Patients Underwent Limb Salvage Surgery Research Articles

Metal Ion Release in Cancer Patients Following Megaprosthesis Salvage Surgery

BackgroundMegaprostheses contain many more modular components than conventional total hip and knee arthroplasty, which may lead to higher serum levels of metal ions. The aim of this study was to determine serum concentrations of titanium, chromium, and cobalt ions in cancer patients after limb salvage surgery with a megaprosthesis. MethodsA retrospective, descriptive cohort analysis consisting of patients who underwent cancer-related limb salvage surgery with a megaprosthesis at our hospital between 2010 and 2020 was conducted. Baseline and follow-up data were extracted from clinical and surgical records. Blood samples were prospectively obtained. Descriptive statistics were used for the analysis. ResultsA total of 71 patients underwent limb salvage surgery during the study period. Of these, 22 (10 women, 12 men) were included in the study. The mean age was 52 years (range, 21 to 80). Most cases (n = 16; 72.7%) involved the femur. Most patients (n = 14, 63.6%) underwent total knee megaprosthesis surgery. Implant revision surgery was required in 45% of cases (n = 10), with a mean interval of 4.32 years between the initial and revision surgeries. The mean follow-up time after revision surgery was 4.05 years. High levels of chromium were observed in 22.7% of patients (n = 5). High cobalt levels were found in 68.2% (n = 15) of patients, with toxic levels in 9.1% (n = 2). Titanium levels were high in 77.3% (n = 17) of cases and toxic in 22.7% (n = 5). Postoperative chemotherapy was significantly associated with titanium levels (P = .017). No correlation was observed between metal ion levels and time from primary or revision surgery or time from the first to revision surgery. ConclusionsThis study shows that cancer-related limb salvage surgery with megaprosthesis is associated with metal ion levels that exceed established safe thresholds. Compared to conventional hip arthroplasty, a higher proportion of the patients in this cohort presented elevated levels of metal ions. Level of evidenceIII.

Risk factors for peri-megaprosthetic joint infections in tumor surgery: A systematic review.

Peri-megaprosthetic joint infections (PJI) in tumor surgery are complex and challenging complications that significantly impact the outcomes of the patients. The occurrence of PJI poses a substantial threat to the success of these operations. This review aims to identify and summarize the risk factors associated with PJI in tumor surgery with megaprosthetic reconstruction as well as to determine the overall risk of PJI in limb salvage surgery. A thorough examination of published literature, scrutinizing the incidence of PJI in tumor prostheses after limb salvage surgery was done. Research studies that documented the incidence of PJI in tumor patients who underwent limb salvage surgery, and explored the risk factors associated with the occurrence of PJI were deemed eligible. A total of 15 studies were included in the analysis and underwent comprehensive examination. After the exploration of key parameters, several significant risk factors for PJI concerning the type of implant coating, surgical site characteristics, patient demographics, and procedural factors were recorded. The findings underscore the need for a nuanced approach in managing tumor patients undergoing limb salvage surgery and megaprosthetic reconstruction, with emphasis on individualized risk assessments and individualized preventive strategies.

Forequarter Amputation for Malignant Tumours: Tale of Sustained Relevance or Telltale Sign of Doom?

Forequarter amputation (interscapulothoracic amputation) includes surgical removal of an upper limb and the shoulder girdle, including the scapula and a portion of the clavicle. We aim to report about our recent experience of having to resort to this mutilating surgery and the clinicopathological variables in that context. The study was done at a cancer centre in Northeast India. It was an ambispective study design, where the patient cohort who underwent FQA was identified retrospectively from the operative register of major surgeries for the time period 1st June 2020 to 31st May 2022 (24 months), and these patients were followed up prospectively from 1st June 2022 to 31st May 2023 (1 year). The study variables were obtained from the electronic medical records (EMR), the physical case files and the hospital-based cancer registry (HBCR). There were 7 patients who underwent forequarter amputation (FQA) during the two years, and in the same period, 15 patients underwent limb salvage surgery for tumours around the shoulder girdle. This translates to a FQA rate of 31.8%. The male:female ratio of the patients was 3:4. The median age of the patients was 32 years (range 19 to 59 years). The histologies included osteosarcoma (2), chondrosarcoma (2), Ewing's sarcoma (2) and hidradenocarcinoma (1). None of these patients had any distant metastatic disease. Four patients had local disease progression on neoadjuvant chemotherapy. Three of the patients had emergency surgery as a life-saving procedure on account of bleeding from their ulcerated tumours. Two patients had disease which was recurrent and unsalvageable due to the encasement of the neurovascular bundle. The median follow-up was 8 months (range 4 to 18 months). Five patients had distant recurrence with pulmonary metastases (100%) and bone secondaries (14.3%) within a range of 3 to 8 months. None of the patients had any local recurrence. Two patients are on follow-up without any evidence of disease (17 and 18 months respectively). Forequarter amputation is the surgical option when tumours around the shoulder girdle are not amenable to limb-sparing procedures by virtue of their disease extent. These cancers are usually aggressive leading to early distant metastasis.

