High sacrectomy for locally recurrent rectal cancer: Can long-term survival be achieved?

BACKGROUND: Locally recurrent rectal cancer involving the upper sacrum is generally considered a contra-indication to curative surgery. The aim of this study was to determine if a survival benefit was seen in patients undergoing high sacrectomy. METHODS: All patients with locally recurrent rectal cancer involving the sacrum above the 3rd sacral body between 1999 and 2007 were retrospectively reviewed. Kaplan-Meier survival analysis was performed. RESULTS: Nine patients were identified with a median age of 63 years. The proximal extent of sacral resection was through S2 (n = 6), S1 (n = 2), and L5-S1 (n = 1). All patients had R0 negative-margin resection. Median operative time was 13.7 hr, and median operative blood transfusion was 3.7 L. Thirty-day mortality was nil. Postoperative complications requiring surgical intervention occurred in three patients. Local re-recurrence in the pelvis occurred in one patient. The overall median survival was 31 months (range, 2-39 months). Three patients still alive are free of disease after 40, 76, and 101 months, respectively. Ultimately, all deaths were due to metastatic disease. CONCLUSIONS: High sacrectomy that achieves clear margins in patients with recurrent rectal cancer is safe and feasible. A majority will die of metastatic disease, but long-term survival may be possible in some patients.

Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review.

AIMS: Reconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes. PATIENTS AND METHODS: A search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction. RESULTS: A total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing's sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34). CONCLUSION: Both the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes. Cite this article: Bone Joint J 2018;100-B(1 Supple A):22-30.

Does the method of treatment affect the outcome in soft-tissue sarcomas of the adductor compartment?

We have investigated the significance of the method of treatment on the oncological and functional outcomes and on the complications in 184 patients with soft-tissue sarcomas of the adductor compartment managed at three international centres. The overall survival at five years was 65% and was related to the grade at diagnosis and the size of the tumour. There was no difference in overall survival between the three centres. There was, however, a significant difference in local control with a rate of 28% in Centre 1 compared with 10% in Centre 2 and 5% in Centre 3. The overall mean functional score using the Toronto Extremity Salvage Score in 70 patients was 77% but was significantly worse in patients with wound complications or high-grade tumours. The scores were not affected by the timing of radiotherapy or the use of muscle flaps. This large series of soft-tissue sarcomas of the adductor compartment has shown that factors influencing survival do not vary across the international boundaries studied, but that methods of treatment affect complications, local recurrence and function.

Randomized study of systemic chemotherapy following complete excision of nonosseous sarcomas.

Between June 1975 and April 1981, 61 of the 177 eligible patients whose nonosseous sarcomas of extremity or trunk origin had been completely excised primarily or after local recurrences agreed to participate in a randomized study of adjuvant chemotherapy. Dermatofibrosarcoma, lymphomas, myeloma, Kaposi's sarcoma, and embryonal rhabdomyosarcoma were excluded as were patients with significant second primary cancers and those who received either preoperative or postoperative radiation therapy. After stratification by anatomic status of disease, site of origin, and histologic grade, a random one half of the 61 participants began alternating courses of vincristine/cyclophosphamide/dactinomycin, and vincristine/doxorubicin/dacarbazine at six-week intervals for one year. The control group was evaluated at six-week intervals without adjuvant chemotherapy, but these patients were offered this chemotherapy later if they had progressive disease excised. Although 30% of the 61 patients experienced local recurrence of disease within the first five years after randomization, and only 54% were continuously disease free for five or more years, 82% were surviving at five years (Kaplan-Meier calculations) with a median follow-up of 64.3 months. Partial suppression of distant metastasis by adjuvant chemotherapy was apparent in the overall study, in the extremity tumor category, and in the subgroup of patients who had received limb-sparing surgery; however, no survival advantage for chemotherapy-treated patients was demonstrated. The 30 adjuvant chemotherapy-treated patients received a total of three thoracotomies as compared with 17 salvage thoracotomies for the 31 control patients; however, salvage surgery for local recurrences has been similar in the two groups. Recent improvement in the survival of patients with soft-tissue sarcomas is not necessarily a result of adjuvant chemotherapy or radiation therapy.

