Limb sparing surgery for pediatric musculoskeletal tumors

Endoprosthetic Reconstruction in Ewing's Sarcoma Patients: A Systematic Review of Postoperative Complications and Functional Outcomes

Ewing's sarcoma (ES) is a rare primary bone cancer managed by radiotherapy, chemotherapy and surgical resection. The existing literature on limb salvage surgery with endoprostheses combines data for ES patients with osteosarcoma. This review aimed to evaluate surgical and functional outcomes of endoprosthetic reconstruction in exclusively Ewing's patients. We believe that this is the first comprehensive review to evaluate the outcomes of limb salvage surgery with endoprostheses exclusively in Ewing's sarcoma patients. Clinical data and outcomes were collected from PubMed, Embase, Medline and Scopus. The inclusion criteria were studies on limb salvage surgery in ES patients, where individual patient data was available. Seventeen studies with a total of 57 Ewing's patients were included in this review. Fifty-three of the ES patients preserved the limb after limb salvage with endoprostheses. The average five-year implant survivorship was 85.9% based on four studies in this review. Postoperative complications were categorised by Henderson's failure modes. Soft tissue failure was the most common, occurring in 35.1% of patients, followed by deep infection in 15.7% of patients. There was a suggestion of 'good' functional outcomes with limb salvage surgery. The salient limitation of this review is the variability and rarity of the patient population. Homogenous data in a larger population is necessary to provide more insight into outcomes of limb reconstruction in ES.

Long-term follow-up of children treated with the Repiphysis expandable prosthesis for lower extremity bone sarcoma

Expandable endoprostheses provide a limb salvage option for skeletally immature patients with bone sarcoma of the lower extremities. Initial reports of the Repiphysis prosthesis were encouraging; however, medium-term follow-up revealed high complication rates. We report on the long-term follow-up of a cohort of patients treated with the Repiphysis prosthesis. Eleven patients were included in the study. Data collected included sex, age at surgery, duration of follow-up, site of disease, histologic diagnosis, number of lengthening sessions, amount lengthened, postoperative complications, endoprosthetic failure, mode of endoprosthetic failure, duration from index surgery to failure and to revision, type of revision surgery and final limb-length discrepancy. The average duration of follow-up from the time of surgery was 180 months (range, 144-215 months). Fifteen Repiphysis implants were used in 11 patients. All implants failed with an average time from surgery to failure of 36 months (range, 3-72 months). Twenty-four complications were observed: one wound dehiscence, two deep infections, 18 mechanical failures, implant collapse with destruction of proximal tibia epiphysis in two and one periprosthetic proximal femur fracture with dislodgement of the stem. Despite being an option for limb salvage, the Repiphysis prosthesis has a high rate of mechanical failure and need for revision, similar to other expandable implants. The authors, therefore, recommend full disclosure of the potential short- and long-term complications and need for revision, as well as alternative treatment options if their use is considered. Level of evidence: IV (Therapeutic).

Oncological and Functional Outcomes in Joint-sparing Resections of the Proximal Femur for Malignant Primary Bone Tumors

BACKGROUND

Joint-sparing resections (JSR) of the proximal femur allow for preservation of the proximal femoral growth plate and native hip joint, but whether this offers fewer complications or better function and longevity of the reconstruction remains unknown. In this study, we compared the functional outcomes of pediatric patients with bone sarcomas undergoing JSR of the proximal femur with intercalary allograft (ICA) reconstruction to those undergoing proximal femoral resections (PFR) with allograft-prosthetic composite (APC) reconstructions.

METHODS

We retrospectively reviewed all patients undergoing JSR with ICA reconstruction and PFR with APC reconstructions between 1995 and 2013 at a tertiary pediatric referral center. Primary outcomes included major and minor complications and secondary outcomes included the need for a secondary procedure, presence of local or distant relapse, survival status, and the presence of pain and ambulatory status (limp, assistive device, highest level of function). We assessed differences in outcomes using the Fisher exact and Wilcoxon rank-sum tests.

RESULTS

Eight patients underwent a JSR and ICA reconstruction, while 7 patients underwent a PFR with APC reconstruction. Median patient follow-up was 60.4 months (interquartile range: 36.8 to 112.9) Patients undergoing JSR and ICA reconstruction were younger than patients undergoing PFR with APC reconstruction (7.7 vs. 11.7 y, P=0.043); however, we found no other statistically significant differences in patient demographics. There were no statistically significant differences in primary or secondary outcomes between the study groups; however, patients who underwent JSR with ICA had more major complications (62.5% vs. 42.9%, P=0.29) and a lower rate of minor complications (25% vs. 28.6%, P=0.22).

CONCLUSION

Treatment of proximal femoral bone sarcomas in pediatric and adolescent patients remains a challenging enterprise. JSR with ICA reconstruction in the proximal femur, when feasible, may provide a similar function and risk of intermediate-term major and minor complications when compared with PFR with APC reconstruction. Further long-term studies are required to determine the impact of the native femoral head retention with respect to revision rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Current Treatment Considerations for Osteosarcoma Metastatic at Presentation

Approximately one-fourth of osteosarcoma patients have metastases at presentation. The best treatment options for these patients include chemotherapy, surgery, and radiotherapy; however, the optimal scheme has not yet been defined. Standard chemotherapy for osteosarcoma metastatic at presentation is based on high-dose methotrexate, doxorubicin, and cisplatin (the MAP regimen), with the possible addition of ifosfamide. Surgical treatment continues to be fundamental; complete surgical resection of all sites of disease (primary and metastatic) remains essential for survival. In patients whose tumors do not respond to neoadjuvant chemotherapy, early surgical resection of the primary tumor with limb-salvage surgery or amputation and multiple metastasectomies, if feasible, after the completion of adjuvant chemotherapy is a reasonable option, as the reduction of the tumor volume could probably increase the effect of chemotherapy. Advanced radiotherapy techniques, such as carbon ion radiotherapy and stereotactic radiosurgery, and molecular targeted chemo-therapy with drugs such as pazopanib or apatinib have improved the dismal prognosis, especially for patients who are medically inoperable or who refuse surgery. Given that the presence of metastatic disease at diagnosis of a patient with osteosarcoma is a poor prognostic factor, a multidisciplinary approach by surgeons, medical oncologists, and radiotherapists is important. [Orthopedics. 2020;43(5):e345-e358.].

