Muscle strength and functional recovery for soft-tissue sarcoma of the thigh: a prospective study.

BACKGROUND: This study aimed to investigate changes in muscle strength and functional outcome before and after surgery for soft-tissue sarcoma of the thigh and to examine the timing of recovery. METHODS: From 2014 to 2019, 15 patients who underwent multiple resections of the thigh muscle for soft-tissue sarcoma of the thigh were included in this study. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint. The functional outcome assessment was based on the Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and maximum walking speed (MWS). All measurements were conducted preoperatively and at 3, 6, 12, 18, and 24 months postoperatively, and the ratio of postoperative to preoperative value was used. A repeated-measures analysis of variance was performed to compare changes over time and to investigate the recovery plateau. Correlations between changes in muscle strength and functional outcomes were also examined. RESULTS: The muscle strength of the affected limb, MSTS score, TESS, EQ-5D, and MWS were significantly decreased at 3 months postoperatively. The recovery plateau was subsequently reached at 12 months postoperatively. The changes in muscle strength of the affected limb and functional outcome showed a significant correlation. CONCLUSIONS: The estimated postoperative recovery for soft-tissue sarcoma of the thigh is 12 months after surgery.

The usefulness of immunohistochemistry for phosphohistone H3 as a prognostic factor in myxoid liposarcoma.

Myxoid liposarcoma (MLS) is a common subtype of liposarcoma. Although the prognosis is generally good, there are factors known to be associated with poor prognosis. Accurate indices are important to predict prognosis. We aimed to assess the usefulness of immunohistochemistry for phosphohistone H3 (PHH3) as a potential biomarker in comparison with Ki-67 antigen and other prognostic factors. Twenty-five patients with MLS were evaluated. Age, sex, depth of tumor, tumor size, surgical margin, oncological outcome, histological grade, presence of necrosis, proportion of round cell component (RC%), PHH3 index, and Ki-67 index were examined. Prognostic factors of the examination criteria were statistically analyzed, survival rate analyses were performed using the Kaplan-Meier method, and multivariate analysis was performed using Cox proportional-hazard regression analysis. The number of PHH3-positive tumor cells and the PHH3 and Ki-67 indices demonstrated a statistical correlation with the prognosis of MLS in univariate analysis (P < 0.001, P < 0.001, P = 0.01, respectively). PHH3 index and RC% were significant factors in multivariate analysis (P = 0.03, P = 0.02). The immunohistochemistry of PHH3 may be associated with prognosis and could serve as a valid criterion of histological grade in MLS.

Influence of the adductor compartment resection on muscle strength and postoperative function in soft-tissue sarcoma of the thigh.

OBJECTIVE: To predict the muscle strength and postoperative function for soft-tissue sarcoma arising from the adductor compartment of the thigh. METHODS: Between 2003 and 2019, 17 cases that underwent resection of the adductor muscle group (adductor longus, adductor magnus, adductor brevis, gracilis and pectineus) for soft-tissue sarcoma in the adductor compartment of the thigh were included. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint (ratio of affected to unaffected side). The Musculoskeletal Tumor Society score, Toronto Extremity Salvage Score, European Quality of Life-5 Dimensions and maximum walking speed were used to assess postoperative function and examine correlations with muscle strength. RESULTS: In 13 cases that underwent an isolated resection of the adductor compartment, reduced adduction strength correlated with increased number of resected muscles in the adductor muscle group (P < 0.001). Postoperative function was maintained, showing no correlations with adduction strength. In four cases that underwent combined resections of other compartments, a decrease was observed in adduction strength as well as the muscle strength of other resected muscles, in addition to a decline in postoperative function. In the 4 or 5 adductor muscle resection group, the comparison between isolated and combined resection revealed comparable results for adduction strength but a significant decrease in postoperative function for the combined resection group. CONCLUSIONS: Postoperative function can be preserved for isolated adductor compartment resection. Combined resections of multiple muscles in other compartments and most adductor muscles may result in decreased postoperative function.

Points of consideration when performing surgical procedures for proximal femoral bone metastasis.

