Characteristics and Long-Term Outcome of Surgically Managed High-Grade Extremity Chondrosarcoma.

Background: Dedifferentiated chondrosarcoma (DCS) is a highly malignant variant that portends a poor prognosis. Although factors such as clinico-pathological characteristics, surgical margin, and adjuvant modalities likely play a role in overall survival, debate continues with varying results on the importance of these indicators. The purpose of this study is (1) To delineate the characteristics, local recurrence (LR), and survival of patients with intermediate (IGCS), high (HGCS) and dedifferentiated (DCS) chondrosarcoma of the extremity by utilizing detailed cases at one tertiary institution. (2) To assess survival between high grade chondrosarcoma and DCS utilizing a less detailed but large cohort from the Surveillance, Epidemiology, and End Results (SEER) database. Methods: Twenty-six cases of high-grade (conventional FNCLCC grades 2 and 3, dedifferentiated) chondrosarcoma were identified from an ongoing prospective cohort of 630 sarcoma patients managed surgically at a tertiary referral university hospital between 9/1/2010-12/30/2019. A retrospective review of demographics, tumor characteristics, surgical procedure, treatment course, and survival data was performed to determine prognostic factors for survival. An additional 516 cases of chondrosarcoma were identified from the SEER database. Using the Kaplan-Meier method, both the large database and case series were evaluated, and estimated cause-specific survival was calculated at 1, 2, and 5 years. Results: There were 12 IGCS, 5 HGCS, and 9 DCS patients in the single institution cohort. DCS had a higher stage at diagnosis (p=0.04). Limb salvage was the most common procedure performed in every group (11/12 IGCS, 5/5 HGCS, and 7/9 DCS; p=0.56). Margins included 8/12 wide and 3/12 intralesional for IGCS. For HGCS, there were 3/5 wide, 1/5 marginal, and 1/5 intralesional. A majority of DCS margins were wide (8/9) with only 1 marginal. There was no difference of associated margins between the groups (p=0.85), however there was a difference when margins were classified based on numerical measurement (IGCS: 0.125cm (0.1-0.35); HGCS: 0cm (0-0.1); DCS: 0.2cm (0.1-0.5); p=0.03). The overall median follow-up was 26 months (IQR:16.1-70.8). The time interval from resection to death was lower in DCS (11.5 months (10.7-12.2)), followed by IGCS (30.3 months (16.2-78.2)), and HGCS (55.1 months (32.0-78.2; p=0.047). LR occurred in 5/9 DCS, 1/5 HGCS, and 1/14 IGCS patients. Of the DCS patients only 2/6 who received systemic therapy had LR, while all 3/3 who did not receive systemic therapy had LR. Overall systemic therapy and radiation did not impact incidence of LR (p=0.67; p=0.34). However, patients who had LR were 17.5 times more likely to die within one year (HR=17.5, 95%CI (1.01-303.7), p=0.049), after adjusting for the age at the surgery. There was no correlation with the utilization of systemic therapy, radiation therapy, or margin and overall survival (p=0.63, p=0.52, p=0.74). In the SEER patient cohort, 149 cases (28.9%) were DCS and 367 (71.1%) were HGCS. At final follow-up, 49.6% (n=256) of the cohort had a cause of death due to chondrosarcoma. HGCS was associated with higher chance of 1-year survial (p<0.001), 2-year survival (p<0.001), 5-year survival (p<0.001), and overall survival (p<0.001). Additionally, decreased survival was associated with metastatic disease at presentation (p=0.01). Overall limb salvage was most utilized for both HGCS (76.5%) and DCS (74.3%). In regard to limb salvage vs. amputation, there was no difference in survival at 1 year (p=0.10) or 2 year (p=0.13) between the groups, however those who underwent limb salvage procedure had a significantly better chance of survival at 5 years when compared to amputation (HR=1.49 (1.11-1.99); p=0.002). Conclusion: High-grade chondrosarcoma remains a fatal disease in many patients, particularly if associated with dedifferentiated subtype. Interestingly, all (100%) DCS patients who did not receive systemic therapy had LR. However, chemotherapy and radiation did not significantly increase survival. In this case series and large database study, HGCS had the smallest surgical margin, but with the longest time interval for both LR and death. Additionally, using the SEER database, DCS and amputation had worse prognosis at the 5-year survival time. Further studies on valuable prognostic influences as well as earlier identification of this rare disease may help in developing better management options. Level of Evidence: III.

Characteristics and symptomatology of colorectal cancer in the young.

