Custom three-dimensional printed implants for reconstruction of oncologic pelvic defects.

The use of three-dimensional printed implants in the field of orthopedic surgery has become increasingly popular and has potentiated hip reconstruction in the setting of oncologic resections of the pelvis and acetabulum. In this review, we examine and discuss the indications and technical considerations for custom implant reconstruction of pelvic defects.

Transcutaneous Oximetry Does Not Reliably Predict Wound-healing Complications in Preoperatively Radiated Soft Tissue Sarcoma.

BACKGROUND: Surgical wound-healing complications after tumor resections in tissue that has been preoperatively radiated are a major clinical problem. Most studies have reported that complications occur in more than 30% of patients undergoing such resections in the lower extremity. There is currently no available method to predict which patients are likely to have a complication. Transcutaneous oximetry has been identified in preliminary studies as potentially useful, but the available evidence on its efficacy for this application thus far is inconclusive. QUESTIONS/PURPOSES: (1) Does transcutaneous oximetry measurement below 25 mmHg at any location in the surgical wound bed predict a wound-healing complication? (2) Does recovery (increase) in transcutaneous oxygen measurement during the rest period between the end of radiation and the time of surgery protect against wound-healing complications? METHODS: A prospective, multi-institution study was coordinated to measure skin oxygenation at three timepoints in patients undergoing surgery for a lower extremity soft tissue sarcoma after preoperative radiation. Between 2016 and 2020, the five participating centers treated 476 patients for lower extremity soft tissue sarcoma. Of those, we considered those with a first-time sarcoma treated with radiation before limb salvage surgery as potentially eligible. Based on that, 21% (98 of 476) were eligible; a further 12% (56 of 476) were excluded because they refused to participate or ultimately, they were treated with a flap, amputation, or skin graft. Another 1% (3 of 476) of patients were lost because of incomplete datasets or follow-up less than 6 months, leaving 8% (39 of 476) for analysis here. The mean patient age was 62 ± 14 years, 62% (24 of 39) of the group were men, and 18% (7 of 39) of patients smoked cigarettes; 87% (34 of 39) of tumors were intermediate/high grade, and the most common histologic subtype was undifferentiated pleomorphic sarcoma. In investigating complications, a cutoff of 25 mmHg was chosen based on a pilot investigation that identified this value. All patients were assessed for surgical wound-healing complications, which were defined as: those resulting in a return to the operating room, initiation of oral or IV antibiotics, intervention for seroma, or prolonged wound packing or dressing changes. To answer the first research question, we compared the proportion of patients who developed a wound-healing complication between those patients who had any reading below 25 mmHg (7 of 39) and those who did not (32 of 39). To answer the second question, we compared the group with stable or decreased skin oxygenation (22 of 37 patient measurements [two patients missed the immediate postoperative measurement]) to the group that had increased skin oxygen measurement (15 of 37 measurements) during the period between the end of radiation and the surgical procedure; again, the endpoint was the development of a wound-healing complication. This study was powered a priori to detect an unadjusted odds ratio for wound-healing complications as small as 0.71 for a five-unit (5 mmHg) increase in TcO 2 between the groups, with α set to 0.05, ß set to 0.2, and a sample size of 40 patients. RESULTS: We found no difference in the odds of a wound-healing complication between patients whose transcutaneous oxygen measurements were greater than or equal to 25 mmHg at all timepoints compared with those who had one or more readings below that threshold (odds ratio 0.27 [95% confidence interval (CI) 0.05 to 1.63]; p = 0.15). There was no difference in the odds of a wound-healing complication between patients who had recovery of skin oxygenation between radiation and surgery and those who did not (OR 0.63 [95% CI 0.37 to 5.12]; p = 0.64). CONCLUSION: Transcutaneous oximetry cannot be considered a reliable test in isolation to predict wound-healing complications. This may be a function of the fact that transcutaneous oximetry samples a relatively small portion of the landscape in which a wound-healing complication could potentially arise. In the absence of a reliable diagnostic test, clinicians must still use their best judgment regarding surgical timing and work to address modifiable risk factors to avoid complications. The unanswered question that remains is whether there is a skin perfusion or oxygenation issue at the root of these complications, which seems likely. Alternative approaches that can assess the wound more broadly and in real time, such as fluorescent probes, may be deserving of further investigation. LEVEL OF EVIDENCE: Level II, diagnostic study.

