body mass index (bmi) at diagnosis is associated with surgical wound complications in patients with...

Body mass index (BMI) at diagnosis is associated with surgical wound complications in patients with localized osteosarcoma: a report from the Children’s Oncology Group Douglas S. Hawkins, Kristy Seidel, Mark Krailo, Leo Mascarenhas, Paul Meyers, Neyssa Marina,

Ernest U. ConradConnective Tissue Oncology Society

November 2008

23. September - Sitzung der EGF

Bert Uwe Drechsel

Results 498 patients in INT-0133 OS CT trial BMI breakdown:

Low BMI (<10%): 73 patients (14.7%) Middle BMI (10-94%): 382 patients (76.7%) High BMI (>95%): 43 patients (8.6%)

Complications: Any: 76 patients (15.3%) Wound slough: 52 patients (10.5%) Infection: 15 patients (3.0%) Hematoma: 15 patients (3.0%) Thrombosis: 6 patients (1.2%) Hemorrhage: 4 patients (0.8%)


Bert Uwe Drechsel

Results Wound slough or infection:

Low BMI: 14 patients (19.2%) OR=2.0 (p=0.04) Middle BMI: 40 patients (10.5%) Reference High BMI: 7 patients (16.3%) OR =1.7 (p=0.25)

Thrombosis: Low BMI: 0 patients (0%) OR=1.4 (p=1.0) Middle BMI: 3 patients (0.8) Reference High BMI: 3 patients (7.0%) OR=9.4 (p=0.03)


Bert Uwe Drechsel

Conclusions: Low BMI at study entry for patients with

localized osteosarcoma receiving neo-adjuvant chemotherapy is associated with an increased risk of wound infection or wound slough after delayed definitive surgery

Future studies should evaluate whether correction of malnutrition reduces the risk of surgical complication


Bert Uwe Drechsel

Qqqqqq

This study measured BMI at start of Rx – did you look at change in BMI as a more potent cause of problems – eg the underweight child who loses weight?

Were wound problems related to toxicity of chemotherapy?

Royal Brompton Hospital Pulmonary Metastasectomy for Sarcoma

The Presence of Pleural Effusion in Sarcomatous Pulmonary Metastatic

Disease Does Not Affect Survival

Simon Jordan, Peter Goldstraw, Elizabeth Belcher, Ambrus Szántho,

Jeremy Whelan*, Beatrice Seddon*, Maria Michelagnoli*,Anna Cassoni*, Sandra Strauss*, Michelle Scurr+,

Frank Saran+,Ian Judson+, George Ladas

Royal Brompton Hospital, London, United Kingdom;*University College Hospital, London, United Kingdom;

+Royal Marsden Hospital, London, United Kingdom


Objectives and Methods

Prolonged survival following pulmonary metastasectomy is well documented. However, the presence of a pleural effusion raises concerns as to the suitability of aggressive treatment. The prognostic significance of such effusions has not been addressed.

Retrospective assessment of 105 consecutive patients operated on by a single surgeon undergoing pulmonary metastasectomy for sarcomatous disease between 01/01/95 and 31/03/2007 was undertaken. Kaplan-Meier methods, Log-rank test and Cox regression models were utilised to compare survival.


Results and Conclusions 105 patients underwent 157 metastasectomy procedures. Operative mortality was 0%.

Operative mortality was 51.7% at 5 years and 46.7% at 10 years. A pleural effusion was

present pre-operatively in 11 of 105 patients. In 7 patients the effusion was haemorrhagic.

The presence of a pleural effusion, did not affect prognosis (HR 1.44 (CI: 0.61-3.4, p=0.408)).

Moreover, a haemorrhagic pleural effusion did not influence survival (HR 1.49 (CI: 0.53-4.17,

p=0.447)). We suggest that the presence of a pleural effusion

should not preclude patients from undergoing pulmonary

metastasectomy.

Figure. 1. Overall survival following lung metastasectomy in sarcoma patients.

Patients at risk 105 57 34 27 16 11 10 6 4 2


Qqqqq

Was surgical technique any different for patients with a pleural effusion?

Did the surgeon find pleural metastases more commonly in these cases?

If a pleural metastasis was found ‘stuck’ to the chest wall – was the chest wall resected ‘en bloc’?

Survey: Mangement of Pulmonary Metastatic Osteosarcoma

D. Carrle, S. Bielack – COSS Stuttgart Background:Evidence: 1. Detection: No perfect imaging method2. Treatment: Complete surgical resection of all malignant leseions in

osteosarcoma Lack of evidence:Practical diagnostic and therapeutic aspects of management. Purpose: Survey to determine current practice of experts in the field.

