Comparison of Features and Outcomes of Undifferentiated Pleomorphic Sarcoma of Bone and Soft Tissue.

BACKGROUND: This investigation compared outcomes of patients with undifferentiated pleomorphic sarcoma of soft tissue (UPS-S) to UPS of bone (UPS-B). METHODS: The Surveillance, Epidemiology, and End Results database was reviewed from 1975-2016. Disease-specific survival (DSS) was estimated using Kaplan-Meier, and a multivariable Cox regression model identified factors prognostic of DSS. The UPS-S cohort consisted of 4529 patients and the UPS-B cohort consisted of 200 patients. The smaller UPS-B cohort was bootstrapped to create a size-matched cohort of 4500 patients. RESULTS: The median age of patients with UPS-S was 67 (54;78) y compared to 55 (40;69) y for UPS-B patients (P < 0.001). For UPS-S, the median DSS was 317 mo compared to 70 for UPS-B (P = 0.020). On multivariable analysis for UPS-S, age (HR, 1.018; 95% CI, 1.01-1.03; P < 0.001), non-extremity tumors (HR, 1.490; 95% CI 1.14-1.95; P = 0.004), and AJCC Stage III (HR, 2.238; 95% CI 1.2-4.17; P = 0.011), and Stage IV (HR, 9.388; 95% CI 4.69-18.79; P < 0.001) disease were negative prognostic factors, while surgery (HR 0.234; 95% CI, 0.16-0.34; P < 0.001) was a positive prognostic factor. For UPS-B, tumor size > 8 cm (HR, 3.101; 95% CI, 1.09-8.75; P = 0.033) was the only prognostic factor identified. CONCLUSIONS: The current study found a strong association between surgery and survival for UPS-B patients on a univariable analysis, but no treatment type was associated with survival in a multivariable model. Further research is needed to reliably inform the optimal treatment of these patients.

Extraskeletal myxoid chondrosarcoma: Clinicopathological features and outcomes from the United States sarcoma collaborative database.

BACKGROUNDS AND OBJECTIVES: This investigation described clinicopathological features and outcomes of extraskeletal myxoid chondrosarcoma (EMC) patients. METHODS: EMC patients were identified from the United States Sarcoma Collaborative database between 2000 and 2016. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and prognostic factors were analyzed. RESULTS: Sixty individuals with a mean age of 55 years were included, and 65.0% (n = 39) were male. 73.3% (n = 44) had a primary tumor. A total of 41.6% (n = 25) developed tumor relapse following resection. The locoregional recurrence rate was 30.0% (n = 18/60), and mean follow-up was 42.7 months. The 5-year OS was 71.0%, while the 5-year RFS was 41.4%. On multivariate analysis for all EMC, chemotherapy (hazard ratio [HR], 6.054; 95% confidence interval [CI], 1.33-27.7; p = 0.020) and radiation (HR, 5.07, 95% CI, 1.3-20.1; p = 0.021) were independently predictive of a worse RFS. Among patients with primary EMC only, the 5-year OS was 85.3%, with a 30.0% (n = 12) locoregional recurrence rate, though no significant prognostic factors were identified. CONCLUSIONS: Long-term survival with EMC is probable, however there exists a high incidence of locoregional recurrence. While chemotherapy and radiation were associated with a worse RFS, these findings were likely confounded by recurrent disease as significance was lost in the primary EMC-only subset.

The clinical utility of next-generation sequencing for bone and soft tissue sarcoma.

