomies for DPVNS of the knee and the only one describing functional outcomes or the use of external beam radiotherapy. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Carvallo PI, Griffin AM, Ferguson PC, Wunder JS. Salvage of the proximal femur following pathological fractures involving benign bone tumors. J Surg Oncol 2015; 112:846-52. [PMID: 26482583 DOI: 10.1002/jso.24072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/08/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES To describe the surgical treatment of patients with a pathologic fracture through a benign tumor of the proximal femur to determine if there is a difference in local recurrence, complications or functional outcome compared to patients with tumors in the same location without pathologic fractures. METHODS From 1989-2010, of 97 patients, 29 presented with a pathologic fracture (PF) through a proximal femoral benign bone tumor and 68 presented without a pathologic fracture (NPF). Outcomes of the two groups were compared in terms of surgical management, postoperative complications, local recurrence and functional scores. RESULTS Fibrous dysplasia, giant cell tumor of bone and chondroblastoma were the most common subtypes. Most patients were managed with joint preservation in both PF (86.2%) and NPF (98.5%) groups (P = 0.03). Local recurrence risk was similar for patients in the PF (10.3%) and NPF (8.8%) groups. Mean follow-up was 105.7 months (P = 0.8). Functional outcome scores were high in both groups and not statistically significantly different. CONCLUSIONS The majority of pathologic fractures through a benign bone tumor of the proximal femur can be successfully treated with curettage, burring, bone grafting and internal fixation without increasing the risk of local recurrence or negatively impacting functional outcome.
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Griffin AM, Dickie CI, Catton CN, Chung PWM, Ferguson PC, Wunder JS, O'Sullivan B. The influence of time interval between preoperative radiation and surgical resection on the development of wound healing complications in extremity soft tissue sarcoma. Ann Surg Oncol 2015; 22:2824-30. [PMID: 26018726 DOI: 10.1245/s10434-015-4631-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to determine the relationship of the time interval between completion of preoperative radiation therapy (RT) and surgical resection on wound complications (WCs) in extremity soft tissue sarcoma (STS). METHODS Overall, 798 extremity STS patients were managed with preoperative RT and surgery from 1989 to 2013. WCs were defined as requiring secondary operations/invasive procedures for wound care, use of vacuum-assisted closure, prolonged dressing changes, or infection within 120 days of surgery. RESULTS Mean tumor size was 8.8 cm. A total of 743 (93 %) tumors were primary presentations, 565 (71 %) patients had lower extremity tumors, and 238 patients (30 %) had a prior unplanned excision. Of 242 patients (30 %) who developed a WC, 206 (37 %) had lower extremity tumors and 36 (15 %) had upper extremity tumors. Mean time from RT completion to surgery was 41.3 (range 4-470) days; 42.0 (range 4-470) days for upper extremity cases, and 41.1 (range 4-109) days for lower extremity cases. Similarly, mean time interval for patients who developed a WC was 40.9 (range 4-100) days, and 41.5 (range 4-470) days for those who did not develop a WC (p = 0.69). Thirty-nine cases (5 %) had surgery within 3 weeks of RT; 15 (38 %) patients developed WCs versus 227 (30 %) patients who had their tumors excised after 3 weeks (p = 0.28). One hundred and twenty-nine (16 %) patients had surgery within 4 weeks, and 39 (30 %) patients developed WCs versus 203 (30 %) patients who had their tumors excised after 4 weeks (p = 1.0). A trend towards a higher rate of WCs was seen for those patients who had surgery after 6 weeks (28 % prior vs. 34 % after; p = 0.08). There was no difference in WCs with intensity-modulated RT (IMRT) versus non-IMRT cases (p = 0.6). CONCLUSION The time interval between preoperative RT and surgical excision in extremity STS had minimal influence on the development of WCs. Four- or 5-week intervals showed equivalent complication rates between the two groups, suggesting an optimal interval to reduce potential WCs.
