Abstract
Simple SummaryOsteosarcoma (OS) is the most common bone cancer in children. OS most commonly arises in the legs, but can arise in any bone, including the spine, head or neck. Along with chemotherapy, surgery is a mainstay of OS treatment and in the 1990s, surgeons began to shift from amputation to limb-preserving surgery. Since then, improvements in imaging, surgical techniques and implant design have led to improvements in functional outcomes without compromising on the cancer outcomes for these patients. This paper summarises these advances, along with a brief discussion of future technologies currently in development.Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.
Highlights
Osteosarcoma (OS) is the most common paediatric bone cancer [1,2]
Cho et al further evaluated the use of computer assisted navigation surgery (CANS) in pelvic tumour surgery; of the 10 patients included, all had clear margins and only two developed local recurrence after a minimum of three years follow up, with the authors feeling that it increased the accuracy of resection and minimised the resection of unnecessary healthy tissue [70]
OS tumours pose a challenge for orthopaedic surgeons due to their complex anatomical variation, close proximity to critical structures and high risk of recurrence if adequate margins are not achieved [174]
Summary
Osteosarcoma (OS) is the most common paediatric bone cancer [1,2]. It occurs most frequently in adolescents, with a second peak in those aged 60–80 years old, and is more common in males [2,3]. Improved imaging pre-operatively allows improved planning of the surgery to be performed, while intraoperative imaging may guide surgeons to more accurately identify pertinent anatomical structures and avoid straying into the tumour during the procedure This increases the likelihood of clear margins, but should increase confidence in leaving behind as much normal tissue as possible, in turn benefiting functional outcomes. The resolution for CL imaging has been shown to be far better than any concurrent nuclear imaging modality [49,50], being able to identify much smaller structures than PET scanners, which are currently deemed gold standard [35] Despite their high resolution, the average amount of CL produced is rather low [51], necessitating highly sensitive instrumentation for its detection, alongside longer imaging times of several minutes [35]. Given the use of 18F-FDG as a radioactive tracer for pre-operative PET in OS is established [32], the use of CL in OS surgery is a promising avenue
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