CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 459, pp. 40–47
Osteosarcoma, Chondrosarcoma, and Ewing’s Sarcoma
National Cancer Data Base Report
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Timothy A. Damron, MD*; William G. Ward, MD†; and Andrew Stewart, MA‡
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We summarize descriptive epidemiologic and survival data
from the National Cancer Data Base of the American College
of Surgeons for 26,437 cases of osteosarcoma (n = 11,961),
chondrosarcoma (n = 9606), and Ewing’s sarcoma (n = 4870)
from 1985 to 2003. Survival data are reported on cases with
a minimum 5-year followup from 1985 to 1998 (8,104 osteo-
sarcomas, 6,476 chondrosarcomas, and 3,225 Ewing’s sarco-
mas). The relative 5-year survival rate was 53.9% for osteo-
sarcoma, 75.2% for chondrosarcoma, and 50.6% for Ew-
ing’s sarcoma. Survival rates did not change notably over the
collection period. Within osteosarcomas, the relative 5-year
survival rates were 52.6% for high grade, 85.9% for paros-
teal, and 17.8% for Paget’s subtypes. For osteosarcoma pa-
tients, the relative 5-year survival rate was 60% for those
younger than 30 years, 50% for those aged 30 to 49 years,
and 30% for those aged 50 years or older. Within chondro-
sarcomas, the relative 5-year survival rate was 76% for con-
ventional, 71% for myxoid, 87% for juxtacortical, and 52%
for mesenchymal. While the National Cancer Data Base has
limitations, the survival data and demographics for bone
sarcomas are unprecedented in numbers and duration. Our
report supports continued efforts to refine data collection
and stimulate further data analysis.
Level of Evidence: Level II, prognostic study. See the Guide-
lines for Authors for a complete description of levels of evi-
dence.
Much of what we know and teach about the epidemiology
of musculoskeletal tumors in general and bone sarcomas in
particular derives from retrospective series collected at
large teaching centers. Many series have been reported in
the peer-reviewed literature, but the largest series have
been included in published textbooks. Mirra’s5 text re-
From the *Musculoskeletal Sciences Research Laboratories, Department of
Orthopedics, Syracuse, NY; †Wake Forest University Health Services, Win-
ston-Salem, NC; and the ‡Commission on Cancer, National Cancer Data
Base, American College of Surgeons, Chicago, IL.
This research was reviewed and approved for IRB exempt status.
Correspondence to: Timothy A. Damron, MD, Department of Orthopedic
Surgery, Suite 130, 550 Harrison Street, Syracuse, NY 13202. Phone: 315-
464-4472; Fax: 315-464-6446; E-mail: damront@upstate.edu.
DOI: 10.1097/BLO.0b013e318059b8c9
40
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
© 2007 Lippincott Williams & Wilkins
ported 854 patients with osteosarcomas, 325 patients with
chondrosarcomas, and 528 patients with Ewing’s sarcoma.
A series of patients from Memorial Sloan-Kettering Can-
cer Center treated between 1921 and 1979 accrued 1,095
patients with osteogenic sarcoma, 493 with chondrosar-
coma, and 334 with Ewing’s sarcoma.2 A series including
1274 patients with osteosarcomas, 634 with chondrosar-
comas, and 402 with Ewing’s sarcomas from the Mayo
Clinic have also been reported.7 Campanacci’s1 text de-
scribed 1,682 high-grade central osteosarcomas, 500 cen-
tral chondrosarcomas, and 788 Ewing’s sarcomas evalu-
ated at the Istituto Rizzoli in Bologna.
The care of musculoskeletal oncology patients contin-
ues to evolve over time, and with the ever-increasing num-
ber of facilities staffed with musculoskeletal oncology
trained surgeons, bone tumor treatment has become de-
centralized away from the major centers to some degree.
While the major centers still see the largest series of pa-
tients, reports from those individual centers are limited by
inherent geographic and established referral patterns. Fur-
ther advances in the understanding of bone sarcoma epi-
demiology will require evaluation of tumor registry data
from multiple centers. The two largest tumor registries in
the United States are the National Cancer Data Base
(NCDB) of the American College of Surgeons and the
National Cancer Institute’s Surveillance, Epidemiology
and End Results program.
The NCDB currently collects data from over 1,400
Commission on Cancer approved cancer program regis-
tries in the United States and regularly reports detailed
survival data on the 11 most frequently diagnosed solid
tumors. However, the relatively low prevalence of bone
sarcomas leaves these tumors largely unreported. In lieu of
establishing a tumor-specific database, the members of the
Musculoskeletal Tumor Society have recently established
a collaborative relationship with staff from the American
College of Surgeons for the specific purpose of mining the
available data on musculoskeletal tumors.
We summarize the currently available data for the three
most common bone sarcomas reported to the NCDB. We
 Number 459
June 2007
