Postoperative recurrence of desmoid tumors: clinical and pathological perspectives.

BACKGROUND: The clinical features and the pathological changes of desmoid tumors were studied to point out the key factors affecting the recurrence. METHODS: The clinical data and specimens of 56 patients who underwent desmoid tumor resection from 2003 to 2008 were reviewed. Possible clinical factors related to the postoperative recurrence were analyzed statistically. The specimens round the lesions were studied histopathologically. RESULTS: The overall recurrence rate was 39.3%. The postoperative recurrence rate of the patients with negative surgical margins and no tumor invasion of the major vessels and nerves was low (P < 0.05). However, the desmoid tumors could destroy the cortical bone and invade the medullary cavity. CONCLUSIONS: Desmoid tumors were pathologically benign, which could extensively invade tissues around the lesions. The invasion of major vessels and nerves and quality of surgical margins are the key factors for the high postoperative recurrence rate.

[Surgical treatment and prognostic analysis of osteosarcoma in adults older than 40 years].

OBJECTIVE: To determine the prognostic factors of primary osteosarcoma in adults. METHODS: This is a review of 54 patients older than 40 years (24 men and 30 women) who were treated between 1998 and 2011 at the authors' institution. Demographic information and follow-up data were obtained and statistically analyzed. RESULTS: Tumors involved the limbs in 30 patients (55.5%) and axial skeleton in 17 patients (31.5%), and arose from soft tissue in 7 patients (13%). And 6 patients (11.1%) had synchronous metastasis. According to our review, tumors were treated surgically in 52 patients (96.3%). Local recurrence was documented in 14 patients (26.9%). Metastasis after diagnosis appeared in 21 patients (38.9%). In the 52 patients who received the surgical treatment, the 5 year disease-free survival and overall survival rates were 43.7% and 50.4%, respectively. CONCLUSION: Adult patients with primary osteosarcoma had a poor clinical outcome. Inadequate surgical margins, more tumors in the axial location due to high recurrence rates, metastatic disease at presentation, and large tumor volumes were associated with significantly lower survival rates. Aggressive multi-agent treatment regimens might improve survival.

Endoprosthetic reconstruction for large extremity soft-tissue sarcoma with juxta-articular bone involvement: functional and survival outcome.

BACKGROUND: Large extracompartmental limb soft-tissue sarcoma with juxta-articular bone involvement poses major challenges in disease management. Radical resection of sarcoma frequently requires concomitant bone resection and reconstruction. We describe the clinical outcomes of endoprosthetic reconstruction and the complications associated with this procedure. METHODS: Thirty patients with soft-tissue sarcomas with local juxta-articular bone involvement in an extremity underwent surgery at our center between May 2004 and October 2011, 20 for primary sarcomas and 10 for local recurrences. Clinical data from those patients were analyzed retrospectively. The bone affected included the proximal femur (10 cases), the distal femur (nine cases), the proximal humerus (eight cases), the proximal tibia (two cases), or the total femur (one case). Wide excision of the tumor and the bone tissue involved was performed on every patient, followed by reconstruction of the subsequent defect using tumor endoprosthesis. All patients underwent regular follow-up for an average of 25 (range, 3-84) mo. RESULTS: Three patients had poor wound healing. Implant fractures leading to additional revisions occurred in two cases. Local tumor recurrence developed in four patients. There were 15 patients with lung metastases, and 11 patients died of disseminated metastases. In the latest follow-up, 14 patients survived free of disease and five were alive with tumors. The mean Musculoskeletal Tumor Society functional analysis for proximal femur, distal femur, proximal tibia, proximal humerus, and total femur were 90%, 82%, 73%, 71%, and 60%, respectively. The 2- and 5- y survival rates were 61.6% and 30.0%, respectively. CONCLUSIONS: Endoprosthetic reconstruction could yield satisfactory results as a wide excision and limb salvage therapeutic strategy for patients with large extracompartmental soft-tissue sarcomas with juxta-articular bone involvement. Acceptable complications occurred in the present report.

Energy and oxygen metabolism disorder during septic acute kidney injury.

