Preliminary Surgical Findings and Complications After National Centralization of Pediatric Bone Sarcoma Resections in the Netherlands: A Benchmarking Study

Background – Pediatric bone sarcomas are rare malignancies that are usually treated with specialized multimodal care to allow specialized oncologists to gain experience and provide expertise in treatment. In the Netherlands, oncologic care for all pediatric cancers, including pediatric bone sarcoma, has been centralized in one tertiary referral center for pediatric oncology since 2018. Surgical decision-making is not solely driven by whether limb salvage is oncologically feasible, but rather by a comprehensive shared decision-making process in which all surgical options are carefully weighed against one another. This includes not only oncologic safety, but also expected functional outcomes such as sports participation, the risk of complications, and the burden of additional surgeries that may be performed over time. By openly discussing these trade-offs with patients and families, we aim to reach a decision that best aligns with the family’s values and expectations, and thereby with the child’s long-term well-being and priorities. The objective of this study was to provide benchmark values for future comparisons of short-term perioperative and postoperative outcomes.Questions/purposes – We evaluated results following the national centralization of pediatric bone sarcoma care in the Netherlands to determine: (1) What were the intraoperative complications and blood loss? (2) What was the proportion of patients who achieved R0 margins? (3) What were the 30- and 90-day complications after surgical treatment, and what proportion had a delay in resuming chemotherapy?Methods – Between 2018 and 2024, a total of 157 children age 0 to 18 years underwent surgical resection for primary malignant bone sarcoma. We excluded 42 patients who had centralized systemic treatment but underwent surgery at referring adult sarcoma centers and 16 patients who had an axial localization. We included 99 patients who underwent surgery at the national pediatric oncology center for osteosarcoma (n = 69), Ewing sarcoma (n = 25), or other (n = 5); the extremities were involved in most patients (91% [90]). Of these, none were lost to follow-up; 1% (1) died within the first year from other causes. Seventy percent (69 of 99) had ≥ 1 year of follow-up. Ninety-day postoperative outcomes were evaluated to capture clinically relevant short-term treatment morbidity and care continuity. Tumor and treatment characteristics were retrospectively analyzed. The median (IQR) age was 13 years (9 to 15); 36% (36) were female. The median (IQR) follow-up time was 18 months (8 to 43). Among the 99 included patients, surgical procedures included limb-sparing surgery (68% [67]), amputation (15% [15]), rotationplasty (17% [17]), and other (1% [1]). Medical charts were reviewed for blood loss and surgical margins. Postoperative complications (using the Clavien-Dindo and the Henderson classifications) are reported from short-term (< 30 days) to midterm (< 90 days).Results – Three percent (3 of 99) of patients had serious intraoperative complications, and the median (range) blood loss was 100 mL (50 to 4000). R0 margins were realized in 94% (93) of patients. Twenty-two percent (22) of patients experienced any complication (infection, wound dehiscence, pressure ulcer, fracture, neurovascular) within 30 days postoperatively, with 11% (11) undergoing another operation for a complication. The most common complications were infections and/or wound dehiscence (11% [11]); one fracture occurred. The median (IQR) time to postoperative chemotherapy was 18 days (16 to 22). In 7% (7) of patients, chemotherapy was started > 28 days postoperatively because of complications. At 90 days, prosthetic joint infections (Henderson Type 4a) were treated with debridement, antibiotics, and implant retention (DAIR) (4% [4]) or a two-stage revision (2% [2]).Conclusion – Although complications were considerable, this seldom delayed postoperative chemotherapy. Minimizing postoperative complications may support improved treatment continuity and outcomes. This initial benchmark following national centralization of care provides clinically meaningful perioperative and postoperative outcome indicators for evaluating surgical performance in future studies; late postoperative complications and oncologic outcomes will be reported once longer follow-up becomes available.Level of Evidence – Level III, therapeutic study.