Oncological and functional outcomes of planned and unplanned excision of soft tissue sarcoma: A retrospective study.

BACKGROUND: In soft tissue sarcomas, the oncological and functional outcomes between planned excision and unplanned excision with additional wide resection remains controversial. The purpose of this study is to determine the impact of unplanned excision on oncological and functional outcomes. METHODS: A retrospective single-center study was performed. Patients with soft tissue sarcoma surgically treated in 2005-2019 were included in this study. A total of 120 patients consisting of planned excision (PE) group (n = 88), and unplanned excision (UE) group (n = 32) were included. Overall-survival (OS), local recurrence-free survival (LRFS), metastasis-free survival (MFS), disease-free survival (DFS), incidence rate of reconstructive surgery and musculoskeletal tumor society (MSTS) score were assessed. Propensity score matching method was used in statistical analysis. RESULTS: The 5-year survival rate of OS, LRFS, MFS, and DFS did not differ between the PE and UE groups, however, rates of reconstructive surgery were higher in the UE group (PE: 48% vs. UE: 84%, p < 0.001). These results did not differ (PE: 41% vs. UE: 82%, p = 0.012) after propensity score matching was performed to align the backgrounds with difference in tumor size and depth. For MSTS score, the total score and "pain" and "emotional acceptance" scores were higher in the PE group before propensity score matching. The "pain" and "emotional acceptance" scores were higher in the PE group after propensity score matching also. CONCLUSIONS: Unplanned excision did not deteriorate oncological outcomes, however unplanned excision lead to unnecessary reconstructive surgery. Unplanned excision adversely affected patient-reported outcomes without worsening pure functional outcomes.

Neutrophil-, Monocyte- and Platelet-to-Lymphocyte Ratios, and Absolute Lymphocyte Count for Diagnosis of Malignant Soft-tissue Tumors.

BACKGROUND/AIM: Soft-tissue tumors are difficult to differentiate as benign or malignant. Immune markers, such as the neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and absolute lymphocyte count (ALC) in serum, have been reported to be useful in the diagnosis and predicting prognosis of several malignancies. We investigated the diagnostic value of these immune markers in differentiating soft-tissue tumors. PATIENTS AND METHODS: A total of 692 patients who underwent biopsy or surgery of soft-tissue tumors were included and divided into benign tumor, low-grade malignancy, or high-grade malignancy groups. Immune markers were calculated from the preoperative blood tests and compared between the groups. A receiver operating curve (ROC) analysis was conducted between the benign disease group and a combination of the groups with malignancy to determine which immune marker had the most diagnostic value. RESULTS: NLR and MLR were significantly different between the three groups with benign disease having the lowest value and high-grade malignancies the highest. Benign disease was also associated with lower PLR and higher ALC. There was no difference between the low- and high-grade malignancies in PLR and ALC. From the ROC analysis, NLR had the highest area under the curve (AUC) value of 0.773 out of the four markers. When limited to small tumors (≤30 mm), NLR had the highest AUC value of 0.729. CONCLUSION: The NLR showed the highest diagnostic value, although the diagnostic ability was not adequately high to differentiate benign and malignant soft-tissue tumors alone. NLR may serve as diagnostic support in combination with clinical history, physical findings, and tumor-imaging results.

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.

Late development of malignant fibrous histiocytoma at the site of a giant cell tumour 38 years after initial surgery.

The authors report on a patient who developed a malignant fibrous histiocytoma at the site of a benign giant cell tumour, which had been treated by curettage 38 years previously. This latency period is, to their knowledge, the longest yet reported. This female patient was initially treated for a benign giant cell tumour of the proximal tibia when she was 33 years old; she underwent curettage and Kiel bone grafting. She had not received radiation therapy. Twenty eight years later, she underwent a second operation due to recurrence of a tumour. No specific histological diagnosis was possible: histology suggested a benign tumour, however compatible with a low-grade malignant potential but not associated with giant cell tumour. The patient underwent a third operation, with extensive curettage and total knee arthroplasty 38 years after the initial surgery, because of progressive knee pain. Postoperative histopathology study showed high-grade malignant fibrous histiocytoma. Finally, she underwent above-knee amputation because of uncontrollable progression of the tumour. The use of xenogenic bone graft, bone cement and associated bone necrosis potentially contributed to the development of a malignant tumour adjacent to the primary giant cell tumour.

