Delay in Diagnosis of High-Grade Osteosarcoma of the Extremities. Has it any Effect on the Stage of Disease?

Impact of delay of local control in nonmetastatic extremity primary osteosarcoma

INTRODUCTION

The timing of local control (LC) is not well studied in osteosarcoma. We assessed the impact of the delay of LC on the survival outcome of patients with osteosarcoma.

METHODS

We conducted a retrospective analysis of children (≤18 years) with nonmetastatic extremity primary osteosarcoma at King Hussein Cancer Center from January 2005 until March 2020. Patients' demographics, disease characteristics, and outcomes were collected. Events were defined as death, progression, or relapse. Cox proportional hazards regression was used for univariable and multivariable comparisons of different covariates.

RESULTS

Eighty-two patients were included; 41 (50%) were females; the median age was 12.5 years (range: 5.9-18). Sixty-four patients (78%) underwent LC by limb-salvage surgery. Fifteen patients (18%) had a delay of LC greater than or equal to 18 weeks. After a median follow-up of 54 months (range: 8-188), the 5-year event-free survival (EFS) and overall survival (OS) were 55.3% ± 5.8% and 66.6% ± 6%, respectively. On univariable analysis, LC greater than or equal to 18 weeks, progression before LC, amputation, and poor histologic response were associated with worse EFS (p = .007, .007, .006, .002) and OS (p = .01, .001, .006, .004). On multivariable analysis, LC greater than or equal to 18 weeks, progression before LC, and poor histologic response were associated with worse EFS (p < .001, .007, .002); and OS (p < .001, .007, .008). Male gender was associated with worse OS on univariable and multivariable analysis (both p = .02). After exclusion of patients with early progression before Week 11, good histologic response and LC less than 18 weeks were associated with better EFS (p = .04 and .03). While good histologic response was associated with better OS (p = .02), LC less than 18 weeks was not significant (p = .2).

CONCLUSIONS

Our findings suggest that delay in LC could have an impact on the outcomes in patients with osteosarcoma. However, further investigations involving larger sample sizes and longer follow-up are necessary to fully comprehend the extent of this influence.

Deep Learning-Based Detection of Bone Tumors around the Knee in X-rays of Children

Even though tumors in children are rare, they cause the second most deaths under the age of 18 years. More often than in other age groups, underage patients suffer from malignancies of the bones, and these mostly occur in the area around the knee. One problem in the treatment is the early detection of bone tumors, especially on X-rays. The rarity and non-specific clinical symptoms further prolong the time to diagnosis. Nevertheless, an early diagnosis is crucial and can facilitate the treatment and therefore improve the prognosis of affected children. A new approach to evaluating X-ray images using artificial intelligence may facilitate the detection of suspicious lesions and, hence, accelerate the referral to a specialized center. We implemented a Vision Transformer model for image classification of healthy and pathological X-rays. To tackle the limited amount of data, we used a pretrained model and implemented extensive data augmentation. Discrete parameters were described by incidence and percentage ratio and continuous parameters by median, standard deviation and variance. For the evaluation of the model accuracy, sensitivity and specificity were computed. The two-entity classification of the healthy control group and the pathological group resulted in a cross-validated accuracy of 89.1%, a sensitivity of 82.2% and a specificity of 93.2% for test groups. Grad-CAMs were created to ensure the plausibility of the predictions. The proposed approach, using state-of-the-art deep learning methodology to detect bone tumors on knee X-rays of children has achieved very good results. With further improvement of the algorithm, enlargement of the dataset and removal of potential biases, this could become a useful additional tool, especially to support general practitioners for early, accurate and specific diagnosis of bone lesions in young patients.

Determinants and impact of diagnostic interval in bone sarcomas: A retrospective cohort study

BACKGROUND

Diagnostic delays in cancers are frequent in developing countries due to poor health infrastructure. Existing literature from developed countries suggests that diagnostic interval in bone sarcomas is primarily dictated by tumour biology with no impact on survival. This study evaluates the social and biological determinants of the diagnostic interval in bone sarcomas in a resource-challenged setting and assesses its impact on treatment outcomes.

