Bone Radiation-Induced Sarcomas: Outcomes Based on Histology and Surgical Treatment: A Systematic Review of the Literature.

BACKGROUND: Bone radiation-induced sarcomas (B-RIS) are secondary neoplasms with reportedly worse overall survival than de novo bone sarcoma. Treatment strategy for these neoplasms remains uncertain. Our systematic review sought to assess overall survival based on histology and surgical intervention. METHODS: A systemic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and registered in PROSPERO (438415). Studies describing oncologic outcomes of patients with B-RIS in the appendicular and axial skeleton were included. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Survival analysis by histologic subtype and surgery type was performed in a subset of 234 patients from 11 articles with individualized data. A total of 20 articles with a total of 566 patients were included. The most frequent location was the pelvis (27.7%), and the main histological types were osteosarcoma (69.4%), undifferentiated pleomorphic sarcoma (14.1%), and fibrosarcoma (9.2%). Limb-salvage and amputation were performed in 68.5% and 31.5% of cases, respectively. RESULTS: Local recurrence was 13%, without difference between limb-salvage surgery and amputation (p = 0.51). The metastasis rate was 42.3%. Five-year OS was 43.7% (95% confidence interval [CI], 33.3%-53.5%) for osteosarcoma, 31.5% (95% CI, 11.3%-54.2%) for UPS, and 28.1% (95% CI, 10.6%-48.8%) for fibrosarcoma. Five-year OS was 49.2% (95% CI, 35.3%-61.6%) for limb-salvage and 46.9% (95% CI, 29.1%-62.9%) for amputation. There was no difference in 5-year OS between histologic subtypes (p = 0.18) or treatment type (p = 0.86). CONCLUSION: B-RIS demonstrated poor OS at 5 years after initial management regardless of histology. Limb-salvage surgery was not associated with lower 5-year OS compared with amputation. Future studies should compare both groups while controlling for confounders. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Is Unplanned Excision of Soft Tissue Sarcomas Associated with Worse Oncological Outcomes?-A Systematic Review and Meta-Analysis.

BACKGROUND: Soft tissue sarcomas are a group of rare neoplasms which can be mistaken for benign masses and be excised in a non-oncologic fashion (unplanned excision). Whether unplanned excision (UE) is associated with worse outcomes is highly debated due to conflicting evidence. METHODS: We performed a systematic review and meta-analysis following PRISMA guidelines. Main outcomes analyzed were five-year overall survival (OS), five-year local recurrence-free survival (LRFS), amputation rate and plastic reconstruction surgery rate. Risk ratios were used to compare outcomes between patients treated with planned and unplanned excision. RESULTS: We included 16,946 patients with STS, 6017 (35.5%) with UE. UE was associated with worse five-year LRFS (RR 1.35, p = 0.019). Residual tumor on the tumor bed was associated with lower five-year LRFS (RR = 2.59, p < 0.001). Local recurrence was associated with worse five-year OS (RR = 1.82, p < 0.001). UE was not associated with a worse five-year OS (RR = 0.90, p = 0.16), higher amputation rate (RR = 0.77, p = 0.134), or a worse plastic reconstruction surgery rate (RR = 1.25, p = 0.244). CONCLUSIONS: Unplanned excision of Soft Tissue Sarcomas and the presence of disease in tumor bed after one were associated with worse five-year LRFS. Tumor bed excision should remain the standard approach, with special consideration to the presence of residual disease.

Treatment and Outcomes of Radiation-Induced Soft Tissue Sarcomas of the Extremities and Trunk-A Systematic Review of the Literature.