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O'Donnell PW, Griffin AM, Eward WC, Sternheim A, Catton CN, Chung PW, O'Sullivan B, Ferguson PC, Wunder JS. The effect of the setting of a positive surgical margin in soft tissue sarcoma. Cancer 2014; 120:2866-75. [PMID: 24894656 DOI: 10.1002/cncr.28793] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/17/2014] [Accepted: 02/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objectives of this study were to evaluate the risk of local recurrence and survival after soft tissue sarcoma (STS) resection with positive margins and to evaluate the safety of sparing adjacent critical structures. METHODS One hundred sixty-nine patients with localized STS who had positive resection margins were identified from a prospective database. Patients who had positive margins were stratified into 3 groups, each representing a specific clinical scenario: critical structure positive margin (eg major nerve, vessel, or bone), tumor bed resection positive margin, and unexpected positive margin. The rates of local recurrence-free survival (LRFS) and cause-specific survival (CSS) were calculated and compared with relevant control patients who had negative margins after STS resection. RESULTS After planned close dissection to preserve critical structures, the 5-year LRFS and CSS rates both depended on the quality of the surgical margins (97% and 80.3%, respectively, for those with negative margins vs 85.4% and 59.4%, respectively, for those with positive margins; P = .015 and P = .05, respectively). Negative margins achieved through resection of critical structures because of tumor invasion or encasement only slightly improved the 5-year rates of LRFS (91.2%) and CSS (63.6%; P = .8 and P = .9, respectively). The lowest 5-year LRFS and CSS rates were 63.4% and 59.2%, respectively, after an unexpected positive margin during primary surgery. CONCLUSIONS After patients undergo resection of STS with positive margins, oncologic outcomes can be predicted based on the clinical context. Sparing adjacent critical structures in this setting is safe and contributes to improved functional outcomes.
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O'Donnell PW, Griffin AM, Eward WC, Sternheim A, Wunder JS, Ferguson PC. Early follow-up of a custom non-fluted diaphyseal press-fit tumour prosthesis. INTERNATIONAL ORTHOPAEDICS 2013; 38:123-7. [PMID: 24005239 DOI: 10.1007/s00264-013-2078-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/10/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this study was to evaluate the early results of a custom non-fluted diaphyseal press-fit stem for use with the global modular replacement system (GMRS) tumour prosthesis and the early complications associated with this implant. METHODS A total of 53 patients (54 implants) were identified from a prospective database where a custom non-fluted diaphyseal press-fit stem was used as part of the reconstruction of the limb. All patients had a minimum of 22 months of follow-up. RESULTS The rates of stem revision for any reason were calculated. The median follow-up was 36 months (range 22-85 months). Aseptic loosening was not observed in any patient. CONCLUSIONS At early term follow-up, an uncemented non-fluted stem used with the GMRS tumour endoprosthesis provides a stable bone-prosthesis interface with no evidence of aseptic loosening.
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O'Sullivan B, Griffin AM, Dickie CI, Sharpe MB, Chung PWM, Catton CN, Ferguson PC, Wunder JS, Deheshi BM, White LM, Kandel RA, Jaffray DA, Bell RS. Phase 2 study of preoperative image-guided intensity-modulated radiation therapy to reduce wound and combined modality morbidities in lower extremity soft tissue sarcoma. Cancer 2013; 119:1878-84. [PMID: 23423841 DOI: 10.1002/cncr.27951] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/30/2012] [Accepted: 12/04/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study sought to determine if preoperative image-guided intensity-modulated radiotherapy (IG-IMRT) can reduce morbidity, including wound complications, by minimizing dose to uninvolved tissues in adults with lower extremity soft tissue sarcoma. METHODS The primary endpoint was the development of an acute wound complication (WC). IG-IMRT was used to conform volumes to avoid normal tissues (skin flaps for wound closure, bone, or other uninvolved soft tissues). From July 2005 to June 2009, 70 adults were enrolled; 59 were evaluable for the primary endpoint. Median tumor size was 9.5 cm; 55 tumors (93%) were high-grade and 58 (98%) were deep to fascia. RESULTS Eighteen (30.5%) patients developed WCs. This was not statistically significantly different from the result of the National Cancer Institute of Canada SR2 trial (P = .2); however, primary closure technique was possible more often (55 of 59 patients [93.2%] versus 50 of 70 patients [71.4%]; P = .002), and secondary operations for WCs were somewhat reduced (6 of 18 patients [33%] versus 13 of 30 patients [43%]; P = .55). Moderate edema, skin, subcutaneous, and joint toxicity was present in 6 (11.1%), 1 (1.9%), 5 (9.3%), and 3 (5.6%) patients, respectively, but there were no bone fractures. Four local recurrences (6.8%, none near the flaps) occurred with median follow-up of 49 months. CONCLUSIONS The 30.5% incidence of WCs was numerically lower than the 43% risk derived from the National Cancer Institute of Canada SR2 trial, but did not reach statistical significance. Preoperative IG-IMRT significantly diminished the need for tissue transfer. RT chronic morbidities and the need for subsequent secondary operations for WCs were lowered, although not significantly, whereas good limb function was maintained.