What has changed in the last 25 years in osteosarcoma treatment? A single center experience.

Osteosarcoma is the most common type of primary malignant bone tumor in the extremities. The main purpose of this study was to determine clinical features, prognostic factors, and treatment results of patients with osteosarcoma at our center. We retrospectively analyzed the medical records of children with osteosarcoma between the years 1994-2020. 79 patients were identified (54.4% male, 45.6% female). The most common primary site was the femur (62%). Twenty-six of them (32.9%) had lung metastasis at diagnosis. The patients were treated between 1995- 2013 according to the Mayo Pilot II Study protocol, while the others were treated with the EURAMOS protocol between the years 2013-2020. Sixty-nine patients underwent limb salvage surgery as a local treatment, whereas seven underwent amputation. The median follow-up time was 53 months (2.5-265 months). The event-free survival (EFS) and overall survival (OS) rates at 5 years were 52.1% and 61.5%. The 5-year EFS and OS rates were 69.4% and 80% in females; 37.1% and 45.5% in males (p=0.008/p=0.001). The 5-year EFS and OS rates of the patients without metastasis were 63.2% and 66.3%; with metastasis 28.8% and 51.8% (p=0.002/p=0.05). For good-responders, the 5-year EFS and OS rates were 80.2% and 89.1%; while for poor-responders, 35% and 46.7% (p=0.001). Mifamurtide was used in addition to chemotherapy as of the year 2016 (n=16). The 5-year EFS and OS rates were 78.8% and 91.7%, respectively for the mifamurtide group; 55.1% and 45.9%, respectively for the non-mifamurtide group (p=0.015, p=0.027). Metastasis at diagnosis and poor response to preoperative chemotherapy were the most important predictors of survival. Females had a better outcome than males. In our study group, the mifamurtide group`s survival rates were significantly higher. Further large studies are needed to validate the efficacy of mifamurtide.

Tourniquet use in patients undergoing tumour resection and endoprosthetic reconstruction of the knee.

The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee. We retrieved data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial; specifically, differences in baseline characteristics, surgical details, and postoperative functional outcomes between patients who had undergone surgery under tourniquet and those who had not. A linear regression model was created to evaluate the impact of tourniquet use on postoperative Toronto Extremity Salvage Scores (TESSs) while controlling for confounding variables. A negative-binomial regression model was constructed to explore predictors of postoperative length of stay (LOS). Of the 604 patients enrolled in the PARITY trial, 421 had tumours around the knee joint, of whom 225 (53%) underwent surgery under tourniquet. The tourniquet group was younger (p = 0.014), more likely to undergo surgery for a tumour of the tibia, and had shorter operating times by a mean of 50 minutes (95% confidence interval 30 to 72; p < 0.001). The adjusted linear regression model found that the use of a tourniquet, a shorter operating time, and a higher baseline TESS independently predicted better function at both three- and six-month follow-up. The negative-binomial regression model showed that tourniquet use, shorter operating time, younger age, and intraoperative tranexamic acid administration independently predicted a shorter LOS in hospital. The results of this study show that in patients undergoing resection of a tumour around the knee and endoprosthetic reconstruction, the use of an intraoperative tourniquet is associated with a shorter operating time, a reduced length of stay in hospital, and a better early functional outcome.Cite this article: Bone Joint J2022;104-B(10):1168-1173.