BACKGROUND/AIMS: Acute kidney injury (AKI) during septic shock, which is one of the most common clinical syndromes in the intensive care unit (ICU), has a high mortality rate and poor prognosis, partly because of a poor understanding of the pathogenesis of renal dysfunction during septic shock. Although ischemic injury of the kidney has been reported to result from adenosine triphosphate (ATP) depletion, increasing evidence has demonstrated that AKI occurs in the absence of renal hypoperfusion and even occurs during normal or increased renal blood flow (RBF); nevertheless, whether energy metabolism disorder is involved in septic AKI and whether it changes according to renal hemodynamics have not been established. Moreover, tubular cell apoptosis, which is closely related to ATP depletion, rather than necrosis, has been shown to be the major form of cell injury during AKI. METHODS: We used canine endotoxin shock models to investigate the hemodynamics, renal energy metabolism, renal oxygen metabolism, and pathological changes during septic AKI and to explore the underlying mechanisms of septic AKI. RESULTS: The present results revealed that the nicotinamide adenine dinucleotide (NAD+) pool and the ATP/adenosine diphosphate (ADP) ratio were significantly decreased during the early phase of septic AKI, which is accompanied by a decreased renal oxygen extraction ratio (O2ER%) and decreased renal oxygen consumption (VO2). Furthermore, significant apoptosis was observed following renal dysfunction. RBF and renal oxygen delivery were not significantly altered. CONCLUSION: These results suggest that imbalanced energy metabolism, rather than tubular cell apoptosis, may be the initiator of renal dysfunction during septic shock.

Extracellular cold-inducible RNA-binding protein mediated neuroinflammation and neuronal apoptosis after traumatic brain injury.

Background: Extracellular cold-inducible RNA-binding protein (eCIRP) plays a vital role in the inflammatory response during cerebral ischaemia. However, the potential role and regulatory mechanism of eCIRP in traumatic brain injury (TBI) remain unclear. Here, we explored the effect of eCIRP on the development of TBI using a neural-specific CIRP knockout (KO) mouse model to determine the contribution of eCIRP to TBI-induced neuronal injury and to discover novel therapeutic targets for TBI. Methods: TBI animal models were generated in mice using the fluid percussion injury method. Microglia or neuron lines were subjected to different drug interventions. Histological and functional changes were observed by immunofluorescence and neurobehavioural testing. Apoptosis was examined by a TdT-mediated dUTP nick end labelling assay in vivo or by an annexin-V assay in vitro. Ultrastructural alterations in the cells were examined via electron microscopy. Tissue acetylation alterations were identified by non-labelled quantitative acetylation via proteomics. Protein or mRNA expression in cells and tissues was determined by western blot analysis or real-time quantitative polymerase chain reaction. The levels of inflammatory cytokines and mediators in the serum and supernatants were measured via enzyme-linked immunoassay. Results: There were closely positive correlations between eCIRP and inflammatory mediators, and between eCIRP and TBI markers in human and mouse serum. Neural-specific eCIRP KO decreased hemispheric volume loss and neuronal apoptosis and alleviated glial cell activation and neurological function damage after TBI. In contrast, eCIRP treatment resulted in endoplasmic reticulum disruption and ER stress (ERS)-related death of neurons and enhanced inflammatory mediators by glial cells. Mechanistically, we noted that eCIRP-induced neural apoptosis was associated with the activation of the protein kinase RNA-like ER kinase-activating transcription factor 4 (ATF4)-C/EBP homologous protein signalling pathway, and that eCIRP-induced microglial inflammation was associated with histone H3 acetylation and the α7 nicotinic acetylcholine receptor. Conclusions: These results suggest that TBI obviously enhances the secretion of eCIRP, thereby resulting in neural damage and inflammation in TBI. eCIRP may be a biomarker of TBI that can mediate the apoptosis of neuronal cells through the ERS apoptotic pathway and regulate the inflammatory response of microglia via histone modification.

[Surgical managements for bone metastases in tibia of 16 cases].

