Early Referral for Multidisciplinary Management:
From January 1991, we evaluated the referral patterns of 50 consecutive sarcoma patients, 28 were referred after biopsy.
Fourteen of these 28 patients had a diagnostic delay of 6 months and in 11 of these it was greater than 1 year. In this group of inappropriately managed patients there were 3 unnecessary amputations it is likely that 4 patients’ chances of a cure from systemic treatment were significantly reduced
In 2014 the WA Department of Health formally recognised the State Sarcoma Service at Sir Charles Gairdner Hospital. Of the x number of patients diagnosed with a sarcoma in that calendar year
Y were referred after biopsy. The development of a formal multidisciplinary service and improvement in referral patterns has been the most significant factor in improving our surgical outcomes.
Adjuvant TherapyThe wider use of preoperative neo-adjuvant radiation therapy for soft tissue sarcomas has reduced our local recurrence rates, but presented us with a higher rate of wound problems. 1in 3 patients will have significant wound breakdown problems following surgery in an irradiated field. The use of denosunab in giant cell tumour of bone has enabled down staging of giant cell tumours before resection , without evidence of direct effect on the tumour cells. Denosunab neutralises the recruited osteoclasts rather than the tumour cells, which persist within the tumour field and once denosunab treatment stops, reignite their symbiotic relationship with the bone resorptive cells from the monocyte macrophage lineage
Margin of Surgical Resection - Back to the Future
The use of post adjuvant therapy imaging to plan surgical resection predisposes to local recurrence in some sarcomas. Further outcome evaluation requires a consensus on the precise definition of a wide surgical margin.
Computer Navigation Robotics and 3D Printing
The accuracy of resection is improved by computer navigation with pre-loaded CT and MRI scans collated by intraoperative registration.
Pelvic fracture and spinal reconstruction software has been adapted with good effect and made a case for the production of tumour specific software with planned preoperative resection lines matched to custom made implants.
Most of these implants are silver coated to reduce infection rates.
Robots are most efficient with repetitive precise tasks & their use in radical prostatectomy has become established. There has been slower progress in musculoskeletal reconstruction where the institutional commercial publicity is more evident than the clinical benefit.
Reconstruction
The use of allograft, tumour prostheses and the full complement of soft tissue reconstructions make up the surgical armamentarium. Irradiated autograft has become more popular despite the lost opportunity to inspect the surgical margin and evaluate the effect of chemotherapy.