Soft-Tissue Masses: A Visual Guide to the Good, the Bad, and the Ugly.

Benign soft-tissue masses drastically outnumber malignant tumors. Both benign and malignant soft-tissue masses can present in the same manner, as a painless growing soft-tissue lump or bump. The implications of misdiagnosing a soft-tissue sarcoma can be devastating. The most common mistake occurs when all masses are assumed to be lipomas. A careful history, physical examination, and appropriate imaging can determine the benign or malignant nature of a tumor. A mass that is large (>5 cm), deep (in relation to investing fascia), and firmer than the surrounding muscle should raise suspicion for a malignancy. Small, superficial masses are more likely to be benign, but up to 32% of soft-tissue sarcomas can present in this manner. The orthopaedic surgeon should be able to recognize common imaging findings for benign and malignant entities.

Declining Geographic Access to High-Volume Revision Total Hip Arthroplasty Surgeons: A National Medicare Analysis.

BACKGROUND: While trends in the economics of revision THA (revTHA) procedures have been well-described from the standpoint of both hospitals and surgeons, their population-level effects of these trends on patient access are not well-understood. METHODS: The Medicare fee-for-service provider utilization and payment public use files were used to extract data for primary and revTHA for beneficiaries between 2013 and 2019. Primary and revTHA procedures were identified using the Healthcare Common Procedure Coding System code; 27130 for primaries and 27132, 27134, 27137, or 27138 for revisions. Geospatial analyses were performed by aggregating surgeon practice locations at the level of individual counties, hospital service areas, and hospital referral regions. RESULTS: The number of high-volume primary THA surgeons within the Medicare population increased by 17.6% over the study period (3,838 in 2013 to 4,515 in 2019). Conversely, the number of high-volume revTHA surgeons decreased by 36.1% (178 in 2013 to 129 in 2019). Linear regression revealed a significant increase and decrease in high-volume primary (ß = 109.07, P ≤ .001) and revision (ß = -13.04, P = .011) THA surgeons, respectively. Over the study period, the number of counties with at least 1 high-volume primary THA surgeon increased by 6.1% (1,194 to 1,267), while the number of counties with at least 1 high-volume revTHA surgeon decreased by 30.2% (159 to 111). CONCLUSION: The present findings of declining geographic access may represent a consequence of shifting economic incentives and declining reimbursements for the care of complicated revTHA patients.

NCCN Guidelines® Insights: Gastrointestinal Stromal Tumors, Version 2.2022.

Gastrointestinal stromal tumors (GIST) are the most common type of soft tissue sarcoma that occur throughout the gastrointestinal tract. Most of these tumors are caused by oncogenic activating mutations in the KIT or PDGFRA genes. The NCCN Guidelines for GIST provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with these tumors. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines, including revised systemic therapy options for unresectable, progressive, or metastatic GIST based on mutational status, and updated recommendations for the management of GIST that develop resistance to specific tyrosine kinase inhibitors.

Soft Tissue Sarcoma, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology.

Soft tissue sarcomas (STS) are rare malignancies of mesenchymal cell origin that display a heterogenous mix of clinical and pathologic characteristics. STS can develop from fat, muscle, nerves, blood vessels, and other connective tissues. The evaluation and treatment of patients with STS requires a multidisciplinary team with demonstrated expertise in the management of these tumors. The complete NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Soft Tissue Sarcoma provide recommendations for the diagnosis, evaluation, and treatment of extremity/superficial trunk/head and neck STS, as well as retroperitoneal/intra-abdominal STS, desmoid tumors, and rhabdomyosarcoma. This portion of the NCCN Guidelines discusses general principles for the diagnosis and treatment of retroperitoneal/intra-abdominal STS, outlines treatment recommendations, and reviews the evidence to support the guidelines recommendations.

The Potential Effects of Imposing a Body Mass Index Threshold on Patient-Reported Outcomes After Total Knee Arthroplasty.

