Session 5: Tumor
Torsdag den 25. oktober
09:30-10:30
Lokale: Reykjavik
Chairmen: Michala Skovlund Sørensen og Johnny Keller
Kolja Weber, Bjarne Hauge Hansen
Orthopaedic Department, Rigshospitalet; Orthopaedic Department, Aarhus Universitetshospital
Background: Solitary enchondromas in long bones are benign cartilage lesions, that have a low risk of transformation into a secondary chondrosarcoma. They are often asymptomatic and a common incidental finding on MRI scans and x-rays. There is no national or international consensus on the management or follow-up of these findings.
Purpose / Aim of Study: The aim of this study was to create a short clinical guideline for the follow-up of benign appearing solitary enchondromas in long bones in adults.
Materials and Methods: A literature search for the keywords enchondroma and follow-up/control was performed. Four articles were found to be relevant for this study: one minireview, one literature review and two retrospective studies. Primary outcomes were signs of growth or malignancy.
Findings / Results: There was found wide variation and low evidence for the proposed follow-up of an incidentally found enchondroma in the literature. There seems to be consensus that MRI is the best modality to detect growth or signs of malignancy. Furthermore, several studies recommend the first follow-up scan after one year. There is however great uncertainty about the long-term follow-up.
Conclusions: Based on these findings we recommend a follow-up with MRI scan one and three years after the incidental finding of an intramedullary, asymptomatic, benign appearing enchondroma in long bones in adults. A longer or more frequent follow-up should be considered in selected cases after multidisciplinary evaluation.
Orthopaedic Department, Rigshospitalet; Orthopaedic Department, Aarhus Universitetshospital
Background: Solitary enchondromas in long bones are benign cartilage lesions, that have a low risk of transformation into a secondary chondrosarcoma. They are often asymptomatic and a common incidental finding on MRI scans and x-rays. There is no national or international consensus on the management or follow-up of these findings.
Purpose / Aim of Study: The aim of this study was to create a short clinical guideline for the follow-up of benign appearing solitary enchondromas in long bones in adults.
Materials and Methods: A literature search for the keywords enchondroma and follow-up/control was performed. Four articles were found to be relevant for this study: one minireview, one literature review and two retrospective studies. Primary outcomes were signs of growth or malignancy.
Findings / Results: There was found wide variation and low evidence for the proposed follow-up of an incidentally found enchondroma in the literature. There seems to be consensus that MRI is the best modality to detect growth or signs of malignancy. Furthermore, several studies recommend the first follow-up scan after one year. There is however great uncertainty about the long-term follow-up.
Conclusions: Based on these findings we recommend a follow-up with MRI scan one and three years after the incidental finding of an intramedullary, asymptomatic, benign appearing enchondroma in long bones in adults. A longer or more frequent follow-up should be considered in selected cases after multidisciplinary evaluation.
Michala Skovlund Sørensen, Klaus Hindsø, Michael Mørk Petersen
Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet; Børnesektionen, Ortopædkirurgisk klinik, Rigshospitalet; Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet
Background: Treatment of metastatic bone disease (MBD) at highly specialized centers (HSC) will cause a treatment delay. As studies indicate treatment delay for non-pathological proximal femur fractures increases the risk of early mortality we hypothesized that treatment delay was a risk factor for early postoperative mortality when treating MBD of the proximal femur.
Purpose / Aim of Study: Is surgical delay when treating MBD in proximal femur a risk factor for postoperative mortality?
Materials and Methods: A prospective population-based multicenter study was conducted identifying patients having surgery for Fractured Metastatic Lesions of the proximal/diaphysial Femur (MBDf) (AO classification 31./32.) from May 2014-May 2016. Known risk factors for postoperative survival was obtained for adjustment in regression analysis (Karnofsky score, ASA-score, preoperative hemoglobin, major bone resection).
Findings / Results: Eighty-five patients underwent surgery for MBDf (HSC n=33, secondary surgical center (SSC) = 52). Mean treatment delay from fracture to surgery was 6 days (0-63) (HSC: 11 days, SSC: 3 days). Overall 30-day survival was 81 % (C.I.: 73-90) and 16 patients succumbed to disease during the period. Association with early postoperative death was not found in crude neither adjusted analysis (OR: 1.22; C.I.: 0.31-4.85; p=0.776) but patients treated at SSC had an OR 8.82; C.I.: 0.98-85.18, p=0.051 risk of mortality.