Role of anlotinib in the treatment of early advanced osteosarcoma of limbs in children.

e23509 Background: The prognosis of advanced or early advanced osteosarcoma during neoadjuvant chemotherapy is unfavorable. Many patients can only accept brutal amputation without a new and reliable limb rescue solution. There are no clinical data on the efficacy and safety of anlotinib in the treatment of osteosarcoma in children and adolescents. We investigate the efficacy of anotinib plus first-line chemotherapy (platinum + doxorubicin liposome/ifosfamide) in the treatment of early advanced osteosarcoma in children and adolescents. Methods: Early advanced osteosarcoma in this study was defined as pathologically identified osteosarcoma that progressed within 6 months after radical surgery, with neoadjuvant chemotherapy or adjuvant chemotherapy. 11 cases of limb osteosarcoma with Enneking stage IIB (8 cases in the lower femur and 3 cases in the upper tibia), aged 8-15 years, were selected from February 2018 to December 2021. After 1 cycle of first-line neoadjuvant chemotherapy, patients locally advanced received anlotinib (12mg/d) combined with first-line chemotherapy for 1-2 cycles. The tumor shrinkage rate, limb salvage rate, disease-free survival time (DFS), progression-free survival time (PFS), disease control rate (DCR), and safety were analyzed. Results: 9 patients had locally advanced during neoadjuvant chemotherapy. After 2 cycles of anlotinib combined with first-line chemotherapy, the tumor shrunked and was well demarcated from surrounding tissue. All patients underwent limb salvage surgery Postoperative chemotherapy lasted for 4-6 cycles, with a median DFS of 12 months. 2 patients who developed recurrence or metastasis after radical surgery continued to complete at least 8 cycles of standard first-line chemotherapy combined with anlotinib, PFS showed separately 6 months and 8 months. The tumor shrinkage rate was 54.55% and the DCR was 72.73%. The adverse reactions associated with anlotinib were epistaxis (8 cases, 72.72%) and oral ulcer (1 case, 9.09%), which were controlled immediately after withdrawal. Conclusions: Combination of anlotinib with first-line chemotherapy can shrink the tumor, improve limb salvage rate for children with early advanced osteosarcoma, and delay disease progression for children with recurrence and metastasis after radical surgery. The toxicity of anlotinib combined with first-line chemotherapy were tolerated which is expected to be a new approach for the treatment of early advanced osteosarcoma.

Is 2 mm a wide margin in high-grade conventional chondrosarcomas of the pelvis?

Controversy exists as to what should be considered a safe resection margin to minimize local recurrence in high-grade pelvic chondrosarcomas (CS). The aim of this study is to quantify what is a safe margin of resection for high-grade CS of the pelvis. We retrospectively identified 105 non-metastatic patients with high-grade pelvic CS of bone who underwent surgery (limb salvage/amputations) between 2000 and 2018. There were 82 (78%) male and 23 (22%) female patients with a mean age of 55 years (26 to 84). The majority of the patients underwent limb salvage surgery (n = 82; 78%) compared to 23 (22%) who had amputation. In total, 66 (64%) patients were grade 2 CS compared to 38 (36%) grade 3 CS. All patients were assessed for stage, pelvic anatomical classification, type of resection and reconstruction, margin status, local recurrence, distant recurrence, and overall survival. Surgical margins were stratified into millimetres: < 1 mm; > 1 mm but < 2 mm; and > 2 mm. The disease--specific survival (DSS) at five years was 69% (95% confidence interval (CI) 56% to 81%) and 51% (95% CI 31% to 70%) for grade 2 and 3 CS, respectively (p = 0.092). The local recurrence-free survival (LRFS) at five years was 59% (95% CI 45% to 72%) for grade 2 CS and 42% (95% CI 21% to 63%) for grade 3 CS (p = 0.318). A margin of more than 2 mm was a significant predictor of increased LRFS (p = 0.001). There was a tendency, but without statistical significance, for a > 2 mm margin to be a predictor of improved DSS. Local recurrence (LR) was a highly significant predictor of DSS, analyzed in a competing risk model (p = 0.001). Obtaining wide margins in the pelvis remains challenging for high-grade pelvic CS. On the basis of our study, we conclude that it is necessary to achieve at least a 2 mm margin for optimal oncological outcomes in patients with high-grade CS of the pelvis. Cite this article: Bone Joint J2021;103-B(6):1150-1154.

