Outcomes: wedge resection versus lobectomy for non–small cell lung cancer at the Cancer Centre of Southeastern Ontario 1998–2009

Background

Sublobar resection for non–small cell lung cancer (NSCLC) remains controversial owing to concern about local recurrence and long-term survival outcomes. We sought to determine the efficacy of wedge resection as an oncological procedure.

Methods

We analyzed the outcomes of all patients with NSCLC undergoing surgical resection at the Cancer Centre of Southeastern Ontario between 1998 and 2009. The standard of care for patients with adequate cardiopulmonary reserve was lobectomy. Wedge resection was performed for patients with inadequate reserve to tolerate lobectomy. Predictors of recurrence and survival were assessed. Appropriate statistical analyses involved the χ² test, an independent samples t test and Kaplan–Meier estimates of survival. Outcomes were stratified for tumour size and American Joint Committee on Cancer seventh edition TNM stage for non–small cell lung cancer.

Results

A total of 423 patients underwent surgical resection during our study period: wedge resection in 71 patients and lobectomy in 352. The mean age of patients was 64 years. Mean follow-up for cancer survivors was 39 months. There was no significant difference between wedge resection and lobectomy for rate of tumour recurrence, mortality or disease-free survival in patients with stage IA tumours less than 2 cm in diameter.

Conclusion

Wedge resection with lymph node sampling is an adequate oncological procedure for non–small cell lung cancer in properly selected patients, specifically, those with stage IA tumours less than 2 cm in diameter.     

Influence of delays to nonemergent colon cancer surgery on operative mortality,disease-specific survival and overall survival

Background

There has been minimal research on the influence of delays for cancer treatments on patient outcomes. We measured the influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival.

Methods

We used the linked Surveillance, Epidemiology and End Results (SEER)-Medicare databases (1993–1996) to identify patients who underwent nonemergent colon cancer surgery. We assessed 2 time intervals: surgeon consult to hospital admission for surgery and first diagnostic test for colon cancer to hospital admission. Follow-up data were available to the end of 2003. We selected the time intervals to create patient groups with clinical relevance and they did not extend past 120 days.

Results

We identified 7989 patients who underwent nonemergent colon cancer surgery. Median delays from surgeon consult to admission and from first diagnostic test to admission were 7 and 17 days, respectively. The odds of operative mortality were similar if the consult-to-admission interval was 22 days or more versus 1–7 days (odds ratio [OR] 1.0, 95% confidence interval [CI] 0.6–1.8, p = 0.91) or if the test-to-admission interval was 43 days or more versus 1–14 days (OR 0.8, 95% CI 0.4–1.5, p = 0.51), respectively. For these same respective interval comparisons, disease-specific survival was not influenced by the consult-to-admission wait (hazard ratio [HR] 1.0, 95% CI 0.9–1.2, p = 0.91) or the test-to-admission wait (HR 1.0, 95% CI 0.8–1.1, p = 0.63). The risk of death was slightly greater if the consult-to-admission interval was 22 or more days versus 1–7 days (HR 1.1, 95% CI 1.0–1.2, p = 0.013) and if the test-to-admission interval was 43 days or more versus 1–14 days (HR 1.2, 95% CI 1.1–1.3, p = 0.003).

Conclusion

It is unlikely that delays to nonemergent colon cancer surgery longer than 3 weeks from initial surgical consult or longer than 6 weeks from first diagnostic test negatively impact operative mortality, disease-specific survival or overall survival.     

Influence of a province-wide trauma system on motor vehicle collision process of trauma care and mortality: a 10-year follow-up evaluation

Background

Mature trauma systems have evolved to respond to major injury-related morbidity and mortality. Studies of mature trauma systems have demonstrated improved survival, especially among seriously injured patients. From 1995 to 1998, a province-wide trauma system was implemented in the province of Nova Scotia. We measured the proportion of admissions to a tertiary level trauma centre and the proportion of in-hospital deaths among patients with major injuries as a result of a motor vehicle collisions (MVCs) before and 10 years after provincial trauma systems implementation.