Conclusions: Surgical delay when treating MBDf does not seem to influence postoperative mortality and the authors advocate for taking the time to perform thorough preoperative evaluation of patient performance and anatomical considerations aiming to customize surgical intervention to individual patients rather than rushing into surgery.
Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet; Børnesektionen, Ortopædkirurgisk klinik, Rigshospitalet; Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet
Background: Treatment of metastatic bone disease (MBD) at highly specialized centers (HSC) will cause a treatment delay. As studies indicate treatment delay for non-pathological proximal femur fractures increases the risk of early mortality we hypothesized that treatment delay was a risk factor for early postoperative mortality when treating MBD of the proximal femur.
Purpose / Aim of Study: Is surgical delay when treating MBD in proximal femur a risk factor for postoperative mortality?
Materials and Methods: A prospective population-based multicenter study was conducted identifying patients having surgery for Fractured Metastatic Lesions of the proximal/diaphysial Femur (MBDf) (AO classification 31./32.) from May 2014-May 2016. Known risk factors for postoperative survival was obtained for adjustment in regression analysis (Karnofsky score, ASA-score, preoperative hemoglobin, major bone resection).
Findings / Results: Eighty-five patients underwent surgery for MBDf (HSC n=33, secondary surgical center (SSC) = 52). Mean treatment delay from fracture to surgery was 6 days (0-63) (HSC: 11 days, SSC: 3 days). Overall 30-day survival was 81 % (C.I.: 73-90) and 16 patients succumbed to disease during the period. Association with early postoperative death was not found in crude neither adjusted analysis (OR: 1.22; C.I.: 0.31-4.85; p=0.776) but patients treated at SSC had an OR 8.82; C.I.: 0.98-85.18, p=0.051 risk of mortality.
Conclusions: Surgical delay when treating MBDf does not seem to influence postoperative mortality and the authors advocate for taking the time to perform thorough preoperative evaluation of patient performance and anatomical considerations aiming to customize surgical intervention to individual patients rather than rushing into surgery.
Michala Skovlund Sørensen, Peter F. Horstmann, Klaus Hindsø, Michael Mørk Petersen
Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet; Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet; Børnesektionen, Ortopædkirurgisk klinik, Rigshospitalet; Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet
Background: Endoprosthesis is considered a more durable implant for treating metastatic bone disease of the proximal femur (MBDf),hitherto no prospective studies of a population based cohort has been conducted, thus the evidence level is very low.
Purpose / Aim of Study: Investigate if the use of endoprosthesis for treatment of MBDf posed a lower risk of failure of implant compared to internal fixation.
Materials and Methods: A prospective population-based cross-sectional multicenter study. Inclusion criteria: MBDf and anatomical location of AO 31./32. Exclusion criteria: no implantation used (Girdlestone procedure). This resulted in inclusion of 118 patients during the two year period (2014-2016) and exclusion of 1 patient. Patients were followed for a minimum of two-years after surgery or death.
Findings / Results: Forty-eight internal fixations (5 plates, 42 nails, 1 screw-fixation), 35 total hip replacements (2 partial pelvic replacement cups), 32 hemiarthroplasty (all bipolar heads) and 2 intercalary spacers was implanted. Twenty complications were observed, 9 requiring revision surgeries (4 endoprosthesis/5 internal fixations). One intercalary spacer and 5 internal fixations was removed. One-year implant removal risk was 8 % (CI:1%-16%) for internal fixation. No endoprothesis was removed within 1 year. For the implants in risk of dislocation (n=67) 4 dislocated (1-2 times) resulting in a 1-year risk of experiencing a dislocation of 6% (CI:0%-12%).
Conclusions: We find that the use of endoprosthesis for treatment of MBDf result in a decreased risk of implant removal compared to internal fixation and endoprosthesis is thus a more durable implant. Interpretation of our result should however imprint that no randomization of implants were present in current study and thus our study is limited by selection bias.
Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet; Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet; Børnesektionen, Ortopædkirurgisk klinik, Rigshospitalet; Tumor sektionen, Ortopædkirurgisk klinik, Rigshospitalet
Background: Endoprosthesis is considered a more durable implant for treating metastatic bone disease of the proximal femur (MBDf),hitherto no prospective studies of a population based cohort has been conducted, thus the evidence level is very low.
Purpose / Aim of Study: Investigate if the use of endoprosthesis for treatment of MBDf posed a lower risk of failure of implant compared to internal fixation.
