Pseudolesions involving bone and soft tissue regarding orthopedic oncology.

Pseudolesions in bone and muscle are encountered mostly incidentally in routine imaging studies, especially due to the recent advancements on many different imaging modalities. These lesions can be categorized into the following categories: normal variants; congenital; iatrogenic; degenerative; and postoperative. In this review, we discuss the many different radiological characteristics of musculoskeletal pseudolesions that appear on imaging, which can prevent non-essential additional studies.

Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach.

PURPOSE: To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone. METHODS: Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement. RESULTS: All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up. CONCLUSIONS: In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications. LEVEL OF EVIDENCE: Therapeutic level IV.

Postoperative Outcomes of Total Femur Replacement in Oncologic and Nononcologic Patients: A Systematic Review of the Literature.

BACKGROUND: Total femur replacement (TFR) is used for primary reconstruction after extensive tumor resection or as a revision surgery due to prosthetic failure. Studies on TFR rates of failure and functional outcomes are scarce. The purpose of our study was to compare the modes of failure, amputation rates, and functional outcomes after TFR between oncologic and nononcologic patients. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were for this manuscript. Our study was registered on PROSPERO (413582). Quality assessment of all studies was performed using Strengthening the Reporting of Observational Studies in Epidemiology checklist. Endoprosthesis failure was assessed using the Henderson classification and functional outcomes using the Musculoskeletal Tumor Society score. Weighted means and standard deviations were calculated. RESULTS: Overall failure rate was similar between groups. Henderson type 4 failures were more common within the nononcologic group, while the others were more frequently found in the oncologic group. Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Amputations occurred mainly after type 4 and type 5 failures. Functional outcome was better within the oncologic group (70.5 versus 61.7, respectively; P < .001). CONCLUSIONS: Total femoral replacement in the oncologic and nononcologic group is associated with a high rate of failure (31% and 32.5%, respectively). Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Functional outcome was better within the oncologic group. LEVEL OF EVIDENCE: Level III.

Do cancer patients undergoing surgery for a non-neoplastic related fragility hip fracture have worse outcomes? A retrospective study.

INTRODUCTION: An increasing number of patients sustaining a fragility hip fracture (FHF) have either an active diagnosis or a history of cancer. However, little is known about the outcomes of non-malignant related FHF in this group of patients. We aimed to evaluate the mortality and complications rates during hospitalization, as well as at 1-year follow-up within this population. METHODS: A retrospective cohort study of patients 65 years of age and above, who underwent surgery for the treatment of proximal femoral fractures between January 2012 and June 2016 was conducted. Patients diagnosed with malignancies, both solid (Carcinomas) and a hematological neoplasias (Lymphomas, Multiple Myeloma) were included, along with consecutive controls without a diagnosis of cancer in the 5 years prior to the study period. Demographic, clinical and radiographic parameters were recorded and analyzed. RESULTS: Seven hundred and fifty-two patients with FHF were included, of whom 51 had a malignancy diagnosis within the 5-year period preceding the fracture (18% metastatic disease). The mean time from malignancy diagnosis to FHF was 4.3 ± 4.8 years. Time to surgery did not differ between groups, and the vast majority of patients from both groups (over 87%) were operated within the desirable 48 h from admission. Patients with malignancy had a higher probability of being admitted to an internal medicine department both pre and post-surgically (p < 0.001), and were more susceptible to pre-operative anemia (p = 0.034). In-hospital mortality did not differ between groups, yet 1-year mortality was higher for the malignancy group (41.2% vs 19.5%, p < 0.001). At 1-year post-operatively, orthopedic complications were similar between groups. CONCLUSION: Patients with a history of malignancy in the 5-years prior to a non-neoplastic FHF, showed similar mortality and complications rates during admission but increased 1 year mortality rate when compared to patients without cancer undergoing surgical treatment of a non-neoplastic proximal femoral fracture.

Epidemiology and survival factors for sarcoma patients in minority populations: a SEER-retrospective study.

