Impact of Metastasectomy and Aggressive Local Therapy in Newly Diagnosed Metastatic Soft Tissue Sarcoma: An Analysis of the NCDB.

BACKGROUND: The optimal management of patients with stage IV soft tissue sarcoma of the extremity (STSE) with distant metastases at diagnosis is unclear due to limited evidence and heterogeneity of current practice patterns. National guidelines have recommended surgical management of the primary site (SP) with or without radiotherapy (R), chemotherapy (C), and metastasectomy (M). METHODS: In the National Cancer Database (NCDB), patients with initially metastatic STSE who received definitive SP from 2004 to 2014 were identified. Survival distributions were estimated and compared using the Kaplan-Meier method and log-rank tests, and covariates were compared using Chi-square tests or analysis of variance (ANOVA). Propensity score analysis using inverse probability of treatment weighting was used. RESULTS: Overall, 1124 patients were included, with a median age of 55 years (range 18-90). Utilization of SP+M increased over time from 18.8% in 2004-2006, to 33.3% in 2007-2009, to 47.9% in 2010-2014 (p = 0.024). The addition of M to SP was associated with superior 5-year overall survival (OS) at 30.8% (SP+M+/-C+/-R) compared with 18.2% for those treated with non-surgical adjuvant therapies (SP+/-C+/-R) and 12.6% for SP alone (p < 0.0001). Positive surgical margins were noted in 24.1% of patients and was associated with worse OS (hazard ratio 1.44, p < 0.001) on multivariable analysis. CONCLUSIONS: This is the first known study utilizing a large database to explore practice patterns and outcomes for patients with metastatic STSE receiving definitive SP. Utilization of metastasectomy increased in the study period and was associated with longer survival compared with SP alone. These hypothesis-generating data warrant additional study.

Cooled Radiofrequency Ablation for Chronic Joint Pain Secondary to Hip and Shoulder Osteoarthritis.

Osteoarthritis (OA) of the shoulder and hip is a leading cause of physical disability and mental distress. Traditional nonsurgical management alone is often unable to completely address the associated chronic joint pain. Moreover, a large number of patients are not eligible for joint replacement surgery owing to comorbidities or cost. Radiofrequency ablation (RFA) of articular sensory nerve fibers can disrupt the transmission of nociceptive signals by neurolysis, thereby providing long-term pain relief. A subtype of RFA, cooled RFA (CRFA), utilizes internally cooled electrodes to generate larger ablative zones compared with standard RFA techniques. Given the complex variable innervation of large joints such as the glenohumeral and hip joints, a larger ablative treatment zone, such as that provided by CRFA, is desired to capture a greater number of afferent nociceptive fibers. The suprascapular, axillary, and lateral pectoral nerve articular sensory branches are targeted during CRFA of the glenohumeral joint. The obturator and femoral nerve articular sensory branches are targeted during CRFA of the hip. CRFA is a promising tool in the interventionalist's arsenal for management of OA-related pain and symptoms, particularly in patients who cannot undergo, have long wait times until, or have persistent pain following joint replacement surgery. An invited commentary by Tomasian is available online. ©RSNA, 2022.

Pilot study for treatment of symptomatic shoulder arthritis utilizing cooled radiofrequency ablation: a novel technique.

OBJECTIVE: To introduce cooled radiofrequency nerve ablation (C-RFA) as an alternative to managing symptomatically moderate to severe glenohumeral osteoarthritis (OA) in patients who have failed other conservative treatments and who are not surgical candidates or refuse surgery. MATERIAL AND METHODS: This prospective pilot study includes a total of 12 patients experiencing chronic shoulder pain from moderate to severe glenohumeral OA. Patients underwent anesthetic blocks of the axillary, lateral pectoral, and suprascapular nerves to determine candidacy for C-RFA treatment. Adequate response after anesthetic block was over 50% immediate pain relief. Once patients were deemed candidates, they underwent C-RFA of the three nerves 2-3 weeks later. Treatment response was evaluated using the clinically validated American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) to assess pain, stiffness, and functional activities of daily living. Follow-up outcome scores were collected up to 6 months after C-RFA procedure. RESULTS: Twelve patients underwent C-RFA procedure for shoulder OA. VAS scores significantly improved from 8.8 ± 0.6 to 2.2 ± 0.4 6 months after the C-RFA treatment (p < 0.001). Patient's ASES score results significantly improved in total ASES from 17.2 ± 6.6 to 65.7 ± 5.9 (p < 0.0005). No major complications arose. No patients received re-treatment or underwent shoulder arthroplasty. CONCLUSION: Image-guided axillary, lateral pectoral, and suprascapular nerve C-RFA has minimal complications and is a promising alternative to treat chronic shoulder pain and stiffness from glenohumeral arthritis.