BACKGROUND: The incidence of colorectal cancer in patients <50 years has rapidly risen recently. Understanding the presenting symptoms may facilitate earlier diagnosis. We aimed to delineate patient characteristics, symptomatology, and tumor characteristics of colorectal cancer in a young population. METHODS: A retrospective cohort study was conducted evaluating patients <50 years diagnosed between 2005 and 2019 with primary colorectal cancer at a university teaching hospital. The number and character of colorectal cancer-related symptoms at presentation was the primary outcome measured. Patient and tumor characteristics were also collected. RESULTS: Included were 286 patients with a median age of 44 years, with 56% <45 years. Nearly all patients (95%) were symptomatic at presentation, with 85% having 2 or more symptoms. The most common symptoms were pain (63%), followed by change in stool habits (54%), rectal bleeding (53%), and weight loss (32%). Diarrhea was more common than constipation. More than 50% had symptoms for at least 3 months before diagnosis. The number and duration of symptoms were similar in patients older than 45 compared to those younger. Most cancers were left-sided (77%) and advanced stage at presentation (36% stage III, 39% stage IV). CONCLUSION: In this cohort of young patients with colorectal cancer, the majority presented with multiple symptoms having a median duration of 3 months. It is essential that providers be mindful of the ever-increasing incidence of colorectal malignancy in young patients, and that those with multiple, durable symptoms should be offered screening for colorectal neoplasms based on symptoms alone.

Web-Based Patient Educational Material on Osteosarcoma: Quantitative Assessment of Readability and Understandability.

BACKGROUND: Patients often turn to web-based resources following the diagnosis of osteosarcoma. To be fully understood by average American adults, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend web-based health information to be written at a 6th grade level or lower. Previous analyses of osteosarcoma resources have not measured whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT) is a validated measurement of understandability and actionability. OBJECTIVE: The purpose of this study was to evaluate web-based osteosarcoma resources using measures of readability, understandability, and actionability. METHODS: Using the search term "osteosarcoma," two independent Google searches were performed on March 7, 2020 (by AGS), and March 11, 2020 (by TRG). The top 50 results were collected. Websites were included if they were directed at providing patient education on osteosarcoma. Readability was quantified using validated algorithms: Flesh-Kincaid Grade Ease (FKGE), Flesch-Kincaid Grade-Level (FKGL). A higher FKGE score indicates that the material is easier to read. All other readability scores represent the US school grade level. Two independent PEMAT assessments were performed with independent scores assigned for both understandability and actionability. A PEMAT score of 70% or below is considered poorly understandable or poorly actionable. Statistical significance was defined as P≤.05. RESULTS: Two searches yielded 53 unique websites, of which 37 (70%) met the inclusion criteria. The mean FKGE and FKGL scores were 40.8 (SD 13.6) and 12.0 (SD 2.4), respectively. No website scored within the acceptable NIH or AHA recommended reading level. Only 4 (11%) and 1 (3%) website met the acceptable understandability and actionability threshold. Both understandability and actionability were positively correlated with FKGE (ρ=0.55, P<.001; ρ=0.60, P<.001), but were otherwise not significantly associated with other readability scores. There were no associations between readability (P=.15), understandability (P=.20), or actionability (P=.31) scores and Google rank. CONCLUSIONS: Overall, web-based osteosarcoma patient educational materials scored poorly with respect to readability, understandability, and actionability. None of the web-based resources scored at the recommended reading level. Only 4 achieved the appropriate score to be considered understandable by the general public. Authors of patient resources should incorporate PEMAT and readability criteria to improve web-based resources to support patient understanding.

Total Knee Arthroplasty: A Quantitative Assessment of Online Patient Education Resources.

Background: Patients often turn to the online resources to learn about orthopedic procedures. As the rate of joint arthroplasty is projected to increase, the corresponding interest in relevant online education material will increase as well. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that publicly available online health information be written at the 6th grade or lower reading level to be fully understood by the average adult in the United States. Additionally, educational resources should be written such that readers can process key information (understandability) or identify available actions to take (actionability). The purpose of this study was to quantify the readability, understandability, and actionability of online patient educational materials regarding total knee arthroplasty (TKA). Methods: The most common Google™ search term utilized by the American public was determined to be "knee replacement". Subsequently two independent online searches (Google.com) were performed. From the top 50 search results, websites were included if directed at educating patients regarding TKA. Non-text websites (audiovisual), articles (news/research/industry), and unrelated resources were excluded. Readability was quantified using the following valid objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). PEMAT was utilized to assess understandability and actionability (0-100%; score ≥70% indicates acceptable scoring). The relationship between search rank with FKGL and PEMAT scores was quantified. Results: A total of 34 (68%) unique websites met inclusion criteria. The mean FKGL, SMOG, CLI, and GFI was 11.8±1.6, 11.1±1.2, 11.9±1.4, and 14.7±1.6, respectively. None of the websites scored within the acceptable NIH/AMA recommended reading levels. Mean understandability and actionability scores were 54.9±12.1 and 30.3±22.0. Only 5.9% (n=2) and 9.2% (n=1) of websites met the ≥70% threshold for understandability and actionability. Only 29.4% (n=10) sources used common language and only 26.9% (n=9) properly defined complicated medical terms. Based on website type, the mean understandability scores for academic institution, private practice, and health information publisher websites were 57.2±8.8%, 52.6±11.1%, and 54.3±15.3% (p=0.67). Readability (rho: -0.07; p=0.69), understandability (rho: -0.02; p=0.93), and actionability (rho: -0.22; p=0.23) scores were not associated with Google™ search rank. Conclusion: TKA materials scored poorly with respect to readability, understandability, and actionability. None of the resources scored within the recommended AMA/NIH reading levels. Only 5.9% scored adequately on understandability measures. Substantial efforts are needed to improve online resources to optimize patient comprehension and facilitate informed decision-making. Level of Evidence: III.

