Impact of a specialised palliative care intervention in patients with advanced soft tissue sarcoma - a single-centre retrospective analysis.

BACKGROUND: Soft tissue sarcomas (STS) account for less than 1% of all malignancies. Approximately 50% of the patients develop metastases with limited survival in the course of their disease. For those patients, palliative treatment aiming at symptom relief and improvement of quality of life is most important. However, data on symptom burden and palliative intervention are limited in STS patients. AIM: Our study evaluates the effectiveness of a palliative care intervention on symptom relief and quality of life in STS patients. DESIGN/SETTING: We retrospectively analysed 53 inpatient visits of 34 patients with advanced STS, admitted to our palliative care unit between 2012 and 2018. Symptom burden was measured with a standardised base assessment questionnaire at admission and discharge. RESULTS: Median disease duration before admission was 24 months, 85% of patients had metastases. The predominant indication for admission was pain, weakness and fatigue. Palliative care intervention led to a significant reduction of pain: median NRS for acute pain was reduced from 3 to 1 (p < 0.001), pain within the last 24 h from 5 to 2 (p < 0.001) and of the median MIDOS symptom score: 18 to 13 (p < 0.001). Also, the median stress level, according to the distress thermometer, was reduced significantly: 7.5 to 5 (p = 0.027). CONCLUSIONS: Our data underline that specialised palliative care intervention leads to significant symptom relief in patients with advanced STS. Further efforts should aim for an early integration of palliative care in these patients focusing primarily on the identification of subjects at high risk for severe symptomatic disease.

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects.

AIM: Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS: We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS: Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS: The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

[Motor replacement surgery via tendon transfer in radial nerve palsy]. / Motorische Ersatzplastik durch Sehnentransposition bei Lähmung des Nervus radialis.

OBJECTIVE: Restoration of active extension of wrist, thumb and digits by muscle-tendon transposition. INDICATIONS: Radial nerve palsy due to peripheral nerve injury. Peripheral nerve disease. Muscle or tendon injury. Restoration of wrist extension in high radial nerve palsy. CONTRAINDICATIONS: Reversible distal radial nerve palsy, absence of suitable donor muscles, spasticity, limited range of motion of affected joints, extensive scarring and inappropriate soft tissue conditions, unjustifiable loss of function at donor site. Reinnervated donor muscles, progressive muscle disease, insufficient patient compliance. SURGICAL TECHNIQUE: Dissection of the flexor carpi ulnaris, palmaris longus and pronator teres tendon insertion. Transposition of the tendons. Interweaving of tendons of the pronator teres and extensor carpi radialis brevis muscles, the extensor digitorum communis and flexor carpi ulnaris muscles, as well as the extensor pollicis longus and palmaris longus muscles using the Pulvertaft technique. POSTOPERATIVE MANAGEMENT: 3 Weeks immobilization in forearm splint. Additional immobilization for 2 weeks at night. Subsequently, intensive physical and occupational therapy for another 4-6 weeks is required, starting 3 weeks postoperatively. RESULTS: The procedure was carried out in 12 patients over the past 14 years. We treated proximal radial nerve palsy in nine cases. In accordance with the current medical literature, we consider the described motor replacement surgery a reliable procedure.

Solitary metastasectomy in non-small cell lung cancer.

PURPOSE: Stage IV disease at initial presentation ac-counts for approximately 41% of newly diagnosed cases with non-small cell lung cancer (NSCLC). Although the majority of these patients have disseminated metastatic disease at diagnosis, a small percentage of them are found to have a solitary site of extrathoracic metastasis. In addition, patients who have received surgical or multimodality treatment with curative intent may experience metachronous solitary distant recurrences during the natural course of their disease. Our aim was to review the possible role of surgical resection in the management of NSCLC with solitary hematogenous metastasis. METHODS: We performed electronic literature search of PubMed, EMBASE and the Cochrane Library for articles in English using a number of key words. RESULTS: All identified studies reported survival benefit for patients operated for their single metastatic lesion. Patients with metachronous disease had slightly better prognosis than those with synchronous metastatic lesions. We found no prospective randomized trials comparing surgical and non-surgical treatment modalities for NSCLC with solitary hematogenous metastasis. CONCLUSIONS: Available evidence supports the presumption that in highly selected patients with isolated synchronous or metachronous hematogenous metastasis surgical resection as part of an aggressive approach positively affects patients' survival. Factors that are in favor of a satisfactory outcome include control of primary site, confirmed solitary metastatic disease, good performance status (PS), metachronous lesions and longer disease-free interval (DFI). Prospective randomized trials are necessary to provide stronger evidence. Finally, it is worth investigating the biology of these tumors presenting with single-site distant metastasis.

