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.

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.

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.

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.

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.

Kinematic analysis of posterior-stabilized total knee arthroplasty during standing up from and sitting down on a chair.

BACKGROUND: Total knee arthroplasty is effective to regain quality of life. Standing up from and sitting down on a chair and stair stepping motion are important in daily living. We previously reported in vivo kinematics of this implant during a stepping exercise. The purpose of this analysis was to assess in vivo knee motion during standing up from and sitting down on a chair and determine the motion pattern in patients with the unique knee prosthesis. METHODS: A total of 15 patients implanted with Bi-Surface PS were assessed during standing up from and sitting down on a chair. 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 standing up from and sitting down on a chair using a two-dimensional to three-dimensional registration technique. RESULTS: During standing up from and sitting down on a chair from minimum to 30° knee flexion, anterior femoral translation was slight. From 30° knee flexion to maximum flexion, the kinematic pattern was a medial pivot and rollback. CONCLUSIONS: This study demonstrated that the knee motion kinematic patterns observed in this study were not similar to normal knee kinematics and derived from the unique design of the Bi-Surface PS.

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.

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.

Gait parameters in women with bilateral osteoarthritis after unilateral versus sequential bilateral total knee arthroplasty.

PURPOSE: To compare gait parameters in women after unilateral total knee arthroplasty (TKA) versus sequential bilateral TKA to determine the need for sequential TKA. METHODS: 35 women aged 60 to 74 (mean, 70) years with bilateral varus knee osteoarthritis (OA) underwent unilateral (n=23) or sequential bilateral (n=12) TKA by a single surgeon. All patients underwent unilateral TKA; 12 patients then underwent sequential TKA after 3 to 6 months of the first TKA. Gait parameters (step length, step width, gait velocity, single support phase value, and the maximum centre of gravity ratio) were compared before and after TKA, and between patients with unilateral versus bilateral TKA. RESULTS: Patients with sequential bilateral TKA had more severe OA in their contralateral knee than patients with unilateral TKA. In patients with unilateral and sequential bilateral TKA respectively, the mean step width differed at postoperative one month (12.9 vs. 19.1, p<0.01) and 3 months (11.9 vs. 16, p=0.03), and the mean maximum centre of gravity ratio differed at postoperative 3 months (2.43 vs. 1.75, p=0.02), whereas the mean step length, mean gait velocity, and mean single support phase values did not differ significantly between groups. CONCLUSION: After unilateral TKA, contralateral TKA may not be necessary in some patients whose gait has improved.

Functional reconstruction of the deltoid muscle following complete resection of musculoskeletal sarcoma.

Although the deltoid muscle has been assumed to be an essential shoulder muscle, the full extent of postoperative functions of the upper extremity following its complete resection due to sarcoma has not been thoroughly investigated. In this study, we review patients who underwent wide resection for sarcoma in the deltoid muscle, followed by functional reconstruction using pedicled latissimus dorsi (LD) muscle transfer. Four patients with sarcoma arising in the deltoid muscle were reviewed. Tumor resection with a wide surgical margin resulted in loss of the entire deltoid muscle together with the axillary nerve. For reconstruction, the ipsilateral pedicled LD muscle was transferred on its neurovascular pedicle for use as a functional substitute. One case had local recurrence and the transferred LD myocutaneous flap was resected. There were no serious complications after the operation, and all flaps survived perfectly. Wound healing at both the recipient and donor sites was uneventful. Active abduction of the shoulder joint was >160° in all patients. The muscle manual test of shoulder flexion was good to normal and abduction was fair to good. Musculoskeletal Tumor Society scores were excellent in all cases and the average score was 92% (range, 87-93%). Our results suggest that removal of the entire deltoid muscle resulted in a slight impairment of function. Pedicled LD musculocutaneous flaps are useful for covering the defect that results from resection of the deltoid muscle and they contribute additional function to the affected shoulder.

Unusual appearance of an osteochondral lesion accompanying medial meniscus injury.

An osteochondral lesion in the knee joint is caused by a focal traumatic osteochondral defect, osteochondritis dissecans, an isolated degenerative lesion, or diffuse degenerative disease. An osteochondral lesion with a cleft-like appearance accompanying medial meniscus injury is rare without trauma. We report the case of a 13-year-old boy who complained of right knee pain and swelling, with radiographic findings of an osteochondral defect. Arthroscopic inspection showed an osteochondral lesion in the medial condyle of the femur and tibial plateau accompanying a partial medial meniscus discoid tear. Partial meniscectomy was performed, and a microfracture procedure was carried out on the osteochondral defect. The patient was asymptomatic at 2 years' follow-up. This technique is a relatively easy, completely arthroscopic procedure that spares the bone and cartilage and has yielded a good clinical outcome in a skeletally immature patient who had an osteochondral lesion with a cleft-like appearance.

Subungual glomus tumours: diagnosis and microsurgical excision through a lateral subperiosteal approach.

Digital glomus tumour is a rare neoplasm. Surgical excision is the only known curative treatment but the best approach for subungual glomus tumours is still controversial. A total of 12 patients with subungual glomus tumour were reviewed. There were 11 female patients and one male patient, with a mean age of 48.6 years. Surgical procedures were performed using an operative microscope and tumours were excised using the lateral subperiosteal approach. In all, 10 patients were satisfied with the outcome from the lateral operative approach because they were able to use the affected hand for kitchen work shortly after the treatment. One case presented residual tumour and underwent re-operation. No tumour recurrences and nail deformity were detected after excision with the lateral approach. The lateral subperiosteal approach was safe and reliable for the subungual glomus tumour and allowed full access to any glomus tumours. Microscopy allows careful visualisation of the tumour. It is important that surgeons accurately locate tumours to achieve complete excision.