Methods

We identified major trauma patients aged 16 years and older using external cause of injury codes pertaining to MVCs from population-based hospital claims and vital statistics data. Individuals who were admitted to hospital or died because of an MVC in 1993–1994 (preimplementation), were compared with those who were admitted to hospital or died in 2003–2005 (postimplementation).

Results

Postimplementation, there was a 9% increase in the number of seriously injured individuals with primary admission to tertiary care. This increase was statistically significant even after we adjusted for age, head injury and municipality of residence (relative risk [RR] 1.09, 95% confidence interval [CI] 1.04–1.14). The probability of dying while in hospital in the postimplementation period decreased by 29% (adjusted RR 0.57, 95% CI 0.32–1.03), although this difference was not statistically significant.

Conclusion

Individuals seriously injured in MVCs in Nova Scotia were more likely to be admitted to tertiary care after the implementation of a province-wide trauma system. There was a trend toward decreased mortality, but further research is warranted to confirm the survival benefit and delineate other contributing factors.     

Hip fracture surgery in Nova Scotia: a comparison of treatment provided by “generalist” general surgeons and orthopedic surgeons

Objective

To determine quality of hip fracture services provided by “generalist” general surgeons (generalists) in Nova Scotia.

Design

Chart review and postoperative, blinded, random-ordered radiologic analysis.

Setting

Three community hospitals and 1 tertiary care hospital in Nova Scotia.

Participants

Seven generalists who performed 120 hip fracture repairs and 7 orthopedic surgeons (specialists) who performed 135 hip fracture repairs.

Outcome measures

Patient demographics, preoperative, perioperative, postoperative and discharge information, technical quality of reduction as determined through postoperative radiologic assessment.

Results

There were no differences between patients treated by generalists and those treated by specialists with respect to age, sex, American Society of Anesthesiologists’ class, level of function and fracture type. Intraoperatively, the patient groups were similar with respect to type of anesthesia, use of antibiotics, number of transfusions and surgical complications. Significant differences were noted in length of operation (54.4 v. 41.1 minutes), use of C-arm imaging (6.7% v. 85.9%) and management of Garden classes 1 and 2 subcapital fractures. Postoperatively, the 2 groups had similar numbers of medical complications, wound complications, reoperations, readmissions and deaths, and a similar level of function on discharge. Significant differences included the number of intensive care unit admissions (5.8% v. 15.6%) and length of stay there (5.7 v. 2.8 days) and of postoperative stay (14.5 v. 10.7 days). The assessment of radiographs did not demonstrate any significant difference in the quality of reduction.

Conclusion

In Nova Scotia the outcomes of hip fracture surgery performed by generalists are comparable to those performed by specialists.     

The efficacy of adjuvant imatinib therapy in improving the prognosis of patients with colorectal gastrointestinal stromal tumourss

Introduction

Although it has now been accepted that imatinib is a valid treatment for gastrointestinal stromal tumour (GIST) patients in the adjuvant setting, information on its clinical efficacy in improving the prognosis for patients with colorectal GISTs is limited.

Methods

The clinical and follow-up records of 42 colorectal GIST patients who underwent surgical resection at our institution between January 2004 and December 2013 were reviewed retrospectively. The effect of postoperative imatinib treatment on recurrence free survival and overall survival time was analysed with the Kaplan–Meier method and the multivariate Cox proportional hazards model.

