Inadvertent Tumor Violation during Musculoskeletal Sarcoma Surgery and Risk of Recurrence
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Abstract:
During the limb preserving procedure for musculoskeletal sarcoma, the course of action that should be taken when a tumor or tumor-cell-contaminated adjacent tissue is violated remains controversial. From January, 1973, to July, 1989, 120 patients with musculoskeletal sarcoma were treated by limb salvage surgery and, in 40 of them, such violations inadvertently occurred during surgery. Follow-up studies on the patients have been conducted for at least one year after the violation. Soft tissue sarcoma was noted in 24 cases (low grade, 4; high grade, 20) and bone sarcoma in 16 (low grade, 6; high grade, 10). To treat the violation, re-excision with a clean margin and copious lavage was generally conducted after careful closure of the violated site. Sixteen cases in the soft tissue sarcoma group and eight in the bone sarcoma group were treated in this way. Local recurrences were found in 13 of the 40 cases (33%), but the percentage was reduced to 13 in cases treated by re-excision with a clean margin. In the present study, there was no significant effect of adjuvant therapy after violation. The survival rate in cases of local recurrence was very low, and not at all improved by adjuvant therapy.Keywords:
Bone Sarcoma
Adjuvant Therapy
Surgical margin
Bone Sarcoma
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From the records of Memorial Hospital of the past 50 years, 47 cases with an established diagnosis of radiation-induced sarcoma were identified and divided into two groups: the first included 20 cases of soft-tissue sarcoma arising from irradiated tissues, and the second comprised 27 cases of bone sarcoma arising from normal bones in the irradiated field. Medians for the latent periods from irradiation to diagnosis of bone and soft-tissue sarcoma were 11 and 12, years, respectively. In bone sarcomas, the latent period was longer after larger radiation doses and children appeared to be more susceptible to cancer induction than adults. Criteria for establishing the diagnosis of radiation-induced sarcoma and the magnitude of the risk of bone sarcoma are discussed.
Bone Sarcoma
Bone cancer
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During the limb preserving procedure for musculoskeletal sarcoma, the course of action that should be taken when a tumor or tumor-cell-contaminated adjacent tissue is violated remains controversial. From January, 1973, to July, 1989, 120 patients with musculoskeletal sarcoma were treated by limb salvage surgery and, in 40 of them, such violations inadvertently occurred during surgery. Follow-up studies on the patients have been conducted for at least one year after the violation. Soft tissue sarcoma was noted in 24 cases (low grade, 4; high grade, 20) and bone sarcoma in 16 (low grade, 6; high grade, 10). To treat the violation, re-excision with a clean margin and copious lavage was generally conducted after careful closure of the violated site. Sixteen cases in the soft tissue sarcoma group and eight in the bone sarcoma group were treated in this way. Local recurrences were found in 13 of the 40 cases (33%), but the percentage was reduced to 13 in cases treated by re-excision with a clean margin. In the present study, there was no significant effect of adjuvant therapy after violation. The survival rate in cases of local recurrence was very low, and not at all improved by adjuvant therapy.
Bone Sarcoma
Adjuvant Therapy
Surgical margin
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Bone Sarcoma
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Abstract Sarcomas account for over 20% of all pediatric solid malignant cancers and less than 1% of all adult solid malignant cancers. The vast majority of diagnosed sarcomas will be soft tissue sarcomas, while malignant bone tumors make up just over 10% of sarcomas. The risks for sarcoma are not well-understood. We evaluated the existing literature on the epidemiology and etiology of sarcoma. Risks for sarcoma development can be divided into environmental exposures, genetic susceptibility, and an interaction between the two. HIV-positive individuals are at an increased risk for Kaposi’s sarcoma, even though HHV8 is the causative virus. Radiation exposure from radiotherapy has been strongly associated with secondary sarcoma development in certain cancer patients. In fact, the risk of malignant bone tumors increases as the cumulative dose of radiation to the bone increases (p for trend <0.001). A recent meta-analysis reported that children with a history of hernias have a greater risk of developing Ewing’s sarcoma (adjusted OR 3.2, 95% CI 1.9, 5.7). Bone development during pubertal growth spurts has been associated with osteosarcoma development. Occupational factors such as job type, industry, and exposures to chemicals such as herbicides and chlorophenols have been suggested as risk factors for sarcomas. A case-control study found a significant increase in soft tissue sarcoma risk among gardeners (adjusted OR 4.1, 95% CI 1.00, 14.00), but not among those strictly involved in farming. A European-based study reported an increased risk in bone tumors among blacksmiths, toolmakers, or machine-tool operators (adjusted OR 2.14, 95% CI 1.08, 4.26). Maternal and paternal characteristics such as occupation, age, smoking status, and health conditions experienced during pregnancy also have been suggested as sarcoma risk factors and would be important to assess in future studies. The limited studies we identified demonstrate significant relationships with sarcoma risk, but many of these results now require further validation on larger populations. Furthermore, little is known about the biologic mechanisms behind each epidemiologic association assessed in the literature. Future molecular epidemiology studies may increase our understanding of the genetic versus environmental contributions to tumorigenesis in this often deadly cancer in children and adults.
