RESUMEN
BACKGROUND: Two-stage revision for periprosthetic joint infection (PJI) in patients who have undergone segmental replacement of the distal femur or proximal tibia after tumor resection can be associated with considerable morbidity, pain, and risk of complications because the procedure often results in removal of long, well-fixed stems from the diaphysis. A less-aggressive surgical approach, such as debridement, antibiotics, and implant retention (DAIR), may be attractive to patients and surgeons because of less morbidity, but the likelihood of eradicating infection in comparison to the traditional two-stage revision is not well established for oncology patients. Furthermore, the relative risk of subsequent amputation for DAIR versus two-stage revision has not been defined for this population. QUESTIONS/PURPOSES: (1) How does DAIR compare with two-stage revision in terms of infection control for patients with distal femoral or proximal tibial segmental modular endoprostheses? (2) Is DAIR as an initial procedure associated with an increased risk of amputation compared with two-stage revision for infection? METHODS: From the longitudinally maintained orthopaedic oncology surgical database at our institution, we identified 69 patients who had been treated for a clinical diagnosis of PJI at the knee between 1993 and 2015. We excluded 32% (22) of patients who did not meet at least one of the major criteria of the Musculoskeletal Infection Society (MSIS) for PJI, 3% (2) of patients who underwent immediate amputation, 3% (2) of patients who had a follow-up time of < 24 months, and 7% (5) of patients who did not have a primary tumor of the distal femur or proximal tibia. The study consisted of 38 patients, of whom eight underwent two-stage revision, 26 underwent DAIR, and four underwent extended DAIR (removal of all segmental components but with retention of stems and components fixed in bone) for their initial surgical procedure. To be considered free of infection, patients had to meet MSIS standards, including no positive cultures, drainage, or surgical debridement for a minimum of 2 years from the last operation. Factors associated with time-dependent risk of infection relapse, clearance, amputation, and patient survival were analyzed using Kaplan-Meier survivorship curves and the log-rank test to compare factors. Association of demographic and treatment factors was assessed using chi-square and Fisher exact tests. RESULTS: Continuous infection-free survival at 5 years was 16% (95% CI 2% to 29%) for patients undergoing DAIR compared with 75% (95% CI 45% to 100%) for patients undergoing two-stage revision (p = 0.006). The median (range) number of total surgical procedures was 3 per patient (1 to 10) for DAIR and 2 (2 to 5) for two-stage revision. Twenty-nine percent (11 of 38) of patients eventually underwent amputation. Survival without amputation was 69% (95% CI 51% to 86%) for DAIR compared with 88% (95% CI 65% to 100%) for two-stage revision at 5 years (p = 0.34). The cumulative proportion of patients achieving infection-free status (> 2 years continuously after last treatment) and limb preservation was 58% (95% CI 36% to 80%) for patients initially treated with DAIR versus 87% (95% CI 65% to 100%) for patients first treated with two-stage revision (p = 0.001). CONCLUSION: Infection control was better with two-stage revision than DAIR. The chance of eventual clearance of infection with limb preservation was better when two-stage revision was chosen as the initial treatment. However, the loss to follow-up in the two-stage revision group would likely make the true proportion of infection control lower than our estimate. Our experience would suggest that the process of infection eradication is a complex and difficult one. Most patients undergo multiple operations. Nearly one-third of patients eventually underwent amputation, and this was a serious risk for both groups. While we cannot strongly recommend one approach over the other based on our data, we would still consider the use of DAIR in patients who present with acute short duration of symptoms (< 3 weeks), no radiographic signs of erosion around fixed implants, and organisms other than Staphylococcus aureus. We would advocate the extended DAIR procedure with removal of all segmental or modular components, and we would caution patients that there is a high likelihood of needing further surgery. A prospective trial with strict adherence to indications may be needed to evaluate the relative merits of an extended DAIR procedure versus a two-stage revision. LEVEL OF EVIDENCE: Level III, therapeutic study.
RESUMEN
BACKGROUND: Regional lymph node metastasis in extremity and trunk soft tissue sarcoma (ETSTS) is rare with no standardized management. We sought to determine management patterns for regional lymph node metastasis in ETSTS. METHODS: A survey regarding the management of ETSTS lymph node metastasis was distributed to the membership of the Musculoskeletal Tumor Society (MSTS) and the Society of Surgical Oncology (SSO) in January 2022. The survey queried the type of training (surgical oncology, orthopedic oncology), details of their practice setting, and management decisions of hypothetical ETSTS scenarios that involved potential or confirmed lymph node metastasis. RESULTS: The survey was distributed to 349 MSTS members (open rate of 63%, completion rate 21%) and 3026 SSO members (open rate of 55%, completion rate 4.7%) and was completed by 214 respondents, of whom 73 (34.1%) and 141 (65.9%) were orthopedic oncology and surgical oncology fellowship-trained, respectively. The majority of respondents practiced in an academic setting (n = 171, 79.9%) and treat >10 extremity sarcoma cases annually (n = 138, 62.2%). In scenarios with confirmed nodal disease for clear cell and epithelioid sarcoma, surgical oncologists were inclined to perform lymphadenectomy, while orthopedic oncologists were inclined to offer targeted lymph node excision with adjuvant radiation (p < 0.001). There was heterogeneity of responses regarding the management of nodal disease regardless of training background. CONCLUSION: Self-reported management of nodal disease in ETSTS was variable among respondent groups with differences and similarities based on training background. These data highlight the variability of practice for nodal disease management and the need for consensus-based guidelines.