Clinical outcome of limb-salvage surgery after wide resection of sarcoma and femoral vessel reconstruction.

BACKGROUND: Malignant sarcomas of the femur present major challenges in their management. Radical resection of sarcoma frequently requires concomitant major femoral vessel resection and reconstruction. We describe the clinical outcomes of vascular reconstruction, the long-term patency of vascular repair, and complications involved, and also discuss possible solutions to the problems associated with this procedure. METHODS: In the past 15 years, 15 patients underwent wide resection of sarcoma of the femur with curative intent, including vascular reconstruction of the femoral arteries and/or veins. Arterial reconstruction was performed in 14 patients. In 12 patients, femoropopliteal reconstruction was performed with a contralateral great saphenous vein graft. In two cases involving femoroinguinal reconstruction, expanded polytetrafluoroethylene grafts were used because of unacceptable discrepancy. Myocutaneous flaps were used for covering of soft-tissue in 12 patients. RESULTS: One patient developed a local recurrence and eight died because of their tumor. Seven patients remained completely free of recurrence after a mean follow-up time of 69 months. One case showed gradual deterioration with ischemic pain in the affected lower extremity requiring amputation. The remaining 14 cases showed sufficient vascularity primarily. Complications after surgery were noted in nine cases, with the most common being leg edema in five cases, wound infection in three, and lymphatic fistula in two. The average Musculoskeletal Tumor Society score at the final assessment was 24 points (80%). CONCLUSIONS: For patients with sarcoma involving major vessels in the lower limb, wide resection followed by vascular reconstruction provides long-term local control and limb salvage with acceptable function. The complication rate from extensive resection and associated vascular reconstruction is high. The great saphenous vein graft produced results that were superior to prosthetic graft. Aggressive use of musculocutaneous flap transfers may help to minimize complications and reduce postoperative severe edema.

Schwannoma in the extremity: clinical features and microscopic intra-capsular enucleation.

Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation. Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique. Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up. Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

Selection of myocutaneous flaps for reconstruction following oncologic resection of sarcoma.

The use of myocutaneous flaps for reconstruction following sarcoma resection is an important surgical technique. In this study, we discuss the issues surrounding proper selection of myocutaneous flaps following wide resection. A total of 59 patients underwent tumor resection and immediate reconstruction. In 26 patients, the tumor location was in the trunk and reconstructed mainly with pedicled latissimus dorsi and tensor fascia lata flaps. Functional muscle transfers were used for extremity reconstruction in 25 patients. Reinnervation was observed for 23 muscles after a mean period of 5.7 months. At final follow-up, primary wound healing was satisfactory in all surviving patients without severe complications. For sarcoma within the trunk, a pedicle latissimus dorsi flap is most suitable. The tensor fascia lata flap is best indicated for lower buttock or abdominal wall sarcomas. For extremity sarcomas, functional latissimus dorsi or gracilis muscle flaps produce good outcomes for restoration of motor function as well as wound healing.

Surgical correction of claw toe deformity following harvesting of fibula flaps.

Complications after the harvesting of vascularized fibula grafts are rare. Here we present our results on patients who developed claw deformity of the great and lesser toes. We discuss the etiology of claw toe deformity and the surgical correction of this condition. Seven patients developed claw toe deformity in the donor side foot after the harvesting of a vascularized fibula graft. They comprised 5 males and 2 females with an average age of 29 years (range: 6-59 years). The affected toes in 6 patients were 1 and 2, or 1, 2, and 3. All toes were affected in the remaining patient. Four patients underwent Z-lengthening of the flexor hallucis longus at the medial malleolus of the ankle, while 3 underwent cutting of the tendons. The average time between harvesting a fibula graft and development of claw toe deformity was 13 months (range: 2.5-42 months), and the average follow-up time was 30 months (range: 10-47 months). Claw deformity of affected toes was successfully corrected in all patients by release of the flexor hallucis longus. Full extension of the affected toes was achieved by the time of final follow-up. Flexion of the interphalangeal joint was preserved in all patients except one who underwent cutting of the tendon beneath the metatarsophalangeal joint. Lengthening or cutting of the flexor hallucis longus tendon at the medial malleolus successfully corrects claw toe deformity following the harvesting of vascularized fibula grafts. Even after cutting the tendon, flexion of the great toe is possible by interconnection with the flexor digitorum longus tendon.