BACKGROUND: To assess the points of consideration when performing surgical procedures for proximal femoral bone metastasis. METHODS: Fourty patients who underwent surgery for proximal femoral bone metastasis from 2009 to 2019 were included. Prognostic assessments were performed based on the Katagiri scoring system. The low-risk group underwent endoprosthetic replacement (EPR) following resection, while the high-risk group underwent internal fixation (IF). For the intermediate-risk group, one of the surgical procedures was chosen depending on general and local condition. Survival period, walking ability, and treatment failure were evaluated. RESULTS: Sixteen and 24 patients underwent EPR and IF, respectively. Although walking reacquisition rate was 94% (15 of 16 patients) for EPR and 75% (18 of 24 patients) for IF (p = 0.210), the median time to walking was shorter in IF compared to EPR (EPR, 29 days, interquartile range [IQR] 23-40; IF, 14 days, IQR 9-24; p = 0.014). Neither EPR nor IF resulted in treatment failure for those with survival periods of <1 year. The treatment failure rate for those with survival periods of ≥1 year was significantly different between EPR (9%, 1 of 11 patients) and IF (50%, 5 of 10 patients) (p = 0.038). All five patients of treatment failure for IF were renal cancer with no bone formation in the intermediate-risk group. Of the 13 patients who underwent IF for the intermediate-risk group, treatment failure did not occur in 5 patients with bone formation. CONCLUSIONS: Although EPR is a more reliable treatment than IF, patients with life expectancy of <1 year are sufficiently manageable with IF. For the intermediate-risk group, EPR should be selected for cases without expected bone formation, and IF can be considered for cases with expected bone formation due to the risk of treatment failure for IF at ≥ 1 year after surgery.

Antitumor Effect of Sclerostin against Osteosarcoma.

Various risk factors and causative genes of osteosarcoma have been reported in the literature; however, its etiology remains largely unknown. Bone formation is a shared phenomenon in all types of osteosarcomas, and sclerostin is an extracellular soluble factor secreted by osteocytes that prevents bone formation by inhibiting the Wnt signaling pathway. We aimed to investigate the antitumor effect of sclerostin against osteosarcoma. Osteosarcoma model mice were prepared by transplantation into the dorsal region of C3H/He and BALB/c-nu/nu mice using osteosarcoma cell lines LM8 (murine) and 143B (human), respectively. Cell proliferations were evaluated by using alamarBlue and scratch assays. The migratory ability of the cells was evaluated using a migration assay. Sclerostin was injected intraperitoneally for 7 days to examine the suppression of tumor size and extension of survival. The administration of sclerostin to osteosarcoma cells significantly inhibited the growth and migratory ability of osteosarcoma cells. Kaplan-Meier curves and survival data demonstrated that sclerostin significantly inhibited tumor growth and improved survival. Sclerostin suppressed the proliferative capacity and migratory ability of osteosarcoma cells. Osteosarcoma model mice inhibited tumor growth and prolonged survival periods by the administration of sclerostin. The effect of existing anticancer drugs such as doxorubicin should be investigated for future clinical applications.

Distal femoral impaction bone grafting in revision for tumor endoprosthesis.

BACKGROUND: Reconstruction using tumor endoprosthesis has been widely used in cases with large bone defects caused by bone and soft tissue tumor resection of the distal femur which extend into the knee joint. However, reconstruction failure can lead to major problems in the long term. We have been performing impaction bone grafting with allogeneic cancellous bone during revision surgery for tumor endoprosthesis of the distal femur to compensate for the thinness and fragility of the remaining femur. The aim of this study is to examine the surgical method, problems, and clinical outcomes of revision surgery with impaction bone grafting. METHODS: Three patients who underwent revision surgery for tumor endoprosthesis using impaction bone grafting at our institution with more than 2 years of follow-up were included. RESULTS: Union between the graft and host bone were achieved in all cases. The mean time to radiographic union was 1.0 year (0.6-1.5 years). Although intraoperative penetration to the anterior cortex of the distal femur occurred in 2 cases, there were no postoperative fractures. There were no failures of tumor endoprosthesis at final observation. CONCLUSION: Good short-term results were observed in 3 patients who underwent revision tumor endoprosthesis with impaction bone grafting following a bone and soft tissue tumor resection of the distal femur. The method was considered to be a useful treatment option. Impaction bone grafting is an established surgical option that can be applied to revision surgery for tumor endoprosthesis.

