eMedicine Specialties > Orthopedic Surgery > Neoplasms

Postradiation Sarcoma

Nagarjun Rao, MD, FRCPath, Assistant Professor, Department of Pathology, Medical College of Wisconsin
Donald A Hackbarth Jr, MD, FACS, Professor of Clinical Orthopedic Surgery, Division Chief, Musculoskeletal Oncology, Department of Orthopedic Surgery, Medical College of Wisconsin; Stuart Wong, MD, Assistant Professor, Department of Medicine, Section of Hematology/Oncology, Froedert Memorial Lutheran Hospital; Vivek Panikkar, MBBS, MS, MCh, FRCS, Consulting Surgeon, Departments of Trauma and Orthopedics, Doncaster Royal Infirmary, UK; Vinod B Shidham, MD, FRCPath, FIAC,, Professor, Director of Cytopathology Fellowship Training Program, FNAB Service, and International Cytopathology Fellowship, Department of Pathology, Medical College of Wisconsin; Co-Editor-in-Chief and Executive Editor, CytoJournal

Updated: Jul 14, 2009

Introduction

Background

A late effect of ionizing radiation is the development of sarcoma within the field of irradiation, referred to as postradiation sarcoma (PRS). Ionizing radiation has had many varied uses in medicine. In early years, in addition to being used in the treatment of a variety of malignancies, radiation was used to treat benign conditions, such as acne, fungal infections, eczema, and various bone diseases.^{1,2,3,4,5,6,7,8,9}
 

Light microscopic appearance of postradiation osteosarcoma; tumor is composed of pleomorphic plump spindle cells with focal presence of neoplastic osteoid (pink areas) in between tumor cells. This meningeal tumor occurred 10 years postradiation in a patient who had received radiation for a recurrent pituitary neoplasm.

The diagnosis of PRS generally is based on the following criteria:

• The histologic features of the original lesion and PRS are completely different.
• PRS is located within the field of irradiation.
• Patients with cancer syndromes such as Li-Fraumeni and Rothmund-Thomson are excluded.
• The latent period (period between initiation of radiotherapy and histologic diagnosis of second neoplasm) is more than 4 years. Although arbitrary given the wide age range reported in the literature (4-55 y), a period of 4 years generally has been accepted as being the lower limit for the latent period.

Recent studies

Neuhaus et al retrospectively reviewed histopathologic features, surgery, and outcome in 67 patients with radiation-induced sarcoma (RIS) treated between 1990 and 2005. Previous breast cancer was the most common indication for radiotherapy. Median time from irradiation to development of RIS was 11 years (3-36 years). Of 67 patients, 34 underwent potentially curative surgery, and microscopically clear margins were achieved in 75% of cases. Pedicled or free tissue transfer was required in 12 patients, and abdominal or chest wall mesh reconstructions were required in 8 patients. Median follow-up was 53 months, and median sarcoma-specific survival was 54 months (2- and 5-year survival: 75% and 45%, respectively). Local relapse rate was 65%, and negative histopathologic margins were a significant predictor of sarcoma-specific survival. Grade and size of tumor approached, but did not attain, significance.¹¹

Bjerkehagen et al studied the prevalence and outcome of radiation-induced sarcomas (RISs) in 90 sarcoma patients. RIS represented 3% of the sarcomas; median latency time from radiotherapy of the primary tumor to diagnosis of RIS was 13.6 years (range, 2.5-57.8 years). Gynecologic, breast, and testicular cancers were the most common primary diagnoses. For the RISs, 13 histologic types were identified, including 25 malignant fibrous histiocytomas (28% of all cases) and 22 osteosarcomas (24% of all cases). The sarcoma-related 5-year crude survival was 33%, and unfavorable prognostic factors were metastases at presentation, incomplete surgery, and presence of tumor necrosis. According to the authors, complete surgical resection is mandatory for cure.¹²

Pathophysiology

Postradiation sarcoma (PRS) can occur with orthovoltage (low-energy) and megavoltage (high-energy) radiation. With orthovoltage radiation, the dosages are lower and the latent periods are longer. The threshold dose for PRS is not known, although in most published series, a dosage of 40-60 Gy has been reported.^2,13,14 Development of PRS also is influenced by other factors, including genetic tendency andinfluence of chemotherapeutic agents.