BACKGROUND: Operative eligibility thresholds based on body mass index (BMI) alone may risk restricting access to improved pain control, function, and quality of life. This study evaluated the use of BMI-cutoffs to offering TKA in avoiding: 1) 90-day readmission, 2) one-year mortality, and 3) failure to achieve clinically important one-year PROMS improvement (MCID). METHODS: A total of 4126 primary elective unilateral TKA patients from 2015 to 2018 were prospectively collected. For specific BMI(kg/m2) cutoffs: 30, 35, 40, 45, and 50, the positive predictive value (PPV) for 90-day readmission, one-year mortality, and failure to achieve one-year MCID were calculated. The number of patients denied complication-free postoperative courses per averted adverse outcome/failed improvement was estimated. RESULTS: Rates of 90-day readmission and one-year mortality were similar across BMI categories (P > .05, each). PPVs for preventing 90-day readmission and one-year mortality were low across all models of BMI cutoffs. The highest PPV for 90-day readmission and one-year mortality was detected at cutoffs of 45 (6.4%) and 40 (0.87%), respectively. BMI cutoff of 40 would deny 18 patients 90-day readmission-free, and 194 patients one-year mortality-free postoperative courses for each averted 90-day readmission/one-year mortality. Such cutoff would also deny 11 patients an MCID per avoided failure. Implementing BMI thresholds alone did not influence the rate of improvements in KOOS-PS, KRQOL, or VR-12. CONCLUSION: Utilizing BMI cutoffs as the sole determinants of TKA ineligibility may deny patients complication-free postoperative courses and clinically important improvements. Shared decision-making supported by predictive tools may aid in balancing the potential benefit TKA offers to obese patients with the potentially increased complication risk and cost of care provision.

Does PET/CT Aid in Detecting Primary Carcinoma in Patients with Skeletal Metastases of Unknown Primary?

BACKGROUND: Patients older than 40 years presenting with osteolytic bone lesions are likely to have a diagnosis of carcinoma, even if they had no prior cancer diagnosis. For patients with no prior cancer diagnosis, there is a well-accepted algorithm to determine a potential primary site. That algorithm, however, leaves approximately 15% of people without a detectable primary tumor site, making treatment decisions extremely difficult. Positron emission tomography (PET) fused with CT, more commonly known as PET/CT, has emerged as an important staging modality for many other malignancies but has been used in a very limited fashion in musculoskeletal oncology. QUESTIONS/PURPOSES: We asked (1) What is the ability of PET/CT to detect the source of the primary tumor in patients with a skeletal metastasis of unknown primary? (2) How does PET/CT perform in detecting metastases in other sites in patients with a skeletal metastasis of unknown primary? METHODS: A retrospective analysis between 2006 and 2016 of the pathology database of a single tertiary center identified 35 patients with a biopsy-proven skeletal metastasis (histologically confirmed carcinoma or adenocarcinoma) and a PET/CT scan that was performed after the standard diagnostic evaluation of the primary cancer site. Patients were identified through use of our pathology database to identify all biopsy-proven bone carcinomas. This was then cross referenced with our imaging database to identify all patients who were at any time evaluated with PET/CT. During this time, we identified 1075 patients with biopsy-proven metastatic bone disease through our pathology database. Any indication for a PET/CT was included, and was most often done for staging of the identified malignancy or evaluation for the unknown source. Data regarding the ability of PET/CT to find or confirm the primary cancer and all metastatic sites were evaluated. The standard diagnostic evaluation (history and physical, laboratory evaluation, CT of the chest/abdomen/pelvis and whole body bone scan) identified the primary cancer in 22 of the 35 patients. Among the 35 patients, there were a total of 176 metastatic sites of disease identified, with 115 identified with the standard diagnostic evaluation (before PET/CT). RESULTS: Among patients with a skeletal metastasis of unknown primary, PET/CT was unable to identify the primary cancer in 12 of 13 patients. PET/CT confirmed the site of the known primary cancer in all 22 patients. There were 176 total metastatic sites. Of the 115 metastases known before PET/CT, PET/CT failed to identify three of 115 (3% false-negative rate). CONCLUSIONS: PET/CT may not provide any additional benefit over the standard evaluation for identification of the primary cancer in patients with a skeletal metastasis of unknown primary, although it may have efficacy as a screening tool equivalent or superior to the standard diagnostic algorithm for evaluation of the overall metastatic burden in these patients. LEVEL OF EVIDENCE: Level III, diagnostic study.