A novel preoperative risk score to guide patient selection for resection of soft tissue sarcoma lung metastases: An analysis from the United States Sarcoma Collaborative.

BACKGROUND: Surgical resection for sarcoma lung metastases has been associated with improved overall survival (OS). METHODS: Patients who underwent curative-intent resection of sarcoma lung metastases (2000-2016) were identified from the US Sarcoma Collaborative. Patients with extrapulmonary metastatic disease or R2 resections of primary tumor or metastases were excluded. Primary endpoint was OS. RESULTS: Three hundred and fifty-two patients met inclusion criteria. Location of primary tumor was truncal/extremity in 85% (n = 270) and retroperitoneal in 15% (n = 49). Forty-nine percent (n = 171) of patients had solitary and 51% (n = 180) had multiple lung metastasis. Median OS was 49 months; 5-year OS 42%. Age ≥55 (HR 1.77), retroperitoneal primary (HR 1.67), R1 resection of primary (HR 1.72), and multiple (≥2) lung metastases (HR 1.77) were associated with decreased OS(all p < 0.05). Assigning one point for each factor, we developed a risk score from 0 to 4. Patients were then divided into two risk groups: low (0-1 factor) and high (2-4 factors). The low-risk group (n = 159) had significantly better 5-year OS compared to the high-risk group (n = 108) (51% vs. 16%, p < 0.001). CONCLUSION: We identified four characteristics that in aggregate portend a worse OS and created a novel prognostic risk score for patients with sarcoma lung metastases. Given that patients in the high-risk group have a projected OS of <20% at 5 years, this risk score, after external validation, will be an important tool to aid in preoperative counseling and consideration for multimodal therapy.

Safety and efficacy comparison of three- vs four-needle technique in the management of moderate to severe osteoarthritis of the knee using cooled radiofrequency ablation.

PURPOSE: To analyze the safety and efficacy of image-guided genicular nerve cooled radiofrequency ablation (C-RFA) for the treatment of pain in non-surgical candidates with moderate to severe knee osteoarthritis (OA) and to compare three- vs four-needle technique. METHOD: This retrospective study included 50 consecutive patients with pain from moderate to severe knee OA refractory to anti-inflammatory analgesia that failed multiple intra-articular lidocaine-steroid injections and who were non-surgical total knee arthroplasty candidates because of comorbidities. Patients initially underwent anesthetic blocks of the superior medial/lateral femoral and inferior medial tibial genicular nerve branches and in some cases the suprapatellar genicular nerve branch. Radiofrequency ablations of the same nerve branches were performed 1-2 weeks after the nerve blocks. Follow-up outcome was collected at approximately 2 weeks, 1, 3, and 6 months after the C-RFA procedure utilizing VAS and clinically validated questionnaires. RESULTS: A total of 77 knees were treated. The mean total KOOS score improved significantly from baseline at 24.7 ± 14.1 to 59.4 ± 26.5 at 6 months after treatment (p < 0.0001), with significant improvement in mean pain score from 25.5 ± 15.2 to 64.5 ± 25.2 (p < 0.0001) and mean stiffness score from 35.1 ± 21.9 to 65.8 ± 24.9 (p < 0.0001). At 6 months, 65% of all patients demonstrated decreased opiate medication usage, 79% of patients in the four-needle, and 45% of patients in the three-needle arms (p = 0.03). No complications were reported. CONCLUSIONS: The four-needle treatment approach offers an advantage in the overall efficacy in treating stiffness and pain in patients with moderate-to-severe OA refractory to conservative treatments leading to decreased opiate usage without complications.

The accuracy of a novel sonographic scanning and reporting protocol to survey for soft tissue sarcoma local recurrence.