Ionizing radiation is thought to act via genetic alterations, including mutations of p53 and retinoblastoma (Rb) genes. Experimental evidence shows p53 gene alterations or increased p53 messenger ribonucleic acid (mRNA) levels in murine PRS.¹⁵

Frequency

United States

If the criteria listed above are followed strictly, the overall incidence of PRS in patients who survive longer than 5 years following radiation therapy is about 0.1%.¹⁰ In one large series, the incidence was reported to be 0.11% following orthovoltage radiation therapy and 0.09% following megavoltage radiation therapy.¹⁰ In earlier published studies, many patients had received radiation therapy for benign bone and soft-tissue conditions. In contrast, other reports have shown larger numbers of patients who have received radiation therapy for malignancies such as breast cancer, lymphoma, and Ewing sarcoma.^5,6,10,16 In a large retrospective study from the Mayo Clinic spread over several years (1933-1992), benign bone conditions were found to be the single largest group of index lesions in patients with PRS, followed by genitourinary malignancies (especially cervical cancers).¹⁰

Mortality/Morbidity

The reported 5-year survival rate for PRS has been extremely poor, ranging from 8.7-22%.^13,14,17 The poor survival rate is thought to be due to a number of interrelated factors, such as the following:

• Significant delay in diagnosis
• Large unresectable lesions
• Older age
• Anaplastic nature of lesions
• Lack of effective adjuvant treatment

Race

A racial predilection has not been reported in the literature.

Sex

Predilection based on sex has not been reported. In the Mayo study, although the male-to-female ratio was 8:5, when sex-specific tumors (eg, breast, cervix, testis, ovary) were excluded, no difference was demonstrated on the basis of sex.

Age

Patients of all ages are affected. In the Mayo study, which involved 130 patients, the average age at diagnosis of index lesion was 28.7 years (range 4 mo to 65 y).¹⁰ The mean age at diagnosis of PRS was 47.9 years (range 10.5-80.9 y). The latent period ranged from 4 years to 55 years (average 17 y).

Clinical

History

Pain is the most common complaint and is abrupt and rapid in onset, relentless and progressive, constant, and worse at night. Pain usually is not relieved with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). Mass (soft tissue or bone), bleeding, and pathologic fracture also are reported. Clinical factors that favor a diagnosis of PRS include the following:

• Sarcoma in bone or soft tissue appearing at an unusual age
• Sarcoma in bone or soft tissue at an unusual site
• Addition of intensive chemotherapy to irradiation

Physical

Physical findings are localized to the irradiation area. These usually are a mass (bony or soft tissue), tenderness, and/or a pathologic fracture.

Causes

Causes are discussed in detail in Pathophysiology. While ionizing radiation is the triggering factor (a dose of 40-60 Gy is thought to be the threshold dose), other factors (eg, genetic tendency, concomitant use of chemotherapeutic agents, as yet unknown factors) appear to be responsible for development of PRS.

Differential Diagnoses

Bursitis
Calcifying Tendonitis
Gout
Non-neoplastic Conditions Simulating Bone Tumors
Osteoarthritis
Rotator Cuff Pathology

Other Problems to Be Considered

Differential diagnoses for bone pain in a patient with a history of irradiation include the following:

• Metastatic bone disease
• Radiation osteopathy
• Nonneoplastic causes of bone pain, such as rotator cuff impingement syndrome, osteoarthritis, bursitis/tendonitis, gout, and pseudogout

Workup

Laboratory Studies

• No specific laboratory blood tests are used to diagnose postradiation sarcoma (PRS). Routine laboratory investigations may be ordered.
• Cytogenetic studies on PRS tumor cells do not have much value because the tumor cells can have numerous quantitative (numerical) and qualitative abnormalities that lack specificity. However, the value of cytogenetic analysis lies in excluding other conditions that may have specific anomalies and that may present a challenge in light microscopic examination.

Imaging Studies

• Plain radiographs
  • Obtain plain radiographs in 2 planes.
  • Cortical bone destruction is the most common finding.
  • A mineralized soft-tissue mass is seen in most patients.
  • Changes such as osteopenia and sclerosis are seen in a minority of patients.
• CT scan and MRI
  • If plain radiograph findings are normal and the patient has significant pain, these scans are useful for identifying abnormal areas in the medullary cavity, cortical bone destruction, and the presence of an extramedullary soft-tissue mass.
  • MRI is the best modality to detect soft-tissue involvement in PRS.
  • CT scan of the chest is performed to detect pulmonary metastases.
• Technetium bone scan is performed to detect bone metastases.