Continued growth of locally aggressive fibrous dysplasia of 22 years duration after reaching adulthood: a case report.

Fibrous dysplasia generally stops growing when patients reach adulthood. Locally aggressive fibrous dysplasia is an extremely rare subtype of fibrous dysplasia that is characterized by progressive enlargement after bone maturation, cortical bone destruction and soft tissue invasion but without malignant transformation. At 50 years of age, a tumor was found in the rib of a patient. The tumor gradually enlarged over time and imaging findings suggested a malignant tumor. The case was further complicated by restrictive lung disorder. Biopsies from multiple sites showed no malignant findings, and marginal resection with partial curettage was performed. The final diagnosis was locally aggressive fibrous dysplasia, and the restrictive lung disorder improved postoperatively. The natural history of the disease is also unknown. This is the first report in the literature to describe a case in which a lesion exhibited long-term growth over a period of 22 years after reaching adulthood.

Risk factor for wound complications following wide resection of soft tissue sarcoma in the adductor compartment of the thigh.

BACKGROUND: The purpose of this study was to investigate deep-seated soft tissue sarcoma (STS) occurring in the adductor compartment of the thigh that underwent wide resection and to clarify the high-risk group for wound complications. PATIENTS AND METHODS: From 2000 to 2017, we reviewed 104 cases of deep-seated STS occurring in the adductor compartment of the thigh that were treated at four specialized facilities with expertise in sarcoma treatment. RESULTS: Wound complications occurred in 40 cases (38.5%), of which 23 cases (22.1%) were cases with major wound complications (MWC). In univariate analysis, BMI (P < 0.01), maximum tumor diameter (P < 0.01), operation time (P < 0.01), amount of intraoperative bleeding (P < 0.01), and intraoperative intervention to the femoral artery and vein (P < 0.01) were significantly associated with wound complications. In multivariate analysis, the associated parameters were BMI (P < 0.01), maximum tumor diameter (P = 0.02), and intraoperative intervention to the femoral artery and vein (P = 0.01). When limited to cases with MWC, univariate analysis showed that maximum tumor diameter (P < 0.01), diabetes mellitus (P = 0.03), operation time (P < 0.01), amount of intraoperative bleeding (P < 0.01), and intraoperative intervention to the femoral artery and vein (P = 0.02) were significantly associated parameters. In multivariate analysis, maximum tumor diameter (P = 0.02) and amount of intraoperative bleeding (P = 0.04) were associated parameters. CONCLUSIONS: For patients with risk factors for wound complications, control of bleeding are crucial when resecting deep-seated STS in the adductor compartment of the thigh. In cases with large tumors, surgeons should be especially cautious of cases requiring interventions that surround the femoral artery and vein in order to attain an appropriate surgical margin.

Combined treatment using Mohs' paste and neoadjuvant chemotherapy for giant gluteal soft tissue sarcoma with malignant fungating wound: a case report.

A malignant fungating wound is a cutaneous infiltration of malignant tumor or metastatic lesion that develop into ulceration. Local control is often difficult to obtain, because the Quality of Life of patients can decrease considerably due to bleeding, exudation, odor and pain from the wound. There are few studies in the literature that report the use of Mohs' paste for soft tissue sarcoma with malignant fungating wound. We report a case resulting in good local control for a patient with dedifferentiated liposarcoma with gluteal ulceration by the combined use of Mohs' paste and chemotherapy as a pre-operative adjuvant therapy. Mohs' paste controlled the infection, odor and exudation in approximately 2 weeks, and good visualization of the surgical field was obtained due to tumor volume reduction. We found that Mohs' paste is effective as a neoadjuvant therapy for disintegrated soft tissue sarcoma.

Relationship of Malnutrition During Hospitalization With Functional Recovery and Postdischarge Destination in Elderly Stroke Patients.

