Prevalence of sarcopenia in patients with gynecological cancer.

BACKGROUND: The aim of the study was to investigate a prevalence of sarcopenia in patients with gynecological cancer in accordance with current diagnostic criteria of sarcopenia. METHODS: A series of 513 patients with gynecological cancer who were intended to newly receive initial or salvage treatment were recruited in a prospective study. Eligible patients were examined with dual energy X-ray absorptiometry and underwent handgrip strength test and the Short Physical Performance Battery before treatment. Sarcopenia was defined as both low skeletal muscle mass (skeletal muscle mass index) and low muscle strength (handgrip strength of <18.0 kg) or both low skeletal muscle mass index and low physical performance (Short Physical Performance Battery score of ≤9). RESULTS: A total of 475 patients (92.6%) were completely assessed in this study. Eligible patients' median age was 60 years (range: 29-89 years). Frequencies of patients with low skeletal muscle mass index, low hand grip strength and low Short Physical Performance Battery were 118 (24.8%), 70 (14.7%) and 80 (16.8%), respectively. Sarcopenia was finally identified in 45 patients (9.5%), which accounted for 38.1% of patients with low skeletal muscle mass index, 64.3% of the patients with low hand grip strength and 56.3% of the patients with low physical performance, respectively. CONCLUSIONS: The prevalence of sarcopenia of 9.5% in patients with gynecological malignancy who were scheduled to newly receive an initial or a salvage treatment. A large-scale, nation-wide study might be planned to elucidate an accurate prevalence of sarcopenia among gynecologic cancer patients.

Prognosis by cancer type and incidence of zoledronic acid-related osteonecrosis of the jaw: a single-center retrospective study.

PURPOSE: Survival time after bisphosphonate use has been increasingly recognized to be associated with the incidence of medication-related osteonecrosis of the jaw (MRONJ); however, this has not been elucidated sufficiently in the literature. This study aimed to clarify the incidence of MRONJ and the corresponding survival rate of patients treated with zoledronic acid (ZA) for each type of cancer and obtain useful information for the oral/dental supportive care of cancer patients. METHODS: We evaluated 988 patients who were administered ZA at our hospital; among them, 862 patients with metastatic bone tumors or myeloma were included. RESULTS: The median survival time (MST) after ZA initiation was 35, 34, 8, 41, 12, and 6 months for patients with breast, prostrate, lung, myeloma, renal, and other cancers, respectively. Patients with cancers that had a short survival time (lung and other cancers [MST = 8 and 6 months, respectively] and cancers with MST < 10 months) did not develop MRONJ; this could be attributed to the shorter duration of ZA administration. The cumulative incidence of MRONJ in breast cancer, prostate cancer, and multiple myeloma was related to the frequency of anti-resorptive drug use and the increased risk over time. In renal cancer, the cumulative incidence of MRONJ increased early, although the MST was 12 months. CONCLUSION: For the dentists in charge of dental management, it is essential to be aware of prognosis-related factors, predict MRONJ risk for each cancer treatment, and use risk prediction in dental management planning, particularly for cancers with non-poor prognosis.

Validity of skeletal muscle mass index measurements for assessing sarcopenia in patients with gynecological cancer.

BACKGROUND: The current study investigated an optimal method for using CT scan in detection of low skeletal muscle mass quantity (SMQ). METHODS: In total, 82 consecutive patients with gynecological cancers were examined using computed tomography (CT) and dual-energy X-ray absorptiometry (DEXA) before treatment. Low SMQ was defined as a DEXA-based skeletal muscle mass index (SMI) of <5.40 kg/m2. Furthermore, CT-based SMI values were measured by six evaluators, and each evaluator measured SMI values two times for each subject. The first SMI value and the average SMI value were used for analyses. Receiver operating characteristic (ROC) analyses were performed to evaluate the performance of CT-based SMI measurements for detecting low SMQ. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). RESULTS: In total, 23 patients (28.0%) were diagnosed with low skeletal muscle mass. All areas under the curve (AUC) values from twelve (six evaluators × two measurements) ROC curves were within the range of 0.8-0.9. AUC values based on a single measurement and those based on two measurements were almost the same. The ICC was 0.828 (95% CI 0.777-0.874, P < 0.001) when using a single measurement value and increased to 0.959 (95% CI 0.944-0.971, P < 0.001) when using the average of the two measurements. CONCLUSIONS: A single measurement CT-based SMI efficiently identified patients with low SMQ in a daily clinical setting. The reliability of SMI measurements might be further improved by using a mean value of two measurements compared with the use of a single measurement value.