Treatment Outcomes of Pediatric Patients With Ewing Sarcoma in a War-Torn Nation: A Single-Institute Experience From Iraq

PURPOSE

Ewing sarcoma (ES) is a relatively rare, highly malignant tumor of the musculoskeletal system. It is the second most common malignant bone tumor in children and adolescents in the age group of 5 to 20 years. The aim of this study was to identify the treatment outcomes of pediatric patients with ES in Sulaimani governorate, Iraq.

PATIENTS AND METHODS

This was a retrospective study that reviewed the medical records of pediatric patients with ES who were managed between 2009 and 2015, with follow-up until late 2017. Patient- and tumor-related factors were correlated with clinical outcomes.

RESULTS

A total of 31 pediatric patients with ES were included in this study. All the patients received chemotherapy and radiotherapy, whereas only 14 patients underwent surgical resection and just eight had free surgical margins. The median age at diagnosis was 13 years, 58% were male, and 42% were female. The presenting symptoms at diagnosis were mostly pain (67.7%) and palpable mass (25.8%). The primary tumor was located in the extremities (51.6%), the thoracic cage (19.4%), the pelvis (16.1%), and the lumbar vertebrae (12.9%). Approximately two thirds of the patients (61.3%) had localized disease at the time of presentation. The 5-year overall survival was 19%, and the 5-year recurrence-free survival was 34%.

CONCLUSION

Clinical outcomes of ES in pediatric patients in our war-torn nation, Iraq, are still markedly inferior to the published outcomes from stable, developed nations. Additional large and multicenter national studies are required. Diagnostic and therapeutic measures need improvement, and multidisciplinary and comprehensive cancer-integrated approaches are vital for better outcomes.

Clinical and radiographic presentation of pelvic sarcoma in children

Introduction: Pelvic sarcomas may present with vague symptoms. The aim of this study was to examine the characteristics and clinical presentations of different types of pelvic sarcoma in children.

Methods: This is a retrospective cohort study of patients up to 21 years of age with the diagnosis of pelvic sarcoma between January 2000 and June 2013. Data on demographics, tumor type and location, and clinical presentation were collected from the medical records.

Results: A total of 59 patients [37 males (62.7%) and 22 females (37.3%)] were examined in this study. Mean age at presentation was 11.3 ± 5 years (range 0.8–21 years). Thirty-six patients had Ewing sarcoma (61%), 9 osteosarcoma (6.8%), 4 undifferentiated sarcoma (6.8%), 2 (3.4%) rhabdomyosarcoma, 2 synovial cell sarcoma, and one (1.7%) of each fibrosarcoma, dermatofibrosarcoma, fibromyxoid sarcoma, chondrosarcoma, chordoma, and epithelioid sarcoma. Pain at presentation was reported in 41 patients, 13 mass, 8 limping, and 5 neurologic symptoms. Most of the bony tumors were painful (77%), while most of the soft tissue tumors were painless (70%). Nine patients presented with constitutional symptoms. Most patients presented within 4–12 months from symptoms beginning. Twenty-one patients (35.6%) presented with metastases (14 Ewing sarcoma, 6 osteosarcoma, and 1 synovial cell sarcoma). Pelvic radiographs showed lytic lesion in 11 patients, 4 sclerotic lesions, 6 mixed lesion, 6 had only soft tissue mass, 1 radiograph showed osteopenia, and 2 radiographs were reported normal.

Conclusion: Ewing sarcoma was the most common pelvic sarcoma tumor in children. In most cases, pelvic sarcoma in children presented with pain mimicking other benign conditions. Some patients presented with metastatic disease with no prognostic clinical or radiographical signs or symptoms. Pelvic sarcoma should be considered a differential diagnosis as part of children work up.

Surgical treatment of pelvic sarcoma in children: outcomes for twenty six patients

PURPOSE

Pelvic sarcoma is uncommon in children and challenging to treat. This study examined different surgical approaches to treat pelvic sarcoma with the aim of assessing the oncologic, and functional outcomes.

METHODS

We retrospectively examined the medical records of patients younger than 21 years of age who underwent surgery for pelvic sarcoma at our institution from 1992 to 2010. The functional status of the patients was examined after a minimum follow-up of two years.

RESULTS

Twenty-six patients were included in the analysis. Nineteen (73%) patients were male and seven (27%) were female. Mean age at presentation was 12.0 ± 3.9 years. Nineteen patients had Ewing sarcoma (73%), five had osteosarcoma (19%), one had chondrosarcoma (4%) and one had rhabdomyosarcoma (4%). Iliac wing resection with no reconstruction was done in three patients. Reconstruction with free fibular graft A-frame was performed in four patients, saddle endoproshtesis in five patients, iliac autoclave in one patient, and internal hemipelvectomy in nine patients. Hindquarter amputation was performed in five patients. Median follow-up was 4.6 years (range, 2.6-16 years). Nineteen patients were alive (73%); of those, 13 were known to be without disease, three were with disease and three did not have known tumor status. Six patients were reported deceased, three had osteosarcoma and three had Ewing sarcoma. Function was assessed in 17 patients; 64% were asymptomatic and ambulatory and 36% were symptomatic and ambulatory.

CONCLUSIONS

Salvage reconstruction for pelvic sarcoma can be performed through various procedures on the extent of necessary bony resection. Survival rate and functional outcomes were promising in the performed study.

