Effectiveness of immune checkpoint inhibitor therapy on bone metastases in non-small-cell lung cancer.

Background: Bone metastases (BoMs) are prevalent in patients with metastatic non-small-cell lung cancer (NSCLC) however, there are limited data detailing how BoMs respond to immune checkpoint inhibitors (ICIs). The purpose of this study was to compare the imaging response to ICIs of BoMs against visceral metastases and to evaluate the effect of BoMs on survival. Materials and methods: A retrospective, multicentre cohort study was conducted in patients with NSCLC treated with nivolumab or pembrolizumab in Alberta, Canada from 2015 to 2020. The primary endpoint was the real-world organ specific progression free survival (osPFS) of bone versus visceral metastases. Visceral metastases were categorized as adrenal, brain, liver, lung, lymph node, or other intra-abdominal lesions. The secondary outcome was overall survival (OS) amongst patients with and without BoMs. Results: A total of 573 patients were included of which all patients had visceral metastases and 243 patients (42.4%) had BoMs. High PD-L1 expression was identified in 268 patients (46.8%). No significant difference in osPFS was observed between bone, liver, and intra-abdominal metastases (p=0.20 and p=0.76, respectively), with all showing shorter osPFS than other disease sites. There was no difference in the osPFS of extra-thoracic sites of disease in patients with high PD-L1 expression. There was significant discordance between visceral disease response and bone disease response to ICI (p=0.047). The presence of BoMs was an independent poor prognostic factor for OS (HR 1.26, 95%CI: 1.05-1.53, p=0.01). Conclusion: Metastatic bone, liver, and intra-abdominal lesions demonstrated inferior clinical responses to ICI relative to other sites of disease. Additionally, the presence of bone and liver metastases were independent poor prognostic factors for overall survival. This real-world data suggests that BoMs respond poorly to ICI and may require treatment adjuncts for disease control.

What are the indications and survivorship of tumor endoprosthetic reconstructions for patients with extremity metastatic bone disease?

BACKGROUND AND OBJECTIVES: Given advances in therapies, endoprosthetic reconstruction (EPR) in metastatic bone disease (MBD) may be increasingly indicated. The objectives were to review the indications, and implant and patient survivorship in patients undergoing EPR for MBD. METHODS: A review of patients undergoing EPR for extremity MBD between 1992 and 2022 at two centers was performed. Surgical data, implant survival, patient survival, and implant failure modes were examined. RESULTS: One hundred fifteen patients were included with a median follow-up of 14.9 months (95% confidence interval [CI]: 9.2-19.3) and survival of 19.4 months (95% CI: 13.6-26.1). The most common diagnosis was renal cell carcinoma (34/115, 29.6%) and the most common location was proximal femur (43/115, 37.4%). Indications included: actualized fracture (58/115, 50.4%), impending fracture (30/115, 26.1%), and failed fixation (27/115, 23.5%). Implant failure was uncommon (10/115, 8.7%). Patients undergoing EPR for failed fixation were more likely to have renal or lung cancer (p = 0.006). CONCLUSIONS: EPRs were performed most frequently for renal cell carcinoma and in patients with a relatively favorable survival. EPR was indicated for failed previous fixation in 23.5% of cases, emphasizing the importance of predictive survival modeling. EPR can be a reliable and durable surgical option for patients with MBD.

MDM2 analysis in the management of benign lipomas versus atypical lipomatous tumors/well-differentiated liposarcomas: A useful prognostication tool?

INTRODUCTION: Well-differentiated liposarcomas (WDLS) are low-grade lipomatous tumors with low malignant potential. Previous review identified controversy on whether upfront wide resection is necessary when they occur on the trunk or the extremities. MDM2 amplification is a genetic mutation typically present in WDLS and absent in benign lipomas (BL). We aimed to study the influence of MDM2 status on the management/recurrences of lipomatous tumors in the trunk or the extremities. METHODS: All patients with lipomatous tumors with MDM2 testing in the Province of Alberta between 2015 and 2020 were identified from the Cancer Cytogenetics Laboratory dataset. High grade sarcomas, retroperitoneal, head/neck, or groin tumors were excluded. Primary outcome measures including MDM2 status, surgical margin, local recurrence, reoperation rate, dedifferentiation, and metastasis were abstracted from chart review. Descriptive statistics were used to analyse treatment patterns and recurrence rates according to MDM2 status. RESULTS: Total of 764 charts were retrieved, and 282 were included for analysis. 33 showed MDM2 amplification (11.7%), and 2 of them had local recurrence (6.1%). Two patients with recurrent tumors underwent limb-salvaging reoperation (6.1%), but no dedifferentiation or metastasis was seen. CONCLUSION: Findings in this study confirmed the benign behaviour of truncal/extremities lipomas with no MDM2 amplification. Given we found a 6.1% recurrence rate in MDM2 amplified tumors, a prolong follow up of this subset of patients is warranted. Overall, regardless of the MDM2 status, we believe an initial marginal excision is a reasonable surgical approach as recurrences are rare, and they can be managed with re-excision when they occur.

