Improved Metastatic-Free Survival after Systematic Re-Excision Following Complete Macroscopic Unplanned Excision of Limb or Trunk Soft Tissue Sarcoma.

BACKGROUND: Whether re-excision (RE) of a soft tissue sarcoma (STS) of limb or trunk should be systematized as adjuvant care and if it would improve metastatic free survival (MFS) are still debated. The impact of resection margins after unplanned macroscopically complete excision (UE) performed out of a NETSARC reference center or after second resection was further investigated. METHODS: This large nationwide series used data from patients having experienced UE outside of a reference center from 2010 to 2019, collected in a French nationwide exhaustive prospective cohort NETSARC. Patient characteristics and survival distributions in patients reexcised (RE) or not (No-RE) are reported. Multivariate Cox proportional hazard model was conducted to adjust for classical prognosis factors. Subgroup analysis were performed to identify which patients may benefit from RE. RESULTS: Out of 2371 patients with UE for STS performed outside NETSARC reference centers, 1692 patients were not reviewed by multidisciplinary board before treatment decision and had a second operation documented. Among them, 913 patients experienced re-excision, and 779 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, size, depth, grade and histotype in patients re-excised (RE) or not (No-RE). In univariate analysis, final R0 margins are associated with a better MFS, patients with R1 margins documented at first surgery had a better MFS as compared to patients with first R0 resection. The study identified RE as an independent favorable factor for MFS (HR 0.7, 95% CI 0.53-0.93; p = 0.013). All subgroups except older patients (>70 years) and patients with large tumors (>10 cm) had superior MFS with RE. CONCLUSIONS: RE might be considered in patients with STS of limb or trunk, with UE with macroscopic complete resection performed out of a reference center, and also in originally defined R0 margin resections, to improve LRFS and MFS. Systematic RE should not be advocated for patients older than 70 years, or with tumors greater than 10 cm.

Prognostic Factors in Extremity Soft Tissue Sarcomas Treated with Radiotherapy: Systematic Review of the Literature.

Soft tissue sarcomas of the extremities are rare tumors with various prognostic factors. Their management is debatable due to their inconsistent results within the literature and the lack of large prospective studies. The objective of this systematic review is to analyze the available scientific data on prognostic factors concerning the characteristics of the patients, the disease and the treatments performed, as well as their potential complications, on studies with a median follow-up of 5 years at minimum. A search of articles following the "PRISMA method" and using the PubMed search engine was conducted to select the most relevant studies. Twenty-five articles were selected, according to preestablished criteria. This review provides a better understanding of the prognosis and disease outcome of these tumors. Many factors were described comparing the frequency of occurrence according to the studies, which remain heterogeneous between them. Significant factors that could orient patients to radiotherapy were highlighted. These positive prognostic factors provide valuable insight to optimize radiotherapy treatments for patients treated for soft tissue sarcoma of the extremities.

Total Scapular Prosthesis, an Option for the Treatment of Scapular Chondrosarcoma.

Introduction: Chondrosarcoma has the highest prevalence among the primary malignant bone tumors in adults over the age of 50, and the scapular region is the most affected anatomical site. Case Report: We report the case of a 66-year-old female patient, with no previous medical history, who consulted for aggravating mixed, non-specific, and atraumatic pain in the right shoulder, evolving for a year. The radiological assessment, including a computed tomography (CT) scan, a magnetic resonance imaging, and a tumor CT-guided biopsy, confirmed the diagnosis of a Grade 2 chondrosarcoma. A curative surgical treatment was performed, by an extended tumor resection and simultaneous joint reconstruction by a reversed total shoulder prosthesis with a custom-made total scapular prosthesis. This option allows to maintain survival prognosis, associated with the preservation of upper limb function. Conclusion: The results were conclusive at the curative level and very encouraging from the functional point of view with progressive and partial recovery of the articular amplitudes, allowing the preservation of patient's autonomy and quality of life. No complications such as scapular dislocation or tumor recurrence were documented at 3-year postoperative follow-up.

Effects of a metallic implant on radiotherapy planning treatment-experience on a human cadaver.

