Patterns of Failure in High-Grade Soft Tissue Sarcomas of the Extremities and Trunk Wall After Pre- or Postoperative Radiation Therapy.

Purpose: Radiotherapy (RT) is a mainstay of treatment for high-grade soft tissue sarcomas (STS). We sought to examine the pattern of local recurrence (LR) with regard to target volume, clinical course, and tumor characteristics in extremity and trunk wall STS patients receiving pre- or postoperative RT. Methods and Materials: In this retrospective study, LR rates and patterns in 91 adult patients with a primary diagnosis of localized high-grade STS of the extremities and trunk wall treated with pre- or postoperative RT at our institution between 2004 and 2021 were analyzed. Radiation treatment plans and imaging data sets at diagnosis and LR were compared. Results: Seventeen out of 91 (18.7 %) patients developed a LR after a median time of 12.7 months. In 10 out of 13 LRs (76.9%) with available treatment plans and radiographic imaging data at the time of recurrence, the LR occurred within the planned target volume (PTV), 2 LRs were marginal (15.4%, at the edge of the PTV volume), and one relapsed out-of-field (7.7%, outside the PTV volume). Positive surgical margins (microscopic or macroscopic) were found in 5 out of 91 patients (5.5%), 1 of which was found in the 17 patients with LRs (5.9%). Eleven of 13 LR patients (84.6%) with available treatment plans and radiographic imaging data received postoperative RT; the median total RT dose was 60 Gy. Volumetric-modulated arc therapy was used in 10 (76.9%), intensity-modulated RT in 2 (15.4%), and 3-dimensional conformal radiation therapy in 1 (7.7%) of 13 LRs. Conclusions: The majority of LRs occurred within the PTV suggesting that LR is most likely not a consequence of inadequate target volume definition, but rather of radioresistant tumor biology. To further improve local tumor control, future research on the potential of dose escalation with normal tissue sparing, STS subtype-specific tumor biology, radiosensitivity, and surgical technique is indicated.

Sarcoma Patients Admitted to the Intensive Care Unit (ICU): Predictive Relevance of Common Sepsis and Performance Parameters.

Purpose: Prognosis of sarcoma patients is improving, with a better understanding of sarcomagenesis revealing novel therapeutic targets. However, aggressive chemotherapy remains an essential part of treatment, bearing the risk of severe side effects that require intensive medical treatment. Available data on the characteristics and clinical outcome of sarcoma patients admitted to intensive care units (ICU) are sparse. Patients and Methods: We performed a retrospective analysis of sarcoma patients admitted to the ICU from 2005 to 2022. Patients ≥18 years with histologically proven sarcoma were included in our study. Results: Sixty-six patients were eligible for analysis. The following characteristics had significant impact on overall survival: sex (p=0.046), tumour localization (p=0.02), therapeutic intention (p=0.02), line of chemotherapy (p<0.001), SAPS II score (p=0.03) and SOFA score (p=0.02). Conclusion: Our study confirms the predictive relevance of established sepsis and performance scores in sarcoma patients. For overall survival, common clinical characteristics are also of significant value. Further investigation is needed to optimize ICU treatment of sarcoma patients.

Prosthetic Joint Infection in Mega-Arthroplasty Following Shoulder, Hip and Knee Malignancy-A Prospective Follow-Up Study.