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Sarcoma , Neoplasias de los Tejidos Blandos , Oncología Quirúrgica , Humanos , Metástasis Linfática , Escisión del Ganglio Linfático , Sarcoma/cirugía , Sarcoma/patología , Extremidades/cirugía , Extremidades/patología , Neoplasias de los Tejidos Blandos/cirugía , Neoplasias de los Tejidos Blandos/patología , Encuestas y CuestionariosRESUMEN
BACKGROUND: Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival. QUESTIONS/PURPOSES: (1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score? METHODS: We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system. RESULTS: Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22% (95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 ± 8.1 (42% ± 27%) preoperatively to 21.5 ± 5.0 (72% ± 17%) at 3 months postoperatively (p < 0.001) and 21.6 ± 8.5 (72% ± 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years). CONCLUSION: Resection of diaphyseal metastases with intercalary reconstruction can provide stability and short-term improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision. LEVEL OF EVIDENCE: Level IV, therapeutic study .
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Neoplasias Óseas , Diáfisis , Masculino , Humanos , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Diáfisis/cirugía , Diáfisis/patología , Estudios Retrospectivos , Factores de Riesgo , Reoperación , Resultado del Tratamiento , Fémur/diagnóstico por imagen , Fémur/cirugía , Fémur/patología , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/cirugía , Húmero/diagnóstico por imagen , Húmero/cirugía , Húmero/patologíaRESUMEN
BACKGROUND: The standard preoperative radiotherapy regimen of 50 Gy delivered in 25 fractions for 5 weeks for soft tissue sarcomas results in excellent local control, with major wound complications occurring in approximately 35% of patients. We aimed to investigate the safety of a moderately hypofractionated, shorter regimen of radiotherapy, which could be more convenient for patients. METHODS: This single-centre, open-label, single-arm, phase 2 trial (HYPORT-STS) was done at a single tertiary cancer care centre (MD Anderson Cancer Center, Houston, TX, USA). We administered preoperative radiotherapy to a dose of 42·75 Gy in 15 fractions of 2·85 Gy/day for 3 weeks (five fractions per week) to adults (aged ≥18 years) with non-metastatic soft tissue sarcomas of the extremities or superficial trunk and an Eastern Cooperative Oncology Group performance status of 0-3. The primary endpoint was a major wound complication occurring within 120 days of surgery. Major wound complications were defined as those requiring a secondary operation, or operations, under general or regional anaesthesia for wound treatment; readmission to the hospital for wound care; invasive procedures for wound care; deep wound packing to an area of wound measuring at least 2 cm in length; prolonged dressing changes; repeat surgery for revision of a split thickness skin graft; or wet dressings for longer than 4 weeks. We analysed our primary outcome and safety in all patients who enrolled. We monitored safety using a Bayesian, one-arm, time-to-event stopping rule simulator comparing the rate of major wound complications at 120 days post-surgery among study participants with the historical rate of 35%. This trial is registered with ClinicalTrials.gov, NCT03819985, recruitment is complete, and follow-up continues. FINDINGS: Between Dec 18, 2018, and Jan 6, 2021, we assessed 157 patients for eligibility, of whom 120 were enrolled and received hypofractionated preoperative radiotherapy. At no time did the stopping rule computation indicate that the trial should be stopped early for lack of safety. Median postoperative follow-up was 24 months (IQR 17-30). Of 120 patients, 37 (31%, 95% CI 24-40) developed a major wound complication at a median time of 37 days (IQR 25-59) after surgery. No patient had acute radiation toxicity (during radiotherapy or within 4 weeks of the radiotherapy end date) of grade 3 or worse (Common Terminology Criteria for Adverse Events [CTCAE] version 4.0) or an on-treatment serious adverse event. Four (3%) of 115 patients had late radiation toxicity (≥6 months post-surgery) of at least grade 3 (CTCAE or Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Late Radiation Morbidity Scoring Scheme): femur fractures (n=2), lymphoedema (n=1), and skin ulceration (n=1). There were no treatment-related deaths. INTERPRETATION: Moderately hypofractionated preoperative radiotherapy delivered to patients with soft tissue sarcomas was safe and could therefore be a more convenient alternative to conventionally fractionated radiotherapy. Patients can be counselled about these results and potentially offered this regimen, particularly if it facilitates care at a sarcoma specialty centre. Results on long-term oncological, late toxicity, and functional outcomes are awaited. FUNDING: The National Cancer Institute.