IAP Chemotherapy Regimen Is a Viable and Cost-effective Option in Children and Adolescents With Osteosarcoma: A Comparative Analysis With MAP Regimen on Toxicity and Survival

Cisplatin and doxorubicin are integral components of chemotherapy regimens in the treatment of osteosarcoma. Choice of third agent high-dose methotrexate (HDMTX) or an alkylating agent such as ifosfamide is debatable. The present study compared the impact of MAP (HDMTX-doxorubicin-cisplatin) and IAP (ifosfamide-doxorubicin-cisplatin) chemotherapy regimens on toxicity and survival in children and adolescents with osteosarcoma. This was a retrospective study including patients 18 years and younger with osteosarcoma during the study period. Clinical, demographic, chemotherapy regimen, and surgical details and treatment-related toxicity were retrieved from hospital medical records. Prognostic factors affecting overall survival (OS) and event-free survival (EFS) were analyzed. Among 102 patients included in the study, 59 (57.8%) and 43 (42.2%) patients were treated with MAP and IAP regimens, respectively. Two groups were comparable in terms of pretreatment characteristics and surgical treatment. Overall, 95.9% patients underwent limb salvage surgery. There was a statistically increased incidence in supportive care admissions and delay in starting the next cycle of chemotherapy in the MAP group. Among the MAP cohort, the 5-year OS and EFS were 62% and 55% compared with 47% and 44%, respectively, in the IAP cohort (P=0.143 and 0.316, respectively). On univariate and multivariate analyses, statistically significant factors affecting EFS of the whole group included tumor size, stage, site of metastasis, histologic necrosis, and type of surgery. OS and EFS with both regimens were similar. However, the MAP regimen was associated with a statistically significant increase in incidence of supportive care admissions, delay in next cycle of chemotherapy, and predicted higher cost of treatment.

The Correlation of Surgical Margins and Outcome Of Soft Tissue Sarcomas of The Extremities and Trunk in Hospital Sultan Ismail, Johor Bahru

Introduction: Patients with soft tissue sarcoma are treated following the standardized guidelines, however it is not guaranteed patient will remain free from local recurrence (LR) and metastasis. This study was conducted to determine the association between microscopic marginal status with local recurrence, metastasis and the survival of the patient. Materials and Methods: This retrospective study was conducted from January 2015 to December 2017 in Hospital Sultan Ismail, Johor Bahru. All patients underwent complete standadized resection of the tumour and had been follow up for 5 years. An operating and follow-up records of 70 cases who fulfill the inclusion and exclusion criteria were collected and analysed using Pearson chi square test and Kaplan-Meier curves. Results: Of the 70 patients, 52 were males and 18 were females. The age of the patients were between 16 and 73 years with the means age of 48.8 years old. Sixty eight patients underwent limb salvage surgery and 2 had amputation. 42 of them had positive post-operative microscopic surgical margin (PMSM) while 28 were negative. Local recurrence was noted in 28 and metastasis in 30 patients. Patient who had PMSM has higher risk to get local recurrence and metastasis compared to patient with negative margin (p-value &lt;0.001). The overall median survival was 23 months. Overall survival rates for 3 years was 80% and for 5 years was 65%. Conclusion: In our study, patient with positive post-operative microscopic surgical margin had higher possibility to develop local recurrence, metastases and decrease overall survival rate.

Impact of 3-year survival rate on treating IIB limb osteosarcoma patients with methotrexate plus DIA chemotherapy regimen

