Rob Pollock

The Use of Massive Endoprostheses for the Treatment of Bone Metastases

Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a five-year period at our institution. Introduction. The recent advances in adjuvant and neoadjuvant therapy in cancer treatment have resulted in improved prognosis of patients with bone metastases. Most patients who have either an actual or impending pathological fracture should have operative stabilisation or reconstruction. Endoprosthetic reconstructions are indicated in patients with extensive bone loss, failed conventional reconstructions, and selected isolated metastases. Methods and Results. We identified all patients who were diagnosed with metastatic disease to bone between 1999 and 2003. One hundred and seventy-one patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 84 lesions (49%). Fifty-eight patients with isolated bone metastasis to the appendicular skeleton had an endoprosthetic reconstruction. There were 28 males and 30 females. Twelve patients had an endoprosthesis in the upper extremity and 46 patients had an endoprosthesis in the lower extremity. The mean age at presentation was 62 years (24 to 88). At the time of writing, 19 patients are still alive, 34 patients have died, and 5 have been lost to follow up. Patients were followed up and evaluated using the musculoskeletal society tumour score (MSTS) and the Toronto extremity salvage score (TESS). The mean MSTS was 73% (57% to 90%) and TESS was 71% (46% to 95%). Mean follow-up was 48.2 months (range 27 to 82 months) and patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Complications included 5 superficial wound infections, 1 aseptic loosening, 4 dislocations, 1 subluxation, and 1 case, where the tibial component of a prosthesis rotated requiring open repositioning. Conclusions. We conclude that endoprosthetic replacement for the treatment of isolated bone metastases is a reliable method of limb reconstruction in selected cases. It is associated with low complication and failure rates in our series, and achieves the aims of restoring function, allowing early weight bearing and alleviating pain.

Custom-made hinged spacers in revision knee surgery for patients with infection, bone loss and instability

Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion. We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The SMILES spacer was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24-70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients. In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma: characterization of five cases

ObjectiveTo describe the imaging and histopathology of pseudomyogenic hemangioendothelioma.Materials and methodsFive cases of pseudomyogenic hemangioendothelioma, which presented over the last 5xa0years, were retrieved from the files of the Royal National Orthopaedic Hospital. The imaging and histopathology were reviewed in all cases. Magnetic resonance imaging, which was available from all cases, was assessed for the following features: the number of lesions, location in soft tissue (superficial and or deep/subfascial) and bone, and the signal characteristics and morphology of individual lesions. Immunohistochemistry was performed in all cases to characterize the lesions.ResultsFour of the five patients had multiple lesions involving a single limb. Bone was involved in 3 of the 5 individuals. All tumors diffusely expressed ERG and cytokeratins AE1/3, but not MNF116. CD31 was weakly positive in 4 cases. INI-1 expression was retained in all cases. Imaging features included ill-defined, infiltrative lesions in subcutaneous fat with extension to the adjacent skin, poor- to well-defined intramuscular nodules and predominantly intracortical focal bone lesions with rare medullary involvement.ConclusionPseudomyogenic hemangioendothelioma represents a distinct recently characterized tumor type presenting in young adults, with a tendency towards multicentric bone and soft tissue involvement.

Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre.

BACKGROUNDnA two-stage revision remains the gold standard to eradicate deep infection in total knee arthroplasty. Higher failure rates are associated with a number of factors including poly-microbial infections, multiresistant organisms and previous operations. The aims are to investigate [1] the overall success rate of a two-stage revision for infections in TKA, [2] the outcome of repeat two-stage revisions in recurrent infections and [3] the factors affecting the outcomes of such cases.nnnMETHODSnWe present the outcomes of a consecutive, retrospective case series of 51 periprosthetic joint infections managed with a two-stage revision knee arthroplasty over a three year period.nnnRESULTSnForty-six (90%) of 51 were referred from other hospitals. Infection was successfully eradicated in 24 (65%) of 37 patients undergoing an initial two-stage procedure. Following a failed two-stage revision, a repeat two-stage revision was performed in 19 patients eradicating infection in 8 (42%). A third two-stage was performed in five of these patients eradicating infection in three with an average follow-up of 43 months. Multidrug resistance was present in 69%, and 47% of the patients were infected with multiple organisms. All unsuccessful outcomes involved at least one multidrug-resistant organism compared to 43% in the successful cohort (P=0.0002). Serological markers prior to a second-stage procedure were not significantly different between successful and unsuccessful outcome groups.nnnCONCLUSIONnSingle or multiple two-stage revisions can eradicate infection despite previous failed attempts. In this series, failure is associated with multidrug resistance, previous failed attempts to eradicate infection and a less favourable host response.

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is £18,002 at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.

Avulsion fracture of the anterior superior iliac spine: misdiagnosis of a bone tumour

Avulsion fractures of the anterior superior iliac spine are rare. This injury is usually seen in adolescents, as an avulsion fracture of the apophyses, a result of sudden vigorous contraction or repetitive contraction of the sartorius and tensor fasciae latae muscles. Treatment for this injury is usually conservative; however, surgical management has been reported in those with significant displacement. We present a 14xa0year old male patient who was referred to our unit for biopsy of a possible pathological fracture of his right ilium. The authors feel it is essential to understand the importance of ruling out a bone tumour, if the possibility has been raised, before managing a suspected fracture. If there is any doubt, the case should be referred to an appropriate sarcoma unit for review prior to any intervention.