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Jones KB, Ferguson PC, Lam B, Biau DJ, Hopyan S, Deheshi B, Griffin AM, White LM, Wunder JS. Effects of neoadjuvant chemotherapy on image-directed planning of surgical resection for distal femoral osteosarcoma. J Bone Joint Surg Am 2012; 94:1399-405. [PMID: 22854993 PMCID: PMC3401141 DOI: 10.2106/jbjs.k.00971] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Standard therapy for localized osteosarcoma includes neoadjuvant chemotherapy preceding local control surgery, followed by adjuvant chemotherapy. When limb-salvage procedures were being developed, preoperative chemotherapy allowed a delay in definitive surgery to permit fabrication of custom endoprosthetic reconstruction implants. One rationale for its continuation as the care standard has been the perception that it renders surgery easier and safer. Our objective was to compare surgical procedures planned on the basis of magnetic resonance images (MRIs) of distal femoral osteosarcomas acquired before neoadjuvant chemotherapy with surgical procedures planned on the basis of MRIs acquired after neoadjuvant chemotherapy as a measure of the surgically critical anatomic effects of the chemotherapy. METHODS Twenty-four consecutive patients with distal femoral osteosarcoma had available digital MRIs preceding and following neoadjuvant chemotherapy. Thorough questionnaires were used to catalogue surgically critical anatomic details of MRI-directed surgical planning. Four faculty musculoskeletal oncologic surgeons and two musculoskeletal radiologists evaluated the blinded and randomly ordered MRIs. Interrater and intrarater reliabilities were calculated with intraclass correlation coefficients. The Student t test and chi-square test were used to compare pre-chemotherapy and post-chemotherapy continuous and categorical variables on the questionnaire. Mixed-effect regression models were employed to compare surgical procedures planned on the basis of pre-chemotherapy MRIs and with those planned on the basis of post-chemotherapy MRIs. RESULTS The blinded reviews generated strong intraclass correlation coefficients for both interrater (0.772) and mean intrarater (0.778) reliability. The MRI-planned resections for the majority of tumors changed meaningfully after chemotherapy, but in inconsistent directions. On the basis of mixed-effect regression modeling, it appeared that more amputations were planned on the basis of post-chemotherapy MRIs. No other parameters differed in a significant and clinically meaningful fashion. Surgeons demonstrated their expectation that neoadjuvant chemotherapy would improve resectability by planning more radical surgical procedures on the basis of scans that they predicted had been obtained pre-chemotherapy. CONCLUSIONS Surgeons can reliably record the anatomic details of a planned resection of an osteosarcoma. Such methods may be useful in future multi-institutional clinical trials or registries. The common belief that neoadjuvant chemotherapy increases the resectability of extremity osteosarcomas remains anecdotally based. Rigorous assessment of this phenomenon in larger cohorts and at other anatomic sites as well as re-evaluation of other arguments for neoadjuvant chemotherapy should be considered.