Solitary plasmacytoma of bone: Mayo Clinic experience.

A review of 46 cases of solitary plasmacytoma of bone was undertaken in an attempt to better define the clinical features and prognostic indicators associated with this disease. Criteria for inclusion in the study included the following: (a) solitary lytic bone lesion on skeletal survey; (b) histologic confirmation of the lesion; and (c) bone marrow plasmacytosis of less than 10 percent. Patients with extramedullary plasmacytomas and osteosclerotic lesions were excluded. All patients were evaluated with serum and urine protein studies at the time of diagnosis. The median follow-up was 90 months with a minimum of 30 months. Fifty-four percent of the lesions involved the vertebral column. The thoracic spine was the single most commonly involved site (13/46 patients). The initial lesion was treated with radiotherapy in all but three patients in whom complete surgical resection was achieved. Total doses ranged from less than 20 Gy to 70 Gy with a median of 39.75 Gy. Overall, 54% developed multiple myeloma, 2% failed with new bone lesions without multiple myeloma, and 11% developed local recurrences. No patient receiving 45 Gy or more to the solitary lesion had a local failure. While the median time to progression was 18 months, 23% of the failures occurred after 60 months. The five local failures occurred at 7, 12, 18, 40, and 114 months. The overall survival was 74% at 5 years and 45% at 10 years. The 5- and 10-year disease-free survivals, however, were 43 and 25%, respectively. Evidence of abnormal serum and/or urine protein was found in 25 of 46 patients. Neither survival nor disease-free survival was significantly influenced by the presence of abnormal proteins even if they persisted after irradiation.

Clear cell sarcoma of soft tissues. Mayo Clinic experience with 35 cases.

Thirty-five cases of clear cell sarcoma of soft tissues were studied to determine the clinical or morphologic features that are important in predicting prognosis. Tumors occurred most commonly in the extremities, and the majority of the patients were young women. Surgery was the elected treatment in every case. Five patients experienced local recurrences, and metastases developed in 22. Fifty-four percent of the patients died of tumor, 11% are alive with disease, and the remaining 34% are alive and well; the average survival for each group was 67 months, 113 months, and 103.5 months, respectively. This sarcoma is characterized by small clusters of polygonal to spindle cells featuring clear to slightly basophilic cytoplasm and vesicular nuclei with prominent nucleoli. The clusters are separated by delicate fibrous septa. In a deletion, clear cell sarcoma has low mitotic activity, little or no necrosis, and mild nuclear pleomorphism. Tumor size and the presence of necrosis are statistically significant predictors of prognosis. All 12 patients with tumors measuring > 5 cm died of disease or are alive with disease. Eleven of the 20 patients with tumors measuring < 5 cm are alive with no evidence of disease. Tumor necrosis was present in 10 cases; eight of these patients died of disease and one is alive with disseminated metastases.

Malignant giant cell tumor of the tendon sheaths and joints (malignant pigmented villonodular synovitis).

Malignant pigmented villonodular synovitis (PVNS) is a rare lesion whose existence may be debatable. We studied eight cases that we consider to be examples of malignant PVNS. The three male and five female patients were aged 12 to 79 years. The knee was involved in three cases; the ankle in two; and the cheek, dorsum of the foot, and thigh in one each. Four patients had swelling for 6 months to 17 years before presentation. Three cases of malignant PVNS were secondary, arising in patients in whom PVNS had been documented previously, and five cases were primary, with histologic features similar to those of the secondary ones. Important histologic features of malignancy were (a) a nodular, solid infiltrative pattern of the lesion; (b) large, plump, round or oval cells with deep eosino philic cytoplasm and indistinct borders; (c) large nuclei with prominent nucleoli; and (d) necrotic areas. Atypical mitoses were occasionally seen. Four patients died with pulmonary metastasis (two also had metastasis to inguinal lymph nodes). Four patients are alive from 3 1/2 to 5 years after the last surgical treatment. The malignant nature of this lesion, the histologic architecture similar to that of PVNS, and the fibrohistiocytic appearance of the cells suggest that malignant PVNS is an entity.