OBJECTIVE: This study aims to determine the accuracy of a novel ultrasonography (US) scanning and reporting protocol to detect recurrences. The secondary aim is to compare US and MRI accuracy and agreement. MATERIALS AND METHODS: In this IRB-approved prospective study, consecutive patients presenting for MRI surveillance after resection were enrolled and underwent same-day US. Blinded to clinical information and the MRI, the US scanner characterized lesions using a proposed novel lexicon. Outcome was defined either by histology or a subsequent MRI scan confirming the presence or absence of recurrence. Fisher's exact test and Kappa test were performed to assess of the significance and agreement between US, MRI, and outcome. RESULTS: A total of 68 US scans were performed on 55 patients. The overall accuracy to diagnose recurrence was the same for US and MRI (92.6%) while US was less sensitive (75.0% vs. 91.7%) but more specific (97.6% vs. 92.9%) than MRI. The two lesions missed by US but not MRI were an entirely intraosseous metastasis and a subcentimeter skin nodule. There was strong agreement between US and MRI with outcome (k = 0.787 and 0.801, respectively). CONCLUSIONS: These pilot data suggest the accuracy of this novel US local recurrence surveillance method is comparable to MRI. A multi-institutional prospective trial would increase power and determine reproducibility.

Nodal metastases of soft tissue sarcomas: risk factors, imaging findings, and implications.

Soft tissue sarcomas (STS) are malignancies derived from connective tissue, and regional lymph node metastasis (RLNM), while not common, is an important aspect of prognosis and treatment. Various risk factors, in particular the histological subtype, affect the likelihood of nodal involvement, which can be characterized by imaging features such as nodal dimension and morphology. Currently, surveillance and management vary by institution, as concrete societal guidelines have not been established. Common nodal status assessment strategies include physical exam, US CT, MRI, sentinel lymph node biopsy (SLNB) and radical lymphadenectomy. This article summarizes data regarding relevant risk factors of RLNM, imaging features, and any available data regarding surveillance recommendations.

Assessing the Role of Neoadjuvant Chemotherapy in Primary High-Risk Truncal/Extremity Soft Tissue Sarcomas: An Analysis of the Multi-institutional U.S. Sarcoma Collaborative.

BACKGROUND: The role of neoadjuvant chemotherapy (NCT) for high-risk soft tissue sarcoma (STS) is questioned. This study aimed to define which patients may experience a survival advantage with NCT. METHODS: All the patients from the U.S. Sarcoma Collaborative database (2000-2016) who underwent curative-intent resection of high-grade, primary truncal/extremity STS size 5 cm or larger were included in this study. The primary end points were recurrence-free survival (RFS) and overall survival (OS). RESULTS: Of the 4153 patients, 770 were included in the study. The median tumor size was 10 cm, and 669 of the patients (87%) had extremity tumors. The most common histology was undifferentiated pleomorphic sarcoma (UPS), found in 42% of the patients. Of the 770 patients, 216 (28%) received NCT. The patients who received NCT had deeper, larger tumors (p < 0.001). Of the patients with tumors 5 cm or larger and 8 cm or larger, NCT was not associated with improved RFS or OS. However for the patients with tumors 10 cm or larger, NCT was associated with improved 5-year RFS (51% vs 40%; p = 0.053) and 5-year OS (58% vs 47%; p = 0.043). By location, the patients with extremity tumors 10 cm or larger but not truncal tumors had improved 5-yearr RFS (54% vs 42%; p = 0.042) and 5-year OS (61% vs 47%; p = 0.015) with NCT. According to histology, no subtype had improved RFS or OS with NCT, although the patients with UPS had a trend toward improved 5-year RFS (56% vs 42%; p = 0.092) and 5-year OS (66% vs 52%; p = 0.103) with NCT. CONCLUSION: For the patients with high-grade STS, NCT was associated with improved RFS and OS when tumors were 10 cm or larger and located in the extremity. However, no histiotype-specific advantage was identified. Future studies assessing the efficacy of NCT may consider focusing on these patients, with added focus on histology-specific strategies.

Combined classical spindle cell/pleomorphic lipoma spectrum imaging and clinical data.