Results

Sixteen patients were assigned to imatinib treatment (imatinib group) after surgical tumour resection while twenty-six patients did not receive any adjuvant treatment (control group). The one, three and five-year recurrence free survival rates were 100%, 90% and 77% respectively. This was significantly higher than in the control group (92%, 53% and 36%) (logrank test, p=0.012). The one, three and five-year overall survival rates were 100%, 91% and 68% in the imatinib group compared with 96%, 77% and 39% in the control group (logrank test, p=0.021). Analysis with the multivariate Cox regression model yielded similar results on the efficacy of adjuvant imatinib in prolonging both recurrence free survival (hazard ratio [HR]: 0.23, 95% confidence interval [CI]: 0.07–0.80) and overall survival (HR: 0.20, 95% CI: 0.05–0.91).

Conclusions

Adjuvant imatinib therapy seems to be effective in decreasing the risk of tumour occurrence and prolonging the overall survival time in colorectal GIST patients.     

A Prospective Study of the Role of Inflammation in Bladder Cancer

Introduction

To examine the role of inflammation in bladder cancer, we assessed the relationship between a systemic inflammation prognostic score (modified Glasgow Prognostic Score, mGPS), the tumor inflammatory cell infiltrate as measured by the Klintrup-Makinen score and tumor necrosis with cancer specific survival in patients with bladder cancer.

Materials and Methods

The cohort consisted of 68 bladder cancer patients, 47 with localised disease and 21 with muscle invasive disease. The mGPS response was constructed by measuring C-reactive protein and albumin concentrations and the Klintrup-Makinen score was evaluated histologically for the local inflammatory response. Pathological parameters such as grade, T stage and tumor necrosis were also assessed.

Results

Median follow was 47 months and 24 patients died of their disease. On univariate analysis, T stage (p < 0.001), grade (p < 0.001) and mGPS (p = 0.002) were significant predictors of cancer specific survival. On multivariate analysis, T stage (hazard ratio 5.98, 95% confidence interval 3.18–11.24, p < 0.001) and mGPS (hazard ratio 1.78, 95% confidence interval 1.09–2.9, p = 0.02) were significant independent predictors of cancer specific survival.

Conclusion

A preoperative systemic inflammatory response is an independent predictor of poor cancer specific survival in patients with bladder cancer.Key Words: Bladder cancer, C-reactive protein, Inflammation, Glasgow prognostic score, Klintrup-Makinen score     

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis

Background

Older adults (≥ 65 yr) are the fastest growing population and are presenting in increasing numbers for acute surgical care. Emergency surgery is frequently life threatening for older patients. Our objective was to identify predictors of mortality and poor outcome among elderly patients undergoing emergency general surgery.

Methods

We conducted a retrospective cohort study of patients aged 65–80 years undergoing emergency general surgery between 2009 and 2010 at a tertiary care centre. Demographics, comorbidities, in-hospital complications, mortality and disposition characteristics of patients were collected. Logistic regression analysis was used to identify covariate-adjusted predictors of in-hospital mortality and discharge of patients home.

Results

Our analysis included 257 patients with a mean age of 72 years; 52% were men. In-hospital mortality was 12%. Mortality was associated with patients who had higher American Society of Anesthesiologists (ASA) class (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.43–10.33, p = 0.008) and in-hospital complications (OR 1.93, 95% CI 1.32–2.83, p = 0.001). Nearly two-thirds of patients discharged home were younger (OR 0.92, 95% CI 0.85–0.99, p = 0.036), had lower ASA class (OR 0.45, 95% CI 0.27–0.74, p = 0.002) and fewer in-hospital complications (OR 0.69, 95% CI 0.53–0.90, p = 0.007).

Conclusion

American Society of Anesthesiologists class and in-hospital complications are perioperative predictors of mortality and disposition in the older surgical population. Understanding the predictors of poor outcome and the importance of preventing in-hospital complications in older patients will have important clinical utility in terms of preoperative counselling, improving health care and discharging patients home.     

Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority

Background

Existing literature demonstrating the negative impact of delayed hip fracture surgery on mortality consists largely of observational studies prone to selection bias and may overestimate the negative effects of delay. We conducted an intervention study to assess initiatives aimed at meeting a 48-hour benchmark for hip fracture surgery to determine if the intervention achieved a reduction in time to surgery, and if a general reduction in time to surgery improved mortality and length of stay.