OBJECTIVE: To investigate the different surgical options for tibia metastatic disease and to evaluate the survival prognostic factors, postoperation function and complications. METHODS: A retrospective evaluation of 16 patients treated for tibia metastatic disease between Jan. 2000 and Feb. 2013 was conducted at our center. The underlying histology of the lesions showed metastatic lung carcinoma (five),breast carcinoma (three), bladder carcinoma (two), unknown (two), renal cell carcinoma, colon carcinoma, hepatic cellular cancer and lymphoma (one each). The locations of these lesions were proximal in 11 patients (with one patient having two synchronous lesions in the proximal metaphysis on both sides), diaphyseal in 4 patients, and distal metaphyseal in two patients. One patient presented with a pathologic fracture,and the risk of impending pathologic fracture of the remainders was evaluated by Mirels scoring system. Of all the 16 patients, 15 were treated surgically (with 16 operations performed). Six of them were reconstructed with proximal tibial replacement, 9 underwent curettage and cementation (with or without inner-fixations), and 1 patient had lower third calf amputation. We employed VAS scoring system to evaluate the pain intensity of the lesions before and after operation.The post-operation function was assessed by MSTS scoring system. The survival rate was described by Kaplan-Meier survival curve. RESULTS: Fourteen of all the patients were followed-up and enrolled in the research. The median postoperative survival was 7 months (1-72 months).The mean half year survival rate and 2-year survival rate were 57.14% and 8.9% respectively.The mean Mirels score was 9.8 ± 1.0. The mean VAS score before the operation was 7.62 ± 1.03, which turned out to be 1.36 ± 0.86 after the operation. The mean MSTS score for the endoprosthesis and curettage was 21.0 ± 0.63 and 23.1 ± 1.25 respectively. CONCLUSION: The mobidity of tibia metastatic diseases is very low.Surgical intervention, combined with the application of bisphosphonate and postoperative radiotherapy, is absolutely necessary for the treatment of tibial metastatic disease, contributing to an improved quality of life and limb function.

[Multicentric giant cell tumor: clinical analysis of 9 cases].

OBJECTIVE: To explore the clinical profiles, imaging features and prognosis of patient with multicentric giant cell tumor of bone (MGCT). METHODS: Nine MGCT patients treated at our hospital between 1997 and 2010 were retrospectively examined. They had two or more separate lesions of giant cell tumor. There were 5 males and 4 females with an average age of 23 (14-37) years. Three patients (33%) were under 20 years old. There were 29 tumors in the series with an average of 3.2 (range, 2-10) per patient. Among 6 of them, a second lesion did not develop for >2 years after initial presentation. There were >2 sites of tumor involvement (n = 4) and 10 lesions (n = 1). Two patients had synchronous lesions involves 2 isolated locations. Twenty-nine lesions were located in spine, rib, femur, tibia, foot, hand, fibula and humerus. Three lesions of 2 patients involved metaphysic of long bones, one of whom was skeletally immature. All lesions had the typical histological features of giant cell tumor. The tumors were treated with curettage or resection was performed according to location and the Campanacci grade. RESULTS: Twenty-two lesions underwent surgery in all 29 lesions of 9 patients. A total of 31 operations were performed. The average follow-up period was 6 (3-10) years.Four lesions of 2 patients had no recurrence during follow-up. Ten lesions (34%) relapsed in all 29 lesions and 4 operations were performed firstly at other hospitals.Seven patients had one or more recurrences with an average recurrence time of 2.5 years (range, 2 months-9 years).Six cases of local recurrence were within the first 2 years. Post-radiotherapy malignant transformation developed in 1 male patient with 10 lesions dying of malignant pulmonary metastasis. The total recurrence rate was similar to that of unifocal giant cell tumor. CONCLUSION: MGCTs are likely to occur more in a younger population than unifocal giant cell tumors. And its risk of recurrence depends on the type of surgery.It is similar to the risk of recurrence for unifocal GCT. MGCT has vessel-axial distribution and multicentric generation. Long-term follow-up is necessary.

[Surgical classification and therapeutic strategy for metastases of proximal femur].

