Published online Sep 18, 2018. doi: 10.5312/wjo.v9.i9.173
Peer-review started: April 10, 2018
First decision: May 15, 2018
Revised: May 20, 2018
Accepted: June 27, 2018
Article in press: June 27, 2018
Published online: September 18, 2018
Reconstructive surgery using megaprosthesis is widely applied as a treatment for bone sarcomas of the lower extremities. Even though reconstructive surgery has been used for several decades it seems that there is no clear consensus in surgical treatment strategies for this group of patients.
The low number of bone sarcomas limits the possibility to run randomized clinical trials. This is in contrast to non-surgical treatment of bone sarcomas, where standard protocols are available to test new treatment regimes since the sites of the sarcoma are of less significance. Only a few international randomized studies have been initiated to gain new evidence on the surgical treatment of bone sarcoma patients. This is due to the difficulty in achieving sufficient sample sizes due to the rarity of the disease.
The goal of this study was to identify common strategies in the surgical treatment of patients with bone sarcomas of the lower extremities in terms of surgical/technical considerations, choice of antibiotics, dosage, and duration of treatment, and choice of antithrombotic drug, initial start-up, dosage, and duration.
The study was based on an internet-based survey on the surgical management of bone sarcomas in the lower extremity amongst sarcoma surgeons in the Scandinavian countries.
This study demonstrates a large variation in the treatment of patients with bone sarcomas located in the lower extremities. With regard of implant fixation, the Danish and Swedish sarcoma centers tended to consider a cemented prosthesis not only for the older patients but also for the youngest patients below 20 years old, contrary to the rest of the Scandinavian centers. All participants would administer intravenous prophylactic antibiotics regarding endoprosthetic reconstructive surgery. First choice of antibiotics was cephalosporin. Less commonly used were glycopeptide, penicillin, or a combination. The duration of prophylactic antibiotic treatment ranged from less than one day to more than four days. All participants would administer heparins as antithrombotic prophylaxis. Fifty-five percent of the participants answered that initial treatment was started preoperatively, 3% perioperatively and 42% postoperatively. Range of antithrombotic treatment went from 5-28 d.
Today, patients diagnosed with bone sarcomas of the lower extremity are to a great extent offed treatment with a resection prosthesis. The treatment is well established, however, there is a significant inconsistency in the surgical treatment algorithm between sarcoma centers. Still the treatment is primarily based on best clinical practice, due to the absence of evidence-based medicine in the surgical management of bone sarcomas.
The current study elucidates, that the surgical sarcoma community needs to support the ongoing randomized control trials and encourage the initiation of new randomized studies to gain knowledge of the surgical treatment of bone sarcoma patients based on evidence-based medicine.