What is the impact of local control in Ewing sarcoma: analysis of the first Brazilian collaborative study group - EWING1

Background

Relapse in localized Ewing sarcoma patients has been a matter of concern regarding poor prognosis. Therefore, we investigated the impact of local control modality (surgery, surgery plus radiotherapy, and radiotherapy) on clinical outcomes such as survival and recurrence in patients with non-metastatic Ewing sarcoma treated on the first Brazilian Collaborative Group Trial of the Ewing Family of Tumors (EWING1).

Methods

Seventy-three patients with localized Ewing sarcoma of bone aged < 30 years were included. The treating physicians defined the modality of local control based on the recommendations of the coordinating center and the patient and tumor characteristics. Possible associations of local control modality with local failure (LF), disease-free survival (DFS), event-free survival (EFS), overall survival (OS), and clinical characteristics were analyzed.

Results

Mean patient age was 12.8 years (range, 2 to 25 years) and median follow-up time was 4.5 years (range, 2.3 to 6.7 years). Forty-seven patients underwent surgery, 13 received radiotherapy, and 13 received both. The 5-year EFS, OS, and DFS for all patients was 62.1%, 63.3%, and 73.1%, respectively. The 5-year cumulative incidence (CI) of LF was 7.6% for surgery, 11.1% for radiotherapy, and 0% for postoperative radiotherapy (PORT) (p = 0.61). The 5-year EFS was 71.7% for surgery, 30.8% for radiotherapy, and 64.1% for PORT (p = 0.009).

Conclusions

There was a significant effect of local control modality on EFS and OS in the study. Surgery and PORT modalities yielded very close results. The group treated with radiotherapy alone had considerably worse outcomes. This may be confounded by greater risk factors in these patients. There was no significant effect of local control modality on the CI of LF and DFS.

Clinical features and outcomes of infants with Ewing sarcoma under 12 months of age

BACKGROUND

Ewing sarcoma peaks in incidence in adolescence. Infants <12 months old have rarely been reported. We aimed to compare clinical features, treatment, and survival of infants <12 months to those of older pediatric patients with Ewing sarcoma.

PROCEDURE

We utilized the SEER database to identify patients <12 months of age diagnosed with Ewing sarcoma between 1973 and 2011. We used Fisher exact tests to compare clinical features and treatment modalities between these patients and patients aged 1-19 years. We used Kaplan-Meier methods to describe overall survival in these two groups.

RESULTS

Of 1,957 patients in the cohort, 39 (2.0%) were diagnosed at <12 months of age. Infants had a different distribution of primary tumor sites, with lower extremity tumors under represented. Compared to older patients, infants were more likely to have soft tissue tumors (81.6% vs. 27.1%; P < 0.001); have primitive neuroectodermal tumor/Askin tumor (61.5% vs. 19.9%; P < 0.001); and have tumors <8 cm (81.0% vs. 53.2%; P < 0.014). Infants were less likely to receive radiation therapy (13.2% vs. 53.3%; P < 0.001). Infants were at increased risk for early death (P < 0.013 by Wilcoxon), though long-term overall survival was not different between age groups (P < 0.25 by log rank).

CONCLUSIONS

Ewing sarcoma is rare in infants, with different clinical presentations and treatment approaches. These patients appear to be at higher risk for early death, but long-term survival is similar to older pediatric patients.

Comparative evaluation of local control strategies in localized Ewing sarcoma of bone: a report from the Children's Oncology Group

BACKGROUND

Patients with Ewing sarcoma require local primary tumor control with surgery, radiation, or both. The optimal choice of local control for overall and local disease control remains unclear.

METHODS

Patients with localized Ewing sarcoma of bone who were treated on 3 consecutive protocols with standard-dose, 5-drug chemotherapy every 3 weeks were included (n=465). Propensity scores were used to control for differences between local control groups by constructing multivariate models to assess the impact of local control type on clinical endpoints (event-free survival [EFS], overall survival, local failure, and distant failure) independent of differences in their propensity to receive each local control type.

RESULTS

Patients who underwent surgery were younger (P=.02) and had more appendicular tumors (P<.001). Compared with surgery, radiation had higher unadjusted risks of any event (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.18-2.44), death (HR, 1.84; 95% CI, 1.18-2.85), and local failure (HR, 2.57; 95% CI, 1.37-4.83). On multivariate analysis, compared with surgery, radiation had a higher risk of local failure (HR, 2.41; 95% CI, 1.24-4.68), although there were no significant differences in EFS (HR, 1.42; 95% CI, 0.94-2.14), overall survival (HR, 1.37; 95% CI, 0.83-2.26), or distant failure (HR, 1.13; 95% CI, 0.70-1.84) between local control groups.

CONCLUSIONS

In this large group of similarly treated patients, choice of the mode of local control was not related significantly to EFS, overall survival, or distant failure, although the risk of local failure was greater for radiation compared with surgery. These data support surgical resection when appropriate, whereas radiotherapy remains a reasonable alternative in selected patients.

Outcome of expandable prostheses in children

BACKGROUND

Expandable prostheses offer the advantages of limb-salvage and limb-length equality at skeletal maturity. However, what is the cost for achieving that goal, and in how many children this is achieved?

MATERIALS AND METHODS

We present 32 children (16 boys and 16 girls; mean age, 9 y) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The Kotz Growing prosthesis and the noninvasive Repiphysis and Stanmore expandable prostheses were used. The mean follow-up was 49 months. Survival analysis of the children and primary implants and functional evaluation were performed.

RESULTS

Survival of the children was 94% and 84% at 48 and 72 months. Survival of the primary prostheses was 78% and 66% at 48 and 72 months; survival was significantly higher only for the Kotz when compared with the Repiphysis prostheses (P=0.026). The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection, and breakage. A mean total lengthening of 28 mm (4 to 165 mm) was achieved by 84 procedures (2.6 procedures/patient). Three of the 9 children who reached skeletal maturity had limb-length equality and 6 discrepancy of 15 to 30 mm. The mean Musculoskeletal Tumor Society score was excellent (79%) without a significant difference between the type of prostheses (P=0.934).

