Minna Laitinen

Treatment of pathological humerus shaft fractures with intramedullary nails with or without cement fixation

IntroductionBone metastasis is a severe complication for patients with cancer. Not only does it cause intractable pain and other clinical problems such as fracture after trivial injury, it also signifies that the malignant process is incurable. Since life expectancy of metastasised cancer patients has improved due to advanced oncological treatment but is still limited, appropriate surgical intervention has increased.MethodThis is a retrospective control study of 21 patients who underwent cemented intramedullary nailing for pathological fractures in the humeral shaft between 2005 and 2009 as compared to a historical control group of 19 patients that underwent locked intramedullary nailing for pathological fractures in the humeral shaft between 1999 and 2004. Four major outcomes were assessed, namely, pain relief, use of analgesics, recovery of function and rate of complication.ResultsPatients treated with cemented intramedullary nailing had better pain relief, less use of analgesics and better functional restoration immediately after surgical procedure when compared to the patients without cement fixing. The rate of complication did not differ between these two groups.ConclusionSince surgery for metastases does not prolong life but improves the quality of life, the aim towards a short postoperative rehabilitation time is recommended. Cement fixation gives immediate stabilisation to the fracture site and thus allows less pain but full range of motion from the first postoperative day.

The role of grade in local recurrence and the disease-specific survival in chondrosarcomas

Aims The purpose of this study was to describe the effect of histological grade on disease‐specific survival in patients with chondrosarcoma. Patients and Methods A total of 343 patients with a chondrosarcoma were included. The histological grade was assessed on the initial biopsy and on the resection specimen. Where the histology showed a mixed grade, the highest grade was taken as the definitive grade. When only small focal areas showed higher grade, the final grade was considered as both. Results The concordance between the highest preoperative biopsy grading and the highest final grading of the resection specimen in total was only 43% (146/343). In 102 specimens (30%), a small number of cells or focal areas of higher grade were observed in contrast to the main histology. The disease‐specific survival, stratified according to the predominant histological grade, showed greater variation than when stratified according to the highest grade seen in the resection specimen. Conclusion The diagnostic biopsy in chondrosarcoma is unreliable in assessing the definitive grade and the malignant potential of the tumour. When categorizing the grade of the resection specimen, the prognosis for local recurrence and disease‐specific survival should be based on the highest grade seen, even when seen in only a few cells. Cite this article: Bone Joint J 2018;100‐B:662–6.

The prognostic and therapeutic factors which influence the oncological outcome of parosteal osteosarcoma

The aim of this study was to evaluate the prognostic and therapeutic factors which influence the oncological outcome of parosteal osteosarcoma. A total of 80 patients with a primary parosteal osteosarcoma were included in this retrospective study. There were 51 females and 29 males with a mean age of 29.9 years (11 to 78). The mean follow-up was 11.2 years (1 to 40). Overall survival was 91.8% at five years and 87.8% at ten years. Local recurrence occurred in 14 (17.5%) patients and was associated with intralesional surgery and a large volume of tumour. On histological examination, 80% of the local recurrences were dedifferentiated high-grade tumours. A total of 12 (14.8%) patients developed pulmonary metastases, of whom half had either a dedifferentiated tumour or a local recurrence. Female gender and young age were good prognostic factors. Local recurrence was a poor prognostic factor for survival. Medullary involvement or the use of chemotherapy had no impact on survival. The main goal in treating a parosteal osteosarcoma must be to achieve a wide surgical margin, as inadequate margins are associated with local recurrence. Local recurrence has a significant negative effect on survival, as 80% of the local recurrences are high-grade dedifferentiated tumours, and half of these patients develop metastases. The role of chemotherapy in the treatment of parosteal osteosarcoma is not as obvious as it is in the treatment of conventional osteosarcoma. The mainstay of treatment is wide local excision.

