Prognostic value of necrosis after neoadjuvant therapy for soft tissue sarcoma.

BACKGROUND AND OBJECTIVES: While treatment-induced tissue necrosis is a well-documented predictor of patient survival in malignant bone tumors, its prognostic value in soft tissue sarcomas is controversial. A prior study from our institution did not find a prognostic value to tumor necrosis. We analyze a more extensive database of high-grade soft tissue sarcomas treated with neoadjuvant chemotherapy, radiation therapy, or both to re-evaluate if the degree of tumor necrosis alone can be used as a predictive factor for local recurrence, metastasis, and disease-specific survival. METHODS: Two hundred and seven patients with high-grade extremity soft tissue sarcoma received neoadjuvant chemotherapy and/or radiation therapy and wide excision. Tumor treatment response was determined by histopathologic analysis, and patients were followed for local recurrence, metastasis, or death. RESULTS: Tumor necrosis ≥ 90% correlates with improved disease-free survival with univariate analysis, but this does not reach statistical significance on multivariate analysis. Age and tumor volume were found to be the only independent predictors of disease-free survival on multivariate analysis. CONCLUSIONS: There is insufficient evidence to support the use of necrosis to prognosticate survival and alter chemoradiation regimens in high grade soft tissue sarcomas of the extremity. Larger studies are needed to definitively address the prognostic value of necrosis. LEVEL OF EVIDENCE: Level II, Prognostic

Lipoma arborescens of the biceps tendon sheath.

Lipoma arborescens, described as lipomatous infiltration and distention of synovial villi resulting in a frond-like appearance, most frequently affects the suprapatellar recess of the knee. While there have been reports of this entity involving the upper extremity joints, bursa, and tendon sheaths, we present the first reported case of lipoma arborescens isolated to the biceps tendon sheath. We describe imaging and histologic findings with clinical correlation.

A comparison of fine-needle aspiration, core biopsy, and surgical biopsy in the diagnosis of extremity soft tissue masses.

BACKGROUND: Biopsy tissue can be obtained through a fine needle, a wider coring needle, or through an open surgical incision. Though much literature exists regarding the diagnostic yield of these techniques individually, none compare accuracy of diagnosis in the same mass. QUESTIONS/PURPOSES: We asked how the diagnostic accuracy of fine-needle aspiration, core biopsy, and open surgical biopsy compare in regard to identifying malignancy, establishing the exact diagnosis, and guiding the appropriate treatment of soft tissue masses. PATIENTS AND METHODS: We prospectively studied 57 patients with palpable extremity soft tissue masses, performing fine-needle aspiration, followed by core biopsy, followed by surgical biopsy of the same mass. RESULTS: Open surgical biopsy was 100% accurate on all accounts. With regard to determining malignancy, fine-needle aspiration and core biopsy had 79.17% and 79.2% sensitivity, 72.7% and 81.8% specificity, 67.9% and 76% positive predictive value, 82.8% and 84.4% negative predictive value, and an overall accuracy of 75.4% and 80.7%, respectively. In regard to determining exact diagnosis, fine-needle aspiration had a 33.3% accuracy and core biopsy had a 45.6% accuracy. With regard to eventual treatment, fine-needle aspiration was 38.6% accurate and core biopsy was 49.1% accurate. CONCLUSIONS: In soft tissue mass diagnosis, core biopsy is more accurate than fine-needle aspiration on all accounts, and open biopsy is more accurate than both in determining malignancy, establishing the exact diagnosis, and the guiding appropriate treatment.

Porcine Mesothelium-Wrapped Diced Cartilage Grafts for Nasal Reconstruction.

