Prognostic factors in soft tissue sarcomas: the Aarhus experience.

In the present study, the outcome, patterns of local recurrence and survival, as well as prognostic factors, were evaluated in patients surgically treated for soft tissue sarcomas. Between January 1979 and July 1993, 316 consecutive patients were referred to the Sarcoma Centre in Aarhus with localised malignant soft tissue sarcoma of the extremities or trunk. If possible, the patients were treated with a limb-sparing resection, primarily by use of a wide excision. 50 patients received adjuvant radiotherapy. There were 161 men (51%) and 155 women (49%) median age 56 years (range 1-94 years). 94 patients (30%) had tumours in the trunk, including shoulder and buttock lesions, 163 (52%) in the lower extremity and 59 (19%) in the upper extremity. 52 patients (16%) had grade 1 tumour, 60 (19%) grade 2 and 204 (65%) grades 3A-3B. The 5-year local recurrence rate was 18% and the 5-year survival rate was 75%. Multivariate analysis indicated the following variables as independent unfavourable factors for local recurrence: extracompartmental location, histological high grade, local excision, no adjuvant radiotherapy and intralesional/marginal excision. Independent unfavourable factors for survival were advanced age, extracompartmental location, histological high grade, lower extremity location and large tumour size. If the variable local recurrence was included in the analysis, it was found to have a very strong influence on survival. Based on these variables, a prognostic model was developed.

Synovial sarcoma. An immunohistochemical study of the epithelial component.

Twenty-five synovial sarcomas were studied with a battery of antibodies directed against keratin and epithelial membrane antigen (EMA). The keratin antibody MNF 116 showed reactivity in 24 tumors. In addition, 22 tumors showed reactivity with the antibody Keratin Wide Spectrum, 20 with the antibody Keratin 56, 64, and 19 with CAM 5.2. Seventeen tumors showed reactivity with EMA. The keratin and EMA reactivity was present in cells lining obvious cleft-like structures in biphasic tumors. In the spindle cell areas of both biphasic and monophasic fibrous tumors, we found clusters of a few reacting cells apparently located around small clefts. In the synovioblastic tumors, clusters of plump tumor cells reactive for both the keratins and EMA were present. In conclusion, we found that proper identification of epithelial differentiation in synovial sarcomas is facilitated by an immunohistochemical application of anti-epithelial antibodies. In most tumors, there was immunoreactivity for the same type of keratins as are normally identified in simple epithelia (the antibody CAM 5.2), but also for those found in stratified squamous epithelia (the antibody Keratin 56, 64). The results indicate that screening for epithelial features on paraffin sections in the various types of synovial sarcoma, even the poorly differentiated synovioblastic tumors, is improved if epithelial antibodies with a broad spectrum of reactivity are chosen.

Numerical assessment of bone scintigraphy in primary bone tumors and tumor-like conditions.

Fifty-four tumors or tumor-like conditions in bone were studied by numerically assessed 99m-technetium polyphosphate scintigraphy. The uptake was expressed as a ratio of the uptake in the tumor region to the uptake in a corresponding region in the contralateral part of the body. In the malignant tumors there was marked variation in the uptake within each individual tumor group, a variation that rendered a differential diagnosis impossible. In general, the uptake was fairly high in malignant tumors and lower in benign ones. A ratio below 1.5 suggested the likelihood that the lesion was benign. The ratios also varied considerably with the site of the tumor and the patients' ages. Relatively low ratios were found for tumors of the trunk and for juxta-articular tumors in children, whereas higher and more varied ratios were observed in tumors of the peripheral skeleton in adults. It is concluded that numerically assessed scintigraphy is not a useful supplement to other methods used for diagnosing bone tumors.

Imaging of chondrosarcoma with histopathological and prognostic correlation. An analysis of 49 cases mainly based on plain film radiography.

