Musculoskeletal tumours are relatively rare and as such, they are not well known by the population and by general practicioners. We observed that an important proportion of our patients has seen major delays at diferent stages of their referral pathway. It is well recognised that such delays can cause avoidable loss of function, local and systemic recurrence and increase in health system costs. The main objective of this study was to prospectively assess the referral paterns of our patients to pinpoint the causes of the delays. This should allow the formation of strategies to minimise delas and their impact. The secondary objective was to assess the performance of our centre in comparaison to other centre with the goal of improving quality of care.

Prospective follow up data is available for 457 patient referred to our musculoskeletal oncology team between july 2011 and november 2014. Every patients filled questionnaires on their initial referral patterns. Site specific function and quality of life are evaluated at baseline and at subsequent follow-up (six months, one year, three years and five years).

The average delay between the first symptoms and the first medical consultation with a general practitioner was 37 weeks (CI: 27–46). The average delay between the first medical consultation and the referral to orthopaedic oncology was 54 weeks (CI: 43–65). The delay between the first consultation with a general practitioner and the first radiologic test was 31 weeks (CI: 22–39). The delay between the first radiologic test and the referral to orthopaedic oncology was 28 weeks (CI 24–32). The delay between the referral to orthopaedic oncology and the first appointment to our centre was three weeks (CI 2–4). Before the referral to our center, 23% of the patients met two general practitioners and 10% met with 3 or more general practitioner. Fifty-two pervent of the patients had a consultation with a specialist and 19% saw two or more specialists.

It is imperative to raise awareness of musculoskeletal tumours and indication for early referral in general practitioners. One of the main problems in our actual referral patern is early access to appropriate imaging. The creation of a referral program with specific guidelines is, in our opinion, the best way to significantly reduce the delays for appropriate management of patients with suspiscion of musculoskeletal tumours.

High grade sarcoma present a systemic metastatic progression in approximaly 50% of cases. The effectiveness of palliative chemotherapy as a treatment of systemic metastases is still controversed. The main objectif of this study is to assess disease progression and survival of patients diagnosed with metastatic soft tissue sarcomas treated with palliative chemotherapy, analyse chemotherapy treatment patterns and response to different lines of treatment.

Retrospective chart review of 75 patients treated with palliative chemotherapy for metastatic soft tissue sarcomas between 2003 and 2013 at Maisonneuve-Rosemont Hospital. Data for control group of 40 patients with metastatic soft tissue sarcomas not treated with chemotherapy was collected retrospectively. Collected data include demographic data, overall survival, time free survival, type of chemotherapy treatment, surgical treatment and adverse reaction to palliative chemotherapy. Overall survival was analysed with Kaplan-Meier test. Categorial variable were compared with Log-Rank test.

Seventy-five patients (37% female; mean age 50.4 years) received minimally one line of chemotherapy for their metastatic sarcomas. The regimens most commonly used in first-line were doxorubicin (48%) and doxorubicin combined with ifosfamide (21.3%). Favorable response was achieved by 38.7% in first-line and 27.9% in second-line therapy. Median overall survival with chemotherapy treatments was more than two times overall survival without treatments. Median overall survival was 19 months with chemotherapy treatments and 7 months without chemotherapy (p<0.0001). There was no statistically significant difference between survivals for treated and untreated patients with chemotherapy when analysed in term of the histological subtype, age and monotherapy versus combined treatment. Event-free survival was statistically longer during the first year for the group of patients treated with combined chemotherapy (p=0.0125).

Results have shown a significantly improved overall survival in all histological groups, resulting in an OS of 19 vs 7 months for the chemotherpy and non chemotherapy group respectively. Nevertheless, patients with favorable response to chemotherapy have poor outcomes. Additional treatment options are needed.

Major wound complication risk factors following soft tissue sarcoma resection.

Wound-healing complications represent an important source of morbidity in patients treated surgically for soft tissue sarcomas (STS). The purpose of this study was to determine which factors are predictive of major wound complication rates following STS resection, including tumour site, size, grade, and depth, as well as radiotherapy and chemotherapy.