AIM: Malnutrition during hospitalization affects the functional recovery and postdischarge destinations of elderly stroke patients. However, insufficient studies exist about nutritional status during hospitalization in the acute stroke phase in this population. This study determined factors of nutritional status changes during hospitalization in elderly patients in the acute phase of stroke, and investigated the relationship between nutritional status changes and improved activities of daily living and postdischarge destination. METHODS: This retrospective observational study included 205 acute-phase stroke patients admitted to Shinshu University Hospital from 2010-2016. Multiple regression analysis was conducted to determine relationships between nutritional status changes, patient characteristics, and improved activities of daily living. Binomial logistic regression analysis was used to determine the relationship between the postdischarge destination and nutritional status changes. RESULTS: Prevalence of malnutrition was 42% at admission and 76% at discharge. Factors affecting nutritional status changes at admission included Geriatric Nutritional Risk Index (ß = -0.35, P < .001) and Barthel Index/feeding (ß = 0.22, P = .002), and factors during hospitalization included age (ß = -0.21, P < .001), ischemic stroke (ß = 0.16, P = .008), and National Institute of Health Stroke Scale score (ß = -0.29, P < .001). Significant associations of changes in geriatric nutritional risk index occurred with improved activities of daily living during hospitalization (ß = 0.26, P < .001) and discharge to home (odds ratio = 1.11, 95% confidence interval: 1.03-1.19, P = .008). CONCLUSION: Many elderly patients in the acute phase of stroke with malnutrition exhibited worsening conditions during hospitalization, which was negatively associated with their activities of daily living abilities and postdischarge destinations. Nutritional status changes and associated factors must be evaluated during hospitalization in this patient population.

Using the Barthel Index to Assess Activities of Daily Living after Musculoskeletal Tumour Surgery: A Single-centre Observational Study.

OBJECTIVE: The objective of the current study was to find the factors affecting the activities of daily living, as evaluated by the Barthel Index, at the end of rehabilitation after musculoskeletal tumour surgery. Further, we evaluated whether the Barthel Index correlates with functional scores that are specific to musculoskeletal tumours at final follow-up. METHODS: The activities of daily living of 190 patients who underwent postoperative rehabilitation after surgery to treat musculoskeletal tumours were evaluated at the end of the program using the Barthel Index. Functional evaluation at the time of final follow-up observation was evaluated using the Musculoskeletal Tumour Society Score and the Toronto Extremity Salvage Score. RESULTS: The post-rehabilitation Barthel Index was significantly lower in elderly patients aged more than 60 years and in those with malignant tumours and tumours larger than 10 cm. Malignancy and large tumour size were risk factors for a low Barthel Index. There was significant correlation between the Musculoskeletal Tumour Society Score/Toronto Extremity Salvage Score at final functional evaluation and the Barthel Index at the end of rehabilitation. CONCLUSION: The Barthel Index is a simple method to assess the activities of daily living and can potentially predict disease-specific health-related quality of life at final functional evaluation after musculoskeletal tumour surgery.

The status quo of treatment and clinical outcomes for patients over 80 years of age with high-grade soft tissue sarcoma: report from the soft tissue tumor registry in Japan.

OBJECTIVE: The purpose of this study is to clarify the status quo of management and clinical outcome of treatments for oldest-old (≥80 years) patients with high-grade soft tissue sarcomas in Japan. METHOD: The present study was conducted using data from the Soft Tissue Tumor Registry in Japan. There were 956 oldest-old patients with soft tissue sarcoma who were registered from 2006 to 2012. Among them, cases with incomplete data, low-grade soft tissue sarcoma and those who underwent treatment at other institutions were excluded from analysis. RESULTS: We examined 451 cases of high-grade soft tissue sarcoma in oldest-old patients. Three-hundred fifty-one cases (77.8%) were surgically managed, while 100 cases were conservatively managed. In patients aged 85 years and older, 73.1% underwent surgical treatment. A significantly higher proportion of patients underwent conservative therapy in oldest-old patients aged 85 years or older (P = 0.036), patients with deep-seated tumors (P = 0.027) and patients with distant metastases at the first visit (P = 0.000). The median follow-up period was 18.9 months (range, 0.2-83.1). Risk factors for overall survival were extracompartmental tumor progression (P = 0.014) and presence of distant metastases at the first visit (P = 0.000). CONCLUSION: We reported the status quo of treatment and clinical outcome for oldest-old patients with high-grade soft tissue sarcoma in Japan. Although surgery is the primary treatment for soft tissue sarcoma, a significantly higher proportion of patients underwent conservative therapy over surgical treatment in patients aged 85 years or older, patients with deep-seated tumors and patients with distant metastases.