CONCLUSIONS

The Kotz Growing prosthesis, although it requires an open lengthening procedure, has shown higher survival when compared with the noninvasive Repiphysis prosthesis. However, the total lengthening remains small, and the complications rates are high even with the noninvasive prostheses.

Results of surgical resection in pediatric pelvic tumors

Thirty nonmetastatic patients with malignant tumors of the pelvis underwent surgical resection between November 2000 and December 2009. The diagnosis included Ewing's sarcoma (22), osteogenic sarcoma (four), chondrosarcoma (two), and synovial sarcoma (two). Eighteen resections included the acetabulum and 12 did not. Twenty-seven patients were available for follow-up. Follow-up ranged from 4 to 138 months (mean 43 months). Nineteen patients are currently alive. There were two local recurrences. The overall survival was 68% at 5 years. The Musculoskeletal Tumor Society Score ranged from 22 to 29. Surgery provides good local control and oncologic outcomes with acceptable function in these patients.

Pathological fractures in children

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated.

Development of reference values for the Functional Mobility Assessment

PURPOSE

To obtain reference values for healthy participants performing the Functional Mobility Assessment (FMA). The FMA is a reliable and valid tool used to examine functional abilities subjectively and objectively in patients with lower-extremity sarcoma in all components of the International Classification of Functioning, Disability, and Health model (body function, activity, and participation).

METHODS

Children, adolescents, and young adults who were healthy, representing a sample of convenience (n = 503; 260 females, age 10-21 years), participated in this study.

RESULTS

Means and standard deviations for all participants: Timed Up and Down Stairs 6.18 ± 0.8 seconds, Timed Up and Go 3.78 ± 0.6 seconds, 9-minute run/walk 4161 ± 893 feet, and the FMA total 59 ± 3.

CONCLUSION

The reference values provided in this study will allow health care professionals to compare the functional abilities of children, adolescents, and young adults with lower extremity sarcoma to age- and gender-matched healthy peers when using the FMA.

Paediatric diaphyseal malignant tumors: options for reconstruction after intercalary resection

From January 2002 to June 2008, 525 malignant pediatric skeletal tumors were operated. Forty-two (8%) tumors were diaphyseal in origin. The age of the patients ranged from two to 16 years. Femur was the most common site.After resection, various methods of reconstruction were adopted based on tumor site and availability of reconstruction options. Thirty-seven patients were available for follow-up. Follow-up duration ranged from 4 months to 86 months (mean 38.3 months). Eight patients succumbed to the disease. There were three local recurrences. The Musculoskeletal Tumor Society Score ranged from 18 to 30 (mean 27). Joint-preserving intercalary resections are an oncologically safe option with gratifying functional results.

Physical activity among adult survivors of childhood lower-extremity sarcoma

INTRODUCTION

Adult survivors of childhood lower-extremity sarcoma are largely physically inactive, a behavior which potentially compounds their health burden. Altering this behavior requires understanding those factors that contribute to their physical inactivity. Therefore, this investigation sought to identify factors associated with inactivity in this subpopulation of cancer survivors.

METHODS

Demographic, personal, treatment, and physical activity information from adult survivors of childhood lower-extremity sarcomas was obtained from the Childhood Cancer Survivor Study (CCSS) cohort. Generalized linear models were used to identify variables that best identified those individuals who were physically inactive.

RESULTS

Only 41% of survivors met Center for Disease Control (CDC) activity guidelines. Survivors were 1.20 (95% confidence intervals (CI) 1.11-1.30) more likely compared to CCSS sibling cohort and 1.12 (95% CI 1.10-1.15) times more likely than the general population to fail to meet CDC guidelines. Significant predictors of physical inactivity included female sex, hemipelvectomy surgery, and platinum and vinca alkaloid chemotherapy.

CONCLUSIONS

The primary findings of this study are that survivors of childhood onset lower-extremity sarcoma are (1) highly likely to be physically inactive and (2) less likely than their siblings or the general population to regularly exercise. This study has identified treatment-related risk factors associated with inactivity that will help health and wellness practitioners develop successful exercise interventions to help these survivors achieve recommended levels of physical activity for health.

IMPLICATIONS FOR CANCER SURVIVORS

These results suggest that physical activity interventions for adult survivors of childhood lower-extremity sarcomas should be sex specific and responsive to unique physical late effects experienced by these survivors.

Torsional stability of uncemented femoral stems in oncologic reconstructions

Modular oncology implants using uncemented fixation represent a popular reconstruction technique for limb salvage patients. Initial stability is critical to facilitate bony ingrowth of host bone into the stem of a press-fit oncologic modular rotating-hinge total knee arthroplasty (TKA). The impact of stem design on initial stability has not been defined. The goal of this study was to evaluate the initial stability of 3 different stem designs as defined by torsional load to failure. An analysis of imaging was also performed. The pilot study consisted of 5 femora in each of 3 groups based on stem design. The specimen was mounted on a multi-axis biomechanical test frame equipped with a Vicon 3D motion analysis 4-camera system (Vicon Motion Systems, Lake Forest, California) to track the relative motion between the implant and the femur. Torsional force was applied until failure. The straight-fluted stem design had the highest average torsional stiffness (18.3±8.2 Nm/deg) and average torque at 150 μm of implant micromotion (23.2±10.6 Nm) of the 3 stem types tested.The results of this study will help to guide surgical decision making in limb salvage cases. Further investigation is warranted.

Seven-year experience of using Repiphysis expandable prosthesis in children with bone tumors

BACKGROUND

Results of the use of the non-invasive expandable endoprosthetic device Repiphysis in limb salvage surgery for skeletally immature children with bone cancer have been promising.