What Demographic and Clinical Factors Are Associated with In-hospital Mortality in Patients with Necrotizing Fasciitis?

BACKGROUND: Necrotizing fasciitis is a rare infection with rapid deterioration and a high mortality rate. Factors associated with in-hospital mortality have not been thoroughly evaluated. Although predictive models identifying the diagnosis of necrotizing fasciitis have been described (such as the Laboratory Risk Indicator for Necrotizing Fasciitis [LRINEC]), their use in predicting mortality is limited. QUESTIONS/PURPOSES: (1) What demographic factors are associated with in-hospital mortality in patients with necrotizing fasciitis? (2) What clinical factors are associated with in-hospital mortality? (3) What laboratory values are associated with in-hospital mortality? (4) Is the LRINEC score useful in predicting mortality? METHODS: We retrospectively studied all patients with necrotizing fasciitis at our tertiary care institution during a 10-year period. In all, 134 patients were identified; after filtering out patients with missing data (seven) and those without histologically confirmed necrotizing fasciitis (12), 115 patients remained. These patients were treated with early-initiation antibiotic therapy and aggressive surgical intervention once the diagnosis was suspected. Demographic data, clinical features, laboratory results, and treatment variables were identified. The median age was 56 years and 42% of patients were female. Of the 115 patients analyzed, 15% (17) died in the hospital. Univariate and receiver operating characteristic analyses were performed due to the low number of mortality events seen in this cohort. RESULTS: The demographic factors associated with in-hospital mortality were older age (median: 64 years for nonsurvivors [interquartile range (IQR) 57-79] versus 55 years for survivors [IQR 45-63]; p = 0.002), coronary artery disease (odds ratio 4.56 [95% confidence interval (CI) 1.51 to 14]; p = 0.008), chronic kidney disease (OR 4.92 [95% CI 1.62 to 15]; p = 0.006), and transfer from an outside hospital (OR 3.47 [95% CI 1.19 to 10]; p = 0.02). The presenting clinical characteristics associated with in-hospital mortality were positive initial blood culture results (OR 4.76 [95% CI 1.59 to 15]; p = 0.01), lactic acidosis (OR 4.33 [95% CI 1.42 to 16]; p = 0.02), and multiple organ dysfunction syndrome (OR 6.37 [95% CI 2.05 to 20]; p = 0.002). Laboratory values at initial presentation that were associated with in-hospital mortality were platelet count (difference of medians -136 [95% CI -203 to -70]; p < 0.001), serum pH (difference of medians -0.13 [95% CI -0.21 to -0.03]; p = 0.02), serum lactate (difference of medians 0.90 [95% CI 0.40 to 4.80]; p < 0.001), serum creatinine (difference of medians 1.93 [95% CI 0.65 to 3.44]; p < 0.001), partial thromboplastin time (difference of medians 8.30 [95% CI 1.85 to 13]; p = 0.03), and international normalized ratio (difference of medians 0.1 [95% CI 0.0 to 0.5]; p = 0.004). The LRINEC score was a poor predictor of mortality with an area under the receiver operating characteristics curve of 0.56 [95% CI 0.45-0.67]. CONCLUSIONS: Factors aiding clinical recognition of necrotizing fasciitis are not consistently helpful in predicting mortality of this infection. Identifying patients with potentially compromised organ function should lead to aggressive and expedited measures for diagnosis and treatment. Future multicenter studies with larger populations and a standardized algorithm of treatment triggered by high clinical suspicion can be used to validate these findings to better help prognosticate this potentially fatal diagnosis.Level of Evidence Level III, therapeutic study.

Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes.

BACKGROUND: The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS: This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS: Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS: Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.

Time to treatment initiation and survival in adult localized, high-grade soft tissue sarcoma.