OBJECTIVES: Compile the largest study to date on the imaging and clinical features of the classic spindle cell/pleomorphic lipoma spectrum and suggest this diagnosis be included in the differential for benign and malignant macroscopic fat-containing soft tissue masses regardless of the mass location or patient demographics. MATERIALS AND METHODS: An institutional search was performed to identify all available classic-type spindle cell/pleomorphic lipomas with available demographic and imaging data. Images and reports were analyzed by one MSK-trained radiologist and radiographic, anatomic and clinical data were recorded. Additionally, a literature search was performed to identify studies describing the spindle cell lipoma spectrum imaging features and were combined with institutional data. RESULTS: Forty-two institutional cases were identified, 37 of which had MRIs performed among which 21 had images available (T1- and T2-weighted pulse sequences) for review while the remainder had outside reports detailing the mass imaging features. There was a mean age of 57 with 79% of cases occurring in males. Contrary to prior reports, 57% of masses were subcutaneous, and the neck and back region accounted for 26% of cases. When the institutional cases were combined with available data in the literature, there was a new sample size of 91 masses, 74 of which had MRI and/or CT data. Eighty-seven percent of masses were heterogeneous, 51% were composed of less than 75% fat, 65% were in the back, neck or shoulder region, 27% of masses were deep and 91% demonstrated enhancement. Eighty-two percent of patients were males with a mean age of 58 at excision. CONCLUSION: Imaging features, patient demographics and tumor location alone are not enough to differentiate tumors of the spindle cell lipoma spectrum from other macroscopic fat-containing benign and malignant tumors, and these entities should be included in the same imaging differential diagnosis.

The Oncologic Impact of Postoperative Complications Following Resection of Truncal and Extremity Soft Tissue Sarcomas.

INTRODUCTION: Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; however, little is known regarding their effect in soft tissue sarcoma (STS). The aim of this study was to determine the impact of POCs on survival after resection of truncal and extremity STS. METHODS: All patients who underwent resection for a primary truncal or extremity STS at a single academic institution from 2000 to 2015 were included and analyzed. Primary outcome was disease-specific survival (DSS). RESULTS: Among 546 STS patients, POCs occurred in 159 (29%) patients; 57% were major and 55% were surgical site infections. Patients with POCs were older (61 vs. 53 years), had more comorbidities (50 vs. 38%), longer operative time (127 vs. 93 min), higher-grade tumors (93 vs. 86%), and were more likely to receive preoperative radiation (42 vs. 33%; all p < 0.05). There was no difference in receipt of postoperative therapy between the POCs and no POCs groups (19 vs. 18%, p = 0.74). Median follow-up for survivors was 37 months, and the 5-year DSS for the entire cohort was 78%. Compared with patients without POCs, patients with POCs had a worse DSS (68% vs. 81%, p = 0.001). Predictors for decreased DSS on univariate analysis included POCs (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.37-3.28, p = 0.001), advanced age, neurovascular/bone resection, positive margin, high grade, and preoperative and postoperative therapy (all p < 0.05). POCs (HR 1.76, 95% CI 1.08-2.87, p = 0.02) remained an independent predictor for reduced DSS on multivariate analysis, along with age (HR 1.02, p = 0.046) and tumor grade (HR 7.62, p = 0.046). CONCLUSIONS: POCs following resection of truncal and extremity STS are associated with decreased DSS. Efforts to optimize modifiable risk factors and decrease the rate of POCs warrant further investigation.

Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections.

BACKGROUND: Proximal humerus reconstructions after resection of tumors are challenging. Early success of the reverse shoulder arthroplasty for reconstructions has recently been reported. The reverse allograft-prosthetic composite offers the advantage of improved glenohumeral stability compared with hemiarthroplasty for proximal humeral reconstructions as it uses the deltoid for stability. METHODS: This article describes the technique for treating proximal humeral tumors, including preoperative planning, biopsy principles, resection pearls, soft tissue tensioning, and specifics about reconstruction using the reverse allograft-prosthetic composite. Two cases are presented along with the functional outcomes with use of this technique. Biomechanical considerations during reconstruction are reviewed, including techniques to improve the deltoid compression force. RESULTS: Reported instability rates are less with reverse shoulder arthroplasty reconstruction as opposed to hemiarthroplasty or total shoulder arthroplasty reconstructions of tumor resections. Reported functional outcomes are promising for the reverse allograft-prosthetic composite reconstructions, although complications are reported. CONCLUSION: Reverse allograft-prosthetic composites are a promising option for proximal humeral reconstructions, although nonunion of the allograft-host bone junction continues to be a challenge for this technique.