Methods

We compared time to surgery, length of stay and mortality between pre- and postintervention patients with a hip fracture using the Kaplan–Meier estimator and Cox proportional hazards model adjusting for age, sex, comorbidities, type of surgery and year.

Results

We included 3525 pre- and 3007 postintervention patients aged 50 years or older. The proportion of patients receiving surgery within the benchmark increased from 66.8% to 84.6%, median length of stay decreased from 13.5 to 9.7 days, and crude in-hospital mortality decreased from 9.6% to 6.8% (all p < 0.001). Adjusted analyses revealed reduced mortality in hospital (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.57–0.81) and at 1 year (HR 0.87, 95%CI 0.79–0.96). Independent of the intervention period, having surgery within 48 hours demonstrated decreased adjusted risk of death in hospital (HR 0.51, 95%CI 0.41–0.63) and at 1 year postsurgery (HR 0.72, 95% CI 0.64–0.80).

Conclusion

Coordinated, region-wide efforts to improve timeliness of hip fracture surgery can successfully reduce time to surgery and appears to reduce length of stay and adjusted mortality in hospital and at 1 year.     

Prognostic variables in adult Wilms tumour

Objective

To identify outcomes and prognostic variables that predict survival outcomes in adult Wilms tumour patients.

Methods

We collected data on 128 patients with adult Wilms tumour treated between 1973 and 2006. Six cases from our 2 Canadian centres have not been previously reported. We collected data on the remaining 122 patients from published case reports or case series. Analyzed factors included age, sex, favourable or unfavourable histopathology, clinical stage (I, II, III or IV) and chemotherapy and radiotherapy received. The outcomes studied included overall survival (OS) and disease-specific survival (DSS). Univariate analysis with Kaplan–Meier actuarial methodology and multivariate analyses with Cox regression were used to determine outcomes and predictive clinical factors.

Results

The patients'' mean age was 26 (range 15–73) years. After a mean follow-up of 54 (range 2–240) months, the OS and DSS of the entire cohort were both 68%. Favourable histopathology predicted superior OS and DSS (both p < 0.001). Higher clinical stage predicted inferior OS and DSS (both p < 0.001).

Conclusion

Adult Wilms tumour has a poorer prognosis than pediatric Wilms tumour. In adults with Wilms tumour, more aggressive patient-and tumour-specific surveillance and adjunctive therapies than those advocated by pediatric National Wilms Tumor Study guidelines may be warranted, especially in patients with an unfavourable histopathology and higher clinical stage.     

2015 Marshall Urist Young Investigator Award: Prognostication in Patients With Long Bone Metastases: Does a Boosting Algorithm Improve Survival Estimates?

Background

Survival estimation guides surgical decision-making in metastatic bone disease. Traditionally, classic scoring systems, such as the Bauer score, provide survival estimates based on a summary score of prognostic factors. Identification of new factors might improve the accuracy of these models. Additionally, the use of different algorithms—nomograms or boosting algorithms—could further improve accuracy of prognostication relative to classic scoring systems. A nomogram is an extension of a classic scoring system and generates a more-individualized survival probability based on a patient’s set of characteristics using a figure. Boosting is a method that automatically trains to classify outcomes by applying classifiers (variables) in a sequential way and subsequently combines them. A boosting algorithm provides survival probabilities based on every possible combination of variables.

Questions/purposes

We wished to (1) assess factors independently associated with decreased survival in patients with metastatic long bone fractures and (2) compare the accuracy of a classic scoring system, nomogram, and boosting algorithms in predicting 30-, 90-, and 365-day survival.

