X-ref For other Roundups in this issue that cross-reference with Oncology see: Spine Roundup 1; Knee Roundup 2; Hip Roundup 2, 4.
Surgery for spinal lung mets? X-ref
Lung cancer has traditionally been considered a terminal diagnosis. The mean interval from diagnosis to death has remained at or around six months for many years, and although surgery can be curative, often presentation is at a stage where surgery is not a viable option. There have been a number of recent studies however that have lowered the threshold for spinal metastatic surgery suggesting improved quality of life, particularly in the case of metastatic cord compression where spinal decompression has been found almost universally to have a surprisingly good result. Surgeons in Chongqing (China) have published their own experience of surgery for spinal metastasis arising from non-small-cell lung carcinoma.1 They report the results of 133 patients, all with metastasis, 86 of whom survived six months and were included in the final results. Of the 86 patients, 45 received decompression, and 41 did not. Outcomes were assessed using survival and the Functional Assessment of Cancer Therapy-General questionnaire. The results are almost universally in favour of the surgical group, with longer survivals and improved functional outcome scores at all follow up intervals. It does seem that the results from other cancer diagnoses have been mirrored here in a more aggressive primary than most – spinal metastatic disease is best treated surgically when possible, whatever the primary diagnosis.
Low grade chondrosarcoma suitable for less aggressive treatment X-ref
The less aggressive cartilage tumours (variably known as grade 1 chondrosarcoma or atypical cartilaginous tumours) are known to be suitable for less intrusive surgical excision than their higher-grade counterparts – the question at the moment is how much less aggressive is less aggressive? A large series of 108 patients is reported from Groningen (The Netherlands) this month confirming previous reports that less may very well be more in these cases.2 The surgical team used a conservative surgical strategy of curettage and adjuvant phenolisation to excise 108 tumours over a six year period, all in long bones, and present their results with a minimum of two year follow-up. During the observation period of the study, the research team established that there were no local recurrences at a mean of 48 months follow-up, although there was likely residual tumour in five cases giving a 95.4% disease-free survival rate. However, there were significant complications seen with a 10.2% fracture rate and a smattering of other complications such as infection and arthrofibrosis. There were no appreciable patient or tumour factor associations with complication occurrence. The authors conclude that a less aggressive strategy is certainly viable in these tumours, and pose the interesting question that given the fracture rate perhaps even less could be done with similar success, either observation or minimally invasive approaches.
Knowing when to operate on metastatic disease
Across all disciplines of oncological surgery, the excision of solitary or even multiple metastases is becoming more commonplace. What was once considered oncological heresy is now becoming the gold standard of care – thanks mainly to the improved survivals afforded by better chemotherapy regimes. The decision whether or not to excise is a tricky one and in many branches of surgery survival models are used to aid decision-making. However in orthopaedic oncology there isn’t a decent survival model available. We were delighted to see this new prognostic model to help with that tricky decision – should appendicular skeleton metastases be treated with curative surgery or not? A study team in Copenhagen (Denmark) used a relatively slim database of 130 consecutive patients all undergoing total joint arthroplasty to establish what the likely outcome was for patients presenting with metastatic bone disease.3 Their score was produced using the now familiar logistic regression method and the multivariate analysis included covariates such as primary diagnoses, pre-operative haemoglobin, fracture presence, Karnofsky score, visceral metastasis, bony metastasis and ASA score. The survival outcomes were cross referenced at three, six and 12 months. Although dodgy methodology, the research team also report the outcomes of their own internal cross-validation – where clearly an independent (preferably prospective) validation set is required for calculators such as these. The ROC analysis performed by the study team suggested that there was an overall diagnostic accuracy of between 79% and 85% between three and 12 months’ follow-up. This paper, in our opinion at 360, is potentially a landmark one. A simple calculator (if externally validated successfully) to predict survival following total joint arthroplasty for metastatic disease, which could gain the traction and usefulness of Mirell’s scores.
Ganz style debridement of osteochondromas X-ref
Treatment of multiple hereditary exostosis is a lifelong undertaking. When the exostosis mutate into osteochondromas they will usually require surgical treatment. It is not uncommon for exostosis to be seen around the proximal femur, and whilst in the older patient clearly a total hip arthroplasty is an option, in the younger patient with symptomatic osteochondromas, total hip replacement is fraught with longevity issues. Surgical oncologists in Amsterdam (The Netherlands) have been using the Ganz approach for surgical debridement of femoral neck osteochondromas in young patients for a number of years, the blood supply-sparing approach potentially offering the option of decent access for debridement and improved longer-term outcomes over the total hip.4 They report their results of 20 hips (17 patients) treated in this way over a five-year period. Outcomes were reported at just shy of four years and included range of motion, quality of life scores and symptom scales. As perhaps would be expected, the range of motion scores were significantly better following surgery and the benefit was maintained throughout. There were also improvements in quality of life scores and pain scores. There were however a range of complications including avascular necrosis, and it is important for the treating surgeon to weigh the risks and benefits; clearly this approach is not a solution for all, but may very well be the answer for a number of patients.