Does surgical technique influence the burden of lung metastases in patients with pathologic long bone fractures?

BACKGROUND: The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery. METHODS: Retrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher's exact tests, and Kaplan-Meier survival analyses. RESULTS: Patients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4-49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p < 0.001). CONCLUSIONS: In this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival. LEVEL OF EVIDENCE: III, therapeutic study.

Longitudinal survival trends of patients with cancer with surgically managed appendicular metastatic bone disease: systematic review.

BACKGROUND: Advances in systemic cancer therapies have improved survival for patients with metastatic carcinoma; however, it is unknown whether these advances have translated to improved survival for patients with appendicular metastatic bone disease (A-MBD) after orthopedic interventions. We conducted a study to evaluate the trend in overall survival for patients who underwent orthopedic surgery for A-MBD between 1968 and 2018. METHODS: A systematic search of Embase and Medline to identify studies published since 1968 evaluating patients treated with orthopedic surgery for A-MBD was conducted for a previously published scoping review. We used a meta-regression model to assess the longitudinal trends in 1-, 2- and 5-year overall survival between 1968 and 2018. The midpoint year of patient inclusion for each study was used for analysis. We categorized primary tumour types into a tumour severity score according to prognosis for a further meta-regression analysis. RESULTS: Of the 5747 studies identified, 103 were retained for analysis. Meta-regression analysis showed no significant effect of midpoint study year on survival across all time points. There was no effect of the weighted average of tumour severity scores for each study on 1-year survival over time. CONCLUSION: There was no significant improvement in overall survival between 1968 and 2018 for patients with A-MBD who underwent orthopedic surgery. Orthopedic intervention remains a poor prognostic variable for patients with MBD. This finding highlights the need for improved collection of prospective data in this population to identify patients with favourable survival outcomes who may benefit from personalized oncologic surgical interventions.

Communication in surgical decision-making while managing metastatic bone disease: matching patient expectations with surgical goals.

BACKGROUND: There is a paucity of research examining how surgical decision-making for metastatic bone disease (MBD) can be optimized to improve quality of life (QOL) and functional outcomes, while accurately aligning with patient goals and expectations. The objective of this study was to survey and interview patients with MBD and support persons (PS), physicians, and allied health care providers (HCP) with the goal of identifying (1) important surgical issues related to MBD management, (2) discordance in perioperative expectations, and (3) perceived measures of success in the surgical management of MBD. METHODS: Utilizing a custom survey developed by HCP and patients with MBD, participants were asked to (1) identify important issues related to MBD management, (2) rank perceived measures of success, and (3) answer open-ended questions pertaining to the management of MBD. RESULTS: From the survey, increased life expectancy, minimizing disease progression, removal of local tumour, timely surgery after diagnosis, increased length of hospitalization, and physiotherapy access were all identified as significant discordant goals between PS and physicians/HCP. Conversely, there was an agreement between physicians and HCP who considered improved QOL and functional outcomes as most important goals. Structured homogenous-group workshops identified the need for (1) improved discussions of prognosis, surgical options, expectations, timelines, and resources, (2) the use of a care team "quarterback", and (3) an increased use of multi-disciplinary treatment planning. CONCLUSIONS: We feel this data highlights the importance of improved communication and coordination in treating patients with MBD. Further research evaluating how surgical techniques influence survival and disease progression in MBD is highly relevant and important to patients.

One-stage versus 2-stage bilateral total joint arthroplasty: a matched cohort study.