Initial clinical presentation of single soft tissue metastasis of medullary thyroid carcinoma without primary tumor in the thyroid gland.

BACKGROUND: Single soft tissue metastasis of medullary thyroid carcinoma is extremely rare. In addition, several occult medullary thyroid carcinomas with distant metastasis were reported, but undetectable primary lesion at diagnosis was also extremely rare. CASE PRESENTATION: A 74-year-old man was admitted to our hospital because of a painful nodule in his left buttock for over 1 year. Needle biopsy was performed, and the histological findings revealed adenocarcinoma positive for thyroid transcription factor-1. No evidence of a primary tumor, including the lung and thyroid gland, could be found elsewhere despite detailed examinations, including thyroid echography, chest computed tomography, and fluorodeoxyglucose-positron emission tomography. The soft tissue tumor was resected with a wide margin. Immunohistochemical analysis showed the tumor cells to be positive for cytokeratin-AE1/3, cytokeratin 7, synaptophysin, chromogranin A, calcitonin, and carcinoembryonic antigen, but negative for cytokeratin 20, Napsin A, Pax8, and p40, resulting in a diagnosis of metastasis of medullary thyroid carcinoma. CONCLUSION: Initial presentation with a single metastasis to soft tissue and undetectable primary tumor in the thyroid gland is an extremely rare clinical manifestation in patients with medullary thyroid carcinoma.

Clinical outcomes of patients 80 years of age and older with soft tissue sarcoma.

OBJECTIVES: Although soft tissue sarcoma (STS) is rare, its incidence is increasing among older patients. Few studies have compared the outcomes between conservative and surgical treatments for STS patients aged ≥80 years. We assessed the outcomes of both treatments in this population and the association between older age and surgical outcome. METHODS: We recruited consecutive patients with STS aged ≥80 years treated at our institution between January 2006 and May 2014. We recommended surgical resection for all patients without multiple distant metastases. Overall survival and sarcoma-specific survival were assessed using the Kaplan-Meier method. RESULTS: Of the 39 patients with STS who presented at our institution, 37 were included in this analysis (19 men and 18 women with a median age of 85 [range 80-94] years). Tumors were classified as Stage IB (n = 3), IIA (n = 6), IIB (n = 3) or III (n = 24). Four patients underwent conservative therapy and 33 underwent surgical resection. The most common tumor site was the lower extremity, and the majority of tumors were classified as undifferentiated pleomorphic sarcoma. The follow-up rate was 100%. One-year sarcoma-specific survival rates were 25.0% in the conservative therapy group and 90.9% in the surgical resection group. No associations were found between age ≥85 years and perioperative complications or clinical outcome. CONCLUSIONS: Surgical resection had relatively few complications, given the age group, and improved the prognosis of older patients with STS. Surgical resection of STS with curative intent should be considered in older patients.

Massive trapezial metastasis from gastric adenocarcinoma resected and reconstructed with a vascularized scapular bone graft: A case report.