Background: Epidemiologic studies have demonstrated race as a predictor of worse oncological outcomes. To better understand the effect of race on oncological outcomes, we utilized the Surveillance, Epidemiology, and End Results (SEER) database to determine what treatment courses are provided to minority patients and how this impacts survival. Materials and methods: A retrospective review of bone and soft tissue sarcoma cases was performed using the SEER database for a minimum 5-year survival rate (SR) using Kaplan-Meier curves. Categorical variables were compared using Pearson's χ2 test and Cramer V. Kaplan-Meier curves were used to determine survival rates (SR) and Cox regression analysis was used to determine hazard ratios (HRs). Results: Races that had an increased risk of death included Native American/Alaska Native (NA/AN) [hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.049-1.761, p = 0.020) and Black (HR = 1.17, 95% CI: 1.091-1.256, p < 0.001). NA/AN individuals had the lowest SR (5-year SR = 70.9%, 95% CI: 63.8-78.0%, p < 0.001). The rate of metastasis at diagnosis for each race was 13.07% - Hispanic, 10.62% - NA/AN, 12.77% - Black, 10.61% - Asian/Pacific Islander (A/PI), and 9.02% - White individuals (p < 0.001). There were increases in the rate of metastasis at diagnosis and decreases in rates of surgical excision for Hispanic and Black patients (p < 0.001). Conclusion: Race is determined to be an independent risk factor for death in NA/AN and Black patients with sarcomas of the extremities. Access to healthcare and delay in seeking treatment may contribute to higher rates of metastasis upon diagnosis for minority patients, and decreased rates of surgical excision could be associated with poor follow up and lack of resources.

Epidemiology and survival factors of appendicular myxofibrosarcoma: a SEER-retrospective study.

Background: The low incidence of myxofibrosarcoma (MFS) makes high power studies difficult to perform. Demographic and prognostic factors for MFS and how they differ from all extremity soft tissue sarcomas (STS) are not well understood. The purpose of this study was to characterize a large cohort of patients with MFS and evaluate epidemiologic and survival factors when compared to all STS. Materials and methods: We performed a retrospective review of the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2015 to identify 1,440 patients diagnosed with MFS and 12,324 with STS. Survival curves were creased using Kaplan-Meier, and Cox regression analyses were performed to identify hazard ratios (HRs). Results: Overall survival was greater for STS than MFS (79% vs. 67%). Patients with MFS had a higher average age at diagnosis than STS (62 vs. 56), and older age was strongly associated with decreased survivorship for MFS (HR = 7.94). A greater proportion of patients under 30 diagnosed with MFS were female when compared to STS (49.6% vs. 45.4%). The incidence of MFS and STS increased over the 15-year period, with MFS increasing at a greater rate than STS (1.25% vs. 2.59%). Survival increased for patients diagnosed after 2008 for both STS (9.4%) and MFS (13.2%). Conclusions: There are differences between patient demographics and survival factors when comparing MFS to all STS. Monitoring changes in demographic and survival trends for rare STS subtypes like MFS is important to improve diagnostic algorithms and treatment options.

Differential diagnosis of T2 hypointense masses in musculoskeletal MRI.

Many soft tissue masses have an indeterminate appearance on MRI, often displaying varying degrees and extent of T2 hyperintensity. However, a subset of neoplasms and tumor-like lesions may exhibit prominent areas of T2 hypointensity relative to skeletal muscle. The hypointensity observed on T2-weighted MRI can be caused by a variety of substances, including evolving blood products, calcifications or other inorganic crystals, or fibrous tissue. Carefully evaluating the presence and pattern of T2 hypointensity in soft tissue masses and considering potential causes in their associated clinical contexts can help to narrow the differential diagnosis among neoplastic and non-neoplastic possibilities. These include endometriosis, aneurysmal bone cysts, tenosynovial giant cell tumor, arteriovenous malformation and pseudoaneurysm, calcium pyrophosphate and hydroxyapatite deposition diseases, tumoral calcinosis, gout, amyloidosis, hemangiomas with phleboliths, low-grade fibromyxoid sarcoma, ossifying fibromyxoid tumor, collagenous fibroma, desmoid-type fibromatosis, myxofibrosarcoma, peripheral nerve sheath tumors, dedifferentiated liposarcoma, and treated sarcoma.

Radiomics on radiography predicts giant cell tumor histologic response to denosumab.