We reviewed 256 cases of STS treated surgically between 2000 and 2011. The primary outcome was occurrence of major wound complications post STS resection.

Major wound complications were more likely to occur post STS resection with larger tumour diameters (p = 0.001), high grade tumours (p = 0.04), location in the proximal lower extremity (p = 0.01), and use of preoperative radiotherapy (p = 0.01). Tumours located in the adductor compartment were at highest risk of complications. We did not demonstrate a significant difference in complications rates based on method of closure. Diabetes, smoking, obesity, tumour diameter, tumour location in the proximal lower extremity, and preoperative radiotherapy were independent predictors on multivariate analysis.

There are multiple predictors for major wound complications post STS resection. A more aggressive resection of irradiated soft tissues, combined with primary reconstruction, should be considered in cases with multiple risk factors.

Purpose

Due to the aging population, an increasing proportion of elderly patients with soft tissue sarcoma are presenting to cancer centers. This population appears to have a worse prognosis but the reasons for this has not been studied in depth. The purpose of this study is to examine the effect of age on the outcome of patients with extremity and trunk soft tissue sarcoma.

Purpose: Management of local recurrence (LR) remains unclear. Optimal management of primary tumour by specialised teams minimises this risk. However, previous treatments may impact on the available options when LR is encountered. We thus studied the outcome of this population with recurrent STS.

Method: Retrospective review was carried based on our prospective sarcoma databases. DFSP and ALT were excluded. Among 618 primarily managed STS we found 35 cases of local recurrences (5.7%). Median f-up after LR was 14 mos (0–98).

Results: Twenty were female. Mean age was 54 (Range 15 – 92). 22 involved lower limb, 11 upper limb and 2 the trunk. Mean delay from original surgery was 23 mos (3–75) and the mean size of LR was 4.7 cm (0.4–28.0 cm). Primary tumours were superficial in 4 and deep in 31 while recurrences were found superficial in 8 and deep in 26. Most frequent histology was MFH 8, Leiomyosarcoma 6, Liposarcoma, synovial sarcoma and MPNST had 4 each. 84% were high grade. Only 23 showed no meta-static disease at time LR was diagnosed. All 5 pts without initial RT got RT for their LR. 7 pts with therapeutic level of RT to the primary tumour got full course of RT as well for their LR. 11 did not undergo surgery. 6/18 who had initial RT underwent amputation as opposed to 0/6 who did not. Trend to amputate was for younger age, deep and large tumour and previous RT. Ultimatly, 21(60%) locally recurrent tumours showed metastatic disease; 6 prior diagnosis of LR, 6 concomitantly and 9 after with an average delay of 17 months (1–24). 6 pts developed additional local recurrences.

Conclusion: Although infrequent local recurrence correlates with impaired outcome. Albeit challenging, limb salvage and additional radiotherapy remain possible despite optimal multi modality management of the initial tumour.

To identify the presence of the Adamkiewica artery before operating spine tumor patients and avoid neurological complications as well as evaluate the impact on surgical strategy.

All tumor patients requiring spinal fixation from Feb 2002 to March 2006 were prospectively enrolled in the study. Included patients either had a primary spine tumor or a spine metastasis. Patients underwent a selective arteriography of the level above, the level below and the level involved by the tumor in order to document any Adamkiewicz artery (AKA).

Eighteen patients were enrolled. Six had a primary tumor and twelve had a metastasis between levels T1 to L3. There were no complications related to the radiological procedure. For ten (55%) of patients, the AKA was identified during the selective arteriogram. In seven of the twelve (58%) metastatic cases the AKA was found adjacent to the involved level. In 60% of cases the AKA was found on the left side. In all cases where the AKA was found, the surgical strategy was modified in order to preserve the AKA. No patients had permanent neurological complications.

The location of the AKA is extremely variable. in more than half our cases, the AKA was found immediately adjacent to the involved level. This could suggest a vascular explanation for the location of tumors in the spine. The vicinity of the AKA to the tumor site may explain why neurological complications are frequent when operating such spine cases.