Hemangiopericytoma of bone.

Hemangiopericytoma primary in bone is a rare tumor. A review of 15 cases (five from the Mayo Clinic files and 10 from the consultation files) revealed that all tumors were unifocal and that the most common location was the pelvis (three lesions in the sacrum and two in the ischium). The series involved seven male and eight female patients whose ages ranged from 14 to 74 years. Histologically, all of the tumors were composed of cells with round to oval nuclei arranged around vascular spaces. On the basis of cellularity, nuclear atypia, and mitotic activity, four tumors were benign, two intermediate, and nine malignant. Surgery was the primary treatment for the 15 patients. Of the 14 patients with adequate follow-up, eight died of disease, three were alive with recurrent disease, and three were alive and disease-free.

Clear cell chondrosarcoma of bone. Observations in 47 cases.

Clear cell chondrosarcoma of bone, a low-grade malignant tumor, frequently presents diagnostic difficulties. Its clinical, roentgenographic, and pathologic characteristics separate it from conventional chondrosarcoma and, more importantly, from several benign bone tumors with which it is often confused. This report analyzes 47 cases seen at the Mayo Clinic and in consultation. The lesion is more common in males than females (2.6:1) and has a predilection for the end of long bones, particularly the proximal femur. The age range is wide; most patients are in the third and fourth decades of life. Roentgenographically, the lesion most often is purely lytic and slightly expansile, with a sharp margin between the tumor and the adjacent normal bone. Pathologically, clear cells arranged in an indistinct lobular pattern characterize the tumor. Frequently, areas mimicking other primary bone tumors, benign and malignant, are present, often to such an extent as to obscure the true identity of the process. The overall mortality in the present series was 15%. En bloc resection, including a margin of normal bone and soft tissue, appears to be the treatment of choice.

Dedifferentiated clear cell chondrosarcoma.

Dedifferentiation, a change in the histologic character and clinical behavior of a tumor to a more immature and aggressive one, occurs in approximately 11% of all chondrosarcomas. The original lesion is usually a low-grade chondrosarcoma. Clear cell chondrosarcoma is a rare cartilaginous tumor of low-grade malignancy with a preference for the ends of long bones. It is usually curable by resection. Recurrence commonly follows inadequate surgery, and metastases to lung, brain, and bones can develop. However, dedifferentiation has not yet been described in association with clear cell chondrosarcoma. Three patients are described who were initially diagnosed as having clear cell chondrosarcoma of the femur. Two were treated with en bloc resection for a clear cell chondrosarcoma. One of these had an undifferentiated sarcoma in a local recurrence after 6 years. In the second, metastasis of the clear cell chondrosarcoma developed 5(1/2) years after surgery; autopsy revealed undifferentiated sarcoma in the lung, heart, and lumbar spine. The third patient had dedifferentiated clear cell chondrosarcoma at the time of resection following the biopsy diagnosis of clear cell chondrosarcoma. All three died with metastatic disease. These three patients represent three different manifestations of dedifferentiation-at initial diagnosis, at recurrence, and at metastasis. To our knowledge, this is the first description of dedifferentiation occurring in clear cell chondrosarcoma.

Surgical management of malignant melanoma of the trunk and extremities.

The surgical management of newly diagnosed melanoma should be tailored to the characteristics of the individual lesion. The actual thickness of the lesion is the main consideration in planning surgical treatment. Prophylactic lymphadenectomy is no longer routinely recommended. For early detection of clinically suspicious nodes, however, close follow-up of the patient is necessary so that therapeutic lymphadenectomy can be accomplished. Surgical intervention plays a limited role in the management of disseminated melanoma.

Symposium on sports medicine: Part I. Current concepts in the treatment of ligamentous instability of the knee.

Ligamentous injury to the knee remains a difficult diagnostic and therapeutic problem. Modern knowledge of the pathoanatomy of various instability problems has made diagnosis of injuries to key structures possible. Aggressive treatment, nonoperative and operative, has vastly improved the prognosis for return to stable function of the knee.

Participation in sports after hip and knee arthroplasty: review of literature and survey of surgeon preferences.