OBJECTIVE: To establish a surgical classification system for metastases of proximal femur and discuss the therapeutic strategy with retrospective analysis and literature review. METHODS: The data of 99 patients who underwent a total of 102 operations for femoral metastatic lesions from January 2003 to December 2011 was analyzed. There were 50 males and 49 females, and the median age was 56 years (range 15-87 years). The most common diagnosis was lung cancer (30 cases), followed by breast cancer (17 cases). All femoral lesions were divided into 4 types (I-IV) with different anatomic site and biomechanic characteristic. The patients with various surgical reconstruction mode and postoperative follow-up data were recorded. RESULT: There were 65 side who received widely or marginal resection and 37 side who received intralesional resection. The patients were operated with bipolar hip prosthesis (n = 3), ordinary total hip replacement (THR) (n = 10), bipolar tumor prosthesis (n = 48), THR with tumor prosthesis (n = 8), intramedullary nailing (n = 21), and plate/screw (n = 12). The estimated survival for the 99 patients was 10.3 months. Type I, II, III and IV patients with postoperative American Society of bone and soft tissue tumors-93 rating were 86.5%, 77.3%, 81.3% and 69.1%. Patients with type IV were worse compared with the other 3 groups (t = 4.763, P = 0.031). The 10 operations were followed by complications of any kind. Complication rate of patients with type IV were 3/12, and it was significantly higher than the other 3 groups of patients (χ(2) = 4.018, P = 0.045). CONCLUSIONS: The classifications and corresponsive surgical methods for upper femur metastases had some superiority in hinting prognosis and guiding treatment.

[Surgical management and prognostic factors in patients with spinal metastatic tumors].

OBJECTIVE: To identify the survival prognostic factors and clinical outcome of the patients with spinal metastatic tumors and to discuss the surgical treatment strategy of spinal metastatic tumors. METHODS: The patients with spinal metastatic tumors who received surgeries during January 2003 to June 2012 were enrolled. The survival was analyzed by Kaplan-Meier survival curve. The prognostic factors, divided into patient-related factors, tumor-related factors and therapy-related factors, were analyzed univariately and multivariately by Cox comparative hazard model. RESULTS: There were 453 patients were enrolled in research including 263 male and 190 female patients with an average age of (56 ± 13) years (10-86 years). The median postoperative survival was 9 months. Local recurrences and peri-operative complications were found in 78 (17.2%) and 72 (15.9%) patients, respectively. Univariate analysis showed the significant prognostic factors for postoperative survival included poor preoperative general condition (χ(2) = 4.16), severe preoperative neurologic deficit(χ(2) = 10.23), not receiving bisphosphonate therapy(χ(2) = 10.47), short disease-free interval before spinal metastasis (χ(2) = 23.31), spinal metastasis as the first manifestation (χ(2) = 10.94), rapid-growth primary tumor(χ(2) = 15.45), visceral metastasis (χ(2) = 4.10), not receiving postoperative radiotherapy(χ(2) = 18.10) and not receiving post-operative sensitive systemic therapy(χ(2) = 11.20) (P < 0.05). Multivariate analysis showed the independent prognostic factors include severe preoperative neurologic deficit (P = 0.012, 95%CI: 1.11-2.30), short disease-free interval before spinal metastasis (P = 0.023, 95%CI:1.05-1.83), rapid-growth primary tumor (P = 0.000, 95%CI:1.74-3.06), visceral metastasis (P = 0.008, 95%CI: 1.08-1.68), not receiving postoperative radiotherapy (P = 0.000, 95%CI:1.38-2.35) and not receiving post-operative sensitive systemic therapy (P = 0.045, 95%CI:1.01-1.58). CONCLUSION: The prognostic factors for survival are useful for determining the indication of operation and improving survival and clinical outcome for patients with spinal metastatic tumors.

Single-cell transcriptome profiling of sepsis identifies HLA-DRlowS100Ahigh monocytes with immunosuppressive function.