[Soft tissue reconstruction with a temporoparietal fascial flap (TPFF)]. / Der temporoparietale Faszienlappen zur Rekonstruktion von Weichteildefekten.

OBJECTIVE: Soft tissue reconstruction with a temporoparietal fascial flap (TPFF). INDICATIONS: Defect coverage with thin, pliable, and well-vascularized tissue. A bilayered TPFF provides a gliding surface in tendon reconstruction. Further options include TPFF harvest with overlying skin or subjacent bone for composite tissue reconstruction or the application as a sensate local fascial flap. Maximum defect dimensions: 17 × 14 cm. CONTRAINDICATIONS: Absolute: prior injury to the flap or flap pedicle, temporal arteritis, Moyamoya syndrome, defects with volume deficit. Relative: alopecia along the planned incision. SURGICAL TECHNIQUE: Pedicle location is outlined using Doppler ultrasound. Injection of the incision line with diluted epinephrine solution. Skin incision with subsequent visualization of the temporoparietal fascia and supplying vessels. Skin flaps are raised carefully paying special attention to the hair follicles (CAVE: postoperative alopecia). Primary closure of the donor site. Defect coverage with pedicled or free TPFF with subsequent full or split-thickness skin grafting. Dressing: Bolster or V.A.C. POSTOPERATIVE MANAGEMENT: Immobilization/elevation in the setting of extremity reconstruction. Removal of bolster dressing or V.A.C. on postoperative day 5. Dangling protocol instituted on postoperative day 7. Removal of sutures/staples at the donor site on postoperative day 5-7 and at the recipient site on postoperative day 12-14. RESULTS: The TPFF was utilized for soft tissue reconstruction in 8 patients. A pedicled TPFF was used in 2 patients. Mean time to healing was 16.3 days. Mean follow-up was 13.4 months. Successful reconstructive results with satisfactory functional and aesthetic appearance were obtained in all patients. Complications were encountered in 3 patients and included alopecia at the donor site and iatrogenic injury to the frontal branch of the facial nerve. Vascular compromise was observed in the early postoperative period in a third patient. However, operative revision resulted in successful flap salvage.

Short-term preoperative radiotherapy is a safe approach for treatment of locally advanced rectal cancer.

BACKGROUND AND AIMS: The Swedish Rectal Cancer Trial (SRCT) demonstrated that a short term regimen of high-dose preoperative radiotherapy (5x5 Gy) not only reduces the risk of local recurrence but also improves overall survival rate. An increase in postoperative mortality and morbidity has also been observed, however. We therefore evaluated early postoperative complications in patients treated with neoadjuvant radiotherapy for locally advanced rectal adenocarcinoma. PATIENTS/METHODS: Between 2000 and 2004, 85 patients with locally advanced rectal tumors were treated in our institution. Preoperative staging was based on CT scan and, in several cases, on endorectal ultrasonography. They were 55 men and 30 women, with a median age of 68 years. They were retrospectively divided into two groups: Group A, which included 40 patients undergoing preoperative radiotherapy (25 Gy in five fractions) followed by surgery within 1 week, and Group B, which included 45 patients with rectal cancer receiving surgery immediately after diagnosis. Both groups were homogeneous regarding age, gender and preoperative stage of the disease. The two groups were compared for both technical difficulties during operation and rate of postoperative complications. RESULTS/FINDINGS: No postoperative deaths were recorded in either group. Low anterior resection with total mesorectal excision was performed in all group A patients, whereas eight patients in group B underwent abdominoperineal resection (P<0.05). Diverting stoma was performed in seven patients of group A and it was closed 3-6 months later on every occasion. Postoperative morbidity was not statistically significant between the two groups (40 vs 39%). The rate of postoperative hemorrhage, pelvic or abdominal wound infection, acute urinary infection, and delayed ileus was similar. The percentage of major anastomotic leak was also equivalent (5 vs 6.6%). INTERPRETATION/CONCLUSION: Short-term preoperative radiotherapy does not increase the rate of postoperative complications and is a safe therapeutic adjunct for the treatment of locally advanced rectal cancer.

Ovarian fibrothecoma associated with Meigs' syndrome and elevated serum CA 125.

Meigs' syndrome consists of a benign ovarian tumor accompanied by ascites and hydrothorax. Elevated serum CA 125 in postmenopausal women with a solid adnexal mass, ascites and pleural effusion is highly suggestive of a malignant ovarian tumor. We report on an unusual case of a benign fibrothecoma of the ovary associated with Meigs' syndrome and elevated CA 125 level in an 62-year-old white female. Although rarely, a benign ovarian tumor should be considered in the differential diagnosis of an adnexal mass associated with Meigs' syndrome and elevated serum CA 125 levels.