METHODS

A retrospective single-institutional study was conducted on patients with high-grade bone sarcomas recorded in the sarcoma clinic database between 2003 and 2018. Baseline clinical characteristics and treatment outcomes were recorded. Logistic regression was performed to assess the impact of baseline clinical and social characteristics (distance from treating centre and rural vs. urban residence) on the diagnostic interval. Further, the impact of diagnostic interval on histologic response to neoadjuvant chemotherapy, amputation requirement in extremity sarcomas and survival was evaluated.

RESULTS

A total of 1227 patients were included for analysis. The median diagnostic interval was 4 months (3-7 months). Age above 18 years, Ewing sarcoma (ES) diagnosis, absence of fever at presentation and tumour size above 7.5 cm were predictors of a longer diagnostic interval (>4 months). The length of the diagnostic interval did not impact amputation requirement or survival outcomes. However, the proportion of patients with good necrosis post-neoadjuvant chemotherapy was lower among patients with longer diagnostic intervals (25% vs. 34·16%; p-value = .04).

CONCLUSION

Tumour characteristics rather than social factors determined the diagnostic interval. Diagnostic interval did not impact survival outcomes even in a resource-constrained setting.

The sarcoma diagnostic interval: a systematic review on length, contributing factors and patient outcomes

Sarcomas are rare and heterogeneous mesenchymal tumours of soft tissue or bone, making them prone to late diagnosis. In other malignancies, early diagnosis has an impact on stage of disease, complexity of therapeutic procedures, survival and health-related quality of life (HRQoL). Little is known about what length of diagnostic interval should be considered as delay in patients with bone (BS) or soft tissue sarcomas (STS). To quantify total interval (defined as time from first symptom to histological diagnosis) and its components, identify contributing factors to its length and determine the impact on patients’ outcome in terms of mortality and HRQoL. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventy-six articles out of 2310 met the predefined inclusion criteria. Total intervals, varied broadly; 9–120.4 weeks for BS and 4.3–614.9 weeks for STS. Older age and no initial radiological examinations were contributing factors for a long interval in BS, while in STS results were conflicting. The impact of length of total interval on clinical outcomes in terms of survival and morbidity remains ambiguous; no clear relation could be identified for both BS and STS. No study examined the impact on HRQoL. The length of total interval is variable in BS as well as STS. Its effect on outcomes is contradictory. There is no definition of a clinically relevant cut-off point that discriminates between a short or long total interval. Prospero: CRD42017062492.

Delay in diagnosis of primary osteosarcoma of bone in children: Have we improved in the last 15 years and what is the impact of delay on diagnosis?

Aims

Examine: (1) If length of symptoms (LS) of children with osteosarcoma has improved in the last 15 years (2) Is delay in diagnosis related to the presence of metastases at presentation? (3) The impact of delay in diagnosis on prognosis.

Methods

250 consecutive patients with a diagnosis of osteosarcoma of bone treated at a national bone tumor treatment center between 2004 and 2018 were studied retrospectively. Three groups comprising those diagnosed over a five-year period (Group 1: 2004-2008, Group 2: 2009-2013; Group 3: 2014-2018) were studied.

Results

There were 126 males and 124 females with a mean age 12.2 years. The median LS for all patients was eight weeks. The median LS for Group 3 was significantly shorter than that for other groups. Development of metastasis during follow-up period was significantly less in Group 3 compared to the other groups. Overall survival gradually improved over the whole study period. There was no difference in the proportion presenting with metastases at diagnosis between the three groups. The survival rates in patients with LS shorter than 4 weeks was better than those with LS longer than 4 weeks, irrespective of the study time period.