BACKGROUND: Sustained yet intractable immunosuppression is commonly observed in septic patients, resulting in aggravated clinical outcomes. However, due to the substantial heterogeneity within septic patients, precise indicators in deciphering clinical trajectories and immunological alterations for septic patients remain largely lacking. METHODS: We adopted cross-species, single-cell RNA sequencing (scRNA-seq) analysis based on two published datasets containing circulating immune cell profile of septic patients as well as immune cell atlas of murine model of sepsis. Flow cytometry, laser scanning confocal microscopy (LSCM) imaging and Western blotting were applied to identify the presence of S100A9+ monocytes at protein level. To interrogate the immunosuppressive function of this subset, splenic monocytes isolated from septic wild-type or S100a9-/- mice were co-cultured with naïve CD4+ T cells, followed by proliferative assay. Pharmacological inhibition of S100A9 was implemented using Paquinimod via oral gavage. RESULTS: ScRNA-seq analysis of human sepsis revealed substantial heterogeneity in monocyte compartments following the onset of sepsis, for which distinct monocyte subsets were enriched in disparate subclusters of septic patients. We identified a unique monocyte subset characterized by high expression of S100A family genes and low expression of human leukocyte antigen DR (HLA-DR), which were prominently enriched in septic patients and might exert immunosuppressive function. By combining single-cell transcriptomics of murine model of sepsis with in vivo experiments, we uncovered a similar subtype of monocyte significantly associated with late sepsis and immunocompromised status of septic mice, corresponding to HLA-DRlowS100Ahigh monocytes in human sepsis. Moreover, we found that S100A9+ monocytes exhibited profound immunosuppressive function on CD4+ T cell immune response and blockade of S100A9 using Paquinimod could partially reverse sepsis-induced immunosuppression. CONCLUSIONS: This study identifies HLA-DRlowS100Ahigh monocytes correlated with immunosuppressive state upon septic challenge, inhibition of which can markedly mitigate sepsis-induced immune depression, thereby providing a novel therapeutic strategy for the management of sepsis.

[Evaluation of efficacy and safety of rivaroxaban in the prevention of postoperative venous thromboembolism in adult patients with primary bone tumor undergoing knee operation].

OBJECTIVE: To explore the incidence of postoperative venous thromboembolism (VTE) in adult patients with primary bone tumor undergoing knee operation and evaluate its efficacy and safety in the prevention of VTE. METHODS: For this prospective, randomized and negative-control single-center trial, a total of 100 eligible patients were selected and randomly divided into observation and control groups. Observation group (rivaroxaban): the first rivaroxaban tablet was taken in the first 24 hours after operation. Rivaroxaban was administered daily every 24 hours up to Day 14. CONTROL GROUP: no anticoagulant was taken postoperatively. RESULTS: Efficacy indictors: 6 cases of DVT (an incidence of 12%) occurred in the observation group versus 15 (30%) in the control group. Significant statistical difference existed between two groups (P < 0.05). Furthermore, neither pulmonary embolism nor death was found in either group. Safety indicators:a total of 3 bleeding (1 major and 2 non-major) cases occurred in observation group versus a total of 2 bleeding (no major and 2 non-major) cases in control group. No significant statistical difference existed in bleeding events (P > 0.05). The total incidence of adverse effect was 6% (3/50) in the observation group. The drainage volume of the observation group was a little more than that of the control group. But no significant statistical difference existed in drainage duration (P > 0.05). And there was almost no change in the coagulation system by laboratory examination after oral administration. CONCLUSION: With an excellent safety profile and a low incidence of adverse effects, Rivaroxaban is effective and safe in the prevention of VTE in adult patients with primary bone tumor undergoing knee operation.

G1 cell cycle arrest signaling in hepatic injury after intraperitoneal sepsis in rats.

OBJECTIVE AND DESIGN: Hepatocytes emerge from a quiescent state into a proliferative state to recover from septic injury. We hypothesize that hepatocyte cell cycle regulation after sepsis potentially contributes to the recovery of liver function. METHODS: An animal model of sepsis was induced by cecal ligation and puncture (CLP) in rats. At serial time points after CLP, hepatocyte expression of p21, P53, cyclin D1, cyclin E, CDK2, CDK4 and PCNA was determined by immunoblot analysis, and the DNA content of isolated hepatocytes was analyzed using flow cytometry. RESULTS: Sepsis-induced liver injury of rats was associated with G1 cell cycle arrest. Recovery of liver function was related to cell cycle progression 48 h after CLP. The upregulation of p53 and p21 correlated with G1 cell arrest 48 h after CLP. The upregulation of cyclin D1/CDK4 and cyclin E/CDK2 also correlated with the G1/S transition 48 h after CLP, resulting in PCNA expression. CONCLUSIONS: The data suggests that G1 cell cycle arrest and p53, p21, CDKs, cyclins and PCNA expression may be involved in the injury/recovery of liver function after intraperitoneal sepsis.

[Retrospective analysis of surgical treatment for metastases in humerus of 59 cases].