BACKGROUND: Metallic implants (MIs) complicate radiotherapy planning. Several studies have worked on tissue-equivalent phantoms as experimental models to estimate dose distributions in this context. The application of these results to clinical practice remains disputable because the inhomogeneity of human tissue densities is a difficult factor to integrate into dose calculation software. In this work, we evaluate the impact of human tissue inhomogeneities by assessing the discrepancies between treatment planning system (TPS) dose calculations and measured delivered doses on a human cadaver with hip prostheses. METHODS: A total of 143 alanine dosimeters were positioned in contact with the prostheses (bones group), soft tissues (soft tissues group), skin surfaces (skin group) and natural cavities (cavities group) of a human cadaver. The planning target volume (PTV) corresponded to a standard endometrial cancer treatment. The irradiation was performed with 6 MV X-ray tomotherapy at the one fraction-dose of 10 Gy. RESULTS: A total of 140 dosimeters were analyzed. After applying a temperature correction coefficient to the measured doses, the global analysis of all dosimeters showed a significant difference between the calculated doses and the measured doses (P<0.001). For dosimeters of the bones, soft tissues, skin and cavities groups, this difference was also significant (P<0.001 for each group). The mean measured doses were 21.9% lower than the mean calculated doses in the global analysis and 17.0%, 21.2%, 33.0% and 19.0% lower for the bones, soft tissues, skin and cavities groups, respectively. CONCLUSIONS: This study showed that the received doses were significantly lower than the calculated doses and suggested the need to improve the understanding of this discrepancy.

Conformity to Clinical Practice Guidelines at Initial Management in Adult Soft Tissue and Visceral Tumors since the Implementation of the NetSarc Network in Eastern France.

BACKGROUND: Soft tissue sarcomas are rare and heterogenous tumors that are hard to diagnose. The aim of this study was to evaluate local practices and conformity to clinical practice guidelines (CPGs) for their initial diagnostic management. MATERIALS AND METHODS: Patients were carriers of a soft tissue or visceral tumor, presented at a sarcoma tumor board (STB) between 2010 and 2016. Conformity to CPGs was evaluated using ten criteria designed for this purpose. Associations between different factors and conformity to composite criteria, reflecting the three main diagnostic steps (imaging, biopsy and histological report) were analyzed. RESULTS: A total of 643 patients were included. A preoperative tumor imaging assessment and a biopsy were performed according to CPGs in 80.8% and 36.8% of the cases, respectively. When done, the first surgical resection was R0 in 30.3% of cases, R1 in 28.6%, and R2 in 10.9%. The rest of the operated patients with sarcoma had a second surgical excision (11.4%), an intraoperative fragmentation (4.3%), or margins were unknown (14.4%). Six of the ten quality criteria presented a conformity rate higher than 70%. Two criteria with a conformity rate lower than 20% were the most controversial: presentation at a STB before biopsy and freezing of a tumor fragment. A multivariate analysis revealed that the common predictor of nonconformity to composite criteria was the initial management in a nonexpert center. CONCLUSION: Initial diagnostic management requires improvement, especially outside of specialized centers. IMPLICATIONS FOR PRACTICE: This article supports the essential need to refer patients with soft tissue tumors to specialized centers to improve the management of sarcomas beginning at the diagnostic phase. Indeed, the reported data were very similar to those already described at the national level of the NetSarc network and indicate the necessity to keep raising awareness about this simple issue: early referral to reference centers will save lives.

Minimally invasive surgery with locking plate for periprosthetic femoral fractures: technical note.

PURPOSE: Periprosthetic fractures of the femur are increasing due to the increase of arthroplasties and the aging population. They concern a population that is often elderly and with important comorbidities that complicate managing this already complex pathology. Usual complications of classic osteosynthesis are numerous, including infections and nonunions and the need for delayed weight bearing after surgery. METHODS-RESULTS: The development of locking plates has allowed complication avoidance. When used in minimally invasive surgery, they combine the biological advantages of closed-wound surgery to the mechanical advantages of locking plates, which have better stability in fragile bones. We propose a technical update on handling such fractures by using locking plates under minimally invasive surgery. DISCUSSION-CONCLUSION: In our experience, under certain guidelines, this allows for immediate post-operative full weight bearing, which is beneficial to these often elderly patients.

Negative pressure wound therapy with saline instillation: 131 patient case series.

Negative pressure wound therapy combined with timed, cyclical instillation (NPWTi) of topical wound solutions has been recently presented as a new adjunctive modality for treating wounds with signs of infection. Normal saline, antiseptics and antimicrobials all have been proposed in scientific and clinical studies as potentially effective when used with NPWTi for treating heavily infected wounds. This is a prospective clinical study of 131 patients with 131 wounds treated with NPWTi using saline between January 2012 and December 2012 in two orthopaedic centres and one surgical wound healing centre in France. Saline was exclusively used. Results were favourable: in 98% of the cases, the wounds could be closed after debridement and following the use of NPWTi. Mean duration of NPWTi was 12·19 days. This does not preclude the need for treating the biofilm appropriately with more active antibacterial products when biofilm has been documented.