BACKGROUND: Fascia-wrapped diced cartilage grafts have become a useful tool in modern rhinoplasty surgery. Unfortunately, fascial harvest is associated with donor site morbidity; therefore, a nonautologous alternative to fascia would be ideal. Decellularized porcine mesothelium (PM), Meso BioMatrix™, is an acellular scaffold that could potentially fill this need. To determine if PM could serve as an acceptable alternative, we histologically compared diced cartilage grafts wrapped in fascia versus PM. METHODS: Human rib cartilage and temporoparietal fascia were obtained under an IRB-approved protocol. Cartilage was diced into 0.5 mm pieces and implanted in subcutaneous pockets in nude rats. Implanted materials included cartilage alone, cartilage wrapped in fascia, cartilage wrapped in PM, fascia alone, or PM alone. Specimens were harvested at 8 weeks and stained with hematoxylin and eosin, Masson's trichrome, Safranin-O, and Verhoeff's stain to assess cartilage viability, architecture, and regenerative potential. RESULTS: Unwrapped diced cartilage showed the highest cartilage viability, but was associated with loss of contour and dispersion of the cartilage pieces. Meso BioMatrix-wrapped grafts maintained contour and cartilage pieces had not dispersed; however, there was a significantly lower number of nucleated lacunae and a greater amount of basophilia than both fascia-wrapped cartilage and unwrapped cartilage. There was no significant difference in cartilage resorption between fascia-wrapped cartilage and Meso BioMatrix-wrapped cartilage or in the proteoglycan or collagen content between all groups. CONCLUSION: Off-the-shelf decellularized PM was associated with lower cartilage viability than unprocessed fascial allograft. No cartilage piece dispersion, fibrosis, resorption, or a foreign body reaction to Meso BioMatrix was observed. PM, although not equivalent to autologous tissue, may be utilized to achieve acceptable clinical results and be a viable alternative that limits donor side morbidity. This experimental study supports further clinical investigation of this material in rhinoplasty procedures.

Clavicular eosinophilic granuloma causing adult shoulder pain.

Though rarely reported, neoplasms of the clavicle occur, and their symptoms can be mistaken for more common shoulder conditions. We present the case of a benign clavicular neoplasm, rarely seen in adults, presenting with pain, and eventual pathologic fracture in a 49 year-old. A 49 year-old male firefighter underwent arthroscopic rotator cuff repair for shoulder pain after magnetic resonance imaging revealed supraspinatus tendon tear. The patient's pain persisted after surgery, and was described as routine until he developed severe pain after minor blunt trauma. A local Emergency Room performed the first x-rays, which revealed a pathologic fracture of the distal clavicle through a destructive lesion. The patient was referred to an orthopedic oncologist, who performed incisional biopsy, which initially diagnosed osteomyelitis. The patient was subsequently taken to surgery for debridement. Pathology then yielded the diagnosis of eosinophilic granuloma. The patient was taken back to surgery for formal curettage with open reduction and internal fixation. The patient's pain resolved, the pathologic fracture fully healed, and the patient returned to full time work as a firefighter. Though workup for common shoulder conditions often identifies incidental benign lesions of bone, the converse can be true. Persistent pain despite intervention should raise concern for further investigation. An x-ray alone can reveal a destructive bone lesion as the source of shoulder pain.

Human knee synovial fluid cytokines correlated with grade of knee osteoarthritis--a pilot study.

UNLABELLED: The purpose of this pilot study was to evaluate the cytokine profile of human knee synovial fluid and correlate this with the subject's degree of articular cartilage degradation, radiographic score, and synovial histology. MATERIALS AND METHODS: Synovial fluid was withdrawn before knee meniscectomy in 12 subjects with varying degrees of osteoarthritis and assayed for 21 cytokines, using a multiplex cytokine assay and flow cytometry instrumentation. Articular cartilage surfaces were scored by a single orthopaedic surgeon on the basis of the International Cartilage Repair Society (ICRS) classification during the arthroscopy, and posterior-anterior knee radiographs were graded using the Kellgren-Lawrence (KL) classification. Synovial biopsies were taken in four zones at the time of surgery for histological analysis. RESULTS: Significant concentration differences in IL-2, IL-5, MCP-1, and MIP-1 were found between subjects with advanced arthritis and subjects with little or no arthritis on the ICRS scale (p < .05). No such differences could be appreciated using KL scores. There was no correlation between histology samples and visualized surface osteoarthritis. CONCLUSION: This data suggests a molecular basis of disease progression, with higher levels of cytokines indicative of greater degrees of osteoarthritis. These results add pilot data that can assist investigators in conducting a comparative observational study of the levels of inflammatory cytokines with radiologic and arthroscopic assessments of osteoarthritis.

Cryoablation and resection influences patient survival for soft tissue sarcomas: impact on survivorship and local recurrence.