OBJECTIVE: To evaluate different operative treatment options for patients with metastases of the humerus focusing on surgical procedures, complications, function, and survival rate. METHODS: From 2000 to 2009, 62 bone metastases of the humerus in 59 patients were surgically treated in our institutions. Histological types were of lung (n=19), myeloma (n=10), breast (n=8), kidney (n=5), gastrointestinal tract (n=2), thyroid (n=2), prostate (n=1), bile duct (n=1), larynx (n=1), ovarian (n=1), melanoma (n=1) and unknown tumors (n= 8). Severe osteolytic lesions close to the shoulder and elbow joint were treated with resection and endoprosthetic replacement (n=32). Twenty-eight metasteses were stabilized by intramedullary locked nailing (17 cases) or plate/screws (11 cases) with polymethylmethacrylate-assisted reconstruction. The remaining 2 lesions were treated with amputation because of wide tumor contaminations after pathological fracture. Mirels' rating system was used to predict the risk of pathological fracture. The function of the upper limb was assessed using the Musculoskeletal Tumor Society (MSTS) rating scale and survival rate was retrospectively analyzed. RESULTS: The mean survival time of patients after surgery was 9.6 months. The mean Mirels' score for impending pathologic fractures was 9.3. Complications of endoprosthetic replacement recorded included disease relapse (n=2) and soft tissue infection (n=1), whereas, for intramedullary locked nailing and plate/screws fixation, there were two cases of local recurrence, one case of plate/screw break and one case of radial nerve palsy. The mean MSTS score for the follow-up was 71% for endoprosthesis and 75.1% for locked intramedullary nailing or plate/screws fixation. CONCLUSION: Immediate stability and pain relief were the main purpose of surgical procedures to treat humerus metastases. Radiotherapy was only a local treatment; however systemic therapies, such as chemotherapy, hormonotherapy and bisphophonate play a critical role in increasing survival rate of bone metastatic patients.

[Effects of central venous pressure on acute kidney injury in septic shock].

OBJECTIVE: To investigate the effects of central venous pressure on acute kidney injury (AKI) in septic shock. METHODS: A total of 86 septic shock patients with PiCCO (pulse indicator continuous cardiac output) monitoring admitted at our department from January 2009 to January 2011 were retrospectively studied. They were divided into 2 groups based on central venous pressure (CVP) at 24 hs after PiCCO monitoring. There were 41 cases in low CVP group (CVP ≤ 10 mm Hg and 45 cases in high CVP group (CVP > 10 mm Hg). Their hemodynamic data, lactate concentration, ScvO2 (central venous oxygen saturation), APACHEII (acute physiology & chronic health evaluation II) score and serum creatinine were obtained at the beginning and 24 hours after PiCCO monitoring. The incidence and mortality of AKI, the outcome of these patients in ICU and at Day 28 post-diagnosis were recorded. RESULTS: (1) The incidences of AKI were 51.2% (21/41) and 75.6% (34/45) in low and high CVP groups respectively; (2) Nine cases (22.0%) died in ICU in low CVP group and 20 cases (44.4%) in high CVP group. And 12 cases (29.3%) died within 28 days in low CVP group while 21 cases (46.7%) in high CVP group. CONCLUSION: A high CVP may increase the incidence and morbidity of AKI in septic shock. And an excessively high CVP should be prevented.

[Evaluation of prognostic factors for synovial sarcoma].

OBJECTIVE: To determine the independent prognostic factors of primary synovial sarcoma. METHODS: The clinical data of 52 patients followed up from 66 patients with synovial sarcoma treated between September 1997 and September 2008 was analyzed retrospectively. There were 28 male and 24 female patients aged from 11 to 71 years old. Three and five-year overall survival (OS), recurrence rate and 9 prognostic factors were analyzed in this study. Univariate and multivariate analysis were performed to determine the prognostic factors of OS. RESULTS: Fifty-two patients were followed up with the follow-up time ranged from 6 to 88 months (median 32 months). The 3-, 5-year overall survival rate and local recurrence rate were 52.8%, 30.3% and 32.7% respectively. Univariate showed tumor size < 5 cm, tumor located at extremities, adequate surgical margin and radical resection combined with radiotherapy had better survival rate (P < 0.05). Multivariate analysis demonstrated that tumor size, primary site and adequate surgical margin were independent prognostic factors for OS. Patients received radical resection combined with radiotherapy have longer median relapse time (25 months) compared with marginal resection combined with radiotherapy (18 months) and single radical resection (12 months). Thirty-five (67%) patients were treated with chemotherapy and seventeen (33%) patients received no chemotherapy for the primary tumor. Treatment with chemotherapy was not associated with an improved OS (P = 0.52). CONCLUSIONS: The independent prognostic factors of synovial sarcoma are tumor size, primary site and adequate surgical margin. Doxorubicin and ifosfamide based chemotherapy was not associated with an improved OS in patients with synovial sarcoma. Radical resection combined with radiotherapy can best control local condition.