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Biau DJ, Ferguson PC, Chung P, Griffin AM, Catton CN, O'Sullivan B, Wunder JS. Local recurrence of localized soft tissue sarcoma: a new look at old predictors. Cancer 2012; 118:5867-77. [PMID: 22648518 DOI: 10.1002/cncr.27639] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 04/03/2012] [Accepted: 04/03/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND The objective of this study was to examine the effect of known predictors of local recurrence of soft tissue sarcoma in a competing risk setting. METHODS The outcome of interest was the cumulative probability of local recurrence per category of relevant predictors, with death as a competing event. In total, 1668 patients with a localized soft tissue sarcoma of the extremity or trunk were included. RESULTS Tumor size (hazard ratio, 3.3), depth (hazard ratio, 3.2), and histologic grade (hazard ratio, 4.5) were the variables that had the most effect on the risk of metastasis and, accordingly, were the most likely to induce competition. Surgical margins (hazard ratio, 3.3), histologic grade (hazard ratio, 2.1), presentation status (hazard ratio, 2.4), and tumor depth (hazard ratio, 1.5) were the variables that had the most effect on the risk of local recurrence. The 10-year cumulative probabilities of local recurrence were markedly different within categories for presentation status (P < .001) and surgical margin status (P < .001). However, because of the competing effect of death, there was little difference in the 10-year cumulative probabilities of local recurrence with regard to tumor depth (12% and 11.4% for deep and superficial tumors, respectively; P = .2), tumor size (10.6% and 13.3% for large and small tumors, respectively; P = .99), or histologic tumor grade (12.6%, 10.7%, and 11.1% for high, intermediate, and low-grade tumors, respectively; P = .17). CONCLUSIONS Because of the competition between local recurrence and death, histologic tumor grade, tumor size, and tumor depth had little influence on the cumulative probability of local recurrence. The authors concluded that local management should be based on presentation status and surgical margins rather than other, previously acknowledged factors.
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Weiss KR, Bhumbra R, Biau DJ, Griffin AM, Deheshi B, Wunder JS, Ferguson PC. Fixation of pathological humeral fractures by the cemented plate technique. ACTA ACUST UNITED AC 2011; 93:1093-7. [PMID: 21768635 DOI: 10.1302/0301-620x.93b8.26194] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient's local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.
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Biau DJ, Ferguson PC, Turcotte RE, Chung P, Isler MH, Riad S, Griffin AM, Catton CN, O'Sullivan B, Wunder JS. Adverse Effect of Older Age on the Recurrence of Soft Tissue Sarcoma of the Extremities and Trunk. J Clin Oncol 2011; 29:4029-35. [DOI: 10.1200/jco.2010.34.0711] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To examine the effect of age on the recurrence of soft tissue sarcoma in the extremities and trunk. Patients and Methods This was a multicenter study that included 2,385 patients with median age at surgery of 57 years. The end points considered were local recurrence and metastasis. Cox proportional hazards models were used to estimate hazard ratios across the age ranges with and without adjustment for known confounding factors. Results Older patients presented with tumors that were larger (P < .001) and of higher grade (P < .001). The proportion of positive margins increased significantly as patients age (P < .001), but radiation therapy was relatively underused in patients older than age 60 years. The 5-year cumulative incidences of local recurrence were 7.2% (95% CI, 4% to 11.7%) for patients age 30 years or younger and 12.9% (95% CI, 9.1% to 17.5%) for patients age 75 years or older. The corresponding 5-year cumulative incidences of metastasis were 17.5% (95% CI, 12.1% to 23.7%) and 33.9% (95% CI, 28.1% to 39.8%) for the same groups. Regression models showed that age was significantly associated with local recurrence (P < .001) and metastasis (P < .001) in nonadjusted models. After adjusting for imbalance in presentation and treatment variables, age remained significantly associated with local recurrence (P = .031) and metastasis (P = .019). Conclusion Older patients have worse outcomes because they tend to present with worse tumors and are treated less aggressively. However, there remained a significant increase in the risk of both local and systemic recurrence associated with increasing age that could not be explained by tumor or treatment characteristics.
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Riad S, Biau D, Holt GE, Werier J, Turcotte RE, Ferguson PC, Griffin AM, Dickie CI, Chung PW, Catton CN, O'sullivan B, Wunder JS. The clinical and functional outcome for patients with radiation-induced soft tissue sarcoma. Cancer 2011; 118:2682-92. [DOI: 10.1002/cncr.26543] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 08/01/2011] [Accepted: 08/02/2011] [Indexed: 11/12/2022]
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Davis AM, Punniyamoorthy S, Griffin AM, Wunder JS, Bell RS. Symptoms and their Relationship to Disability Following Treatment for Lower Extremity Tumours. Sarcoma 2011; 3:73-7. [PMID: 18521266 PMCID: PMC2395419 DOI: 10.1080/13577149977677] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose. The aims of this study were to describe the symptoms
experienced by patients in the first year following treatment for lower extremity sarcoma
by limb conservation and to describe the relationship between symptoms and physical
disability. Subjects. Eighty consecutive patients treated for primary bone or
soft tissue sarcoma (STS) of the lower limb who were treated with limb preservation
surgery. Methods. Subjects were evaluated by questionnaire at 6 weeks,
and 3, 6, and 12 months post surgery. They identified
whether they experienced any of the following symptoms: pain, stiffness, fatigue,
weakness, limited range of motion, or swelling.The Toronto Extremity Salvage Score (TESS),
a measure of physical disability, was also completed. Frequency of symptoms over time
was calculated and change was evaluated using the Cochrane test. The relationship of symptoms to
disability was analyzed with regression methods. Results. The mean age was 43.0, SD=20.4 with a gender ratio of 1:1.