Conclusions

There has been an improvement in the LS in patients diagnosed with osteosarcoma over the last 15 years. The development of metastasis during follow-up has reduced and the overall survival in the last 15 years has improved. LS longer than 4 weeks is associated with a poorer prognosis.

Prognostic impact of diagnostic and treatment delays in children with osteosarcoma

BACKGROUND

The aim of this study is to evaluate the relationship between the latency to diagnosis (LD) and the time to completion of chemotherapy (TCC) with clinical outcomes in children with osteosarcoma.

METHODS

We performed a retrospective analysis of all patients who received treatment for osteosarcoma in two tertiary centers in Peru from 2008 to 2015. All causes of delayed LD or TCC were evaluated. Overall survival (OS) and event-free-survival (EFS) were estimated and compared according to LD, TCC, and established clinical prognostic factors.

RESULTS

One hundred and thirteen patients were included in the study. The median LD was 13.5 weeks (interquartile range, 10-18.5 weeks). No association was observed among clinical stage, tumor size, and LD. Delayed LD was not associated with a worse clinical outcome. Multivariate analysis confirmed that OS and EFS were significantly worse in cases of a delayed TCC (≥4 weeks), with hazard ratios of 2.70 (1.11-6.76, P = 0.003) and 1.13 (1.00-1.26, P = 0.016), respectively. Most delays in TCC (85%) were due to extramedical reasons (e.g., lack of available hospital beds).

CONCLUSION

The LD did not seem to influence the EFS and OS in pediatric patients with osteosarcoma. However, a delay in TCC from any cause is independently associated with poor outcome in pediatric patients with osteosarcoma. Based on these results, further efforts may be needed to avoid treatment delays in patients with osteosarcoma in middle-income countries.

Longer duration of symptoms at the time of presentation is not associated with worse survival in primary bone sarcoma

Aims

The primary aim of this study was to determine the effect of the duration of symptoms (DOS) prior to diagnosis on the overall survival in patients with a primary bone sarcoma.

Patients and Methods

In a retrospective analysis of a sarcoma database at a single institution between 1990 and 2014, we identified 1446 patients with non-metastatic and 346 with metastatic bone sarcoma. Low-grade types of tumour were excluded. Our data included the demographics of the patients, the characteristics of the tumour, and the survival outcome of patients. Cox proportional hazards analysis and Kaplan-Meier survival analysis were performed, and the survivorship of the non-metastatic and metastatic cohorts were compared.

Results

In the non-metastatic cohort, a longer DOS was associated with a slightly more favourable survival (hazard ratio (HR) 0.996, 95% confidence interval (CI) 0.994 to 0.998, p < 0.001). In all types of tumour, there was no difference in survival between patients with a DOS of greater than four months and those with a DOS of less than four months (p = 0.566). There was no correlation between the year of diagnosis and survival (p = 0.741). A diagnosis of chondrosarcoma (HR 0.636, 95% CI 0.474 to 0.854, p = 0.003) had the strongest positive effect on survival, while location in the axial skeleton (HR 1.76, 95% CI 1.36 to 2.29, p < 0.001) had the strongest negative effect on survival. Larger size of tumour (HR 1.05, 95% CI 1.03 to 1.06, p < 0.001) and increased age of the patient (HR 1.02, 95% CI 1.01 to 1.03, p < 0.001) had a slightly negative effect on survival. Metastatic and non-metastatic cohorts had similar median DOS (16 weeks, p = 0.277), although the median survival (15.5 months vs 41 months) and rates of survival at one year (69% vs 89%) and five years (20% vs 59%) were significantly shorter in the metastatic cohort.

Conclusion

A longer DOS prior to diagnosis is not associated with a poorer overall survival in patients with a primary bone sarcoma. Location in the axial skeleton remains the strongest predictor of a worse prognosis. This may be helpful in counselling patients referred for evaluation on a delayed basis. Cite this article: Bone Joint J 2018;100-B:652-61.