INTRODUCTION: The risk of prosthetic joint infection (PJI) in mega-prosthesis for malignancy is increased compared with non-tumor cases. While several studies describe PJI in tumor-related arthroplasty, prospective studies comparing infection characteristics among different joints are limited. The present study analyzes mega-arthroplasty for hip, knee, and shoulder malignancy and compares the epidemiology, diagnosis, microbe spectrum, treatments, and outcomes between the different entities. METHODS: The retrospective inclusion criteria were as follows: (1) mega-arthroplasty (2) in the hip, knee, or shoulder joint and a total femur arthroplasty (3) following a malignant bone tumor or metastasis (4) between 1996 and 2019. All included patients were prospectively followed and invited for a renewed hospital examination, and their PJI characteristics (if identified) were analyzed using both retrospective as well as newly gained prospective data. A PJI was defined according to the Infectious Disease Society of America (IDSA) and re-infection was defined according to the modified Delphi Consensus criteria. RESULTS: In total, 83 cases of tumor mega-arthroplasty at a mean follow-up of 3.9 years could be included (32 knee, 30 hip, and 19 shoulder cases and 2 cases of total femur arthroplasty). In total, 14 PJIs were identified, with chondrosarcoma in 6 and osteosarcoma in 3 being the leading tumor entities. Knee arthroplasty demonstrated a significantly higher rate of PJI (p = 0.027) compared with hips (28.1% vs. 6.7%), while no significant difference could be found between the knee and shoulder (10.5%) (p = 0.134) or among shoulder and hip cases (p = 0.631). The average time of PJI following primary implantation was 141.4 months in knee patients, 64.6 in hip patients, and 8.2 months in shoulder patients. Age at the time of the primary PJI, as well as the time of the first PJI, did not show significant differences among the groups. Thirteen of the fourteen patients with PJI had a primary bone tumor. Statistical analysis showed a significant difference in the disadvantage of primary bone tumors (p = 0.11). While the overall cancer-related mortality in the knee PJI group (10%) was low, it was 50% in the hip and 100% in the shoulder group. CONCLUSION: The risk of PJI in knee tumor arthroplasty is significantly increased compared with hips, while cancer-related mortality is significantly higher in hip PJI cases. At the same time, mega-prostheses appear to be associated with a higher risk of infection due to a primary bone tumor compared with metastases. The study confirms existing knowledge concerning PJI in tumor arthroplasty, while, being one of the few studies to compare three different joints concerning PJI characteristics.

Surgical Margins in Soft Tissue Sarcoma Management and Corresponding Local and Systemic Recurrence Rates: A Retrospective Study Covering 11 Years and 169 Patients in a Single Institution.

Soft tissue sarcomas (STSs) are a diverse group of rare malignant soft tissue tumors with a high disease burden. Treatment protocols are complex and, to this day, a precise recommendation for the surgical margin width is lacking. The present study aims to analyze the width of the surgical margins in STS resection specimens and analyze them for local and systemic disease-free survival as well as for most frequent histologic STS subtypes. A total of 169 consecutive patients diagnosed and treated in curative intent in our institution following a primary and localized STS of the extremities or trunk from January 2010 to December 2020 were included in this study regardless of age. Our data reveal that low-grade STSs are best controlled locally by a surgical margin ≥2 mm and in this way also preventing distant metastases effectively. Local recurrence-free survival and metastasis-free survival in high-grade STS were improved by intact muscle fascia or periosteum at the margin when compared only to soft tissue. However, the outcome was independent of the surgical margin width, suggesting a close but negative margin may be safe in high-grade STS subtypes with less invasive growth patterns when combined with adjunct radiochemotherapy.

The role of neoadjuvant radiochemotherapy in the management of localized high-grade soft tissue sarcoma.