presumed these data would confirm previously established
demographic characteristics and published survival rates
for patients with these three bone sarcomas.
MATERIALS AND METHODS
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The National Cancer Database (NCDB) was established in 1989
as a project of the Commission on Cancer (CoC) of the Ameri-
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can College of Surgeons (ACoS), and has received operational
support funding from the American Cancer Society (ACS) since
its inception. The NCDB serves as a comprehensive clinical
surveillance resource for cancer care in the United States. Its
purpose is to improve the quality of cancer care by providing
physicians, cancer registrars, and others with the means to com-
pare their management of cancer patients with the way in which
similar patients are managed in other cancer care centers around
the country. Until 2001 data submission by hospital based reg-
istries was voluntary. On average approximately 1650 registries
submitted data to the NCDB. Since 2001, participation in the
NCDB has been a standing requirement for continued participa-
tion in the CoC-Approvals program and been exclusively limited
to these 1400 cancer programs. Hospital registries excluded
from participation starting in 2001 were typically, but not ex-
clusively, smaller facilities reporting fewer than 300 cancer cases
annually.
During an 18 year period from 1985 to 2003, 35,265
bone/joint tumors were reported from 1656 hospitals (mean 21
cases per facility) to the NCDB. Of those, 26,437 cases reported
from 1526 hospitals (mean of 17 cases per facility) were ex-
tracted for detailed review based upon histology criteria identi-
fying osteosarcoma, chondrosarcoma, or Ewing’s sarcoma. We
excluded 8828 cases of other entities.
Data available for analysis for each of the three types of
sarcomas included date of initial diagnosis by year, patient sex,
age, and insurance status at diagnosis; anatomic site of primary
tumor and histologic subtypes (for osteosarcoma and chondro-
sarcoma) by ICD-O-2/3 classification; NCDB analytic stage
based on American Joint Committee on Cancer pathologic stage
when reported and clinical stage otherwise; tumor grade (well
differentiated, moderately differentiated, poorly differentiated,
undifferentiated); and first-course therapy, including reported
Fig 1. The annual number of osteosarcomas, chon-
drosarcomas, and Ewing’s sarcomas cases by year
of initial diagnosis (1985–2003).
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
National Cancer Data Base Sarcoma Data 41
surgery of the primary site and use of chemotherapy and/or
radiation therapy.
Descriptive epidemiologic and survival data for 26,437 cases
of osteosarcoma (n ⳱ 11,961), chondrosarcoma (n ⳱ 9606), and
Ewing’s sarcoma (n ⳱ 4870) were identified for the 19-year
period. The total number of these three types of sarcomas re-
ported per year ranged from a low of 697 cases (2.7% of the
19-year total) in 1985 (first year reported) to a maximum of 1796
cases (6.8% of the 19-year total) in 1997 (Fig 1). Within each
subtype, the total number of cases reported per year followed the
same general trend, with a range of 318 in 1985 (2.7%) to 806
(6.7%) in 1997 for osteosarcoma, 237 in 1985 (2.5%) to 650
in 1998 (6.8%) for chondrosarcoma, and 142 in 1985 (2.9%) to
354 in 1998 (7.35) for Ewing’s sarcoma (Fig 1). For the most
recent year reported (2003), there were 723 osteosarcomas
(6.0%), 552 chondrosarcomas (5.7%), and 240 Ewing’s sarco-
mas (4.9%).
Anatomic site coding is based on ICD-O-2/3 coding schema
not specific to individual bones. Hence, all long bones of the
lower extremity, including the femur, tibia, and fibula, are
lumped together. Similarly, all long bones of the upper extrem-
ity, including the humerus, radius, and ulna, are grouped to-
gether. There is no distinction for epiphyseal, metaphyseal, and
diaphyseal locations. No additional detailed description is avail-
able for short bones of the lower extremity, short bones of the
upper extremity, pelvic bones, rib/sternum/clavicle (one group),
vertebral column (not broken down into cervical, thoracic, and
lumbar), or bones of the skull and face. The mandible is listed as
a separate site. The sacrum is included in the pelvis. Overlapping
lesions are grouped separately.
Staging data utilized the American Joint Committee on Can-
cer staging system for bone sarcomas. However, this staging
system is not universally accepted for pediatric patients. Thus,
many cases with osteosarcomas and Ewing’s sarcomas did not
have reported staging information and for practical purposes
these two categories could be grouped as essentially missing
data. In addition to clinical and pathologic tumor stage group (I,
II, III, IV), the separate staging elements (G, T, N, M) are also
reported.
Specific surgery codes were assigned by coders based upon
available operative reports utilizing guidelines established by the