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Traumatismos por Radiación , Sarcoma , Neoplasias de los Tejidos Blandos , Adulto , Humanos , Adolescente , Teorema de Bayes , Resultado del Tratamiento , Neoplasias de los Tejidos Blandos/radioterapia , Neoplasias de los Tejidos Blandos/cirugía , Sarcoma/radioterapia , Sarcoma/cirugía , Hipofraccionamiento de la Dosis de RadiaciónRESUMEN
BACKGROUND: The objective of this study was to evaluate treatment outcomes for patients with desmoid tumors (DTs) receiving local therapy with surgery alone, radiation therapy (RT) alone, or combined modality therapy (RT and surgery). METHODS: This was a cross-sectional cohort study of 412 patients with nonmesenteric DTs who received local therapy at the authors' institution between 1965 and 2018. RESULTS: The median follow-up time was 95 months (range, 1-509 months). Local recurrence occurred in 127 patients (31%) at a median time of 21 months (interquartile range, 12-38 months). The 5-year local control (LC) rate was 67%. Patient or tumor factors that were significantly associated with poorer 5-year LC in a multivariable analysis included an age ≤ 30 years (57% vs 75% for an age > 30 years; hazard ratio [HR], 1.73; P = .004), an extremity location (57% vs 71% for a nonextremity location; HR, 1.77; P = .004), and large tumors (59% for >10 cm [HR, 2.17; P = .004] and 65% for 5.1-10 cm [HR, 1.71; P = .02] vs 76% for ≤5 cm). Subset analyses of these high-risk patients revealed no local therapy strategy to be superior for young patients ≤ 30 years old (HR for surgery, 1.42; P = .33; HR for RT, 1.36; P = .38) or for large tumors > 10 cm (HR for surgery, 1.55; P = .46; HR for RT, 0.91; P = .91). However, for patients with extremity tumors, surgery alone was significantly associated with inferior LC (HR for surgery, 5.15; P < .001; HR for RT, 1.51; P = .38). CONCLUSIONS: Local therapy provides durable tumor control in the majority of patients with DTs. However, young patients, patients with an extremity location, and patients with large tumors are at increased risk of recurrence. When active treatment is indicated, systemic therapy should perhaps be considered as a first-line option in these high-risk subsets. Prospective multi-institutional studies evaluating this strategy are warranted.
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Extremidades/patología , Fibromatosis Agresiva/radioterapia , Fibromatosis Agresiva/cirugía , Neoplasias de Cabeza y Cuello/radioterapia , Neoplasias de Cabeza y Cuello/cirugía , Torso/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Terapia Combinada/métodos , Estudios Transversales , Femenino , Fibromatosis Agresiva/epidemiología , Fibromatosis Agresiva/mortalidad , Estudios de Seguimiento , Neoplasias de Cabeza y Cuello/epidemiología , Neoplasias de Cabeza y Cuello/mortalidad , Humanos , Lactante , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Texas/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: Local recurrence in Ewing sarcoma (ES) is associated with poor prognosis. The purpose of the study is to determine what factors affect overall survival after local recurrence and whether wide excision constitutes appropriate treatment. METHODS: From 1992 to 2017, 26 patients were treated for local recurrence of ES. Sixteen patients presented with local recurrence only while 10 had metastasis. The median follow-up was 23 months (range, 3-255 months). Overall survival was assessed with Kaplan-Meier analysis. RESULTS: At the last follow-up, seven of 26 (27%) patients were alive. Overall survival after local recurrence was 28% at 5 years. Later onset of local recurrence (P = .041), surgical treatment (P < .001), and complete eradication of all recurrent disease (P < .001) predicted better survival. Metastasis was associated with worse survival (P = .014). All three patients who survived more than 10 years were treated with wide local excision. A second local recurrence developed in seven patients (28%) but did not predict worse overall survival. CONCLUSIONS: Overall survival after local recurrence is better for patients with nonmetastatic disease treated surgically. Wide excision can be compatible with long survival. We do not advocate amputation on a routine basis for local recurrence. Complete eradication of all diseases is associated with better survival.
