Chest tube insertion was associated with an unacceptably high level of pain and anxiety in our hospital. A new protocol, including housestaff education and changes in nursing policies, technical aspects, local anesthetic dose and delivery, and pre-medication, allowed us to approach the goal of a painless chest tube insertion.

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We report on a retrospective study of 155 patients amputated for nonmetastatic osteosarcoma of the long bones. Among the various prognostic variables considered, a significant correlation was found only between survival and transfusions. In this report, the authors consider some hypotheses reported by others for tumors of a different nature and site and conclude that perioperative transfusion may induce depression in the immune response, which is the cause of a shorter survival in the patients reviewed.Cancer 64:1727-1737, 1989.UMEROUS STUDIES correlate the number of peri-N operative blood transfusions to the survival in patients with malignant tumors. Various authors have reported an increased survival rate in patients who had not been transfused during surgery for colorectal carcinoma.'-' Also considering other factors such as the histologic grade, transfused patients have a worse prognosis.6Recently, numerous studies have reported that in breast cancer and soft tissue sarcomas the association between perioperative transfusions and survival is statistically significant although less marked than in colorectalWe have thus reviewed patients with nonmetastatic osteosarcoma of the long bones surgically treated at the Rizzoli Orthopaedic Institute (Bologna, Italy). Diagnosis was formulated by examination of histologic slides from incisional biopsies or from amputation specimens.For homogeneity only patients amputated and treated from 1972 to 1982 were considered, thus having reliable data on disease-free and overall survival. The median follow-up was 28 months and 3890 of the cases studied had a follow-up of more than 36 months. In our e~perience,~ as well as in that of others," in osteosarcoma the diseasefree survival curves at 3 years remain almost unvaried and after this few relapses occur.All patients were treated with surgery and adjuvant chemotherapy according to four different protocols activated successively and previously reported.' ' , I 2 The statistical analysis is divided in two stages. The first is general and applies methods such as chi-square and Student's t test.I3.l4 The second stage uses the actuarial method to draw survival curves and applies the Mantel- Haenszel test for homogeneity and trend. In all stratified Mantel-Haenszel tests a variety of different categories of the prognostic variables are considered, but only summarized results are reported. Two-sided tests were always used. Patients and MethodsTwo hundred sixty-eight patients were reviewed and 155 were included in the study. These patients were chosen because they received the same combined treatment (surgery plus adjuvant chemotherapy). To be eligible the following variables were analyzed: ( I ) age upon referral; (2) sex; (3) site of the tumor; (4) time lapse between onset of symptoms and diagnosis; ( 5 ) radiologic features of the tumor; ( 6 ) tumor size in relation to the total length of the bone segment; (7) alkaline phosphatase value; (8) type of biopsy: (9) number of perioperative transfusions; (10) interval between surgery an...

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