Materials and Methods: A prospective population-based cross-sectional multicenter study. Inclusion criteria: MBDf and anatomical location of AO 31./32. Exclusion criteria: no implantation used (Girdlestone procedure). This resulted in inclusion of 118 patients during the two year period (2014-2016) and exclusion of 1 patient. Patients were followed for a minimum of two-years after surgery or death.
Findings / Results: Forty-eight internal fixations (5 plates, 42 nails, 1 screw-fixation), 35 total hip replacements (2 partial pelvic replacement cups), 32 hemiarthroplasty (all bipolar heads) and 2 intercalary spacers was implanted. Twenty complications were observed, 9 requiring revision surgeries (4 endoprosthesis/5 internal fixations). One intercalary spacer and 5 internal fixations was removed. One-year implant removal risk was 8 % (CI:1%-16%) for internal fixation. No endoprothesis was removed within 1 year. For the implants in risk of dislocation (n=67) 4 dislocated (1-2 times) resulting in a 1-year risk of experiencing a dislocation of 6% (CI:0%-12%).
Conclusions: We find that the use of endoprosthesis for treatment of MBDf result in a decreased risk of implant removal compared to internal fixation and endoprosthesis is thus a more durable implant. Interpretation of our result should however imprint that no randomization of implants were present in current study and thus our study is limited by selection bias.
Mujgan Yilmaz, Michala S. Sørensen, Casper Sæbye, Thomas Baad-Hansen, Michael M. Petersen
Musculoskeletal Tumor Section, Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej; Musculoskeletal Tumor Section, Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej; Tumor Section Department of Orthopedics, Aarhus University Hospital; Tumor Section Department of Orthopedics, Aarhus University Hospital; Musculoskeletal Tumor Section, Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej
Background: Limb-sparing tumor resection is possible in 90% of patients suffering from bone sarcomas (BS) and the preferred method of reconstruction is tumor-prostheses.
Purpose / Aim of Study: This study aims to demonstrate implant and patient survival following limb-sparing surgery using GMRS tumor prosthesis (Stryker) in oncologic patients.
Materials and Methods: A Danish national consecutive cohort of patients (n= 119, F/M=54/65) reconstructed with GMRS for BS or Giant cell tumor (GCT) (n=78), metastatic bone disease (MBD) (n=41) from 2005 to 2013. Resections performed: distal femur (n= 50), proximal femur (n=41), proximal tibia (n=25), or total femur (n=3). Statistics: Kaplan Meier survival analysis and competing risk analysis.
Findings / Results: All-cause 5- and 10-year estimated patient survival was 63% and 51%, for BS 79% and 70%, for MBD 33% and non-existing. Estimated all-cause 5 and 10-years probability of revision free survival was 74%, and 50%. Five and 10-year probability of revision free survival of bone-anchored components (12 patients revised: deep infection (n=3), aseptic loosening (n=5), open reposition of hip dislocation (n=2) with exchange of prostheses components, revision of acetabular component (n=1) or amputation due to deep infection (n=1)) was 92%, and 69%. Ten amputations were performed due to local relapse (n=8), aseptic loosening (n=1) or recurrent infections (n=1) resulting in a 5 and 10-year estimated limb-survival of 91% and 84%. Competing risk analysis resulted in a 5-year revision risk of 14%, revision due to bone- anchored parts of 6%, and risk of amputation at 8%.
Conclusions: Reconstruction with GMRS results in acceptable revision risk. As current study consists of BS, GCT and MBD with different survival rates, one should note the overestimation of revision risk in survival estimations, compared to the competing risk analysis.
Musculoskeletal Tumor Section, Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej; Musculoskeletal Tumor Section, Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej; Tumor Section Department of Orthopedics, Aarhus University Hospital; Tumor Section Department of Orthopedics, Aarhus University Hospital; Musculoskeletal Tumor Section, Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej
Background: Limb-sparing tumor resection is possible in 90% of patients suffering from bone sarcomas (BS) and the preferred method of reconstruction is tumor-prostheses.
Purpose / Aim of Study: This study aims to demonstrate implant and patient survival following limb-sparing surgery using GMRS tumor prosthesis (Stryker) in oncologic patients.
