Management and outcomes of thoracic sarcomas - a collaboration between Orthopaedic Oncology and cardiothoracic surgery: seven-year clinical data from a tertiary referral centre

Introduction: Sarcomas are rare cancers originating from mesenchymal tissues, manifesting in diverse anatomical locations, but notably in connective tissue, muscles and the skeleton. Thoracic sarcomas present a unique diagnostic and surgical challenge attributable to their rarity and pathoanatomy. Standard practice currently comprises wide surgical excision, often accompanied by adjuvant chemotherapy and/or radiotherapy. This approach necessitates a multidisciplinary team, ideally in specialised cancer centres. The Oxford Bone and Soft Tissue Tumour Service is one such centre, and routinely treats such cancers through collaboration between orthopaedic oncology and cardiothoracic surgeons, as well as members of the wider MDT. This study reports the current management and outcomes of primary thoracic sarcoma patients at the Oxford Sarcoma Service over a seven-year period. Objectives: Given the rarity of thoracic sarcomas, and their associated diagnostic and management complexities, our aim is to report on the treatment strategies and outcomes of primary thoracic sarcoma patients treated at the Oxford Sarcoma Service from 2017 to 2023. Methods: Data pertaining to all thoracic sarcoma cases discussed in multidisciplinary meetings at the Oxford tertiary centre from 2017 to 2023 were retrieved from the local electronic database. These were analysed using appropriate statistical tests to determine significance of the various observations made. Results: Of 113 identified cases, chondrosarcoma emerged as the most prevalent histological subtype among 22 distinct varieties. 58% of cases exhibited high-grade features. 32 sarcoma-related deaths occurred, with a mean time from diagnosis to death of 23.16 months. A notable association was observed between high-grade sarcomas and mortality (p = 0.0280). Surgical resection was performed in 77 cases, with 49% of these undergoing surgical resection alone i.e. the patient received no radio- or chemotherapy. Both surgical intervention (p < 0.0001) and clear margins (p = 0.0051) were significantly linked to improved survival. Local recurrence was noted in 28.6% of the 77 surgical cases, and predominantly in the high-grade sarcomas (81.8%). However, no statistical association was found between recurrence and margin status in our data. Conclusion: Our results indicate that primary resection remains the cornerstone of thoracic sarcoma treatment, representing the single strongest independent factor for survival in treatable cases. Variability in outcomes and overall survival likely stems from factors such as histological diversity, predominance of high-grade sarcomas, and wide age range at diagnosis. Ongoing prospective database update and collaborative efforts across centres would further clarify prognoses and recommendations for specific tumours, based on observational data

Preparation for the next major incident: are we ready? A 12-year update

ObjectivesA major incident is any emergency that requires special arrangements by the emergency services and generally involves a large number of people. Recent such events in England have included the Manchester Arena bombing and the Grenfell Tower disaster. Hospitals are required by law to keep a major incident plan (MIP) outlining the response to such an event. In a survey conducted in 2006 we found a substantial knowledge gap among key individuals that would be expected to respond to the enactment of an MIP. We set out to repeat this survey study and assess any improvement since our original report.MethodsWe identified NHS trusts in England that received more than 30 000 patients through the emergency department in the fourth quarter of the 2016/2017 period. We contacted the on-call anaesthetic, emergency, general surgery, and trauma and orthopaedic registrar at each location and asked each individual to answer a short verbal survey assessing their confidence in using their hospital’s MIP.ResultsOf those eligible for the study, 62% were able to be contacted and consented to the study. In total 50% of respondents had read all or part of their hospital’s MIP, 46.8% were confident that they knew where their plan was stored, and 36% knew the role they would play if a plan came into effect. These results show less confidence among middle-grade doctors compared with 2006.ConclusionsConfidence in using MIPs among specialty registrars in England is still low. In light of this, we make a number of recommendations designed to improve the education of hospital doctors in reacting to major incidents.</jats:sec

Will virtual multidisciplinary team meetings become the norm for musculoskeletal oncology care following the COVID-19 pandemic? - experience from a tertiary sarcoma centre

Abstract Background Like with all cancers, multidisciplinary team (MDT) meetings are the norm in bone and soft tissue tumour (BST) management too. Problem in attendance of specialists due to geographical location is the one of the key barriers to effective functioning of MDTs. To overcome this problem, virtual MDTs involving videoconferencing or telemedicine have been proposed, but however this has been seldom used and tested. The COVID-19 pandemic forced the implementation of virtual MDTs in the Oxford sarcoma service in order to maintain normal service provision. We conducted a survey among the participants to evaluate its efficacy. Methods An online questionnaire comprising of 24 questions organised into 4 sections was circulated among all participants of the MDT after completion of 8 virtual MDTs. Opinions were sought comparing virtual MDTs to the conventional face-to-face MDTs on various aspects. A total of 36 responses were received and were evaluated. Results 72.8% were satisfied with the depth of discussion in virtual MDTs and 83.3% felt that the decision-making in diagnosis had not changed following the switch from face-to-face MDTs. About 86% reported to have all essential patient data was available to make decisions and 88.9% were satisfied with the time for discussion of patient issues over virtual platform. Three-fourths of the participants were satisfied (36.1% - highly satisfied; 38.9% - moderately satisfied) with virtual MDTs and 55.6% of them were happy to attend MDTs only by the virtual platform in the future. Regarding future, 77.8% of the participants opined that virtual MDTs would be the future of cancer care and an overwhelming majority (91.7%) felt that the present exercise would serve as a precursor to global MDTs involving specialists from abroad in the future. Conclusion Our study shows that the forced switch to virtual MDTs in sarcoma care following the unprecedented COVID-19 pandemic to be a viable and effective alternative to conventional face-to-face MDTs. With effective and efficient software in place, virtual MDTs would also facilitate in forming extended MDTs in seeking opinions on complex cases from specialists abroad and can expand cancer care globally. </jats:sec