Delay in Diagnosis and Its Effect on Clinical Outcome in High-grade Sarcoma of Bone: A Referral Oncological Centre Study

OBJECTIVE

To investigate delay in diagnosis by both patients and doctors, and to evaluate its effect on outcomes of high-grade sarcoma of bone in a single-referral oncological center.

METHODS

Fifty-four patients with osteosarcoma, 29 with Ewing sarcoma and 19 with chondrosarcoma were enrolled in this retrospective study. Delay in diagnosis was defined as the period between initial clinical symptoms and histopathological diagnosis at our center. The delays were categorized as patient- or doctor-related. Short total delays were defined as <4 months; prolonged delays >4 months were assumed to have prognostic relevance.

RESULTS

Total delay in diagnosis was 688.0 days in patients with chondrosarcoma, which is significantly longer than the 163.3 days for osteosarcoma (P < 0.01) and 160.2 days for Ewing sarcoma (P < 0.01). Most doctor-related delays were at the pre-hospital stage, occurring at the general practitioner (GP)'s office. However, prolonged total delays (≥4 months) did not result in lower survival rates. Five-year-overall survival rates were 67.0% for osteosarcoma, 49.0% for Ewing sarcoma and 60.9% for chondrosarcoma. Survival was significantly lower for patients with metastatic disease for all three types of sarcoma.

CONCLUSION

Prolonged delay in diagnosis does not result in lower survival. Metastatic disease has a pronounced effect on survival. Aggressive tumor behavior results in shorter delays. Minimizing GP-related delays could be achieved by adopting a lower threshold for obtaining plain radiographs at the pre-hospital stage.

Extraskeletal osteosarcoma: A European Musculoskeletal Oncology Society study on 266 patients

PURPOSE

Prognosis of extraskeletal osteosarcoma (ESOS) is reported to be poorer than that of skeletal osteosarcoma. This multicenter retrospective study aimed to evaluate factors influencing ESOS prognosis.

PATIENTS AND METHODS

Members of the European Musculoskeletal Oncology Society (EMSOS) submitted institutional data on patients with ESOS.

RESULTS

Data from 274 patients treated from 1981 to 2014 were collected from 16 EMSOS centres; 266 patients were eligible. Fifty (18.7%) had metastases at diagnosis. Of 216 patients with localised disease, 211 (98%) underwent surgery (R0 = 70.6%, R1 = 27%). Five-year overall survival (OS) for all 266 patients was 47% (95% CI 40-54%). Five-year OS for metastatic patients was 27% (95% CI 13-41%). In the analysis restricted to the 211 localised patients who achieved complete remission after surgery 5-year OS was 51.4% (95% CI 44-59%) and 5-year disease-free survival (DFS) was 43% (95% CI 35-51%). One hundred twenty-one patients (57.3%) received adjuvant or neoadjuvant chemotherapy and 80 patients (37.9%) received radiotherapy. A favourable trend was seen for osteosarcoma-type chemotherapy versus soft tissue sarcoma-type (doxorubicin ± ifosfamide) regimens. For the 211 patients in complete remission after surgery, patient age, tumour size, margins and chemotherapy were positive prognostic factors for DFS and OS by univariate analysis. At multivariate analysis, patient age (≤40 years versus >40 years) (P = 0.05), tumour size (P = 0.0001) and receipt of chemotherapy (P = 0.006) were statistically significant prognostic factors for survival.

CONCLUSION

Patient age and tumour size are factors influencing ESOS prognosis. Higher survival was observed in patients who received perioperative chemotherapy with a trend in favour of multiagent osteosarcoma-type regimen which included doxorubicin, ifosfamide and cisplatin.

Osteosarcoma in patients younger than 12 years old without metastases have similar prognosis as adolescent and young adults

BACKGROUND

Childhood cancer is relatively rare and tends to present specific age distribution, as a prognostic factor for some of these diseases. Information on how young age affects prognosis, response to chemotherapy, and local control options in children versus AYA with osteosarcoma (OST) is minimal.

