Evolution of a Novel Tissue Preservation Protocol to Optimize Osteochondral Transplantation Outcomes.

OBJECTIVE: Osteochondral allograft transplantation is a procedure to treat focal osteochondral lesions (OCLs), but is limited by tissue availability, the quality of transplanted tissue, and inconsistent storage protocols. The objective of this study was to assess the clinical outcomes of a novel tissue procurement, storage, and quality control protocol in treating OCLs. DESIGN: Prospective case series. Donor cadaveric tissue was processed, stored, and the tissue quality analyzed using the unique tissue preservation protocol developed at our institution. Advanced cross-sectional imaging was used to size match donor tissue with recipient patients. Osteochondral allografts were transplanted using the Arthrex Allograft OATS. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS), and 36-Item Short Form Survey (SF-36) preoperatively and at 1 year and 2 years postoperatively. RESULTS: Twenty patients (17 knees, 3 shoulders) were included in the study. There was a significant improvement in the following scores: overall WOMAC score, WOMAC function and pain subcategories; KOOS pain, knee-related symptoms, activities of daily living, sports and recreation, and quality of life; SF-36 physical functioning, physical role, pain, and social functioning subcategories; and VAS at all time points postoperatively. There was a significant improvement in WOMAC stiffness at 2 years postoperatively. There were 2 failures, defined by graft subsidence and persistent pain requiring reoperation. CONCLUSION: The protocol developed at our institution for OAT resulted in significant clinical improvement in patients with OCLs and is an improvement on existing tissue storage techniques.

Necessity is the mother of invention: William Stewart Halsted's addiction and its influence on the development of residency training in North America

Summary: William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine. This paper dissects how his innovative multi-tier residency program helped him hide his addiction while simultaneously providing outstanding patient care and academic training.

Outcomes of surgical treatment alone in patients with superficial soft tissue sarcoma regardless of size or grade.

BACKGROUND AND OBJECTIVES: Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS: A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS: Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS: Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.

Quality of life, functional outcomes, and wound complications in patients with soft tissue sarcomas treated with preoperative chemoradiation: a prospective study.

BACKGROUND: Preoperative irradiation reduces local recurrence of soft tissue sarcomas (STSs), but major wound complication rates approach 25-35 %. Using a novel neoadjuvant chemoradiation protocol, we prospectively documented functional outcomes and quality of life (QOL) and hypothesized a lower major wound complication rate. METHODS: Patients with STS deep to muscular fascia were treated with 3 days of doxorubicin (30 mg/day) and 10 days of irradiation (300 cGy/day) followed by limb-sparing surgery. Wound complications were assessed, and functional assessment and QOL were followed prospectively using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and Short Form (SF)-36 questionnaires preoperatively and 6 and 12 months postoperatively. RESULTS: Altogether, 52 consecutive patients were accrued during 2006-2011. Overall, 80.8 % of STSs were >5 cm, and 67.3 % involved the lower extremity. Seven (13.5 %) major wound complications occurred, all requiring reoperation. Preoperative scores for TESS, MSTS, and SF-36 physical (PCS) and mental (MCS) health components were 83.3, 86.7, 40.6, and 49.4, respectively. There were no differences seen 6 months postoperatively. By 12 months, however, patients showed improved functional scores (TESS 93.0, p = 0.02; MSTS 93.3, p < 0.01) and QOL scores (PCS 45.1, p = 0.02; MCS = 52.9, p = 0.05). No differences in scores were seen between patients with or without wound complications. CONCLUSIONS: Patients treated with our neoadjuvant chemoradiation protocol had stable QOL and functional scores 6 months postoperatively and showed improvement by 12 months. Importantly, the major wound complication rate was low.

Desmoids: a revelation in biology and treatment.