Methods

We included all 927 patients in our retrospective study who underwent surgery for a metastatic long bone fracture at two institutions between January 1999 and December 2013. We included only the first procedure if patients underwent multiple surgical procedures or had more than one fracture. Median followup was 8 months (interquartile range, 3-25 months); 369 of 412 (90%) patients who where alive at 1 year were still in followup. Multivariable Cox regression analysis was used to identify clinical and laboratory factors independently associated with decreased survival. We created a classic scoring system, nomogram, and boosting algorithms based on identified variables. Accuracy of the algorithms was assessed using area under the curve analysis through fivefold cross validation.

Results

The following factors were associated with a decreased likelihood of survival after surgical treatment of a metastatic long bone fracture, after controlling for relevant confounding variables: older age (hazard ratio [HR], 1.0; 95% CI, 1.0–1.0; p < 0.001), additional comorbidity (HR, 1.2; 95% CI, 1.0–1.4; p = 0.034), BMI less than 18.5 kg/m² (HR, 2.0; 95% CI, 1.2–3.5; p = 0.011), tumor type with poor prognosis (HR, 1.8; 95% CI, 1.6–2.2; p < 0.001), multiple bone metastases (HR, 1.3; 95% CI, 1.1–1.6; p = 0.008), visceral metastases (HR, 1.6; 95% CI, 1.4–1.9; p < 0.001), and lower hemoglobin level (HR, 0.91; 95% CI, 0.87–0.96; p < 0.001). The survival estimates by the nomogram were moderately accurate for predicting 30-day (area under the curve [AUC], 0.72), 90-day (AUC, 0.75), and 365-day (AUC, 0.73) survival and remained stable after correcting for optimism through fivefold cross validation. Boosting algorithms were better predictors of survival on the training datasets, but decreased to a performance level comparable to the nomogram when applied on testing datasets for 30-day (AUC, 0.69), 90-day (AUC, 0.75), and 365-day (AUC, 0.72) survival prediction. Performance of the classic scoring system was lowest for all prediction periods.

Conclusions

Comorbidity status and BMI are newly identified factors associated with decreased survival and should be taken into account when estimating survival. Performance of the boosting algorithms and nomogram were comparable on the testing datasets. However, the nomogram is easier to apply and therefore more useful to aid surgical decision making in clinical practice.

Level of Evidence

Level III, prognostic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4446-z) contains supplementary material, which is available to authorized users.     

Impact of perioperative acute ischemic stroke on the outcomes of noncardiac and nonvascular surgery: a single centre prospective study

Background

Although ischemic stroke is a well-known complication of cardiovascular surgery it has not been extensively studied in patients undergoing noncardiac surgery. The aim of this study was to assess the predictors and outcomes of perioperative acute ischemic stroke (PAIS) in patients undergoing noncardiothoracic, nonvascular surgery (NCS).

Methods

We prospectively evaluated patients undergoing NCS and enrolled patients older than 18 years who underwent an elective, non-daytime, open surgical procedure. Electrocardiography and cardiac biomarkers were obtained 1 day before surgery, and on postoperative days 1, 3 and 7.

Results

Of the 1340 patients undergoing NCS, 31 (2.3%) experienced PAIS. Only age (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.01–3.2, p < 0.001) and preoperative history of stroke (OR 3.6, 95% CI 1.2–4.8, p < 0.001) were independent predictors of PAIS according to multivariate analysis. Patients with PAIS had more cardiovascular (51.6% v. 10.6%, p < 0.001) and noncardiovascular complications (67.7% v. 28.3%, p < 0.001). In-hospital mortality was 19.3% for the PAIS group and 1% for those without PAIS (p < 0.001).

Conclusion

Age and preoperative history of stroke were strong risk factors for PAIS in patients undergoing NCS. Patients with PAIS carry an elevated risk of perioperative morbidity and mortality.     

The Importance of Early Carotid Endarterectomy in Symptomatic Patients

INTRODUCTION

Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients.

PATIENTS AND METHODS

A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan–Meier analysis and predictive factors identified using Cox regression analysis.

