Sarcoma treatment during the covid-19 pandemic is a new challenge. This patient population is often immunocompromised and potentially more susceptible to viral complications.
Government guidelines highlight the need to minimize patient exposure to unnecessary hospital visits. However, those guidelines lack practical recommendations on ways to manage triage and diagnosis expressly for new cancer patients. Furthermore, there are no reports on the efficiency of the guidelines.
One of the main issues in treating musculoskeletal tumours is the complexity and variability of presentation. We offer a triage model, used in a quaternary-referral musculoskeletal oncology centre, that allows us to maintain an open pathway for referral of new patients while minimizing exposure risks. A multidisciplinary approach and analysis of existing investigations allow for a pre-clinic evaluation.
The model identifies 3 groups of patients:
Patients with suspected high-grade malignancy, or benign cases with aggressive features, both in need of further evaluation in the clinic and prompt treatment
Patients with low-grade malignancy, and benign cases whose treatment is not urgent, that are managed, during the pandemic by telemedicine, with reassurance and information about their illness
Patients who can be managed by their local medical professionals
In comparison to a pre-pandemic period, that approach resulted in a higher ratio of malignant-to-benign conditions for new patients seen in the clinic (3:4 vs. 1:3 respectively), thus using available resources more efficiently and prioritizing patients with suspected high-grade malignancy.
We believe that this triage system could be applied in other surgical oncology fields during a pandemic.
A woman in her 70s presented with a small subcutaneous retrosacrococcygeal mass and a history of elevated erythrocyte sedimentation rate present for several years. It was misdiagnosed as an inflammatory process of unclear origin. She underwent further investigation with the appearance of weight loss and weakness. A sacrococcygeal mass was noted on CT scan. A core needle biopsy was inconclusive for chordoma versus myoepithelioma. Wide surgical resection of the tumour including the coccygeal bone was performed. Following surgery, all the systemic symptoms resolved with normalisation of inflammatory markers. The pathological examination showed a relatively circumscribed multinodular myxoid tumour with lymphatic tissue cuff. Pan-sarcoma fusion analysis detected an EWSR1 (Exon7)-CREB1 (Exon7) fusion gene. The lesion was diagnosed as angiomatoid fibrous histiocytoma with paraneoplastic syndrome presentation of several years’ duration.
Case:
A 7-year-old boy presented with osteosarcoma of the ulna that required a transhumeral amputation. The patient completed neoadjuvant chemotherapy before surgery. To prevent bone overgrowth and improved prosthetic fitting, a modified amputation was performed with acute shortening and distal epiphysis preservation.
Conclusion:
In this modified amputation, bone overgrowth was not seen and repeated surgeries for stump shaping were prevented. The modified technique enabled length for the prosthetic elbow and a wide stump for better fitting. In cases of transhumeral amputation in children, the modified technique should be considered.
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