PURPOSE: To investigate the course of chondrosarcoma in relation to radiographic and histopathologic findings. MATERIAL AND METHODS: 49 consecutive patients seen during an 11-year-period were analysed, including re-evaluation of their radiographic and histopathologic material. RESULTS: Forty-two patients had radiographic changes typical for cartilaginous tumours, in 37 with malignant stigmata. Seven patients had malignant changes not typical for chondrosarcoma. By histopathologic grading 16 patients had grade I, 17 grade II and 16 grade III tumours. Six of the grade II-III tumours were histopathologic variants (mesenchymal, dedifferentiated or myxoid chondrosarcomas). Surgical removal of the tumour was performed in 42 patients, 41 of whom were followed up for 0.4-11.4 years (median 3.8 years). Local recurrence occurred in 7 patients, and 11 patients developed metastases. Ten patients, 4 with local recurrence and metastases, and 6 with metastases only were dead at the end of the follow-up. The actuarial 5-year overall survival rate was 64%. The occurrence of local recurrence, metastases and death was found to be related to the histopathologic grades II and III. Atypical radiographic features only occurred in grade II-III tumours and were related to metastases and death, but not to local recurrence. CONCLUSION: Atypical radiographic findings were related to high-grade malignancy and poor prognosis.

Laxity of the elbow after experimental excision of the radial head and division of the medial collateral ligament. Efficacy of ligament repair and radial head prosthetic replacement: a cadaver study.

We studied the stabilising effect of prosthetic replacement of the radial head and repair of the medial collateral ligament (MCL) after excision of the radial head and section of the MCL in five cadaver elbows. Division of the MCL increased valgus angulation (mean 3.9 +/- 1.5 degrees) and internal rotatory laxity (mean 5.3 +/- 2.0 degrees). Subsequent excision of the radial head allowed additional valgus (mean 11.1 +/- 7.3 degrees) and internal rotatory laxity (mean 5.7 +/- 3.9 degrees). Isolated replacement of the radial head reduced valgus laxity to the level before excision of the head, while internal rotatory laxity was still greater (2.8 +/- 2.1 degrees). Isolated repair of the MCL corrected internal rotatory laxity, but a slight increase in valgus laxity remained (mean 0.7 +/- 0.6 degrees). Combined replacement of the head and repair of the MCL restored stability completely. We conclude that the radial head is a constraint secondary to the MCL for both valgus displacement and internal rotation. Isolated repair of the ligament is superior to isolated prosthetic replacement and may be sufficient to restore valgus and internal rotatory stability after excision of the radial head in MCL-deficient elbows.

A custom-made prosthesis for the treatment of supracondylar femoral fractures after total knee arthroplasty: report of four cases.

Four supracondylar femoral fractures following total knee arthroplasty, two because of intraoperative notching of the anterior femoral cortex and two because of osteoporosis, were revised using a custom-made prosthesis with femoral condyle section. At 1-6 year follow-up (median 3 years) after the revision, all patients had an excellent clinical result, although 2 had a prolonged rehabilitation period because of severe osteoporosis. At roentgenographic examination, no signs of loosening of the prostheses at the cement-bone interface were present.

Shoulder arthroplasty in complex acute and chronic proximal humeral fractures.

From 1983 to 1988, 42 shoulder arthroplasties were performed on comminuted acute or chronic proximal humeral fractures. Patients were categorized according to the post-fracture operative delay; there were 15 four-part fractures, with median post-fracture delay of 13 days (range: 7 to 21), and 27 chronic fractures, including 11 four-part fractures, 9 three-part fractures, and 7 two-part fractures, with median post-fracture delay of 14 months (range: 4 to 72). Follow up was approximately 2 years in both groups (range: 1 to 5). All patients were evaluated according to a modified Neer score-system and classified into four groups. Pain relief was satisfactory in the acute group, but was unpredictable in the chronic group. The results in the acute group were significantly superior (P less than .05). In the acute group, 3 (20%) patients had an excellent result and 6 patients (40%) had a good result, compared to a good result obtained by 6 patients (22%) in the chronic group. Two patients (13%) in the acute group and 11 patients (40%) in the chronic group had a poor result. There were no statistical differences between two-part, three-part, or four-part fractures in the chronic group. Five cases of persistent instability were seen in shoulders formerly treated with osteosynthesis (one acute and four chronic cases). Two of these cases developed an infection. Good results can be expected after prosthetic replacement in acute proximal humeral fractures. Failed primary treatment reduces the possibility of a good result with revision arthroplasty.

[Primary aneurysmal bone cyst. Evaluation of the symptomatology, treatment and prognosis based on 21 patients]. / Den primaere aneurysmatiske knoglecyste. En evaluering af symptomatologi, behandling og prognose på basis af 21 patienter.