Validity of measuring psoas muscle mass index for assessing sarcopenia in patients with gynecological cancer.

OBJECTIVE: The current study evaluated the performance of psoas muscle mass measurement for detecting low skeletal muscle mass quantity. METHODS: A sample of 82 consecutive patients with gynecological cancers was examined using computed tomography and dual energy X-ray absorptiometric scan before treatment. Skeletal muscle mass index was measured by dual energy X-ray absorptiometric scan and its cut-off value was set at 5.40 kg/m2 for detecting low skeletal muscle mass. Psoas muscle mass index was manually measured with cross-sectional computed tomography imaging at the level of L3 by six evaluators. RESULTS: Low skeletal muscle mass index was identified in 23 (28.0%) patients. Two-way analysis of variance confirmed a significant main effect of skeletal muscle mass index on mean psoas muscle mass index values (P < 0.0001). A receiver operating characteristic curve obtained from a total of 492 psoas muscle mass index data points gathered from six evaluators produced an area under the curve value of 0.697 (95% confidence interval 0.649-0.744) and a cut-off value of 3.52 cm2/m2, with sensitivity of 79.0% and specificity of 59.6%. Using the cut-off value, the kappa coefficient for evaluating diagnostic agreement between skeletal muscle mass index (low vs. normal) and psoas muscle mass index (low vs. normal) was 0.308 (95% confidence interval 0.225-0.392), suggesting poor agreement. Fleiss' kappa produced a coefficient of 0.418 (95% confidence interval 0.362-0.473), suggesting moderate agreement. CONCLUSIONS: Although relevance between skeletal muscle mass index and psoas muscle mass index was confirmed, intensity of relevance between them was weak. Psoas muscle mass index measurement should be subordinated to skeletal muscle mass index measurement for detection of low skeletal muscle mass.

Posterior thigh flap revisited: clinical use in oncology patients.

PURPOSE: The posterior thigh flap is a reliable flap owing to the dependability of the inferior gluteal artery. Its utility for the reconstruction of sacral, perineal, ischial, pelvic, trochanteric and vulvar defects is well established. We herein describe the use of the flap for a variety of indications, and discuss the results with respect to postoperative complications in oncology patients. METHODS: We reviewed nine oncology patients who were treated with pedicled posterior thigh flaps. We assessed the use of this treatment by recording the site of the defect, the type of flap used, and the presence or absence of previous surgical procedures, radiation therapy and postoperative complications. RESULTS: Defects after resection of soft tissue sarcomas were the most common condition (n = 4), followed by skin cancers (n = 2), gastrointestinal cancers (n = 2) and radiation osteomyelitis (n = 1). Six patients (66 %) developed complications; three (33 %) were major and three (33 %) were minor. There was one case of total necrosis of the flap and two cases of partial necrosis. CONCLUSIONS: In oncology patients, the posterior thigh flap is an excellent choice for the reconstruction of sacral, ischial, pelvic or buttock defects, since it does not cause any donor site morbidity.

Clinical experience using a tensor fascia lata flap in oncology patients.

PURPOSE: The tensor fascia lata (TFL) flap is used to reconstruct various anatomical structures in different regions of the body. We herein describe the use of TFL flaps for a variety of indications, and discuss the results of such procedures with respect to postoperative complications in oncology patients. METHODS: We reviewed 15 oncology patients who were treated with TFL flaps. RESULTS: The lesions were located in the groin in five patients, the lower abdomen in five, and the buttocks, ischium, shoulder, thigh and upper abdomen in one patient each. Abdominal wall reconstruction was performed in nine patients. Three patients underwent resection of femoral vessels and the tumor in the groin, followed by a vascular graft implant. In these patients, the combined flaps were transferred to reconstruct the defects. Nine patients developed complications. No total flap loss occurred in any patient. CONCLUSIONS: Postoperative complications, such as necrosis in the distal part of the flap (33 %) and ventral hernias (11 %) were seen, but these percentages were comparable to those seen in previous reports. Our review shows that the TFL flap is useful to reconstruct the defects in various anatomical sites in oncology patients.