Background: Sarcomas are a rare and heterogeneous tumor group composed of a variety of histologic subtypes. Targeted next-generation sequencing (NGS) of bone and soft tissue sarcomas is a nascent field with limited evidence for its use within clinical practice. Therefore, further research is needed to validate NGS in sarcoma and assess the clinical utility of these techniques with the hope of improving treatment options.Methods: Comprehensive molecular profiling with NGS was performed on 136 tumors (116 soft tissue, 20 bone) using two commercial vendors. Patient records were retrospectively reviewed, and the clinical impact of NGS-related findings were qualitatively analyzed to determine actionable mutations and number of changes in treatment.Results: The median age was 55.0 years (IQR 42-67 years), and most patients were non-metastatic at presentation (80.9%, n = 110). Prior to performing NGS, 72.1% (n = 98) were treated with a mean 1.1 ± 1.2 lines of systemic chemotherapy. NGS identified 341 putative alterations with at least one mutation present in 89.7% (n = 122) of samples. In a subset of 111 patients with available TMB data, 78.7% (n = 107) had a low (<6 m/Mb) mutational burden. Among all 136 cases, 47.1% (n = 64) contained clinically actionable alterations, and 12 patients had a change in medical treatment based on NGS. Those who underwent a treatment change all had metastatic or recurrent disease; three of these patients experienced a clinical benefit.Conclusion: Most bone and soft tissue sarcomas harbor at least one genetic alteration, and it appears a sizeable number of tumors contain mutations that are clinically actionable. While a change in treatment based off NGS-related findings occurred in 12 cases, three patients experienced a clinical benefit. Our data provide further proof-of-concept for NGS in sarcoma and suggest a clinical benefit may be observed in select patients.

Tumors and Tumorlike Conditions of Which Every Orthopaedic Surgeon Should Be Aware.

All orthopaedic surgeons during the course of their career will likely encounter both benign and malignant musculoskeletal neoplasms. Given the rarity of these entities and the stress conferred by diagnosing a tumor or tumorlike condition, many orthopaedic surgeons may benefit from a review of the contemporary treatment of such patients. Whether in the outpatient clinic or following a high-energy trauma, special attention should be given to concerning signs and symptoms that will aid in the workup of children and adults with a possible tumor. A thorough and logical workup in this manner will often lead to a definitive diagnosis such as metastatic bone disease or perhaps a benign lesion. In these instances, the informed general orthopaedic surgeon or subspecialist may choose to treat the patient independently. However, if the workup is inconclusive or if the diagnosis is even questionably malignant, referral to an orthopaedic oncologist should be sought as to avoid pitfalls in diagnosis and treatment.

A Population-based Analysis of Lymph Node Metastasis in Extremity Soft Tissue Sarcoma: An Update.

BACKGROUND: Soft tissue sarcomas (STSs) are mesenchymal tumors that may rarely metastasize to lymph nodes. This investigation sought to evaluate regional lymph node metastasis (RLNM) in extremity STS using a national cohort. MATERIALS AND METHODS: This study was a retrospective review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016. A Cox proportional hazards model was used to identify prognostic factors associated with disease-specific survival (DSS). RESULTS: RLNM was present in 3.7% (n = 547) of extremity STS. The rate of RLNM was highest in rhabdomyosarcoma (26.7%), clear cell sarcoma (18.8%), epithelioid sarcoma (14.5%), angiosarcoma (8.1%), spindle cell sarcoma (5.0%), and synovial sarcoma (3.2%). The 5-year DSS probability without RLNM was 69% (standard error: 1.3%) compared to 26% (standard error: 3.6%) with RLNM (P < 0.001). For the historically high-risk extremity STS, advanced age (hazard ratio (HR), 1.036; 95% confidence interval (CI), 1.0-1.04; P < 0.001), higher grade tumors (HR, 1.979; 95% CI, 1.3-3.0; P < 0.001), tumor size greater than 10 cm (HR, 1.892; 95% CI, 1.3-2.7; P < 0.001), primary site surgery (HR, 0.529; 95% CI, 0.3-0.8; P = 0.006), distant metastasis (HR, 4.585; 95% CI, 3.0-6.8; P < 0.001), and RLNM (HR, 2.153; 95% CI, 1.3-3.5; P = 0.003) were each independent disease-specific prognostic factors. CONCLUSIONS: The prognosis of RLNM in historically high-risk extremity STS is poor with a 5-year DSS of 26%. These data support a staging system of STS inclusive of nodal involvement and contribute to the growing body of evidence that characterizes the rates of RLNM in STS.

Comparison of clinicopathological features and outcomes in patients with primary leiomyosarcoma of bone and soft tissue.