PROCEDURE

In this report, we analyze the outcomes and complications associated with using 17 Repiphysis prosthesis from January 2002 to March 2009 in 17 skeletally immature children with bone sarcoma around the knee.

RESULTS

The average follow-up was 61.7 months. All patients who underwent active expansion experienced successful lengthening with a total of 38 lengthening sessions and an average of 8.6 mm gained per session. The Musculoskeletal Tumor Society functional scores averaged 90% at the most recent follow-up. The average survival time of the device from implementation to revision or last follow-up was 2 years and 8 months. There were 12 complications in 12 patients, including 6 mechanical problems, 2 tibial fractures and 3 infections. For the 17 insertions, 7 revision operations were performed, 3 of which were done using a new Repiphysis device.

CONCLUSIONS

Despite the high rate of complications, the goal of achieving equal leg length at skeletal maturity with fewer surgeries per patient has been relatively achieved with the use of this device.

Incidence and outcomes of extremity soft-tissue sarcomas in children

BACKGROUND

We studied the outcomes of pediatric extremity tumors on a population scale.

METHODS

The Surveillance, Epidemiology, and End Results database (1973-2006) was queried for all patients under 20 y of age.

RESULTS

Overall, 1175 patients were identified. The median age at diagnosis was 12 y, but most patients were ≥10 y of age (72%, n = 842). Most tumors were non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) (79%, n = 879). The most common tissue of origin was muscle (43%, n = 474). Most rhabdomyosarcoma (RMS) (n = 220) were alveolar type (n = 140). Most patients presented with local disease (64%, n = 699), and underwent surgical intervention (88%, n = 1027), but did not have radiotherapy (62%, n = 710). RMS was more likely to present in younger children (P < 0.001) and with distant disease (P < 0.001). Older patients were more likely to receive radiotherapy than infants (P < 0.001). Overall 5-y survival was 79%. RMS had significantly worse 5-y survival (56% versus 85% for NRSTS, P < 0.001). Surgical intervention was associated with higher 5-y survival (84% versus 48%, P < 0.001). Radiotherapy was associated with worse 5-y survival (74% versus 83%, P = 0.002). Multivariate analysis identified RMS (HR 2.20, P < 0.001), nerve and muscle (not synovial sarcoma) tissue of origin (HR 2.26, P = 0.002, and HR 1.59, P = 0.036), regional or distant disease (HR 1.65, P = 0.011, and HR 5.96, P < 0.001, respectively), and lack of surgical intervention (HR 2.20, P < 0.001) as independent predictors of poor outcome.

CONCLUSIONS

Extremity sarcomas are most common in older children. RMS is more common in younger children, but is associated with lower survival, and is an independent prognostic indicator of mortality.

Osteosarcoma

Osteosarcoma, the most common bone sarcoma, affects approximately 560 children and adolescents annually in the United States. The incidence of new diagnoses peaks in the second decade of life. Twenty percent of patients present with clinically detectable metastases, with micrometastases presumed to be present in many of the remaining patients. Treatment typically includes preoperative chemotherapy, surgical resection, and postoperative chemotherapy. Limb-salvage procedures with wide surgical margins are the mainstay of surgical intervention. Advances in chemotherapy protocols have led to a 5-year survival rate of 60% to 78%. Among the goals of future treatment regimens are improved chemotherapeutic agents with higher specificity and lower toxicity.

Rhabdomyosarcoma of the extremities: a focus on tumors arising in the hand and foot

BACKGROUND

Extremities are peculiar sites of origin for rhabdomyosarcomas (RMS) and are usually associated with an unfavorable outcome.

METHODS

The authors reviewed the clinical data on 60 patients <21 years old with limb RMS treated at the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan, in Italy, over a 30-year period. Twelve patients had tumors arising in the hand and foot.

RESULTS

Complete tumor resection was achieved in 21 patients (but in only 1 case of hand/foot RMS); all patients received chemotherapy and 43 also had radiotherapy. The alveolar subtype was identified in 62% of cases. Half of the hand/foot cases had metastatic disease at onset. Overall survival at 5 years was 33% among the hand/foot cases and 56% for the others. Most of the relapsing cases had distant metastases.

CONCLUSIONS

A particularly poor survival was observed for RMS of the hand/foot due its marked tendency to spread. Surgical resection is particularly difficult in such cases and a multimodality treatment approach seems crucial to improving their outcome.

Osteosarcoma: review of the past, impact on the future. The American experience

Major advances have been achieved in the treatment of osteosarcoma with the discovery of several chemotherapeutic agents that were active in the disease. These agents comprise high-dose methotrexate with leucovorin rescue, Adriamycin, cisplatin, ifosfamide and cyclophosphamide. The agents were integrated into various regimens and administered in an effort to destroy silent pulmonary micrometastases which are considered to be present in at least 80% of patients at the time of diagnosis. Their efficacy in achieving this goal was realized and their use was further extended to the application of preoperative (neoadjuvant) chemotherapy to destroy the primary tumor and achieve safe surgical resections. Disease free survival was escalated from <20% prior to the introduction of effective chemotherapy to 55-75% and overall survival to 85%. Further, the opportunity to perform limb salvage was expanded to 80% of patients. Of interest also was an attempt in one series to treat the primary tumor exclusively with chemotherapy, and abrogation of surgery. Adding to these advances, varieties of subsequently discovered agents are currently undergoing investigations in patients who have relapsed and/or failed conventional therapy. The agents include Gemcitabine, Docetaxel, novel antifolate compounds, and a liposome formulation of adriamycin (Doxil). A biological agent, muramyl tripeptide phosphatidyl ethanolamine (MTPPE) was also recently investigated in a 2x2 factorial design to determine its efficacy in combination with chemotherapy (methotrexate, cisplatin, Adriamycin and ifosfamide).In circumstances where the tumor was considered inoperable, chemotherapy and radiotherapy were advocated for local control. High dose methotrexate, Adriamycin and cisplatin and Gemcitabine interact with radiation therapy and potentiate its therapeutic effect. This combination is also particularly useful in palliation. Occasionally, the combination of radiation and chemotherapy may render a tumor suitable for surgical ablation. Samarium153, a radio active agent, is also used as palliative therapy for bone metastases.However, despite the advances achieved with the multidisciplinary application of chemotherapy, radiotherapy and surgical ablation of the primary tumor over the past 3(1/2) decades, the improved cure rate reported initially has not altered. Particularly vexing is the problem of rescuing patients who develop pulmonary metastases after receiving seemingly effective multidisciplinary treatment. Approximately 15-25% of such patients only are rendered free of disease with the reintroduction of chemotherapy and resection of metastases. Extrapulmonary metastases and multifocal osteosarcoma also constitute a major problem. The arsenal of available agents to treat such patients has not made any substantial impact in improving their survival. New chemotherapeutic agents are urgently required to improve treatment and outcome. Additional strategies to be considered are targeted tumor therapy, anti tumor angiogenesis, biotherapy and therapy based upon molecular profiles. This communication outlines sequential discoveries in the chemotherapeutic research of osteosarcoma in the United States of America. It also describes the principles regulating the therapeutic application of the regimens and considers the impact of their results on the conduct in the design of future investigations and treatment.