42 Damron et al
Commission on Cancer’s Facility Oncology Registry Data Stan-
dards manual. Limited explanation of the surgery treatment
codes is provided. The general categories include local tumor
destruction, local excision, partial resection, radical excision or
resection, amputation of the limb, and major amputation.
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Beginning in 2001, cancer registries began using the third
edition of the International Classifications of Diseases (ICD-O-
3) coding manual as a guide to tumor morphology. Accordingly,
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clinically recognized histologic entities not previously acknowl-
edged as separate codes in ICD-O-2 were added that affected
only osteosarcoma coding. Before 2001, the specific osteosar-
coma histology subtype codes included high-grade conventional,
Paget’s, small cell, and parosteal. The newly added diagnoses in
2001 included intraosseous (9187), intracortical (9192), perios-
teal (9193), and high-grade surface (9194) osteosarcomas. Of
these, all except intracortical have been reported to the NCDB.
Before 2001, these tumors had been coded as osteosarcoma not
otherwise specified (NOS). Hence, in this review, the numbers
for intraosseous, periosteal, and high-grade surface osteosarco-
mas reflect a limited period of time (2001–2003) when compared
to the remainder of the osteosarcoma diagnoses. For chon-
drosarcomas, the histologic subtypes (NOS, juxtacortical,
mesenchymal, and myxoid) did not change over the period of
collection. Ewing’s sarcoma in our series did not include primi-
tive neuroectodermal tumors, as they are coded separately. Our
series also likely includes some soft-tissue osteosarcomas, Ew-
ing’s sarcomas, and mesenchymal chondrosarcomas, as no dis-
tinction has been made between these bone and soft-tissue sar-
comas.
Survival rates were calculated for each of the three sarcomas
overall, for the histologic subtypes of both osteosarcoma and
chondrosarcoma, and for three periods of data collection (1985–
1988, 1989–1993, 1994–1998). Only data through 1998 were
employed to ensure 5-year followup on confirmed data and thus
do not include recently recognized osteosarcoma designations
introduced with publication of the ICD-O-3. Survival analyses
were limited to categories containing at least 50 cases to assure
sufficient sample size. Survival was calculated both as observed
and relative (adjusted to age-matched patient population) rates.
Differences in five-year survival calculated by the Kaplan-Meier
method were then compared using the log rank (Mantel Cox)
test.
Data reported to the NCDB are retrospective in nature. No
patient or physician identifiers were collected as part of the
study. Case identification information (facility identification
number and local registry accession number) was collected for
administrative purposes only. Analyses were reported only at the
aggregate level to assist hospital cancer programs with quality
assurance, rather than used to make decisions about individuals
and their care. The American College of Surgeons has executed
a Business Associate Agreement that includes a data-use agree-
ment, with each of its CoC approved hospitals. Results reported
in this study were in compliance with the privacy requirements