OBJECTIVE: To summarize previously published findings and to present the opinions of a group of reconstructive orthopedic surgeons from a single institution on participation in sports after hip or knee arthroplasty. DESIGN: We reviewed the literature pertaining to participation in sports after hip or knee arthroplasty and surveyed a group of orthopedic surgeons about their recommendations for resumption of various sports activities by patients who had undergone total hip or knee arthroplasty. MATERIAL AND METHODS: A computerized literature search was performed, and salient issues about participation in sports after joint replacement procedures were synthesized. At the Mayo Clinic, 28 orthopedic surgeons (13 consultants and 15 fellows or residents) completed a single-page questionnaire that requested a recommendation ("yes," "no," or "depends") about patients resuming participation in 28 common sports after recovery from total hip or knee arthroplasty. Staff surgeon responses were compared with responses from fellows and residents by using the Mann-Whitney U test. Sports in which 75% of surgeons would not allow participation were identified as "not recommended," whereas sports in which 75% of surgeons would allow participation were labeled as "recommended." RESULTS: Fellows and residents were less likely than staff surgeons to allow return to cross-country skiing after total knee arthroplasty. Otherwise, responses from consultant surgeons and from fellows and residents did not differ significantly. Recommended sports included sailing, swimming laps, scuba diving, cycling, golfing, and bowling after hip and knee replacement procedures and also cross-country skiing after knee arthroplasty. Sports not recommended after hip or knee arthroplasty were running, waterskiing, football, baseball, basketball, hockey, handball, karate, soccer, and racquetball. CONCLUSION: After hip or knee arthroplasty, participation in no-impact or low-impact sports can be encouraged, but participation in high-impact sports should be prohibited.

Malignant melanoma: Mayo Clinic experience.

To present the Mayo Clinic experience with treatment of melanoma of the trunk and extremities, we reviewed previous Mayo Clinic studies on the management of malignant melanoma and summarized the survival data and treatment-related outcome. A prospective trial involving elective lymph node dissection in 171 patients with malignant melanoma showed no advantage in overall survival and disease-free survival in the group whose nodes were removed. In an assessment of the treatment variables, a Cox stepwise multiple regression analysis showed a strong correlation of lesion thickness and level of invasion with survival. Another study of 535 patients with melanomas that involved the trunk and extremities, who were treated at the Mayo Clinic between 1971 and 1980, showed an overall survival of 83%. Patients with thin lesions (less than 0.76 mm thick) had a 98% 5-year survival, whereas patients with lesions 4 mm thick or thicker had only a 45% 5-year survival. Because the Mayo Clinic prospective randomized study showed no benefit for patients with melanoma who undergo immediate or delayed lymphadenectomy in the trunk and extremities, we do not perform elective lymph node dissection; however, close follow-up of patients is instituted, and lymph node dissection is performed when nodal involvement is first suspected.

Musculoskeletal injuries in competitive swimmers.

Competitive swimming is a rigorous sport being engaged in by an increasing number of young athletes. In swimmers, shoulder pain is the most common musculoskeletal complaint and is usually due to supraspinatus or biceps tendinitis. Glenohumeral instability (often multidirectional) can also be a cause of shoulder pain in swimmers and may be more common than has been reported. Surgical treatment is seldom indicated. Physical therapy modalities and training modifications are the mainstay of treatment. Medial knee pain in breaststroke swimmers and extensor tendon inflammation over the dorsum of the foot are less common injuries and respond to conservative therapy. These overuse syndromes are best prevented by proper training schedules, strength training, flexibility exercises, and avoidance of errors in stroke technique. The rehabilitation program for a competitive swimmer should be chosen with an understanding of the goals of the swimmer and the cooperation of the coach.

Total joint arthroplasty. Applications in the management of bone tumors.

Limb-saving resection has become a valid alternative to amputation in carefully selected patients with bone tumors. As interest grows in this technique, efforts continue to improve our methods of bone and joint reconstruction to restore a functional extremity. Previously there was little interest in this form of treatment despite a limb-saving potential, because of inadequate methods of skeletal reconstruction. The purpose of this paper is to review these previous methods and to outline our present approach to the problem.