OBJECTIVE: Denosumab is an established targeted systemic therapy for treatment of giant cell tumor of bone (GCTB). We sought to determine whether treatment response could be quantified from radiomics analysis of radiographs taken longitudinally during treatment. MATERIALS AND METHODS: Pre- and post-treatment radiographs of 10 GCTB tumors from 10 patients demonstrating histologic response after treatment with denosumab were analyzed. Intensity- and texture-based radiomics features for each manually segmented tumor were calculated. Radiomics features were compared pre- and post-treatment in tumors. RESULTS: Mean intensity (p = 0.033) significantly increased while skewness (p = 0.028) significantly decreased after treatment. Post-treatment increases in fractal dimensions (p = 0.057) and abundance (p = 0.065) approached significance. A potential linear correlation in mean (p = 0.005; ΔMean = 0.022 * duration - 0.026) with treatment duration was observed. CONCLUSION: Radiomics analysis of plain radiographs quantifies time-dependent matrix mineralization and trabecular reconstitution that mark positive response of giant cell tumors of bone to denosumab.

Unplanned excision of soft tissue sarcoma: does it impact the accuracy of intra-operative pathologic assessment at time of re-excision?

PURPOSE: An "unplanned excision" refers to soft tissue sarcomas excised without planning imaging studies and a diagnostic biopsy, resulting in the presence of residual disease and usually necessitating a re-excision procedure. We aimed to assess the impact of previous unplanned excisions on the intra-operative pathologic assessment at the time of re-excision, in terms of need to perform repeat assessments and the accuracy to predict margin status of the final pathologic specimen. METHODS: Data was collected for all patients with extremity soft tissue sarcoma who had undergone wide local excision limb salvage surgery or amputation between 2012 and 2017. Intra-operative pathologic assessment with frozen sections was performed in all cases and was classified as negative, negative but close (< 1 mm), and positive. RESULTS: A total of 173 patients with extremity soft tissue sarcoma were included, 54 in the unplanned excision group and 119 in the planned excision group. The accuracy of intra-operative pathologic assessment to predict the margin status on final pathology was similar between groups (87% unplanned vs. 90.7% planned excisions). However, the need for repeat intra-operative pathologic assessment and subsequent resection due to microscopically positive margins was found to be higher within the unplanned excision group ((p = 0.04), OR = 3.2 (95% CI: 1.1-9.1, p = 0.048)). CONCLUSIONS: Intra-operative pathologic assessment of resection margins had a similar accuracy in planned and unplanned excisions; however, unplanned excisions showed a higher risk of re-resection during the same surgical setting.

Survival in patients with carcinomas presenting with bone metastasis at diagnosis: a SEER population-based cohort study.

INTRODUCTION: Carcinoma metastasis to bone is a common reason for consultation to orthopedic surgeons. The presence of bone metastases (BM) is usually associated with poor prognosis which is worsened in the presence of synchronous metastases. The purpose of this study was to: (1) identify the most common carcinomas presenting with BM at diagnosis, to (2) analyze their survival, and (3) compare this against the survival of patients with additional synchronous metastasis based on a large population analysis. MATERIALS AND METHODS: Patients diagnosed with carcinoma between January 2010 and December 2015 were identified from the Surveillance, Epidemiology and End Results (SEER) database. The most common carcinomas presenting with BM at diagnosis were identified. Survival based on the presence of BM and synchronous metastases (lung, brain, liver, lymph nodes) was evaluated with Kaplan-Meier analysis. Five-year survival (%) stratified by carcinoma type was calculated. Hazard ratio (HR) for mortality comparing isolated BM to other synchronous metastases was performed. RESULTS: A total of 4.85% of patients (98,606/2,035,204) with carcinoma presented with BM at diagnosis, most commonly from a lung primary. Five-year survival with isolated BM was lowest in patients with pancreatic carcinoma (5.8%, 95% CI 3.0-9.9%), and highest in patients with breast carcinoma (41.1%, 95% CI 38.6-43.5%). Synchronous metastases increased significantly the risk of mortality within the majority of carcinomas. CONCLUSION: BM at diagnosis has a poor prognosis which is worsened if synchronous metastases are present; a fact to consider when planning orthopedic interventions. LEVEL OF EVIDENCE: Level III, prognostic study.

Significance of incidental intra-articular and peri-articular FDG avid foci on PET/CT.

