1. Adductor Compartment STS - Does method of treatment affect outcome? Anup Pradhan, Yiu-Chung Cheung Birmingham Medical School, UK Supervisors: Mr Robert J Grimer Royal Orthopaedic Hospital, Birmingham, UK Dr Peter Ferguson Mount Sinai Hospital, Toronto, Canada

2. Background Presents late Often large Neurovascular bundle close

3. Surgical challenge!

4. Marginal close to femoral vessels

5. Vessels preserved Big hole !

6. 7 days later… 14 days later…

7. 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

8. 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

9. Method  Prospective 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

10. Exclusions  Metastases at diagnosis  Previous treatment elsewhere  Patients lost to follow up  Unfit for surgery

11. Patient age distribution P = 0.98 Median Age 55yrs ROH Median Age 56.5yrs MSH

12. Tumour size at diagnosis P = 0.11 Median = 13cm ROH Median = 9.5cm MSH

13. FactorROH (n = 64) MSH (n = 62) P- value Mean (median) Age55 (57)55 (56.5)0.98 Mean (median) Size (cm) 13.2 (12.8)11.4 (9.5)0.11 Proportion > 10cm38 (59%)25 (40%)0.03 Proportion of high grade tumours 36 (56%)35 (56%)0.98 Adequate margins46 (72%)44 (71%)0.91 Pre-operative radiotherapy NIL26 (42%) Post-operative radiotherapy 60 (94%)30 (48%) Use of muscle flapsNIL26 (42%) Patient and Treatment Factors

14. FactorROH (n = 64) MSH (n = 62) P- value Length of stay10.411.60.50 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 score72%79%0.18 Outcomes Oncological and Functional Outcomes

15. Comparing OS between the 2 centres P = 0.13 5yr OS = 74% MSH 5yr OS =57% ROH

16. Overall survival by grade Low/Intermediate grade High grade P < 0.001

17. Overall survival by size P = 0.015 Size ≤ 10cm Size > 10cm

18. Comparison of OS between pre and post RT groups P = 0.55 (combined data from both centres) Postop RT Preop RT

19. Comparing LR between the 2 centres P = 0.0145 5YLR = 10% 5YLR = 28%

20. Factor associated with LRROH (p-value) MSH (p-value) Overall (p-value) Grade (high)0.530.13NS Size (< 10cm)0.23NS Diagnosis (leiomyosarcoma and MPNST vs. others) 0.0650.49NS Margins (clear)0.0350.260.026 Age (50 years or over)0.430.81NS Sex (female)0.640.73NS Timing of Radiotherapy (post-op) 0.81NS Factors associated with LR

21. Summary of Overall Findings  OS 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

22. Conclusion  OS – unaffected by treatment strategies  RT Timing – no affect on OS, LR, and function  LR – Higher rate in ROH  Positive margins (28%)  quality of RT

23. Acknowledgements  SupervisorsMr Rob Grimer Dr Peter Ferguson  Mr Seggy Abudu  Dr Anthony Griffin  Medical Records, ROH, Birmingham  Orthopaedic Oncology Team, MSH, Toronto

24. References 1. 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 1.