of the Health Insurance Portability and Accountability Act of
1996 as reported in the Standards for Privacy of Individually
Identifiable Health Information; Final Rule (45 CFR Parts 160
and 164).
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics
and Related Research
All descriptive analysis and survival calculations were per-
formed using SPSS v. 12 (SPSS Inc, Chicago, IL), a standard
statistical package (p < 0.05).
RESULTS
The annual reports to the NCDB include 11,961 cases of
osteosarcoma, 9606 of chondrosarcoma, and 4870 of Ew-
ing’s sarcoma between 1985 and 2003 (Fig 1). Osteosar-
coma data were available for 10,922 high-grade conven-
tional, 647 parosteal, 247 Paget’s, 93 small cell, 33 peri-
osteal, 11 low-grade intraosseous, and eight high-grade
surface lesions. Since the osteosarcoma codes changed in
2001, the osteosarcoma histologic data for 2001 to 2003
were analyzed separately to provide a relative frequency of
the various subtypes in the latest classification schema.
For this more recent time period, there were 2030 high-
grade conventional (90.7%), 92 parosteal (4.1%), 39 Pag-
et’s (1.7%), 33 periosteal (1.5%), 24 small cell (1.1%), 11
intraosseous (0.5%), and eight high-grade surface (0.4%)
osteosarcomas. Data were available for 8419 conventional
“NOS” (89.2%), 725 myxoid (7.7%), 210 mesenchymal
(2.2%), and 88 juxtacortical (0.9%) chondrosarcomas.
Sex and age data were available for all cases. Each of
the sarcomas was more common in males than females,
with the predilection being strongest in Ewing’s sarcoma
(nearly 6:4 male:female), although both parosteal and peri-
osteal osteosarcomas showed a reciprocal nearly 6:4 fe-
male:male ratio (Fig 2).
The age distributions were as traditionally taught for
each tumor type, but there were exceptions (Fig 3). Almost
50% of reported Ewing’s sarcoma and almost 40% of the
osteosarcoma cases were reported in patients aged 10 to 19
years. Chondrosarcoma was reported among elderly pa-
tients, with over 70% of reported cases in patients aged 40
years and older. Only 6% of Ewing’s sarcoma cases were
in patients aged 40 years or older, while 30% of osteosar-
coma patients were in this age range.
The anatomic site was specified for 98.1% of all cases.
The largest proportion of each of the three general histo-
logic types of bone sarcomas occurred in the long bones of
the lower extremity, although this site showed a much
greater proportion for osteosarcomas (57.6%) than for ei-
ther chondrosarcomas (31.3%) or Ewing’s sarcomas
(27.9%) (Table 1). For osteosarcoma, the next most com-
mon general sites were long bones of the upper extremity
(11.7%) and pelvic bones (10.1%). For chondrosarcoma,
the pelvic bones were the next most common site (18%),
followed by the long bones of the upper extremity (16.3%)
and the rib/sternum/clavicle (13.6%). For Ewing’s sar-
coma, we found nearly as high a percentage of pelvic bone
cases (25%) as for the number one site. Next most com-
 Number 459
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Fig 2A–B. (A) The percent distribution of osteosarcoma,
chondrosarcoma, and Ewing’s sarcoma by sex. (B) The per-
cent distribution of osteosarcoma histologic subtypes.
mon for Ewing’s sarcoma was the upper-extremity long
bones (13.1%) followed by the rib/sternum/clavicle