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Neoplasias Óseas/mortalidad , Recurrencia Local de Neoplasia/mortalidad , Sarcoma de Ewing/mortalidad , Procedimientos Quirúrgicos Operativos/mortalidad , Adolescente , Adulto , Neoplasias Óseas/patología , Neoplasias Óseas/cirugía , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Pronóstico , Sarcoma de Ewing/patología , Sarcoma de Ewing/cirugía , Tasa de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: Although cephalomedullary nail fixation is often used for metastatic peritrochanteric lesions of the femur, there is concern regarding the durability of the implant in comparison to endoprosthetic reconstruction. Previous studies have reported the proportion of patients who undergo reoperation for loss of stability, but the adequacy of the construct has not been critically evaluated in a competing risk analysis that incorporates death of the patient in the calculation. QUESTIONS/PURPOSES: (1) What is the cumulative incidence of reoperation of cephalomedullary nails with death as a competing risk for metastatic lesions of the proximal femur? (2) What is the survival of patients with metastases to the proximal femur after cephalomedullary nailing? (3) What clinical factors are associated with implant stability in these patients? METHODS: Between 1990 and 2009, 11 surgeons at one center treated 217 patients with cephalomedullary nails for metastatic proximal femoral lesions. This represented 40% (217 of 544) of the patients undergoing surgery for metastases in this location during the study period. In general, we used cephalomedullary nails when there was normal bone in the femoral head, no fracture in the neck, and a moderate-sized lesion; we favored bipolar hemiarthroplasty for femoral neck fractures and disease affecting the femoral head; finally, we used proximal femoral endoprosthetic replacement for large lesions with severe bone destruction. A retrospective study was conducted of 199 patients with cephalomedullary nails for peritrochanteric metastases from 1990 to 2009. Pathologic fracture, defined as a breach in cortex with a clear fracture line either with or without displacement, was present in 61 patients. The most common primary cancers were breast (42 of 199 patients [21%]), lung (37 of 199 patients [18%]), and renal cell (34 of 199 patients [17%]). A competing risk analysis was performed to describe the cumulative incidence of implant revision. Patient overall survival was assessed by Kaplan-Meier survivorship. A univariate analysis was performed to determine whether there was an association between revision surgery and various patient factors, including tumor histology, pathologic fracture, cementation, and radiation. RESULTS: Loss of implant stability necessitating revision surgery occurred in 19 of 199 patients (10%). In a competing risk analysis with death of the patient as the competing event, the cumulative incidence of revision surgery was 5% (95% confidence interval [CI], 3%-9%) at 12 months and 9% (95% CI, 5%-13%) at 5 years. Using Kaplan-Meier analysis, the overall patient survival was 31% (95% CI, 25%-37%) at 12 months and 5% (95% CI, 3%-9%) at 60 months. Patients with lung cancer had the shortest overall survival of 11% (95% CI, 1%-21%) at 12 months, and patients with multiple myeloma had the longest overall survival of 71% (95% CI, 49%-94%) at 12 months (p < 0.001). Duration of patient survival beyond the median 7 months was the only factor associated with a greater likelihood of revision surgery. Factors not associated with revision included tumor histology, pathologic fracture, closed versus open nailing, cementation, gender, age, and postoperative radiation. CONCLUSIONS: The competing risk analysis demonstrates a relatively low cumulative incidence of reoperation and suggests that cephalomedullary nailing is reasonable for patients with moderate-sized proximal femoral metastasis not affecting the femoral head. For the large majority of patients, the construct achieves the goal of stabilizing the femur for the duration of the patient's life. Longer patient survival was associated with greater risk of revision surgery, but no particular tumor histology was found to have a greater cumulative incidence of reoperation. Future work with a larger number of patients and stricter surgical indications may be needed to corroborate these findings. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Clavos Ortopédicos/efectos adversos , Fracturas del Fémur/cirugía , Fijación Intramedular de Fracturas/instrumentación , Fracturas Espontáneas/cirugía , Fracturas de Cadera/cirugía , Femenino , Fracturas del Fémur/etiología , Neoplasias Femorales/patología , Neoplasias Femorales/cirugía , Fijación Intramedular de Fracturas/efectos adversos , Fracturas Espontáneas/etiología , Fracturas de Cadera/etiología , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Patients with primary bone and soft tissue sarcoma are at risk for skeletal metastases. Although uncommon, these metastases can result in impending or pathologic fractures. Intramedullary nailing traditionally has been an accepted form of palliative treatment for patients with metastatic carcinoma, but we could find no studies that report specifically on intramedullary nailing of metastatic sarcoma lesions. QUESTIONS/PURPOSES: We asked: (1) What is the survival of patients with an impending or pathologic fracture from a sarcoma metastasis? (2) What proportion of patients treated with intramedullary nailing subsequently underwent a revision procedure or nail removal during their lifetimes? METHODS: Between 1996 and 2014, we performed 40 intramedullary nailing procedures in 34 patients with multifocal metastases from sarcomas who showed signs or symptoms of impending fracture or who presented with a pathologic fracture. All of these patients are accounted for, either through the time of death or to the present, and all are included at a mean of 13 months (range, 0.3-86 months) in this retrospective study. During the study period, we generally applied the same surgical indications for patients with nailing of metastatic sarcoma lesions as we did for patients with metastatic carcinoma; in general, we used intramedullary nailing (with or without cement) rather than resection for diaphyseal lesions with less cortical destruction and no substantial soft tissue mass or metadiaphyseal lesions that could be adequately supplemented with cementation. The goal was to use this approach when it would allow immediate weightbearing, or in patients whose medical conditions were such that a more-extensive procedure seemed unsafe. During the same period, an additional 58 patients underwent resection