Multidisciplinary management of soft tissue sarcoma.

Soft tissue sarcoma is a rare malignancy, with approximately 11,000 cases per year encountered in the United States. It is primarily encountered in adults but can affect patients of any age. There are many histologic subtypes and the malignancy can be low or high grade. Appropriate staging work up includes a physical exam, advanced imaging, and a carefully planned biopsy. This information is then used to guide the discussion of definitive treatment of the tumor which typically involves surgical resection with a negative margin in addition to neoadjuvant or adjuvant external beam radiation. Advances in imaging and radiation therapy have made limb salvage surgery the standard of care, with local control rates greater than 90% in most modern series. Currently, the role of chemotherapy is not well defined and this treatment is typically reserved for patients with metastatic or recurrent disease and for certain histologic subtypes. The goal of this paper is to review the current state of the art in multidisciplinary management of soft tissue sarcoma.

Intraoperative Radiographic Detection of Intrapelvic Acetabular Screw Penetration: Lessons Learned From Our Trauma Colleagues.

BACKGROUND: Intraoperative vascular injury during total hip arthroplasty represents a catastrophic complication. Acetabular screw placement represents one possible mode of injury. The purpose of this study was to evaluate the utility of various fluoroscopic views in the detection of intrapelvic screw penetration. METHODS: A radiopaque pelvis Sawbones model was instrumented with a hemispherical acetabular component. Four intrapelvic quadrants were defined. Screws were placed, 3 in each quadrant, and imaged sequentially at 3 depths: 0 mm, 5 mm, and 10 mm penetrated. Eight fluoroscopic images were used: anteroposterior, inlet, outlet, iliac oblique, obturator oblique, "down the wing," obturator outlet, and a "quad" view. Three blinded, independent surgeons evaluated the images for intrapelvic screw penetration. Images were analyzed in isolation and as a "triple-shot series" consisting of the "quad," obturator outlet, and iliac oblique views. Sensitivity and specificity values were then calculated. RESULTS: In isolation, the "quad" view had the highest sensitivity for screw penetration (62%). The triple-shot series was found to be 100% sensitive in all 4 quadrants for detecting 10 mm of screw penetration. The specificity of the series was found to be 100% in all quadrants except for the posterior superior quadrant where it was 67%. Interobserver agreement approached perfection (Kappa ≥0.947) between all surgeons (P < .001) when using the 3-view series. CONCLUSIONS: This study is the first to assess the use of fluoroscopy in the detection of intrapelvic penetration of transacetabular screws. We found that a 3-radiograph series provided a sensitive and specific metric for the detection of intrapelvic screw penetration.

Alternate treatment approach to subchondral insufficiency fracture of the knee utilizing genicular nerve cooled radiofrequency ablation and adjunctive bisphosphonate supplementation: A case report.

Subchondral insufficiency fractures of the knee are commonly misdiagnosed fractures that are both very painful and difficult to treat. A conservative treatment modality to control symptoms during rehabilitation has not previously been described. This case report presents the alternate use of cooled radiofrequency ablation technique of the genicular nerves for pain relief and bisphosphonate infusion to address the underlying poor bone mineralization/density with imaging follow-up before and after instituted treatments. A middle-aged female patient presenting with atraumatic pain in the medial aspect of the left knee diagnosed on an original magnetic resonance imaging as an insufficiency fracture and debilitating pain. Multiple-surgeon opinions of total knee arthroplasty were not a consideration the patient wanted or could consider given her lifestyle. Cooled radiofrequency ablation of the genicular nerve branches was performed with significant-complete pain relief achieved that lasted at least 6 months. Bisphosphonate infusions were instituted to address the underlying osteoporosis detected by a dual energy X-ray absorptiometry (DEXA) scan. Clinical performance after the radiofrequency ablations was followed with clinically validated surveys (The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)/Knee Injury and Osteoarthritis Outcome Score (KOOS)) at 2 weeks, 1, 3, and 6 months. Patient was also asked to follow a restricted-modified weight-bearing plan for 3 months followed by physical therapy. Eight weeks apart of bisphosphonate infusions were delivered after proper administration of vitamin D. There was resolution of the insufficiency fracture at the medial femoral condyle between the magnetic resonance imaging exams within 4.5 months apart treated with restricted weight-bearing regimen. Pain resolution, significant improved function, and range of motion were the end results of our instituted treatment plan. This case reports presents an alternate pathway for the treatment of this condition especially when there is lack of consensus among physicians in how to best address this condition.