Materials and Methods: A Danish national consecutive cohort of patients (n= 119, F/M=54/65) reconstructed with GMRS for BS or Giant cell tumor (GCT) (n=78), metastatic bone disease (MBD) (n=41) from 2005 to 2013. Resections performed: distal femur (n= 50), proximal femur (n=41), proximal tibia (n=25), or total femur (n=3). Statistics: Kaplan Meier survival analysis and competing risk analysis.
Findings / Results: All-cause 5- and 10-year estimated patient survival was 63% and 51%, for BS 79% and 70%, for MBD 33% and non-existing. Estimated all-cause 5 and 10-years probability of revision free survival was 74%, and 50%. Five and 10-year probability of revision free survival of bone-anchored components (12 patients revised: deep infection (n=3), aseptic loosening (n=5), open reposition of hip dislocation (n=2) with exchange of prostheses components, revision of acetabular component (n=1) or amputation due to deep infection (n=1)) was 92%, and 69%. Ten amputations were performed due to local relapse (n=8), aseptic loosening (n=1) or recurrent infections (n=1) resulting in a 5 and 10-year estimated limb-survival of 91% and 84%. Competing risk analysis resulted in a 5-year revision risk of 14%, revision due to bone- anchored parts of 6%, and risk of amputation at 8%.
Conclusions: Reconstruction with GMRS results in acceptable revision risk. As current study consists of BS, GCT and MBD with different survival rates, one should note the overestimation of revision risk in survival estimations, compared to the competing risk analysis.
Andreas Saine Granlund, Michael Mørk Petersen, Claus Lindkær Jensen, Michala Skovlund Sørensen
Department of Orthopaedic Surgery, Rigshospitalet; Department of Orthopaedic Surgery, Rigshospitalet; Department of Orthopaedic Surgery, Rigshospitalet; Department of Orthopaedic Surgery, Rigshospitalet
Background: Scwhannoma is a benign, encapsulated and slowly growing tumor originating from the Scwhann cells and is rarely seen in the peripheral nerve system. Typical symptoms are soreness, radiating pain and sensational loss combined with a soft tissue mass
Purpose / Aim of Study: To evaluate the pre- and postoperative symptoms in patients treated for benign schwannomas in the extremities and investigate the rate of malignant transformation.
Materials and Methods: A retrospective study was conducted with data from the institutional pathology database and patient files.
Findings / Results: We identified 858 cases from the institutional pathology register. We excluded cases with doublets (n=407), pathology not including Schwannoma (n =149), surgery in the torso, spine and neck (n=150) leaving 152 patients for further analysis. A total of 110 patients had surgery and five complications to surgery were observed: 2 infections (cured with antibiotics) and 3 nerve palsies (2 n.radialis and 1 n.medianus) which remitted spontaneously. At end of follow-up a post-operative decrease in percentage of following symptoms were registered: paresthesia 18% (41/50), local pain 81% (6/36), radiating pain 90% (6/61), swelling 38% (8/13) and uncharacteristic complains 50% (10/20). One patient with a schwannoma diagnosed by needle biopsy had malignant transformation verified after final surgery. No local recurrences were reported. Mean follow-up was 4 months (0 – 62)
Conclusions: This study shows that operation of schwannomas can be conducted with low risk of complications and with acceptable clinical results. The remission rate of symptoms is high and risk for malignant transformation is low.
Department of Orthopaedic Surgery, Rigshospitalet; Department of Orthopaedic Surgery, Rigshospitalet; Department of Orthopaedic Surgery, Rigshospitalet; Department of Orthopaedic Surgery, Rigshospitalet
Background: Scwhannoma is a benign, encapsulated and slowly growing tumor originating from the Scwhann cells and is rarely seen in the peripheral nerve system. Typical symptoms are soreness, radiating pain and sensational loss combined with a soft tissue mass
Purpose / Aim of Study: To evaluate the pre- and postoperative symptoms in patients treated for benign schwannomas in the extremities and investigate the rate of malignant transformation.
Materials and Methods: A retrospective study was conducted with data from the institutional pathology database and patient files.