Background: Patients with bilateral end-stage hip or knee arthritis want to know if it is safe to have bilateral surgery under a single anesthetic, to restore their quality of life as quickly as possible. The purpose of this study was to assess if there is an increase in the rate of postoperative medical adverse events, length of stay (LOS), blood transfusion rate and 30-day readmission rate among patients who undergo 1-stage bilateral total hip arthroplasty (BTHA) and 1-stage bilateral total knee arthroplasty (BTKA) compared with patients who undergo 2-stage BTHA and BTKA. Methods: Our study cohorts included patients who underwent BTHA and BTKA between Apr. 1, 2009, and Jan. 31, 2016, in Alberta, Canada. To minimize selection bias associated with our retrospective study design, we matched patients who underwent 1-stage BTHA and BTKA with patients with patients who underwent 2-stage BTHA and BTKA, respectively, for age, sex and number of presurgical risk factors using propensity score in a matching ratio of 1:1. Results: Our study included 1645 patients who underwent BTHA and 4125 patients who underwent BTKA. We matched 195 patients who underwent 1-stage BTHA and 302 patients who underwent 1-stage BTKA with patients who underwent 2-stage BTHA and BTKA, respectively. There was no significant difference in postoperative medical adverse events between the 1-stage and 2-stage matched cohort groups for both BTHA (adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 0.3-4.9) and BTKA (adjusted OR 0.9, 95% CI 0.3-2.6). There was no difference in inpatient, 30- or 90-day mortality between the 2 groups for BTHA or BTKA. Patients who underwent 1-stage BTHA and BTKA had a shorter acute length of stay but increased total length of stay (acute care and rehabilitation unit) and were less likely to be discharged home postoperatively. One-stage BTHA and BTKA were associated with higher odds of blood transfusion than 2-stage BTHA and BTKA. The 30-day readmission rate was significantly lower for 1-stage BTHA than for the 2-stage BTHA matched cohort (adjusted OR 0.3, 95% CI 0.1-0.8), whereas there was no difference in the 30-day readmission rate (adjusted OR 0.6, 95% CI 0.2-1.7) between the 1-stage and 2-stage BTKA matched cohorts. Finally, operating room time was significantly lower for 1-stage BTHA (49.6 min less) and 1-stage BTKA (66.7 min less) than for the 2-stage arthroplasty procedures. Conclusion: Healthy patients who undergo 1-stage BTHA and BTKA have postoperative medical complication rates comparable to those of patients who undergo 2-stage procedures with the additional benefits of a shorter acute length of stay, but they do have a higher risk of blood transfusion and are less likely to be discharged directly home from the acute care hospital. A multicentre randomized controlled trial on this topic is currently being condcuted by the Canadian Arthroplasty Society.

Contexte: Les patients atteints d'arthrite bilatérale de la hanche ou du genou au stade terminal veulent savoir s'il est sécuritaire de subir une chirurgie bilatérale avec une seule anesthésie pour retrouver leur qualité de vie le plus rapidement possible. Le but de cette étude était de comparer le taux de complications postopératoires de nature médicale, la durée du séjour hospitalier, le taux de transfusions sanguines et le taux de réadmissions à 30 jours chez les patients selon que les arthroplasties totales de la hanche bilatérales (ATHB) et les arthroplasties totales du genou bilatérales (ATGB) se font en 1 étape ou en 2 étapes. Méthodes: Les cohortes de notre étude incluaient des patients qui ont subi des ATHB et des ATGB entre le 1er avril 2009 et le 31 janvier 2016 en Alberta, au Canada. Pour réduire le biais de sélection associé à notre protocole d'étude rétrospective, nous avons assorti les patients soumis aux ATHB et aux ATGB en 1 étape à ceux qui les ont subies en 2 étapes, respectivement, selon l'âge, le sexe et le nombre de facteurs de risque préopératoires, avec score de propension et rapport 1:1. Résultats: Notre étude a regroupé 1645 patients soumis à des ATHB et 4125 patients soumis à des ATGB. Nous avons assortis 195 patients soumis aux ATHB en 1 étape et 302 patients soumis aux ATGB en 1 étape avec des patients soumis à des ATHB et des ATGB en 2 étapes, respectivement. On n'a noté aucune différence significative quant aux complications postopératoires de nature médicale entre les groupes des cohortes assorties pour les interventions en 1 et en 2 étapes, tant avec les ATHB (rapport des cotes [RC] ajusté 1,3, intervalle de confiance [IC] de 95% 0,3­4,9), qu'avec les ATGB (RC ajusté 0,9, IC de 95% 0,3­2,6). Il n'y a pas eu de différences au plan de la mortalité à 30 jours ou à 90 jours chez les patients hospitalisés des 2 groupes avec les ATHB ou les ATGB. Les patients soumis aux ATHB et aux ATGB en 1 étape ont séjourné moins longtemps en soins actifs, mais la durée totale de leur séjour a été plus longue (soins actifs et réadaptation) et ils étaient moins susceptibles de retourner à la maison au moment de leur congé hospitalier après l'intervention. Les ATHB et les ATGB en 1 étape ont été associées à un risque plus grand de transfusions sanguines que les ATHB et les ATGB en 2 étapes. Le taux de réadmission à 30 jours a été significativement plus faible avec les ATHB en 1 étape que dans la cohorte assortie soumise aux ATHB en 2 étapes (RC ajusté 0,3, IC de 95% 0,1­0,8), tandis qu'il n'y a eu aucune différence au plan des taux de réadmission à 30 jours (RC ajusté 0,6, IC de 95% 0,2­1,7) entre les cohortes assorties soumises aux ATGB en 1 et 2 étapes. En terminant, le temps opératoire a été significativement plus bref avec les ATHB et les ATGB en 1 étape (respectivement 49,6 minutes et 66,7 minutes de moins) comparativement aux arthroplasties en 2 étapes. Conclusion: Les patients en bonne santé qui subissent des ATHB et des ATGB en 1 étape ont des taux de complications postopératoires de nature médicale comparables à ceux qui les subissent en 2 étapes, avec l'avantage additionnel d'un séjour hospitalier plus bref en soins actifs; mais ils sont exposés à un risque plus grand de transfusions sanguines et sont moins susceptibles de retourner directement à la maison en quittant l'hôpital de soins actifs. La Société canadienne d'arthroplastie procède actuellement à un essai randomisé et contrôlé multicentrique à ce sujet.