BACKGROUND: Although shorter delays in soft tissue sarcoma (STS) diagnosis may improve overall survival (OS), the influence of time to treatment initiation (TTI) on OS in STS has not been determined. OBJECTIVE: To determine if TTI influences OS in localized, high-grade STS. METHODS: An analysis of the National Cancer Database identified 8648 patients meeting criteria with localized, high-grade STS diagnosed between 2004 and 2012. TTI and secondary variable associations with OS were determined using Kruskal-Wallis tests in univariate analyses, and a Cox regression multivariable model. RESULTS: In a multivariable Cox regression, TTI was associated with OS in a nonlinear fashion with a minimum hazard ratio (HR) demonstrated at 42 days. Secondary variables significantly associated (P < .05) with decreased OS included, advanced age, increased Charlson/Deyo score, nonprivate insurance, axial tumor location, tumor size more than 5 cm, stage III disease, and a nonsurgical treatment modality. CONCLUSIONS: Minimum HR was observed at a TTI of 42 days, with HR = 0.64, when compared with TTI = 1 day. Appropriate referrals to a higher volume sarcoma centers may account for these delays and explain a potential OS advantage. This is important in counseling patients, who may seek referral to a higher volume treatment center.

Upper extremity myxofibrosarcoma mimicking an erosive inflammatory arthritis: a case report.

Myxofibrosarcoma is a malignant fibroblastic soft tissue neoplasm containing a variable amount of myxoid stroma that commonly presents as a slow-growing mass in elderly patients. The neoplasm may be superficial or deep to the muscle fascia and characteristically has an infiltrative growth pattern with a dominant or multinodular mass. We describe an unusual case of high-grade myxofibrosarcoma of the wrist and forearm that infiltrated the muscles, tendons, and wrist joint, causing bone erosions. The tumor was mistakenly diagnosed as synovitis and a chronic, erosive, inflammatory process. The diffuse nature, absence of a dominant mass, and radiographic appearance complicated the diagnosis. Although neoplasms of the synovial spaces are rare, this case demonstrates that tumors with a highly infiltrative growth pattern can mimic inflammatory synovitis and that neoplasms should be considered in the differential diagnosis when clinical and laboratory features are discordant with the imaging appearance.

Adult soft tissue sarcoma and time to treatment initiation: An analysis of the National Cancer Database.

BACKGROUND: The primary goal of this investigation is to determine the current national standards for time to treatment initiation (TTI) in soft tissue sarcoma (STS). Additionally, we aim to identify the variables affecting TTI variability in STS. METHODS: An analysis of the National Cancer Database identified 41 529 patients diagnosed with STS between 2004 and 2013. Kruskall-Wallis tests identified differences between covariates regarding TTI. Negative binomial regression models identified variables that independently influenced TTI, and adjusted for confounders. RESULTS: The median TTI was 22.0 days and the mean TTI was 29.7 days. Longer TTI was correlated with transitions in care between institutions (Incidence rate ratio [IRR] = 1.76; P < 0.001), neoadjuvant radiotherapy (IRR = 1.53; P < 0.001), neoadjuvant systemic therapy (IRR = 1.40; P < 0.001), treatment at an academic center (IRR = 1.23; P < 0.001), Medicaid (IRR = 1.18; P < 0.001), being uninsured (IRR = 1.13; P = 0.001), and Medicare (IRR = 1.05 P = 0.016) status. Shorter TTI was correlated with tumor size >5 cm (IRR = 0.93; P < 0.001), high grade (IRR = 0.92; P = 0.015), truncal tumor site (IRR = 0.94; P = 0.003), and median income >$63 000 (IRR = 0.95; P = 0.028). CONCLUSIONS: The median TTI in the United States for STS is 22 days. Increased TTI in STS are associated with tumor and treatment characteristics, socio-economic factors and hospital systems issues. Transitions in care between institutions are responsible for the greatest increases.

Creating an Intraoperative MRI Suite for the Musculoskeletal Tumor Center.