PABC is a rather rare, non-malignant osteolytic bone disease, affecting children and young people. Most frequently, it is localized to the metaphyses of the long bones. The present material consists of 21 cases, treated in the Orthopaedic Hospital in Aarhus between 1973 and 1991. Nineteen patients were treated with curettage of the cyst followed by bone grafting to the cavity. Six (31%) had recurrences. Five were operated again without any recurrence. The last patient has not yet received any further treatment. Two patients were initially treated by bone resection. No postoperative complications occurred. Curettage of PABC followed by bone grafting is recommended as the treatment of choice, in spite of the recurrence rate mentioned above. Because of the risk of recurrence after this treatment, regular follow-up examinations are necessary until healing has occurred i order to treat a possible local recurrence in time.

[Arthroscopic subacromial decompression]. / Artroskopisk subakromial dekompression.

The aim of this prospective study was to evaluate the results of arthroscopic subacromial decompression (ASAD) in the treatment of impingement syndrome in patients without full thickness rotator cuff tears. Sixty patients (64 operative procedures) underwent ASAD during the study period; 37 men and 23 women, average age 46 years (range 28-63), average duration of symptoms 37 months (range 8-132). Patients with calcifying tendintis were not included. Evaluation preoperatively and one year postoperatively included: Constant score, clinical examination and radiological evaluation (supraspinatus outlet view). All follow-up examinations were done by an independent observer. Fifty-six patients (60 procedures) were available for follow-up. The average length of follow-up was 13 months (range 10-23). Forty-six patients (77%) achieved a good or excellent result according to Constant score criteria. Preoperatively twenty-four patients had applied for worker's compensation benefits (WCB). Only half of the patients in the WCB group achieved a satisfactory result, whereas 94% of the non-WCB patients had a good or an excellent result. Arthroscopic subacromial decompression is an effective procedure for the majority of patients with stage II impingement syndrome. In this study WCB claims were associated with inferior results.

[Frozen shoulder. Arthroscopy and manipulation in general anesthesia, followed by early passive mobilization]. / Frossen skulder. Artroskopi og manipulation i generel anoestesi, efterfulgt af tidlig passiv mobilisation.

Over a 15 month period 20 patients with 20 arthroscopically verified frozen shoulders were treated with manipulation under general anaesthesia and early passive motion. The study had a minimum of six months follow-up. The average duration of the disease before treatment was eight months. Prior to treatment all patients suffered from moderate to severe pain and the average range of motion was less than 40% of the normal shoulder. During the follow-up period 55% had obtained a normal or almost full range of motion and 75% suffered from only slight pain or had no pain at all. Fourteen patients returned to prior work within a mean of nine weeks after treatment. We found no relation between the end-result and the prior pathology. We believe that manipulation with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment fails.

[Synovial sarcoma]. / Sarcoma synoviale.

During the period 1962-1984, 26 cases of synovial sarcoma were seen in the center for bone and soft tissue tumours in Arhus, Denmark. None of the tumours were located in direct relation to bursa or joint cavities and the majority of the patients were initially operated in other hospitals and subsequently referred to the centre. Twenty-three patients were operable. Local excision was the primary treatment in 17 patients and amputation in six patients. Fourteen had local recurrence after an average of 12 months. At the status in June 1987, 14 patients had died of the disease, one survived with metastases to the lungs 30 months after the initial operation, one showed no evidence of disease after approximately three years, six patients were alive and without evidence of disease after at least five years. Five and ten-year survival rates for operable cases were 42% and 31%, respectively.

[Thoraco-scapular amputation in sarcomas of the shoulder girdle]. / Intertorakoskapulaer amputation ved sarkomer i skulderbaeltet.

A total of 121 patients with sarcomas localized to the shoulder girdle were referred to the Sarcoma Centre in Arhus. Of these, 17 (14%) underwent interscapulothoracic amputation. At the time of treatment, the average age was 51 years (17-82 years). Eleven of these patients had sarcomas of bone and six had soft tissue sarcomas. Late diagnosis or previous surgical interventions contributed to the indication for the mutilating procedure. At the time of referral, six of the 11 cases of bone sarcomas were complicated by a pathological fracture and all six soft tissue sarcomas had been submitted to incisional biopsy or non-radical treatment. The soft tissue sarcomas were usually large with an average maximum diameter of 10 cm (4-15 cm). Postoperative recovery was uncomplicated in all cases. Local recurrence occurred in three patients (18%). Eight patients (47%) developed metastases and died from the tumour on an average of 32 months (7-94 months) after operation. Two patients died from other causes without tumour. Seven patients (41%) were tumourfree and alive for an average of 69 months (21-128 months) after operation. Only three of these seven patients wore their shoulder-arm prosthesis regularly while the remainder preferred to be either without a prosthesis or to use a lightweight shoulder prosthesis. None of the seven patients still experienced phantom pain necessitating analgetics. All of the patients were self-reliant in everyday life and the five patients who had been occupationally active until the time of operation had returned to work. The prognosis after interscapulothoracic amputation depends upon the primary malignant disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Radiation induced sarcoma of the shoulder girdle]. / Stråleinducerede sarkomer i skulderbaeltet.