BACKGROUND: Positron emission tomography/computed tomography (PET/CT) is a useful imaging adjunct in patients with sarcoma. Intra-articular and peri-articular 18F-fluoro-2-deoxy-D-glucose (FDG) avid lesions are often discovered incidentally. PURPOSE: To describe the etiology, appearance, and standardized uptake values (SUV) of incidentally detected FDG avid intra-articular and peri-articular foci in patients with sarcoma. MATERIAL AND METHODS: The institutional sarcoma database between November 2011 and November 2016 was retrospectively reviewed. Patients were included if a PET/CT scan was performed and an FDG avid intra-articular or peri-articular focus was found that was distinct from the primary sarcoma. RESULTS: The majority of FDG avid foci represented benign, non-physiologic conditions such as osteoarthritis, enthesopathy, bursitis, and post-surgical changes. Six patients each had radiographic features consistent with tenosynovial giant cell tumor (TSGCT) and metastatic disease, respectively. Lower SUV, bilateral findings, and the absence of metastatic disease elsewhere were associated with benign etiologies. There was a statistically significant difference between the mean SUV measured in patients with TSGCT and those with benign, non-physiologic conditions ( P < 0.001). The difference between the benign, non-physiologic cohort and the cohort with widespread metastatic disease did not reach statistical significance ( P = 0.07). CONCLUSIONS: In patients with soft-tissue or osseous sarcomas, isolated FDG avid intra-articular or peri-articular foci without additional metastatic lesions likely represent benign processes. Isolated intra-articular or peri-articular foci with significantly elevated SUV measurements were favored to represent TSGCT in this series.

Small soft tissue masses indeterminate at imaging: histological diagnoses at a tertiary orthopedic oncology clinic.

OBJECTIVE: To review histologic diagnoses of soft-tissue masses (STMs) ≤ 2 cm with indeterminate imaging features encountered in musculoskeletal oncology clinic at a tertiary referral center. MATERIALS AND METHODS: This was an IRB-approved retrospective review of patients with STMs ≤ 2 cm, referred to our tertiary care orthopedic oncology clinic over 4.75 consecutive years. Maximum diameter was based on imaging measurement by a fellowship-trained musculoskeletal radiologist. Simple lipomas, synovial cysts, metastases, and cases without histologic confirmation were excluded. Patient demographics, tumor imaging features (location, depth, size, and tumor:muscle enhancement and T2 signal ratios), and histology were recorded and compared. RESULTS: Mean maximum diameter for 42 trunk/extremity STMs was 1.5 cm (range, 0.7 to 2 cm). Mean age was 48 years (range, 18-83 years). Nine (21%) of the masses were malignant, while 33 (79%) were non-malignant. Thirty-nine (93%) of masses were superficial; 7/39 (18%) of these superficial tumors were malignant. Malignancy was not associated with underlying vessels, tendon, or fascia (p = 0.19). The non-malignant vs. malignant tumor:muscle enhancement ratio was 2.15 vs. 2.32 (p = 0.58) and enhancement coefficient of variation was 0.14 vs. 0.10 (p = 0.29). Most common malignant histologic subtypes were synovial sarcoma (n = 3), fibroblastic/myofibroblastic sarcoma (n = 2), leiomyosarcoma (n = 2), myxofibrosarcoma (n = 1), and angiomatoid fibrous histiocytoma (n = 1). The majority (67%) of non-malignant lesions were: leiomyoma (n = 6), angiomyoma (n = 5), schwannoma (n = 4), benign fibrous histiocytoma (n = 4), and hemangioma (n = 3). CONCLUSIONS: At a tertiary musculoskeletal oncology referral clinic, primary STMs ≤ 2 cm with indeterminate imaging features should be managed cautiously despite their small size and/or superficial location.

Early outcomes of locked noncemented stems for the management of proximal humeral fractures: a comparative study.

BACKGROUND: Proximal humeral fractures are common and a major concern in public health resources utilization. There is an increase in the use of reverse total shoulder arthroplasty (RTSA) as an option for complex fractures in the elderly. The complexity of the technique in RTSA is increased because of the fracture. To find an advantage of locking stems in RTSA for the treatment of proximal humeral fractures, we designed a comparative study between fracture-dedicated locking stems vs. cemented stems. MATERIALS AND METHODS: We retrospectively studied 58 patients treated with an RTSA after a fracture. We compared how the implant design and the tuberosity consolidation affects patient outcome through measuring range of motion and the Constant score. RESULTS: The groups were similar in age, sex, time to surgery, and Constant score in the uninjured side. Patients treated with a dedicated locking noncemented stem performed better, with an increased Constant score (P > .05) and reached more mobility with no statistical significance. We found that 13 of the 24 fractures (54%) treated with a cemented stem consolidated, and 26 of 34 tuberosities (76%) healed in the noncemented locked stems. Patients with tuberosity consolidation acquired better range of motion and Constant scores (P < .05). CONCLUSIONS: A dedicated stem improves tuberosity healing and increases outcomes seen in Constant scores. Tuberosity consolidation is a main goal when treating proximal humeral fractures with RTSA.