METHODS

In order to identify the main differences in clinical pathologic features, surgical approaches and survival rates of primary high grade OST of the extremity between children (n = 156; <12 years old) and AYA (n = 397; 12-30 years old), the institutional database with 553 patients treated by BOTG studies over 15 years were reviewed.

RESULTS

There were no differences in metastases at diagnosis, tumor size, and grade of necrosis between the two age groups. The rate of amputation was 30% higher in the children group (P = 0.018). The rate of limb salvage surgery using reconstruction with allograft or autograft was 70% higher in the children group (P = 0.018) while endoprosthesis rate was 40% higher in the AYA group (P = 0.018). The log rank test revealed that survival is similar between the two age groups for non-metastatic patients (P = 0.424 for OS and P = 0.393 for EFS). Metastatic patients of both ages group had higher risk of dying compared to non-metastatic (HR 3.283 95% CI 2.581-4.177; P < 0.001). Children with metastases at diagnosis had less OS time (P = 0.049) and EFS time (P = 0.032) than adolescents.

CONCLUSION

Non-metastatic OST in preadolescent patients does not appear to be significantly different from those seen in AYA patients, but has local control challenges. Children presenting with metastases should be considered an ultra-high-risk group.

Metastatic cancer mimicking mechanical low back pain: a case report

OBJECTIVE AND IMPORTANCE

The purpose of this report is to describe the clinical course of a patient referred to physiotherapy (PT) for the treatment of low back pain who was subsequently diagnosed with metastatic non-small cell carcinoma of the lung.

CLINICAL PRESENTATION

A 48-year old woman was referred to PT for the evaluation and treatment of an insidious onset of low back pain of 2 month duration. The patient did not have a history of cancer, recent weight changes, or general health concerns. The patient's history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction and no red flag findings were present that warranted immediate medical referral.

INTERVENTION

Short-term symptomatic improvements were achieved using the treatment-based classification approach. However, despite five PT sessions over the course of 5 weeks, the patient did not experience long-term symptomatic improvement. On the sixth session, the patient reported a 2-day history of left hand weakness and headaches. This prompted the physiotherapist to refer the patient to the emergency department where she was diagnosed with lung cancer.

CONCLUSION

Differential diagnosis is a key component of PT practice. The ability to reproduce symptoms or achieve short-term symptomatic gains is not sufficient to rule out sinister pathology. This case demonstrates how extra caution should be taken in patients who are smokers with thoracolumbar region pain of unknown origin. The need for caution is magnified when one can achieve no more than short-term improvements in the patient's symptoms.

Clinical presentation and waiting time targets do not affect prognosis in patients with pancreatic cancer

INTRODUCTION

The prognosis of patients with pancreatic cancer remains poor despite recent advances in treatment. It is not known whether delays in referring, diagnosing and treating these patients and the way they present can affect their survival.

AIMS

In our study we investigated the impact of clinical presentation (jaundice, abdominal pain, weight loss) and delays in management of these patients on their treatment and survival.

METHODS

Data on all patients with pancreatic cancer referred to the Pancreatic Unit (1997-2002) were collected prospectively and analysed using SPSS 16((R).) The delay in diagnosis and treatment for each patient was measured by estimating the time from the beginning of symptoms to the date of the referral letter (T1), the time from the referral date to the date of first review at the Unit (T2) and the time from date of review to the date of diagnosis/treatment (T3). Treatments were defined as 1) pancreatic resections, 2) gastric and biliary bypass and 3) biliary stents. The term 'operability' was used to describe patients thought to have a potentially removable tumour and had an operation and 'resectability' applied to the patients whose tumour was actually removed at the operation. Follow-up time and survival were recorded by reviewing the patient's notes, hospital electronic databases and by contacting patients General Practitioners.