[An analysis of prognostic factors for malignant fibrous histiocytoma of bone].

OBJECTIVE: To study the risk factors related to the survival rate, recurrence and metastasis of malignant fibrous histiocytoma of bone. METHODS: From July 1997 and July 2010, 56 patients with malignant fibrous histiocytoma of bone were treated. Univariate and multivariate analysis were performed to determine the probable risk factors including gender, age, tumor location, tumor size and so on. RESULTS: Forty-four cases were followed up ranged from 2 weeks to 78 months (medium 33.3). The 5-year overall survival rate was 50.1%, local recurrence rate 40.9% with a median time of 12 months (3 to 60 months) and metastatic rate 27.5% (11/40) with a median time of 6.5 months (2 to 23 months). Univariate analysis indicated that gender, condition of presentation (primary case or recurrence case), tumor location, surgical margin and surgical stage were significantly related to survival rate (P < 0.05), and tumor location and surgical margin were related to local recurrence rate (P < 0.05), and important vessel or nerve invasion was related to metastatic rate (P < 0.05). Multivariate analysis showed that surgical margin and surgical stage were independent risk factors for survival rate, of which surgical margin was the independent risk factor for recurrence rate. CONCLUSIONS: Surgical margin and surgical stage are independent risk factors for survival rate, of which surgical margin is the independent risk factor for recurrence rate.

Surgical Treatment and Proposed Modified Classification for Harrington Class III Periacetabular Metastases.

OBJECTIVES: This study aims to: (i) evaluate the outcome of patients with Harrington class III lesions who were treated according to Harrington classification; (ii) propose a modified surgical classification for Harrington class III lesions; and (iii) assess the efficiency of the proposed modified classification. METHODS: This study composes two phases. During phase 1 (2006 to 2011), the clinical data of 16 patients with Harrington class III lesions who were treated by intralesional excision followed by reconstruction of antegrade/retrograde Steinmann pins/screws with cemented total hip arthroplasty (Harrington/modified Harrington procedure) were retrospectively reviewed and further analyzed synthetically to design a modified surgical classification system. In phase 2 (2013 to 2019), 62 patients with Harrington class III lesions were classified and surgically treated according to our modified classification. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) 93 scoring system. The outcome of local control was described using 2-year recurrence-free survival (RFS). Owing to the limited sample size, we considered P < 0.1 as significant. RESULTS: In phase 1, the mean surgical time was 273.1 (180 to 390) min and the mean intraoperative hemorrhage was 2425.0 (400.0 to 8000.0) mL, respectively. The mean follow-up time was 18.5 (2 to 54) months. Recurrence was found in 4 patients and the 2-year RFS rate was 62.4% (95% confidence interval [CI] 31.6% to 93.2%). The mean postoperative MSTS93 score was 56.5% (20% to 90%). Based on the periacetabular bone destruction, we categorized the lesions into two subgroups: with the bone destruction distal to or around the inferior border of the sacroiliac joint (IIIa) and the bone destruction extended proximal to inferior border of the sacroiliac joint (IIIb). Six patients with IIIb lesions had significant prolonged surgical time (313.3 vs 249.0 min, P = 0.022), massive intraoperative hemorrhage (3533.3 vs 1760.0 mL, P = 0.093), poor functional outcome (46.7% vs 62.3%, P = 0.093), and unfavorable local control (31.3% vs 80.0%, P = 0.037) compared to the 10 patients with IIIa lesions. We then modified the surgical strategy for two subgroup of class III lesions: Harrington/modified Harrington procedure for IIIa lesions and en bloc resection followed by modular hemipelvic endoprosthesis replacement for IIIb lesions. Using the proposed modified surgical classification, 62 patients in the phase 2 study demonstrated improved surgical time (245.3 min, P = 0.086), intraoperative hemorrhage (1466.0 mL, P = 0.092), postoperative MSTS 93 scores (65.3%, P = 0.067), and 2-year RFS rate (91.3%, P = 0.002) during a mean follow-up time of 19.9 (1 to 60) months compared to those in the phase 1 study. CONCLUSION: The Harrington surgical classification is insufficient for class III lesions. We proposed modification of the classification for Harrington class III lesions by adding two subgroups and corresponding surgical strategies according to the involvement of bone destruction. Our proposed modified classification showed significant improvement in functional outcome and local control, along with acceptable surgical complexity in surgical management for Harrington class III lesions.