Evidence-based orthopaedic oncology?
There is little argument that the evidence basis for much of medicine in general, and orthopaedics specifically, leaves something to be desired, but this has improved of late. There are few patients for whom there is no evidence to support their treatments these days, yet there is still rightly a drive to improve levels of evidence and provide higher-quality evidence for the majority of treatments. A small but interesting study from authors in Salt Lake City (USA) asks the question, has this drive towards higher evidence levels yet hit the musculoskeletal tumour world?5 They used the level of evidence framework tool to categorise the data for studies presented at the Musculoskeletal Tumor Society and the Orthopaedic Trauma Association between 2005 and 2014. There were 1222 abstracts included in total with a roughly 50:50 split, and the authors quantified the changes over time. The Musculoskeletal Tumor Society papers did not change over time, with no improvement in levels of evidence for any study type, whilst there was a marked improvement in the Orthopaedic Trauma Association papers. There were less level IV papers, and the proportion fell over time, whilst there were no improvements seen in the proportion of level IV papers at the MSTS. The authors make the slightly worrying observation that the evidence base for musculoskeletal tumours is still dominated by uncontrolled case series. In rarer diagnoses it is difficult to conduct randomised controlled trials, however comparative case series or prospective work is relatively easy to perform, and authors should be encouraged to increase the scientific rigor of their work.
Grafting reduces complications in giant cell tumours
Sticking with the theme of lower malignancy tumours, our interest here at 360 was definitely piqued by a paper from New Jersey (USA) which sets out to answer the question, ‘are bone grafts beneficial in the treatment of giant cell tumours?’. The primary treatment of giant cell tumours (intralesional excision and curettage) is not in doubt; the interesting debate surrounds the periphery – is bone grafting or PMMA indicated? The authors present a series of 49 patients all treated for GCT in the epiphysis of the long bones. The patients were reconstructed with a variety of techniques, with 21 receiving femoral head allografts and 22 receiving PMMA alone. The patients were treated by different surgeons thus the authors were able to present a comparative series with less selection bias than the traditional retrospective mixed series. The key outcome message was that whilst there was no difference in the oncologic complications (29% vs 32% recurrence) between the two groups, there were dramatic differences in the non-oncological complication rates (10% vs 55%) favouring the bone graft group. It certainly appears that the use of bone graft improves the complication profile of surgical treatment of giant cell tumours.
References
1 Tang Y , QuJ, WuJ, et al.. Effect of surgery on quality of life of patients with spinal metastasis from non-small-cell lung cancer. J Bone Joint [Am]2016;98:396-402.CrossrefPubMed Google Scholar
2 Dierselhuis EF , GerbersJG, PloegmakersJJ, StevensM, SuurmeijerAJ, JuttePC. Local treatment with adjuvant therapy for central atypical cartilaginous tumors in the long bones: analysis of outcome and complications in one hundred and eight patients with a minimum follow-up of two years. J Bone Joint Surg [Am]2016;98:303-13.CrossrefPubMed Google Scholar
3 Sørensen MS , GerdsTA, HindsøK, PetersenMM. Prediction of survival after surgery due to skeletal metastases in the extremities. Bone Joint J2016;98-B:271-7.CrossrefPubMed Google Scholar
4 Sorel JC , Façee SchaefferM, HomanAS, ScholtesVA, KempenDH, HamSJ. Surgical hip dislocation according to Ganz for excision of osteochondromas in patients with multiple hereditary exostoses. Bone Joint J2016;98-B:260-65.CrossrefPubMed Google Scholar
5 Lerman DM , CableMG, ThornleyP, et al.. has the level of evidence of podium presentations at the Musculoskeletal Tumor Society annual meeting changed over time?Clin Orthop Res2016Feb26. [Epub ahead of print]CrossrefPubMed Google Scholar
6 Benevenia J , RiveroSM, MooreJ, IppolitoJA, SiegermanDA, BeebeKS, PattersonFR. Supplemental bone grafting in giant cell tumor of the extremity reduces nononcologic complications. Clin Orthop Relat Res2016Mar1. [Epub ahead of print]CrossrefPubMed Google Scholar