(10.7%) and vertebral column (9.3%). All other sites of
sarcoma occurrence represented less than 10% of each
type of sarcoma’s cases.
For those 53.1% with available American Joint Com-
mission on Cancer staging data, the most prevalent stage
of chondrosarcomas was Stage I, and for both Ewing’s
Fig 3. Percent distribution of osteosarcoma, chondrosar-
coma, and Ewing’s sarcoma by patient age.
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National Cancer Data Base Sarcoma Data 43
sarcoma and osteosarcoma Stage II (Table 2). Stage IV
disease was present at diagnosis in 5.5% of chondrosar-
comas, 13.5% of Ewing’s sarcomas, and 10.1% of osteo-
sarcomas. The unavailability of staging data for pediatric
patients due to the lack of a consensus staging system is
underscored by the high percentage of “NA” coding for
both osteosarcoma (27%, 3230/11,961 cases) and Ewing’s
sarcoma (44.3%, 2158/4870 cases), both tumors with a
higher proportion of young patients when compared to
chondrosarcoma (1.5%, 144/9606 cases), predominately a
disease of adulthood. Although grade was missing in over
36% of cases, 84% (6723/8022) of chondrosarcomas were
low grade and 80% (5457/6851) of osteosarcomas were
high grade. For Ewing’s sarcoma, which is generally con-
sidered a high-grade sarcoma by definition, 1956 of the
total 4870 cases were still assigned grades, and 2.8% (55
cases) of those graded Ewing’s cases were inaccurately
assigned low grades.
Although the first course of therapy varied consider-
ably within each type of sarcoma, the most common
type of treatment for chondrosarcoma was surgery only
(69%) (Table 3). For Ewing’s sarcoma, the most fre-
quent treatments were nearly equally divided between
surgery/chemotherapy (24%) and radiation/chemotherapy
(23%), while 18% received chemotherapy alone and 15%
received surgery/radiation/chemotherapy. For osteosar-
coma, combined surgery and chemotherapy were em-
ployed initially only for 46% of patients.
The first course of therapy involved surgery in 18,725
of the total 26,437 cases (71%). For osteosarcoma, 71%
(8454/11,961 cases) had initial therapy that included sur-
gery. For chondrosarcoma, 83% (7959/9606 cases) had
surgery as part of initial therapy. For Ewing’s sarcoma,
only 47% (2312/4870 cases) involved initial surgery. The
most frequently employed surgical intervention for each of
the diseases was a limb-sparing radical excision/resection
(Table 4). Excluding those cases for which the specific
type of surgery was not specified (26.7%, 5001/18,725
cases), nonablative surgery was performed for 69%
(4371/6376) of osteosarcomas, 79% (4560/5745) of chon-
drosarcomas, and 81% (1299/1603) of Ewing’s sarcomas.
Radiation was employed for 10% (1198/11,961) of os-
teosarcoma, 14% (1339/9606) of chondrosarcoma, and
46% (2238/4870) of Ewing’s sarcoma cases. External
beam radiotherapy was the most commonly employed
technique, used in 91.6% of irradiated osteosarcomas,
94.5% of irradiated chondrosarcomas, and 93.3% of irra-
diated Ewing’s sarcomas (Table 3).
Chemotherapy was employed for 71% (8547/11,961) of
osteosarcoma, 8% (771/9606) of chondrosarcoma, and
89% (4314/4870) of Ewing’s sarcoma cases. When speci-
fied, chemotherapy was usually multiagent (76.3%,
10,404/13,632) as opposed to single agent (4.5%,
 Clinical Orthopaedics
44 Damron et al and Related Research