procedures for metastatic sarcomas to long bones because they either did not meet the above indications, had a solitary resectable metastasis, or because of surgeon preference; these patients were excluded from this study. The median age of the patients was 52 years (range, 27-81 years). Eleven patients with 11 impending or pathologic fractures were documented to have received either preoperative or postoperative radiation therapy and 29 patients received some form of chemotherapy. RESULTS: Thirty (88%) patients died during the period of observation, at a median of 5 months (range, 0.3-80 months) after surgery. Twenty-nine patients (85%) underwent no additional surgery and retained their original intramedullary nail. One patient (3%) underwent nail removal for infection, and four patients (12%) underwent further surgical revision secondary to local progression. CONCLUSIONS: Patients with an impending or pathologic fracture from multifocal metastatic sarcoma to a long bone have a dismal prognosis, but they may gain short-term benefit from surgical fixation with the goal of reducing pain and maintaining mobility. Although we have no group for comparison, such as treating with radiotherapy alone or resection and an endoprosthesis, our findings suggest that use of intramedullary nails is helpful for providing fixation that in most instances lasts for the lifetime of patients with multifocal bone metastases from sarcomas. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Neoplasias Óseas/cirugía , Neoplasias Femorales/cirugía , Fijación Intramedular de Fracturas , Fracturas Espontáneas/cirugía , Húmero/cirugía , Sarcoma/cirugía , Tibia/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Óseas/secundario , Femenino , Neoplasias Femorales/secundario , Curación de Fractura , Humanos , Húmero/lesiones , Húmero/patología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Sarcoma/secundario , Tibia/lesiones , Tibia/patología , Resultado del TratamientoRESUMEN
INTRODUCTION: The patellar height can influence extensor mechanism and the knee function. Thus, during knee arthroplasty, the surgeon seeks to maintain the correct patellar height. However, it is more difficult to define and maintain the correct patella height in megaprosthesis reconstructions after tumor resections. The objective of this study was to evaluate patellar height after distal femur endoprosthesis reconstruction and its association to knee function. METHODS: This retrospective analysis included 108 patients who underwent distal femur resections and endoprosthesis reconstruction. The minimum follow-up was 1 year or until the patients underwent patellar resurfacing or endoprosthesis revision. Patellar height was calculated using Insall-Salvati ratio (ISR) and Insall-Salvati patellar tendon insertion ratio (PTR) at 2 different times: postoperatively and at the final follow-up. The postoperative ratio was calculated using the best postoperative radiograph taken at least 1 month after the procedure. The final measures were based on the radiograph available at the last follow-up consultation. The ISR and PTR were associated to anterior knee pain (AKP), range of motion (ROM), and extension lag (EXL). RESULTS: The average follow-up was 4.5years. The mean postoperative ISR was 1.02, and the mean ISR at final follow-up was 0.95 (P<.0001). The mean postoperative PTR was 1.45, and the mean PTR at final follow-up was 1.40 (P=.016). There was no association between patellar height and AKP, ROM, and EXL. Patellar height decreases significantly after distal femur resections but does not affect AKP, ROM, and EXL.
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Artralgia/etiología , Fémur/cirugía , Articulación de la Rodilla/fisiología , Rótula , Implantación de Prótesis/efectos adversos , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ligamento Rotuliano/fisiología , Rango del Movimiento Articular , Reoperación , Estudios Retrospectivos , Tendones/cirugía , Adulto JovenRESUMEN
BACKGROUND: Despite improvements in treatment of primary osteosarcoma, treatment of patients who have local recurrence is not well defined. QUESTIONS/PURPOSES: We asked: (1) What are the 5- and 10-year overall survival rates of patients with osteosarcoma who have a local recurrence? (2) What factors are associated with better survival after a local recurrence? (3) Does chemotherapy affect overall survival after local recurrence? (4) What are the rates of rerecurrence after amputation and with limb salvage? METHODS: We reviewed 45 patients with nonmetastatic conventional high-grade osteosarcoma who had local recurrence between 1985 and 2007, during which time 461 patients were treated for the same disease. Seven patients with known local recurrence were lost to followup and not included in our study. The median age of the patients was 18 years, and minimum followup was 2 months (median, 39 months; range, 2-350 months). The primary tumor was located in the extremity in 36 patients and the pelvis in nine. The median time from initial surgery for resection or amputation of the primary tumor to local recurrence was 18 months (range, 2-149 months). Ten recurrences developed in bone and 35 in soft tissue. In 21 of the latter cases, the soft tissue recurrence was undetectable on conventional radiographs. Prognostic factors for overall patient survival after recurrence were evaluated by Kaplan-Meier survival and Cox multivariate analyses. RESULTS: Overall postrecurrence patient survival was 30% at 5 years and 13% at 10 years. Cox multivariate analysis revealed that concurrent metastasis (relative risk = 4, p = 0.003) and recurrent tumor size 5 cm or larger (relative risk = 13, p < 0.0001) were independent predictors of worse survival. With the numbers available, treatment with chemotherapy after local recurrence was not associated with better survival (p = 0.54). Nine patients had a second local recurrence, and the actuarial risk of rerecurrence was 34% at 5 years. There was no difference in the frequency of rerecurrence between patients treated by amputation and wide local excision (p = 0.23). CONCLUSIONS: The long-term prognosis of patients who have local recurrence of osteosarcoma is poor. Followup beyond 5 years is essential, because the disease can have a protracted course. Most recurrences develop in soft tissue and are difficult to see on plain radiographs alone. The size of the recurrence and presence of metastasis were independent prognostic factors, suggesting that early detection may be important. Chemotherapy did not have a significant effect on survival, and surgical eradication of recurrence with wide margins may be critical to maximizing the chances for survival.