BACKGROUNDS AND OBJECTIVES: This investigation sought to describe the outcomes of primary leiomyosarcoma of bone (PLB) compared to soft tissue leiomyosarcoma (SLMS). METHODS: This was a review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016. Kaplan-Meier methods were used to estimate disease-specific survival (DSS), and a Cox regression model was used to identify prognostic factors. RESULTS: Of the 7502 identifiable cases, 1% (n = 74) were PLB and 99% (n = 7428) were SLMS. Survival was the same between PLB and SLMS (p = .209). On multivariable analysis for high-grade SLMS, radiation (neoadjuvant: hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.4-0.8; p = .003; adjuvant: HR, 0.75; 95% CI, 0.6-0.9; p = .008) and surgery (procedure specific) improved DSS. For PLB, wide resection/limb salvage (HR, 0.40; 95% CI, 0.3-0.5; p = .018) and amputation (HR, 0.69; 95% CI, 0.5-0.9; p < .001) were positive prognostic factors. Neither radiation nor chemotherapy were prognostic factors for survival in PLB. CONCLUSIONS: For SLMS, radiation portends a survival advantage. For PLB, however, neither chemotherapy nor radiation were significant prognostic factors, which suggests the optimal treatment for PLB, similar to other primary soft tissue sarcomas originating in bone, remains an unmet medical need.

The prognostic significance of lymphovascular tumor invasion in localized high-grade osteosarcoma: Outcomes of a single institution over 10 years.

BACKGROUNDS AND OBJECTIVES: Lymphovascular invasion (LVI) has shown evidence of an association with worse survival in high-grade osteosarcoma patients. The purpose of this investigation was to prognosticate LVI as a predictor of survival. METHODS: This was a retrospective review of high-grade, localized osteosarcoma patients over a consecutive 10-year period. Proportional hazards regression was used to identify prognostic factors. Cumulative mortality incidence was estimated with recurrence as a competing risk. RESULTS: Forty-two cases with a median follow-up of 64 months (range, 6-158 months) were reviewed. LVI was present in 21.4% (n = 9) cases. The five- and ten-year survivals in LVI (+) were 40% and 20%, compared to 93% and 81% in LVI (-), respectively (p < .001). After controlling for confounders, advanced age (hazards ratio [HR], 1.134; 95% confidence interval [CI], 1-1.2; p = .01) and LVI (HR, 21.768; 95% CI, 3-135; p = .001) were negative prognosticators. The cumulative incidence of recurrence was no different between LVI (+) and LVI (-) (p = .811), though the incidence of mortality was significantly higher in LVI (+) (p = .003). CONCLUSION: The presence of LVI in the setting of high-grade, localized osteosarcoma is associated with greater rates of mortality and appears to portend a dismal prognosis.

Rare Dedifferentiated Periosteal Chondrosarcoma with 11-Year Metastatic Relapse: A Case Report.

A 50-year-old man presented for evaluation of a periscapular mass. Biopsy suggested a low-grade chondrosarcoma; however, the resected specimen revealed a grade 2 chondrosarcoma with a low-grade dedifferentiated mesenchymal component. The mass multiply recurred as chondrosarcoma without a dedifferentiated component before the patient developed lung metastases of chondrosarcoma without a dedifferentiated component 11 years after the initial diagnosis and died of disease. This is one of the first reported cases of a dedifferentiated chondrosarcoma with low-grade dedifferentiated component. While overall prognosis may be better than in typical dedifferentiated chondrosarcoma, this tumor demonstrated numerous local recurrences as well as metastasis.

Hypoalbuminemia Increases Mortality after Two-Stage Revision Total Joint Arthroplasty.

Objectives: This study aimed to evaluate the effect of hypoalbuminemia on failure rates and mortality after a two-stage revision for PJI. Methods: 199 Patients (130 knees and 69 hips) with a mean age of 64.7 ± 10.7 years who underwent a two-stage exchange were retrospectively reviewed at a mean of 51.2 ± 39.7 months. Failure of treatment was defined as any revision within the follow-up period, failure to undergo reimplantation, or death within one year of initiating treatment. Results: There were 71 failures (35.7%), including 38 septic failures (19.1%). We found no differences between successful revisions and failures regarding hypoalbuminemia (43% vs. 42% prior to stage 1, P=1 and 32% vs. 29% prior to stage 2, P=0.856). There were also no differences in hypoalbuminemia rates between septic failures and the rest of the cohort (42% vs. 43% prior to stage 1, P=1.0 and 34% vs. 30% prior to stage 2, P=0.674). Hypoalbuminemia prior to stage 2 was a significant predictor of mortality based on multivariate analysis (odds ratio 5.40, CI 1.19-24.54, P=0.029). Hypoalbuminemia was independently associated with a greater length of stay by 2.2 days after stage 1 (P=0.002) and by 1.0 days after the second stage reimplantation (P=0.004). Conclusion: Preoperative hypoalbuminemia is a significant predictor of mortality and increased length of stay following two-stage revision but is not a predictor of failure of PJI treatment. Further study is required to understand if hypoalbuminemia is a modifiable risk factor or a marker for poor outcomes.