RESULTS

There were a total of 355 patients with pancreatic cancer. Median age at diagnosis was 64 (i.q.r. 56-71) years and median follow-up was 8 (i.q.r. 4-14) months. The overall 1, 3 and 5 years patient's survival was 26%, 5% and 4% respectively. 1, 3 and 5 years survival of inoperable patients was 24%, 2% and 0% and for operable patients was 35%, 13% and 9% respectively. The median survival time for those patients that underwent operation was significantly higher than those that did not (12 vs 6 months, p < 0.001). The overall median time from initial symptoms to diagnosis/treatment (T1 + T2 + T3) was 102 (i.q.r. 56-182) days, T1 was 65 (i.q.r. 31-143), T2 17 (i.q.r. 8-28) and T3 11 (i.q.r. 6-21) days. The time delay from symptoms to referral (T1) had minimal clinical relevance to survival, with a hazard ratio of only 1.001 (95% CI 0.001-0.002, p = 0.043) per day. Of all 355 patients, 305 (86%) were reviewed and treated within 62 days from the GP referral (T2 + T3). There was no significant difference in operability, resectability and survival of patients that were diagnosed/treated before or after 62 days from referral (T2 + T3) (median months 6.5 and 7.9 respectively, p = 0.134). Patients presenting with jaundice were referred (T1, median 56 vs 103) and diagnosed/treated (T2 + T3, median 96 vs 130) days (p < 0.001) sooner, had a higher operability rate (33% vs 21%, p = 0.035) but not a significantly higher resectability rate of (37% vs 29%) (p = 0.608). Isolated or combined mode of clinical presentation had no significant effect on survival (p = 0.965). On multivariate regression analysis, prognostic factors of survival were a resectable tumour and the time from the beginning of symptoms to referral.

CONCLUSION

This study showed that pre-hospital delays in referring patients to a specialist unit, but not hospital related 62 days target, had an no impact on operability, resectability and survival. Clinical presentation also had no impact on the survival. We confirmed that pancreatic resection is the most important factor in determining the length of survival in patients with pancreatic cancer. Our study implies that the successful implementation of the 62 days National Cancer Waits Target across the UK is unlikely to have an impact on prognosis in patients with pancreatic cancer. Focusing on early referral to specialist Pancreatic Units might be more effective.

Osteosarcoma in Patients Older Than 65 Years

Purpose

We reviewed the outcome of osteosarcoma patients older than 65 years, an age group usually excluded from protocols, to determine the different clinical features and prognostic factors in this age group compared with younger patients.

Patients and Methods

Patients treated at our institute who had high-grade osteosarcoma and were older than 65 years were observed.

Results

Forty-three patients were eligible to be enrolled onto this study; of these, 22 were male and 21 were female. The median age of this group was 69 years (range, 65 to 80 years). Of the 43 patients, 29 patients had localized disease, and 14 patients had metastatic disease. Localizations were appendicular in 33 patients, and axial in 10 patients. Twenty-nine patients had a primary osteosarcoma, 13 patients (30%) had a sarcoma in Paget's disease, and one patient had postradiotherapy (RT) osteosarcoma. The median interval from onset of symptoms to diagnosis was 4 months (range, 0 to 73 months).Thirty-two of 43 patients received surgery for a primary tumor. Of these, 18 patients had limb salvage, 13 patients had an amputation, and one patient had palliative surgery; the remaining 11 patients received palliative RT. Fourteen patients received chemotherapy; two deaths related to chemotherapy were observed. Median overall survival (OS) for all 43 patients was 19 months (range, 3 to 229 months); 5-year OS was 22% (SE = 3%) for the whole group, and 45% OS for those patients with localized primary osteosarcoma. Multivariate analysis demonstrated that stage, volume, and surgery were significant prognostic factors. Insignificant prognostic factors were sex, type of surgery, chemotherapy, and Paget's disease.