A retrospective review of our prospectively collected database was undertaken and the functional and oncologic outcomes after Type One pelvic resections for bone tumours of the ilium and sacrum were analyzed. Seventeen patients were identified with a minimum followup after resection of twelve months. In seven patients the bone defect was reconstructed, with no reconstruction in the remaining ten patients. The functional/oncologic outcomes of the two groups are similar, however patients without reconstruction had fewer complications and less dependence on walking aids suggesting that reconstruction may not be justified.

Management of defects created by Type One pelvic resections of large iliac bone tumours remains controversial. We reviewed the functional/oncologic outcome following resection with and without reconstruction.

Similar functional/oncologic outcome was achieved in both groups suggesting that reconstruction is not justified.

A retrospective review of our prospectively collected database was undertaken analyzing functional/oncological outcome of seventeen patients with Type One pelvic resection. Minimum follow up was twelve months (12–96). Outcome data was available on 8/10 patients managed without reconstruction (WOR), with residual ilium collapsing back onto sacrum, and on 5/7 patients with bone graft reconstruction (WR).

Average age thirty-three years (WOR) and 48yrs (WR), (p=0.04), with average maximal tumour dimensions of 12cm and 9cm (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (24–96) compared to 69%, 21/35 and 51% at an average of 37 months (12–60) for the WR group. 33% of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 57% of WR patients. No local recurrences.

The perceived advantages of no reconstruction are shorter operating times, reduced incidence of complications and improved functional outcome due to medialization of the weightbearing axis in the absence of hip abductors. The oncologic/functional outcomes of both groups were similar but in those not reconstructed there was a lower incidence of complications and walking aids.

A prospective evaluation of the functional status and quality of life of patients undergoing surgery for long bone and acetabular metastases was performed. Sixty-nine patients were enrolled in the study. IM nailing and prosthetic replacement were the most common methods of treatment. Results were assessed using the MSTS 1987, MSTS 1993, TESS and SF-36 pre-op and then at six and twelve weeks post-op. There was a significant improvement in all of these parameters. The need for pain medication also decreased significantly. These results show surgical treatment of bone metastases can be benificial to patients with a short life expectancy.

The purpose of this study was to objectively assess the benefits of surgical treatment of bone metastases in the first three months post-operatively.

This is the first prospective study to evaluate the impact of surgery on the quality of life and function of patients burdened by metastases to the appendicular skeleton.

Sixty-nine patients gave their informed consent to be followed prospectively. Patients were administered the SF-36, MSTS 1987, MSTS 1993 and TESS questionnaires pre-op, at six weeks and three months post-op.

Average age was sixty-one years. Average follow-up was six months with 71% of patients deceased at the latest follow-up. Thirty-five patients had a pathological fracture and thirty-four had an impending fracture. IM Nailing was performed in thirty-six patients, prosthetic replacement in twenty and various other methods of stabilization in the thirteen other cases. Complications occurred in 25% of patients. There was a statistically significant improvement in the MSTS 1987 (from 13,6 to 22,8), MSTS 1993 (21,7 to 51,7), TESS (37,7 to 67,7) and pain medication use in the first three months post-op. SF-36 physical component scores improved significantly at six and twelve weeks while mental component scores improved significantly only at twelve weeks post-op.

Our data shows that surgical treatment of metastatic disease to long bones improves functional status and quality of life in a relatively short time frame. This is significant in a group of patients suffering from advanced neoplasia.

This study suggest interesting benefits in the overall well-being of patients treated surgically for bone metastases.

Funding: Funding was received from CHIR and FREOM.

Purpose: Osteosarcoma (OS) is the most common type of cancer in children. OS demonstrates aggressive growth with a high risk of early, pulmonary metastasis. Here we investigated expression of malignancy-related factors in six osteosarcoma cell lines (SaOS, MNNG/ HOS, MG63, SW1353, SKES, SJSA), ten biopsies of primary OS and OS derived cells.