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Neoplasias Óseas/terapia , Recurrencia Local de Neoplasia , Procedimientos Ortopédicos , Osteosarcoma/terapia , Adolescente , Adulto , Anciano , Amputación Quirúrgica , Neoplasias Óseas/mortalidad , Neoplasias Óseas/patología , Niño , Femenino , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Análisis Multivariante , Clasificación del Tumor , Neoplasia Residual , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/mortalidad , Osteosarcoma/mortalidad , Osteosarcoma/secundario , Modelos de Riesgos Proporcionales , Reoperación , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Carga Tumoral , Adulto JovenRESUMEN
BACKGROUND: Bone metastasis is a poor prognostic indicator in melanoma. Some authors have advocated only palliative treatment for patients with osseous disease. QUESTIONS/PURPOSES: We determined (1) overall survival after surgery for bone metastasis in patients with malignant melanoma, (2) the rate of local relapse after surgery for bone metastasis, (3) whether certain patients might benefit from more extensive surgery to reduce the risk of local recurrence, and (4) whether there is an effect of prior radiation on survival and local progression. METHODS: We identified 37 patients who underwent 41 orthopaedic procedures for metastatic melanoma to bone in the pelvis or appendicular skeleton, including 20 for pathologic fracture, from our institutional orthopaedic database and performed a retrospective review of their charts and radiographs. The femur (n = 19) and humerus (n = 11) were the most common operative sites. Kaplan-Meier survivorship was used to determine overall survival and local progression-free survival. RESULTS: The median survival from surgery was 9 months (range, 1-135 months). Kaplan-Meier analysis showed overall survival of 30% at 12 months and 17% at 24 months. Local recurrence developed in seven of 41 lesions (17%). The local progression-free survival was 87% at 12 months and 67% at 24 months. Patients for whom prior radiation failed and patients who did not have excision of osseous metastases had higher rates of local recurrence. Two patients underwent amputation for uncontrolled local progression of disease. CONCLUSIONS: Osseous metastasis from melanoma behaves aggressively. The rate of local progression is substantial, and two of 37 patients in this series required amputation for progressive disease. Despite the poor overall prognosis, local control of bone disease is an important issue, and patients may benefit from resection of osseous metastases, particularly if prior radiation has failed.
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Neoplasias Óseas/secundario , Neoplasias Óseas/cirugía , Osteotomía , Neoplasias Cutáneas/patología , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Neoplasias Óseas/mortalidad , Neoplasias Óseas/radioterapia , Legrado , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Lineales , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Neoplasia Residual , Oportunidad Relativa , Osteotomía/efectos adversos , Osteotomía/mortalidad , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Neoplasias Cutáneas/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Pelvic metastasis is a common presentation among patients presenting with skeletal metastasis. Image-guided percutaneous cementation of these lesions is becoming increasingly popular for the treatment of these lesions. The objective of this study was to conduct a systematic review that investigates clinical outcomes after percutaneous cementation for pelvic metastasis. METHODS: A systematic review was registered with International Prospective Register of Systematic Reviews and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed, SCOPUS, and Ovid MEDLINE databases. All level I to IV clinical studies published in the English language investigating the clinical outcomes after percutaneous cementation for pelvic metastasis were included. RESULTS: Fourteen studies with 579 patients (278 men, 301 women) and 631 metastatic pelvic lesions were included in the study. The mean follow-up range was 0.7 to 26.4 months. Percutaneous cementation alone was performed in 441 patients (76.2%). Supplemental ablative procedures were performed in 77 patients (13.3%), and supplemental internal fixation using cannulated screws was performed in 107 patients (18.5%). Twelve studies with 430 patients (74.2%) reported pain-related and/or functional outcome scores, of which all studies reported overall clinically notable improvement at short-term follow-up. All studies reported periprocedural complications. Local cement leakage was the most common complication (162/631 lesions, 25.7%) followed by transient local pain (25/579 patients, 4.3%). There were no reported cases of major complications. Seven patients (1.2%) underwent re-intervention for persistent symptoms. CONCLUSIONS: Percutaneous cementation may be an effective method for treating pain and function related to pelvic metastasis. The most common complication was cement leakage surrounding the lesion. The rates of major complications were low, and most complications appeared minor and transient. Additional prospective studies are needed to further assess the efficacy of this procedure. LEVEL OF EVIDENCE: IV, systematic review of level I to IV therapeutic studies.