Musculoskeletal sarcomas in the forearm and hand: standard treatment and microsurgical reconstruction for limb salvage.

Sarcomas in the forearm and hand are very rare, accounting for less than 1% of all upper-limb tumors and clinical outcomes after surgery and adjuvant therapies are uncertain. The forearm and hand present specific challenges due to their unique anatomical structures. There is little soft tissue and each compartment is narrow, such important structures exist in close proximity. Anatomic constraints make it difficult to achieve wide surgical margins. Although sarcomas often metastasize to the lung, the overall survival rate is excellent. Wide marginal resection during initial surgery is the most predictive factor for tumor control. The role of reconstructive surgery following wide excision for sarcoma of the forearm and hand is even more important than elsewhere in the body because excision is likely to cause bone, tendon and nerve defects, leading to severe functional deficits. Multiple options exist for bony and soft tissue reconstruction of the upper limb, with the choice dependent upon tumor type, wound characteristics, surgeon preference and the patients' functional requirements. Success should be measured not just by stable wound coverage but also by preservation of patient's health, limb cosmesis, sensation and function. Careful preoperative planning with consideration of all the possible resected structures should improve patient outcomes.

Collagen expression in various degenerative meniscal changes: an immunohistological study.

PURPOSE. To examine changes in acid mucopolysaccharides and collagen expression during meniscal degeneration, tearing, and repair, using menisci excised from knee joint surgeries. METHODS. Menisci excised from 23 patients aged 15 to 80 years who underwent meniscal surgery for flap and bucket handle tears (n=11) and total knee arthroplasty (TKA) for osteoarthritis (n=12) were examined histologically. Staining images were converted to greyscale images to measure the mean grey levels, which indicated densitometry. Comparisons were made between acutely injured menisci and menisci with and without degeneration (from patients with osteoarthritis) in terms of acid mucopolysaccharides, collagen types I, II, and III expression. RESULTS. In menisci with no degeneration, acid mucopolysaccharides, collagen types I and II were expressed throughout the entire meniscus except for the circulating area. Collagen type III was intensely expressed at the exterior peripheral border and on the surface. During progression of meniscal degeneration, the expression of acid mucopolysaccharides increased, and the expression of collagen types I, II, and III decreased. In acutely injured menisci, collagen types II and III disappeared first, followed by collagen type I, resulting in the abrogation of fibre construction. CONCLUSION. In normal menisci, acid mucopolysaccharides and collagen types I, II, and III were well-balanced, and meniscal function was maintained. When the limits of repair were exceeded, the meniscus tissue deteriorated owing to the disappearance of collagen types II and III and a decrease in collagen type I, resulting in the abrogation of meniscus fabric construction.

Synovial sarcoma arising in the vulva cytogenetically confirmed by SYT break-apart rearrangement fluorescence in situ hybridization: A case report and discussion of diagnostic methods.

Synovial sarcoma (SS) is a soft tissue sarcoma of unknown histogenesis that rarely occurs in the female genital tract. We report a case of SS occurring in the right vulva of a young Japanese female. The tumor was composed of poorly differentiated rounded cell areas, surrounded by fibroblastic spindle-shaped cell areas. Immunohistochemically, the tumor cells were focally positive for cytokeratin, vimentin, CD99, Bcl-2 and neuron-specific enolase. The tumor was suspected, but was difficult to confirm as it was an SS based solely on light-microscopic and immunohistochemical findings. Although reverse transcription polymerase chain reaction (RT-PCR) failed to detect SS-specific SYT-SSX fusion gene transcripts using an RNA sample extracted from the formalin-fixed paraffin-embedded tumor tissue, SYT break-apart rearrangement fluorescence in situ hybridization (SYT bar-FISH) successfully confirmed our diagnosis of SS for the tumor. Thus, SYT bar-FISH may be more suitable for the purpose of the molecular diagnosis of SS than conventional RT-PCR when using archival formalin-fixed paraffin-embedded tissue specimens.

Shelf syndrome of the knee in elderly people: a report of three cases.

Shelf syndrome occurs mainly in younger people (particularly athletes) and rarely in elderly people. We report on 3 elderly patients with a medial synovial plica causing severe pain and locked knees. They had had no symptoms in their early or middle life. After removal of the shelf, the symptoms improved considerably. Although shelf syndrome is rare in the elderly, it should be suspected whenever severe pain and a locked knee are present.

Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma.

The strategy of limb salvage following surgical resection of skeletal tumor has led to an increased demand for more complex reconstructive options in order to achieve better functional outcomes. Functional neuro-vascularized muscle transfer (FMT) is a beneficial tool for restoring joint movement involving the reconstruction of "movement" in the affected extremity. Until now, however, the clinical application of FMT was mainly limited to trauma cases and to date, very few studies have focused on musculoskeletal oncology. In this study, we reviewed patients who underwent wide resection for extremity sarcoma and functional reconstruction using FMT and discussed the advantages, indications and complications of the procedure.

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.