Methods: For this project, we are using RT-PCR and immunohistochemistry to detect PARP, ET-1, ETA and ETB receptor. We also, examined the expression of osteocrin by in situ hybridization. Zymography and Northern Blot were use to observe the presence of gela-tinases (MMP-2 and MMP-9) and finally, we showed the presence of ET-1(1–31) by Elisa-immunoassay.

Results: In OS tissues and cells, we observed ET-1, MMP-2, and ETA receptor overexpression, in contrast to under-expression of MMP-9 and ETB receptor. Additionally, in high malignant OS cells, MMP-2, MMP-3, MMP-13 and PARP were overexpressed and TIMP-1, TIMP-2 and TIMP-4 expressed at low levels. Using a new specific immunoassay for ET-1 (1–31) we showed presence of this alternative form of ET-1 in OS-derived cells. We also showed that, in cells exposed to ET-1, the inhibition of NF-kB pathway (NF-kB is an ubiquitous transcription factor playing a central role in differentiation, proliferation and malign transformation) drastically blocked MMP-2 production and activity, and that ET-1 induces NF-kB p65 unit translocation to the nucleus.

Conclusions: Thus, we concluded that expression of malignancy-related factors in parallel to the histological evaluation of these tumors, could be beneficial for malignancy understanding. Tumor cells invasion and aggressiveness of OS cells are the results, in part, of the tumorigenic potential of alternative forms of ET-1 generated by MMPs and enhanced in malignant microenvironment. These factors could be predictive for tumoral progression. Funding: Educational Grant from the Canadian Orthopaedic Foundation. Funding Parties: Canadian Orthopaedic Foundation (Carrol A. Laurin Award) and MENTOR program of CIHR

Purpose: To determine the outcome of patients 80 years old and greater that were diagnosed with a primary soft tissue sarcoma and if these patients should be treated as aggressively as younger patients.

Methods: One-hundred two patients were retrospectively reviewed.Well differentiated liposarcoma and der-matofibrosarcoma were excluded.

Results: There were 52 males. Average age was 84 years (80–94). Malignant fibrous histiocytoma was most common (36 patients) followed by leiomyosarcoma (22 pts) and liposarcoma (17 pts). Tumors were superficial in 25 patients and deep in 75. The lower extremity was most frequent site(70 patients), 27 patients had upper extremity involvement and 9 had a back lesion. MSTS stages were IA 6 patients, IB 22 patients, IIA 55 patients, IIB 9 patients, III 1 patient, and was unknown for 9 cases. Lesions were larger than 5cm in 80%. Four patients had no surgery, 89 patients had limb salvage, and 8 patients underwent amputation. Thirty-two patients had pre-operative radiotherapy, 30 patients had post-operative radiation, and 3 patients received both. No patients were given chemotherapy. The average follow up was 24 months (0–107months). Seventeen patients experienced local recurrence. Thirty-one patients developed metastatic disease. At latest follow-up 49 patients were alive without disease, 21 patients were alive with disease, 22 patients died of their disease, 8 patients died of another cause and the final status was unknown for 2 patients.. The MSTS functional score pre-treatment was 24 (11–72) and 31 (20–77) one year following treatment.

Conclusions: Elderly patients with soft tissue sarcoma have a poor outcome. Taking into account their associated medical condition, this group should likely be managed as younger patients although chemotherapy has no role according to our experience Funding: Other Education Grant Funding Parties: CIHR,|Stryker Canada

This study was designed to be the first to prospectively evaluate CT-guided radiofrequency ablation for osteoid osteoma in terms of pain control, medication consumption, quality of life and patient function.

Over two years, forty patients with symptoms and radiographic findings classic for osteoid osteoma were offered radioablation. Patients were asked to fill out facial, subjective and visual analog pain scales and to undergo the Musculoskeletal Tumour Society 1987 functional assessment.

Results show immediate and lasting resolution of symptoms, a sharp drop in drug use and a significant improvement in function thus supporting the role of radioablation as first line therapy.

The purpose of this study was to prospectively evaluate the usefulness of radioablation for osteoid osteoma in terms of pain control, analgesic drug consumption, quality of life and patient function.