Limb salvage surgery for children and adolescents with malignant bone tumors in a developing country

PURPOSE

To describe the 5-year experience of a multidisciplinary limb salvage program for children and adolescents with malignant bone tumors in Lebanon.

PATIENTS AND METHODS

Between January 2002 to February 2007, 30 children and adolescents (2 with Ewing sarcoma and 28 with osteosarcoma) underwent Limb Salvage Surgeries (LSS) at the American University of Beirut Medical Center after partnering with the multidisciplinary team at St. Judes Children's Research Hospital (SJCRH). Procedures performed included 12 Repiphysis, noninvasively expandable, prostheses inserted in skeletally immature children, 15 modular prostheses, 2 allografts and 1 rotationplasty. All patients received pre- and postoperative chemotherapy.

RESULTS

With a mean follow-up of 31 months, 20 patients are now off therapy, 4 died, and 6 are receiving chemotherapy (3 due to pulmonary recurrence). Complications of surgery included infections in three cases, failure of the expansion mechanism in two, femoral stem fracture in one, prostheses femoral stem loosening in one and wound dehiscence in one. Lengthening of Repiphysis prostheses was achieved by subjecting the limb to an electromagnetic field that would allow controlled release of the Repiphysis expansion mechanism. Ten patients underwent a total of 42 lengthening procedures with an average of 9 mm lengthened per procedure (range 2-15 mm). All patients have good function of the affected limb.

CONCLUSION

Our LSS results are comparable to those reported in the literature. Collaboration with SJCRH and fund raising were critical to the program's success. This endeavor could serve as a model for establishing LSS programs in developing countries.

A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma

BACKGROUND

Comparison of functional mobility and quality of life is performed in patients with lower-extremity bone sarcoma following either amputation, limb-sparing surgery, or rotationplasty with four different types of outcome measures: (1) an objective functional mobility measure that requires patients to physically perform specific tasks, functional mobility assessment (FMA); (2) a clinician administered tool, Musculoskeletal Tumor Society Scale (MSTS); (3) a patient questionnaire, Toronto Extremity Salvage Scale (TESS); and (4) a health-related quality of life (HRQL) measure, Short Form-36 version 2 (SF-36v.2).

PROCEDURE

This is a prospective multi-site study including 91 patients with lower-extremity bone sarcoma following amputation, limb-sparing surgery, or rotationplasty. One of three physical therapists administered the quality of life measure (SF-36v.2) as well as a battery of functional measures (FMA, MSTS, and TESS).

RESULTS

Differences between patients who had amputation, limb-sparing surgery, or rotationplasty were consistently demonstrated by the FMA. Patients with limb sparing femur surgery performed better than those patients with an above the knee amputation but similarly to a small number of rotationplasty patients. Several of the more conventional self-report measures were shown to not have the discriminative capabilities of the FMA in these cohorts.

CONCLUSION

In adolescents with lower-extremity bone sarcoma, it may be advantageous to consider the use of a combination of outcome measures, including the FMA, for objective functional mobility assessment along with the TESS for a subjective measure of disability and the SF-36v.2 for a quality-of-life measure.

Soft-tissue sarcomas of the extremities in patients of pediatric age

PURPOSE

The extremity site is a peculiar location for soft-tissue sarcomas (STS) of children and adolescents. Here we report the experience of the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan, Italy, concerning 204 patients with STS of the limbs treated between 1977 and 2006.

METHODS

The study series included 52 patients with rhabdomyosarcoma (RMS)(65% of which were of the alveolar subtype), nine with extraosseous Ewing sarcoma and 143 with non-rhabdomyosarcoma soft-tissue sarcomas (NRSTS), 38% of which were synovial sarcoma. Patients were treated with a multimodality approach including surgery, chemotherapy, and radiotherapy.

RESULTS

For the RMS patients, the 5-year event-free survival (EFS) rate was 37.1%, with distant metastases being the main cause of treatment failure. The outcome was particularly poor for patients with large invasive tumors, hand/foot involvement and/or nodal or distant metastases, and for patients who were not given radiotherapy. For the extraosseous Ewing sarcoma cases, 5-year EFS was 74%. For the NRSTS cases, the 5-year EFS was 72.6%: tumor size and local invasiveness, tumor grade, malignant peripheral nerve sheath tumor (MPNST) histology, and distant metastases were the main prognostic factors.

DISCUSSION

While the limbs are the most common sites of NRSTS and are often characterized by a more favorable prognosis than for axial tumors, the clinical features of extremity RMS often differ from those of RMS of other sites, with a higher incidence of unfavorable prognostic factors (e.g., alveolar subtype) and consequently unsatisfactory treatment results. The treatment of these patients is complex and necessarily multidisciplinary, and it demands not only adequate experience of treating children and adolescents in clinical trials, but also particular skills in the field of orthopedic surgery.