Clinical Outcomes Following Resection of Distal Lower Extremity Soft Tissue Sarcomas.

OBJECTIVE: Resection of soft tissue sarcoma (STS) in the distal lower extremity can result in large soft tissue defects that create difficult wounds to manage and significant risks for complications. Often, the anticipated or resultant tissue defect or loss of functional anatomy is an indication for amputation over limb salvage. Soft tissue reconstruction managed by plastic and reconstructive surgery (PRS) may help offer limb salvage as a therapeutic option with acceptable oncologic outcomes and wound complication rates. METHODS: This was a review of 52 patients who underwent resection of STS at the level of the knee or distal between 2010 and 2020. Plastic and reconstructive surgery soft tissue management was utilized in 40.4% (n = 21) of cases, most of whom would have otherwise been considered candidates for amputation. RESULTS: The overall rate of limb salvage was 76.9%. The overall rate of wound complications was 19.2%. The overall rate of negative margins of resection was 92.3%. The 1-, 5-, and 10-year overall survival probabilities were 92%, 85%, and 85%, respectively. Of the 40 limb salvage procedures, two required subsequent amputation, one for multiply recurrent disease and one for necrosis. The wound complication rate was 14.3% in the PRS management group and 22.6% in cases of wound closure managed by the primary surgeon. There were zero instances of total wound or flap loss in PRS- managed closures. When comparing patients with wound complications to those without, there was no difference in age (59.5 ± 21 vs. 51 ± 18 years, p = 0.42), body mass index (31.1 ± 4.8 vs. 26.1 ± 7.1 kg/m2 , p = 0.19), or tumor size (6.8 ± 5.0 vs. 6.4 ± 4.7 cm, p = 0.82). At final follow-up, 67% (n = 35) of patients were alive and disease-free. CONCLUSIONS: Wound complications are not uncommon after resection of distal lower extremity STS. Our experience has been successful in achieving limb salvage in these challenging cases. Without PRS soft tissue management, however, many patients may alternatively be candidates for amputation.

What factors are important to new patients when selecting an orthopedic oncologist?

BACKGROUND: Understanding how patients choose a provider may improve the overall experience by identifying ways to tailor a clinical practice. AIM: To identify factors that patients consider important when choosing an orthopedic oncologist. METHODS: New patients presenting to an orthopedic oncology clinic within a tertiary academic medical center from January 2019 to August 2020 were invited to complete an anonymous survey. The questionnaire consisted of 27 items including a Likert-type assessment of the importance of selection factors. RESULTS: A total of 101 new patients with a median age of 66 years (range, 14 years to 91 years) responded. Most were referred by another doctor (n = 63, 62.4%), and of the referring providers, the most frequent specialty was orthopedic surgery (n = 32, 51%). Using a Likert-type scale with 1 representing 'least important' and 5 representing 'most important', the most important factor was the hospital reputation (mean, 4.65; SD, 0.85). Additional factors of importance were the number of years in practice (3.87 ± 1.3) and a primary care provider referral (3.71 ± 1.6). Patients younger than 40 years old found social media (P = 0.016) and internet presence (P = 0.035) of their surgeon to be more important than older patients. In contrast, older patients considered care within an academic center to be of greater importance than younger patients (P = 0.014). CONCLUSION: This investigation suggests a primary care referral, as well as hospital and physician reputation, are among the most important factors when selecting an orthopedic oncologist. Furthermore, social media utilization appears to be more important for younger patients.

En Bloc Resection of Giant Cell Tumor following Neoadjuvant Denosumab: A Case Report and Review of the Literature.