INTRODUCTION: Radiation-induced soft tissue sarcomas (RISs) are rare secondary malignancies with a dire prognosis. The literature on the management of these tumors remains scarce due to their low incidence. Our systematic review sought to assess the treatment alternatives and outcomes of patients with RIS. METHODS: A systematic review was conducted following the PRISMA guidelines. Our study was registered in PROSPERO (ID: CRD42023438415). Quality assessment was performed using the STROBE checklist. Weighted means for both continuous and categorical values were calculated. RESULTS: Twenty-one studies comprising 1371 patients with RIS were included. The mean latency period from radiation to RIS diagnosis was 14 years, and the mean radiation dose delivered to the primary malignancy was 29.2 Gy. The most common histological type was undifferentiated pleomorphic sarcoma (42.2%), and 64% of all tumors were high-grade. The trunk was the most common location (59%), followed by extremities (21%) and pelvis (11%). Surgery was performed in 68% of patients and, among those with an appendicular tumor, the majority (74%) underwent limb-salvage surgery. Negative margins were attained in 58% of patients. Chemotherapy and radiotherapy were administered in 29% and 15% of patients, respectively. The mean 5-year overall survival was 45%, and the local recurrence and metastasis rates were 39% and 27%, respectively. CONCLUSIONS: In our study, the most common treatment was surgical resection, with RT and chemotherapy being administered in less than one third of patients. Patients with RIS exhibited poor oncologic outcomes. Future studies should compare RIS with de novo STS while controlling for confounders.

Surgical Management of Metastatic Pathologic Subtrochanteric Fractures: Treatment Modalities and Associated Outcomes.

BACKGROUND: Subtrochanteric pathological fractures (PFs) occur in approximately one-third of femur bone metastases. We seek to analyze surgical treatment strategies for subtrochanteric metastatic PFs and their revision rates. METHODS: A systematic review was performed using the PubMed and Ovid databases. Reoperations as a result of complications were analyzed according to initial treatment modality, primary tumor site, and type of revision procedure. RESULTS: We identified a total of 544 patients, 405 with PFs and 139 with impending fractures. The study population's mean age was 65.85 years with a male/female ratio of 0.9. Patients with subtrochanteric PFs who underwent an intramedullary nail (IMN) procedure (75%) presented a noninfectious revision rate of 7.2%. Patients treated with prosthesis reconstruction (21%) presented a noninfectious revision rate of 8.9% for standard endoprostheses and 2.5% for tumoral endoprostheses (p < 0.001). Revision rates because of infection were 2.2% for standard and 7.5% for tumoral endoprostheses. There were no infections within the IMN and plate/screws group (p = 0.407). Breast was the most common primary tumor site (41%) and had the highest revision rate (14.81%). Prosthetic reconstructions were the most common type of revision procedure. CONCLUSION: No consensus exists regarding the optimal surgical approach in patients with subtrochanteric PFs. IMN is a simpler, less invasive procedure, ideal for patients with a shorter survival. Tumoral prostheses may be better suited for patients with longer life expectancies. Treatment should be tailored considering revision rates, patient's life expectancy, and surgeon's expertise. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment and survival outcomes in metastatic Merkel cell carcinoma: Analysis of 2010 patients from the SEER database.

INTRODUCTION: Merkel cell carcinoma (MCC) is an aggressive cutaneous cancer that frequently compromises the lymph nodes (LN) and distal organs. We sought to describe clinical and demographic characteristics of affected patients, analyze risk factors for LN compromise, metastasis, and death, and evaluate their impact on survival. MATERIALS AND METHODS: Patients with MCC were retrieved from the SEER database. Demographic, clinical and treatment data were analyzed. Logistic and Cox proportional hazard regression were used to analyze risk factors. Survival analysis was done with the Kaplan-Meier method. RESULTS: A total of 2010 patients were included, among which 288 (14.33%) had distant metastases at diagnosis. LN involvement occurred in 45.8% and 20.1% of patients with and without distant metastasis, respectively. Males were more likely to present LN compromise (OR = 1.33, p<0.001). Tumors >10 mm showed a significantly higher risk for LN involvement and distant metastasis, with those >20 mm showing the highest risk (OR = 2.76 p<0.001 and OR = 8.88 p<0.001 respectively). Location of the tumor in the trunk was a protective factor for overall death (OR = 0.27), while LN compromise was a risk factor (OR = 3.12). Only history of previous malignancy significantly affected disease-specific death (OR = 0.32, p = 0.01). One-year survival was 79.7% and 38.2% for patients with regional LN disease and distant metastasis, respectively. CONCLUSION: MCC is an aggressive cancer with high rates of LN involvement and distant metastases. Male gender and tumor size were risk factors for regional LN and metastatic disease. Tumor location in the trunk decrease the risk of overall death, while LN involvement increased it.