RATIONALE: Isolated metastasis to the hand bones is very rare. Only seven cases of metastasis to the trapezium have been reported. To the best of our knowledge, this is the first report of a single metastasis to the trapezium from a gastric adenocarcinoma. PATIENT CONCERNS: A 62-year-old man presented with pain and massive swelling in the right carpometacarpal joint of the thumb. DIAGNOSES: The patient was diagnosed with trapezial metastasis of advanced gastric adenocarcinoma. INTERVENTIONS: The patient underwent systemic chemotherapy with cisplatin and S-1, radiotherapy to the metastatic bone, and treatment with denosumab. One year later, the huge metastatic tumor was resected, and the hand was reconstructed using vascularized scapular bone. OUTCOMES: Eighteen months postoperatively, the patient was satisfied with the appearance of the reconstructed hand and was able to use his right thumb in activities of daily living. LESSONS: Although rare, metastasis to the trapezium should be considered in patients with persistent and progressive thumb CMC joint pain.

Clinical outcome of dedifferentiated liposarcoma in the extremities: A retrospective case series of 7 patients.

BACKGROUND: Wide resection is the generally recommended surgical treatment for dedifferentiated liposarcoma (DDLPS) in the extremities. However, it may be appropriate to distinguish the surgical margin of low-grade atypical lipomatous tumor (ALT)/well-differentiated liposarcoma (WDLPS) area from the high-grade dedifferentiated area, because the low- and high-grade areas can be clearly separated, both radiologically and histologically. This study re-evaluated the details of surgical margin of DDLPS in the extremities, and aimed to investigate the optimal surgical margin and the usefulness of adjuvant therapy for DDLPS in the extremities. METHODS: Seven patients diagnosed with DDLPS in the extremities and treated between 1995 and 2013 were analyzed. The use of adjuvant therapy before and after surgery was assessed, and the surgical margins for the ALT/WDLPS and dedifferentiated areas were re-evaluated by using the specimens resected at surgery. Subsequently, the recurrence rates, metastatic rates, and oncological outcomes were examined. RESULTS: Four and three patients had wide (adequate wide margin, n = 3; inadequate wide margin, n = 1) and marginal margins for the dedifferentiated area, respectively, while three and four patients had wide (adequate wide margin, n = 2; inadequate wide margin, n = 1) and marginal margins for the ALT/WDLPS area, respectively. Postoperative radiotherapy was performed in three patients with an inadequate wide margin or a marginal margin for the dedifferentiated area. No patient had local recurrence. Distant metastases occurred in two patients. These patients died of their disease. The other five patients were disease-free. CONCLUSION: The ALT/WDLPS and dedifferentiated areas in the tumor margin may be better to be considered separately in determining the appropriate resection extent for DDLPS in the extremities. Postoperative radiotherapy may provide good local control for cases with a narrow surgical margin.

Chondroitin sulfate synthase 1 expression is associated with malignant potential of soft tissue sarcomas with myxoid substance.

The glycosyltransferases chondroitin sulfate synthase 1 (CHSY1) and exostoses-like 3 (EXTL3) specifically function in biosynthesis of the glycans chondroitin sulfate and heparan sulfate, respectively. Although these glycans play important roles in pathogenesis of various tumors, their significance in soft tissue sarcoma remains unknown. Here, we asked whether CHSY1 or EXTL3 expression correlates with malignant potential of soft tissue sarcomas with myxoid substance. To do so, we examined 40 samples representing specific types, including 12 cases of myxoid liposarcoma, 14 of myxofibrosarcoma, 12 of malignant peripheral nerve sheath tumor, and 2 of low-grade fibromyxoid sarcoma. We performed immunohistochemistry with anti-CHSY1 and anti-EXTL3 antibodies and compared enzyme expression levels with tumor histologic grade as assessed by the Fédération Nationale des Centres de Lutte Contre le Cancer classification and with patient 5-year survival rate. CHSY1 and EXTL3 were expressed in 72.5% and 32.5% of all tumors, respectively. Notably, CHSY1 was strongly expressed in myxofibrosarcoma and malignant peripheral nerve sheath tumor compared with other tumors and significantly associated with higher- rather than lower-grade tumors (P < .01). High expression of CHSY1 was also significantly associated with poorer patient outcomes (P = .031) and higher stages assessed by American Joint Committee on Cancer staging system (P = .004). By contrast, EXTL3 expression was not correlated with histologic grade or patient prognosis. We conclude that CHSY1 expression is closely associated with malignant potential of soft tissue sarcomas with myxoid substance.