Baebler, Boštjan

Lamovec, Janez

Novak, Janez

Červek, Jožica

Čuček-Pleničar, Marjana

Špiler, Marko

English

Digital repository of Slovenian research organizations

Radio! 011col 1997; 31: 131-3. Malignant bone tumours of the extremities: The role of limb sparing surgery M. Čuček-Pleničar,1 J. Novak,2 M. Špiler,2 B. Baebler,1 J. Červek,2 J. Lamovec2 1University Orthopaedic Hospital, 2/nstitute of Oncology, Ljubljana, Slovenia The aim oj our retrospective analysis was to evaluate the treatment outcome in 88 patients with malignant bone tumours oj extremities treated in Ljubljana between 1980 and 1995. The histologic type oj tumours were: osteogenic sarcoma 61, chondrosarcoma 12, Ewing sarcoma 4, PNET 2, malignant gigantocellular tumour 2 mul unclassified malignant tumour in 7. OJ these 40 were resected and 48 amputated. The percentage oj amputations is decreasing by time (first 5 year period 74%, second 46% and third 42%). The overall survival at ten years for the resected patients is 60% mul for the amputated 50%, while these figures for patients with osteosarcoma are 52% and 34% respectively. We could achieve an improvement oj our results with strict use oj core needle biopsies, application oj more effective chemotherapy preoperatively and multidisciplinary surgical approach. Key words: bone neoplasms; amputation; extremities; survival rate Introduction With the development of effective preoperative chemotherapy for malignant bone tumours limb sparing procedures replaced amputations in an im-portant percentage of patients. 1 The aim of our retrospective analysis was to evaluate the treatment outcome in patients with malignant bone tumours of extremities treated in Ljubljana between 1980 and 1995. Patients and methods During this period 88 patients with malignant bone tumours of extremities underwent treatment. Chemotherapy was administered at the University Paediatric Hospital or Institute of Oncology, Correspondence to: Dr. M. Čuček-Pleničar, University Orthopaedic Hospital, Zaloška 9, SI-! 000 Ljubljana, Slovenia UDC: 616.717/.718-006.6-089.87 Ljubljana. Surgery was performed at the Universi-ty Orthopaedic Hospital with a combined team consisting of an oncological surgeon who per-formed the resection of the tumour, and orthopae-dic surgeon for reconstruction. Of the 88 patients treated 40 had a limb sparing procedure (15 males, 25 females, age 9 to 64 years, median 21 years), and 48 were amputated (32 males, 15 females, age 6 to 68 years, median 25 years). Tables 1, 2 and 3 show the distribution of TNM Stage,2 site and histology between the resected and amputated pa-tients. Table 4 shows the distribution of TNM Stage in osteogenic sarcoma patients for whom follow-up data are available. In the resected pa-tients the preoperative diagnosis was obtained by open biopsy in 20 and by core needle biopsy in 20 patients. In the amputated patients the preopera-tive diagnosis was obtained by open biopsy in 33 and by core needle biopsy in 15. Preoperative his-tology erroneously classified 3 cases of classical osteogenic sarcomas as paraosteal osteogenic sar-comas. Preoperative chemotherapy was adminis-tered in 26/40 resected patients and in 29/48 am-putated patients. 132 Čuček-Pleničar Metal. Table l. Distribution of ali patients by TNM Stage and type of surgery la Ib Ila Ilb !Va !Vb Ali Resections 2 5 12 19 o 2 40 Amputations 1 6 1 36 1 3 48 Ali 3 11 13 55 1 5 88 Table 2. Ali patients by site of primary turno ur and type of surgery Resections Amputations Ali Distal femur 21 23 44 Proximal femur 2 1 3 Distal tibia 2 5 7 Proximal tibia 6 15 21 Humerus 8 4 12 Other 1 o 1 Ali 40 48 88 Table 3. Ali patients by histology and type of surgery Resections Amputations Ali Osteogenic sarcoma 22 31 53 Paraosteal osteogenic sarcoma 6 2 8 Chondrosarcoma 7 5 12 Ewing sarcoma 2 2 4 PNET 1 1 2 Gigantocellular tumour 1 1 2 Unclassified malignant tumour 1 6 7 Ali 40 48 88 Table 4. Distribution of osteogenic sarcoma patients with available follow-up information by TNM Stage and type of surgery la Ib Ila Ilb !Va !Vb Ali Resections 1 2 5 15 o 2 25 Amputations o 2 1 22 1 3 29 Ali 1 4 6 37 1 5 54 Surgery in resected patients After resection of the tumour the reconstruction was performed with endoprothesis in 24, in 3 with rotation plasty tibia pro femur, in 3 with autograft fibula pro humerus (two of them with vascularized graft and microsurgery) in 7 patients with a combination of auto and homografts. In 3 patients expendable bones (2 fibulas, 1 clavicle) were resected. Surgery in amputated patients. 