Outcomes
“What’s going to happen to me, doc – will I live?” Treatments for bone and soft tissue tumours are better today than they were when Terry Fox ran his Marathon of Hope. Today, we are able to cure more people and undertake surgery that salvages the limb more often.
As we improve we are better able to tell our patients what to expect in terms of survival from their tumour. But we also need to explain what patients should expect from their treatments – what the long term side-effects of their radiation or chemotherapy might be, and what the long term functional results of their surgery might be.
Survival
Cure rates for patients with sarcoma overall are better now than they have ever been. Improved surgery and radiation control the local disease better, while better chemotherapy has improved systemic cure rates. However, many challenges remain.
Predictors of Survival
Soft Tissue Sarcoma
Most people with soft tissue sarcomas can be cured. The following factors have all been shown to affect whether metastases will occur. Some staging systems, like that published by Memorial Sloan Kettering, use three of these factors (size, grade, and depth) to predict outcome.
- Histologic subtype
- Histologic grade
- Size >5 cm
- Depth in relation to fascia
- Age
Bone Sarcoma
The factors predicting survival for bone sarcomas are broadly similar to those for soft tissue sarcoma. Different types of bone sarcoma have different survival rates.
- Size >8 cm
- Histologic subtype
- Histologic grade
- Anatomic site (e.g., those in the pelvis do worse)
- Response to chemotherapy
- Surgical resectability with negative margins
Why It Is Better Now
Imaging techniques have improved
- Better planning of resections
- Better detection of disease
Surgical techniques are better
- Able to resect larger lesions more effectively
- Advanced plastic surgical techniques aid reconstruction
- Can combine with skeletal reconstruction when needed
- Results more durable
- Amputation required occasionally, but much less often
Radiation Therapy is more precise and safe
- Better technology
- Better understanding of role in local control
- Pre-operative use to reduce functional effects in suitable tumours
Chemotherapy agents are being refined and new agents discovered
- Cure rates of osteosarcoma improve from 20 to 70%
- Ewing Family Tumour has a large increase in survival with chemotherapy
- Role in soft tissue sarcoma still controversial
What Needs To Improve
Referral patterns
- Earlier referral improves outcomes
- Reduced incidence of prior intervention
- Unfortunately many patients with sarcoma take a long time to acquire specialist care
Surgical Challenges
- Wound healing after radiation therapy
- Eliminate infection rates
- Durability of implants
Systemic Therapies
- While large inroads have been made, further advances in cure rates are dependent on the development of effective novel systemic therapies
- Area of much active research
Function
Determinants
Most patients will now return to largely normal function and lives. Functional outcome depends on:
- Infection and wound complications
- Loss of major nerves
- Loss of major muscle groups
Limb Salvage
Limb Salvage is usually feasible, although amputation is sometimes required. Amputees can have surprisingly good function and amputations below the knee do especially well. Modern devices such as the C-leg are often used.
Long Term Effects
Chemotherapy
- Young patients receiving chemotherapy have an increase risk of later illness
- This can include other cancers
- Risk will depend on the agents used
Radiation Therapy
- Modern Radiation Therapy minimizes long term complications, but they still exist
- Lymphedema and joint stiffness are reduced with pre-operative radiation therapy
- Second malignancies occur in about 1 in a 1000 people
Surgery
- Modern limb preserving implants can save limbs we never could before, but they have finite life spans
- Revision surgery for large implants is complicated
- Rotationplasty is popular in many places as it has few long term complications