There were 38 bone tumours and 42 STS.The most frequently reported symptoms were:
stiffness 48 (60%), weakness 41 (51%), fatigue 26 (33%), and pain 25 (31%) at 6 weeks.
Stiffness and fatigue decreased and plateaued by 3 months. Complaints of weakness and
pain continued to decrease over time. At 6 weeks, pain, stiffness, weakness and limited motion
predicted disability in both univariate and multivariate analyses. At 12 months, pain, stiffness,
fatigue, weakness and limited motion were significant predictors of the TESS in univariate
analysis with only pain, stiffness and limited motion significant predictors in the
multivariate model. Discussion. Pain, stiffness, fatigue, weakness and limited motion are
common symptoms with stiffness and weakness decreasing significantly over time.
The symptoms predictive of disability differ between the acute and late phases of recovery.
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Probyn LJ, Wunder JS, Bell RS, Griffin AM, Davis AM. A comparison of outcome of osteoarticular allograft reconstruction and shoulder arthrodesis following resection of primary tumours of the proximal humerus. Sarcoma 2011; 2:163-70. [PMID: 18521249 PMCID: PMC2395401 DOI: 10.1080/13577149877920] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose. The purpose of this study was to compare the oncologic, reconstructive and functional outcomes of patients who underwent osteoarticular allograft reconstruction with those who underwent arthrodesis for a primary malignant bone tumour of the proximal humerus. Patients. Eleven patients were treated with osteoarticular allograft reconstruction of the proximal humerus. Five of these reconstructions failed, necessitating revision to a secondary arthrodesis. Five patients underwent arthrodesis as a primary reconstruction, for a total of ten patients in the arthrodesis group. Methods. End points included local and systemic disease recurrence, complications and functional outcome (measured using the 1987 and 1993 Musculoskeletal Tumour Society Rating Scales (MSTS) and the Toronto Extremity Salvage Score (TESS)). Results. One patient died of systemic disease 2 years post-operatively and one patient had an axillary node recurrence resected 10 months post-operatively and remains free of disease 53 months later. The other 14 patients were alive with no evidence of disease at the time of the last follow-up. Complications after the osteochondral allografts (n=11) included two infections, four fractures and three subluxations in eight patients. Six of these patients required removal of the allograft; one had a repeat osteochondral allograft and five were converted to an arthrodesis. Complications after arthrodesis in the ten patients (five primary and five secondary arthrodeses) included two non-unions, one infection and one fracture in three patients. Patients who underwent shoulder arthrodesis scored better in all outcome measures and this was statistically significant in the MSTS 1993 (p=0.001, Mann–Whitney U Test). Discussion. In this study, there was a trend towards improved function following arthrodesis compared to osteochondral allograft reconstruction following proximal humerus bone tumour resection.