Findings / Results: We identified 858 cases from the institutional pathology register. We excluded cases with doublets (n=407), pathology not including Schwannoma (n =149), surgery in the torso, spine and neck (n=150) leaving 152 patients for further analysis. A total of 110 patients had surgery and five complications to surgery were observed: 2 infections (cured with antibiotics) and 3 nerve palsies (2 n.radialis and 1 n.medianus) which remitted spontaneously. At end of follow-up a post-operative decrease in percentage of following symptoms were registered: paresthesia 18% (41/50), local pain 81% (6/36), radiating pain 90% (6/61), swelling 38% (8/13) and uncharacteristic complains 50% (10/20). One patient with a schwannoma diagnosed by needle biopsy had malignant transformation verified after final surgery. No local recurrences were reported. Mean follow-up was 4 months (0 – 62)
Conclusions: This study shows that operation of schwannomas can be conducted with low risk of complications and with acceptable clinical results. The remission rate of symptoms is high and risk for malignant transformation is low.
T.D. Hariharan, V.T.K. Titus, V.M. George, Jerry Nesraj
Orthopaedics, Unit 2, Christian Medical College, Vellore; Orthopaedics, Unit 2,, Christian Medical College, Vellore; Orthopaedics, Unit 2, Christian Medical College, Vellore.; Orthopaedics, Unit 2, Christian Medical College, Vellore
Background: The approach to distal radius(DR) tumors that require en-bloc excision is usually volar but may require a secondary incision if tumor size is large. We present a lateral single incision approach that has the prerequisites for tumor surgery- visualization and extensile exposure.
Purpose / Aim of Study: We aimed to approach tumors of the distal radius through a lateral approach. We looked for short term complications, tumor spillage, skin issues and time to union after reconstruction.
Materials and Methods: We prospectively treated 9 DR tumors requiring en-bloc excision (GCT and Osteosarcoma) using this approach. A preliminary study was done on 4 cadavers and the skin incision and approach was based on vascularity and natural barriers to tumor spread. All patients were operated on by a single surgeon under tourniquet and a regional block +/- GA. The incidence of paraesthesia and motor dysfunction was recorded at 24, 48 and 72 hours post op. Skin complications including necrosis and delay of suture removal and tumor spillage was recorded. Time to union and infections were documented.
Findings / Results: Tumors tended to blow out dorsally and laterally. One tumor involved a branch of the sensory radial nerve and this patient had partial paraesthesia post op. There was tumor spillage in one patient (GCT) where the shaft fractured while incising the IO membrane. All reconstructions utilized the fibula and had united within 12 weeks.
Conclusions: This approach incorporates natural barriers to tumor expansion into the excision bloc. The pronator quadratus, the BR tendon, the deep layer of the dorsal-retinaculum and wrist ligaments were not violated. Medially the IOM limited spread. Volar and dorsal ligament reconstruction was easily visualised. This approach allows adequate visualisation and extensile exposure and facilitates volar and dorsal reconstruction.
Orthopaedics, Unit 2, Christian Medical College, Vellore; Orthopaedics, Unit 2,, Christian Medical College, Vellore; Orthopaedics, Unit 2, Christian Medical College, Vellore.; Orthopaedics, Unit 2, Christian Medical College, Vellore
Background: The approach to distal radius(DR) tumors that require en-bloc excision is usually volar but may require a secondary incision if tumor size is large. We present a lateral single incision approach that has the prerequisites for tumor surgery- visualization and extensile exposure.
Purpose / Aim of Study: We aimed to approach tumors of the distal radius through a lateral approach. We looked for short term complications, tumor spillage, skin issues and time to union after reconstruction.
Materials and Methods: We prospectively treated 9 DR tumors requiring en-bloc excision (GCT and Osteosarcoma) using this approach. A preliminary study was done on 4 cadavers and the skin incision and approach was based on vascularity and natural barriers to tumor spread. All patients were operated on by a single surgeon under tourniquet and a regional block +/- GA. The incidence of paraesthesia and motor dysfunction was recorded at 24, 48 and 72 hours post op. Skin complications including necrosis and delay of suture removal and tumor spillage was recorded. Time to union and infections were documented.
Findings / Results: Tumors tended to blow out dorsally and laterally. One tumor involved a branch of the sensory radial nerve and this patient had partial paraesthesia post op. There was tumor spillage in one patient (GCT) where the shaft fractured while incising the IO membrane. All reconstructions utilized the fibula and had united within 12 weeks.
Conclusions: This approach incorporates natural barriers to tumor expansion into the excision bloc. The pronator quadratus, the BR tendon, the deep layer of the dorsal-retinaculum and wrist ligaments were not violated. Medially the IOM limited spread. Volar and dorsal ligament reconstruction was easily visualised. This approach allows adequate visualisation and extensile exposure and facilitates volar and dorsal reconstruction.