Bone Sarcoma
Bone cancer
Surgical oncology
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Background Death within one year has been shown for some cancers to be an indicator of late presentation. They may have widespread disease by the time of diagnosis and many will have experienced delays in diagnosis. The aim of this study is to identify if this holds true for patients with bone and soft tissue sarcomas.
Method A prospective sarcoma database was used to identify all patients with a newly diagnosed bone or soft tissue sarcoma and to compare those who had died within one year with those who had survived for at least that time.
Results 5633 patients were included in the analysis of whom 3039 had a bone sarcoma and 2593 a soft tissue sarcoma. 839 patients (15%) died within one year of diagnosis, of whom 430 had a bone sarcoma (14%) and 409 a soft tissue sarcoma (16%). Significant differences (p⋋0.0001) were seen with age, size and metastases at diagnosis for bone sarcomas and age, size, symptom duration, metastases at diagnosis, a previous whoops excision and superficial tumours for soft tissue sarcomas.
Conclusion 15% of patients with a newly diagnosed sarcoma will be dead within one year. This appears to be associated with known poor prognostic factors (metastases at diagnosis, age and tumour size) and is not clearly associated with duration of symptoms. Whether it is a surrogate for delays in diagnosis has not been proved by this study.
Bone Sarcoma
Presentation (obstetrics)
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The Australia and New Zealand Sarcoma Association established the Sarcoma Guidelines Working Party to develop national guidelines for the management of Sarcoma. We asked whether surgery at a specialised centre improves outcomes. A systematic review was performed of all available evidence pertaining to paediatric or adult patients treated for bone or soft tissue sarcoma at a specialised centre compared with non-specialised centres. Outcomes assessed included local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival. Definitive surgical management at a specialised sarcoma centre improves local control as defined by margin negative surgery, local or locoregional recurrence, and local recurrence free survival. Limb conservation rates are higher at specialised centres, due in part to the depth of surgical experience and immediate availability of multidisciplinary and multimodal therapy. A statistically significant correlation did not exist for 30-day and 90-day mortality between specialised centres and non-specialised centres. The literature is consistent with improved survival when definitive surgical treatment is performed at a specialised sarcoma centre. Evidence-based recommendation: Patients with suspected sarcoma to be referred to a specialised sarcoma centre for surgical management to reduce the risk of local recurrence, surgical complication, and to improve limb conservation and survival. Practice point: Patients with suspected sarcoma should be referred to a specialised sarcoma centre early for management including planned biopsy.
Bone Sarcoma
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The goal of surgeons treating soft tissue sarcoma is to gain local control, to avoid risk of local recurrence and to avoid compromise of the patient's potential survival. The aim of the investigation was to assess the significance of the extent of surgical margin on the chance of death, metastasis and local recurrence.Two hundred and seventy-nine patients who presented with soft tissue sarcoma without metastatic disease were analysed.The extent of the surgical margin was not clinically or statistically significant in the development of metastatic disease. The presence of a contaminated surgical margin led to a significantly higher rate of local recurrence (as did a narrow surgical margin less than 1 mm). A margin greater than 1 mm allowed a satisfactory outcome in terms of low local recurrence rates. In terms of overall survival, the failure to achieve a wide surgical margin (wide contaminated margin) led to an increased relative death rate. However, when the margin was not contaminated (even if the margin was very close, less than 1 mm), the overall survival rate was similar across all groups. Patients who had radical resections did poorly; they generally belonged to a group in which palliative surgery was carried out, and they showed very high relative metastasis and death rates.The present study provides statistically significant evidence that increasing the width of resection improves local control and overall survival.
Surgical margin
Margin (machine learning)
Distant metastasis
Resection margin
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Summary Bone sarcomas are rare, representing only 0.2% of all diagnosed cancers. Incidence is higher in children and adolescents, but bone sarcomas are still numerically outnumbered by benign bone tumors in this patient cohort. This article summarizes the management of treatment for bone sarcomas. Systemic therapy, surgical therapy, and radiotherapy are presented. Osteosarcoma, chondrosarcoma, and Ewing sarcoma are among the most frequently occurring bone sarcomas in all age groups. In recent decades, multimodal treatment of these rare entities has increased disease-free survival for these patients. As malignant primary bone tumors are rare cancers, and since management is complex, the standard of treatment should be performed by reference centers. If possible, wide en-bloc resection of the bone sarcoma should be performed. The role of radiotherapy in osteosarcoma and chondrosarcoma is limited, but Ewing sarcoma is a radiation-responsive tumor. In primary bone sarcomas, the efficacy of chemotherapy varies according to histological type. Prognosis is poor in patients with osteosarcoma or Ewing’s sarcoma if surgery without neoaqdjuvant chemotherapy is performed. Despite advances in surgical, medical, and radiation therapy, few significant positive changes in overall survival have been observed in patients with these diseases in recent decades.
Bone Sarcoma
Primary bone
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Bone Sarcoma
Spindle cell sarcoma
Undifferentiated Pleomorphic Sarcoma
Primary bone
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