Objecitve To evaluate the impact of adding methotrexate into DIA chemotherapy regimen (cisplatin, theraru-bicin and ifosfamide) on 3-year disease-free and overall survival of patients with IIB osteosarcoma in extremities. Methods Retro-spectively analyzed 34 cases of IIB limb osteosarcoma according to the Musculoskeletal Tumor Society (MSTS) surgical staging system with pathologically diagnosed concurrent chemotherapy and comprehensive surgical treatment from May 2008 to April 2014. There were 20 males and 14 females, with an average age of 19.5±7.7 years (ranged from 9 to 44 years). 28 patients underwent limb salvage surgery, and 6 patients received amputation. Tumor site included distal femur in 21 patients, proximal tibia in 9 patients, other sites in 4 patients. Seventeen patients underwent cisplatin, THP and ifosfamide (DIA) regimen of chemotherapy. The other 17 patients underwent cisplatin, THP, ifosfamide and methotrexate (MDIA) regimen. Patients charts were reviewed to get demographic data including age, gender, site, tumor size, surgery type, chemotherapy regimen, alkaline phosphatase, lactase dehydrogenase. The prognostic value of these factors on 3 years disease free survival and overall survival were calculated with Kaplan-Meier method and compared with Log-Rank test between different groups in univariate comparison and COX model for multivariate analysis was used to determine whether these demographic factors are independent prognostic factor for survival. Results Two patients had local recurrence, 7 patients had metastasis, and 2 patients had both local recurrence and metastasis. The 3-year survival of the whole group was 67.6% (23/34). Seven patients died during follow-up. The overall survival was 79.4% (27/34). The 3-year disease-free survival in DIA group and MDIA group was 70.6% (12/17) and 64.7% (11/17), respectively. The 3-year overall survival was 82.4% (14/17) and 76.5% (13/17) in DIA group and MDIA group, respectively. Univariate analysis showed that there was no significant difference in either 3-year disease-free survival (χ2=0.113, P=0.737) or overall survival (χ2=0.197, P=0.657) between DIA and MDIA. Age was significantly correlated with prognostic in univariate analysis (χ2=5.869, P=0.015), while gender, tumor site, tumor size, surgery type, ALP, LDH was not correlated with disease-free survival. Kaplan-meier analysis with Log-Rank test showed age (χ2=6.134, P=0.013) and tumor size (χ2=5.108, P=0.024) were statistically correlated with overall survival. Multivariate analysis with COX model showed that chemotherapy regimen was not an independent prognostic factor for 3-year disease-free survival or overall survival. Age was an independent prognostic factor for 3-year disease-free survival (HR=5.836, P=0.017). Conclusion The addition of MTX on the basis of DIA chemotherapy regimen did not significantly improve the 3-year disease-free survival and overall survival of stage IIB limb osteosarcoma. Key words: Osteosarcoma; Extremities; Antineoplastic combined chemotherapy protocols; Survival rate

Vascularized fibula with and without extracorporeal radiotherapy for limb salvage surgery in Indian patients

BackgroundReconstruction of segmental bone defects following resection of bone sarcomas is a challenging procedure. Vascularised fibula grafts alone or in combination with extracorporeal radiotherapy and reimplantation of tumor bone have long been established as a method of reconstruction of such defects, with satisfying results. Prompted by paucity of data on Indian patients, we report our experience with vascularised fibula graft for patients undergoing limb salvage surgery for sarcomas of bone. Material and methodsA total of 25 patients underwent the procedure from December 2008 to December 2014. Femur was the commonest site and osteosarcoma was the commonest diagnosis. Intercalary resection was done in 19 patients and arthrodesis in 6 patients. Vascularised fibula was used in combination with extra corporeally irradiated bone in eight patients, and alone in 17 patients. ResultsAll but one limb could be salvaged, and all but three patients had united at final follow up. Combination of extracorporeal radiotherapy and reimplantation with vascularised fibula fared better than vascularised fibula alone in terms of time to union (9.6 months vs 12.2 months) and rate of graft related complications (14.2% vs 62.5%). ConclusionReconstruction with VFG with or without ECRT has a good and predictable functional outcome. Though manageable with active intervention, complications were more commonly seen with vascularised fibula alone than a combination of the two techniques.

Modular cementless prosthetic reconstruction after resection of lower extremity malignant tumor

IntroductionThe aim of the study is to report the preliminary clinical and functional outcomes of a modular cementless tumor resection prosthesis system (Megasystem-C®, Waldemar Link GmbH&Co. KG, Hamburg, Germany) in patients undergoing limb salvage surgery with wide resection in a lower extremity primary or metastatic malignant bone tumor. Material and methodsFifty-two consecutive patients (33 male and 19 female; mean age 37.1 years (range, 16 to 79) with primary or metastatic lower extremity malignant bone tumor who underwent wide resection and reconstruction with cementless Megasystem-C® system were included in the study. Patients were analyzed for age at diagnosis, gender, type and localization of the tumor, time of follow-up, patient and prosthesis survival, complications, oncological and functional outcomes. ResultsMean follow-up time was 43.2 months (range, 8 to 66). Cumulative patient survival rate was 92.3 percent and cumulative prosthetic survival rate was 65.4 percent. 18 complications were recorded and 9 of them required revision (17.3 percent). Mean overall Musculoskeletal Tumor Society score score was 72.7 percent (range, 52 to 86). Subgroup analyzes demonstrated no difference in complication rates, overall patient or prosthetic survivals. Functional scores according to age, diagnosis and location of the reconstruction also were not significantly different. ConclusionThe preliminary short-term follow-up results revealed that, the new generation modular cementless endoprosthetic system offers promising clinical and functional outcomes with reasonable complication rates. Level of evidenceLevel IV, Therapeutic study

Risk-Based Therapy for Localized Osteosarcoma.