Procedures

• Biopsy
  • Fine-needle aspiration biopsies or Tru-Cut core biopsies can be obtained from the lesion for histopathologic/cytopathologic confirmation of diagnosis and to type and grade the lesion.
  • In the case of a deep-seated lesion, CT-guided biopsies can be obtained.
  • The biopsy should be the final diagnostic procedure because it can distort imaging studies, especially MRI.
  • Careful preoperative planning is required before biopsy is attempted. Imaging studies aid the surgeon in selecting the best site for tissue diagnosis. Usually, the best diagnostic site is at the interface between the tumor and adjacent normal tissue; this also prevents the occurrence of fracture at the biopsy site, as biopsy in this location usually does not violate cortical bone.
  • A frozen section can be obtained to determine whether adequate representative tissue has been obtained. A definitive diagnosis usually is delayed until permanent sections are analyzed.

Histologic Findings

Postradiation sarcoma (PRS) in bone and soft tissue usually is a high-grade lesion, which partly accounts for the almost uniformly grim prognosis.^4,7 In a study of 130 patients with PRS of bone and soft tissue from the Mayo Clinic, osteosarcoma was the most common type, constituting 61.5% of all cases.¹⁰ This was followed by fibrosarcoma (23.7%), malignant fibrous histiocytoma (MFH, 9.6%), chondrosarcoma (3.7%), and rare cases of angiosarcoma and Ewing sarcoma. No difference in histologic type of PRS was demonstrated between the orthovoltage and megavoltage groups.

Among soft-tissue PRS lesions, the most common histologic type is MFH (70%), followed by osteosarcoma, fibrosarcoma, malignant peripheral nerve sheath tumor (MPNST), chondrosarcoma, and angiosarcoma.¹⁸

Grossly, these tumors are soft and fleshy, with extension into adjacent soft tissue and formation of a soft-tissue mass. Hemorrhagic/necrotic foci and matrix production (osteoid/chondroid) may be seen. Degenerative calcific changes also may be noted.

Light microscopic appearance of postradiation osteosarcoma; tumor is composed of pleomorphic plump spindle cells with focal presence of neoplastic osteoid (pink areas) in between tumor cells. This meningeal tumor occurred 10 years postradiation in a patient who had received radiation for a recurrent pituitary neoplasm.

Staging

Careful staging is a prerequisite for appropriate management of postradiation sarcoma (PRS).

The marrow extent and soft-tissue involvement of PRS should be gauged using radiologic modalities, of which MRI is the best choice. Biopsies may be obtained to confirm the diagnosis and to type and grade the lesion.

A CT scan of the chest is obtained to detect pulmonary metastases. A technetium bone scan is performed to detect bone metastases.

Based on the results of imaging and histopathologic/cytopathologic studies, the lesion may be staged. The American Joint Committee on Cancer (AJCC) and Musculoskeletal Tumor Society (MSTS) staging systems generally are used.

• The AJCC staging system is based on the TNM staging system and uses the following categories:
  • Size and extension of primary tumor (T)
  • Involvement of lymph nodes (N)
  • Presence of metastases (M)
  • Type and grade of sarcoma (G)
• Definitions of the TNMG staging system are as follows:
  • T - Primary tumor
    • T1 - Tumor smaller than 5 cm
    • T2 - Tumor 5 cm or larger
  • N - Regional lymph nodes
    • N0 - No histologically verified regional node metastasis
    • N1 - Histologically verified regional node metastasis
  • M - Distant metastasis
    • M0 - No distant metastasis
    • M1 - Distant metastasis
  • G - Histologic grade of malignancy
    • G1 - Well differentiated
    • G2 - Moderately well differentiated
    • G3 - Poorly differentiated
    • G4 – Undifferentiated
• The MSTS staging system classifies tumors as follows:
  • Stage IA - Low grade, intracompartmental
  • Stage IB - Low grade, extracompartmental
  • Stage IIA - High grade, intracompartmental
  • Stage IIB - High grade, extracompartmental
  • Stage III - Systemic or regional metastases
• In the MSTS staging system, the margins are classified as follows:
  • Intralesional - Margin through tumor tissue
  • Marginal - Margin through reactive zone around tumor consisting of edema, inflammatory cells, fibrous tissue, and tumor cell satellites
  • Wide - Margin through normal tissue outside reactive zone
  • Radical – Removal of entire compartment containing tumor

Treatment

Medical Care

Postradiation sarcoma (PRS) ideally is managed with a multidisciplinary approach with input from the radiation oncologist, medical oncologist, and surgeon. Because PRS is high grade and advanced stage or metastatic at the time of diagnosis, patients commonly are not eligible for curative surgery, and the prognosis for these patients generally is poor. Chemotherapy is the most common treatment modality and typically is associated with poor response rates.