INTRODUCTION: Using a preoperative neoadjuvant chemoradiation protocol, followed by complete excision, we have achieved local control rates exceeding that found in most large series. METHODS: From October 1990 through May 2008, resectable desmoids were initially treated with a preoperative protocol using Adriamycin 30 mg x 3 days continuous intravenous infusion followed by 3,000 cGy of radiation (300 cGy fractions over 10 days). Resection was performed 4-6 weeks later. After 2001, all patients were initially offered Tamoxifen 120 mg/day and Celebrex 400 mg/day for 1 year. Patients who progressed on Tamox/Celeb were treated with protocol and those with stabilization or regression were observed. Patient demographics, tumor size, history of previous recurrences, and follow-up status were recorded prospectively. RESULTS: There were 40 females and 12 males with a mean follow-up of 45 months. Forty patients presented with primary tumors and eight presented with recurrent disease. Thirty-nine patients had surgical resection and 13 were observed. Thirty patients underwent the neoadjuvant protocol. Tamoxifen and Celebrex were used in 16 patients, 6 had stabilization in growth, 1 had a 50% reduction in the size of the tumor, there was 1 complete regression, and 8 progressed. Of the patients who had resectable disease Tamoxifen and Celebrex obviated surgery in 30%. Overall 13% (5) of patients developed a recurrence. There were three recurrences among the protocol group for a local control rate of 90%. CONCLUSION: Although our neoadjuvant protocol demonstrates the best results to date in eradication of disease, an initial conservative approach is reasonable to determine who would most benefit from surgery.

Preoperative chemoradiotherapy (modified Eilber protocol) provides maximum local control and minimal morbidity in patients with soft tissue sarcoma.

BACKGROUND: Local recurrence rates of 15% to 30% after treatment of soft tissue sarcoma (STS) are still common but unacceptable. Our hypothesis was that a refined neoadjuvant chemotherapy and radiation protocol (modified Eilber protocol) improves local control rates while minimizing major morbidity. METHODS: Consecutive patients with STS deep to the fascia of the extremity or trunk during 1984 to 1996 were treated with 3 days of doxorubicin (30 mg/day) and sequential radiation (300 cGy/day for 10 days). Wide excision with limb preservation was performed 4 to 8 weeks after radiation completion. Treatment complications, margins, local recurrence, and survival were prospectively documented. RESULTS: Of 75 patients, 66% had tumors >5 cm, and 71% were grade 2/3. In eight patients, negative margins were not achieved, and four of these had amputation (95% limb salvage). Three of the remaining four had local recurrence with a 5- and 7-year actuarial local control rate of 50% and 25%, respectively. In contrast, of the 67 patients with negative margins, a local control rate of 97% at 5 years and 94% at 7 years and an overall survival of 63% were achieved. Although margin (P = .001) and stage (P = .035) were correlated, these were not significant on multivariate Cox regression analysis. Risk factors for death included tumor stage (hazard ratio, 1.54; P = .001) and tumor grade (hazard ratio, 1.4; P = .02). Three patients (4%) required reoperation for tissue loss, and eight patients (10.6%) developed minor wound complications. CONCLUSIONS: This modified Eilber protocol seems to maximize local control and minimize major wound complications for extremity/truncal STS.

Pathologic fracture through a unicameral bone cyst of the pelvis: CT-guided percutaneous curettage, biopsy, and bone matrix injection.

Unicameral bone cysts of the pelvis are extremely rare. A 19-year old man presented with a pathologic fracture through a pelvic unicameral bone cyst. He was treated with computed tomography-guided percutaneous curettage, biopsy, and demineralized bone matrix injection. Treatment has proven successful in short-term follow-up.

Hemipelvectomy: a changing perspective for a rare procedure.

OBJECTIVE: To compare the prognosis of patients undergoing a hemipelvectomy (HP) in the treatment of pelvic sarcomas and carcinomas and to review the morbidity and mortality associated with HP. DESIGN: Retrospective chart review. SETTING: The Foothills Hospital, University of Calgary, Calgary, Alberta. PATIENTS: Thirteen patients with clinically and radiographically isolated malignancies involving the bony pelvis and adjacent structures. INTERVENTIONS: Patients were treated with either an external HP (9 patients) or internal HP (4) in 1983-2001. OUTCOME MEASURES: Survival and recurrence rates for patients in 2 histopathologic groups (sarcoma v. carcinoma); morbidity and mortality associated with HP. RESULTS: Hemipelvectomy was performed for 7 sarcomas (4 primary bone and 3 soft tissue) and 6 carcinomas (5 genital tract and 1 unknown primary). Seven of the 9 external HPs involved composite resection of other pelvic structures, including other pelvic viscera (3 patients), sacrum (3) and portions of lumbar vertebrae and nerves (1). There were no additional resections among the 4 internal HPs, but 3 patients had allograft reconstruction. Length of stay averaged 30 days (range 14-70 d). At least 1 complication occurred in 10 of 13 cases. The most common complication was flap necrosis occurring in 5 patients (38%). There was 1 perioperative death (8%). The survival of patients treated for sarcomas was better than for carcinomas, which were primarily of the genital tract. Only 1 of the patients with a pelvic sarcoma died of disease (86% disease-specific survival), with a median follow-up of 12 months (range 9-108 mo). Of the 7 sarcoma patients 5 were disease-free at last follow-up. One of 6 pelvic carcinoma patients died perioperatively, with another dying of unknown causes 4 months after surgery. Of the 4 remaining patients 3 died of disease, resulting in a median survival of 9 months (range 4-20 mo). Four of 6 patients with pelvic carcinomas developed recurrent disease, none local. CONCLUSIONS: HP has considerable morbidity but is a viable and potentially curative treatment for patients with pelvic sarcomas. With pelvic carcinomas HP was not curative, but did provide short-term local disease control. Future improvements in imaging techniques and quality-of-life studies may help with patient selection. The role of HP in recurrent carcinoma remains to be determined.