[The survival and functional outcome of primary bone sarcomas in distal lower extremity].

OBJECTIVE: To analyze the oncological and functional outcome of limb salvage in this location. METHODS: From November 2003 to January 2010, 20 patients with primary malignant bone tumors of the distal lower extremity were treated. There were 15 male and 5 female, the mean age was 20 years. Among 14 patients with malignant distal tibial sarcoma, 11 patients had ankle arthrodesis reconstructed by using allograft (7 patients) or autografts (4 patients), the other 3 patients underwent below-knee amputation. Three patients with osteosarcoma of distal fibula reconstructed with ipsilateral fibular head, 3 patients with calcaneus osteosarcoma underwent total calcanectomy and reconstructed with fibular segment and iliac crest. The mean follow-up was 36.4 months. RESULTS: Five of 7 (71.4%) patients with allograft reconstruction were associated with delayed wound healing, however, only 1 of 10 patients with autograft had this problem (P = 0.036). One local recurrence was observed, 2 osteosarcoma patients died of disseminated disease. The estimated 2-year and 5-year overall survival for the patients with malignant tibial sarcomas were 92.9% and 79.6% respectively, for the patients with distal tibial high-grade osteosarcoma were 87.5% and 70.0% respectively. The mean functional MSTS score was 82% for limb salvage patients. CONCLUSIONS: The survival of patients with primary malignant bone tumor of distal lower extremity seems to be better than that of other sites. Limb salvage can provide satisfactory local control and functional results.

[Ewing's sarcoma of bone:treatment results and prognostic factors].

OBJECTIVE: To determine the prognostic factors from the view of clinic and pathology. METHODS: A retrospective analysis was performed on a data set of 78 patients with Ewing's sarcoma treated at Peking University People's Hospital Musculoskeletal tumor center between July 1998 and July 2007. Five-year overall survival (OS), recurrence rate and prognostic factors were analyzed in this study. Univariate and multivariate analysis were performed to determine the prognostic factors for OS. RESULTS: Fifty-three cases were followed up, follow-up time ranged from 8.0 to 101.0 months (median 37.6 months). The 5-year overall survival rate and local recurrence rate were 33.7% and 20.8% respectively. Univariate showed age < 20 years, metastases free at diagnosis, tumor located at extremities, tumor size < 10 cm, adequate surgical margin had better survival rate (all P < 0.05). Multivariate analysis demonstrated that metastases at diagnosis, primary site and tumor size were independent prognostic factors for OS. CONCLUSION: The independent prognostic factors Ewing's sarcoma are metastases at diagnosis, primary site, tumor size.

Expert recommendations on blood purification treatment protocol for patients with severe COVID-19.

Coronavirus disease (COVID-19) was first diagnosed in Wuhan in December 2019. The World Health Organization defined the subsequent outbreak of COVID-19 worldwide as a public health emergency of international concern. Epidemiological data indicate that at least 20% of COVID-19 patients have severe disease. In addition to impairment of the respiratory system, acute kidney injury (AKI) is a major complication. Immune damage mediated by cytokine storms and concomitant AKI is a key factor for poor prognosis. Based on previous experience of blood purification for patients with severe acute respiratory syndrome and Middle East respiratory syndrome combined with clinical front-line practice, we developed a blood purification protocol for patients with severe COVID-19. This protocol is divided into four major steps. The first step is to assess whether patients with severe COVID-19 require blood purification. The second step is to prescribe a blood purification treatment for patients with COVID-19. The third step is to monitor and adjust parameters of blood purification. The fourth step is to evaluate the timing of discontinuation of blood purification. It is expected that blood purification will play a key role in effectively reducing the mortality of patients with severe COVID-19 through the standardized implementation of the present protocol.