RESULTS

A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2–360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan–Meier survival analysis). Age (HR 1.059; 95% CI 1.014–1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7–621 days) after the first event. Eleven of 60 (18%) patients waiting ≤?97 days for surgery and 23 of 58 (40%) patients waiting >?97 days had repeat events. (P = 0.011, chi-squared test).

CONCLUSIONS

Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.     

Associations with chest illness and mortality in chronic spinal cord injury

Objective

Identify factors associated with chest illness and describe the relationship between chest illness and mortality in chronic spinal cord injury (SCI).

Design

Cross-sectional survey assessing chest illness and a prospective assessment of mortality.

Methods

Between 1994 and 2005, 430 persons with chronic SCI (mean ± SD), 52.0 ± 14.9 years old, and ≥4 years post SCI (20.5 ± 12.5 years) underwent spirometry, completed a health questionnaire, and reported any chest illness resulting in time off work, indoors, or in bed in the preceding 3 years. Deaths through 2007 were identified.

Outcome measures

Logistic regression assessing relationships with chest illness at baseline and Cox regression assessing the relationship between chest illness and mortality.

Results

Chest illness was reported by 139 persons (32.3%). Personal characteristics associated with chest illness were current smoking (odds ratio =2.15; 95% confidence interval =1.25–3.70 per each pack per day increase), chronic obstructive pulmonary disease (COPD) (3.52; 1.79–6.92), and heart disease (2.18; 1.14–4.16). Adjusting for age, subjects reporting previous chest illness had a non-significantly increased hazard ratio (HR) for mortality (1.30; 0.88–1.91). In a multivariable model, independent predictors of mortality were greater age, SCI level and completeness of injury, diabetes, a lower %-predicted forced expiratory volume in 1 second, heart disease, and smoking history. Adjusting for these covariates, the effect of a previous chest illness on mortality was attenuated (HR = 1.15; 0.77–1.73).

Conclusion

In chronic SCI, chest illness in the preceding 3 years was not an independent risk factor for mortality and was not associated with level and completeness of SCI, but was associated with current smoking, physician-diagnosed COPD, and heart disease history.     

The epidemiology of cutaneous malignant melanoma in Nova Scotia

BACKGROUND:

Since 1993, the annual increase in cutaneous malignant melanoma (MM) incidence has been one of the highest for all cancers registered in Canada, with the leading rate in Nova Scotia (NS). The purpose of the present study was to document the pathological and epidemiological data on MM cases found in NS.

PATIENTS AND METHODS:

All MM cases identified by the Nova Scotia Cancer Registry from January 1998 to December 2002 were evaluated. The five-year survival outlook, by major prognostic factors, was also determined. In addition, the annual incidence and mortality rates from 1972 to 2002 were computed.

RESULTS:

Between 1998 and 2002, 925 MM cases were recorded. The age-standardized incidence rate for males and females in this period was 19.2 and 16.1 per 100,000 respectively. Men 65 years of age or older had the highest age-specific rate. The most common MM had a Breslow’s depth of less than 1.0 mm (61.9%) and was Clark’s level II (34.9%). There was no significant seasonal variation noted in the time of diagnosis. Survival analyses indicated that sex, age, tumour location and thickness were significant independent predictors. Despite the increase in incidence, there have only been modest changes in the annual mortality rate.

CONCLUSION:

The incidence of MM in NS increases with age, and is nearly double for men 65 years of age or older, compared with women in the same age group. Thin melanomas on the extremities of young females have the best prognosis in NS, which is similar to other parts of the world. Incidence appears to be unrelated to season. Public health interventions are necessary to reduce the burden of this disease.     

Comparison of oncological safety between nipple sparing mastectomy and total mastectomy using propensity score matching

Introdcution

Although nipple sparing mastectomy (NSM) has attracted increased recognition as an alternative to traditional mastectomy approaches, its oncological safety is unclear. The purpose of this study was to compare the local recurrence rate between NSM and total mastectomy (TM).