Cryosurgical ablation has been used successfully for treating various carcinomas and bone tumors; however, few studies report the use of cryosurgery followed by tumor resection for the treatment of soft tissue sarcomas. We evaluated local recurrence, progression of disease, histologic necrosis from the cryoablation, complications, patient survival, and functional outcomes using this approach. We retrospectively reviewed 38 patients with no prior treatment for their neoplasm who underwent cryosurgery followed by wide excision of soft tissue sarcomas. Three patients developed local recurrence. Sixteen patients had evidence of more than 95% tumor necrosis, and 11 of these had 100% histologic necrosis. We observed a difference in overall survival and disease-free survival based on the adequacy of freezing process. Patients with more than 95% necrosis had a survival rate of 94% at 2 years and 86% at 5 years, while those with less than 95% necrosis survived 53% at 2 years and 34% at 5 years. Complications included transient neuropraxia (13%), superficial wound infections (8%), and seroma (21%). Cryosurgical ablation appears a safe and effective method of devitalizing tumor cells of soft tissue sarcomas.

Tumor necrosis has no prognostic value in neoadjuvant chemotherapy for soft tissue sarcoma.

Neoadjuvant chemotherapy for treatment of soft tissue sarcomas is controversial, and the correlation between local recurrence and survival is unclear. Histologic necrosis is a well-documented predictor of survival in patients with malignant bone tumors; however, the association is unknown in patients with soft tissue sarcomas. We assessed the prognostic significance of tumor necrosis for treatment of soft tissue sarcomas. We retrospectively collected data from 82 patients who received neoadjuvant chemotherapy for treatment of soft tissue sarcomas of the extremities. Patients had wide resections if tumors were high-grade, deep to the investing fascia, and had clear margins. We quantified the amount of necrosis and analyzed the relationship with local recurrence and overall survival. At an average followup of 65 months (range, 24-154 months), the 5-year local recurrence rates for patients with less than 95% and 95% or greater necrosis were 20% and 33%, respectively. The overall 5-year survivorship rates for patients with less than 95% necrosis and 95% or greater necrosis were 82% and 78%, respectively. There was no difference in recurrence-free survival or overall patient survival based on the amount of histologic necrosis. Tissue necrosis from neoadjuvant chemotherapy does not seem to predict outcome in soft tissue sarcomas.

Influence of cryosurgery on treatment outcome of low-grade chondrosarcoma.

Successfully managing low-grade chondrosarcomas with margins considered less than wide would minimize the need for extensive reconstruction. We report our experience using cryotherapy as an adjuvant to treat patients with low-grade intracompartmental chondrosarcomas. Ten consecutive patients had intralesional resections including curettage, cryo-surgery, and polymethylmethacrylate application. Eight of these patients required prophylactic skeletal stabilization. We retrospectively reviewed the outcomes for tumor recurrence, disease progression, and complications. The Musculo-skeletal Tumor Society rating scale was used to evaluate functional outcome, and the mean score was 27 points (range, 25-30 points). The mean age of the patients was 54.4 years (range, 29-83 years), and the average followup was 38.5 months (range, 24-60 months). Patients were treated for lesions of the femur (n = 3), humerus (n = 3), scapula (n = 2), tibia (n = 1), and acetabulum (n = 1). There was no evidence of recurrence or metastases. At the latest followup, all patients were well, however, one patient had hardware loosening. In this small group of patients, intralesional resection with adjuvant cryoablation provided an alternative to more radical procedures for low-grade intracompartmental chondrosarcoma.

A rare case of periosteal osteoblastoma located in the frontal cranial bone.

Periosteal osteoblastoma is an extremely rare bone-forming neoplasm located on the surface of cortical bone. Of the fewer than 30 cases of periosteal osteoblastomas found in the literature, 2 have been reported to be located in cranial bone, and these have not been documented in detail with clinical history, radiographic findings, macroscopic features, and microscopic findings. Although the differential diagnoses of periosteal lesions include parosteal and periosteal osteosarcoma, periosteal chondroma and chondrosarcoma, osteochondroma, osteoid osteoma, periostitis ossificans, and myositis ossificans, an important differential diagnosis both radiologically and pathologically of such a lesion in the cranium is meningioma. We report an unusual case of periosteal osteoblastoma located in the frontal cranial bone that was radiologically consistent with a meningioma. The differential diagnosis of metaplastic meningioma with differentiation toward bone is discussed.