Conclusion

Patients older than 65 years with osteosarcoma have a worse prognosis compared with younger patients. This older age group is characterized by a longer time lapse from the onset of symptoms to diagnosis, more metastatic cases at diagnosis, less use of limb salvage, fewer patients receiving chemotherapy, and more patients excluded from clinical trials than a younger age group.

Treatment delay of bone tumours, compilation of a sociodemographic risk profile: a retrospective study

BACKGROUND

Bone tumours are comparatively rare tumours and delays in diagnosis and treatment are common. The purpose of this study was to analyse sociodemographic risk factors for bone tumour patients in order to identify those at risk of prolonged patients delay (time span from first symptoms to consultation), professional delay (from consultation to treatment) or symptom interval (from first symptoms to treatment). Understanding these relationships might enable us to shorten time to diagnosis and therapy.

METHODS

We carried out a retrospective analysis of 265 patients with bone tumours documenting sociodemographic factors, patient delay, professional delay and symptom interval. A multivariate explorative Cox model was performed for each delay.

RESULTS

Female gender was associated with a prolonged patient delay. Age under 30 years and rural living predisposes to a prolonged professional delay and symptom interval.

CONCLUSION

Early diagnosis and prompt treatment are required for successful management of most bone tumour patients. We succeeded in identifying the histology independent risk factors of age under 30 years and rural habitation for treatment delay in bone tumour patients. Knowing about the existence of these risk groups age under 30 years and female gender could help the physician to diagnose bone tumours earlier. The causes for the treatment delays of patients living in a rural area have to be investigated further. If the delay initiates in the lower education of rural general physicians, further training about bone tumours might advance early detection. Hence the outcome of patients with bone tumours could be improved.

Ewing’s sarcoma family tumours

Despite local treatment with systemic chemotherapy in Ewing’s sarcoma family tumours (ESFT), patients with detectable metastases at presentation have a markedly worse prognosis than those with apparently localised disease. We investigated the clinical, pathological and laboratory differences in 888 patients with ESFT, 702 with localised disease and 186 with overt metastases at presentation, seen at our institution between 1983 and 2006.

Multivariate analyses showed that location in the pelvis, a high level of serum lactic dehydrogenase, the presence of fever and a short interval between the onset of symptoms and diagnosis were indicative of metastatic disease. The rate of overt metastases at presentation was 10% without these four risk factors, 22.7% with one, 31.4% with two, and 50% for those with three or four factors. We concluded that in ESFT the site, the serum level of lactic dehydrogenase, fever, and the interval between the onset of symptoms and diagnosis are indicators of tumours having a particularly aggressive metastatic behaviour.

Size matters for sarcomas!

INTRODUCTION

By the time of diagnosis, sarcomas have frequently reached a large size and many patients have a long history of symptoms prior to diagnosis. The aim of this study was to assess whether size of tumour at presentation or duration of symptoms was a significant factor affecting outcome.

PATIENTS AND METHODS

A prospective database recording patient, tumour, treatment and outcome factors was reviewed. A total of 1460 patients with newly diagnosed sarcomas and with > 3 years of follow-up were included for analysis.

RESULTS

The mean size of sarcomas presenting to our unit was 10.7 cm at the time of diagnosis. Bone sarcomas averaged 11.3 cm with little variation by age or diagnosis, whilst subcutaneous soft tissue sarcomas averaged 10 cm. The incidence of metastases at diagnosis increased almost linearly with increasing size and the prognosis, even for patients without metastases at diagnosis became steadily worse with increasing size for all tumours, independent of other factors. Duration of symptoms did not correlate with size but patients with symptoms > 1 year had a slightly better prognosis than those with a shorter duration.

CONCLUSIONS

The author makes a plea for greater awareness of potential malignancy in lumps and bumps, particularly those over the size of a golf ball (4.27 cm), making the point that the smaller the tumour at diagnosis the better the prognosis.