Methods

Between 2003 and 2013, 121 and 557 patients with stage 0–III breast cancer underwent NSM and TM respectively. Multivariate Cox regression and propensity score models were used to compare the two groups.

Results

There was no significant difference in the five-year local recurrence rate between the NSM and TM groups (7.6% vs 4.9%, p=0.398). In multivariate analysis, NSM was not a risk factor for local recurrence (hazard ratio: 1.653, 95% confidence interval: 0.586–4.663, p=0.343). Propensity score matching found similar five-year local recurrence free survival rates between the two groups (92.3% vs 93.7%, p=0.655).

Conclusions

Our results suggest that NSM may provide oncological safety comparable with mastectomy for carefully selected patients.     

Hip resurfacing arthroplasty at a non-specialist centre

INTRODUCTION

Few studies have reported the outcome of hip resurfacing arthroplasty (HRA) with respect to implant characteristics from non-specialist centres. We report the survival, clinical and radiological outcomes of a single surgeon series of HRA with an average follow-up duration of five years.

METHODS

All consecutive HRAs performed by a single surgeon between 2003 and 2011 at a district general hospital were retrospectively examined clinically and radiologically.

RESULTS

A total of 85 patients underwent 109 HRAs (58 male [53.2%] and 51 female patients [46.8%]) with a mean follow-up period of 62 months (range: 12–102 months). The median age was 57 years (range: 25–75 years). The mean acetabular and femoral head component sizes were 54mm (range: 48–64mm) and 48mm (range: 42–58mm) respectively with a mean acetabular inclination angle of 42.9º (range: 20–75º).The survival rate was 95% with five revisions due to aseptic loosening (n=3) and fracture (n=2): these were predominantly for female patients (n=4), with significantly smaller mean acetabular (51mm, p=0.04) and femoral (44mm, p=0.02) implant sizes. Furthermore, they had a higher mean acetabular inclination angle of 48.1º (p=0.74). The mean Oxford hip score was 43.8 (range: 25–48) and the mean University of California Los Angeles (UCLA) activity score was 6.8 (range: 3–10). Radiological findings included heterotopic ossification in 13 (11.9%), radiolucent lines in 6 (5.5%), femoral neck thinning in 2 (1.8%) and femoral neck notching in 5 patients (4.6%).

CONCLUSIONS

We have shown that HRA at a non-specialist centre has short to medium-term outcomes comparable with those at specialist centres. HRA therefore remains a viable option although vigilance is required in case selection and follow-up according to national guidance.     

Should High-grade Extraosseous Osteosarcoma Be Treated With Multimodality Therapy Like Other Soft Tissue Sarcomas?

Background

Extraosseous osteosarcoma is rare, and the most appropriate therapy is unclear because there are few studies regarding its treatment. The effectiveness of radiation and chemotherapy remains uncertain owing to conflicting results in previous reports.

Questions/purposes

To review our experience with contemporary multimodality treatment, we asked: (1) What is the disease-specific survival and local relapse-free survival? (2) Does American Joint Commission on Cancer (AJCC) stage, tumor size, or location relate to disease outcome? (3) Does radiation therapy improve local control or survival? (4) Do doxorubicin and ifosfamide improve local control or survival?

Methods

Between 1990 and 2012, we treated 40 patients for localized, high-grade extraosseous osteosarcoma. In this retrospective study, we could determine the status of 36 patients (90%) either to death or for a minimum of 24 months of followup; four (10%) were lost to followup before 24 months. There were 11 patients with AJCC Stage IIA and 25 with Stage III disease. All patients underwent wide surgical excision. Of the patients with Stage IIA disease, four received radiation and none received chemotherapy. Of the patients with Stage III disease, six received radiation, seven were treated with chemotherapy, and six received radiation and chemotherapy. During the study period, high-dose doxorubicin and ifosfamide was the preferred chemotherapy regimen for patients younger than 60 years with normal cardiac and renal function. Local relapse-free survival and disease-specific survival were determined by Kaplan-Meier analysis using a prospectively maintained institutional database supplemented by information from the institutional tumor registry. The Cox proportional hazard model was used to determine the effect of various factors on local recurrence and patient survival.

