Robert Ashford

University of Leicester | LE · Leicester Cancer Research Centre

The incidence of skeletal metastases is increasing as survival from cancer increases. This introductory chapter looks at the epidemiology of metastatic bone disease and the impact of increasing survival of patients with cancer. Special attention is given to socioeconomic factors that may lead to healthcare disparities among patients with metastatic...

We present a novel case of a malignant transformation of an extremity soft tissue angioleiomyoma to leiomyosarcoma in a man in his late 70s who presented with a painful and increasing lump on his anterior tibia. Initial imaging and biopsy showed a benign angioleiomyoma which was excised for symptomatic reasons. An analysis of the resulting specimen...

Background: Megaprosthetic replacement (MPR) of the femur is typically reserved for salvage or oncological reconstruction. Presently little is known about the provision of femoral MPRs performed nationally, the trends in indications for their use, and their outcomes beyond published unit-level data. Although the National Joint Registry (NJR) colle...

Background Regional lymph node metastases (RLNM) in cases of soft tissue sarcoma (STS) are relatively rare, with limited data available on optimal patient management and prognosis. To help address this, we present our own experiences of patients with STS RLNMs. Methods We performed a retrospective review of all patients with STS RLNM managed at ou...

Introduction Skeletal muscle wasting is a common complication of chronic kidney disease which leads to a loss of muscle function. The pathogenesis of skeletal muscle wasting is incompletely understood, which is preventing the development of targeted therapeutics. Recent evidence implicates miRNAs in the of skeletal muscle wasting. Our aim was to fi...

Background Leiomyosarcomas are aggressive malignancies which can occur on the trunk and extremities whose pathogenesis is poorly understood. We aim to quantify the prognostic impact of various clinical and pathological markers on survival and recurrence of leiomyosarcomas. Methods We conducted a systematic review as per PRISMA protocol. Survival,...

Background: Skeletal muscle wasting and dysfunction are common characteristics noted in people who suffer from chronic kidney disease (CKD). The mechanisms by which this occurs are complex, and although progress has been made, the key underpinning mechanisms are not yet fully elucidated. With work to date primarily conducted in nephrectomy-based a...

Background People with chronic kidney disease (CKD) experience skeletal muscle wasting, reduced levels of physical function and performance and chronic systemic inflammation. Whilst it is known that a relationship exists between inflammation and muscle wasting, the association between inflammation and physical function or performance in CKD has not...

Bone and Soft Tissue Tumours

Introduction Soft tissue sarcomas (STS) are a group of rare malignant tumours that can occur at almost any anatomical location in patients of any age, which often present to health care professional working outside a recognised sarcoma service. We aimed to review our experiences of foot and ankle STSs, reporting on patient and tumour characteristic...

Polyostotic bone diseases can present with skeletal lesions in multiple bones, or at several locations within the same bone. They consist of a small number of conditions, which includes both benign and malignant pathologies. The treatment and prognosis of polyostotic bone diseases varies hugely, which makes a methodical approach to their investigat...

Background and Aims Skeletal muscle wasting and dysfunction is a debilitating co-morbidity for people who suffer from kidney disease. To date research has sought to understand the mechanisms by which this occurs, in order to inform the prescription of required interventions in order to counteract such effects. Though progress has been made through...

Incidence of hip fractures has remained unchanged during the pandemic with overlapping vulnerabilities observed in patients with hip fractures and those infected with COVID-19. We aimed to investigate the independent impact of COVID-19 infection on the mortality of these patients. Healthcare databases were systematically searched over 2-weeks from...

Background Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS),...

Skeletal muscle wasting and dysfunction is a common characteristic of non-dialysis dependent chronic kidney disease (NDD-CKD). The mechanisms by which this occurs are not clearly understood and one reason for this is a lack of well controlled in-vitro methodologies to simulate NDD-CKD induced muscle wasting for mechanistic investigation at the cell...

Quality of life assessment represents a key process of deciding treatment success and viability. As such, patients' perceptions of their functional status and well-being are important inputs for impairment assessment. Given that patient completed questionnaires are often used to assess patient status and determine future treatment options, it is im...