Lymphadenectomy in the management of stage I malignant melanoma: a prospective randomized study.

A prospective randomized study was initiated at our institution in 1972 to determine the efficacy of routine elective lymphadenectomy in localized (stage I) melanoma. Included in the study were 171 patients, 62 of whom had no lymphadenectomy, 55 of whom had delayed lymphadenectomy, and 54 of whom had immediate lymphadenectomy. No significant difference was found among the three treatment groups with respect to survival or metastasis-free survival. Multifactorial analysis indicated that the level of invasion and the thickness of the lesion were the most important prognostic factors, followed by age (60 years or older), site (legs), and tumor type (nodular). A prognostic index based on these variables was highly predictive of metastasis or death. Even when this score was considered, no significant variation was noted among the three treatment groups. More subsequent complications of melanoma, however, occurred in the group with no lymphadenectomy--36 in this group but only 19 in each of the other treatment groups. This finding was not statistically significant but does indicate that a few additional problems may be associated with leaving regional nodes intact. Further studies are needed, and indeed are being conducted, to determine whether elective lymphadenectomy improves survival sufficiently to offset the costs and the complications associated with this approach.

Psychologic, situational, and physiologic variables and on-ice performance of youth hockey goalkeepers.

OBJECTIVE: To determine the relationship between psychologic, situational, and physiologic variables and on-ice performance of youth hockey goalkeepers. DESIGN: This study was structured to identify relationships and predictors of goalie performance. MATERIAL AND METHODS: Because athletes playing solo positions in team sports have not been analyzed in depth in terms of precompetition anxiety and because goalkeeper performance is critical to game outcome, we undertook a study of 43 goalies at a hockey camp. These goalies completed psychometric inventories to assess trait and state anxiety, confidence, life stress, and social support. Holter monitors measured heart rate while the goalies rotated through on-ice stations. Goalies were videotaped at the puck-shooting machine station, and performance (percent saves) was calculated. RESULTS: Trait (somatic) anxiety and positive mood state (ability to share) had different but significant relationships with on-ice performance. Heart rates ranged from 88 to 208 beats/min at the on-ice stations. Mean heart rate for older goalies (14 to 18 years of age) was 164 beats/min at the puck-shooting machine and 176 beats/min at other stations such as the slap-shot station. CONCLUSION: Older goalies performed well at a high level of arousal. Better performing goalies were more experienced, had faster heart rates "in the net," and had lower scores on all measures of anxiety.

Rehabilitative techniques for athletes after reconstruction of the anterior cruciate ligament.

A wide spectrum of protocols is available for rehabilitation after anterior cruciate ligament reconstruction, and little agreement exists on the specifics of strengthening exercises or the sequence of activities. In this article, we discuss the current rehabilitative techniques used at the Mayo Clinic for athletes who have undergone anterior cruciate ligament reconstruction. These techniques are based on established principles of rehabilitation, clinical experience, and new information about the related biomechanics of the knee. An illustrative case reflects the benefits of this rehabilitation program, which lasts up to 1 year and is divided into five stages. The early stages focus on protected mobilization and a strengthening program that emphasizes closed rather than open kinetic chain exercises. Later, neuromuscular-proprioceptive training and sport-specific agility training redevelop the reaction time and the "coordination engrams" necessary for athletic competition. High-quality surgical care and a closely supervised rehabilitation program, based on kinesiologic and biomechanical factors as they pertain to the anterior cruciate ligament, are necessary for a successful outcome.

Anterior knee pain.

Anterior knee pain is a common symptom, especially in adolescence, and often no specific cause is sought or identified. Physicians who treat patients with knee pain should understand the normal anatomic features and the biomechanics of the patellofemoral joint. We review this information and discuss important aspects of the physical examination and roentgenographic evaluation in patients with anterior knee pain. Once the clinical cause of anterior knee pain has been established, directed nonoperative treatment including physical therapy should be initiated. Surgical intervention is generally reserved for patients in whom nonoperative management is unsuccessful and identifiable abnormalities exist.