Desmoid tumors: a novel approach for local control.

BACKGROUND AND OBJECTIVES: After resection, desmoid tumors are associated with a recurrence rate that is typically 25-50%. Although this is an unusual problem, we instituted a prospective cohort study with neoadjuvant chemotherapy and radiation, followed by surgical resection, in an effort to improve local control. METHODS: Between 1985 and 1999, 13 patients with potentially resectable disease were managed with a treatment protocol of preoperative doxorubicin (30 mg continuous infusion daily for 3 days) and radiotherapy (10 x 300 cGy). Resection was performed 4-6 weeks later. All lesions were resected with an intended margin of 1 cm, but clear adventitial margins were accepted in order to preserve critical structures. RESULTS: The median follow-up was 71 months (range, 22-109). Six patients (46%) presented after failure of a previous surgery. Clear microscopic margins were obtained in 11 patients, and 2 patients had positive margins. There were two local recurrences (15% local recurrence). Both recurrences followed resection of large thigh lesions, which appeared at 30 and 49 months of follow-up. In one patient with a chest wall tumor, two new primary desmoid tumors developed outside the treatment area, in the ipsilateral arm and forearm. Eleven patients have been disease free for a median of 71 months (range, 22-109). CONCLUSIONS: For potentially resectable lesions, this protocol provides excellent local control, even in those with recurrent disease. Neoadjuvant treatment with doxorubicin and radiotherapy appears to be a better option than surgery alone, or surgery and adjuvant radiotherapy. These results need to be confirmed in larger, prospective randomized trials.

Giant cell tumor of long bone: a Canadian Sarcoma Group study.

A multicentric retrospective study of giant cell tumor of bone was conducted among Canadian surgeons. The hypothesis was that no differences would be found in health status, function, or recurrence rate irrespective to the nature of filling material or adjuvant used in patients treated with curettage. One hundred eighty-six cases were collected. There were 96 females and 90 males. The mean age of the patients was 36 years (range, 14-72 years), the minimum followup was 24 months, and the median followup was 60 months. Sixty-two percent of the tumors involved the knee region. One hundred fifty-eight were primary tumors and 28 were recurrences. Campanacci grading was as follows: Grade 1, seven patients; Grade 2, 100 patients; Grade 3, 76 patients; and unknown in three patients. Fifty-six patients had a pathologic fracture. Resection was done in 38 patients and 148 patients had curettage. The latter was supplemented with high speed burring in 135 patients, cement in 64 patients, various combinations of autograft or allograft bone in 61 patients, phenol in 37 patients, and liquid nitrogen in 10 patients. Structural allografts were used in 25 patients. The overall recurrence rate was 17%, 18% after curettage, and 16% after resection. Patients with primary tumors treated with curettage had a 10% recurrence rate. For recurrent lesions treated by curettage, the recurrence rate was 35%. The nature of the filling material used or the type of adjuvant method used or any combination of both failed to show any statistical impact on the recurrence risk. The results from the Musculoskeletal Tumor Society rating from 1987 were significantly lower in patients who sustained a displaced fracture. Results from the bodily pain section of the Short Form-36 also were found to be lower when a pathologic fracture was present. Results from the Musculoskeletal Tumor Society Rating 1987, the Short Form-36, and the Toronto Extremity Salvage Score did not show differences when either cement or bone graft were used after curettage.