Osteosarcoma of the pelvis

AIMS

To describe the outcomes of a large number of patients with pelvic osteosarcoma, and to define the guidelines for appropriate treatment.

METHODS

We reviewed 60 consecutive patients with primary pelvic high-grade osteosarcoma. The tumour involved the whole hemipelvis in 15 cases, while the most common location was the iliac wing in 29 cases (48.3%): 25 of these adjacent to or passing the sacroiliac joint.

RESULTS

Thirty patients underwent surgery; there were 16 hindquarter amputations and 14 internal hemipelvectomies. All the patients who presented with metastasis died of their disease. In 18 cases wide margins were achieved, however, eight patients experienced local recurrence. Of the series, only eight patients are still alive.

CONCLUSION

The use of intense chemotherapy and surgical wide margin, hardly seems to achieve local control, however, tumour necrosis was correlated with positive prognosis. When internal hemipelvectomy it is not safe enough, amputation must be considered, particularly for cases with sacrifice of the sciatic nerve roots or for older patients where a shorter surgical procedure can be less risky.

[Analysis of the delay in surgical treatment of adenocarcinoma of the prostate]

INTRODUCTION

The prostate cancer is an important cause of men's mortality in our society.

PURPOSE

To know the time of delay in to realise the surgical treatment of the prostate cancer.

MATERIALS AND METHODS

Analysis of 30 cases of patients treated with radical prostatectomy, cuantifying the time of delay in all the periods of the process.

RESULTS

Appointment in general practitioner-first appointment in urology: 21.7 days. First appointment in urology-biopsy: 22.8. Biopsy-diagnosis: 34.3. Diagnosis-appointment of anesthesiology: 28.5. Anesthesiology-radical prostatectomy: 25.7.

CONCLUSIONS

There are actions for to reduce the delay in to perform the diagnosis or treatment, where we can act how an improvement plan: to give poblational education in general and information to the patient in particular, to analyze the rules of medical action, to improve the coordination between level, to improve the flexibility in outpatients appointment and time waiting for diagnosis test and treatment, to correct the temporality, to create clinical units of many specialties and to improve the politics of health.

Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols

PURPOSE

To define prognostic factors for response and long-term outcome for a wide spectrum of osteosarcomas, extending well beyond those of the typical young patient with seemingly localized extremity disease.

PATIENTS AND METHODS

A total of 1,702 consecutive newly diagnosed patients with high-grade osteosarcoma of the trunk or limbs registered into the neoadjuvant studies of the Cooperative Osteosarcoma Study Group before July 1998 were entered into an analysis of demographic, tumor-related, and treatment-related variables, response, and survival. The intended therapeutic strategy included preoperative and postoperative chemotherapy with multiple agents as well as surgery of all operable lesions.

RESULTS

Axial tumor site, male sex, and a long history of symptoms were associated with poor response to chemotherapy in univariate and multivariate analysis. Actuarial 10-year overall and event-free survival rates were 59.8% and 48.9%. Among the variables assessable at diagnosis, patient age (actuarial 10-year survival > or = 40, 41.6%; < 40, 60.2%; P =.012), tumor site (axial, 29.2%; limb, 61.7%; P <.0001), and primary metastases (yes, 26.7%; no, 64.4%; P <.0001), and for extremity osteosarcomas, also size (> or = one third, 52.5%; < one third, 66.7%; P <.0001) and location within the limb (proximal, 49.3%; other, 63.9%; P <.0001), had significant influence on outcome. Two additional important prognostic factors were treatment related: response to chemotherapy (poor, 47.2%; good, 73.4%; P <.0001) and the extent of surgery (incomplete, 14.6%; macroscopically complete, 64.8%; P <.0001). All factors except age maintained their significance in multivariate testing, with surgical remission and histologic response emerging as the key prognostic factors.

CONCLUSION

Tumor site and size, primary metastases, response to chemotherapy, and surgical remission are of independent prognostic value in osteosarcoma.