Association between Allogeneic Blood Transfusion and Wound Infection after Total Hip or Knee Arthroplasty: A Retrospective Case-Control Study.

Background: To assess using a retrospective case control study, whether patients undergoing primary, elective total hip or knee arthroplasty who receive blood transfusion have a higher rate of post-operative infection compared to those who do not. Materials and Methods: Data on elective primary total hip or knee arthroplasty patients, including patient characteristics, co-morbidities, type and duration of surgery, blood transfusion, deep and superficial infection was extracted from the Alberta Bone and Joint Health Institute (ABJHI). Logistic regression analysis was used to compare deep infection and superficial infection in blood-transfused and non-transfused cohorts. Results: Of the 27892 patients identified, 3098 (11.1%) received blood transfusion (TKA 9.7%; THA 13.1%). Overall, the rate of superficial infection (SI) was 0.5% and deep infection (DI) was 1.1%. The infection rates in the transfused cohort were SI 1.0% and DI 1.6%, and in the non-transfused cohort were SI 0.5% and DI 1.0%. The transfused cohort had an increased risk of superficial infection (adjusted odds ratio (OR) 1.9 [95% CI 1.2-2.9, p-value 0.005]) as well as deep infection (adjusted OR 1.6 [95% CI 1.1-2.2, p-value 0.008]). Conclusion: The odds of superficial and deep wound infection are significantly increased in primary, elective total hip and knee arthroplasty patients who receive blood transfusion compared to those who did not. This study can potentially help in reducing periprosthetic hip or knee infections.

A sub-meniscal arthrotomy improves the medium-term patient outcome of tibial plateau fractures.

PURPOSE: This trial was conducted to determine the medium-term functional outcome of displaced tibial plateau fracture patients treated with closed fluoroscopic assisted reduction and internal fixation (CRIF) versus patients treated with standard open reduction with sub-meniscal arthrotomy and internal fixation (ORIF). METHODS: A prospective trial was conducted in adult patients with displaced AO/OTA 41 B and 41 C tibial plateau fractures. Patients were assigned to treatment based upon the standard treatment of the surgeon involved following the call schedule for the day, either CRIF or ORIF. Postoperative radiographs and CT were performed on all patients and patients were followed for a minimum of 2 years. Primary outcome measures were the KOOS, SMFA and SF-36. RESULTS: Seventy patients were recruited with 2 year follow-up on 35 patients in the CRIF group and 27 patients in the ORIF group. Postoperative CT scans showed that reductions were better with the ORIF group especially in the posterolateral quadrant as compared to the CRIF group. The frequency of mal-reductions was higher in the CRIF group. The KOOS, at two years, showed that the CRIF had significantly less good outcomes in the subcategories of SPORT (p = 0.03) and QOL (p = 0.01) measurements. CONCLUSIONS: ORIF with a sub-meniscal arthrotomy provides better quality reductions and better medium-term results as compared to CRIF for tibial plateau fractures. This may provide more long-term benefit from osteoarthritic symptoms in this patient group. LEVEL OF EVIDENCE: Therapeutic, Level 2.