Denosumab treatment for giant-cell tumor of bone: a systematic review of the literature.

BACKGROUND: Denosumab is a human monoclonal antibody (mAb) that specifically inhibits tumor-associated bone lysis through the RANKL pathway and has been used as neoadjuvant therapy for giant-cell tumor of bone (GCTB) in surgical as well as non-surgical cases. The purpose of this systematic review of the literature, therefore, is to investigate: (1) demographic characteristics of patients affected by GCTBs treated with denosumab and the clinical impact, as well as, possible complications associated with its use (2) oncological outcomes in terms of local recurrence rate (LRR) and development of lung metastasis, and (3) characteristics of its treatment effect in terms of clinical, radiological, and histological response. METHODS: A systematic review of the literature was conducted using PubMed, EMBASE, and COCHRANE search including the following terms and Boolean operators: "Denosumab" AND "primary bone tumor", "denosumab" AND "giant cell tumor", "denosumab" AND "treatment", and finally, "denosumab" AND "giant cell tumor" AND "treatment" since 2000. After applying inclusion and exclusion criteria, a total of 19 articles were included. The quality of the included studies was assessed using STROBE for the assessment of observational studies. RESULTS: A total of 1095 patients were included across all 19 studies. Across all the studies included, there were 615 females and 480 males. The mean patient age was 33.7 ± 8.3 years when starting the denosumab treatment. The pooled weighted local recurrence rate was 9% (95% CI 6-12%) and the pooled weighted metastases rate was 3% (95% CI 1-7%). The most common adverse event was fatigue and muscular pain. Radiologic response was estimated to occur in 66-100% of the patients. A significant reduction in pain under denosumab treatment was reported in seven studies and additional improvement in function and mobility was reported by several authors. Only two studies reported musculoskeletal tumor society (MSTS) scores which were better after denosumab treatment. CONCLUSIONS: The use of denosumab as an adjuvant treatment of GCTB has shown a positive but variable histological response with consistent radiological changes and several types of adverse effects. There is a positive clinical response in terms of pain relief with decrease on the morbidity of surgical procedures to be performed. Finally, oncological outcomes are disparate with neither effect on metastatic disease nor local recurrence rates. LEVEL OF EVIDENCE: IV.

Surgical treatment of low-grade chondrosarcoma involving the appendicular skeleton: long-term functional and oncological outcomes.

BACKGROUND: The traditional treatment for chondrosarcoma is wide local excision (WLE), as these tumors are resistant to chemotherapy and radiation treatment. While achieving negative margins has traditionally been the goal of chondrosarcoma resection, multiple studies have demonstrated good short-term results after intralesional procedures for low-grade chondrosarcomas (LGCS) with curettage and adjuvant treatments (phenol application, cauterization or cryotherapy) followed by either cementation or bone grafting. Due to the rarity of this diagnosis and the recent application of this surgical treatment modality to chondrosarcoma, most of the information regarding treatment outcomes is retrospective, with short or intermediate-term follow-up. The aim of this study was to assess the long-term results of patients with LGCS of bone treated with intralesional curettage (IC) treatment versus WLE. This retrospective analysis aims to characterize the oncologic outcomes (local recurrence, metastases) and functional outcomes in these two treatment groups at a single institution. METHODS: Using an institutional musculoskeletal oncologic database, we retrospectively reviewed medical records of all patients with LGCS of the appendicular skeleton that underwent surgical treatment between 1985 and 2007. Thirty-two patients (33 tumors) were identified with LGCS; 17 treated with IC and 15 with WLE. RESULTS: Seventeen patients (18 tumors) with a minimum clinical and radiologic follow-up of 10 years were included. Nine patients were treated with IC (four with no adjuvant, three with additional phenol, one with liquid nitrogen and one with H2O2) with either bone graft or cement augmentation, and nine others were treated with WLE and reconstruction with intercalary/osteoarticular allograft or megaprosthesis. The mean age at surgery was 41 years (range 14-66 years) with no difference (p = 0.51) between treatment cohorts. There was a mean follow-up of 13.5 years in the intralesional cohort (range 10-19 years) and 15.9 years in the WLE cohort (range 10-28 years, p = 0.36). Tumor size varied significantly between groups and was larger in patients treated with WLE (8.2 ± 3.1 cm versus 5.4 ± 1.2 cm, at the greatest dimension, p = 0.021). There were two local recurrences (LR), one in the intralesional group and one in the wide local excision group, occurring at 3.5 months and 2.9 years, respectively, and both required revision. No further LR could be detected with long-term follow-up. The MSTS score at final follow-up was significantly higher for patients managed with intralesional procedures (28.7 ± 1.7 versus 25.7 ± 3.4, p = 0.033). There were less complications requiring reoperation in the intralesional group compared with the wide local excision group, although this difference was not found to be statistically significant (one versus four patients, respectively; p = 0.3). CONCLUSION: This series of low-grade chondrosarcoma, surgically treated with an intralesional procedures, with 10-year follow-up, demonstrates excellent local control (88.9%). Complications were infrequent and minor and MSTS functional scores were excellent. Wide resection of LGCS was associated with lower MSTS score and more complications. In our series, the LR in both groups were detected within the first 3.5 years following the index procedure, and none were detected in the late surveillance period.