Combination of Extracorporeally-irradiated Autograft and Vascularized Bone Graft for Reconstruction of Malignant Musculoskeletal Tumor.

BACKGROUND: Reconstruction after wide resection of a malignant musculoskeletal tumor is challenging. We performed biological reconstruction with an extracorporeally-irradiated autograft in combination with a vascularized bone graft. PATIENTS AND METHODS: Fifteen patients who underwent curative resection of malignant musculoskeletal tumor followed by reconstruction with this method were included. Oncological outcomes, survival of the graft, radiological findings and functional outcomes were reviewed. RESULTS: No local recurrences were detected from the irradiated bones, and 93% of the vascularized bone grafts survived. The mean MSTS score was 24.8 in all cases, 22.9 in the osteoarticular cases, and 27 in the intercalary cases. The intercalary tibia cases showed excellent results with a mean MSTS score of 29.3. CONCLUSION: This method has the advantage of combining the mechanical quality of an irradiated autograft and biological quality of a vascularized bone graft. The best indication of this method is for intercalary defects of the tibia.

Reconstruction of periacetabular bone tumor by vascularized fibula graft and irradiated autograft.

BACKGROUND: Periacetabular reconstruction following malignant bone tumor resection for limb saving is extremely challenging. We attempted a new reconstruction method in two patients by combining a free vascularized fibula graft with an extracorporeally irradiated autograft. PATIENTS: A 14-year-old boy with osteosarcoma and a 44-year-old man with chondrosarcoma were treated with wide excision of the tumor, followed by periacetabular reconstruction with an autogenous, extracorporeally irradiated osteoarticular graft combined with a free vascularized fibula graft. RESULTS: Incorporation of the irradiated pelvic bone was achieved without any complications and the resulting limb function was good. Osteoarthritic changes were seen in one patient. CONCLUSION: This reconstruction method was safe and reliable for primary, limb-sparing surgery. It is best indicated when the femoral head can be preserved and the mechanical strength of the affected acetabulum is maintained.

Sarcoma in the forearm and hand: clinical outcomes and microsurgical reconstruction for limb salvage.

Sarcomas in the forearm and hand are very rare, and surgical outcomes have been unclear. The aim of this study was to examine oncologic outcome, microvascular reconstruction, and functional evaluation. A retrospective review was performed in 19 patients who were treated for soft tissue or osseous sarcoma. All 12 patients with sarcoma in the forearm were treated with limb salvage and needed microvascular reconstruction. Flap survival was excellent. Local recurrence occurred in 4 patients, 3 of which had previously undergone inadequate resection. Three patients had distant recurrence and 1 died of disease. The mean Enneking functional score was 83% at a mean follow-up period of 37 months. Although sarcomas often metastasize, the overall survival rate is excellent. Wide marginal resection during initial surgery is the most predictive factor for tumor control. Microvascular cutaneous, myocutaneous, or osteocutaneous flap reconstruction is essential for limb salvage and provides reliable, safe coverage with reasonable preservation of function.

Calcific myonecrosis of the lower leg: diagnosis and options of treatment.