An Unusual Case of Clear Cell Chondrosarcoma with Very Late Recurrence and Lung Metastases, 29 Years after Primary Surgery

Clear cell chondrosarcoma is a rare bone neoplasm with low-grade clinical course and the potential to metastasize to the skeleton and lungs. The aim of this report is to present a case that is extremely rare, but in accordance with the literature where the clear cell chondrosarcoma reportedly has a tendency for late metastases. In our patient the primary surgery was intralesional, since it was mistakenly interpreted as a benign tumour in the early 80s. The local recurrence and lung metastases occurred, however, 29 years after the initial treatment. The local recurrence was resected with wide margins, no additional surgery or oncological treatments were given, and two and half years postoperatively patient is doing well and there is no progression in the disease. In conclusion, it is important to have a long follow-up to the clear cell chondrosarcoma patients even for decades or lifelong, because the malignancy tends to metastasize or recur after an extended period. The course of metastasized disease may be unusually slow, so relatively aggressive treatment in metastasized and recurring cases is justified.

Resection of the ilium in patients with a sarcoma

Aims The aim of the study was to investigate the controversial issue of whether the pelvic ring should be reconstructed following resection of the sarcomas of the ilium. Patients and Methods From our database, we identified 64 patients who underwent excision of a tumour involving the ilium between 1976 and 2015. A total of 35 underwent complete resection, of whom 24 were reconstructed with a non‐vascularised fibula graft, and four with extracorporeal irradiation and reimplantation. A total of 29 patients had a partial resection. The mean follow‐up was 9.2 years (1.1 to 25.6). Functional outcomes were assessed using the Toronto Extremity Salvation Score (TESS) at final follow‐up. In all, 32 patients (50%) had a chondrosarcoma. Results The mean TESS for all patients was 71.6% (17% to 100%). The mean TESS for those who underwent total resection with reconstruction was 72.0% (17% to 100%) and without reconstruction it was 53.3% (20% to 90%) and for those who underwent partial resection it was 76.3% (31.3% to 100%). The rate of local recurrence was 42.2% and this was more common in those treated by partial resection (p = 0.048). The risk of local recurrence was related to the margin achieved at resection. Conclusions Given the high rate of local recurrence following excision of a tumour from the ilium, obtaining wide surgical margins should be a priority even if this requires more aggressive surgery. In young patients, where late recurrence may occur, more radical complete resection should be considered. When total resection of the ilium is considered, reconstruction should also be considered as it confers a higher functional outcome than total resection without reconstruction.

Risk analysis factors for local recurrence in Ewing’s sarcoma: when should adjuvant radiotherapy be administered?

Aims The aim of this study was to analyse a group of patients with non‐metastatic Ewings sarcoma at presentation and identify prognostic factors affecting the development of local recurrence, in order to assess the role of radiotherapy. Patients and Methods A retrospective review of all patients with a Ewings sarcoma treated between 1980 and 2012 was carried out. Only those treated with chemotherapy followed by surgery and/or radiotherapy were included. Patients were grouped according to site (central or limb) for further analysis of the prognostic factors. Results A total of 388 patients were included in the study. Of these, 60 (15%) developed local recurrence at a mean median of 27 months (sd 24, range 7 to 150) and the five‐year local recurrence‐free survival (5yrLRFS) was 83%. For central tumours, the size of the tumour and histological response to chemotherapy were found to be significant factors for local recurrence. For limb tumours, local recurrence was affected by intralesional and marginal resections, but not by the histological response to chemotherapy. Radiotherapy in those with a marginal resection reduced the risk of local recurrence (5yrLRFS: 96% versus 81%, p = 0.044). Conclusion Local recurrence significantly affects the overall survival in patients with a Ewings sarcoma. For those with a tumour in a limb, radiotherapy reduced the risk of local recurrence, especially in those with a marginal margin of excision, but the effect in central tumours was less clear. Radiotherapy for those who have had a wide margin of resection does not reduce the risk of local recurrence, regardless of the histological response to chemotherapy.