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Cementos para Huesos , Neoplasias Óseas , Huesos Pélvicos , Humanos , Neoplasias Óseas/secundario , Neoplasias Óseas/cirugía , Neoplasias Óseas/complicaciones , Cementos para Huesos/uso terapéutico , Osteólisis/etiología , Cementación , Resultado del Tratamiento , Femenino , Neoplasias Pélvicas/secundario , MasculinoRESUMEN
Based on the demonstrated clinical activity of immune-checkpoint blockade (ICB) in advanced dedifferentiated liposarcoma (DDLPS) and undifferentiated pleomorphic sarcoma (UPS), we conducted a randomized, non-comparative phase 2 trial ( NCT03307616 ) of neoadjuvant nivolumab or nivolumab/ipilimumab in patients with resectable retroperitoneal DDLPS (n = 17) and extremity/truncal UPS (+ concurrent nivolumab/radiation therapy; n = 10). The primary end point of pathologic response (percent hyalinization) was a median of 8.8% in DDLPS and 89% in UPS. Secondary end points were the changes in immune infiltrate, radiographic response, 12- and 24-month relapse-free survival and overall survival. Lower densities of regulatory T cells before treatment were associated with a major pathologic response (hyalinization > 30%). Tumor infiltration by B cells was increased following neoadjuvant treatment and was associated with overall survival in DDLPS. B cell infiltration was associated with higher densities of regulatory T cells before treatment, which was lost upon ICB treatment. Our data demonstrate that neoadjuvant ICB is associated with complex immune changes within the tumor microenvironment in DDLPS and UPS and that neoadjuvant ICB with concurrent radiotherapy has significant efficacy in UPS.
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Inhibidores de Puntos de Control Inmunológico , Liposarcoma , Terapia Neoadyuvante , Neoplasias Retroperitoneales , Humanos , Liposarcoma/tratamiento farmacológico , Liposarcoma/inmunología , Terapia Neoadyuvante/métodos , Neoplasias Retroperitoneales/tratamiento farmacológico , Neoplasias Retroperitoneales/inmunología , Masculino , Femenino , Inhibidores de Puntos de Control Inmunológico/uso terapéutico , Persona de Mediana Edad , Anciano , Linfocitos T Reguladores/inmunología , Linfocitos T Reguladores/efectos de los fármacos , Adulto , Sarcoma/terapia , Sarcoma/inmunología , Sarcoma/tratamiento farmacológico , Nivolumab/uso terapéutico , Linfocitos B/inmunología , Linfocitos B/efectos de los fármacosRESUMEN
BACKGROUND: During hip arthroplasties for treating proximal femur metastases, a long femoral stem frequently is used, presumably protecting the entire femur against progression of the existing lesions or development of new lesions. However, it is unclear whether a long stem is really required. QUESTIONS/PURPOSES: We therefore determined in patients with proximal femur metastases (1) the reoperation rate related to different stem lengths after hip arthroplasty, (2) the risk of tumor progression in the same femur (the progression of preexisting lesions and the development of new distal femur lesions), and (3) complications. METHODS: We retrospectively reviewed 203 patients (206 femurs) with proximal femur metastases treated with hip arthroplasty. These femurs were divided into three groups based on femoral stem length: short stem (SS), 12 to 14 cm; medium stem (MS), 20 to 24 cm; and long stem (LS), 25 to 35 cm. We reviewed reoperations, disease progression in the same femur, and complications. Minimum followup was 2 days (median, 487 days; range, 2-4853 days), with most patients followed to their death. RESULTS: Only three femurs were revised owing to tumor progression, with no difference among the SS, MS, and LS groups. Two SS prostheses were revised for nononcologic reasons. Tumor progression in the same femur was uncommon during the patient's survival, with 11 femurs showing progression of the proximal lesion and five femurs showing new distal lesions. The complication rate was higher in the LS group (28%) than the combined rate in the MS and SS groups (16%), especially acute cardiopulmonary complications (18% versus 7.5%). CONCLUSIONS: Reoperation after hip arthroplasty for proximal femur metastases is uncommon and not correlated with femoral stem length. Considering the high complication rate associated with a LS hip prosthesis, we do not believe its routine use is justified.
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Artroplastia de Reemplazo de Cadera/instrumentación , Neoplasias Femorales/cirugía , Prótesis de Cadera , Adulto , Anciano , Artroplastia de Reemplazo de Cadera/efectos adversos , Progresión de la Enfermedad , Femenino , Neoplasias Femorales/diagnóstico por imagen , Neoplasias Femorales/secundario , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Radiografía , Reoperación , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
We present a rare osteochondroma, which instead of being the usual exophytic growth outside bone, grew inward into the medullary cavity of distal femur in a patient with prior trauma to his knee. Except for its intramedullary location, the benign tumor had all the classic radiographic and pathologic features of typical osteochondroma.