SYT-SSX breakpoint peptide vaccines in patients with synovial sarcoma: a study from the Japanese Musculoskeletal Oncology Group.

In the present study, we evaluated the safety and effectiveness of SYT-SSX-derived peptide vaccines in patients with advanced synovial sarcoma. A 9-mer peptide spanning the SYT-SSX fusion region (B peptide) and its HLA-A*2402 anchor substitute (K9I) were synthesized. In Protocols A1 and A2, vaccines with peptide alone were administered subcutaneously six times at 14-day intervals. The B peptide was used in Protocol A1, whereas the K9I peptide was used in Protocol A2. In Protocols B1 and B2, the peptide was mixed with incomplete Freund's adjuvant and then administered subcutaneously six times at 14-day intervals. In addition, interferon-α was injected subcutaneously on the same day and again 3 days after the vaccination. The B peptide and K9I peptide were used in Protocols B1 and B2, respectively. In total, 21 patients (12 men, nine women; mean age 43.6 years) were enrolled in the present study. Each patient had multiple metastatic lesions of the lung. Thirteen patients completed the six-injection vaccination schedule. One patient developed intracerebral hemorrhage after the second vaccination. Delayed-type hypersensitivity skin tests were negative in all patients. Nine patients showed a greater than twofold increase in the frequency of CTLs in tetramer analysis. Recognized disease progression occurred in all but one of the nine patients in Protocols A1 and A2. In contrast, half the 12 patients had stable disease during the vaccination period in Protocols B1 and B2. Of note, one patient showed transient shrinkage of a metastatic lesion. The response of the patients to the B protocols is encouraging and warrants further investigation.

Histologic examination of Leeds-Keio artificial ligament implanted on the surface of a tumor endoprosthesis.

The Leeds-Keio (L-K) artificial ligament is made of polyester fibers with an open-weave mesh structure. It has been used clinically for knee ligament reconstruction as a scaffold, allowing tissue ingrowth and new ligament formation. We have used the L-K ligament in bone tumor surgery for reattaching remaining muscles to the target zone of a tumor endoprosthesis. We histologically examined the L-K ligament obtained from 2 patients during revision surgery 39 months after the primary surgery. There were dense fibrous tissues between muscles and the L-K ligament. Collagen fibers proliferated in the space between the polyester fibers, and a slight inflammatory reaction was apparent. We concluded that the L-K ligament had a high potential for inducing biological tissue regeneration even on the metal surface.

Gastrocnemius muscle flap including Achilles tendon after extensive patellectomy for soft tissue sarcoma.

A 72-year-old man developed a soft-tissue sarcoma anterior to his left knee. The tumour was excised widely combined with an extensive patellectomy. A gastrocnemius flap including Achilles tendon was used successfully to cover the soft-tissue defect and to reconstruct the knee extensor mechanism.

Extra-articular diffuse-type tenosynovial giant cell tumor with benign histological features resulting in fatal pulmonary metastases.

Diffuse-type tenosynovial giant cell tumor (TS-GCT) is categorized as a locally aggressive but non-metastasizing neoplasm according to the WHO classification. Herein, we report an extremely rare case of a 41-year-old woman who developed multiple metastases from diffuse TS-GCT with benign histological features. The patient complained of a painful buttock mass and imaging studies revealed a soft tissue tumor of the buttock and multiple pulmonary nodules. The buttock tumor was excised and the final diagnosis was extra-articular diffuse-type TS-GCT. By video-assisted thoracic surgery, pulmonary nodules were pathologically identical to the primary tumor. Residual pulmonary nodules progressively grew, and she developed a muscle metastasis and a subcutis metastasis. She died of respiratory dysfunction due to multiple pulmonary metastases 1 year after primary surgery. Very few reports on histologically benign metastases from TS-GCT have been published, and the natural course of this rare condition remains unclarified. This rare case could provide important information for further clinical evaluation of this tumor.

Methylation status of EXT1 and EXT2 promoters and two mutations of EXT2 in chondrosarcoma.