MRI findings associated with microscopic residual tumor following unplanned excision of soft tissue sarcomas in the extremities.

INTRODUCTION: MRI is often used to determine the presence of residual disease following unplanned excisions (UPE) of soft tissue sarcomas (STS). We sought to identify MRI features associated with histologic evidence of residual disease after TBE. MATERIALS AND METHODS: This was an IRB-approved retrospective review of 27 patients with R1-type UPE of STS over a 32-month period, with subsequent MRI and TBE. MRI studies were retrospectively evaluated to determine depth of tissue involvement, presence of nodular enhancement, and maximum length of soft tissue edema normalized to extremity size. MRI findings were correlated with histology from unplanned excision and TBE. RESULTS: Among the 21 subjects, there were 13 males and 8 females, mean age 58. Eighteen of 21 STS were grade 2 or 3. Deep compartments were involved in 5/21 cases. Original margins were positive in 17/21 UPE, with inadequate margin assessment in the remaining 4 cases. Residual tumor was present at TBE in 11/21 cases; it was found in 4/6 cases with nodular enhancement and 7/15 cases without nodular enhancement (sensitivity = 0.36; specificity = 0.80; PPV = 0.67; NPV = 0.53). Increased extent of soft tissue edema increased the likelihood of residual tumor at TBE (OR = 35.0; 95% CI = 1.6 to 752.7; p = 0.023). CONCLUSION: Nodular enhancement is neither sensitive nor specific in predicting residual microscopic tumor in TBE following UPE. Extensive soft tissue edema on MRI after UPE increases the likelihood of finding a residual microscopic tumor, justifying ample margins at TBE and consideration of adjuvant therapy.

Local recurrence of soft-tissue sarcoma: issues in imaging surveillance strategy.

Soft-tissue sarcomas pose diagnostic and therapeutic challenges to physicians, owing to the large number of subtypes, aggressive tumor biology, lack of consensus on management, and controversy surrounding interval and duration of surveillance scans. Advances in multidisciplinary management have improved the care of sarcoma patients, but controversy remains regarding strategies for surveillance following definitive local control. This review provides an updated, comprehensive overview of the current understanding of the risk of local recurrence of soft-tissue sarcoma, by examining the literature based on features such as histological type and grade, tumor size, and resection margin status, with the aim of helping clinicians, surgeons, and radiologists to develop a tailored approach to local imaging surveillance.

F-18 FDG PET differentiation of benign from malignant chondroid neoplasms: a systematic review of the literature.

