Orthopedic Oncology and Surgery

Introduction
Since the National Cancer Center Hospital East newly opened in July 1992, as many as 1520 cases with bone and soft tissue tumors and tumorous conditions have been referred to our orthopedic clinics from over 250 hospitals in neighboring areas including Tokyo. Our major treatment areas in orthopedic oncology and surgery are osteosarcomas in children, soft tissue sarcomas in adults, pelvic bone and soft tissue tumors and spinal cancer metastases. Our first treatment modality for osteosarcoma is limb-preserving surgery on the basis of chemotherapy employing high-dose methotrexate (MTX) and cisplatinum (CDDP) + adriamycin (ADR) and ifosfamide (Ifos). For highly malignant soft tissue sarcomas we advocate limb salvage surgery, preserving proper surgical margins to prevent local recurrence with local and systemic chemotherapy employing CDDP, ADR and Ifos. Even advanced pelvic and spinal tumors can be treated with radical and reconstructive surgery. In the event of spinal metastases with paralysis, decompression of the spinal cord and rigid fixation of the spine using metal instruments can reduce pain and improve spinal paralysis. The purpose of orthopedic oncology is to establish the standard therapy for these highly malignant bone and soft tissue sarcomas.

Routine Activities
From Jan. 1997 to Dec. 1997, we treated 7 cases with osteosarcoma, 1 with EwingÕ-s sarcoma, 2 with chordoma, and 2 with chondrosarcoma. In addition, we treated 7 cases with malignant fibrous histiocytoma (MFH), 3 with synovial sarcoma, 2 with liposarcoma, 2 with leiomyosarcoma, 7 with small round cell sarcoma (rhabdo-myosarcoma: 3, EwingÕ-s sarcoma: 1, peripheral neuroepithelioma: 3). The assessment of tumor staging has been simplified by the use of recent imaging technologies such as MRI (angio-MRI) and CT (3D helical-CT).
In cases receiving intensive neoadjuvant chemotherapy regimens, for example, high-dose MTX and high-dose CDDP, high-dose Ifos and ADR contribute to therapeutic efficacy. The number of operations for bone and soft tissue tumors was about 150 in 1997. For the training of doctors in neighboring areas, an X-ray film conference is held at the National Cancer Center Hospital East every two months, in addition to multi-institutional telepathology or a TV conference on bone and soft tissue malignancies.

Research activities
The following studies are currently ongoing;
1. Functional evaluation of patients treated with prosthesis and rotationplasty
2. Assessment of QOL in young patients with osteosarcoma
3. Molecular biology of bone and soft tissue sarcomas
4. Retrospective study of bone metastasis from breast cancer

New Developments
1. Diagnosis: In addition to angio-MRI and 3D-CT, the distribution of 201 Tl-Cl in cross cut sections (resected material) is applied to the evaluation of tumor extent and the effects of preoperative treatments.
2. Nonsurgical Treatment: Protocol studies are now ongoing for osteosarcoma (non-randomized), soft tissue sarcoma (for MFH, randomized) and small round cell sarcomas (non-randomized). In addition, charged particle therapy is being tested for spinal and pelvic advanced or radioresistant tumors as a clinical co-operative study with the National Institute of Radiological Sciences.
3. Surgical treatment: Feasibility is assessed for limb (function)-preserving surgery for sarcomas of the extremities, radical resection of spinal and pelvic tumors and instrumental surgery for metastatic spinal tumors.

Statistics
Bone and Soft Tissue Sarcomas Treated in 1997

Resec.Amput.Observ.Prognosis
CDFNEDAWDDOD
Primary malignant bone tumor
Osteosarcoma (n=7)22333
1
Ewing's sarcoma (n=1)

1
1

Chondrosarcoma (n=2)1
11
1
Total (n=10)3254411
Soft tissue sarcoma
MFH (n=8)7
1
71
Synovial sarcoma (n=3)3

3


Liposarcoma (n=2)1
1

2
Leiomyosarcoma (n=2)1
1

11
Rhabdomyosarcoma (n=3)1
2111
Ewing's sarcoma (n=1)1

1


Neuroepithelioma* (n=3)

3

3
Clear cell sarcoma (n=1)1

1


Total (n=23)15
86881
*Peripheral neuroepithelioma CDF, continuous disease free; NED, no evidence of disease; AWD, alive with disease; DOD, died of disease; MFH, malignant fibrous histiocytoma.

(T. Umeda)

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