Germline mutation and functional loss of EXT1 or EXT2 are commonly found in multiple osteochondromas and predispose to the development of chondrosarcoma. Mutations of EXT1 and EXT2 have rarely been detected in sporadic secondary chondrosarcomas from osteochondroma; these frequently display loss of heterozygosity at the EXT1 and EXT2 loci, but primary chondrosarcomas typically do not. To evaluate promoter methylation (which is an epigenetic gene silencing mechanism) of EXT1 and EXT2, we performed methylation-specific polymerase chain reaction (PCR) for 20 chondrosarcoma cases (12 primary, 3 secondary to osteochondroma, 2 secondary to enchondromatosis, 2 extraskeletal ordinary, and 1 clear cell) and in five cell lines. In addition, mutation analysis of the EXT1 and EXT2 coding regions was performed using PCR-single-strand conformation polymorphism and sequencing analysis for 12 of the 20 chondrosarcoma cases (8 primary, 1 secondary to enchondromatosis, 1 secondary to osteochondroma, and 2 extraskeletal ordinary) and five cell lines. Promoter methylation of EXT1 and EXT2 was not detected in any of the cases, and both EXT1 and EXT2 were expressed in all cell lines. Two missense mutations in EXT2 (D227E and R299H) were detected among the chondrosarcoma cases. When considering tumor development in primary chondrosarcoma, we should include mutations in EXT2, along with the status of other members of the EXT gene family.

Scrotum-like protrusion of lipoma arising from the proximal thigh--report of two cases.

We report two cases of large lipomas arising from the proximal thigh with an extremely uncommon shape. The tumors were elastic soft and movable. MRI examination revealed both tumors with high signal intensity as fatty tissue on both T1 and T2-weighted images. Needle biopsy of the specimens revealed lipoma. Marginal excision was carried out for both cases because of the patients' discomfort. No recurrence was found three and five years after surgery, respectively.

Adult rhabdomyoma of the extremity.

Adult rhabdomyoma is a rare benign tumor. It mainly occurs in the head and neck region and rarely occurs outside the head and neck region. We present an extremely rare case of the adult rhabdomyoma arising in the left foot in a 46-year-old male. Microscopically, large polygonal cells and large strap-shaped cells were observed. This is the third case of adult rhabdomyoma arising in an extremity.

Modified digital tourniquet designed to prevent the tourniquet from inadvertently being left in place after the end of surgery.

Digital tourniquets have been used worldwide in finger and toe surgery. Digital tourniquets of various types have been used, and a rolled glove technique provides a simple and quick method. We have modified a rolled glove technique to prevent iatrogenic complications associated with digital tourniquets being inadvertently left in place after surgery.

Persistent sciatic artery aneurysm associated with the development of angiosarcoma: a case report.

Persistent sciatic artery (PSA) is a very rare, but clinically significant, congenital anomaly. PSA is known to undergo aneurysmal formation; however, there have been no previous reports of a soft-tissue sarcoma arising from a PSA. We describe a 79-year-old woman with a 10 year history of a slowly growing mass on her right buttock. Physical examination revealed a painful, firm, pulsatile mass with a maximum diameter of 13 cm. Computed tomography angiography revealed that the mass arose from the PSA. We successfully excised the mass lesion with no postoperative circulatory disturbances. The final pathological diagnosis was aneurysmal PSA that focally developed secondary angiosarcoma.

Calcaneal insufficiency fracture in a child with osteosarcoma after chemotherapy and limb-sparing surgery.

We report a rare case of a calcaneal insufficiency fracture in an 11-year-old boy with an osteosarcoma of the right proximal tibia. After one course of neoadjuvant chemotherapy for 4 months, we performed limb-sparing surgery. The knee joint was replaced with a custom-made endoprosthesis and the knee extensor mechanism was reconstructed with a medial gastrocnemius muscle flap. Seven months postoperatively, he complained of pain in the right foot and a plain radiograph revealed a calcaneal insufficiency fracture. Osteoporosis induced by chemotherapy and change of forces transmitted to the calcaneus after reconstruction with a gastrocnemius muscle flap might contribute to this fracture. It is important to be aware of the rare clinical entity of insufficiency fracture for making an early diagnosis and for differentiating them from pathological fractures associated with malignancy.