IMPROVING OUTCOME FOR MUSCULOSKELETAL TUMOURS:

The Journey So Far

SEYI IDOWU FWACS FMCS

Based on a presentation at the ISOLS/MSTS Conference in Orlando, Florida Oct 2015.

!Introduction: Challenges

" Late presentation

" Limited facilities (2 bone scans for population of 170 million)

" Limited number of specialists and inadequate funding

" Services divided along geographical lines

!" Coastal city along west

Africa Coast

" Most populous city in Africa

" 17 million people (10% of Nigerian population)

" No dedicated sarcoma MDT prior to 2012

Introduction - Lagos

LAMON

LAgos Muscoskeletal Oncology Network A model for Cancer Care in

Resource Poor Countries

LAMON

!AIMS OF LAMON

" Improve the care pathway for patients with sarcoma

" Improve efficient use of scarce resources

" Encourage adherence as much as possible to published national and international guidelines

" Decisions for holistic care plan – diagnosis, radiotherapy, chemotherapy, surgery and timing of interventions

!" 212 patients reviewed in 1st 30 months

"Definitive histological diagnosis in 192 patients (91%)

"Age range: 3 – 95 years

"Tumour Locations: ! Extremity 82% Central: 18%

LAMON" Diagnosis

! Osteosarcoma – 22%; ! Giant cell tumour – 13% ! Soft tissue sarcoma – 11% ! Metastatic bone disease – 8% ! Other benign lesions

" Limb preservation rate 67%

" Local recurrence rate 8.5%

!

10 year old girl with huge osteosarcoma right femur. Late presentation on account of traditional bone setters precluded limb salvage. Unfortunately required emergency

amputation and chemotherapy

Picture of amputated stump

Preoperative X-ray

!

30 yr old lady with recurrent GCT distal femur

!ID AGE IN YRS SEX INDICATIONS SYMPTOMS

INTERVAL IN MONTHS

RESECTION LENGTH IN CM

PROSTHESIS COMPLICATIONS MSTS SCORE IN %

1 82 F non union hip # with osteolysis

5 12 RESTOR PFEPR none 60

2 54 F failed DHS for hip # 24 18 RESTOR PFEPR SSI 96

3 58 M pathological # hip secondary to C.A.P

4 14 RESTOR PFEPR none 70

4 68 M fibrous dysplasia 3 14 RESTOR PFEPR none 96

Proximal Femoral Endoprosthetic Replacement

!ID AGE YRS SEX INDICATION SYMPTOMS INTERVAL IN MONTHS

RESECTION LENGTH IN CM

TYPE OF PROSTHESIS

COMPLICATIONS

MSTS SCORE IN %

1 28 F GCT 60 17 RESTOR DFEPR SSI 86

2 32 M GCT TENDON SHEATH

6 15 IMPOL DFEPR NONE 93

3 4 M PLASMACYTOMA

84 24 IMPOL DFEPR POPLITEAL ARTERY THROMBOSIS . WOUND DEHISCENCE. A/K AMPUTATION

24

4 55 M NON UNION DISTAL FEMORAL # WITH BONE LOSS

18 20 RESTOR DFEPR DVT 86

Distal Femoral Endoprosthetic Replacement

!ID AGE YRS SEX INDICATION SYMPTOMS INTERVAL IN MONTHS

RESECTION LENGTH IN CM

TYPE OF PROSTHESIS

COMPLICATIONS

MSTS SCORE IN %

1 63 M INFECTED TKR 14 12 RESTOR PTEPR NONE 93

2 21 M OSTEOSARCOMA

6 24 RESTOR PTEPR LOOSENING OF THE HINGE MECHANISM

86

Proximal Tibial Endoprosthetic Replacement

!ONGOING CHALLENGES

!

" Rising life expectancy of cancer patients

" Main factors include; 1. primary histology 2. potential instability 3. neural compression

" Multidsciplinary collaboration is required

" Median survival of patients with spinal metastatic disease is 10 months.

" The morbidity of spinal metastatic disease is important, especially in patients with paralysis and/or bowel and bladder involvement.

" Cord compression is normally seen as preterminal event.

" Median survival at that stage is about 3 months.

!

Pelvic MRI cont.

• The lesion is displacing the  caecum and colon superior

ly

• Bilateral hip joints, femor

al  heads, neurovascular

 structures and

sacroiliac joint space appe

ar  normal

• No hip joint effusion is see

n

!

• Pelvic MRI • Large lobulated expansile 

lesion arising from the anter

ior cortex of the right iliac bone  with extensive periosteal reaction and excessive bone  formation 

• It appears heterogenously

 hyperintense on T2 and hypointense on T1 images

• It measures approximately 17.5x 9.0 x 17.4 cm.. 

• It invades the surrounding  iliacus muscle and displacin

g it anteriorly

!" Establish a formal referral pathway: Grants

applications!!!

" Funding for MDT: NGO ——MONSUF

" Funding for investigations and specialist care

" Funding for specialist training

Ongoing challenges

!"The network resulted in improvement in diagnosis,

limb salvage rate and follow up care for musculoskeletal tumours and other conditions.

" Perhaps, with appropriate social and corporate support, communal tumour boards like LAMON may translate into model for multidisciplinary cancer care in resource poor countries

DISCUSSION