Method: Postal survey addressing 17 representatives from international study

groups and selected institutions.

Results: Response rate: 94%Items Yes

Initial staging at 1st presentation:

1. Use of CT-Thorax 16/16

2. Additional use of Chest-X-Ray 12/15

Items Yes

3. Lesion sized > 5 cm: sufficient to distinguish malignant from benign lesion

12/15

4. Lesion sized < .5 cm: insufficient to distinguish malignant from benign lesion

15/15

5. Routine follow-up: Use of CT-Thorax 10/16

6. Suspicious lesion on CT:

Open Thoracotomy as next step 13/16

7. At thoracotomy: Manual exploration routinely recommended

16/16

8. Unilateral disease: Bilateral exploration? 11/16

9. „Disappearing“ lesions under chemotherapy:

Surgery? 8/16Conclusion: Survey amongst experts in the field:

generates new (1, 6) or substantiate (3, 4, 7) existing evidence ( Level 5, °D)exposes controversies in some areas (5, 8, 9).

Prospective studies needed - Join SAREZ/TranSaRNet Consortium (Sarcoma Registry)!

Qqqqq

• Unilateral disease – bilateral exploration - what is hit rate for finding abnormalities

• Role of better imaging for the 5mm nodules? ? PET

• What happens to cases of disappearing mets?

Addition of muramyl tripeptide to Addition of muramyl tripeptide to chemotherapy for patients with newly chemotherapy for patients with newly diagnosed metastatic osteosarcoma: A diagnosed metastatic osteosarcoma: A report from the Children's Oncology Groupreport from the Children's Oncology GroupAJ Chou, ES Kleinerman, MD Krailo, Z Chen, DL Betcher,

JH Healey, EU Conrad, H Nadel, ML Nieder, J Sato, MA Weiner, RJ Wells, RB Womer, PA Meyers, on behalf of the Children’s Oncology Group

21 patients with OS + mets at diagnosis Randomized to chemo

A - Ad/Cisplat/HDMTX + MTPE B - Ad/Cisplat/HDMTX/Ifos + MTPE

Results: Overall SurvivalResults: Overall Survival0.

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ConclusionsConclusions

Predictors of poor outcome Race (Hispanic worse) Gender (males worse) Non-pulmonary sites of disease High alkaline phosphatase, LDH

− Number of pulmonary nodules did not appear to predict poor outcome ? Significance ? Explanation

The pattern seen in the metastatic cohort was similar to the non-metastatic cohort with the same reduction in the relative risk of death associated with the addition of L-MTP-PE to conventional chemotherapy, but the improvement did not reach conventional levels of statistical significance

Qqqqqqq

Did surgical operability effect prognosis

Future role of MTPE ?

HELIOS Klinikum Berlin-Buch

Dimosthenis AndreouHELIOS Klinikum Berlin-Buch – Department Tumororthopädie, Sarkomzentrum Berlin-Brandenburg

Sentinel node biopsy in soft tissue sarcoma of the extremities. A single-

center experience

Dimosthenis Andreou

S. Fehlberg, C. Tiedke, S. Richter, D. Pink, P.-U. Tunn


Sentinel node biopsy in soft tissue sarcoma of the extremities - Results

• a series of 22 consecutive patients with synovial sarcoma (n=17), clear cell sarcoma (n=2), epithelioid sarcoma (n=2) and rhabdomyosarcoma (n=1) underwent a sentinel node biopsy

• 2 positive, 1 false negative and 24 negative sentinel nodes were identified

• at least one sentinel was detected in each patient

• no biopsy-related complications were observed


Sentinel node biopsy in soft tissue sarcoma of the extremities - Discussion

• up to date there is no validated, non-invasive method to assess regional lymph node status in patients with soft tissue sarcoma

• SN-biopsy can be successfully and safely applied

• further prospective studies are required to determine the clinical relevance and the prognostic significance of SN-biopsy in soft tissue sarcoma


Qqqqqq…

• Which were the +ve cases?

• Was there any clinical or radiological suspicion in those?

• Did it alter management?

• Is it cost effective?

Surgery of giant cell tumor of the sacrum: an analysis of 28

cases

Surgery of giant cell tumor of the sacrum: an analysis of 28

cases

Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli

Ruggieri P., Ussia G., Bosco G., Angelini A., Montalti M., Ruggieri P., Ussia G., Bosco G., Angelini A., Montalti M., Pala E., Biagini R., Mercuri M.Pala E., Biagini R., Mercuri M.