Surgical excision versus observation as initial management of desmoid tumors: A population based study.

SYNOPSIS: Desmoid tumors can be safely managed with watchful waiting, including either observation alone or tamoxifen/NSAIDs. Surgery at first presentation can be associated with significant treatment burden. BACKGROUND: Immediate surgery was historically recommended for desmoid tumors. Recently, watchful waiting, (tamoxifen/NSAIDs or observation alone), has been advocated. METHODS: All diagnoses of desmoid tumor within the Alberta Cancer Registry from August 2004 to September 2015 were identified. Patients with FAP were excluded. Demographics, tumor characteristics and treatment and outcome data were collected. Outcomes were compared between immediate surgery and watchful waiting. The effect of abdominal wall site on progression and recurrence and the effect of microscopic margin on recurrence were assessed with Fisher's exact test. RESULTS: We identified 111 non-FAP patients. Median follow-up was 35 months from diagnosis. 74% were female. Mean age was 42. Fifty (45%) underwent watchful waiting, of whom 21(42%) progressed, with median PFS of 10 months. Fifty-three (48%) underwent resection at presentation, of whom 8 (15%) recurred, with median disease-free survival of 22 months. Abdominal wall lesions were equally represented in both groups, and equally likely to progress on watchful waiting (50% vs 39%, p = 0.53), but there was a trend toward decreased recurrence after surgery. (5% vs 23%, p = 0.08). Microscopic margin had no effect on recurrence (14% of margin negative vs 20% of margin positive, p = 1.0). CONCLUSIONS: Watchful waiting was successful in 58% of patients, and a further 28% only required one aggressive treatment thereafter, for a total of 86%. Surgery had a favorable recurrence rate (15%), but some recurrences were associated with significant treatment burden. Treatment should be tailored to individual patients in a multidisciplinary setting. A trial of observation appears warranted in most patients. Recurrence rate was not affected by positive margins.

A scoping review on the surgical management of metastatic bone disease of the extremities.

BACKGROUND: Management of metastatic bone disease of the extremities (MBD-E) is challenging, and surgical directions pose significant implications for overall patient morbidity and mortality. Recent literature reviews on the surgical management of MBD-E present a paucity of high-level evidence and global inconsistencies in study design. In order to steer productive research, a scoping review was performed to map and assess critical knowledge gaps. METHODS: The Arksey and O'Malley framework for scoping studies was followed. A comprehensive literature search identified a large body of literature pertaining to the surgical management of MBD-E. Study data and meta-data was extracted and presented using descriptive analytics and a thematic framework. Literature gaps were identified and analyzed. RESULTS: Three hundred eighty five studies from 1969 to 2017 were included. Studies were categorized into 11 separate themes, with the majority (63%) falling into the "surgical fixation strategies" theme, followed by "complications" at 7% and "prognosis and survival" at 6.2%. Less than 3% of studies were categorized in "patient related outcomes" or "epidemiology" themes. 89% of studies were retrospective and only 6 studies were of level 1 or 2 evidence. We identified a temporal increase in publication by decade, and all studies published on interventional radiology techniques or economic analyses were published after 2007 or 2009, respectively. 64.9% of studies were published in Europe and 20.3% were published in North America. Average patient age was 62 (± 5.2 years), and breast was the most common primary tumour (28%), followed by lung (17%) and kidney (15%). In terms of surgical location, 75% of operations involved the femur, followed by the humerus at 22% and tibia at 3%. CONCLUSIONS: We present a descriptive overview of the current published literature on the surgical management of MBD-E. Critical knowledge gaps have been identified through the development of a thematic framework. Consolidation of literary gaps must involve bolstered efforts towards patient and family-engaged research initiatives and assessment of patient-related surgical outcomes. Multi-disciplinary engagement in developing prospective research will also help guide evidence-based personalized practice for these patients. By building on existing comprehensive patient databases and registries, knowledge on survival and prognostic parameters can be greatly improved.

Fungal periprosthetic joint infection following total elbow arthroplasty: a case report and review of the literature.

