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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