BACKGROUND: Standard treatment of soft tissue sarcoma (STS) of the extremities includes limb-sparing surgery combined with pre- or postoperative radiotherapy (RT). The role of perioperative chemotherapy (CTX) remains uncertain. STS patients with high-risk features for local recurrence, distant metastases, and increased mortality may require additional systemic therapy. The objective of this study was to evaluate predictors of outcome regarding local control (LC), overall survival (OS), and freedom from distant metastases (FFDM) in a large single-center cohort of patients suffering from localized high-grade STS (grade 2/3, G2/G3). Special emphasis was put on a subgroup of patients who received combined neoadjuvant radiochemotherapy (RCT). METHODS: Overall, 115 adult STS patients were included in this retrospective study. The median follow-up was 34 months. Twenty-three patients (20.0%) were treated with neoadjuvant RCT, 92 (80.0%) received other therapies (adjuvant RT alone (n = 58); neoadjuvant CTX + adjuvant RT (n = 17); adjuvant RCT (n = 10), neoadjuvant RT alone (n = 7)). To assess potential prognostic factors on LC, OS, and FFDM, univariate (UVA) and multivariable (MVA) Cox proportional hazards models were applied. RESULTS: UVA showed significantly better LC rates in the neoadjuvant RCT group (p = 0.025), with trends in MVA (p = 0.057). The 3-year LC rate was 89.7% in the neoadjuvant RCT group vs. 75.6% in the "other therapies" group. UVA also showed significantly better OS rates in the neoadjuvant RCT group (p = 0.049), however, this was not confirmed in MVA (p = 0.205), the 3-year OS rate was 85.8% for patients treated with neoadjuvant RCT compared to 73.5% in the "other therapies" group. UVA showed significantly better FFDM rates in (p = 0.018) and a trend towards better FFDM rates in MVA (p = 0.059). The 3-year FFDM rate was 89.7% for patients treated with neoadjuvant RCT compared to 65.9% in the "other therapies" group. In the subgroup of patients with G3 STS, neoadjuvant RCT was a significant positive predictor of LC and FFDM in MVA (p = 0.047, p = 0.027) but not for OS. Overall grade 3 and 4 toxicities were significantly higher (p = 0.019) in the neoadjuvant RCT group and occurred in 73.9% vs. 38.0% in patients receiving other therapies. CONCLUSIONS: The results suggest that neoadjuvant RCT might improve LC and FFDM in patients with localized G3 STS while also being associated with increased acute complication rates. Further prospective research is warranted to confirm these findings.

A computed tomography based survey study investigating the agreement of the therapeutic strategy for fragility fractures of the pelvis.

Treatment recommendations for fragility fractures of the pelvis (FFP) have been provided along with the good reliable FFP classification but they are not proven in large studies and recent reports challenge these recommendations. Thus, we aimed to determine the usefulness of the FFP classification determining the treatment strategy and favored procedures in six level 1 trauma centers. Sixty cases of FFP were evaluated by six experienced pelvic surgeons, six inexperienced surgeons in training, and one surgeon trained by the originator of the FFP classification during three repeating sessions using computed tomography scans with multiplanar reconstruction. The intra-rater reliability and inter-rater reliability for therapeutic decisions (non-operative treatment vs. operative treatment) were moderate, with Fleiss kappa coefficients of 0.54 (95% confidence interval [CI] 0.44-0.62) and 0.42 (95% CI 0.34-0.49). We found a therapeutic disagreement predominantly for FFP II related to a preferred operative therapy for FFP II. Operative treated cases were generally treated with an anterior-posterior fixation. Despite the consensus on an anterior-posterior fixation, the chosen procedures are highly variable and most plausible based on the surgeon's preference.

The Effect of Fat Distribution on the Inflammatory Response of Multiple Trauma Patients-A Retrospective Study.