Radioablation appears to be a safe and effective method of treatment for osteoid osteoma. It offers immediate and lasting resolution of symptoms. Results support its role as first line therapy.

This is the first study to prospectively measure the outcome of patients treated with CT-guided radiofrequency ablation for osteoid osteoma.

The mean follow-up time is 6.93 months (sd: 6.51). All but seven procedures were done under regional anaesthesia. No complications were reported. 50% of core biopsy specimens were diagnostic of osteoid osteoma. The visual analog pain scale showed a value of 2.13(sd: 2.5) pre-op and 0.33(sd: 1.07) at 1 year (p=0.00033). The MSTS score rose from 28.86(sd: 4.68) pre-operatively to 34.06(sd: 1.95) after one year (p=0.000000049). Medication consumption was markedly reduced. All eighteen patients with more than one- year follow-up are drug free.

Over two years, forty patients with symptoms and radiographic findings classic for osteoid osteoma who had already received various treatments were offered radioablation. Written consent was obtained and patients were asked to fill out facial, subjective and visual analog pain scales. The Musculoskeletal Tumour Society 1987 functional assessment was performed. This data was collected two weeks prior to treatment and then at two weeks, three months and one year after treatment. The procedure was performed under CT guidance and on a one-day hospital admission basis.

A retrospective study was performed to evaluate the results of proximal humeral replacement prosthesis in the oncologic setting. Following tumour resection and implantation of the prosthesis, the soft tissues around the shoulder were either sutured directly to the prosthesis (three cases) or a dacron capsuloplasty was performed (five cases). Emphasis was on assessing shoulder instability. Eight patients were availaible for the study. Three patients needed to be re-operated for instability. Average instability rating on the ASES visual analog scale was 3,2/10. We conclude the prosthetic instability can be a significant problem for these patients.

The purpose of this study was to assess the results of oncologic proximal humeral prosthesis with a focus on shoulder instability.

Following limb-salvage procedures of the shoulder girdle, reconstruction of the soft-tissues to obtain prosthetic stability can be a major challenge.

A retrospective study of patients that underwent oncologic shoulder replacement. Results were evaluated using the SF-36 questionnaire, the MSTS 1987 and 1993 scales as well as the Standardized ASES method for assessement of shoulder function, including the visual analog scale for instability.

Nine patients were still living and eight of them were able to participate in this study. Average follow-up was seventy-three months. In five cases a capsuloplasty was performed using a dacron vascular prosthesis. In the remaining cases the capsule, rotator cuff or deltoid were sutured directly to the prosthesis.

Average instability rating was 3,2/10 using the visual analog scale. Three patients were reoperated for instability. Two had a failed soft tissue repair with inferior dislocation of the prosthesis and one had recurrent anterior dislocation.

Average MSTS 1987 and 1993 scores were 19,9 and 18,9 respectively.

SF-36 scores were significantly lower than Canadian standards in the physical functioning, role physical and mental health domains.

Our data show a significant rate of instability related problems following prosthetic replacement of the proximal humerus in cases of limb salvage. We were unable to indentify specific strategies to prevent this.

Further research is needed to determine optimal soft tissue reconstruction for oncologic procedure about the shoulder.

We evaluate the outcome (Functional, Oncological, and complications) after resection of pelvic sarcoma and reconstruction with the saddle prosthesis. Twenty-seven patients with a mean follow up of forty-five months. Fourteen patients were free of disease, eleven patients were deceased, and two patients were alive with disease. MSTS 93 was 51 %, MSTS 87 was15%, and TESS was 64 %. Infection occurred in ten, fracture in six, and dislocation in six patients. Vertical migration stabilized after two years. Five patients were retired, five had full-time employment, six were disabled, and eleven were deceased. Reconstruction with saddle prosthesis following resection for pelvic sarcoma is associated with significant morbidity.

Treatment of pelvic sarcoma is difficult. Of many techniques described for reconstruction of the pelvis following tumor resection, limited data exists to compare functional results.

To evaluate the outcome after resection of pelvic sarcoma and reconstruction with the saddle prosthesis.