The outcome of localized osteosarcoma has remained constant over the past 30 years. Histological response to preoperative chemotherapy is the best predictor of outcome. Strategies to alter treatment based on histological response have not resulted in increased survival. Patients with localized osteosarcoma received preoperative chemotherapy with cisplatin, doxorubicin, and methotrexate. Patients whose tumors had a good histological response (≥90% necrosis) continued with the same treatment postoperatively. Patients with poor histological response (<90% necrosis) received three courses of melphalan 100 mg/m(2) on day -4, cyclophosphamide 2,000 mg/m(2) on days -3, and -2 followed by stem cell infusion. Fifty-two patients were enrolled. Median age was 14 years, and 56% of patients were male. The femur was the most common site. Forty patients underwent limb salvage surgery and amputation was performed in six patients. Forty-eight percent of tumors showed good histological response. Forty patients were evaluable for outcome; 18 patients with poor histologic response received high-dose chemotherapy. The 5-year event-free survival (EFS) and overall survival (OS) for patients treated on the high-dose chemotherapy arm were 28% (95% confidence interval [CI], 10-49) and 48% (95% CI, 23-69), respectively. The 5-year EFS and OS for patients treated on the standard chemotherapy arm were 62% (95% CI, 36-80) and 74% (95% CI, 44-90), respectively. All patients who received high-dose chemotherapy developed grade 3 or higher hematological toxicity. There were no treatment-related deaths. Postoperative alkylator intensification with high-dose cyclophosphamide and melphalan in patients with localized osteosarcoma with poor histological response failed to improve survival.

Predictive factors for successful limb salvage surgery in diabetic foot patients.

BackgroundThe goal of salvage surgery in the diabetic foot is maximal preservation of the limb, but it is also important to resect unviable tissue sufficiently to avoid reamputation. This study aims to provide information on determining the optimal amputation level that allows preservation of as much limb length as possible without the risk of further reamputation by analyzing several predictive factors.MethodsBetween April 2004 and July 2013, 154 patients underwent limb salvage surgery for distal diabetic foot gangrene. According to the final level of amputation, the patients were divided into two groups: Patients with primary success of the limb salvage, and patients that failed to heal after the primary limb salvage surgery. The factors predictive of success, including comorbidity, laboratory findings, and radiologic findings were evaluated by a retrospective chart review.ResultsThe mean age of the study population was 63.9 years, with a male-to-female ratio of approximately 2:1. The mean follow-up duration was 30 months. Statistical analysis showed that underlying renal disease, limited activity before surgery, a low hemoglobin level, a high white blood cell count, a high C-reactive protein level, and damage to two or more vessels on preoperative computed tomography (CT) angiogram were significantly associated with the success or failure of limb salvage. The five-year survival rate was 81.6% for the limb salvage success group and 36.4% for the limb salvage failure group.ConclusionThis study evaluated the factors predictive of the success of limb salvage surgery and identified indicators for preserving as much as possible of the leg of a patient with diabetic foot. This should help surgeons to establish the appropriate amputation level for a case of diabetic foot and help prevent consecutive operations.

Pediatric osteosarcoma: a single institution's experience.

The aim of the study was to evaluate outcomes with an examination of individual predictors influencing survival at a single institution. This was a retrospective review of the 28 pediatric osteosarcoma patients diagnosed and studied from 2000 through 2012. Twenty-eight patient charts and imaging studies were reviewed for age, race, sex, location, extent of disease at presentation, imaging results, histology, treatment options, and overall survival. Of the 28 patients who were identified, the median age at diagnosis was 14 years. The majority of the patients were male African Americans with the tumor located in the lower long bones and most had conventional osteosarcoma histology. Four patients had metastasis at diagnosis. Of the 28 patients, 16 patients underwent limb salvage surgery, 6 underwent amputation, 4 had biopsy only, 1 had hip disarticulation, and 1 moved out of state and had no information available. All 28 patients received chemotherapy. Four patients received additional radiation therapy. On follow-up, 15 patients were still alive at last clinical contact and 13 died. Of the deceased, the median survival time was 2.3 years. The patient who lived the longest survived 8.3 years. Metastasis at diagnosis was associated with poorer outcome (P = 0.002). The 5-year overall survival rate was 40% (95% confidence interval 18-62) for our entire population of patients. Survival in our patient cohort tended to be at the lower end of the spectrum reported by other contemporary treatment centers of excellence or Surveillance, Epidemiology, and End Results databases probably because of the large number of African American patients with associated poor socioeconomic status. Future studies should be conducted to explore biological and nonbiological factors that may affect the prognosis in this disease.