Material and methodsMaterial and methods 28 cases (1986-2006)

• retrospective study

• age range: 4 – 68 ys. (mean age 30)

• mean follow-up 9.6 ys. ( min.2- max.22 )

• No lung metastases at dx., no multicentric GCTs

• Neurologic deficits at presentation 43%• Stage 3 GCT 89%

• Previous treatment elsewhere in 4 cases

• S 1 was involved in 82% of the cases (23/28)

28 cases (1986-2006)

• retrospective study

• age range: 4 – 68 ys. (mean age 30)

• mean follow-up 9.6 ys. ( min.2- max.22 )

• No lung metastases at dx., no multicentric GCTs

• Neurologic deficits at presentation 43%• Stage 3 GCT 89%

• Previous treatment elsewhere in 4 cases

• S 1 was involved in 82% of the cases (23/28)

Surgical treatment: intralesional excision in 28 cases • Surgical approach: - Anterior and posterior 14 cases - Posterior 13 cases - Anterior 1 cases (death after 14 day of surgery)• Radiotherapy (adjuvant) in 20 cases, average dose 43.5 Gy (min.36- max.70 Gy) • Preoperative selective arterial embolization in 22 cases: - 2 times in 2 cases - 1 time in 20 cases• Local adjuvants in 17 cases: phenol (16), liquid nitrogen (3) - 14 cases phenol - 1 case liquid nitrogen - 2 cases both

Treatment and resultsTreatment and results• 24 cases NED 24 cases NED • Local Recurrence in 3 cases ( 2 NED1, 1 DOD with radio-induced Local Recurrence in 3 cases ( 2 NED1, 1 DOD with radio-induced

sarcoma)sarcoma)• 1 DOD with postoperative massive pulmonary embolism1 DOD with postoperative massive pulmonary embolism• Overall mortality 7.1% (2/28)Overall mortality 7.1% (2/28)• Perioperative mortality 3.6% (1/28)Perioperative mortality 3.6% (1/28)• Overall LR rate 11% (3/27):Overall LR rate 11% (3/27):

- 1 LR/7 cases with surgery only (14%)- 1 LR/7 cases with surgery only (14%) - 2 LR/20 cases with surgery and radiotherapy (10%)- 2 LR/20 cases with surgery and radiotherapy (10%)

Radio-induced sarcoma 5% (1/20)Radio-induced sarcoma 5% (1/20)No lung metastasesNo lung metastasesPostoperative neurologic deficit 48%Postoperative neurologic deficit 48%

CONCLUSIONS: recommended treatment is surgical excision with CONCLUSIONS: recommended treatment is surgical excision with local adjuvants, without radiotherapylocal adjuvants, without radiotherapy

[email protected]@ior.it

• 24 cases NED 24 cases NED • Local Recurrence in 3 cases ( 2 NED1, 1 DOD with radio-induced Local Recurrence in 3 cases ( 2 NED1, 1 DOD with radio-induced

sarcoma)sarcoma)• 1 DOD with postoperative massive pulmonary embolism1 DOD with postoperative massive pulmonary embolism• Overall mortality 7.1% (2/28)Overall mortality 7.1% (2/28)• Perioperative mortality 3.6% (1/28)Perioperative mortality 3.6% (1/28)• Overall LR rate 11% (3/27):Overall LR rate 11% (3/27):

- 1 LR/7 cases with surgery only (14%)- 1 LR/7 cases with surgery only (14%) - 2 LR/20 cases with surgery and radiotherapy (10%)- 2 LR/20 cases with surgery and radiotherapy (10%)

Radio-induced sarcoma 5% (1/20)Radio-induced sarcoma 5% (1/20)No lung metastasesNo lung metastasesPostoperative neurologic deficit 48%Postoperative neurologic deficit 48%

CONCLUSIONS: recommended treatment is surgical excision with CONCLUSIONS: recommended treatment is surgical excision with local adjuvants, without radiotherapylocal adjuvants, without radiotherapy

[email protected]@ior.it

Qqqqqq

• Some reports suggest embolisation itself may cure many of these patients…..

• How control bleeding if no embolisaton?

• What is follow up for RT treated patients?

• How many neurologically worse after surgery than before?

• Do you foresee any role for biphosphonates / denosumab in these cases?