TABLE 1. Anatomic Site Distribution of Chondrosarcomas, Ewing’s Sarcoma, and Osteosarcoma

Reported to the NCDB: 1985–2003
ICD-O-2/3 Primary Site Chondrosarcomas Ewing’s Sarcoma Osteosarcomas
Long Bones – Upper limb 16.3 13.1 11.7
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Short Bones – Upper limb 2.1 1.4 0.7

Long Bones – Lower limb 31.3 27.9 57.6
Short Bones – Lower limb 2.2 4.0 1.9
Overlapping lesions 0.2 0.1 0.1
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Bone of limb, NOS 0.9 0.6 0.6

Bones – Skull and face 7.3 2.7 5.9
Mandible 0.9 1.1 4.1
Vertebral column 5.1 9.3 2.5
Rib, sternum, clavicle 13.6 10.7 3.2
Pelvic bones 18.0 25.1 10.1
Overlapping lesions 0.4 0.5 0.2
Bone, NOS 1.7 3.4 1.4
Total cases 9606 4870 11,961

615/13,632). However, fully 19.2% (2613/13,632) of and 17.8% for Paget’s subtypes (Fig 5). For osteosarcoma
cases did not distinguish between even these two broad patients, relative 5-year survival rates were 60% for pa-
categories (Table 3). tients older than 30 years, 50% for patients aged between
Survival data are reported on cases with a minimum 30 and 49 years, and 30% for patients 50 years and older.
5-year followup from 1985 to 1998 (8104 osteosarcomas, Within chondrosarcomas, observed and relative 5-year
6476 chondrosarcomas, and 3225 Ewing’s sarcomas). The survival rates were 68.4% and 75.9%, respectively, for
observed and corresponding relative 5-year survival rates conventional, 64.1% and 71.0% for myxoid, 80.3% and
were 51.2% and 53.9%, respectively, for osteosarcoma; 86.5% for juxtacortical, and 49.2% and 51.7% for mesen-
67.8% and 75.2% for chondrosarcoma, and 50.2% and chymal subtypes.
50.6% for Ewing’s sarcoma (Fig 4). Survival rates did not
change notably over the three periods analyzed (1985– DISCUSSION
1988, 1989–1993, 1994–1998). Over these three time pe- Our report represents the single largest series of cases for
riods, the relative 5-year survival rates were 52.1%, each of the three most common bone sarcomas, with here-
55.2%, and 53.5%, respectively, for osteosarcoma; 74.7%, tofore unreported survival curves according to histologic
76.5%, and 74% for chondrosarcoma; and 50.7%, 49.1%, subtype, year of diagnosis, and multiple demographic vari-
and 52.2% for Ewing’s sarcoma. ables. While the database has limitations in terms of its
Among osteosarcomas, the observed and relative 5-year reporting of local recurrences, the survival data and de-
survival rates were 50.1% and 52.6%, respectively, for mographics are unprecedented in numbers and duration.
conventional high-grade intramedullary, 83.8% and 85.9% Some of these limitations are those common to most
for parosteal, 48.2% and 49.5% for small cell, and 13.0% large registries. First, data has been collected over a long
period of time. By necessity, the documentation for and
the coding of the data have evolved over time and may
TABLE 2. Stage of Reported Chondrosarcomas, potentially have introduced some variation into data docu-
Ewing’s Sarcoma, and Osteosarcoma Reported to mentation and coding. However, the standardization inher-
the NCDB: 1985–2003 ent to such a large and well-managed database is also the
Ewing’s strength of such a study. No single institution or even
Stage Chondrosarcomas Sarcoma Osteosarcomas consortium of major institutions could rival the numbers of
I 53.6 4.1 11.3
patients generated by this database. Second, the collection
II 11.3 15.1 22.8 of the data is biased by the mechanism triggering collec-
III 1.1 1.6 1.7 tion (the generation of a pathology report), the type of
IV 5.5 13.5 10.1 institutions reporting data (American College of Surgeons
NA 1.5 44.3 27.0 accredited cancer centers), and because data collection for
Unknown 27.0 21.4 27.0
Total cases 9606 4870 11,961
sarcomas is not limited to members of the Musculoskeletal
Tumor Society or even to musculoskeletal oncologists.

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 Number 459
June 2007 National Cancer Data Base Sarcoma Data 45

TABLE 3. First Course of Therapy for Chondrosarcomas, Ewing’s Sarcoma, and Osteosarcoma
Reported to the NCDB: 1985–2003
Therapy Chondrosarcomas Ewing’s Sarcoma Osteosarcomas
Surgery only 68.6 3.3 15.8
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Radiation only 3.2 1.6 1.9

Surgery and chemotherapy 3.5 24.4 45.5
Surgery and radiation 8.3 1.0 2.4
Radiation and chemotherapy 1.0 22.8 2.0
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Surgery, radiation and chemotherapy 1.1 15.1 3.2

Chemotherapy only 1.9 17.6 15.9
Other specified Rx 1.7 8.9 5.2
No 1st course Rx 10.7 5.3 8.0
Total cases 9606 4870 11,961

