Editorial Comment: Selected Proceedings From the 2021 Musculoskeletal Tumor Society Meeting

H. Thomas Temple MD

These selected proceedings of the Musculoskeletal Tumor Society (MSTS) contain a number of topics presented at the 2021 MSTS Annual Meeting that are apropos to practicing orthopaedic oncologists. This meeting, held both in person and virtually because of the COVID-19 pandemic, covered a number of key issues. A few papers cover the lessons learned from databases [1, 3, 4], one paper discussed using thromboelastography to assess thromboembolic disease risk in patients with malignant musculoskeletal tumors [7], and several papers looked at outcomes, such as those seen in patients with osteosarcoma [6], as well as the consequences of late amputation in children who had undergone initial limb salvage [2]. What have we learned?

One article [4] examines how large public databases are plagued with vagaries, discrepancies, and limitations that lead to discordant and unexplained findings. The authors advised caution as there are nuanced differences between databases and asking the same question can produce discordant results because of these differences.

Prospective single-institution, longitudinal databases are useful to expand our understanding of factors associated with successful implant outcomes, despite variability among patients treated for bone tumors who underwent reconstruction with cemented distal femoral replacement [3]. The authors of this study showed that increased stem diameter was associated with improved outcomes, and they postulated that decreasing torsional moments around the stem may further improve cemented distal femoral replacement outcomes. Another study using the same database [1] found that high-dose radiation may be associated with higher rates of aseptic loosening in patients with primary cemented segmental implants. For this reason, they recommended closer monitoring for radiolucencies around implant stems and raised the possibility of cross-pin fixation to partially mitigate this risk.

Thromboelastography was used to assess thromboembolic risk in patients with malignant bone and soft tissue tumors [7]. The authors found advanced age, female sex, and soft tissue—not bone tumors—were associated with hypercoagulability using this technique. The preliminary results compel multi-institutional collaboration to validate these findings in the hope of stratifying patients at risk to better inform therapeutic strategies.

Another study had a dual message regarding outcomes in osteosarcoma [6]. First, is that necrosis seems to be an important benchmark for predicting outcome (already known) and second, that socioeconomic factors may result in falling short of that benchmark. These findings should motivate others to study these factors in an effort to mitigate barriers to care and to improve clinical outcomes as a result.

A multi-institutional study [2] evaluated the long-term consequences of limb salvage in young patients who underwent amputation later in life. Despite long-term surveillance, the risk of late amputation was substantial, and the psychological and physical consequences were not unlike those of patients who underwent amputation as an index procedure.

Finally, a multicenter study using transcutaneous oximetry sought to identify patients at risk for wound healing complications after preoperative radiotherapy and surgery [5]. The authors concluded that by itself, transcutaneous oximetry was not a reliable tool to predict wound problems after surgery. Instead, they felt that fluorescent tissue perfusion probes may assess the wound more broadly during the actual procedure and, therefore, may be more useful. Unfortunately, the study does not consider the variability of soft tissue response to radiotherapy, tumor size and location, and patient comorbidities, all of which contribute to the assessment of wound healing.

I congratulate the authors for their scientific rigor and insight. Their findings will inspire future investigations aimed to improve diagnostic strategies and therapeutic approaches on these important clinical issues. These efforts will surely translate into better outcomes for patients with malignant bone and soft tissue tumors.