Soft tissue sarcomas (STS) are rare, malignant tumours with a generally poor prognosis. Our aim was to explore the potential of cell free DNA (cfDNA) and circulating tumour DNA (ctDNA) analysis to track non-metastatic STS patients undergoing attempted curative treatment. The analysed cohort (n = 29) contained multiple STS subtypes including myxofib...

This article provides a brief overview of the current COVID-19 pandemic crisis and the impact on trauma and orthopaedic surgeons. The principles of protect, avoid, restrict and abbreviate are recommended. Coordination of response, communication and support are also important. The versatility of orthopaedic surgeons lends them to having an important...

Aims: we aimed to find out: the typical workload for metastatic bone disease, the conventional treatment for femoral metastases and whether there is a trend for arthroplasty and endoprosthetic reconstruction. Materials and methods: All sequential patients undergoing surgery for femoral metastatic lesions (both pathological fracture and impending p...

Aims We aimed to find out: the typical workload for metastatic bone disease, the conventional treatment for femoral metastases and whether there is a vogue for being more aggressive. Materials and Methods All sequential patients undergoing surgery for femoral metastatic lesions (both pathological fracture and impending pathological fracture) of an...

Patients with chronic kidney disease (CKD) exhibit reduced exercise capacity, poor physical function and symptoms of fatigue. The mechanisms that contribute to this are not clearly defined but may involve reductions in mitochondrial function, mass and biogenesis. Here we report on the effect of non‐dialysis dependent CKD (NDD‐CKD) on mitochondrial...

Background: Late-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and cost-...

Introduction Renal impairment following major surgery is a formidable complication. There is recent evidence suggesting increasing risk of progression to chronic kidney disease and mortality after transient renal impairment. We aimed to evaluate the impact of pre-operative comorbidities on long-term outcomes of renal-function following hip arthrop...

Desmoid fibromatosis (DF) is a rare intermediate soft tissue tumour characterised by myofibroblastic cell proliferation. Although desmoid tumours are locally very infiltrative, they hold no metastatic potential, and a significant proportion of cases naturally regress if simply observed. Considering this, a first-line policy of active observation sh...

Breast cancer can present with bone metastases with a clinical presentation of bone pain, pathological fracture or biochemical disturbance. The detection of metastases via appropriate imaging and involvement of the multidisciplinary team (including the oncologists, breast and orthopaedic surgeons) is paramount in managing the patient with skeletal...

Background: We sought to determine whether patients undergoing secondary patella resurfacing (SPR) benefited from the procedure by assessing postoperative satisfaction via a postal questionnaire. Methods: All such patients included in the Trent and Wales Arthroplasty Register were invited to participate using patient-reported outcome measures (P...

Following treatment 40% of soft tissue sarcoma (STS) patients suffer disease recurrence. In certain cancers circulating cell free DNA (cfDNA) and circulating tumour-derived DNA (ctDNA) characteristics correlate closely with disease burden, making them exciting potential sources of biomarkers. Despite this, the circulating nucleic acid characteristi...

This practical handbook is an essential reference for GPs when dealing with musculoskeletal disorders, as well as a useful exam prep aid for the common MSK cases that occur in the CSA. Responding to increasing pressures on GPs to reduce the number of referrals and treat more patients in the community, the book covers a breadth of orthopaedic disord...

Soft tissue sarcomas (STS) are a heterogeneous group of tumours and surgery is the principal treatment. The majority occur in the limbs and trunk wall and this article refers to management of these anatomical sites. STS is managed within a specialist multidisciplinary team and an individualized treatment plan is produced for each patient. Histologi...

Soft tissue sarcomas (STS) are a diverse group of heterogeneous malignant tumours derived from mesenchymal tissues. Over 50 different STS subtypes are recognised by WHO, which show a wide range of different biological behaviours and prognoses. At present, clinicians managing this complex group of tumours face several challenges. This is reflected b...

Prosthetic joint infection (PJI) is a devastating complication in total knee arthroplasty (TKA) and third most common cause of revision of TKA with significant morbidity and surgical challenges. Treatment options include non-operative measures with long term antibiotic suppression, debridement and implant retention (DAIR), one- or two-stage revisio...

Quality of life assessment represents a key process of deciding treatment success and viability. As such, patients’ perceptions of their functional status and well-being are important inputs for impairment assessment. Given that patient completed questionnaires are often used to assess patient status and determine future treatment options, it is im...