Surgical Care

Surgical options for postradiation sarcoma (PRS) include wide or radical resection (limb salvage) or amputation, and depend upon the stage and location of the tumor and the age and performance status of the patient. In patients with peripherally located tumors at stage IIB and below (MSTS system), it is feasible to expect resection to provide a reasonable 5-year survival rate. (In one study, the 5-year survival rate for this group approached 68%.) Brachytherapy or postoperative external beam radiation can be added if the margins are close to the tumor.

Consultations

A multidisciplinary approach is ideal for postradiation sarcoma (PRS). The surgical oncologist, who preferably has experience in treating sarcomas, should be involved at the outset for the diagnostic evaluation. In addition, input from the radiation oncologist and medical oncologist is necessary to achieve a coordinated treatment plan, particularly for patients in whom combined modality treatment is being contemplated.

Diet

Nutrition is an important aspect in the care of patients receiving active cancer treatment.¹⁹ Surgery, radiation therapy, and chemotherapy may adversely affect the patient's nutritional status and hence may alter quality of life. Cancer treatment can alter the patient's ability to eat, digest, and absorb food. Anticipation of these potential adverse effects, therefore, is necessary. Intervention, such as with commercially available liquid nutritional supplements, may be required to maintain adequate caloric intake. Consultation with a health care provider qualified in nutrition also may be considered.

Activity

The impact of physical activity upon treatment outcome in patients with cancer is not well defined in the literature. However, modest levels of physical activity during cancer treatment may provide benefits with respect to increasing appetite, maintaining mobility and muscle tone, and enhancing a sense of emotional well-being.

Medication

The selection of chemotherapy agents used to treat patients with postradiation sarcoma (PRS) is based largely upon data from clinical trials of soft-tissue and bone sarcomas. The 2 most active single chemotherapy agents are doxorubicin (Adriamycin) and ifosfamide. These agents have roughly equivalent activity. Dacarbazine (DTIC) has modest single-agent activity. MAID (combination of mesna, Adriamycin, ifosfamide, and DTIC) has been a commonly used combination chemotherapy regimen for the treatment of soft-tissue sarcoma over the past decade.

Three randomized trials have been performed in which regimens containing Adriamycin and ifosfamide were compared with Adriamycin alone. Two of these trials showed higher response rates in the treatment arms containing Adriamycin and ifosfamide than in those containing Adriamycin alone. However, the Adriamycin and ifosfamide combinations also were associated with significantly higher myelosuppression (including fatal neutropenic sepsis) but no survival advantage. No standard of care has been established for the choice of chemotherapy agents. Therefore, treatment typically is individualized.

Preoperative chemotherapy can be administered with or without radiation therapy and is administered either intravenously (as a bolus or as a continuous infusion) or regionally via an intra-arterial infusion to an isolated limb. Preoperative chemotherapy generally is considered in order to facilitate a limb-sparing procedure. This approach is considered for patients who otherwise would require amputation for cure or palliation. In some instances, this approach may be considered to convert a marginally resectable lesion into one that is operable. Consideration of preoperative chemotherapy for PRS must take into account that response rates to chemotherapy are low and that most long-term survivors with PRS are patients who have undergone successful surgical resection.

Follow-up

Further Inpatient Care

• Inpatient care frequently is required for patients with postradiation sarcoma (PRS) at different stages of treatment. Inpatient care may be required for diagnostic evaluation to allow surgery with general anesthesia. Most preoperative chemotherapy regimens and palliative chemotherapy regimens for advanced disease require inpatient hospitalization.

Further Outpatient Care

• Radiotherapy is delivered in the ambulatory setting. Follow-up of patients who have received definitive treatment for postradiation sarcoma (PRS) is individualized based upon the site of disease. Generally, follow-up should include a posttreatment imaging study to provide a baseline against which subsequent studies may be compared. Subsequent follow-up should include a thorough history and physical examination, with laboratory tests and chest radiographs and other imaging performed regularly for the first 2 years. Assessments may be spaced further apart after the second year to the fifth year following definitive treatment. Annual assessments may be performed thereafter.