A closer look at the natural history and recurrence patterns of high-grade truncal/extremity leiomyosarcomas: A multi-institutional analysis from the US Sarcoma Collaborative.

BACKGROUND/OBJECTIVE: Natural history and outcomes for truncal/extremity (TE) soft tissue sarcoma (STS) is derived primarily from studies investigating all histiotypes as one homogenous cohort. We aimed to define the recurrence rate (RR), recurrence patterns, and response to radiation of TE leiomyosarcomas (LMS). METHODS: Patients from the US Sarcoma Collaborative database with primary, high-grade TE STS were identified. Patients were grouped into LMS or other histology (non-LMS). Primary endpoints were locoregional recurrence-free survival (LR-RFS), distant-RFS (D-RFS), and disease specific survival (DSS). RESULTS: Of 1215 patients, 93 had LMS and 1122 non-LMS. In LMS patients, median age was 63 and median tumor size was 6 cm. In non-LMS patients, median age was 58 and median tumor size was 8 cm. In LMS patients, overall RR was 42% with 15% LR-RR and 29% D-RR. The 3yr LR-RFS, D-RFS, and DSS were 84%, 65%, and 76%, respectively. When considering high-risk (>5 cm and high-grade, n = 49) LMS patients, the overall RR was 45% with 12% LR-RR and 35% D-RR. 61% received radiation. The 3yr LR-RFS (78vs93%, p = 0.39), D-RFS (53vs63%, p = 0.27), and DSS (67vs91%, p = 0.17) were similar in those who did and did not receive radiation. High-risk, non-LMS patients had a similar overall RR of 42% with 15% LR-RR and 30% D-RR. 60% of non-LMS patients received radiation. There was an improved 3yr LR-RFS (82vs75%, p = 0.030) and DSS (77vs65%,p = 0.007) in non-LMS patients who received radiation. CONCLUSIONS: In our cohort, patients with LMS have a low local recurrence rate (12-15%) and modest distant recurrence rate (29-35%). However, LMS patients had no improvement in local control or long-term outcomes with radiation. The value of radiation in these patients merits further investigation.

Recurrent Epithelioid Hemangioma of the Bony Pelvis Responding to Propranolol.

Epithelioid hemangioma is an uncommon benign vascular neoplasm which can arise in bone. Resection is generally curative, but occasionally lesions recur and recurrence after surgery can be morbid and destructive. Recent case reports have described the effective use of oral propranolol to control recurrent epithelioid hemangioma of the orbit. We report the case of a 26 year old man with recurrent aggressive osseous epithelioid hemangioma in the pelvis of which has been controlled for over a year with outpatient propranolol monotherapy.

External iliac pseudoaneurysm secondary to medial wall penetration of an acetabular screw: a rare cause of total hip arthroplasty failure 15 years after implantation.

Vascular injury as a result of total hip arthroplasty (THA) represents an uncommon complication. Although these injuries typically present acutely, delayed presentation has been reported. In this case, a 70-year-old female presented with groin pain and medial thigh numbness 15 years after a left THA. After initially being misdiagnosed, repeat imaging revealed a large external iliac pseudoaneurysm as a result of a transacetabular screw penetrating the medial acetabular wall. The patient underwent staged endovascular exclusion of the pseudoaneurysm, percutaneous drainage, and revision THA. She had resolution of her symptoms. To our knowledge, this is the only reported case of a late vascular injury related to an aseptic THA with well-fixed components. Staged treatment with endovascular exclusion and revision THA is a viable approach.

Volumetric evaluation of lumbar epidural fat distribution in epidural lipomatosis and back pain in patients who are obese: introducing a novel technique (Fat Finder algorithm).