BACKGROUND: With improving surgical techniques for total elbow arthroplasty clinical outcomes have improved and its utilization continues to increase. Despite these advances, complication rates remain as high as 24%. Of these complications periprosthetic joint infection is one of the most common and morbid. The rheumatoid elbow remains a leading indication for total elbow arthroplasty. Patients with this condition frequently require immunosuppressive therapy, which places them at higher risk of both typical and atypical infections. CASE PRESENTATION: We present the case of a persistent, late-onset periprosthetic joint infection in a total elbow arthroplasty of a 64-year-old Caucasian woman with severe refractory rheumatoid arthritis. The offending pathogen, Aspergillus terreus, is previously unreported in the arthroplasty literature and grew concurrently with coagulase-negative staphylococcus. Eradication of the fungal and bacterial agents involved resection arthroplasty, serial debridement, and multiple courses of intravenous and oral antimicrobial therapy. Two attempts at reimplantation arthroplasty failed to eliminate the infection and our patient ultimately required definitive resection arthroplasty. CONCLUSIONS: Arthroplasty in the rheumatoid elbow confers with it a high complication rate. Inflammatory disease and immunosuppressive drugs combined with the subcutaneous anatomy of the elbow contribute to the risk of infection. Fungal periprosthetic joint infection in the rheumatoid patient presents both diagnostic and therapeutic challenges. Fungal growth should always be treated and requires organism-specific antimicrobials in conjunction with surgical debridement. More literature is needed to determine the optimal treatment regimen for this devastating complication.

Outcomes of surgical treatment alone in patients with superficial soft tissue sarcoma regardless of size or grade.

BACKGROUND AND OBJECTIVES: Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS: A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS: Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS: Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.

Quality of life, functional outcomes, and wound complications in patients with soft tissue sarcomas treated with preoperative chemoradiation: a prospective study.

BACKGROUND: Preoperative irradiation reduces local recurrence of soft tissue sarcomas (STSs), but major wound complication rates approach 25-35 %. Using a novel neoadjuvant chemoradiation protocol, we prospectively documented functional outcomes and quality of life (QOL) and hypothesized a lower major wound complication rate. METHODS: Patients with STS deep to muscular fascia were treated with 3 days of doxorubicin (30 mg/day) and 10 days of irradiation (300 cGy/day) followed by limb-sparing surgery. Wound complications were assessed, and functional assessment and QOL were followed prospectively using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and Short Form (SF)-36 questionnaires preoperatively and 6 and 12 months postoperatively. RESULTS: Altogether, 52 consecutive patients were accrued during 2006-2011. Overall, 80.8 % of STSs were >5 cm, and 67.3 % involved the lower extremity. Seven (13.5 %) major wound complications occurred, all requiring reoperation. Preoperative scores for TESS, MSTS, and SF-36 physical (PCS) and mental (MCS) health components were 83.3, 86.7, 40.6, and 49.4, respectively. There were no differences seen 6 months postoperatively. By 12 months, however, patients showed improved functional scores (TESS 93.0, p = 0.02; MSTS 93.3, p < 0.01) and QOL scores (PCS 45.1, p = 0.02; MCS = 52.9, p = 0.05). No differences in scores were seen between patients with or without wound complications. CONCLUSIONS: Patients treated with our neoadjuvant chemoradiation protocol had stable QOL and functional scores 6 months postoperatively and showed improvement by 12 months. Importantly, the major wound complication rate was low.

Functional outcomes after treatment of aggressive tumors in the distal radius.

We aimed to determine whether wide excision and radiocarpal arthrodesis in patients with aggressive tumors of the distal radius resulted in more significant functional deficit than joint salvage procedures. We compared functional outcomes, surgical complications, and local tumor relapse in 33 consecutive patients. Fourteen patients initially had joint-sparing procedures, whereas 19 underwent wide resection and arthrodesis. At minimum final followup of 18 months (mean, 96 months; range, 18-204 months), local tumor relapse occurred in five of 14 patients after joint salvage versus zero of 19 after arthrodesis. Two of five patients with tumor recurrence retained their native joints, whereas three underwent resection and arthrodesis. Six of 19 patients had complications, including one nonunion, for which we performed additional surgery after arthrodesis. All patients remained disease-free at followup and none developed metastases. Disabilities of the Arm, Shoulder and Hand score, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society scores all indicated more disability after arthrodesis. Persistent pain, radiographic wrist arthritis, and weaker grip strength was seen in some patients following joint salvage. Whenever possible, joint preservation is preferable for the result of better extremity function, but weaker grip, higher local tumor relapse, and late arthritis remain concerns.