Symposium: Highlights of the ISOLS/MSTS 2009 Meeting 31 articles
Local Recurrence After Initial Multidisciplinary Management of Soft Tissue Sarcoma: Is there a Way Out?
Multimodality treatment of primary soft tissue sarcoma by expert teams reportedly affords a low incidence of local recurrence. Despite advances, treatment of local recurrence remains difficult and is not standardized.
We previously reported that over the last 10 years our practice has evolved in the treatment of neurogenic tumors of the pelvis to include a multispecialty team of surgeons, a factor that might decrease morbidity and improve recurrence, survival, and function.
Local Recurrence, Survival and Function After Total Femur Resection and Megaprosthetic Reconstruction for Bone Sarcomas
The choices of treatment for patients with extensive tumors of the femur include total femur megaprosthesis or large allograft-prosthetic composites. Previous reports suggest variable survival ranging from 60–70% at 1 to 2 years. However, these studies described earlier prostheses and techniques.
Osteosarcoma is a rare complication of Paget’s disease with a very poor prognosis. Treatment is controversial: the older age of the patients affected by Paget’s disease may limit the use of chemotherapy and axial involvement may limit the practicality of surgery.
The treatment of choice in sacral chordoma is surgical resection, although the risk of local recurrence and metastasis remains high. The quality of surgical margins obtained at initial surgery is the primary factor to improve survival reducing the risk of local recurrence, but proximal sacral resections are associated with substantial perioperative morbidity.
Established prognostic factors influencing survival in soft tissue sarcomas include tumor stage, histopathologic grade, size, depth, and anatomic site. The presence of tumor near or at the margin of resection increases the risk of local recurrence but whether a positive surgical margin or local recurrence affect overall survival is controversial.
Complications are frequent with osteoarticular allografts, and their long-term survivorship in the distal femur is unclear. Thus, the benefits of osteoarticular allografting remain controversial.
Computer-assisted Navigation in Bone Tumor Surgery: Seamless Workflow Model and Evolution of Technique
Computer-assisted navigation was recently introduced to aid the resection of musculoskeletal tumors. However, it has not always been possible to directly navigate the osteotomy with real-time manipulation of available surgical tools. Registration techniques vary, although most existing systems use some form of surface matching.
Tumors of the fibula comprise only 2.5% of primary bone lesions. Patients with aggressive benign tumors in the proximal fibula may require en bloc resection. Peroneal nerve function, knee stability, and recurrence are substantial concerns with these resections. The incidence and fate of these complications is not well-known owing to the small numbers of patients in previous reports.
Joint-sparing or physeal-sparing diaphyseal resections are technically challenging when only a small length of bone is available for implant purchase.
Limb preservation surgery for extremity sarcomas offers the promise of improved function and cosmesis over amputation. Application of limb salvage surgery for pediatric patients with expandable metallic endoprostheses is gaining acceptance. The few studies reporting these devices have focused on functional outcomes; one has addressed quality of life.
While complications following massive endoprosthetic reconstruction have been previously described, the incidence and effects of these complications over extended periods of time have not been well characterized in large series.
The best treatment of giant cell tumor of the sacrum is controversial. It is unclear whether adjuvant treatment with intralesional surgery reduces recurrences or increases morbidity.
Injection of Demineralized Bone Matrix With Bone Marrow Concentrate Improves Healing in Unicameral Bone Cyst
Unicameral bone cysts are benign lesions that usually spontaneously regress with skeletal maturity; however, the high risk of pathologic fractures often justifies treatment that could reinforce a weakened bone cortex. Various treatments have been proposed but there is no consensus regarding the best procedure.
The emergence of limb salvage surgery as an option for patients with osteosarcoma is attributable to preoperative chemotherapy and advancements in musculoskeletal imaging and surgical technique. While the indications for limb salvage have greatly expanded it is unclear whether limb salvage affects overall survival.
The shoulder is commonly affected by primary and metastatic tumors. Current surgical techniques for complex shoulder reconstruction frequently result in functional deficits and instability. A synthetic mesh used in vascular surgery has the biological properties to provide mechanical constraint and improve stability after tumor related shoulder reconstruction.
The field of orthopaedic oncology in North America has been formalized over the past 30 years with the development of the Musculoskeletal Tumor Society (MSTS) and fellowship education opportunities.
Low-cost indigenous megaprostheses used in the developing world are prone to mechanical failure but the frequency and causes are not well established.
Site-dependent Replacement or Internal Fixation for Postradiation Femur Fractures After Soft Tissue Sarcoma Resection
High-dose radiation retards bone healing, compromising the surgical results of radiation-induced fractures. Prosthetic replacement has traditionally been reserved as a salvage option but may best achieve the clinical goals of eliminating pain, restoring function and avoiding complications.
A Comparison of Fine-needle Aspiration, Core Biopsy, and Surgical Biopsy in the Diagnosis of Extremity Soft Tissue Masses
Biopsy tissue can be obtained through a fine needle, a wider coring needle, or through an open surgical incision. Though much literature exists regarding the diagnostic yield of these techniques individually, none compare accuracy of diagnosis in the same mass.
Factors Predicting Local Recurrence, Metastasis, and Survival in Pediatric Soft Tissue Sarcoma in Extremities
Pediatric soft tissue sarcomas are rare and differ from those in adults regarding the spectrum of diagnoses and treatment. Sarcomas in extremities may have different prognoses from those located elsewhere.
Myxoid liposarcoma is generally considered a low grade tumor but the presence of areas of round cells exceeding 5% is reportedly associated with a worse prognosis. Whether “pure” tumors without round cells are low grade has not been confirmed. While radiotherapy has been used for patients’ myxoid liposarcoma it is unclear whether it reduces local recurrences.
Soft tissue sarcomas are often inappropriately excised without adequate preoperative planning. Inappropriate (unplanned) excisions may adversely affect local recurrence, distant metastasis, patient survival, and /or postoperative function once properly evaluated.
Metastatic disease commonly affects the proximal femur and occasionally the acetabulum. Surgical options include the use of a protrusio cage with a THA. However, the complications and survivorship of these cages for this indication is unknown.
The few available studies documenting the long-term survival of cemented proximal tibial endoprostheses for musculoskeletal tumors do not differentiate between stem designs or patient diagnosis. There is wide variation in survival rates reported, possibly a result of this heterogeneity in patient population and implant design.
Partial hand amputations for malignant tumors allow tumor resection with negative resection margins, which is associated with lower local recurrence rates and improved overall survival while preserving native tissue, which improves functional outcome.
As the life expectancy of patients with musculoskeletal tumors improves, long-term studies of endoprosthetic reconstructions are necessary to establish realistic expectations for the implants and compare them to other reconstruction approaches.
Bone chondrosarcomas are rare malignant tumors that have variable biologic behavior, and their treatment is controversial. For low-grade tumors, there is no consensus on whether intralesional en bloc resections are the best treatment.