Background: Population-based studies of patients with bone metastases in the appendicular skeleton (aBM) requiring surgery for complete or impending fracture are rare. In this epidemiologically-based observational study we created a large population-based cohort of patients treated for aBM, aiming to: (1) monitor possible time-related changes of the incidence of surgical treatment of aBM-lesions, (2) examine differences in the population and care of patients treated at different treatment centers and (3) examine if findings from a previous pilot study regarding absence of a suitable biopsy of the lesions representing debut of cancer or a relapse has improved the awareness of aBM and hereby increased the focus on regular tumor biopsies and follow-up imaging of cancer patients. Methods: We examined a population-based cohort consisting of all patients treated for aBM 2014–2019. Procedures were performed at five secondary surgical centers (SSC) or one tertiary referral Musculoskeletal Tumor Center (MTC). Patients were followed until end of study (30 September 2021) or death. No patients were lost to follow-up. Results: Four-hundred-fifty-seven patients (493 primary aBM-lesions, 482 procedures) were included. Annual incidence of aBM-surgery was 46 aBM-lesions/million. MTC-patients had a significant better preoperative status than SSC-patients considering factors known for survival. Patients with complete fracture experienced longer surgical delay when treated at MTC compared to SSC: 4 (1–9) and 1 (1–3) days (p < 0.001), respectively. Overall survival for the entire cohort was 37% and 11% at 1 and 5 years (MTC and SSC 1 and 5 year respectively: 44% and 15% vs. 29% and 5%, p < 0.001). In patients with debut or relapse of cancer, 8% and 9% had insufficient biopsies, and 21% and 12% had no biopsy, respectively. Comparison showed no change over time. Conclusions: The current study highlights the low awareness on treating aBM at SSC and emphasizes the importance of caution in interpretation of studies not representing an entire population, thus introducing selection bias.

Background: Soft-tissue sarcomas (STSs) are rare and challenging to diagnose due to their heterogeneous presentation. In 2009, Denmark introduced the Cancer Patient Pathways for sarcomas (CPPs) to improve sarcoma treatment by streamlining diagnostic and therapeutic processes. The primary objective of this study is to evaluate the impact of the CPPs on the overall survival of patients with deep-seated, high-grade STSs, comparing outcomes from before and after CPP implementation. Methods: A retrospective cohort study was conducted using data from 712 patients diagnosed with high-grade STSs in the extremities or trunk wall between 2000 and 2018. Patients were grouped into pre-CPP (2000–2008) and post-CPP (2010–2018) cohorts. Overall survival was analyzed using Kaplan–Meier estimates. Results: The five-year overall survival improved from 43% in the pre-CPP cohort to 52% post-CPP (p = 0.05). Time-to-treatment was significantly reduced in the post-CPP cohort, with a median decrease of 3 days (18 vs. 15 days, p < 0.001). We found only a very weak tendency toward larger tumor sizes in the pre-CPP cohort and no difference regarding the percentage of patients that had distant metastases at diagnosis between cohorts. In the post-CPP cohort, the percentage of whoops operations decreased and the use of oncological services increased. Conclusions: After the introduction of the CPPs for the sarcoma patients, overall survival improved and time to treatment was reduced. This study highlights the importance of efficient referral pathways in improving cancer outcomes but cannot exclude that other factors could also have contributed.

Patients with bone metastases in the femur (BMf) may experience pathological fractures requiring surgery with cemented endoprostheses (EPR). At cementation and prosthesis insertion, patients are at risk of experiencing hypoxia, hypotension, cardiac failure and potentially death, known as bone cement implantation syndrome (BCIS). We aimed to 1) investigate the incidence and grade of BCIS in patients with BMf treated with cemented EPR, and 2) examine if the incidence or extent of BCIS has decreased after a change of a combined anesthesiologic and surgical protocol. We retrospectively assessed patients with BMf operated with cemented EPR in two periods 2017 - 2018 (early cohort) and 2019 - 2020 (late cohort) and stratified before and after the intervention. Comparing the early and late cohorts, 26/86 (32 %) vs. 30/80 (35 %) experienced BCIS, but mild BCIS (grade 0 + 1) was seen in 79 % vs. 86 %, and severe BCIS (grade 2 + 3) in 21 % vs. 14 %. In the late cohort the per-operative use of vasopressors was higher (86 % vs. 59 %, p < 0.001), we found fewer pulmonary embolisms (PE) (p = 0.024), and a trend toward a reduced length of stay (LOS). 30-day survival was lower for patients with grade 0 + 1 compared to grade 2 + 3 (p = 0.03). BCIS occurs in more than 1/3 of patients operated for BMf with cemented EPR. An increased multidisciplinary focus on BCIS may reduce the complications of BCIS, such as PE and LOS.