Other concerns deserve attention as they are amenable
to improvement. Anatomic site coding should be more
specific than is currently the case. Specific bones should
be included as subcodes within the broader categories cur-
rently utilized. There is also no distinction between epiph-
yseal, metaphyseal, and diaphyseal portions of the long
bones. In addition, staging data have not been available for
most of the pediatric cases as the American Joint Com-
mittee on Cancer has emphasized staging schemes for
adults (Table 5). This void has resulted in a large percent-
age of cases reported with stage not applicable for osteo-
sarcomas and Ewing’s sarcomas. All Ewing’s sarcomas
should have been coded as high-grade, but yet 2.8% were
still incorrectly coded as low-grade. From the standpoint
of surgery coding, more meaningful definitions are needed
that better correspond to clinically utilized procedures. In
addition, internal hemipelvectomy should be recoded as a
limb-sparing procedure rather than as a “major amputa-
tion.” Other end points, such as local control and outcomes
of limb-sparing surgical reconstructions, would add con-
siderably to the usefulness of the registry.
Reporting of national database statistics for bone sar-
comas is sparse. The American Cancer Society reports
there will be an estimated 2760 new cases (1500 in males,
1260 in females) and 1260 deaths (730 in males, 530 in
females) from bone and joint sarcomas during 2006.3 In
2006, the American Cancer Society provided its annual
report on epidemiologic data derived from the National
Cancer Institute’s Surveillance, Epidemiology and End
Results and survival data from the National Center for
Health Statistics for all cancers. In this report, tumors of
bone and joints are not among the top 10 cancers in esti-
mated new cancers, and limited data are reported. Only for
children under age 15 are relative survival rates for bone
and joint sarcomas reported based on data from 1974 to
2001. Based on these data for pediatric patients, 5-year
relative survival rates for all bone and joint sarcomas have
improved (p < 0.05) from 1974 to 1976 (55%) through
1995 to 2001 (71%). In fact, these reported 5-year survival
rates improved most notably between the 1983 to 1985
collection period (53–57%) and the 1986 to 1988 and 1989
to 1991 collection periods (62–63%) and then again during
the latest collection period (71%).
While most of our findings reflect long-held beliefs,
some of our findings question common clinical under-
standing of bone sarcomas. For osteosarcoma, a bimodal
age distribution is often quoted, with an early and largest
peak (approximately 60% of all osteosarcoma patients)
between age 10 and 19 and a later peak (approximately
10%) after age 60.2 In our data, the age distribution for

TABLE 4. First Course Surgery for Chondrosarcomas, Ewing’s Sarcoma, and Osteosarcoma Reported to
the NCDB: 1985–2003
Surgical Procedure Chondrosarcomas Ewing’s Sarcoma Osteosarcomas
Local tumor destruction 26.1 19.1 11.9
Local excision 1.2 1.0 0.4
Partial resection 0.8 0.7 0.5
Radical excision or resection with limb salvage 29.1 35.3 38.9
Amputation of limb 10.0 10.5 19.6
Major amputation 4.9 2.6 4.2
Surgery, NOS 27.8 30.7 24.6
Total cases 7959 2312 8454

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 Clinical Orthopaedics
46 Damron et al and Related Research
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Fig 4. Five-year observed survival rates with minimum 5-year Fig 5. Five-year observed survival rates for histologic sub-
survival data for osteosarcoma, chondrosarcoma, and Ewing’s types of osteosarcoma; cases diagnosed between 1985 and
sarcoma; cases diagnosed between 1985 and 1998. 1998.