INTRODUCTION Intramedullary nailing is a common treatment for proximal femoral fractures. Fracture of the nail is a rare but devastating complication that exposes often frail patients to complex revision surgery. We investigated which risk factors predict nail failure. METHODS We reviewed all cases of nail breakage seen over a 10-year period in a...

In the context of cancer treatment and surgery, quality of life assessment is a crucial part of determining treatment success and viability. In order to assess it, patients completed questionnaires which employ words to capture aspects of patients well-being are the norm. As the results of these questionnaires are often used to assess patient progr...

Introduction From April 2011 to May 2013 a diagnostic, consultant led 2 week wait clinic, was established at out trust affiliated to the regional sarcoma MDT. A Surgical Care Practitioner (SCP), under the auspices of the consultant reviewed all new patients from May 2013 to date. The aim of this study was to assess the number and type (benign/malig...

The management of a patient with a tumour of the musculoskeletal system has progressed over recent decades. The development of evidence based medicine is a key factor in driving such change. Although now predominantly treated within specialist centres, all orthopaedic surgeons require an understanding of such malignancies and the management options...

This paper aims to provide evidence-based guidance for the general orthopaedic surgeon faced with the presentation of a potential soft tissue sarcoma in an extremity.

In the context of cancer treatment and surgery, quality of life assessment is a crucial part of determining treatment success and viability. In order to assess it, patient-completed questionnaires which employ words to capture aspects of patients’ well-being are the norm. As the results of these questionnaires are often used to assess patient progr...

#### What you need to know A 45 year old woman presented to her general practitioner several times over nine months with a gradually enlarging, hard lump in her anterior thigh. An ultrasound scan showed a solid intramuscular mass in the anterior compartment of her thigh, prompting a two week wait referral to the regional sarcoma diagnostic clinic....

Extra abdominal desmoid fibromatosis is a complex condition with many recognised treatments including active observation, hormonal therapy, chemotherapy, radiotherapy and surgical resection. There is large variation in the natural history of individual desmoid tumours, with some cases progressing aggressively and others regressing spontaneously whe...

The incidence of skeletal metastases is increasing as survival from cancer increases. This introductory chapter looks at the epidemiology of metastatic bone disease and the impact of increasing survival of patients with cancer. The incidence of skeletal related events (SREs) and pathological fracture are reviewed from epidemiological data and the p...

To promote early diagnosis of cancer, NICE published updated guidelines ‘Suspected cancer: recognition and referral – NICE guidelines NG 12 in June 20151. It is our opinion that the new guidelines on sarcomas need urgent review/update to provide clarity on recognition and referral and our response was published on 26th July 20152 Soft tissue lumps...

The management of malignant pathological fractures necessitates careful diagnostic work-up, pre-operative investigation, planning and multidisciplinary input from specialists in the fields of radiology, pathology, oncology, trauma and orthopaedics. Malignant and non-malignant conditions including metabolic disorders, benign tumours and pharmacologi...

To promote early diagnosis of cancer, NICE published updated guidelines ‘Suspected cancer: recognition and referral – NICE guidelines NG 12 in June 20151. It is our opinion that the new guidelines on sarcomas need urgent review to provide clarity on recognition and referral. Sarcomas are rare malignancies constituting about 1% of all cancers. Howev...

Soft tissue sarcomas (STS) are rare malignant connective tissue tumours. A multi-disciplinary approach is required to manage such tumours. This article reviews the diagnosis and management of STSs.

Introduction This study aimed to document a single surgeon’s experience of surgery to excise primary retroperitoneal sarcomas. Method Patients with retroperitoneal sarcoma referred to a surgeon at Nottingham University Hospitals via the East Midlands Sarcoma Service between 2006 and 2013 were included. Patient demographics, tumour characteristics a...

The optimal management of desmoid fibromatosis remains unclear, leading to significant variability in patient management. To assess this problem, the current approach of clinicians managing this complex condition in the UK was investigated. A hypothetical case of intramuscular limb girdle desmoid fibromatosis in a fit 65-year-old patient was devise...

