Malignant bone tumor management. 30 years of achievement.

Malignant bone tumor management has changed drastically over the last three decades. Orthopedic surgery has been in the forefront of these major advances. Amputation is now much less common than other forms of limb reconstruction. Oncologists have come to play a much larger role than do radiotherapists. Indeed, radiotherapy is seldom used now except for its undoubted value in palliation. The development of adjuvant chemotherapy is now prolonging life, assisting the surgeon in local resection, and almost certainly increasing the chances of survival. When one considers the valuable role of thoracic surgery in lung metastectomy and the advances in pathology, imaging, and the staging of bone tumors, it can be seen there has been a revolutionary change in the care of those who suffer from primary malignancy of bone.

Limb preservation in the treatment of bone tumours.

The treatment of primary malignant tumours of bones by resection and prosthetic replacement is discussed in relation to more conventional treatment by amputation. Removal of the hemipelvis with preservation of the limb is suggested as an alternative for some patients who hitherto might have been regarded as only suitable for hindquarter amputation.

The surgical management of primary osteosarcoma.

Regrettably amputation remains to the present day an essential part of treatment in osteosarcoma of the limb bones. Only by its inclusion in the therapeutic regime can the present best level of about 20 per cent survival be achieved in any large group of patients. Preliminary biopsy is essential and there is no evidence that it is harmful even if followed by a delay of many days before definitive treatment. In patients treated initially by radiotherapy, selective amputation some 6 months later only in patients free of metastases, carries just as good a prognosis for the group as a whole as initial primary amputation in all patients. This method, first described by Cade, is widely practiced in the United Kingdom and spares many patients who develop early metastases following initial radiotherapy from unnecessary mutilating surgery shortly before inevitable death. Local recurrence may follow retention of a femoral stump following amputation for osteosarcoma at the most common site in the lower femoral metaphysis. There are cogent arguments in favor of hip disarticulation in such patients although they do not include evidence of greater survival. The balance between the two procedures is finely drawn but is weighted in favor of disarticulation.

Tumours of bone and their management.

The various types of primary tumour that may affect the bones are reviewed. No attempt is made to cover so wide a field in detail, but the more important clinical, radiological, and histological features of each type of tumour are emphasized and its management outlined. Mention is also made of a number of lesions which, while not strictly tumours, may resemble them radiologically.

Bone sarcoma: treatment by irradiation, amputation, or a combination of the two.

A retrospective survey of all cases of osteosarcoma of the femur and tibia treated at the major centres in the United Kingdom during 1952-9 was carried out in an attempt to assess the respective value of treatment by surgery and radiotherapy and the feasibility of a larger prospective study. Of the 192 patients available for the comparison, those treated by radiotherapy alone did least well. A combination of the two treatments-radiotherapy followed by amputation-produced better results, in terms of survival, than amputation alone; however, the comparatively small numbers involved and the inadequacy of information about the factors dictating the choice of treatment make firm conclusions impossible. A controlled clinical trial on a larger scale might provide answers to the outstanding questions.