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O’Sullivan B, Catton CN, Chung PW, Griffin AM, Al Yami A, Ferguson PC, Bell RS, Wunder JS. In Reply Drs. Delaney and Chen. Int J Radiat Oncol Biol Phys 2011. [DOI: 10.1016/j.ijrobp.2011.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jones KB, Griffin AM, Chandrasekar CR, Biau D, Babinet A, Deheshi B, Bell RS, Grimer RJ, Wunder JS, Ferguson PC. Patient-oriented functional results of total femoral endoprosthetic reconstruction following oncologic resection. J Surg Oncol 2011; 104:561-5. [PMID: 21695701 DOI: 10.1002/jso.22003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 05/31/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Functional outcomes following oncologic total femoral endoprosthetic reconstruction (TFR) are lacking. We compared patient-oriented functional results of TFRs to proximal femur and distal femur reconstructions (PFR and DFR). We also compared function and complications with regard to knee and hip componentry. METHODS Fifty-four TFR patients were identified from three institutional prospective databases. Forty-one had fixed- and 13 had rotating-hinge knees, 37 hemiarthroplasty and 17 total hip arthroplasty componentry. Toronto Extremity Salvage Scores (TESS) for n = 27 were compared between groups and to cohorts of PFR (n = 31) and DFR (n = 85) patients using the Mann-Whitney U-test. RESULTS Follow-up averaged 4 years. Mechanical complications included five hip dislocations and one femoral malrotation. Four dislocations were in fixed-hinge implants, all in those lacking abductor reattachment. TESS averaged 69.3 ± 17.8, statistically decreased from DFR (P = 0.002) and PFR patients (P = 0.036). No significant differences were detected between patients in the fixed-hinge (n = 18) and rotating-hinge (n = 9) groups (P = 0.944), or total hip (n = 8) and hemiarthroplasty (n = 19) groups (P = 0.633). CONCLUSIONS TFR is reserved for extreme cases of limb salvage, portending a poor prognosis overall. Function reflects additive impairments from PFR and DFR. TFR outcomes differ little with rotating- or fixed-hinge, total hip or hemiarthroplasty implants.
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Dickie CI, Griffin AM, Parent AL, Chung PWM, Catton CN, Svensson J, Ferguson PC, Wunder JS, Bell RS, Sharpe MB, O'Sullivan B. The relationship between local recurrence and radiotherapy treatment volume for soft tissue sarcomas treated with external beam radiotherapy and function preservation surgery. Int J Radiat Oncol Biol Phys 2011; 82:1528-34. [PMID: 21640506 DOI: 10.1016/j.ijrobp.2011.03.061] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 03/24/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To examine the geometric relationship between local recurrence (LR) and external beam radiotherapy (RT) volumes for soft-tissue sarcoma (STS) patients treated with function-preserving surgery and RT. METHODS AND MATERIALS Sixty of 768 (7.8%) STS patients treated with combined therapy within our institution from 1990 through 2006 developed an LR. Thirty-two received preoperative RT, 16 postoperative RT, and 12 preoperative RT plus a postoperative boost. Treatment records, RT simulation images, and diagnostic MRI/CT data sets of the original and LR disease were retrospectively compared. For LR location analysis, three RT target volumes were defined according to the International Commission on Radiation Units and Measurements 29 as follows: (1) the gross tumor or operative bed; (2) the treatment volume (TV) extending 5 cm longitudinally beyond the tumor or operative bed unless protected by intact barriers to spread and at least 1-2 cm axially (the TV was enclosed by the isodose curve representing the prescribed target absorbed dose [TAD] and accounted for target/patient setup uncertainty and beam characteristics), and (3) the irradiated volume (IRV) that received at least 50% of the TAD, including the TV. LRs were categorized as developing in field within the TV, marginal (on the edge of the IRV), and out of field (occurring outside of the IRV). RESULTS Forty-nine tumors relapsed in field (6.4% overall). Nine were out of field (1.1% overall), and 2 were marginal (0.3% overall). CONCLUSIONS The majority of STS tumors recur in field, indicating that the incidence of LR may be affected more by differences in biologic and molecular characteristics rather than aberrations in RT dose or target volume coverage. In contrast, only two patients relapsed at the IRV boundary, suggesting that the risk of a marginal relapse is low when the TV is appropriately defined. These data support the accurate delivery of optimal RT volumes in the most precise way using advanced technology and image guidance.