Management of Long Bones Metastatic Disease: Concepts That We All Know but Not Always Remember.

Bones are the third most common site of metastatic disease. Treatment is rarely curative; rather, it seeks to control disease progression and palliate symptoms. Imaging evaluation of a patient with symptoms of metastatic bone disease should begin with plain X-rays. Further imaging consists of a combination of (PET)-CT scan and bone scintigraphy. We recommend performing a biopsy after imaging workup has been conducted. Metastatic bone disease is managed with a combination of systemic treatment, radiotherapy (RT), and surgery. External beam RT (EBRT) is used for pain control and postoperatively after fracture stabilization. Single-fraction and multiple-fractions schemes are equally effective achieving pain control. Adequate assessment of fracture risk should guide the decision to stabilize an impending fracture. Despite low specificity, plain X-rays are the first tool to determine risk of impending fractures. CT scan offers a higher positive predictive value and can add diagnostic value. Surgical management depends on the patient's characteristics, tumor type, and location of fracture/bone stock. Fixation options include plate and screw fixation, intramedullary (IM) nailing, and endoprostheses. Despite widespread use, the need for prophylactic stabilization of the entire femur should be individually analyzed in each patient due to higher complication rates of long stems.

Squamous Cell Carcinoma Arising from Chronic Osteomyelitis in the Extremities: Treatment Approach and Oncological Outcomes-A Systematic Review of the Literature.

Aims: In chronic osteomyelitis-derived squamous cell carcinoma, what are the demographic and clinical variables, risk factors associated with worse outcomes, and results of treatment modalities used? Methods: A systematic review was performed using PubMed and EMBASE. Articles were evaluated for inclusion and exclusion criteria, and for quality analysis. PRISMA guidelines were applied. Demographic and clinical data and therapeutic approaches were presented narratively and in descriptive statistics registered at PROSPERO. Results: Most patients were male (40/49), trauma was the most common etiology (27/36), and about half of all SCC were in the tibia (25/48). Amputation was the main definitive treatment (42/47). Adjuvant treatments were not analyzed. Well-differentiated SCC accounted for 58.3% (21/36) of all tumors. Bone invasion was described in 82.8% (24/29); recurrence, in 7.7% (3/39); and metastasis, in 7.7% (3/39). Recurrence and metastasis occurred more frequently when bone invasion was present (p = 0.578 and p = 0.646, respectively). SCC with lymph node involvement showed a higher tendency to metastasize (p = 0.377). Compared with limb salvage, amputation was associated with a tendency for less recurrence (p = 0.312) and longer survival (p = 0.219). Conclusions: COM-derived SCC mostly occurs after trauma and is usually located in the tibia. Bone invasion is common, and patients predominantly undergo amputation. This treatment is associated with a trend toward higher survival, compared to limb salvage.

Appendicular dedifferentiated chondrosarcoma: A management and survival study from the SEER database.

