adductor compartment sts - does method of treatment affect outcome? anup pradhan, yiu-chung cheung...
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Adductor Compartment STS- Does method of treatment
affect outcome?
Anup Pradhan, Yiu-Chung CheungBirmingham Medical School, UK
Supervisors: Mr Robert J Grimer
Royal Orthopaedic Hospital, Birmingham, UKDr Peter Ferguson
Mount Sinai Hospital, Toronto, Canada
Background
•Presents late•Often large•Neurovascular bundle close
Surgical challenge!
Marginal close to femoral vessels
Vessels preserved Big hole !
7 days later… 14 days later…
Aim of the project To assess outcomes at ROH Birmingham
Survival Local control Complications Function
To compare with a major North American Centre
To determine if different treatment methods affected above outcomes
Treatment philosophies in the two Specialist Regional Centres
ROH, Birmingham, UK Surgery followed by RT (most cases)
MSH, Toronto Surgery preceded by RT (most cases) Frequent use of flaps
MethodProspective databases
Study period (Jan 1990 – Jan 2001)
Collection of basic data and outcomes demographic data Size, grade (tumour) Treatment methods Survivorship for LR, OS Wound complications TESS for function
Exclusions
Metastases at diagnosisPrevious treatment elsewhere Patients lost to follow up Unfit for surgery
Patient age distribution
P = 0.98
0
2
4
6
8
10
12
14
16
18
20
Cou
nt
0 20 40 60 80 100Age
Median Age 55yrs
ROH
0
2
4
6
8
10
12
14
16
18
20
Cou
nt
0 20 40 60 80 100Age
Median Age 56.5yrs
MSH
Tumour size at diagnosis
P = 0.11
0
5
10
15
20
25
Cou
nt
0 5 10 15 20 25 30 35 40Size in cms
Median = 13cm
ROH
Median = 9.5cm
MSH
0
5
10
15
20
25
30
35
40
Cou
nt
0 5 10 15 20 25 30 35 40Size in cm
Factor ROH(n = 64)
MSH(n = 62)
P-value
Mean (median) Age 55 (57) 55 (56.5) 0.98
Mean (median) Size (cm)
13.2 (12.8) 11.4 (9.5) 0.11
Proportion > 10cm 38 (59%) 25 (40%) 0.03
Proportion of high grade tumours
36 (56%) 35 (56%) 0.98
Adequate margins 46 (72%) 44 (71%) 0.91
Pre-operative radiotherapy
NIL 26 (42%)
Post-operative radiotherapy
60 (94%) 30 (48%)
Use of muscle flaps NIL 26 (42%)
Patient and Treatment Factors
Factor ROH(n = 64)
MSH(n = 62)
P-value
Length of stay 10.4 11.6 0.50
Wound complications
27 (42%) 14 (23%) 0.019
Local Recurrence(5 Year)
28% 10% 0.015
Metastases(5 Year)
51.5% 38.8% 0.48
Overall survival(5 Year)
58% 74% 0.13
TESS score 72% 79% 0.18
Outcomes
Oncological and Functional Outcomes
Comparing OS between the 2 centres
0
.2
.4
.6
.8
1
Cum
. Sur
viva
l
0 20 40 60 80 100 120 140 160 180Time
Event Times (ROH)
Cum. Survival (ROH)
Event Times (MSH)
Cum. Survival (MSH)
P = 0.13
5yr OS = 74% MSH
5yr OS =57% ROH
0
.2
.4
.6
.8
1
Cum
. S
urvi
val
0 20 40 60 80 100 120 140 160 180
Time
Event Times (low +int)
Cum. Survival (low +int)
Event Times (high)
Cum. Survival (high)
Overall survival by grade
Low/Intermediate grade
High grade
P < 0.001
Overall survival by size
0
.2
.4
.6
.8
1
Cum
. S
urvi
val
0 20 40 60 80 100 120 140 160 180Time
Event Times (>10)
Cum. Survival (>10)
Event Times (10 or under)
Cum. Survival (10 or under)
P = 0.015Size ≤ 10cm
Size > 10cm
Comparison of OS between pre and post RT groups
0
.2
.4
.6
.8
1
Cum
. Sur
viva
l
0 20 40 60 80 100
Event Times (preop)
Cum. Survival (preop)
Event Times (postop)
Cum. Survival (postop)
P = 0.55
(combined data from both centres)
Postop RT
Preop RT
Comparing LR between the 2 centres
0
.2
.4
.6
.8
1
Cum
. S
urv
ival
0 20 40 60 80 100 120 140 160Time
Event Times (ROH)
Cum. Survival (ROH)
Event Times (MSH)
Cum. Survival (MSH)
P = 0.01455YLR = 10%
5YLR = 28%
Factor associated with LR ROH(p-value)
MSH(p-value)
Overall(p-value)
Grade (high) 0.53 0.13 NS
Size (< 10cm) 0.23 NS
Diagnosis (leiomyosarcoma and MPNST vs. others)
0.065 0.49 NS
Margins (clear) 0.035 0.26 0.026
Age (50 years or over) 0.43 0.81 NS
Sex (female) 0.64 0.73 NS
Timing of Radiotherapy (post-op)
0.81 NS
Factors associated with LR
Summary of Overall FindingsOS rate = 66% at 5 yrs
Significant factors High Grade [HR 5.6, CI 2.3 – 13.5] Size (< 10cm) [HR 0.41, CI 0.21 – 0.81]
LR rate = 21% at 5yrs Significant factors
Margin
Functional outcome Average TESS score – 76% Worse TESS - wound complications(65% vs.79%)
- high grade (70% vs. 84%) No association with RT timing
ConclusionOS – unaffected by treatment strategies
RT Timing – no affect on OS, LR, and function
LR – Higher rate in ROH Positive margins (28%) quality of RT
AcknowledgementsSupervisors Mr Rob Grimer
Dr Peter FergusonMr Seggy AbuduDr Anthony GriffinMedical Records, ROH, BirminghamOrthopaedic Oncology Team, MSH,
Toronto
References1. O’Sullivan et al. Preoperative versus postoperative radiotherapy in soft-tissue
sarcoma of the limbs: a randomised trial. Lancet 2002; 359(9325): 2235-2241 2. Grainger MF, Grimer RJ, Carter SR, Tillman RM. Wound complications
following resection of adductor compartment tumours. Sarcoma 5 2001: 203-207
3. Davis AM, O’Sullivan B, Bell RS, et al. Function and Health Status Outcomes in a Randomized Trial Comparing Preoperative and Postoperative Radiotherapy in Extremity Soft Tissue Sarcoma. J Clin Oncol 2002; 20: 4472-4477
4. Bell RS, O’Sullivan B, Davis A, Langer F, Cummings B, Fornasier VL. Functional Outcome in Patients Treated With Surgery and Irradiation for Soft Tissue Tumours. J Surg Oncol 1991; 48: 224-231
5. Gerrand CH, Wunder JS, Kandel RA, O’Sullivan B, Catton CN, Bell RS, Griffin AM, Davis AM. Classification of positive margins after resection of soft-tissue sarcoma of the limb predicts the risk of local recurrence. J Bone Joint Surg Br 2001; 83-B(8): 1149-1155
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