The role of surgical margins in chondrosarcoma

INTRODUCTION Chondrosarcoma (CS) is the second most common primary bone sarcoma with no clear role for adjuvant therapy. The purpose of this study was to investigate (1) the relationship between surgical excision margins and local recurrence free survival (LRFS), and (2) the role of local recurrence (LR) in disease specific survival (DSS) in CS of the extremity and pelvis. MATERIAL AND METHODS 341 pelvic and extremity CS diagnosed between 2003 and 2015 were studied retrospectively. RESULTS LR developed in 23% of cases. Pelvic location, pathologic fracture, margin and grade were significant factors for LR after univariate analysis. Multivariate analysis revealed surgical margin and pelvic location as positive factors for LR, and grade-1 and 2 CS as negative factors for LR. Pathologic fracture, central versus peripheral, grade, and LR were significant factors with univariate analysis for DSS; and grade was significant after multivariate analysis for all patients for DSS. After competing risk analysis, LR was statistically significant for DSS in grade-2 and grade-3 tumors. CONCLUSION Surgical margins determine LR in all CS grades, but LR affects DSS only in grade-2 and grade-3 tumors. Although narrow margins are acceptable in grade-1 tumors, since biopsy is unreliable in predicting final grade, a minimum 4-mm margin should be the aim in all cases.

The Multi-modal Approach to Metastatic Disease

Despite medical and surgical advantages, bone metastases and skeletally- related events such as pathological fractures happen in cancer patients. Even though skeletal metastases and pathological fractures can occur in almost any cancers and sarcomas, about 75% of pathological fractures occur in patients with breast, prostate, lung and kidney cancers and myeloma (Hansen et al., Acta Orthop Scand 75:11–15, 2004; Hansen et al., Acta Orthop 334:85–90, 2009; Ratasvuo et al., Pathological fractures of skeletal metastases – a many sided challenge. A report of 1195 operated metastases. Scandinavian sarcoma group skeletal metastasis registry. Manuscript in preparation, 2011). Skeletal metastases occur in around one-third of patients with these malignancies. Pathological fracture is usually a late manifestation of disease. Pathological fracture causes pain, reduces patients’ functional independence and quality of life if not treated properly. Pathological fractures of the long bones are most common surgical issues in the management of the skeletally-related events. Orthopaedic procedures should be minimally-invasive, producing as little morbidity as possible. However the treatment should aim to be done once and for all and a rapid functional recovery producing maximal pain relief (Ashford, Eur Oncol 5:30–34, 2009; Bauer, J Bone Joint Surg Br 87:608–617, 2005; Clain, Br J Cancer 19:15–29, 1965; Coleman, Clin Cancer Res 12:6243–6249, 2006; Harrington, Cancer 80:1614–1627, 1997; Higinbotham and Marcove, J Trauma 5:792–798, 1965; Weiss and Wedis, Acta Orthop 82:96–101, 2011; Bickels et al., J Bone Joint Surg Am 91:1503–1516, 2009; Fottner et al., BMC Musculoskelet Discord 11:145, 2010; Hansen et al., Acta Orthop Scand 75:11–15, 2004; Hansen et al., Acta Orthop 334:85–90, 2009; Jensen et al., BMC Cancer 24:11–29, 2011; Katagini et al., J Bone Joint Surg Br 87-B:698–703, 2005; Lin et al., J Bone Joint Surg Am 89:1794–1801, 2007; Narazaki et al., Clinics 61:313–320, 2006; Ratasvuo et al., Pathological fractures of skeletal metastases – a many sided challenge. A report of 1195 operated metastases. Scandinavian sarcoma group skeletal metastasis registry. Manuscript in preparation, 2011; Saad et al., Cancer 110:1860–1867, 2007; Wedin et al., Cancer 92:257–262, 2001; Zekri et al., Int J Oncol 19:379–382, 2001). The survival affects the choice of treatment and these issues are discussed later.