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Ramo BA, Griffin AM, Gill CS, McDonald DJ, Wunder JS, Ferguson P, Bell RS, Phillips SE, Schwartz HS, Holt GE. Incidence of symptomatic venous thromboembolism in oncologic patients undergoing lower-extremity endoprosthetic arthroplasty. J Bone Joint Surg Am 2011; 93:847-54. [PMID: 21543674 DOI: 10.2106/jbjs.h.01640] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As both cancer and major orthopaedic surgery are risk factors for venous thromboembolism, patients undergoing lower-extremity oncologic endoprosthetic arthroplasty for neoplastic processes are at substantial risk of the development of symptomatic venous thromboembolism. Therefore, the primary purpose of this study was to determine the incidence of symptomatic venous thromboembolism in patients undergoing lower-extremity oncologic endoprosthetic arthroplasty. Secondary purposes were to assess whether chemoprophylaxis influenced the incidence of venous thromboembolism, surgical complications, or the incidence of local sarcoma recurrence. We also sought to determine whether any known risk factors for venous thromboembolism could be identified in this patient population. METHODS We performed a retrospective comparative review of 423 patients who had undergone mega-endoprosthetic reconstruction following cancer resection. Univariate analysis was used to assess the association between chemoprophylaxis and the incidence of venous thromboembolism, to postulate the surgical complications associated with chemoprophylaxis, and to assess the rate of recurrence of local sarcoma as well the association between risk factors and venous thromboembolism. RESULTS Seventeen patients (4.0%) (95% confidence interval: 2.5% to 6.3%) had a venous thromboembolic event, ten with deep venous thrombosis and seven with nonfatal pulmonary embolism. Risk factors and chemoprophylactic regimens were not statistically associated with the occurrence of venous thromboembolism. CONCLUSIONS The incidence of symptomatic venous thromboembolism in our group of cancer patients who underwent lower-extremity endoprosthetic arthroplasty was lower than anticipated. A significant difference was not identified between the use of any or no chemoprophylactic agent and the incidence of venous thromboembolism or complication rates. No risk factors were associated with the incidence of symptomatic venous thromboembolism.
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Goda JS, Ferguson PC, O'Sullivan B, Catton CN, Griffin AM, Wunder JS, Bell RS, Kandel RA, Chung PW. High-risk extracranial chondrosarcoma. Cancer 2011; 117:2513-9. [DOI: 10.1002/cncr.25806] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 09/25/2010] [Accepted: 10/12/2010] [Indexed: 01/02/2023]
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Dickie CI, Parent AL, Chung PW, Catton CN, Craig T, Griffin AM, Panzarella T, Ferguson PC, Wunder JS, Bell RS, Sharpe MB, O'Sullivan B. Measuring Interfractional and Intrafractional Motion With Cone Beam Computed Tomography and an Optical Localization System for Lower Extremity Soft Tissue Sarcoma Patients Treated With Preoperative Intensity-Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2010; 78:1437-44. [DOI: 10.1016/j.ijrobp.2009.09.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 09/21/2009] [Accepted: 09/23/2009] [Indexed: 10/19/2022]
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Ferguson PC, Deheshi BM, Chung P, Catton CN, O'Sullivan B, Gupta A, Griffin AM, Wunder JS. Soft tissue sarcoma presenting with metastatic disease: outcome with primary surgical resection. Cancer 2010; 117:372-9. [PMID: 20830769 DOI: 10.1002/cncr.25418] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 01/02/2010] [Accepted: 02/11/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective of this study was to assess patient, tumor, and treatment factors that affected overall survival in a group of patients who underwent surgery for soft tissue sarcoma (STS) and presented with American Joint Commission on Cancer stage IV disease. METHODS A retrospective review was undertaken of a single institution's database from the years 1986 to 2006 in all patients who met the following inclusion criteria: 1) surgical management of the primary tumor was undertaken, and 2) metastatic disease was present at the time of initial presentation. In total, 112 patients were identified who met the inclusion criteria. RESULTS The 5-year survival rate for the entire group was 17%. In univariate analysis, the variables that were identified as statistically significant for predicting improved overall survival were resection of metastatic disease (P = .003), <4 pulmonary metastases (P = .05), and the presence of lymph node metastases versus pulmonary metastases (P = .0002). In multivariate analysis, only the presence of lymph node metastases versus pulmonary metastases retained statistical significance (P = .05). The 5-year survival rate for patients who had lymph nodes metastases at diagnosis was 59%, whereas it was only 8% for patients who presented with pulmonary metastases. CONCLUSIONS Patients who presented with metastatic STS had a very poor prognosis despite aggressive surgical management of their primary tumor. The current results indicated that, although patients with isolated lymph node metastases may be cured by surgical resection, patients with pulmonary metastases are unlikely to be cured even with aggressive surgical management and should be treated with palliation of symptoms as the main objective.
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