Limb Sparing Surgery

BACKGROUND Endoprosthetic reconstruction for bone tumor surgery was introduced in the 1970s. It has since evolved to be a successful and acceptable method of reconstruction and has become the gold standard of treatment. At present, 85% of patients will undergo limb salvage surgery with survival ranging from 60% to 90%. PURPOSE The complexity of bone sarcomas and limb-sparing surgery is discussed beginning with the initial presentation of the sarcoma patient. Limb-sparing surgery is depicted from initial exposure and removal of the diseased bone, placement of endoprosthetic, and presentation of patient postoperatively. A graphical portrayal is given to outline a stepwise and multidisciplinary approach when treating bone tumor patients. The discussion also includes postoperative care following surgery. Key aspects of nursing care are outlined. Management of patients with bone tumors involves a multidisciplinary team experienced in diagnostics, chemotherapy, and surgery. The priorities for patient and family education are highlighted. EVALUATION/OUTCOMES There are an increasing number of surgical options available for orthopedic oncology. Research has shown little difference between amputation and those who undergo limb-sparing surgery in overall quality of life. Several studies have demonstrated no adverse effect on local recurrence and overall survival in patients undergoing limb salvage surgery compared with those undergoing amputation. Realistic expectations and thorough multidisciplinary patient/family education contribute to optimistic end results. IMPLICATIONS FOR PRACTICE Nursing considerations in the management of patients undergoing limb-sparing surgery begin prior to and reach beyond the immediate postoperative period. Patient/family education includes expectations and limitations, emotional support, pain management, and progression of activity. A multidisciplinary approach with nursing, oncology, orthopedic surgery, pain management, physical therapy, and occupational therapy contribute to a successful management plan. The importance of compliance and continued support after discharge is integral to achieving a positive outcome. DISCUSSION Moradi et al. found no difference in the disease-free and overall survival outcomes when amputation was compared with limb salvage in 447 patients treated for a pathological fracture of a malignant bone tumor. In a study done by Henderson et al., data correlate with previous scores and indicate a high degree of emotional acceptance after limb salvage with an expandable endoprosthesis in a pediatric population.

Telangiectatic Osteosarcoma

To review records of 8 patients with telangiectatic osteosarcoma (TOS) and determine whether pathologic fractures correlate with recurrence and survival. Records of 4 men and 4 women aged 17 to 44 (mean, 28) years treated for TOS were reviewed. RESULTS; Of the 8 patients, 4 developed a pathologic fracture and 4 did not. In each group, 2 patients underwent limb salvage surgery and 2 underwent amputation. All patients received neoadjuvant and adjuvant chemotherapy with a combination of at least 2 of the following drugs: doxorubicin, methotrexate, cisplatin, and vincristin. After a mean follow-up of 5.6 (range, 2-16) years, all 4 patients with a pathologic fracture and 2 of the 4 patients without a pathologic fracture were still alive and disease-free. For the remaining patients, one died after 31 months from progression of a lung metastasis, and the other was alive with the disease and had had 2 recurrences, a lung metastasis, and an infection with Klebsiella oxytoca that eventually led to an amputation. The presence of a pathologic fracture in patients with TOS was not associated with worse outcome in terms of recurrence and survival.