Inpatient & Outpatient Medications

• See Medication.

Deterrence/Prevention

• Lowering the dosage of radiation and/or adjuvant chemotherapy is the only preventive measure for postradiation sarcoma (PRS); however, this may not be practicable. The discontinuation of radiation for benign bone and soft-tissue diseases has limited PRS to patients receiving radiation treatment for malignancies.

Complications

• Postradiation sarcoma (PRS) is a complication of radiation treatment for various bone and soft-tissue malignancies.
• Complications that arise from PRS are those seen with other soft-tissue and bone tumors, such as pathologic fractures, hemorrhage, metastases, and local complications due to direct invasion.

Prognosis

• The overall reported 5-year survival rates for patients with postradiation sarcoma (PRS) have been poor, ranging from 8.7-22% in different studies.^{11,12,13,14,17,20} However, patients with resectable peripheral lesions at stage IIB or lower have a relatively better prognosis. In the Mayo Clinic series, the 5-year survival rate was 68%.¹⁰
• The overall poor prognosis in these patients is related to delayed diagnosis, large unresectable lesions, poor response to chemotherapy, and high-grade histology.

Multimedia

Media file 1: Light microscopic appearance of postradiation osteosarcoma; tumor is composed of pleomorphic plump spindle cells with focal presence of neoplastic osteoid (pink areas) in between tumor cells. This meningeal tumor occurred 10 years postradiation in a patient who had received radiation for a recurrent pituitary neoplasm.

References

1. Cahan WG. Radiation-induced sarcoma--50 years later. Cancer. Jan 1 1998;82(1):6-7. [Medline].

2. Smith LM, Cox RS, Donaldson SS. Second cancers in long-term survivors of Ewing''s sarcoma. Clin Orthop. Jan 1992;(274):275-81. [Medline].

3. Cahan WG, Woodard HQ, Higinbotham NL, et al. Sarcoma arising in irradiated bone: report of eleven cases. 1948. Cancer. Jan 1 1998;82(1):8-34. [Medline].

4. Debeer P, Van de Meulebroucke B, Stuyck J, Sciot R, Samson I. Postradiation soft tissue sarcoma of the shoulder: a case report. Acta Orthop Belg. Aug 2007;73(4):521-4. [Medline].

5. Nicolas MM, Nayar R, Yeldandi A, De Frias DV. Pulmonary metastasis of a postradiation breast epithelioid angiosarcoma mimicking adenocarcinoma. A case report. Acta Cytol. Nov-Dec 2006;50(6):672-6. [Medline].

6. Hanasono MM, Osborne MP, Dielubanza EJ, Peters SB, Gayle LB. Radiation-induced angiosarcoma after mastectomy and TRAM flap breast reconstruction. Ann Plast Surg. Feb 2005;54(2):211-4. [Medline].

7. Fang Z, Matsumoto S, Ae K, Kawaguchi N, Yoshikawa H, Ueda T. Postradiation soft tissue sarcoma: a multiinstitutional analysis of 14 cases in Japan. J Orthop Sci. 2004;9(3):242-6. [Medline].

8. Fangman WL, Cook JL. Postradiation sarcoma: case report and review of the potential complications of therapeutic ionizing radiation. Dermatol Surg. Aug 2005;31(8 Pt 1):966-72. [Medline].

9. Mullah-Ali A, Ramsay JA, Bourgeois JM, Hodson I, Macdonald P, Midia M, et al. Paraspinal synovial sarcoma as an unusual postradiation complication in pediatric abdominal neuroblastoma. J Pediatr Hematol Oncol. Jul 2008;30(7):553-7. [Medline].

10. Inoue YZ, Frassica FJ, Sim FH, et al. Clinicopathologic features and treatment of postirradiation sarcoma of bone and soft tissue. J Surg Oncol. Sep 2000;75(1):42-50. [Medline].

11. Neuhaus SJ, Pinnock N, Giblin V, Fisher C, Thway K, Thomas JM, et al. Treatment and outcome of radiation-induced soft-tissue sarcomas at a specialist institution. Eur J Surg Oncol. Dec 27 2008;[Medline].