5/48 patients had pathologic fractures at the site of the tumour, in 13/48 patients an inadequate surgical procedure was performed previously (excochlea-tion of the tumour) elsewhere, and in 3 patients there was a rapid progression despite chemothera-py. Ali others had large advanced tumours and a resection was not feasible. Results Table 5 shows the grade of necrosis after preopera-tive chemotherapy (almost ali osteogenic sarcoma patients) in resected and amputated patients. Table 5. Effect of preoperative chemotherapy and type of surgery performed Resection Amputation Ali Grade I Grade II Grade III 5 9 5 14 8 3 19 17 8 Grade IV 7 1 8 Ali 26 29 53 Out of the 40 resected patients 26 are alive, one of these with pulmonary metastases, 1 O patients died and 4 are !ost to follow-up. Causes of death were local recurrence and generalised disease in 5 and generalised disease in 5 patients. In the group of 26 survivors there were 10 patients with grade III and IV response to preoperative chemotherapy whereas in I O patients who died only one had grade IV response. Complications after surgery oc-curred altogether in 12/40 patients and were as fol-lows: local infection requiring amputation in 2 pa-tients, 3 loosening of the prosthesis requiring re-placement and fracture of the prosthesis in 1 pa-tient. There were 7 local recurrences. In 4 of these amputations were performed, 2 patients refused fur-ther treatment. Out of the 48 amputated patients 20 are alive without evidence of disease, 4 are alive with meta-static disease, 17 patients died and 7 are !ost to follow up. Causes of death were local recurrence and generalised disease in 2 patients, and general-ised disease in 14, one patient died in the postoper-ative period due to heart failure. In Figure 1 overall survival of ali patients by type of surgical procedure is shown (Kaplan-Meyer method). In Figure 2 the same plot is shown for the patients with osteogenic sarcoma with available fol-low up information. Discussion and conclusions In our series of 88 patients with malignant bone tumours we performed limb sparing surgery only in 40 but in Figure 3 we can see that the proportion of Malignant bone tumors ofthe extremities 133 amputations is decreasing substantially by tirne. This rather low percentage of resections can be attributed to the advanced stage of tumours in our series as well as previous inadequate surgical inter-ventions. Even in the group of patients with resec-tions 50% had Ilb or IVa stage of disease accord-ing to TNM classification. The overall incidence of local recurrence 7/40 (17.5%) in the resected patients and 2/48 (4%) in the amputated patients is high in comparison with many similar reported series3•4 and could be con-nected either with advanced stage or poor effect of preoperative chemotherapy or high incidence of pre-vious inadequate surgery in our series. We could achieve an improvement of our results with strict use of core needle biopsies, application of more effective chemotherapy preoperatively and multidisciplinary surgical approach. Resection of tumours should be performed by an oncologic surgeon and reconstruction by an ortope-adic and plastic surgeon. 1.0~---------------~ 0.,1~'1, \._. .... , -: o+-+------+++ ➔-- - __ .,.,. I .. 7 1 :; 1111 0,4 1 0,3 0,2 0,1 o.o----------------~ o M • n oo w w m m m -g - 00 M - m - - - m mon,w P„o,2 -amputatioos(-48) •••• rosocOOl\$(40) Figure l. Overall survival of resected and amputated pa-tients for bone sarcomas of the extremities. 1,0,......---------------, f 0,7 i ::: ~ 0,4 i 0,3 a 0.2 0,1 o,o......_ ______________ ....., o M • n oo rn ~ m m m -g • 00 M - m - - - m mcollw ... , - rufVO!a1ions(29) ····-(25) Figure 2. Overall survival of resected and amputated osteosarcoma patients. 25 ~ 20 i 15 o _g 10 E ~ 5 1980-1985 1986-1990 Time period 1991-1995 Figure 3. Proportion of amputations Vs resections in three 5-year periods from 1980 to 1995. References 1. Glasser DB, Lane JM, Huvos AG, Marcove RC, Rosen G. Survival, prognosis, and therapeutic response in os-teogenic sarcoma. Cancer 1992; 69: 698-708. 2. UICC - Intemational Union Against Cancer. TNM clas-sification of malignant tumours, Fourth Edition , 2"" Revision. Berlin: Springer, 1992. 3. Delepine N, Delepine G, Alkallaf S et al. Prognostic factors for local relapses following sparing surgery for osteosarcoma. In: 2"" Osteosarcoma research confer-ence. Bologna, 1996: 140. 4. Bacci G, Ferrari S, Mercuri M et al. Local relapse in primary high grade osteosarcoma of the extremities treated with neoadjuvant chemotherapy: risk factors and prognosis in the Rizzoli experience. In: 2"" Oste-osarcoma research conference. Bologna, 1996: 142. 

Malignant bone tumours of the extremities

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Malignant bone tumours of the extremities

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