THE CLINICAL AND FUNCTIONAL OUTCOME FOR THE CLINICAL AND FUNCTIONAL OUTCOME FOR RADIATION-INDUCED SOFT-TISSUE SARCOMA IN ADULTSRADIATION-INDUCED SOFT-TISSUE SARCOMA IN ADULTS

Soha Riad, Anthony Griffin, Ginger Holt, Cindy Wong, Joel Werier, Robert Turcotte, Soha Riad, Anthony Griffin, Ginger Holt, Cindy Wong, Joel Werier, Robert Turcotte, Peter Ferguson, Benjamin Deheshi, Brian O’Sullivan, Jay WunderPeter Ferguson, Benjamin Deheshi, Brian O’Sullivan, Jay Wunder

Musculoskeletal Oncology Unit, Mount Sinai, Vanderbilt Medical Center, McGill Musculoskeletal Oncology Unit, Mount Sinai, Vanderbilt Medical Center, McGill University Health Center, Ottawa Hospital-General Campus, Departments of University Health Center, Ottawa Hospital-General Campus, Departments of

Radiation Oncology and Surgical Oncology, Princess Margaret Hospital, University Radiation Oncology and Surgical Oncology, Princess Margaret Hospital, University Health Network, The University of TorontoHealth Network, The University of Toronto

Diagnosis Percentage (%)

MFH 33.3

Angiosarcoma 15.2

Liposarcoma 12.1

STS-Osteosarcoma 12.1

Leiomyosarcoma 9.1

NOS 9.1

Rhabdomyosarcoma 6.1

Malignant Peripheral Nerve Sheath Tumour 3.0

Purpose: To compare the clinical and functional outcome of patients with radiation-induced soft tissue sarcomas (RI-STS) to those with primary extremity soft-tissue sarcoma.

Methods: Retrospective data from 4 centers were collected for RI-STS cases treated from 1989-2004.

33 patients with median age of 54.5 yearsMedian period from irradiation of primary cancer to RI-STS was18 years (3-56 years).

4/31 patients had positive resection margins.

42% of RI-STS developed a systemic relapse and 24% developed a local recurrences

05

1015202530354045

LR of OriginalCancer

LR of Sarcoma Node mets ofSarcoma

Systemic metsof Sarcoma

Type of Relapses

Per

cen

tag

e (%

)

RI-STS 5-year overall survival was 39% RI-STS 5-year overall survival was 39% compared to 72% for the Other STS compared to 72% for the Other STS group.group.

14 patients had postoperative functional 14 patients had postoperative functional assessment using TESS and MSTS1987 assessment using TESS and MSTS1987 scores; mean 83 (61-100), 27 (17-33) scores; mean 83 (61-100), 27 (17-33) respectively, compared to 86 (13-100), respectively, compared to 86 (13-100), 30 (14-35) for the Other STS population.30 (14-35) for the Other STS population.

ConclusionsConclusions

Patients with RI-STS have a poor Patients with RI-STS have a poor prognosis due to high local and systemic prognosis due to high local and systemic recurrence rates.recurrence rates.

Limb salvage and negative margins were Limb salvage and negative margins were obtainable for most of the RI-STS group.obtainable for most of the RI-STS group.

Good functional results are possible for Good functional results are possible for these patients.these patients.

Novel systemic treatments are necessary Novel systemic treatments are necessary to help improve their oncologic to help improve their oncologic outcomes.outcomes.

p = > 0.00001

0 24 48 72 96 120 144 168 192

MONTHS

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Overall Survival comparison for Grade 3 RI-STS vs. Other Grade 3 STS groups

Other STS Group

RI-STS Groupp = 0.0002

QqqqqqqQqqqqqq

What most the common siteWhat most the common site What was the most common primaryWhat was the most common primary In how many did you feel there may In how many did you feel there may

be a ‘field change’ rather than a be a ‘field change’ rather than a single focussingle focus

Could you use further RT in any?Could you use further RT in any? Chemotherapy? Chemotherapy?

The Functional Consequence of Femoral Nerve Resection in the Thigh

Kevin B. Jones*†, Soha Riad*, Anthony M. Griffin*, Benjamin Deheshi*, Robert S. Bell*, Peter C. Ferguson*, Jay S. Wunder*

*University Musculoskeletal Oncology Unit, Mount Sinai and Princess Margaret Hospitals, University of Toronto. †Sarcoma Services, Huntsman Cancer Institute and the Department of Orthopaedic Surgery, University of Utah.

Findings

• 10 patients retrospectively identified from a prospective sarcoma database had undergone complete femoral nerve ablation during soft tissue sarcoma resection.