Introduction: Dedifferentiated chondrosarcoma (DDC) is an aggressive osseous neoplasm with a dismal prognosis. Treatment commonly involves limb-salvage surgery or amputation. In patients with appendicular DDC, we sought to describe demographic, clinical and treatment characteristics (1), analyze risk factors for metastasis (2) and overall death (3), and assess survival rates by treatment (4). Materials and methods: Two-hundred-and-five patients from the SEER Database were included in our analysis. Demographic, clinical and treatment variables were analyzed. Multivariate regression was performed to identify risk factors. Survival analysis was performed using the Kaplan-Meier method. Results: Fifty-one (24.9 %) of the patients included presented metastasis at diagnosis. The most common locations were the lungs, other sites, and bone. Surgery to the primary site was more common in patients without metastasis (94.2 %) than those with (78.2 %); limb-salvage procedures were more common than amputations. Tumors >8 cm (T2) and those discontinuous (T3) were more likely to present metastasis at diagnosis (OR = 2.54, p = 0.043 and OR = 7.4, p = 0.008, respectively). Female gender was found to be a protective factor for overall death on crude analysis (OR = 0.33, p = 0.019). Metastases to sites other than the lungs (M1b) had the highest risk of overall death (OR = 49, p = 0.01). Combination of surgery and chemotherapy showed a trend towards higher overall survival in non-metastatic patients (p = 0.1069 and p = 0.1703). Conclusions: Appendicular DDC displays a high metastatic rate and low survival rates. The most common procedure is a limb-salvage surgery. Tumor size increases the risk of presenting metastases at diagnosis and female gender is a protective factor against death.

PET-CT in the Evaluation of Neoadjuvant/Adjuvant Treatment Response of Soft-tissue Sarcomas: A Comprehensive Review of the Literature.

➢: In soft-tissue sarcomas (STSs), the use of positron emission tomography-computed tomography (PET-CT) through a standardized uptake value reduction rate correlates well with histopathological response to neoadjuvant treatment and survival. ➢: PET-CT has shown a better sensitivity to diagnose systemic involvement compared with magnetic resonance imaging and CT; therefore, it has an important role in detecting recurrent systemic disease. However, delaying the use of PET-CT scan, to differentiate tumor recurrence from benign fluorodeoxyglucose uptake changes after surgical treatment and radiotherapy, is essential. ➢: PET-CT limitations such as difficult differentiation between benign inflammatory and malignant processes, inefficient discrimination between benign soft-tissue tumors and STSs, and low sensitivity when evaluating small pulmonary metastases must be of special consideration.

Trastornos de la consolidación: Retardo y pseudoartrosis / Bone defect healing: Delay of consolidation and Pseudarthrosis

No hay una definición universalmente aceptada de pseudoartrosis; en general se acepta que si la consolidación no serealiza en 6-8 meses, estamos frente a una pseudoartrosis. El proceso de consolidación puede ser alterado o perturbado por factores mecánicos, biológicos o una combinación de ambos. El retardo de consolidación y la pseudoartrosis, son dos procesos que difieren en su fisiopatología, pronóstico y tratamiento. El tratamiento debe ser individualizado teniendo en cuenta todos los factores presentes en el paciente, para abordar de manera integral el problema. La pseudoartrosis de los huesos largos se puede tratar con un procedimiento quirúrgico único en más del 90 por ciento de los pacientes, con buenos o excelentes resultados en la restauración del eje mecánico y longitud del miembro afectado, en 80 por ciento de los casos.

There is no universally accepted definition of nonunion of a fracture. Generally, failure of a fracture to heal in 6-8 months constitutes a nonunion. The fracture repair process may be affected by mechanical or biological factors ora combination of both. The delayed union and nonunion are two different entities that differs on their physiophatology, outcome and treatment. Treatment must be tailored to the individual patient to address all components of the problem. Nonunions of long bones fractures can be treated successfully with one operative procedure in more than 90 per cent of patients. In fact, 80 per cent of patients can have good or excellent final restoration of mechanical axis alignmentand proper length.

Fracturas de tibia: Tratamiento con clavo intramedular no fresado (UTN). Experiencia en el Hospital Nacional Cayetano Heredia / Tibial fractures: Treatment with unreamed intramedullar nail (UTN). Experience at the Hospital Nacional Cayetano Heredia