Introduction: The RANK ligand inhibitor denosumab has been used to treat cases of unresectable giant cell tumors of bone (GCTB) or preoperatively to facilitate intralesional curettage. However, there are no clear guidelines for use of denosumab prior to en bloc resection. Case Presentation: In this study, a 26-year-old patient presented with atraumatic lateral knee pain. X-rays demonstrated a destructive lesion within the proximal fibula, and biopsy confirmed the diagnosis of GCTB. Management and Outcomes: The patient received 3 months of neoadjuvant denosumab with complete resolution of his pain and cortical rim formation surrounding the tumor. The tumor was removed en bloc with negative margins. At 6-month follow-up, the patient had returned to his functional baseline with no evidence of tumor recurrence. Conclusion: Neoadjuvant denosumab can mitigate symptoms related to GCTB and promotes cortical bone formation, facilitating en bloc resection and permitting acceptable functional outcomes in select cases.

Dedifferentiated Chondrosarcoma: A Case Series and Review of the Literature.

Background: Dedifferentiated chondrosarcoma (DCS) is a rare and aggressive malignancy with a poor prognosis. The purpose of this investigation was to describe our treatment and outcomes of 16 DCS patients at our institution and provide a review of the current literature. Methods: This study was a retrospective review over a consecutive twenty-year period. Data including treatment details and outcomes were recorded. Results: A total of 16 cases from 2000 to 2018 were identified. The median age (IQR) was 62 years (52; 69) and the majority of DCS arose in the femur (50%, n=8) and pelvis (25%, n=4). Fourteen (88%) cases underwent limb salvage/wide margin resection (n=13) or intralesional surgery (n=1). For all DCS, the median survival (IQR) was 46 months (12; 140), with both a five and ten-year probability of 32.1% (95% CI, 7.3% to 57.0%). At study conclusion, 81.3% (n=13) were deceased and 18.7% (n=3) were alive. Conclusions: Our findings confirm the poor prognosis of DCS patients, with a five-year estimate of 32%. Together with existing literature, our data might help enable future strategic recommendation of these patients.

Extraskeletal myxoid chondrosarcoma: A case series and review of the literature.

BACKGROUND: Extraskeletal myxoid chondrosarcoma (EMC) is a rare malignant soft tissue sarcoma (STS) that accounts for less than 3% of all soft tissue tumors. The conventional treatment for primary EMC is wide local excision with or without radiation therapy. MATERIALS AND METHODS: This study was a retrospective review of all EMC cases treated within a single institution between 1992 and 2019. EMC was diagnosed using a combination of histologic morphology and immunostaining, with confirmatory fluorescent in situ hybridization. Overall survival (OS) and disease-specific survival (DSS) were defined using Kaplan-Meier analysis. RESULTS: Fifteen patients were evaluated, including 11 males and four females. The average age at presentation was 51.7 ± 20.4 years and the mean follow-up time was 61.5 months (range, 5-286 months). The average resected tumor size at largest dimension was 7.14 cm (range, 2.4-18.7). Twelve of fifteen (80%) patients underwent wide local excision, and nine of the twelve (75%) underwent local radiation therapy. The 1-, 5-, and 10-year OS was 80% (95% CI, 59.8-100), 72% (95% CI, 48.5-95.5), and 72% (95% CI, 48.5-95.5), respectively. The 1-, 5-, and 10-year DSS was 92.3% (95% CI, 77.8-100), 83.1% (95% CI, 61.5-100), and 83.1% (95% CI, 61.5-100), respectively. At last follow-up, 11 patients were alive and ten (90.9%) were disease free. CONCLUSIONS: Extraskeletal myxoid chondrosarcoma is a very rare STS most often seen in males and in the extremities. Our cohort was too small to provide meaningful statistical analysis; however, we observed lower rates of local recurrence in patients treated with radiation.

3D-Printed Cutting Guides for Resection of Long Bone Sarcoma and Intercalary Allograft Reconstruction.