INTRODUCTION: Discriminating among benign chondroid tumors, low-grade chondrosarcomas, and grade 2/3 chondrosarcomas is frequently difficult with standard imaging modalities. We systematically reviewed the literature to determine the performance of PET-CT in making this distinction. METHODS: A systematic review was performed identifying 811 PubMed- and Embase-indexed articles containing combinations of "chondrosarcoma," "enchondroma," "chondroid," "cartilage" and "PET/CT," "PET," "positron." Eight articles including 166 lesions were included. Age, gender, tumor size, histologic grade, and SUVmax values were extracted for individual lesions when possible and otherwise recorded as aggregated data. Comparisons in SUVmax among benign, low-grade, and intermediate-/high-grade chondroid neoplasms were made. RESULTS: Individual SUVs were available for 101 lesions; 65 additional lesions were reported as aggregated data. There were 101 malignant and 65 benign tumors. Benign tumors were seen more frequently in females (p = 0.04, Fischer's exact test), but malignancy was not associated with age or lesion size. SUVmax was lower for benign (1.6 ± 0.7) than malignant tumors (4.4 ± 2.5) (p < 0.0001, t-test). SUVmax was lower for grade 0/1 (2.0 ± 0.7) than grade 2/3 (6.0 ± 3.2) (p < 0.0001, t-test). Increasing SUVmax correlated with higher grade chondroid tumors (Spearman's rank, ρ = 0.78). SUVmax ≥4.4 was 99% specific for grade 2/3 chondrosarcoma. CONCLUSIONS: SUVmax correlates with histologic grade in intraosseous chondroid neoplasms; very low SUVmax supports a diagnosis of benign tumor, while elevated SUVmax is suggestive of higher grade chondrosarcoma.

The anterolateral ligament: A cadaveric study in fetuses.

The aim of this study was to determine the presence and morphology of the anterolateral ligament (ALL) of the knee in a sample of fetuses. We hypothesized that the ALL is present in sample fetuses and its origin is not related to repetitive stresses throughout life. Forty fresh-frozen knees from cadaveric fetuses were dissected using a standard technique. The ALL and other structures in the anterolateral compartment of the knee were identified. The details of the femoral and tibial attachments, course and relationships with anatomical structures of the ALL were identified, recorded, and quantitatively characterized. The ALL was identified in 100% of the dissected knees. We found three anatomical patterns regarding the femoral attachment: (1) Proximal and posterior to the fibular collateral ligament (55%); (2) Together with the fibular collateral ligament (25%); and (3). Anterior and distal to it (20%). The ALL was extracapsular with an oblique course attaching into the anterolateral aspect of the tibia, midway between the midpoint of Gerdy's tubercle and the fibular head. The ALL has a strong attachment to the lateral meniscus, creating two fascicles: proximal or meniscofemoral and distal or meniscotibial. The ALL is a constant, extracapsular anatomical structure in the anterolateral compartment of the knee, present from the later prenatal period of life. Its morphology shows three different patterns of femoral attachment in relation to the fibular collateral ligament position, a strong attachment in the lateral meniscus, and a constant tibial attachment. Clin. Anat. 30:625-634, 2017. © 2017 Wiley Periodicals, Inc.

Skeletal muscle metastasis from the most common carcinomas orthopedic surgeons deal with. A systematic review of the literature.

INTRODUCTION: There is scarce information in the literature dealing with the clinical presentation, management and oncologic outcomes of skeletal muscle metastases (SMM). We sought to perform a systematic review of the literature to investigate: (1) tumor characteristics of SMM, (2) therapeutic approach, and (3) oncological outcomes. METHODS: A systematic review of the literature was performed using PubMed and EMBASE search engines. A total of 3231 references were reviewed and 49 studies were included. Demographic data, presentation characteristics, and oncological outcomes were recorded. Statistical analysis was performed using SPSS 22.0 software (IBM; Armonk, New York) and Comprehensive Meta-Analysis software version 3 (Biostat, Inc.), with p < 0.05 as statistically significant. RESULTS: A total of 231 patients were included. These tumors presented more commonly on males 58.4% (135/231), with a mean age of 60.08 ± 10.6 years, and in the axial area 39.6% (88/222). The most common carcinoma type was lung 41.1% (95/231). Resection of a single metastases did not change survival significantly (p = 0.992). LRR was higher within the group of patients that underwent WLE compared with non-WLE [31.3% (23/74) vs. 8.7% (2/23), p ≤ 0.001]. Kaplan-Meier survival analysis for the entire cohort showed an estimate of 15.3 months [95% confidence interval (CI) 11.6-19; standard error (SE) 0.432], with lung carcinoma carrying the worst prognosis 6.7 months (95% CI 5.4-8.07; SE 0.68). Patients with a single SMM showed a worse estimate mean survival time compared to patients with multiple metastases limited to muscles [8.6 months (95% CI 4.7-12.5; SE 2.0) vs 25.4 months (95% CI 19.8-31.05; SE 2.8; p ≤ 0.001)]. CONCLUSIONS: Overall survival is poor and is driven mainly by the type of carcinoma. An Increased LRR might be present due to the systemic nature of the condition, and degree of control of the primary carcinoma.