A well-known complication after irradiation of tissue is development of postradiation sarcomas, and the shoulder girdle is in this connexion a frequent location, because it relatively often is exposured to x-rays. During the period 1956 to 1989 121 patients with sarcomas located to the shoulder girdle were referred to the Sarcoma centre in Arhus. Of these, six were postradiation sarcomas. The indication for the initial irradiation was in two cases cancer of the breast, in one malignant lymfogranulomatosis, in one a metastasis from malignant melanoma and finally two cases of peritendinitis humeroscapularis. In average 15 years (7-26 years) elapsed from irradiation to the diagnosis of the sarcomas. There were four bone sarcomas, two located in the clavicles and 2 in the humeri. Of these, three were osteogenic sarcomas and one a malignant fibrous histiocytoma. There were two soft tissue sarcomas, both located subcutaneously with involvement of deep fascia and muscle. Both tumors were extraskeletal osteogenic sarcomas. Three patients died of tumor on an average after 11 months. Two died without tumor from other causes, and one patient is alive without tumor 11 years after the treatment. If a patients presents with pain at the side of prior radiation, the diagnosis postradiation sarcoma must be considered and the patient referred to the Sarcoma centre. Radiation therapy should not be used in patients with benign lesions.

[Prognostic factors in soft tissue sarcomas. Experiences from the Sarcoma Center in Aarhus]. / Prognostiske faktorer ved bløddelssarkomer. Erfaringer fra Sarkomcentret i Arhus.

In the present study, the outcome, patterns of local recurrence and survival, as well as prognostic factors, were evaluated in patients surgically treated for soft tissue sarcomas. Between January 1979 and July 1993, 316 consecutive patients were referred to the Sarcoma Centre in Aarhus with localised malignant soft tissue sarcoma of the extremities or trunk. There were 161 men (51%) and 155 women (49%), the median age was 56 years (1-94). Histologically 52 patients (16%) had a grade I, 60 patients (19%) a grade 2 and 204 patients (65%) a grade 3A or 3B tumour. The five-year local recurrence rate was 18% and the five-year survival rate was 75%. Multivariate analysis indicated the following variables as independent unfavourable factors for local recurrence: extracompartmental location, histological high-grade (i.e. histologically highly malignant) local excision, no adjuvant radiotherapy and intralesional/marginal excision. Independent unfavourable factors for survival were advanced age, extracompartmental location, histological high-grade, lower extremity location and large tumour size. Based on these variables, a prognostic model was made.

[Sarcoma treatment in Denmark]. / Sarkombehandling i Danmark.

Approximately 240 sarcomas are registered annually in Denmark. Of these, 5/6 are soft-tissue sarcomas while the remainder consist of various types of sarcomas of bone. Determination of the histogenetic type, the degree of aplasia and the anatomical spread of the primary tumour is decisive for optimal prognostic assessment and for planning of the primary local treatment. The surgical treatment is aimed at radical treatment and, where tumours in extremities are concerned, this frequently involves reconstruction with endoprostheses with the object of salvaging the limb. Irradiation is indicated in cases of soft-tissue sarcoma which are not amenable to radical operation and as palliative treatment. In cases of soft-tissue sarcoma, cytostatic therapy with adriamycin alone or combined with iphosphamide in metastasizing disease can result in response in 30-50% of the patients. On the other hand, the value of adjuvant treatment is not yet elucidated. In cases of osteogenic sarcoma, the data available at present suggest that prolongation of the survival rate may be obtained by means of intensive adjuvant cytostatic treatment, but the optimal regimen is not yet defined. In other situations, cytostatic therapy must be considered as experimental and not indicated outside the fields of controlled investigations. Optimal diagnosis and treatment of sarcoma requires extensive multidisciplinary contributions which should be centralized in the fewest possible centres. Intimate national and international cooperation is also essential.