Preparation for the next major incident: are we ready? Comparing major trauma centres and other hospitals

ObjectivesA major incident is any emergency requiring special arrangements by the emergency services. All hospitals are required by law to keep a major incident plan (MIP) detailing the response to such events. In 2006 and 2019, we assessed the preparedness and knowledge of key individuals in hospitals across England and found a substantial gap in responding to the MIP. In this report, we compare responses from doctors at major trauma centres (MTCs) and other hospitals (non-MTCs).MethodsWe identified trusts in England that received over 30 000 patients through the ED in the fourth quarter of 2016/2017. We contacted the on-call anaesthetic, emergency, general surgery and trauma and orthopaedic registrar at each location and asked three questions assessing their confidence in using their hospital’s MIP: (1) Have you read your hospital’s MIP? (2) Do you know where you can access your hospital’s MIP guidelines? (3) Do you know what role you would play if an MIP came into effect while you are on call?We compared data from MTCs and non-MTCs using multinomial mixed proportional odds models.ResultsThere was a modest difference between responses from individuals at MTCs and non-MTCs for question 2 (OR=2.43, CI=1.03 to 5.73, p=0.04) but no evidence of a difference between question 1 (OR=1.41, CI=0.55 to 3.63, p=0.47) and question 3 (OR=1.78, CI=0.86 to 3.69, p=0.12). Emergency medicine and anaesthetic registrars showed significantly higher preparedness and knowledge across all domains. No evidence of a systematic difference in specialty response by MTC or otherwise was identified.ConclusionsConfidence in using MIPs among specialty registrars in England remains low. Doctors at MTCs tended to be better prepared and more knowledgeable, but this effect was only marginally significant. We make several recommendations to improve education on major incidents.</jats:sec

Patient safety associated with the surgical treatment of bone and soft tissue tumours during the COVID-19 pandemic—results from an observational study at the Oxford Sarcoma Service

Abstract Purpose Deferring cancer surgery can have profound adverse effects including patient mortality. During the COVID-19 pandemic, departmental reorganisation and adherence to evolving guidelines enabled provision of uninterrupted surgical care to patients with bone and soft tissue tumours (BST) in need of surgery. We reviewed the outcomes of surgeries on BST during the first two months of the pandemic at one of the tertiary BST centres in the UK. Materials and methods Between 12 March 2020 and 12 May 2020, 56 patients of a median age of 57 years (18–87) underwent surgery across two sites: index hospital (n = 27) and COVID-free facility (n = 29). Twenty-five (44.6%) patients were above the age of 60 years and 20 (35.7%) patients were in ASA III and ASA IV category. The decision to offer surgery was made in adherence with the guidelines issued by the NHS, BOOS and BSG. Results At a minimum follow-up of 30 days post-surgery, 54 (96.4%) patients were recovering well. Thirteen patients (23.2%) had post-operative complications which included four (7.1%) patients developing pulmonary embolism. The majority of complications (12/13 = 92.7%) occurred in ASA III and IV category patients. Four (7.1%) patients contracted COVID-19, of which three required escalation of care due to pulmonary complications and two (3.6%) died. Patients &lt; 60 years of age had significantly less complications than those &gt; 60 years (p &lt; 0.001). Patients operated on in the COVID-free facility had fewer complications compared with those operated on at the index hospital (p &lt; 0.027). Conclusion In spite of the favourable results in majority of our patients, our study shows that patients with sarcoma operated at the height of the pandemic are at a risk of contracting COVID-19 and also having associated with mortality. The use of a COVID-free facility, surgery in patients &lt; 60 60 years and in ASA I &amp; II category are associated with better outcomes. If a second wave occurs, a serious consideration should be given to ways of minimising the risk of contracting COVID-19 in these vulnerable patients either by using COVID-free facilities or delaying treatment until peak of infection has passed. </jats:sec

What Proportion of Patients with Bone and Soft Tissue Tumors Contracted Coronavirus-19 and Died From Surgical Procedures During the Initial Period of the COVID-19 Pandemic? Results From the Multicenter British Orthopaedic Oncology Society Observational Study

Delivering uninterrupted cancer treatment to patients with musculoskeletal tumors has been essential during the rapidly evolving coronavirus 2019 (COVID-19) pandemic, as delays in management can be detrimental. Currently, the risk of contracting COVID-19 in hospitals when admitted for surgery and the susceptibility due to adjuvant therapies and associated mortality due to COVID-19 is unknown, but knowledge of these potential risks would help treating clinicians provide appropriate cancer care