• Compared to sciatic nerve resection patients, a non-nerve-involved thigh sarcoma control group, and a gender-matched control group, TESS, MSTS1987, and MSTS1993 trended toward worse outcomes among the 10 patients with femoral nerve resection. Statistical significance was not reached.

• 6 of the 10 patients suffered a total of 8 fractures following complete femoral nerve resection, many in the contralateral limb, due to frequent falls.

http://www.uhn.ca/

The Functional Consequence of Femoral Nerve Resection in the Thigh

Kevin B. Jones*†, Soha Riad*, Anthony M. Griffin*, Benjamin Deheshi*, Robert S. Bell*, Peter C. Ferguson*, Jay S. Wunder*

*University Musculoskeletal Oncology Unit, Mount Sinai and Princess Margaret Hospitals, University of Toronto. †Sarcoma Services, Huntsman Cancer Institute and the Department of Orthopaedic Surgery, University of Utah.

Relevance

• Sciatic nerve resection in the thigh changed from a categorical indication for amputation to an undertaking compatible with limb salvage when functional outcomes were carefully studied.

• In contrast, it appears that the functional morbidity of femoral nerve resection may have been under-estimated in the absence of nerve-specific outcomes data, perhaps because complete extensor power ablation is somewhat commonly associated with distal femur resection and reconstruction in the sarcoma world, but the effects are there mitigated by implant hyperextension.

• Functional outcomes, as well as fall-preventive interventions, following femoral nerve resection for soft tissue sarcoma merit further attention and study, as do other nerve-specific functional outcomes.

http://www.uhn.ca/

Qqqqqqq

• Did any of the patients have a brace?

• Did any have a tendon graft?

• Anyone know a good reconstruction following excision of the femoral nerve?

Department of Orthopedics, University of Bologna, Istituto Ortopedico RizzoliDepartment of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli

Injection of metilprednisolone Injection of metilprednisolone

acetate in the treatment of acetate in the treatment of

eosinophilic granuloma of boneeosinophilic granuloma of bone..

G. Bosco, A. Bosco, G. Paone, E. Pala,T. Calabrò, G. Bosco, A. Bosco, G. Paone, E. Pala,T. Calabrò,

P. RuggieriP. Ruggieri

Injection of metilprednisolone Injection of metilprednisolone

acetate in the treatment of acetate in the treatment of

eosinophilic granuloma of boneeosinophilic granuloma of bone..

G. Bosco, A. Bosco, G. Paone, E. Pala,T. Calabrò, G. Bosco, A. Bosco, G. Paone, E. Pala,T. Calabrò,

P. RuggieriP. Ruggieri

Injection of metilprednisolone acetato in treatment of the Injection of metilprednisolone acetato in treatment of the eosinophilic granuloma of boneeosinophilic granuloma of bone


50 cases (Jan 1994 - Dec 2004)50 cases (Jan 1994 - Dec 2004)

31 - 19

Age: 9.7 yrs (min 2 – max 60)

Site: Lower limb 17Upper Limb 12Pelvis 11Spine 4

Multiple localizations 6*

Follow up: 36.7 months (min 3 - max 94)

50 cases (Jan 1994 - Dec 2004)50 cases (Jan 1994 - Dec 2004)

31 - 19

Age: 9.7 yrs (min 2 – max 60)

Site: Lower limb 17Upper Limb 12Pelvis 11Spine 4

Multiple localizations 6*

Follow up: 36.7 months (min 3 - max 94)

*all pts. received systemic therapy (Vinblastin+Prednisone) 2 had previous Prednisone local injection



40 pts. healed with a single injection 40 pts. healed with a single injection mean time to radiografic healing mean time to radiografic healing ->-> 9 months 9 months40 pts. healed with a single injection 40 pts. healed with a single injection mean time to radiografic healing mean time to radiografic healing ->-> 9 months 9 months

At the Beginning

One Months

Three Months

Five Months

Ten Months

ConclusionsConclusions- steroids injection effective in single bone lesionssteroids injection effective in single bone lesions- no further injections if at 3 mos. positive X rays no further injections if at 3 mos. positive X rays changeschanges- multiple lesions require systemic treatmentmultiple lesions require systemic treatment

Qqqqqq

• How many Eosinophilic granulomas Rx in the same time period without steroid injection?

• How many healed without injection?

• What are indications for steroid injection?

body mass index (bmi) at diagnosis is associated with surgical wound complications in patients with...

Documents

consecutive patients

low bmi

middle bmi

reference high bmi

united kingdom slide

wound slough

presence of pleural

egf bert uwe drechsel