Objectives In recent years; increasing evidence pointed out the clinical importance of adipose tissue (AT) distribution in various patient populations. In particular, visceral adipose tissue (VAT), when compared to subcutaneous adipose tissue (SAT), was found to play a pivotal role in the development of inflammatory reaction. The aim of the present study was to examine whether body fat distribution has an impact on the development of systemic inflammatory response syndrome (SIRS) in patients with polytrauma. Methods In our retrospective study; we filtered our institution records of the German Trauma Registry (Trauma Register DGU) from November 2018 to April 2021 and included 132 adult polytrauma patients with injury severity score (ISS) >16. Subsequently; we measured the visceral and subcutaneous adipose tissue area based on whole-body CT scan and calculated the ratio of VAT to SAT (VSr). Thereafter, the patient population was evenly divided into three groups; respectively VSr value less than 0.4 for the first group (low ratio), 0.4-0.84 for the second group (intermediate ratio), and greater than 0.84 for the third group (high ratio). Considering the other influencing factors; the groups were further divided into subgroups in the respective analysis according to gender (male/female), BMI (<25 or ≥25), and ISS (<26 or ≥26). Result VSr was an independent factor from body mass index (BMI) (r2 = 0.003; p = 0.553). VSr in male patients was significantly higher (p < 0.001). Patients with low VSr had higher ISS scores (p = 0.028). Polytrauma patients with higher VSr tended to have lower SIRS scores and significant differences of SIRS score were found on multiple days during the whole hospitalization period. In the low VAT/SAT group, male patients, and patients with BMI greater than 25, both exhibited higher SIRS scores during hospital stay (day 16: p = 0.01; day 22: p = 0.048 and p = 0.011; respectively). During hospitalization, patients with higher ISS score (≥26) in the low VSr group was found to have higher SIRS score (day 16; p = 0.007). Over the hospital stay; serum markers of CRP; CK; and leukocyte in patients with low VSr were higher than those in patients in the intermediate and high VSr groups; with significant difference discovered on multiple days (day 16: 0.014; day 22: p = 0.048). Conclusion Lower VSr is associated with increased inflammatory response and worse clinical outcome in patients with polytrauma. Furthermore; VSr is an independent factor providing additional information to BMI.

[Importance of the tibial slope in knee arthroplasty]. / Bedeutung des tibialen Slopes in der Knieendoprothetik.

Notwithstanding the contributions of soft tissue restraints on postoperative kinematics and long-term survival after total knee arthroplasty (TKA), there is an emerging consensus that the underlying anatomy, especially the posterior inclination of the tibial plateau in the sagittal plane (tibial slope), might just have a comparable impact. However, this has not been fully elucidated as yet. Therefore, a thorough literature search, analysis and presentation of current scientific data was conducted. The tibial slope has been shown to relate linearly to the postoperative range of motion and function of the extensor mechanism. Furthermore, it impacts wear of the tibial insert and loosening, as well as instability of the TKA. As no consensus has been reached on the ideal tibial slope, recommendations range from 0° to 10°. Notably, more recent studies favor reconstructing the native, preoperative tibial slope, and the majority of authors advocate that knowledge of this is crucial for optimal TKA surgery.

Fragility Fractures of the Pelvis Classification: A Multicenter Assessment of the Intra-Rater and Inter-Rater Reliabilities and Percentage of Agreement.

BACKGROUND: The fragility fractures of the pelvis (FFP) classification was established to address the specific fracture morphology and dynamic instability in the elderly. Although this system is frequently used, data on the intra-rater and inter-rater reliabilities are lacking. METHODS: Six experienced and 6 inexperienced surgeons and 1 surgeon trained by the originator of the FFP classification ("gold standard") each used the FFP classification 3 times to grade the computed tomography (CT) scans of 60 patients from 6 hospitals. We assessed intra-rater and inter-rater reliabilities using Fleiss kappa statistics and the percentage of agreement using the "gold standard," the submitting hospital, and the majority vote as references. RESULTS: The intra-rater reliability for the FFP classification was mainly moderate, with a mean Fleiss kappa coefficient (and 95% confidence interval) of 0.46 (0.40 to 0.50) for the complete classification (i.e., both the main-group FFP ratings [I through III] and the subgroup ratings [a, b, and c]) and 0.60 (0.53 to 0.65) for the main group only. The inter-rater reliability was substantial for the main group classification (0.61 [0.54 to 0.66]) and moderate for the complete classification (0.53 [0.48 to 0.58]). The percentage of agreement was 68% to 80%. The lowest agreement was found for FFP II and III. CONCLUSIONS: The FFP classification displayed moderate and substantial intra-rater and inter-rater reliabilities. CLINICAL RELEVANCE: With moderate to substantial intra-rater and inter-rater reliabilities, the FFP classification forms a solid basis for future clinical investigations. The differentiation of FFP II from FFP III should be evaluated thoroughly, as the initial treatment changes from nonoperative for II to operative for III.