BACKGROUND: Altered anatomy in a previously irradiated surgical bed can make accurate localization of anatomic landmarks and local recurrence nearly impossible. The use of intraoperative MRI (iMRI) has been described in neurosurgical settings, but to our knowledge, no such description has been made regarding its utility for local recurrence localization in sarcoma surgery. CASE DESCRIPTION: A 58-year-old female presented after previously undergoing two previous resection and reresection procedures of a myxoid liposarcoma located adjacent to her proximal femoral vasculature. After postoperative radiation therapy, she was referred to our institution where she underwent two additional reexcisions of local recurrences during a 3-year span, eventually undergoing a regional rotational muscle flap for coverage. Two years after her third reexcision procedure, she presented with two additional, nonpalpable surgical-bed local recurrences. After converting an MRI bed and scanner to allow for proximal thigh imaging in an iMRI surgical suite, the patient underwent a successful resection that achieved negative margins. To date, she remains without evidence of disease at 37 months. LITERATURE REVIEW: Real-time iMRI in neurosurgical studies has shown a high rate of residual disease leading to immediate subsequent reexcision, thus lending to improved rates of negative margin resection. To our knowledge, this is the first example using iMRI technology to remove a recurrent soft tissue sarcoma that otherwise was clinically nonlocalizable. CLINICAL RELEVANCE: The use of an iMRI surgical suite can aid with identification of soft tissue nodules in conditions such as an altered tumor bed from prior resection and radiotherapy, which otherwise make recurrences difficult to localize. A team approach between administration, surgeons, and engineers is required to design and pragmatically implement the use of an MRI-compatible table extension to enhance existing iMRI surgical suite technology for extremity sarcoma resection procedures.

Overutilization and Cost of Advanced Imaging for Long-Bone Cartilaginous Lesions.

BACKGROUND: The prevalence and cost of unnecessary advanced imaging studies (AIS) in the evaluation of long bone cartilaginous lesions have not been studied previously. METHODS: A total of 105 enchondromas and 19 chondrosarcomas arising in long bones from July 2008 until April 2012 in 121 patients were reviewed. Advanced imaging was defined as MRI, CT, bone scan, skeletal survey, or CT biopsy. Two blinded radiologists independently reviewed the initial imaging study and determined if further imaging was indicated based on that imaging study alone. The cost of imaging was taken from our institution's global charge list. Imaging was deemed unnecessary if it was not recommended by our radiologists after review of the initial imaging study. The difference in cost was calculated by subtracting the cost of imaging recommended by each radiologist from the cost of unnecessary imaging. The sensitivity and specificity for distinguishing enchondromas from chondrosarcomas was calculated. A minimum of 2 years from diagnosis of an enchondroma was required to monitor for malignant transformation. RESULTS: Of patients diagnosed with an enchondroma, 85 % presented with AIS. The average enchondroma patient presented with one unnecessary AIS. The radiologists' interpretations agreed 85 % of the time for enchondromas and 100 % for chondrosarcomas. The sensitivity and specificity for distinguishing enchondromas from chondrosarcomas was 95 % for one radiologist and 87 and 95 % for the other. The average unnecessary cost per enchondroma patient was $1,346.18. CONCLUSIONS: Unnecessary AIS are frequently performed and are a significant source of expense. The imaging algorithms outlined in this study may reduce unnecessary AIS.

MFH and high-grade undifferentiated pleomorphic sarcoma-what's in a name?

BACKGROUND AND OBJECTIVES: In 2002, with the advent of better classification techniques, the World Health Organization declassified malignant fibrous histiocytoma (MFH) as a distinct histological entity in favor of the reclassified entity high-grade undifferentiated pleomorphic sarcoma (HGUPS). To date, no study has evaluated comparative outcomes between patients designated historically in the MFH group and those classified in the new HGUPS classification. Our goal was to determine the presence of clinical prognostic implications that have evolved with this new nomenclature. METHODS: Sixty-eight patients were retrospectively evaluated between January 1998 and December 2007. Forty-five patients diagnosed with MFH between 1998 and 2003 were compared to 23 patients in the HGUPS group, from 2004 to 2007. Primary prognostic outcomes assessed included overall survival, metastatic-free, and local recurrence-free survival. RESULTS: Five-year survivorship between MFH and HGUPS populations, using Kaplan-Meier or competing risk methods, did not show statistical difference for overall survival (60% vs. 74%, P=0.36), 5-year metastasis-free survival (31% vs. 26%, P=0.67), or local recurrence-free survival (13% vs. 16%, P=0.62). CONCLUSION: Despite new classification nomenclature, there appears to be no identifiable prognostic implications for sarcomas that remain in the unclassifiable HGUPS group, as compared to the previously accepted MFH group.