Surgical management of pelvic sarcoma in children

Survival rates of children with pelvic sarcoma have demonstrated unprecedented improvement during the past few decades, with a corresponding increase in the number of limb-sparing surgical procedures being performed. This increase may be attributed to earlier detection with advanced imaging techniques, the availability of a wider armamentarium of surgical techniques of reconstruction and limb salvage, and advances achieved in neoadjuvant chemotherapy and radiation therapy. Undertaking reconstruction after resection of pelvic sarcoma while preserving function of the hip and limb can be extremely challenging; this is especially true in children, who invite concern regarding growth potential and limb-length discrepancy. Decisions for surgery and reconstruction are individualized based on tumor type, size, and location as well as the probability of achieving a wide resection with negative margins and acceptable morbidity.

Anatomically Based Guidelines for Core Needle Biopsy of Bone Tumors: Implications for Limb-sparing Surgery

Diagnostic image-guided needle biopsy plays a vital role in the work-up and treatment of patients with extremity bone tumors. The radiologist and the orthopedic oncologic surgeon should take a team approach to this procedure, especially when the bone lesion might be a primary sarcoma for which limb-sparing surgery (LSS) would be considered. A set of anatomically based guidelines were developed that can be used by the radiologist, in combination with case-by-case consultation with the surgeon, to plan image-guided core needle biopsies of extremity long bone lesions that may be treatable with LSS. By using these guidelines, along with the aforementioned consultation, the radiologist will be able to preserve the patient's chances of receiving optimal surgical treatment.

Barriers to rehabilitation of patients with extremity sarcomas

The treatment of most extremity bone or soft tissue sarcomas involves either limb salvage surgery with adjuvant chemoradiation therapy or amputation. The rehabilitation of patients with extremity sarcomas is challenging, and the approach differs depending on the choice of surgical procedure as well as potential-associated medical complications. Early, interdisciplinary rehabilitation involvement is helpful in lessening the impact of expected impairments and disability. There is a lack of evidence examining specific rehabilitation interventions in this patient population. Functional outcomes and quality of life studies suggest overall similar findings between limb salvage patients and amputees, but with differences in various subscales. Rehabilitation interventions are therefore individualized; based on the assessment of medical limitations, functional goals and expectations, and modification of environmental factors. Overcoming medical and oncologic barriers to rehabilitation; as well as psychological, structural, cultural, political, and economic barriers; can serve to lessen the degree of disability.

Surviving childhood cancer: the impact on life

With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.

Current strategies of chemotherapy in osteosarcoma

Osteosarcoma, the most common type of primary malignant tumour that develops in bone, can be classified into several different sub-types. While the majority of osteosarcomas are highly malignant, there are some low-grade variants. Since the introduction of chemotherapy into the multi-modal treatment regimen of high-grade osteosarcoma, its prognosis has impressively improved, with long-term survival being achieved in two-thirds of all patients. This review summarises current chemotherapeutic treatment strategies in classical osteosarcoma and also addresses the indication for chemotherapy in more unusual types and variants. It emphasises the need for treatment in specialised centres and within prospective, multi-institutional trials, amongst which EURAMOS1 and EURO-B.O.S.S are currently active in many European countries.

Results of the Brazilian Osteosarcoma Treatment Group Studies III and IV: prognostic factors and impact on survival

PURPOSE

To evaluate the impact of chemotherapy and surgery on the outcome of osteosarcoma (OS) of the extremities and to identify prognostic factors in Brazilian patients.

PATIENTS AND METHODS

A total of 225 patients with metastatic and nonmetastatic OS of the extremities were enrolled and assessed in two consecutive studies designed and implemented by the Brazilian Osteosarcoma Treatment Group.

RESULTS

The 5-year survival and event-free survival rates for the 209 assessable patients were 50.1% and 39%, respectively; for the 178 patients with nonmetastatic disease at diagnosis, the rates were 60.5% and 45.5%, respectively. The multivariate analysis showed that the following variables were associated with a shorter survival: metastases at diagnosis (P < .001), necrosis grades 1 and 2 (P = .046), and tumor size (P = .0071).

CONCLUSION

The overall 5- and 10-year survival rates were lower than the rates reported in North American and European trials. A pattern of advanced disease at diagnosis was often present, with a high proportion of patients having metastases (20.8%) and large tumor size (42.9%). However, these features were not necessarily associated with longer duration of prediagnostic symptoms. These findings were considered in the strategic planning of the current Brazilian cooperative study, with the aim of improving survival and quality of life of a large number of patients with OS.

Relationships among range of motion, functional mobility, and quality of life in children and adolescents after limb-sparing surgery for lower-extremity sarcoma

PURPOSE

The study was designed to examine relationships between range of motion (ROM), functional mobility, and quality of life (QL) in patients with lower-extremity sarcoma (LES) after limb-sparing surgery

METHODS

Sixty-eight patients with LES (age, 10-26 years) participated. The patients performed hip flexion, hip extension, knee flexion, and knee extension, Timed Up and Down Stairs (TUDS), Timed Up and Go (TUG), nine-minute run-walk (9-min), and completed the QL measure, Short-Form-36 version two (SF-36v2).

RESULTS

Significant correlations (p < 0.01) were found between hip extension and SF-36v2 physical component scale (PCS; r = 0.33), TUDS (r = -0.32), TUG (r = -0.33); hip flexion and TUDS (r = -0.31), TUG (r = -0.39), 9-min (r = 0.44); knee flexion and TUDS (r = -0.52), TUG (r = -0.40), 9-min (r = 0.37); SF-36v2 PCS and TUDS (r = -0.56), TUG (r = -0.51), 9-min (r = 0.60).