The use of 3-dimensional (3D)-printed cutting guides for resection of long bone sarcoma is a novel technique. These 3D-printed guides provide a potential benefit over navigational or freehand osteotomy. We evaluated whether the use of 3D-printed cutting guides in the resection of long bone sarcoma affects margin status and rates of union compared with historical controls. In this study, we performed a retrospective review of a prospectively maintained surgical database and reviewed 6 patients who underwent limb salvage for long bone sarcoma. We collected and analyzed clinicopathologic and surgical data. Six (100%) cases recorded negative margins, with mean postoperative follow-up of 108 weeks (range, 8-211 weeks). Time (mean±SD) to bony union was 20.5±10.5 weeks. Nine of 12 (75%) cumulative (proximal and distal) osteotomy sites went on to achieve union, with a nonunion rate of 25% per osteotomy. One (33%) nonunion occurred after adjuvant radiation therapy. Long-term complications were limited to 2 (33.3%) patients overall who had implant failure according to the Henderson classification system, and there were zero local recurrences at the conclusion of the study. Our institution has successfully performed limb salvage surgery with patient-specific 3D-printed technology. We show high rates of negative margin resection and junctional union that align with and improve on earlier findings. [Orthopedics. 2022;45(1):e35-e41.].

Does Racial Disparity Exist Among Inpatient Admissions for Heart Attacks in Wisconsin?

OBJECTIVE: Acute myocardial infarction (AMI), or heart attack, carries a high inpatient death risk. Few national studies suggest race affects the outcomes of inpatients with AMI. In Wisconsin, an assessment of racial disparity among admissions for AMI is lacking. METHODS: Using the Wisconsin State Inpatient Database from 2016, demographics and outcomes for AMI admissions were analyzed. The goal was to compare demographic and hospitalization characteristics between non-Hispanic White patients and Black, Indigenous, and People of Color (BIPOC). RESULTS: A total of 6,002 non-Hispanic Whites and 546 BIPOC cases were identified. BIPOC were younger than non-Hispanic White inpatients (median age, 59 years vs 68 years, respectively; P < 0.001). Median length of stay was shorter in non-Hispanic White versus BIPOC (2 days vs 3 days; P = 0.021), and mean total charges were higher for BIPOC than non-Hispanic Whites ($74,716 vs $65,384, respectively; P = 0.002). Using a risk-adjusted model, inpatient mortality was increased for patients over 55 years of age (odds ratio [OR] 2.166; 95% CI, 1-3; P = 0.001) and women (OR 1.319; 95% CI, 1-1.6; PP = 0.03). Race (BIPOC vs non-Hispanic White) was not predictive of inpatient death on univariable analysis (OR 0.771; 95% CI, 0.4-1.2; P = 0.283). CONCLUSION: It appears BIPOC have longer hospital stays and incur higher charges than non-Hispanic White patients, though race does not affect mortality risk. Among Wisconsin counties with higher proportions of AMI, these data may enable strategic recommendation of hospitalized patients or permit risk stratification to identify disparity and encourage equitable care.

Outcomes of brain metastasis in high-grade bone and soft tissue sarcoma: An analysis of clinicopathological characteristics and survival data.

Brain metastases in sarcoma are exceedingly rare, with few published series documenting ranges from 1% to 8%. This study investigated the outcomes of sarcoma patients with brain metastases using a population-based analysis. This was a retrospective review of 5933 patients with high-grade sarcoma identified from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. Of the eligible 5933 patients, 0.7% (n = 44) had brain metastasis. Kaplan-Meier was used to estimate survival and follow-up (reverse Kaplan-Meier), and a multivariable Cox proportional hazards model analyzed prognostic factors of disease-free survival (DFS). Median (IQR) follow-up of all eligible patients was 28 months (12; 47). Patients who developed brain metastasis had a higher proportion of N1 stage disease (p < 0.001), as well as synchronous metastasis to bones, liver, and lungs compared to those without brain metastasis (all p < 0.001). The median (IQR) DFS with brain metastasis was 6 months (2; 12), and survival with brain metastasis was significantly worse than DFS in patients without brain metastasis (p < 0.001). Among those with brain metastasis only, there was no difference in DFS with respect to sex, race, primary tumor origin, T stage or N stage disease, synchronous metastasis to bone, liver or lung, nor with respect to chemotherapy or radiation for treatment of the primary tumor (all p > 0.05). For sarcoma patients with brain metastasis, the outcomes are poor and do not appear to differ by clinicopathologic factors. However, patients with certain histologies and synchronous metastases may warrant more frequent surveillance as there was an association of brain metastasis with these factors.

