Comparison of chondrosarcoma cases (grade I, II, III) current situations with clinical and statistical analysis among institutions.

Background Chondrosarcomas is a rare tumour that has a variable biological characteristic. Also, their treatment clinically and surgically is controversial. We performed a comparison review of different regional institutions series with the aim of assessing the clinical outcome of patients. Purposes We, therefore, compare different institutions from different regions patients with grade 1 to 3 chondrosarcomas to (1)determine difference in survival rate, (2) local recurrence results, (3) determine successful outcome after surgery, (4) differences among surgical procedures. (5) Determine any association of clinical and demographic behaviour with gender, follow-up, treatment and chondrosarcoma affected body locations. Methods A retrospective review of 33 chondrosarcoma(all grades) patient’s data since 2013, compared with 15 author’s total 868 patients research literature to find more about clinical and statistical advantages and similarities with our study. Here is mentioning of clinical information’s, surgery type categorised, adjuvants types, genders, follow-up years, recurrence, affected areas, death rates, successful outcome and survival rates by using statistical methods. Results The overall survival rate was 94%, successful outcome 85% in 4.3 + 1.2 years follow-up. Observed wide resection, distilled water as adjuvant, chemo & radiotherapy significantly shows excellent result over our compared chondrosarcoma literature datas. We have also marked that females and humerus bone are more affected by chondrosarcoma among those literatures data. Conclusions Low-grade chondrosarcoma of the skeleton can be treated with wide resection and by the use of distilled water, which give good oncological outcome and a

very low rate of post-surgical complications, as well as chondrosarcoma all grades recurrence.

Background
Chondrosarcoma is the 2nd most common malignant tumor of the skeleton.
Chondrosarcoma is a rare cancer with an estimated incidence of 1 in 200,000 per year [1] .
The tumors have considerable variation in outcome depending on size, histologic grade, Musculoskeletal Tumor Society (MSTS) stage [2] , and tumor type. All kinds of tumors have different characteristics and biological differences. Chondrosarcoma grade and the anatomical site are important because of both influences the sort of treatment and result.
The chondrosarcoma can affect any part of the bone but has a predilection for pelvis, femur, and proximal humerus [3] . Surgery procedures do not always recommend treatment; neither chemotherapy nor radiation therapy is effective in this tumor [4] . For this tumor male prevalence of two: one, and this usually occurs in the third and fifth decade of a lifetime [5; 6] . This tumor of the pelvis is the most aggressive and has the lowest survival rate [7; 8] . Chondrosarcomas are malignant cartilaginous neoplasms with distinct morphological features and clinical behavior. Among all primary malignant tumors of the skeleton, this rare tumor is 20% [9] . People still making wrong decisions because of a lack of awareness about the treatment of their tumor. So that the survival rate is low and the health care system couldn't help big numbers of people who do not come to hospitals for treatment, but they waste time with quacks or bonesetters. It happens because of many social and cultural factors that patient continues to visit such peoples [10] . The motive of this research is to the comparison among regions chondrosarcoma patient's cases. The goal of this article is not to discuss our accuracy or outcome of 4 chondrosarcoma grades, notwithstanding to look for the weight of the information come up with their clinical information & history, surgical, survival rate, infections, complications, functional and gender for better analytical understanding.

2.
Surgical & treatment information  [13; 14] . Unfortunately, biopsy in the chondral intramedullary lesion is not reliable [15; 16] . Tumor grading often misleads the surgeon to inapplicable surgery. Clinical history and imaging studies are significant when choosing the appropriate surgical technic. We have done 17 wide angel resection, seven marginal resections, two intralesional resections. We collected the age, gender, follow-up (months), anatomical locations, staging according to the Enneking system [17] . Follow as a usual preoperative surgical procedure in our hospital according to the patient's present situation and body conditions. During surgeries, the patient's position for the spine was the prone and supine position for extremity. The target for the treatment is to remove the mass and reduce the possibility that it will cause recurrence. The following kinds of surgeries may be used:-Resection, Curettage, Bone cement, Limb-sparing surgery, Amputation, Reconstructive surgery, Biopsy. Several authors agree to use this technique for tumor cells [18] . The tumor cells will be inactive in due course sop in distilled water for 60 s at 55°C, and the tumor cell death rate was 100%. Tumor cells can be destroyed by distilled water for 60 s at 55°C, which is proved in several author's literatures. This way of treatment provides a new fast and low cost tumor-free technic to inactivate tumor cells, as well as attached to surgical instruments [18] . However, in some cases of chondrosarcoma tumor, intralesional excision may not be adequate, for example, because of an intra-articular or pelvic localization or large size [19] . In some cases, a greater tendency to metastasize or progress occurs with axial-pelvic tumors, which also has higher local recurrence rates [20] . There are 14 fracture cases; we believe that the fractures occur more because of lack of osteosynthesis, although there is no enough data to prove it. The distinction between wide resection and marginal resection was based on a combination of the pathology report and the operative note. Each of These techniques carries different risks and benefits. Also, by the developing of medical science, everyday new methods and techniques are used by doctors, which outcome is slightly better and efficient. In our hospital, we have followed all pre-surgical procedures according to Chinese medical ethics, rules, and regulations.  Patients come for evaluation is first two years every 3 months once, the next five years every 6 months once and annually once after that. Radiographs and physical exam were performed at each time. If local recurrence was suspected, then additional imaging was requested, such as a CT scan or MRI. Chemotherapy and radiotherapy were used for a few malignant tumor patients. If there is lung metastasis, then determine with CT. Tumor margins were evaluated accordingly. Cost of the potential immediate post-surgical neurologic deficits against the advantage of long-term survival should factor heavily into the treatment strategy, also taken part decision making with the patients.

