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Journal of Clinical Oncology, Vol 22, No 12 (June 15), 2004: pp. 2511 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.319
Surgical Expertise and Outcome in Osteosarcoma TrialsCooperative Osteosarcoma Study Group, University Children's Hospital Muenster, Department of Pediatric Hematology and Oncology, Münster, Germany To the Editor: In their letter1 commenting on the article by Goorin et al on therapy for nonmetastatic osteosarcoma,2 Bacci et al point out that they believe osteosarcoma treatment should be centralized, at least for surgery. While we in no way disagree with this statement, we would like to rectify a misrepresentation of some of the facts used to support this conclusion. The institutions participating in the multicentric Cooperative Osteosarcoma Study Group (COSS) trials are misleadingly reported as managing "approximately one case every 5 years." The COSS article on which this calculation is based was not about 480 patients, as Bacci et al erroneously state, but about 1,702 patients.3 In addition, two-thirds of all definitive operative procedures were performed in only 15 surgical centers.4 The 60% amputation rate cited in the letter is also misleading as it refers to the combined rate of amputations and rotationplasties from a COSS study performed between 1986 and 1988.5 If comparisons are to be made between recent monoinstitutional studies and our group's trials, published COSS results from the 1990s with an 84% rate of conservative surgery (69% limb salvage, 15% rotationplasty) should be referred to.4 For these reasons, Bacci et al should no longer use the COSS data, along with data from other renowned international groups, as an indicator of insufficient surgical experience outside of monoinstitutional settings, or to support their reasoning of why limb salvage rates might be lower in multicentric trials. Nevertheless, we still support the suggestion of Bacci et al, that multicentric groups should perform analyses with respect to the number of patients treated per center. Large, specialized surgical referral centers, however, should also feel challenged to review their data. Associations between hospital volume and operative outcomes after cancer resections seem to be largely mediated by experience of the operating surgeon.6 We would be most interested to learn from large monoinstitutional trials, such as the one from Rizzoli, whether the importance of surgeon volume, which was proven for pancreatic resection, esophagectomy, lung resection, and cystectomy6 extends to muskuloskeletal sarcoma surgery as well. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Bacci G, Ferrari S, Longhi A, et al: Preoperative therapy versus immediate surgery in nonmetastatic osteosarcoma. J Clin Oncol 21:4662–4663, 2003
2. Goorin AM, Schwartzentruber DJ, Devidas M, et al: Presurgical chemotherapy compared with immediate surgery and adjuvant chemotherapy for nonmetastatic osteosarcoma: Pediatric Oncology Group Study POG-8651. J Clin Oncol 21:1574–1580, 2003
3. Bielack SS, Kempf-Bielack B, Delling G, et al: Prognostic factors in high-grade osteosarcoma of the extremities or trunk: An analysis of 1702 patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols. J Clin Oncol 20:776–790, 2002
4. Bielack S, Jürgens H: In reply. J Clin Oncol 20:2910–2911, 2002
5. Fuchs N, Bielack SS, Epler D, et al: Long-term results of the co-operative German-Austrian-Swiss Osteosarcoma Study Group's protocol COSS-86 of intensive multidrug chemotherapy and surgery for osteosarcoma of the limbs. Ann Oncol 9:893–899, 1998
6. Birkmeyer JD, Stukel TA, Siewers AE, et al: Surgeon volume and operative mortality in the United States. N Engl J Med 349:2117–2127, 2003
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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