Objective: Spinal epidural lipomatosis (EL) represents an excessive deposition of unencapsulated adipose tissue in the spinal canal that can result in chronic back pain in patients who are obese with and without diabetes. We aim to calculate the total volumetric epidural fat on lumbar spine MRI in a predominately obese population and correlate total epidural fat to lower back pain (LBP) and body mass index (BMI). Research design and methods: We developed a program (Fat Finder) to quantify volumetric distribution of epidural fat throughout the lumbar spine. Eleven patients with LBP were imaged using two MRI protocols: parallel axial slices and conventional clinical protocol. The distribution of epidural fat per level was analyzed and normalized to the spinal canal size. Results: Our sample had an average age of 59.9 years and BMI of 31.57 kg/m2. EL subgroup consisted of seven patients. The L2-L5 total fat volume was 3477.6 mm3 (1431.1-5595.9) in the EL group versus 1783.8 mm3 (815.0-2717.5) in the age-similar non-EL group. A higher percentage of fat volume in the canal was associated with higher LBP scores. The fat percentage was 32.2% among patients with EL versus 15.4% for age-similar non-EL with LBP score of 6.1 and 4.0, respectively. Conclusions: The Fat Finder is a novel volumetric method to quantify epidural lumbar spinal fat. The epidural fat favors the lower spinal segment with direct proportionality between the fat volume and LBP score, independent of BMI.

The Treatment and Outcomes of Extraskeletal Osteosarcoma: Institutional Experience and Review of The Literature.

BACKGROUND: Extraskeletal osteosarcoma is a rare tumor with a poor prognosis. The purpose of this study is to examine the oncologic outcomes of this disease as they relate to surgical treatment and use of adjuvant therapies. METHODS: We retrospectively analyzed all patients treated at our institution for high-grade extraskeletal osteosarcoma of the limb or chest wall. We recorded demographic data, presenting stage, surgical margin, use of adjuvant chemotherapy or radiation, incidence of local recurrence, metastases, and death. Overall and event-free survival were calculated using Kaplan-Meier survival methods. RESULTS: There were 12 patients treated with primary wide resection or re-excision of a previously operated tumor bed. Four patients presented with metastases. Seven patients received chemotherapy and four patients received radiation therapy. There were two local recurrences, six patients developed new metastases, and nine patients died. There was no difference in overall survival in patients who received chemotherapy. There was, however, a trend towards increased length of survival in patients who received chemotherapy compared to those who did not (16.4 months vs. 9.3 months, p=0.16). CONCLUSIONS: Despite no difference in overall survival, patients treated with adjuvant chemotherapy have a trend towards increased length of survival. We suggest that extraskeletal osteosarcoma be treated with standard osteosarcoma chemotherapy regimens in addition to wide resection.

Evaluation of imaging utilization prior to referral of musculoskeletal tumors: a prospective study.

BACKGROUND: Imaging studies are essential when evaluating a patient with a musculoskeletal neoplasm, and they represent a potential waste of resources when used inappropriately. The objective of this study was to prospectively evaluate a consecutive series of patients for inappropriate utilization of imaging prior to referral to a tertiary care facility. Our hypothesis was that advanced imaging is overutilized prior to referral of musculoskeletal neoplasms to a tertiary care center. METHODS: All new patients referred for evaluation of a musculoskeletal neoplasm were prospectively analyzed over a three-month time period. All pre-referral imaging studies were recorded, including radiographs, computed tomographic scans, magnetic resonance imaging scans, bone scans, and 18-fluorodeoxyglucose positron emission tomography scans. Studies were reviewed by two musculoskeletal radiologists and two orthopaedic oncologists and were defined with use of specific preselected criteria as inappropriate if they were not indicated for diagnosis or treatment, if they required repeating because of excessive time since the study was obtained, or if they had poor image quality or technique. RESULTS: We evaluated 298 consecutive patients (550 imaging studies). The inappropriate utilization rate was 1.5% (three of 204) for radiographs, 36.5% (twenty-three of sixty-three) for computed tomographic scans, 26.7% (fifty-six of 210) for magnetic resonance imaging scans, 45.1% (twenty-three of fifty-one) bone scans, and 45.5% (ten of twenty-two) for positron emission tomography scans. The overall inappropriate use of advanced imaging (magnetic resonance imaging, computed tomography, bone scan, positron emission tomography) was 32.4% (112 of 346 images). With regard to inappropriate use of magnetic resonance imaging, there was no difference between orthopaedic surgeons (28.2%) and primary care physicians (26.5%). CONCLUSIONS: Our data indicate a high prevalence (32.4%) of inappropriate advanced imaging of musculoskeletal tumors prior to referral. This represents a substantial cost to the patient and health-care system, a potential delay of referral, an increase in radiation exposure, and identification of other incidental findings.