The preoperative machine learning algorithm for extremity metastatic disease can predict 90-day and 1-year survival: An external validation study.

BACKGROUND: The prediction of survival is valuable to optimize treatment of metastatic long-bone disease. The Skeletal Oncology Research Group (SORG) machine-learning (ML) algorithm has been previously developed and internally validated. The purpose of this study was to determine if the SORG ML algorithm accurately predicts 90-day and 1-year survival in an external metastatic long-bone disease patient cohort. METHODS: A retrospective review of 264 patients who underwent surgery for long-bone metastases between 2003 and 2019 was performed. Variables used in the stochastic gradient boosting SORG algorithm were age, sex, primary tumor type, visceral/brain metastases, systemic therapy, and 10 preoperative laboratory values. Model performance was calculated by discrimination, calibration, and overall performance. RESULTS: The SORG ML algorithms retained good discriminative ability (area under the cure [AUC]: 0.83; 95% confidence interval [CI]: 0.76-0.88 for 90-day mortality and AUC: 0.84; 95% CI: 0.79-0.88 for 1-year mortality), calibration, overall performance, and decision curve analysis. CONCLUSION: The previously developed ML algorithms demonstrated good performance in the current study, thereby providing external validation. The models were incorporated into an accessible application (https://sorg-apps.shinyapps.io/extremitymetssurvival/) that may be freely utilized by clinicians in helping predict survival for individual patients and assist in informative decision-making discussion before operative management of long bone metastatic lesions.

Health Literacy in Clubfoot: A Quantitative Assessment of the Readability, Understandability and Actionability of Online Patient Education Material.

BACKGROUND: Parents often access online resources to educate themselves when a child is diagnosed with clubfoot and/ or prior to treatment initiation. In order to be fully understood by the average adult American, online health information must be written at an elementary school reading level. It was hypothesized that current available online resources regarding clubfoot would score poorly on objective measures of readability (syntax reading grade-level), understandability (ability to process key messages), and actionability (providing actions the reader may take). Additionally, it was hypothesized that the outcomes measured would not correlate with the order of listed search results. METHODS: Patient education materials were identified utilizing two independent online searches (Google.com) of the term "Clubfoot". From the top 50 search results, websites were included if directed at educating patients and their families regarding clubfoot. News articles, non-text material (video), research and journal articles, industry websites, and articles not related to clubfoot were excluded. The readability of included resources was quantified using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG) Grade, Coleman-Liau Index (CLI), Gunning-Fog Index( GFI) and Automated Reading Index (ARI). The Patient Education Materials Assessment Tool (PEMAT) was used to assess actionability and understandability using a 0-100% scale for both measures of interest. RESULTS: Of the 55 unique websites, 37 websites (65.2%) met inclusion criteria. The mean FKGL was 9.2 (+/- 2.1) with only three websites (7.32%) having a reading level ≤6. Mean understandability and actionability scores were 67.2±12.6 and 25.4±25.2, respectively. Thirteen (35%) websites met the understandability threshold of ≥70% but no websites met the actionability criteria. No readability statistics were statistically associated with Google™ search rank (p=0.07). There was no association between readability (p=0.94) nor actionability (p=0.18) scores and Google™ rank. However, understandability scores did correlate with Google™ rank (p=0.02). CONCLUSION: Overall, online clubfoot educational materials scored poorly with respect to readability, understandability, and actionability. There is an association with Google™ search rank for understandability of clubfoot materials. However, readability and actionability are not significantly associated with search rank. In the era of shared decision-making, efforts should be made by medical professionals to improve the readability, understandability, and actionability of online resources in order to optimize parent understanding and facilitate effective outcomes.Level of Evidence.