INTRODUCTION: Calcific myonecrosis is a rare condition characterized by a calcified lesion. Because this lesion sometimes presents as a huge mass with unique radiographic characteristics, it can be confused with soft tissue sarcoma. The appropriate treatment is still controversial. We report here three cases diagnosed as calcific myonecrosis of the lower leg and discuss its clinical presentation, diagnosis and options for treatment. PATIENTS AND METHODS: Three patients presented as expanding masses in the anterior or lateral compartment muscle and occurred more than 10 years after an initial injury. Plain radiographs showed a large soft tissue mass with extensive amorphous calcifications. Computed tomograms revealed a low-density tumor with scattered calcifications. Magnetic resonance imaging showed a bright, high-signal area on T2-weighted imaging consistent with fluid. Two patients underwent excisions for histopathological evaluation and one was treated conservatively because of the absence of disability. RESULTS: Two operative patients had no complication and the returned to work without evidence of deterioration of the disease. In a patient treated conservatively, the mass was not enlarged and was still painless at 2-year follow-up. CONCLUSION: The key points for diagnosis were (1) amorphous liner calcification, (2) anterior or lateral compartment, (3) previous injury (several decades) of the tibia or femur, and (4) compartment syndrome. Although calcific myonecrosis is not commonly encountered, it must be considered in the differential diagnosis of an expanding intramuscular mass. In asymptomatic masses where the diagnosis is recognized, observation may be possible and unnecessary aggressive surgical intervention should be avoided.

Gait oscillation analysis during gait and stair-stepping in elder patients with knee osteoarthritis.

BACKGROUND: Evaluation of knee and lower limb function alone is not sufficient to assess gait. For accurate assessment of gait abnormality, gait oscillation should also be measured. The goal of this analysis was to assess the influence of the knee joint on gait oscillation during gait and stair-stepping in patients with osteoarthritis of the knee. METHODS: In 33 patients diagnosed with knee osteoarthritis and 33 healthy adults as the control group, we examined acceleration (anterior and lateral directions) and gait barycentric factors (single-support phase and ratio of center of gravity maximum values) during gait and stair-stepping. RESULTS: Acceleration in the anterior direction in the sacral region was greater in healthy adults than in osteoarthritis (OA) patients during gait and stair-down. Acceleration in the anterior direction in the dorsal vertebral region was greater in OA patients than in healthy adults during (up and down) stair-stepping. Acceleration in the lateral direction in the sacral region was greater in healthy adults than in OA patients during stair-up. Acceleration in the lateral direction in the dorsal vertebral region was greater in OA patients than in healthy adults during stair-stepping. The single-support phase was close to 1 for gait and stair-stepping in healthy adults and OA patients. The single-support time was largely the same for gait and stair-stepping in healthy adults. On the other hand, the single-support time was longer for stair-stepping than for gait in OA patients. The ratio of the center of gravity maximum values was greater for the sacral region than for the dorsal vertebral region. There was a significant difference in the stair-stepping ratio of the center of gravity maximum values between healthy adults and OA patients for the sacral region. CONCLUSION: We considered that knee OA influenced acceleration in the anterior and lateral direction in the dorsal vertebral and the ratio of the center of gravity maximum values on gait oscillation.

Primary reconstruction with digital ray transposition after resection of malignant tumor.

INTRODUCTION: Hand reconstruction after wide resection of digital malignant tumors is still very challenging. The technique of adjacent digital ray transposition has been used for digital defects arising from trauma, but few papers have focused on reconstruction following resection of malignant tumors of the finger. The indications, complications and functional outcomes with this approach are discussed. PATIENTS AND METHODS: Four patients underwent primary reconstruction with adjacent digital ray transposition after tumor resection. Two were men and two were women and the median age was 62 years. The malignant tumors were low-grade chondrosarcomas of the metacarpal bone in two cases, epithelioid sarcoma at the fingertip in one case and synovial sarcoma at the base of the thumb in the fourth case. RESULTS: Metacarpal osteotomies were rigidly stabilized with a plate and screws and with an intramedullary bone peg graft. Digit length and rotation were satisfactory and there were no non-unions. Local recurrence was not observed at the final follow-up. The mean musculoskeletal tumor society (MTS) score was 60% (range 48-80%). The results of the disabilities of the arm, shoulder and hand score were similar to the MTS score, with a mean score of 35 points (range 22.5-63.5). The worst result was for index-to-thumb transposition and the best was for index-to-middle. All patients experienced emotional difficulty with acceptance of a three-finger hand. CONCLUSION: Primary reconstruction with digital ray transposition produces acceptable functional outcomes after resection of malignant tumor. This procedure is best indicated for central single ray amputation but sometimes is associated with esthetical problems.

Elastofibroma dorsi: diagnosis and treatment.