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Neoplasias Óseas/diagnóstico , Osteocondroma/diagnóstico , Neoplasias Óseas/etiología , Neoplasias Óseas/cirugía , Humanos , Traumatismos de la Rodilla/complicaciones , Masculino , Osteocondroma/etiología , Osteocondroma/cirugía , Adulto JovenRESUMEN
BACKGROUND: Forequarter amputations (FQAs) and extended forequarter amputations (EFQAs) are rare procedures with high morbidity that often require significant soft-tissue or bony reconstruction. The authors describe the largest series of oncologic FQAs and EFQAs to date with associated reconstructive and oncologic outcomes. METHODS: The authors retrospectively reviewed data from all patients who underwent FQA or EFQA at The University of Texas M. D. Anderson Cancer Center from January 1, 2008, to January 1, 2019. Surgical outcomes, survival, and local recurrence rates were summarized and compared. RESULTS: Forty-seven patients met the inclusion criteria, including 14 with EFQAs. Most patients (53%) were male; the median age was 58 years (range, 2 to 74). The most common tumor type was sarcoma (79%), and the most common presentation was recurrent (34%). Nineteen patients (40%) had distant metastases. The median defect size was 351 cm 2 ; flap reconstruction was required in 30 patients (64%). Eight patients (17%) experienced immediate complications and 12 (26%) experienced delayed complications. The median overall survival (OS) time was 21 months and the 5-year OS rate was 28.1%. OS and disease-free survival were superior in the EFQA group (69.8% versus 11.6%, P = 0.017; 58.9% versus 9.8%, P = 0.014, respectively). Metastasis at presentation was the most important predictor of survival on multivariate analysis (OR, 3.98; P = 0.004). CONCLUSIONS: Patients with EFQA had better OS and disease-free survival than did patients with FQA, owing to a lower incidence of metastatic disease. This study suggests a benefit to more aggressive resection and reconstruction when disease is locally confined. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Procedimientos de Cirugía Plástica , Sarcoma , Humanos , Masculino , Persona de Mediana Edad , Femenino , Estudios Retrospectivos , Colgajos Quirúrgicos/patología , Amputación Quirúrgica , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/cirugíaRESUMEN
Imaging should be performed in patients with a suspected soft tissue mass that cannot be clinically confirmed as benign. Imaging provides essential information necessary for diagnosis, local staging, and biopsy planning. Although the modalities available for imaging of musculoskeletal masses have undergone progressive technological advancements in recent years, their overall purpose in the setting of a soft tissue mass remains unchanged. This document identifies the most common clinical scenarios related to soft tissue masses and the most appropriate imaging for their assessment on the basis of the current literature. It also provides general guidance for those scenarios that are not specifically addressed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Imagen por Resonancia Magnética , Sociedades Médicas , Humanos , Estados Unidos , Imagen por Resonancia Magnética/métodosRESUMEN
BACKGROUND: Chondrosarcoma is treated primarily by surgery. The prognosis of patients after local recurrence is not well defined. Both the survival of patients and the risk of further local relapse after surgical treatment of local recurrence have yet to be established. QUESTIONS/PURPOSES: We determined survival after local recurrence of chondrosarcoma, the rate of further local recurrences, and prognostic factors predicting survival. PATIENTS AND METHODS: We retrospectively reviewed 52 patients treated for locally recurrent conventional chondrosarcoma between 1975 and 2008. All patients had nonmetastatic disease at the time of diagnosis. There were 36 males and 16 females with a median age of 39 years (range, 16-79 years). We analyzed variables affecting overall and disease-free survival. The minimum followup was 12 months unless patients died of disease before 12 months (median, 68 months; range, 4-387 months). RESULTS: Thirty patients developed their first local recurrence in axial locations, while 22 developed recurrence in the appendicular skeleton. After local recurrence, overall survival was 74% at 5 years and 60% at 10 years. The mean number of local recurrences was three (range, 1-14). Surgical margin correlated with further local recurrence but not survival. Tumor grade, axial location, metastases, and age independently predicted survival. CONCLUSIONS: Prolonged survival of patients after local recurrence of conventional chondrosarcoma is possible, albeit with further recurrences in many patients. LEVEL OF EVIDENCE: Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Neoplasias Óseas/mortalidad , Recurrencia Local de Neoplasia/mortalidad , Adolescente , Adulto , Anciano , Neoplasias Óseas/patología , Condrosarcoma/mortalidad , Condrosarcoma/patología , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
PURPOSE: In an effort to promote cost-conscious, high-quality, and patient-centered care in the palliative radiation of painful bone metastases, the National Quality Forum (NQF) formed measure 1822 in 2012, which recommends the use of one of the four dose-fractionation schemes (30 Gy in 10 fractions, 24 Gy in 6 fractions, 20 Gy in 5 fractions, or 8 Gy in a single fraction). We investigated whether a custom electronic health record (EHR) alert system improved quality measure compliance among 88 physicians at a large academic center and institutional network. METHODS: In March 2018, a multiphase alert system was embedded in a custom web-based EHR. Prior to a course of palliative bone radiation, the alert system notified the user of NQF 1822 recommendations and, once prescription was completed, either affirmed compliance or advised a change in treatment schedule. Rates of compliance were evaluated before and after implementation of alert system. RESULTS: Of 2,399 treatment courses, 86.5% were compliant with NQF 1822 recommendations. There was no difference in rates of NQF 1822 compliance before or after implementation of the custom EHR alert (86.0% before March 2018 v 86.9% during and after March 2018, P = .551). CONCLUSION: There was no change in rates of compliance following implementation of a custom EHR alert system designed to make treatment recommendations based on national quality measure guidelines. To be of most benefit, future palliative bone metastasis decision aids should leverage peer review, target a clear practice deficiency, center upon high-quality practice guidelines, and allow flexibility to reflect the diversity of clinical scenarios.