Objetivo: Determinar la utilidad del uso del clavo sólido intramedular no fresado (UTN) en el tratamiento de las fracturas diafisarias de tibia cerradas, expuestas y en seudoartrosis. Material y métodos: Se realizó un estudio de cohorte prospectivo y longitudinal en 12 pacientes con fracturas diafisarias de tibia tratados en el servicio de traumatología del Hospital Nacional Cayetano Heredia desde febrero 2000 hasta junio del 2001. La técnica usada para colocar el UTN fue la descrita en el Manual de Técnicas Quirúrgicas de la AO. El tiempo de seguimiento total fue de 1 año. Resultados: La consolidación con el uso de este clavo se dio en promedio a las 16 semanas, no presentándose ningún caso de no unión. A pesar de que alguno de nuestros pacientes presentaron lesiones en piel y tejidos blandos, no observamos infecciones superficiales ni profundas. Por otro lado el movimiento de la rodilla, tobillo y articulación subtalar, se inicio en el postoperatorio inmediato, logrando los pacientes hasta el momento un rango articular normal. Conclusiones: El Clavo Intramedular no fresado, es una buena alternativa en el tratamiento quirúrgico de las fracturas diafisarias de tibia tanto cerradas y expuestas de I° grado, así como en seudoartrosis, debido a todas las ventajas y buenos resultados obtenidos.

Satisfacción de las usuarias de implantes de levonorgestrel. Experiencia del Hospital Nacional Cayetano Heredia / Levonorgestrel implants users satisfaction. Experience at Cayetano Heredia National Hospital

OBJETIVOS: Determinar las características y el porcentaje de satisfacción de las usuarias de implante subdérmico de levonorgestrel (Norplant®) pertenecientes al Programa de Planificación Familiar del HNCH. DISEÑO: Estudio descriptivo, retrospectivo. MATERIAL Y METODOS : Del total de usuarios a quienes se les extrajo el implante entre enero 1995 y diciembre 1999, se incluyo 82. Los datos fueron obtenidos mediante una ficha de recolección de datos y una encuesta. La satisfacción fue evaluada mediante la escala de Likert. RESULTADOS: El 71,9 por ciento de usuarias resultó satisfecha la tasa de embarazo fue 0 por ciento. El 70,7 por ciento de las usuarias presento algún efecto secundario, el mas frecuente fue la alteración de la menstruación (47,6 por ciento). La principal ventaja fue la protección contra el embarazo a largo plazo (53,7 por ciento). Se registro 59 por ciento de continuidad a los 5 años y las principales causas de remoción temprana fueron deseo de embarazo (23,5 por ciento) y alteraciones menstruales (23,5 por ciento). Se encontró significancia estadística con la satisfacción evaluada en la siguientes variables: aumento de peso (p= 0,0077), dolor en zona del implante (p= 0,000055), síntomas depresivos (0,00000), nivel educativo (p =0,033), recomendación del metodo (p= 0,000) y deseo de reimplante (p= 0,0000). CONCLUSIONES: Los implantes subdérmicos de levonorgestrel resultan ser un método anticonceptivo muy bien aceptado por las usuarias, a pesar de los efectos secundarios que presentan, altamente efectivo y una buena alternativa para mujeres que deseen anticoncepción a largo plazo.

OBJECTIVES. To determine the characteristics and satisfaction of levonorgestrel users (Norplant®) at the CHNH Family Planning Program. DESIGN: Descriptive retrospective study. MATERIAL AND METHODS: Eighty-two users to whom Norplant® was removed between January 1995 and December 1999, were included. Data was obtained from records and satisfaction was evaluated through a survey employing Likert' scale. RESULTS: Up to 71,9 per cent of users were satisfied, The pregnancy rate was 0 per cent; 70,7 per cent of users presented a side effect, being menstrual irregularities the most frequent (47,6 per cent). The main advantage was protection against pregnancy at the long term (53,7 per cent). A 59 per cent of continuity was registered during the five years and the main causes of early removal were pregnancy desire and menstrual alterations with 23,5 per cent in both cases. A statistical significance was found with users satisfaction in the following variables: weight gain (p= 0,0077), pain at the implantation zone (p= 0,000055), depressive symptoms (p= 0,000000), educational level (p= 0, 033), method recommendation (p= 0, 0000) and desire for a re -implant (p= 0,00000). CONCLUSIONS. The levonorgestrel subdermal implants (Norplant®) was a very well accepted contraceptive method in spite of the side effects, highly effective and a good alternative for women wishing a long term contraceptive.