Results

At 5 years, local relapse-free survival was 47% (95% CI, 27%–64%), and disease-specific survival was 53% (95% CI, 35%–68%). In multivariate analysis, AJCC stage, which depends on tumor size, was the strongest predictor of local relapse-free survival (hazard ratio [HR] = 0.17, p = 0.02), while tumor depth was the best predictor of disease-specific survival (HR = 5.6, p = 0.02). Radiation improved local relapse-free survival (HR = 0.30, p = 0.03) but not disease-specific survival in multivariate analysis. A regimen of doxorubicin and ifosfamide was associated with better local relapse-free survival for patients with Stage III disease (HR = 0.16, p = 0.04) but not disease-specific survival (HR = 0.32, p = 0.08).

Conclusions

With the limited number of patients in our study, it appears that extraosseous osteosarcoma behaves differently than osteosarcoma of bone. Multimodality treatment that includes doxorubicin and ifosfamide-based chemotherapy, radiation, and surgery may be a valid therapeutic strategy for Stage III disease, but larger, prospective studies will be needed to verify our preliminary observations.

Level of Evidence

Level III, therapeutic study.     

Surgery of skeletal metastases in 306 patients with prostate cancer

Purpose

Skeletal metastases are common in patients with prostate cancer, and they can be a source of considerable morbidity. We analyzed patient survival after surgery for skeletal metastases and identified risk factors for reoperation and complications.

Patients and methods

This study included 306 patients with prostate cancer operated for skeletal metastases during 1989–2010. Kaplan-Meier analysis was used to calculate survival. Cox multiple regression analysis was performed to study risk factors, and results were expressed as hazard ratios (HRs).

Results

The median age at surgery was 72 (49–94) years. The median survival after surgery was 0.5 (0–16) years. The cumulative 1-, 2-, and 3-year survival after surgery was 29% (95% CI: 24–34), 14% (10–18), and 8% (5–11). Age over 70 years (HR 1.4), generalized metastases (HR 2.4), and multiple skeletal metastases (HR 2.3) resulted in an increased risk of death after surgery. Patients with lesions in the humerus (HR 0.6) had a lower death rate. The reoperation rate was 9% (n = 31). The reasons for reoperation were deep wound infection (n = 10), hematoma (n = 7), material (implant) failure (n = 3), wound dehiscence (n = 3), increasing neurological symptoms (n = 2), prosthetic dislocation (n = 2), and others (n = 4).

Interpretation

This study involves the largest reported cohort of patients operated for skeletal lesions from prostate cancer. Our survival data and analysis of predictors for survival help to set appropriate expectations for the patients, families, and medical staff.Advances in the treatment of prostate cancer have extended life expectancy (Berruti et al. 2000, Carlin and Andriole 2000, Saad et al. 2006). Approximately 70% of the patients with advanced disease can be expected to develop skeletal metastases (Coleman 2001).The role of orthopedic surgery in patients with skeletal metastases is to treat spinal cord compression and existing or impending pathological fractures in an effort to relieve pain and restore function. Information on outcomes following surgery for skeletal metastases is important for the patients involved, for their families, and for treating physicians (Wedin et al. 2005, Forsberg et al. 2011).Skeletal metastases from other malignancies are most often osteolytic whereas skeletal metastases from prostate cancer are most often osteoblastic, which may mean unique treatment considerations. However, little attention has been paid to survival and postoperative complications in patients with metastatic prostate lesions.We have determined patient survival following surgery for symptomatic skeletal metastases in a large cohort of prostate cancer patients. A secondary aim was to identify patient-related and procedure-related risk factors for complications and reoperation.