CONCLUSION

ROM correlates with functional mobility and QL in patients with LES after limb-sparing surgery. ROM exercises are important component of a physical therapy program for children and adolescents with LES.

Localized unresectable non-rhabdo soft tissue sarcomas of the extremities in pediatric age

BACKGROUND

Treatment of initially unresectable nonrhabdo soft tissue sarcomas (NRSTS) in pediatric age is debated, due to their different chemosensitivity. The authors objective was to evaluate clinical features and treatment results observed in a series of Italian patients over a 24-year period.

METHODS

Fifty-two patients age 8-18 years (median 8 years) were observed (1979-2002). Primary sites were on the lower limbs in 41 and on the upper limbs in 11 cases. Clinical TNM and surgical Intergroup Rhabdomyosarcoma Staging systems were adopted. Therapeutic guidelines recommended an initial biopsy plus neoadjuvant chemotherapy. Aggressive delayed surgery of residual disease, including compartmental resections, was recommended. Radiotherapy was suggested only for patients age > 3 years when surgery was incomplete or not feasible.

RESULTS

The evaluation was performed dividing the patients into two categories according to their chemosensitivity. Chemosensitive (CTs) sarcomas, 21: synovial sarcoma, 11; extraosseous Ewing sarcomas, 5; primitive peripheral neuroectodermic tumors, 5. Nonchemosensitive (CTns) sarcomas, 31: fibrosarcoma, 11; malignant peripheral nerve sheet tumors, 10; liposarcoma, 2; hemangiopericitoma adult type, 2; epithelioid sarcoma, 2; and alveolar soft part sarcoma, leiomyosarcoma, clear cell sarcoma, and sarcoma NOS, each 1. Nineteen of 21 patients with CTs-NRSTS were alive without disease: the 5-year overall survival (OS) and progression-free survival (PFS) were 94.4% and 79.3%, respectively; 23 of 31 patients with CTns-NRSTS were alive without disease: 5-year OS and PFS were 75.3% and 68.3%, respectively. Response to neoadjuvant chemotherapy was complete or partial in 10 of 20 evaluable CTs and in 8 of 26 evaluable CTns tumors. The achievement of complete delayed resection was particularly important for CTns-NRSTS. Tumor size < 5 cm, distal site, and tumor grading for CTns sarcomas were often linked to a favorable outcome; no conclusive results were detected concerning age of the patients or T status of the tumor.

CONCLUSIONS

Multidisciplinary treatment without mutilating procedures allowed the cure of most patients with CTs and CTns-NRSTS. Relapses were cured in several cases of CTs tumors, whereas almost all patients with relapsed CTns tumors died due to the high rate of metastatic spread.

Favorable long-term results of prosthetic arthroplasty of the knee for distal femur neoplasms

We evaluated implant survival, late complications prompting reoperation and functional outcome in long-term (> 5 years) survivors of bone neoplasms of the distal femur treated with osteoarticular resection and segmental rotating hinge total knee arthroplasty. We retrospectively reviewed 83 patients who survived more than 5 years after the first procedure. Seventy-four of the 83 patients have retained a mobile knee joint. At a median followup of 146 months (range, 62-252 months), 22 patients required 26 additional procedures for a prosthesis-specific event (n = 24) or tumor recurrence (n = 2) after reaching 5-year followup. Aseptic loosening (n = 7) and component breakage (n = 2) occurred between 5 and 10 years. Polyethylene wear (n = 12) occurred only after 10 years. One late tumor recurrence at 62 months prompted amputation. All other patients retained a mobile knee joint. Functional outcome was excellent with a median Musculoskeletal Tumor Society score of 88% and a median Toronto Extremity Severity Scale score of 94%. Patients with bone neoplasms who survive more than 5 years after limb salvage with a segmental rotating hinge total knee arthroplasty can expect to retain a mobile knee joint and function consistently at a high level.

LEVEL OF EVIDENCE

Therapeutic study, Level III-2 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Case report: A rare case of Ewing's sarcoma and osteosarcoma at different sites 10 years apart

Ewing's sarcoma of bone and osteosarcoma are rare tumors. A combination of high-grade osteosarcoma and Ewing's sarcoma of bone in anatomically unrelated sites is unique, especially in the absence of previous radiation or retinoblastoma. We present a patient with a rare case of Ewing's sarcoma of the scapula that showed no evidence of recurrence (after 10 years of continued followup) and who subsequently presented with a primary osteosarcoma of the femur.

Surgical management of pelvic sarcomas in children

Pelvic sarcomas are uncommon in childhood. Survival rates of children with pelvic sarcomas have shown significant improvements over the past few decades. Correspondingly, there has been an increase in limb-sparing surgical procedures being performed in these children. This could be attributed in part to the newer generation imaging techniques, wider armamentarium of surgical techniques of reconstruction, and limb-salvage and advances in neo-adjuvant chemotherapy and radiotherapy. Reconstruction after resection of pelvic sarcomas while preserving function of the hip and limb can be extremely challenging especially in children where there are issues of growth potential and limb-length discrepancies. This article focuses on the presentation and epidemiology of different types of pelvic sarcomas in children, the current state-of-art of imaging and surgical management of children with pelvic sarcomas.

Delaying surgery with chemotherapy for osteosarcoma of the extremities

Osteosarcoma is the most frequent primary cancer of bone. When treated by surgery alone, it is almost invariably followed by metastatic dissemination and death. This dismal prognosis can be improved dramatically by including chemotherapy in an interdisciplinary regimen. Today, two-thirds of patients with localised extremity primaries can achieve long-term survival with such intensive multimodal therapy. This article provides a summary overview of current pharmacotherapy in osteosarcoma of the extremities, focussing on the approach of preoperative 'neoadjuvant' chemotherapy and thus, the potential benefits and pitfalls of delaying surgery. Prospective, multi-institutional trials are essential in guaranteeing that as many patients as possible can benefit from modern, efficacious interdisciplinary therapeutic regimens and that further progress can be made.