Radio & Chemo therapy
If chondrosarcoma tumor can't be removed with surgical procedures, then external beam radiotherapy may be used to treat it. This therapy may apply to destroy any cancer cells after wide resection which left behind. Radiotherapy is also used if the tumor is a recurrence. Based on the skull or in the spinal bones tumor treat by apply of conformal proton beam radiation therapy or intensity-modulated radiation therapy. For low grade chondrosarcoma usually chemotherapy not use due to showing no improve survival rate.
Another minimal invasive percutaneous technique is radiofrequency ablation, which is used mainly for palliating painful bone metastasis [21; 22] . But we haven't done any study or addressing the application of this technique in tumors and more specifically, chondrosarcoma tumors.

Methods
We Few patients were kept out from the current study because of the follow-up was less than 24 months or lack of clinical data. The inclusion data were based on extracted directory from the full database records. This study was approved by the General Hospital of Ningxia Medical University committee for clinical research; also informed consent was gathered from the patients participating.

Results
We have found that using distilled water as an adjuvant during tumor surgeries has an excellent effect.  and 85%, which is better than the UK and Korean institutions (table 3).
This study has a few limits. 1 st , it is not a prospective study, but the rarity of this tumor and the need for extended clinical follow-up make it challenging. 2 nd , comparison of different treatments was not randomized, but based on current information about this pathology; 3 rd , the monitoring of our patients is significant, but still too short for considerations with outcomes.

Conclusions
After optimal diagnosis and treat by an experienced team of specialists, although chondrosarcoma tumors generally have an excellent prognosis. Analysis of the difference between surgical technics and patient outcomes has been limited due to the sparseness of these lesions and few institutions having enough patients and data. Also, different regions and institutions surgical, clinical diagnosis, and treatment are slightly not similar. We observed that females are get affected more than male among those institutions chondrosarcoma patients, which is alarming somehow, because of chondrosarcoma characteristic may changing gradually around the globe. Although our study found that using distilled water as an adjuvant and wide resection giving significantly better results for grade 1 & 2 chondrosarcoma treatment among our 33 patients than compared institutions patients, the total survival rate is 91% and a successful outcome is 85%. To get more accuracy and evidence of this result need to conduct further research in clinical basis because of relatively short follow-up and non-randomized study limitations. This is a systematic review which is a relatively high level of generalizability due to the inclusion of patients among institutions and countries. It may also be susceptible to bias associated with individual patients being reported over others.

8.1Authors' contribution
All authors approved the final manuscript.

Ethics approval to participate
Review board approval was obtained before starting research.

Consent for publication
Not applicable.

Availability of data and material
On reasonable request data portion will be available, but all data are not publicly available, because of patient's information.

Competing interests
All authors have no competing interests.

Funding Information
Authors received no financial support for research or publication of this article yet.

Acknowledgments
Authors would like to thank all individuals to participate in the study.

Abbreviations
Not applicable    Figure 1 Postoperative imaging data a: Immediately after surgery, the X-ray film showed good ulnar and radial end-to-end alignment; b: CT+3D reconstruction showed bone graft reconstruction healing after 3 months; c: X-ray film showed reconstruction bone 3 months after operation and no recurrence, d: 9 months after operation, the reconstructed bone end healed; e: 2 years after surgery, the reconstructed bone end was completely fused, no elbow joint, wrist dislocation, no tumor relapse Flowchart of chondrosarcoma surgical management.

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