Is There a Role for Intramedullary Tissue Sampling During Internal Fixation of Metastatic Disease in Long Bones? A Systematic Review and an Institutional Experience.

BACKGROUND: The purpose of this investigation was to identify and summarize the current utility of intramedullary tissue sampling during long bone internal fixation (IF) for metastatic bone disease (MBD). The secondary aim was to provide the experience of a single institution using this technique. METHODS: First, a systematic database query of the Cochrane Central Register of Controlled Trials (1976 to 2020), Cochrane Database of Systematic Reviews, Ovid MEDLINE (1946 to 2020), EMBASE, and PubMed (1964 to 2020) was performed. Following article identification, a description of the method of sampling and yield was recorded. Second, an institutional cohort was identified following Institutional Review Board approval. Cases of MBD treated with IF from 2018 to 2020 were reviewed. Data were collected and recorded from cases during which intramedullary reamings were sent for histopathology. RESULTS: Ten studies met inclusion criteria. Four of the ten were techniques or technical notes. The remaining six were retrospective reviews in which tissue was sent for histopathology. Among those six, a total of 262 tissue samples were sent, and a negative result was recorded in 37.2% (n = 97) of cases. A total of 18.0% (n = 47) were noted as inadequate for interpretation. For reamings-only studies, the negative rate was higher at 50.5%. In our institutional cohort, a total of 16 tissue samples were sent in the setting of known MBD. The negative rate was 37.5% (n = 6), with zero instances of a change in clinical management after a positive result. CONCLUSION: There are limited descriptions of intramedullary tissue sampling during IF of long bones for MBD. The existing literature, along with our institutional data, suggest this technique is less than optimal for tissue retrieval given the high rates of negative results from samples sent for histopathology. Furthermore, given the lack of clinical impact of a positive sample, we believe a multidisciplinary group should discuss preoperatively the utility of whether treatment might change based off a tissue diagnosis.Level of Evidence: V.

What Is the Clinical Impact of Sending Tissue for Histopathology During Surgery for Known, Diffuse Metastatic Disease to Bone?

BACKGROUND/AIM: During surgery for patients with known, diffuse metastatic bone disease (MBD), lesional tissue is routinely sent for pathological evaluation. However, there are limited data to assess whether there is a role for histopathology for MBD despite time and cost of interpretation, as well as whether a positive sample changes the subsequent treatment course. PATIENTS AND METHODS: Sixty-six cases from 2017 to 2020 were reviewed retrospectively. The median age at surgery was 63.5 years (range of 23 to 84 years), and the primary tumor was most frequently breast (24.2%, n=16), renal (21.2%, n=14) or lung (15.2%, n=10). The most common location of MBD was the femur (60.6%, n=40). RESULTS: The overall yield of a positive tissue sample of MBD was 77.3% (n=51). The positive rate from sending intramedullary reamings was 65.4% (n=17 of 26). Among the 66 cases (63 patients), a change in the subsequent clinical management was recorded in 9.1% (n=6). The most common change was related to the medication regimen (n=5), with one change related to recognition of the carcinoma origin via histology, which was previously unknown. CONCLUSION: Despite the routine practice of sending tissue for histology during surgery for known and diffuse MBD, a change in the subsequent clinical management is uncommon. Prior to sending tissue, surgeons should discuss this practice with the multidisciplinary care team on a per-patient basis.

Rare popliteal mass following retrograde nailing of ballistic femur fracture: a case report.

INTRODUCTION: Civilian ballistic injuries are commonly associated with fracture, vascular injury, and soft tissue trauma. Posttraumatic pseudoaneurysms represent an extremely rare subset of vascular injuries following ballistic fractures. CASE: We present the rare case of a posttraumatic pseudoaneurysm that occurred after retrograde femoral nailing of a ballistic distal femur fracture. The patient presented in clinic postoperatively with a pulsatile popliteal mass. Distal pulses were intact but subsequent ultrasound and angiography revealed a pseudoaneurysm of the distal superficial femoral artery. The pseudoaneurysm was subsequently treated with a covered stent and the patient's recovery was uncomplicated. CONCLUSION: Due to the potential life and limb-threating complications from pseudoaneurysm rupture, this case report emphasizes the early recognition and expeditious management of vascular complications following ballistic fractures in the civilian population.