Elastofibroma dorsi is a rare, benign, soft tumor located at the inferior pole of the scapula. We report a series of 8 patients (5 women, 3 men), with a mean age of 67 years (range, 44-80 years), and discuss the clinical presentation, diagnosis, and treatment. Six lesions were unilateral, and 2 were bilateral. All patients were referred from other clinics with a large, unknown tumor of the back. Two patients presented with symptoms of pain and clunking of the scapula on shoulder abduction. Five underwent simple excision of the tumor. Preoperative diagnosis by magnetic resonance imaging showed agreement with the histopathologic diagnosis. Three patients had the postoperative complication of hematoma formation. Presumptive diagnosis is possible by careful clinical examination and magnetic resonance imaging. Because postoperative hematoma is unexpectedly frequent and symptomatic, radical resection should be avoided, and only excisional biopsy is necessary for histopathologic diagnosis.

Reconstruction of massive femur defect with free vascularized fibula graft following tumor resection.

BACKGROUND: The reconstruction of femur defects following tumor resection remains a surgical challenge. The clinical outcome of free vascularized fibula graft (FVFG) reconstruction for massive femur defects of more than 10 cm that were secondary to skeletal tumor resection is reported. PATIENTS AND METHODS: Six patients with a mean of 3.3 years follow-up were reviewed. Five patients received double or folded vascularized fibula grafts and 1 received a single graft. The mean bony defect of the femur was 13 cm and the mean length of grafted fibula was 15 cm. RESULTS: Five patients were free of disease at final follow-up; 10 out of 11 (91%) FVFGSs were transferred successfully. Five patients had a successful outcome with bony union. No stress fractures had occurred up until the final follow-up. All patients except one could walk without a brace after a mean of 9 months post-operatively. CONCLUSION: Double or folded FVFG is a reliable reconstructive procedure for massive femur defects.

Knee Arthritis Without Other Joint Symptoms in the Elderly With Seronegative Elderly Onset Rheumatoid Arthritis.

Elderly onset Rheumatoid arthritis (EORA) has important clinical distinctions when compared with younger onset RA (YORA). In knee arthritis of elderly patients, infection, crystal-induced arthritis or EORA should be suspected if elevation of CRP in the preoperative examination and turbid joint effusion in their knee joint are found. Furthermore, if joint swelling and effusion remain after performing total knee arthroplasty (TKA), the infection after TKA, implant debris-related arthritis and EORA should be considered. However, it is difficult to diagnose patients as EORA if Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are negative. The differential diagnosis is very important.

The Role of Complete Suprapatellar Plicae.

Shelf syndrome mainly affects younger people, often athletes. Cases of complete suprapatellar plica syndrome are rare. Arthroscopic inspection is necessary to diagnose complete suprapatellar plicae. The patients' symptoms improve after removal of the plicae. Our technique is an easy, completely arthroscopic procedure that has yielded good clinical outcomes in patients who have complete suprapatellar plicae. Although cases of complete suprapatellar plica syndrome are rare, it should be considered in patients with moderate knee pain.

In vivo kinematics of a unique posterior-stabilized knee implant during a stepping exercise.

BACKGROUND: Stair-stepping motion is important in daily living, similar to gait. Knee prostheses need to have even more superior performance and stability in stair-stepping motion than in gait. The purpose of this analysis was to estimate in vivo knee motion in stair stepping and determine if this unique knee prosthesis function as designed. METHODS: A total of 20 patients with Bi-Surface posterior-stabilizing (PS) implants were assessed. The Bi-Surface PS knee is a posterior-cruciate substitute prosthesis with a unique ball-and-socket joint in the mid-posterior portion of the femoral and tibial components. Patients were examined during stair-stepping motion using a 2-dimensional to 3-dimensional registration technique. RESULTS: The kinematic pattern in step up was a medial pivot, in which the level of anteroposterior translation was very small. In step down, the kinematic pattern was neither a pivot shift nor a rollback. From minimum to maximum flexion, anterior femoral translation occurred slightly. CONCLUSIONS: In this study, this unique implant had good joint stability during stair stepping. The joint's stability during stair stepping was affected by the design of the femorotibial joint rather than post/cam engagement or the ball-and-socket joint.