An evaluation of the diagnostic accuracy of the grade of preoperative biopsy compared to surgical excision in chondrosarcoma of the long bones

Chondrosarcoma is the second most common primary malignant bone tumour. Distinguishing between grades is not necessarily straightforward and may alter the disease management. We evaluated the correlation between histological grading of the preoperative image-guided needle biopsy and the resection specimen of 78 consecutive cases of chondrosarcoma of the femur, humerus, and tibia. In 11 instances, there was a discrepancy in histological grade between the biopsy and surgical specimen. Therefore, there was an 85.9% (67/78) accuracy rate for pre-operative histological grading of chondrosarcoma, based on needle biopsy. However, the accuracy of the diagnostic biopsy to distinguish low-grade from high-grade chondrosarcoma was 93.6% (73/78). We conclude that accurate image-guided biopsy is a very useful adjunct in determining histological grade of chondrosarcoma and the subsequent treatment plan. At present, a multidisciplinary approach, comprising experienced orthopaedic surgeons, radiologists, and pathologists, offers the most reliable means of accurately diagnosing and grading of chondrosarcoma of long bones.

Dear John Hunter

Dear Mr John Hunter,nnThank you very much for the thorough history of your patient, who presented with a mass in the thigh. We have now had the opportunity to review the case notes and specimens at the Sarcoma Unit at the Royal Marsden Hospital. We apologise for the breach of requirements on waiting times for cancer treatment, but your patient’s presentation in 1786 predated our founding in 1851.nn#### John Hunter (1728-93)nnJohn Hunter was one of the most distinguished surgeons of his day. He worked at St George’s Hospital in his later career and was appointed as surgeon to King George III. He is said to have died after an argument over the admission of medical students. The specimens and notes reviewed in this article are kept within the Hunterian museum at The Royal College of Surgeons.nnFor our records we quote the following extract from your original notes:nn> “A man came into St George’s Hospital, November 1786, with a hard swelling of the lower part of the thigh. It appeared to be a thickening of the bone. It was increasing very rapidly, and at this time so large as to interfere with the motion of the joint, so as to render the leg useless. The tumour was hard as bone.n> n> The man had been in perfect health in this part, till about 5 months before, and then began to feel shooting or darting pains in that part of the thigh. The part began evidently to enlarge, although at first very slowly; but in the …

High-grade soft tissue sarcomas of the extremities: surgical margins influence only local recurrence not overall survival

PurposeAfter surgical treatment of high-grade soft tissue sarcomas, local recurrences, metastases and survival remain a great concern. Further knowledge on factors with a possible impact on these endpoints, specifically resection margins, is relevant for decision-making regarding the aggressiveness of local treatment. The aim of this study is to investigate the impact of prognostic factors on local recurrence and overall survival for patients with high-grade soft tissue sarcomas of the extremities.MethodsIn a retrospective cohort study of 127 patients (mean age 48xa0years, range five to 91; median follow-up 71xa0months) the prognostic effect of margin status and other clinicopathologic characteristics on local recurrence and overall survival were analysed by employing a multivariate Cox regression.ResultsFive-year cumulative incidence of local recurrence and distant metastases was 26xa0% and 40xa0%, respectively. The estimated five-year overall survival was 59xa0%. Tumour size proved a consistent adverse prognostic factor for local recurrence (hazard ratio (HR) 3.9), distant metastasis (HR 4.9) and overall survival (HR 2.4). The significant association of resection margins with local recurrence (HR 10.2) was confirmed. Margins were however not significantly associated with the occurrence of distant metastasis or overall survival. The occurrence of local recurrence had a significant impact on overall survival (HR 2.0).ConclusionsThe results of this study confirm the critical role of tumour size on survival and margins on local recurrence, and stress the need for further investigation concerning the association between margins, local recurrence and survival.

Individualised risk assessment for local recurrence and distant metastases in a retrospective transatlantic cohort of 687 patients with high-grade soft tissue sarcomas of the extremities: a multistate model

Objectives This study investigates the effect of surgical margins and radiotherapy, in the presence of individual baseline characteristics, on survival in a large population of high-grade soft tissue sarcoma of the extremities using a multistate model. Design A retrospective multicentre cohort study. Setting 4 tertiary referral centres for orthopaedic oncology. Participants 687 patients with primary, non-disseminated, high-grade sarcoma only, receiving surgical treatment with curative intent between 2000 and 2010 were included. Main outcome measures The risk to progress from ‘alive without disease’ (ANED) after surgery to ‘local recurrence’ (LR) or ‘distant metastasis (DM)/death’. The effect of surgical margins and (neo)adjuvant radiotherapy on LR and overall survival was evaluated taking patients and tumour characteristics into account. Results The multistate model underlined that wide surgical margins and the use of neoadjuvant radiotherapy decreased the risk of LR but have little effect on survival. The main prognostic risk factors for transition ANED to LR are tumour size (HR 1.06; 95% CI 1.01 to 1.11 (size in cm)) and (neo)adjuvant radiotherapy. The HRs for patients treated with adjuvant or no radiotherapy compared with neoadjuvant radiotherapy are equal to 4.36 (95% CI 1.34 to 14.24) and 14.20 (95% CI 4.14 to 48.75), respectively. Surgical resection margins had a protective effect for the occurrence of LR with HRs equal to 0.61 (95% CI 0.33 to 1.12), and 0.16 (95% CI 0.07 to 0.41) for margins between 0 and 2u2005mm and wider than 2u2005mm, respectively. For transition ANED to distant metastases/Death, age (HR 1.64 (95% CI 0.95 to 2.85) and 1.90 (95% CI 1.09 to 3.29) for 25–50u2005years and >50u2005years, respectively) and tumour size (1.06 (95% CI 1.04 to 1.08)) were prognostic factors. Conclusions This paper underlined the alternating effect of surgical margins and the use of neoadjuvant radiotherapy on oncological outcomes between patients with different baseline characteristics. The multistate model incorporates this essential information of a specific patients history, tumour characteristics and adjuvant treatment modalities and allows a more comprehensive prediction of future events.