Objective: Soft-tissue lesions are common and often benign. Owing to the rarity of soft-tissue sarcomas (STSs), evidence has shown that patients are increasingly referred urgently onto the 2-week wait pathway, which may have a detrimental impact on the management of patients with a proven STS. Imaging plays a vital role in lesion characterization...

This is an impressive book. Written by a surgeon, a pathologist and an oncologist, the book draws heavily on the Memorial Sloan-Kettering Cancer Center soft tissue sarcoma (STS) database. This prospectively acquired database, established by the senior author in 1982, now includes data on over 8,000 soft tissue sarcoma patients.The book features thr...

This is a multi-author text that forms part of the MD Anderson Cancer Care Series. The stated aim of the book is to facilitate communication between health-care providers who are involved in the care of bone sarcoma patients. The editors state in their preface that “there is a surprisingly limited knowledge by some members of the team as to what ot...

Introduction Desmoid fibromatosis (DF) carries a significant morbidity and a recognised mortality. Despite this there are currently limited diagnostic or treatment algorithms specific to cases of extra-abdominal DF. Historically surgical excision has formed the cornerstone of treatment. Recently however a paradigm shift has meant many practitioners...

Proximal femoral arthroplasty (PFA) is an established treatment modality following oncological resection. Increasingly, these prostheses are being used for non-neoplastic conditions such as fractures and bone loss associated with septic or aseptic loosening. We performed a systematic review of the literature to determine the failure rates, mortalit...

Pigmented villonodular synovitis (PVNS) is a rare benign neoplastic disease of the synovium of joints and tendon sheaths, which may be locally aggressive. It can be broadly classified into localised disease or more diffuse forms, with the latter more prone to recurrence after surgical excision. We describe our experience in the management of foot a...

Proximal femoral replacement (PFR) is an established treatment modality following oncological resection. Increasingly, these prostheses are being used for non-neoplastic conditions such as fractures and bone loss associated with septic or aseptic loosening. We performed a systematic review of the literature to determine the failure rates, mortality...

Endoprosthetic replacement (EPR) for limb salvage is an established treatment modality for orthopaedic malignancies around the knee. Increasingly, they are being used for non-tumour indications such as fractures, bone loss associated with aseptic loosening, septic loosening and ligament insufficiencies. We reviewed the evolution and biomechanics of...

Background: Desmoid fibromatosis is a rare benign soft tissue neoplasm often described as a low-grade fibrosarcoma. Although it does not metastasise, it tends to aggressively infiltrate local tissues complicating surgical excision and leading to high recurrence rates. Methods: A retrospective analysis of all cases referred to our service over the l...

We previously reported early favourable results concerning allograft use in proximal humerus reconstruction following malignancy. We now present the long-term follow-up of patients who underwent tumour resection with massive humeral allograft reconstruction. This is a retrospective review of 8 consecutive patients who underwent massive proximal hum...

Soft tissue sarcomas are relatively uncommon, with approximately 3,200 new cases per year in the UK, accounting for 1% of all malignancies. They are a heterogeneous group of malignancies that occur anywhere in the body, and arise from the mesenchyme inclusive of muscle, endothelial cells, cartilage and supporting elements. Diagnosis is based on tri...

Tumour-to-tumour metastasis is a rare, but well-recognised occurrence. This case report documents the metastasis of a primary laryngeal leiomyosarcoma to a hibernoma. We believe that this is the first recorded case of leiomyosarcoma metastasising to another neoplasm, and the first recorded case of a hibernoma acting as a recipient tumour for metast...

The requirement to use the posterior approach to the knee is uncommon, and many orthopaedic surgeons may not be familiar with the surgical anatomy. However, it is relatively common for a candidate in final professional examinations to be asked to describe the posterior approach to the knee joint, with reference to the relationship of major vessels...

The purpose of this review was to appraise the use of computer-assisted navigation in total knee arthroplasty and to assess whether this technology has improved clinical outcomes. Studies were identified through searches in MEDLINE, Embase, and PubMed. Numerous studies have shown improved leg and component alignment using navigation systems. Howeve...

Radical treatment of limb soft-tissue sarcomas is typically combination treatment of surgery and radiotherapy. The aim of radical treatment is to achieve excellent local control rates with minimal treatment-related morbidity and adverse effects on the quality of life. This article looks at the use and timing of radiotherapy and associated complicat...