Medical malpractice and sarcoma care--a thirty-three year review of case resolutions, inciting factors, and at risk physician specialties surrounding a rare diagnosis.

BACKGROUND: We reviewed medico-legal cases related to extremity sarcoma malpractice in order to recognize those factors most commonly instigating sarcoma litigation. METHODS: Over one million legal cases available in a national legal database were searched for malpractice verdicts and settlements involving extremity sarcoma spanning 1980-2012. We categorized verdict/settlement resolutions by state, year, award amount, nature of the complaint/injury, specialty of the physician defendant, and academic affiliation of defendant-amongst other variables. RESULTS: Of the 216 cases identified, 57% of case resolutions favored the plaintiff, with a mean indemnity payment of $2.30 million (range $65,076-$12.66 million). Delay in diagnosis (81%), unnecessary amputation (11%), and misdiagnosis (7%) accounted for the majority of complaints. The greatest numbers of claims were filed against primary care specialties (34%), orthopaedic surgeons (23%), and radiologists (12%). Individual state tort reform measures were not protective against case resolution outcome. CONCLUSIONS: Reported medico-legal claims involving sarcoma care continue to rise, with mean indemnity payments approaching 10 times that for other reported medical/surgical specialties. Primary care and orthopaedic specialties are the most commonly named physician defendants, citing a delay in diagnosis. This suggests further education in the front line diagnosis and management of sarcomas is needed.

Thirty-day readmission following total hip and knee arthroplasty - a preliminary single institution predictive model.

We sought to identify demographic or care process variables associated with increased 30-day readmission within the total hip and knee arthroplasty patient population. Using this information, we generated a model to predict 30-day readmission risk following total hip and knee arthroplasty procedures. Longer index length of stay, discharge disposition to a nursing facility, blood transfusion, general anesthesia, anemia, anticoagulation status prior to index admission, and Charlson Comorbidity Index greater than 2 were identified as independent risk factors for readmission. Care process factors during the hospital stay appear to have a large predictive value for 30-day readmission. Specific comorbidities and patient demographic factors showed less significance. The predictive nomogram constructed for primary total joint readmission had a bootstrap-corrected concordance statistic of 0.76.

Surgical Margins in Musculoskeletal Sarcoma.

¼ Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.¼ There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.¼ Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.¼ Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.

Accuracy of Time to Treatment Initiation Data in Musculoskeletal Soft Tissue Sarcoma.

Background: Time to treatment initiation (TTI) is a quality metric in cancer care. The purpose of this study is to determine the accuracy of TTI data from a single cancer center registry that reports to the National Cancer Database (NCDB) for sarcoma diagnoses. Methods: A retrospective analysis of a single Commission on Cancer (CoC)-accredited cancer center's tumor registry between 2006 and 2016 identified 402 patients who underwent treatment of a musculoskeletal soft tissue sarcoma and had TTI data available. Registry-reported TTI was extracted from the tumor registry. Effective TTI was manually calculated by medical record review as the number of days from the date of tissue diagnosis to initiation of first effective treatment. Effective treatment was defined as oncologic surgical excision or initiation of radiation therapy or chemotherapy. Registry-reported TTI and effective TTI values were compared for concordance in all patients. Results: In the entire cohort, 25% (99/402) of patients had TTI data discordance, all related to surgical treatment definition. For patients with a registry-reported value of TTI = 0 days, 74% (87/118) had a diagnostic surgical procedure coded as their first treatment event, with 73 unplanned incomplete excision procedures and 14 incisional biopsies. In these patients, effective TTI was on average 59 days (P < 0.001). For patients with a registry-reported value of TTI >0 days, only 4% (12/284) had discordant TTI values. Conclusions: Nearly three-fourths of patients with a registry-reported value of TTI = 0 days in a large, CoC-accredited cancer center registry had a diagnostic procedure coded as their first treatment event, though their effective treatment had not yet started. These data suggest that TTI is likely longer than what is reported to the NCDB. Redefinition of what constitutes surgical treatment should be considered to improve the accuracy of data used in measuring TTI in sarcoma.