12. Bjerkehagen B, Smeland S, Walberg L, Skjeldal S, Hall KS, Nesland JM, et al. Radiation-induced sarcoma: 25-year experience from the Norwegian Radium Hospital. Acta Oncol. 2008;47(8):1475-82. [Medline].

13. Amendola BE, Amendola MA, McClatchey KD, et al. Radiation-associated sarcoma: a review of 23 patients with postradiation sarcoma over a 50-year period. Am J Clin Oncol. Oct 1989;12(5):411-5. [Medline].

14. Taghian A, de Vathaire F, Terrier P, et al. Long-term risk of sarcoma following radiation treatment for breast cancer. Int J Radiat Oncol Biol Phys. Jul 1991;21(2):361-7. [Medline].

15. Strauss PG, Schmidt J, Pedersen L, et al. Amplification of endogenous proviral MuLV sequences in radiation- induced osteosarcomas. Int J Cancer. Apr 15 1988;41(4):616-21. [Medline].

16. Pitcher ME, Davidson TI, Fisher C, et al. Post irradiation sarcoma of soft tissue and bone. Eur J Surg Oncol. Feb 1994;20(1):53-6. [Medline].

17. Smith J. Radiation-induced sarcoma of bone: clinical and radiographic findings in 43 patients irradiated for soft tissue neoplasms. Clin Radiol. Mar 1982;33(2):205-21. [Medline].

18. Enzinger FM, Weiss SW. General considerations. In: Soft Tissue Tumors. 3rd ed. St. Louis:. Mosby;1995.

19. Brown J, Byers T, Thompson K, et al. A cancer journal for clinicians: nutrition during and after cancer treatment. In: A Guide for Informed Choices by Cancer Survivors. Vol 51. 2001.

20. Kalra S, Grimer RJ, Spooner D, Carter SR, Tillman RM, Abudu A. Radiation-induced sarcomas of bone: factors that affect outcome. J Bone Joint Surg Br. Jun 2007;89(6):808-13. [Medline].

Keywords

postradiation sarcoma, PRS, postirradiation sarcoma, radiation-induced sarcoma, osteosarcoma, fibrosarcoma, malignant fibrous histiocytoma, MFH, chondrosarcoma, angiosarcoma, Ewing sarcoma, malignant peripheral nerve sheath tumor, MPNST

Contributor Information and Disclosures

Author

Nagarjun Rao, MD, FRCPath, Assistant Professor, Department of Pathology, Medical College of Wisconsin
Nagarjun Rao, MD, FRCPath is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, and Royal College of Pathologists
Disclosure: Nothing to disclose.

Coauthor(s)

Donald A Hackbarth Jr, MD, FACS, Professor of Clinical Orthopedic Surgery, Division Chief, Musculoskeletal Oncology, Department of Orthopedic Surgery, Medical College of Wisconsin
Donald A Hackbarth Jr, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Tissue Banks, American College of Surgeons, Children's Oncology Group, Christian Medical & Dental Society, Clinical Orthopaedic Society, and Wisconsin Medical Society
Disclosure: Musculoskeletal Transplant Foundation Honoraria Board membership

Stuart Wong, MD, Assistant Professor, Department of Medicine, Section of Hematology/Oncology, Froedert Memorial Lutheran Hospital
Disclosure: Nothing to disclose.

Vivek Panikkar, MBBS, MS, MCh, FRCS, Consulting Surgeon, Departments of Trauma and Orthopedics, Doncaster Royal Infirmary, UK
Disclosure: Nothing to disclose.

Vinod B Shidham, MD, FRCPath, FIAC,, Professor, Director of Cytopathology Fellowship Training Program, FNAB Service, and International Cytopathology Fellowship, Department of Pathology, Medical College of Wisconsin; Co-Editor-in-Chief and Executive Editor, CytoJournal
Vinod B Shidham, MD, FRCPath, FIAC, is a member of the following medical societies: American Association for Cancer Research, American Society of Cytopathology, College of American Pathologists, International Academy of Cytology, Royal College of Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Medical Editor

Miguel A Schmitz, MD, Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports Medicine Clinic
Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Sean P Scully, MD, PhD, Professor, Department of Orthopedics, University of Miami
Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

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Clinical guidelines

Improving outcomes for people with sarcoma. National Collaborating Centre for Cancer - National Government Agency [Non-U.S.].  2006 Mar.  138 pages.  NGC:004878

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