1515 - Predictors of Survival in Adolescents and Young Adults with Non Metastatic Extremity Osteosarcoma-Cancer Institute (WIA), A Tertiary Cancer Center Experience from South India

ABSTRACT Osteosarcoma one of the highly curable malignancy is the most common primary malignant neoplasm of bone in adolescents and young adults. The purpose of this study was to determine the predictors of survival in patients with non metastatic Extremity Osteosarcoma. Methods The study was a retrospective analysis of 272 consecutive patients diagnosed between 1998 and 2008 and 232 of them who had undergone protocol treatment was included for predictors of survival anal. Results Median age of the patients was 17 years (6-52) and males constituted 60 % (n = 163). Distal femur was the commonest site, 49.4% (n = 134) followed by proximal tibia 39.5% (n = 107). Classical osteosarcoma was the commonest subtype 56% (n = 152) followed by Pleomorphic 21% (n = 57) and chondroblastic variant 16.6%9 (n = 45). Majority of the tumours were high grade 96.3% (n = 262).156 (57.6%) patients received Neoadjuvant Chemotherapy and 184 (65%) received ≥ 4 cycles of planned Chemotherapy. 116 (42.4%) of patients underwent limb salvage surgery (LSS). The proportion of patients undergoing LSS improved from 45.3% to 53.2% during the time periods 1998-2002 and 2003-2008 respectively. Febrile Neutropenia was noted in 15 % and 3 patients died due to Chemotherapy related toxicities. Of 156 patients who received neoadjuvant chemotherapy 100 % necrosis was seen in 20 (12.8%) and >90% necrosis in 31 (19.8%). 5 year Disease free survival and overall survival among non metastatic osteosarcoma was 52.9% and 55% respectively.Significant factors for predictors of survival included Age 90% necrosis (79.8% v/s 42.2% p = 0.001). Among Neoadjuvant Chemotherapy patients who received 3-4 cycles of Preoperative Chemotherapy did significantly better than those whoreceived ≥ 5cycles. (62.4% v/s 46.1% p = 0.036). Conclusions Predictivefactors that implicate adverse survival in non metastatic osteosarcoma in our patients include Age Disclosure All authors have declared no conflicts of interest.

Physical Activity Assessment in Adolescents with Limb Salvage

To evaluate ambulatory activity differences between youth with limb salvage procedures and typically developing youth (TDY) and assess differences in self-reported activity levels in the 2 groups, to provide a basis for physical activity assessment in patients who had undergone limb salvage surgery and treatment planning that incorporates regaining normal physical and daily living activities. In this cohort comparison study, we compared ambulatory and self-reported activity levels in 20 youth (aged 11.7-20.8 years) who had undergone limb salvage surgery and a sex- and age-matched comparison cohort of 20 TDY. StepWatch activity monitor and Activity Scale for Kids data were used to answer these questions. Significant differences were found between the youth who had undergone limb salvage surgery and the TDY in total time active each day (43% vs 48%; P = .03), median total strides per day (4487 vs 7671; P = .001), and amount of time per day at high activity levels (20 minutes vs 47 minutes; P = .001). Self-reported overall physical activity, locomotion, and standing Activity Scale for Kids subscale scores were significantly lower in the youth undergoing limb salvage surgery compared with the TDY (summary score, 88.3 vs 97.7; P = .001). Patients undergoing limb salvage surgery exhibit reduced physical activity compared with normal age-matched controls.

Pathologic fracture does not influence local recurrence and survival in high‐grade extremity osteosarcoma with adequate surgical margins

The purpose of this study was to estimate the risk factors having relationships with pathologic fracture of osteosarcoma of extremities and to evaluate the role of limb salvage surgery in this group of patients. We retrospectively analyzed 28 consecutive cases of pathologic fracture of primary high-grade localized osteosarcoma of extremities between June 1, 2001 and June 30, 2009. All patients underwent limb salvage surgery and neo-adjuvant chemotherapy. They had a median age of 14 years (range, 6-30 years). The average follow-up time was 40.7 months (range, 9-108 months). Clinicopathological factors were analyzed in relation to pathologic fracture. Their recurrence and survival rates were compared to those in cohort of 171 osteosarcoma patients without pathologic fracture who underwent limb salvage surgery during the same period at the same institution. Less than 15 years, telangiectatic histological subtype, tumor located at the proximal humerus, and radiographical manifested as osteolytic features were risk factors in relation to pathologic fracture. The overall 3- and 5-year survival rates were 50.5% and 45.4%, respectively, in the fracture group, and were not significantly different from those in the control group (71.0% and 61.9%, respectively). Of all 28 fracture patients, 4 experienced local recurrences (14.2%) and 14 developed distant metastasis (50%), which were not significantly different from the rates in the control group (8.8% and 37.4%, respectively). Limb salvage surgery with adequate margins combined with neo-adjuvant chemotherapy for pathologic fracture of osteosarcoma did not seem to significantly increase the risk of local recurrence or distal metastasis.