osteosarcoma of all types showed an early peak from age ally used in the pediatric population for whom better out-
10 to 19, but it represented only 38.5% of patients and comes in the range of 60% to 70% have been reported.
gradually diminished in older age categories. In fact, the Clearly, age made a difference, as shown by the difference
major difference in age in our population of osteosarcoma in survival curves for patients with osteosarcomas of dif-
patients appeared to be in the young adult category, as our
series included only 30.6% of all osteosarcomas in the 40
and older age group, nearly identical to that described by TABLE 5. American Joint Committee on
others.6 Fully 25.8% of the osteosarcomas occurred in the Cancer (AJCC)/UICC Staging System for
20 to 39 age group, where the normally lower occurrence, Bone Sarcomas
particularly in the 30 to 39 age group, typically creates the
Tumor Grade Description
“valley” in the bimodal distribution. Even for conventional
osteosarcoma, for which it has been said 85% of cases T1 < or = 8 cm
present before the age of 30 and 60% in the second decade, T2 > 8 cm
T3 Multiple/discontinuous tumors
in our series, the group younger than 30 represented only N1 Regional lymph node involvement
62% and those in the second decade only 40%.4,5 G1 Well-differentiated
The second commonly held view of osteosarcoma that G2 Moderately differentiated
appears untrue is the overall prognosis is clearly better G3 Poorly differentiated
than Ewing’s sarcoma.6,7 In our series, the relative 5-year G4 Undifferentiated
Stage IA G1 or 2 T1 N0 M0
survival rate for all osteosarcomas was only 53.9%, well Stage IB G1 or 2 T2 N0 M0
within the reported error limits for Ewing’s sarcoma at Stage IIA G 3 or 4 T1 N0 M0
50.6%. This is likely due to a number of factors. First, the Stage IIB G 3 or 4 T2 N0 M0
aforementioned difference in age distribution even for Stage III Any G T3 N0 M0
conventional osteosarcoma, with a shift into early adult- Stage IVA Any G Any T N0 M (lung only)
Stage IVB Any G Any T Any N Any M
hood, introduces an age group that may be less tolerant of
the high-intensity, multiagent chemotherapy regimen usu- M = metastasis

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Number 459
June 2007
ferent age categories. The relative 5-year survival rate in
our series was 60% for osteosarcoma patients younger
than 30 years. Second, since our series represents all-
comers, including those in advanced stages and those with
the worst histologic diagnoses (eg, Paget’s osteosarcoma),
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the poorer prognosis of the latter lowers the overall group
survival. Third, treatment was not standardized, and only
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 09/20/2022
46% of osteosarcoma patients received combined surgery
and chemotherapy as part of their initial treatment. Further
detailed analysis of specific age, stage, and histologic sub-
type categories is clearly needed to explore osteosarcoma
survival in greater depth.
For chondrosarcoma, the anatomic distribution may
have differed somewhat from conventional description.
According to some, the pelvis is the most common site of
involvement for chondrosarcoma.2,5 In our series, the long
bones of the lower extremity were nearly twice as com-
mon. However, our data set did not allow differentiation of
individual long bones of the upper or lower extremity.
Sites usually thought rare for chondrosarcomas were seen
to host these tumors on occasion, including the spine
(5.1%), small bones of the lower extremity (2.2%), and
small bones of the upper extremity (2.1%).
For Ewing’s sarcoma, as earlier described for osteosar-
coma, the peak age distribution was similar but not exactly
what has been quoted in the past. The oft-quoted 5 to 30
age range was indeed the peak age for Ewing’s sarcoma
patients in our series, and this age range accounted for
81.5% of cases.7 However, nearly 14% of cases in our
series occurred in patients aged 30 years and older.
One of the advantages of working with the NCDB for
musculoskeletal tumors compared to some of the more
prevalent tumors is the reverse economy of scale. Since
there are a relatively small number of cases across the
country and an even smaller number of institutions that
generate a large percentage of the cases for the database,
management of and improvements in the database are at
least theoretically more feasible than for breast, prostate,
and lung cancer, for instance. Since many of the institu-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
National Cancer Data Base Sarcoma Data 47
tions that record sarcomas are represented by members of
a single organization, the Musculoskeletal Tumor Society,
coordinated efforts between the American College of Sur-
geons and the Musculoskeletal Tumor Society may prove
fruitful in improving both the data collection process and
the quality of the data collected. Prior to the current col-
laborative effort, the only formal coordination between the
two societies was by way of a designated member from the
Musculoskeletal Tumor Society being a recognized repre-
sentative to the American College of Surgeons. With the
current effort and continued similar efforts in this vein, the
Musculoskeletal Tumor Society hopes to continue to ex-
pand this collaboration and to improve the data collection
process.
Acknowledgments
The authors wish to thank each of the current and former mem-
bers of the Musculoskeletal Tumor Society who have partici-
pated in data collection for the National Cancer Database at
Cancer Centers accredited by the American College of Surgeons.
In addition, the authors thank Jerri Linn Phillips, MA, CTR,
Manager, Information Technology and Data Standards Section,
National Cancer Data Base, Division of Research and Optimal
Patient Care, American College of Surgeons.
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