This retrospective study includes twenty-seven patients who underwent saddle prosthetic reconstruction for pelvic sarcoma. Functional outcome was assessed with MSTS 1987 & 1993 and the Toronto Extremity Salvage Score (TESS). Oncological outcome parameters and complications were recorded.

We reviewed twenty-seven patients with a mean follow up of forty-five months. Seven (26%) patients underwent type II (periacetabular) pelvic resection, twenty had type II & III (periacetabular and pubis). Eleven patients received chemotherapy. None received radiation. Fourteen patients were free of disease, eleven patients were deceased, and two patients were alive with disease. The survival rate was 60%, 22% had local recurrence, and 22% had metastasis. Functional evaluation was completed in seventeen patients and the mean for MSTS 93 was 50.8 %, the MSTS 87 was15.3%, and the TESS was 64.4 %.

Infection occurred in ten cases, and there were five nerve palsies. Heterotopic ossification occurred in ten, fracture in six, and dislocation in six patients. Limb shortening was initially progressive but stabilized after two years and ultimately ranged between one and six centimeters. Five patients were retired, five had full-time employment, six were disabled, and eleven were deceased.

Reconstruction with saddle prosthesis following resection for pelvic sarcoma is associated with significant morbidity. However the functional results appear to confer an advantage when compared to the significant disability following hemipelvectomy

Introduction and Aims: The management of bone defects created by Type 1 pelvic resections of large iliac bone tumors remains controversial. We reviewed the functional and oncologic outcome following Type I resection with and without bone reconstruction.

Method: A retrospective review of our prospectively collected database was undertaken analysing functional and oncological outcome of 16 patients with Type I pelvic resections. Minimum follow-up was 12 months (range 12–96 months). Outcome data was available on eight of 10 patients managed without reconstruction (WOR), with the residual ilium allowed to collapse back onto the sacrum, and on five of six patients with bone graft reconstruction (WR). Functional outcome was assessed by the Toronto Extremity Salvage score (TESS) and the Musculoskeletal Tumor Society scores (MSTS87 and MSTS93).

Results: Average age at surgery was 33 years (WOR) and 48 years (WR), (p=0.04), with average maximal tumor dimensions of 12cm and 9cm respectively (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (range 24–96 months) compared to 69%, 21/35 and 51% at an average of 37 months (range 12–60 months) for the WR group. Thirty-three percent of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 50% of WR patients. No local recurrences were identified.

Conclusion: Similar functional and oncologic outcome was achieved in both groups suggesting that bone reconstruction is not justified following Type I pelvic resection.

Introduction Morbidity associated with wound complications may translate into disability and quality-of-life disadvantages for patients treated with radiotherapy (RT) for soft tissue sarcoma (STS) of the extremities. Functional outcome and health status of extremity STS patients randomized in a phase III trial comparing pre-operative versus post-operative RT is described.

Methods One hundred and ninety patients with extremity STS were randomized after stratification by tumor size dichotomized at 10 cm. Function and quality of life were measured by the Musculoskeletal Tumor Society Rating Scale (MSTS), the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36) at randomization, six weeks, and three, six, 12, and 24 months after surgery. One hundred and eighty-five patients had function data.

Results Patients treated with post-operative RT had better function with higher MSTS (25.8 v 21.3, P < .01), TESS (69.8 v 60.6, P =.01), and SF-36 bodily pain (67.7 v 58.5, P =.03) scores at six weeks after surgery. There were no differences at later time points. Scores on the physical function, role-physical, and general health sub-scales of the SF-36 were significantly lower than Canadian normative data at all time points. After treatment arm was controlled for, MSTS change scores were predicted by a lower-extremity tumor, a large resection specimen, and motor nerve sacrifice; TESS change scores were predicted by lower-extremity tumor and prior incomplete excision. When wound complication was included in the model, patients with complications had lower MSTS and TESS scores in the first two years after treatment.

Conclusions The timing of RT has minimal impact on the function of STS patients in the first year after surgery. Tumor characteristics and wound complications have a detrimental effect on patient function.