Prognosis and surgical outcome of soft tissue sarcoma with malignant fungating wounds

Polyvinyl alcohol/casein hydrogels with oxymatrine eluting ability for cancer-related wound management

Malignant fungating wounds (MFWs) are cancer-related complications that arise from metastases in advanced cancers. They appear in 5-14% of cancer patients, with higher prevalence in breast (66%) and head and neck (24%) cancers. Novel therapeutic routes for the management of MFWs rely on plant-based treatments, e.g. oxymatrine (OXM), an alkaloid derived from a Chinese plant with anticancer and anti-inflammatory properties. The objective of this work was to assess the potential of polyvinyl alcohol/casein (PVA/CAS) hydrogels to be used as dressings for OXM delivery. CAS can stimulate the immune system, while PVA is one of the most used synthetic polymers in the composition of hydrogels for medical applications. Six different hydrogel formulations were prepared following different procedures: freeze-thawing (FT) and cast drying (CD) for 24 or 48 h, with and without the addition of genipin (GE), a crosslinking agent. The hydrogels were loaded with OXM, and their release behaviour was studied. PVA/CAS-24CD + GE showed the best release profile. After being subjected to sterilisation by high hydrostatic pressure, it was further investigated in terms of physicochemical properties, mechanical characteristics and biocompatibility. Overall, this hydrogel revealed adequate characteristics to be used as a biocompatible medicated dressing for OXM release.

Bizarre Parosteal Osteochondromatous Proliferation With Malignant Transformation and Metastases

A patient with a benign bizarre parosteal osteochondromatous proliferation (BPOP) located in the anterior knee was treated with resection in preparation for total knee arthroplasty (TKA). The BPOP reoccurred and was treated with re-resection at the time of TKA. The BPOP reoccurred a second time and underwent malignant transformation to a fungating high-grade pleomorphic sarcoma with metastatic lesions. This case highlights the rare potential of a previously benign BPOP to undergo malignant transformation after recurrence. A wide margin resection may be considered primarily when surgery is indicated to prevent recurrence and its potential sequelae. [Orthopedics. 2024;47(6):e322-e326.].

Palliative Care Needs of Patients with Musculoskeletal Malignancies

PURPOSE OF REVIEW

This review aims to assess the literature regarding current treatment options for the palliative care of patients with advanced musculoskeletal malignancies whether primary or metastatic.

RECENT FINDINGS

The inclusion of specialized palliative care physicians, in conjunction with surgeons, medical oncologists, radiation oncologists, interventional radiologists, and mental health professionals, results in better control of end-of-life symptoms in both children and adults with terminal musculoskeletal malignancies. The palliative care of patients with musculoskeletal malignancies requires a multi-disciplinary team and benefits from specialized palliative care physicians. The unique impacts of musculoskeletal malignancies on ambulation and independence creates additional mental and physical burdens on patients and care-takers alike. Palliative care should focus on preserving ambulatory function and patient independence, in addition to managing chronic pain and other end-of-life symptoms common to these malignancies.

Assessment of medical students' knowledge of primary limb sarcomas

INTRODUCTION

Typically, oncology is not a structured part of the curriculum in Brazilian medical schools. Furthermore, sarcomas, which are uncommon tumors, are seldom covered in depth. A lack of comprehensive education on sarcomas might result in medical professionals being ill-equipped to care for patients with this condition.

OBJECTIVES

To assess medical students' understanding and awareness of sarcomas and the specific principles related to these tumors.

MATERIALS AND METHODS

A quantitative, cross-sectional study was conducted using a questionnaire, applied to medical students, focusing on the epidemiology, pathophysiology, and treatments of bone and soft tissue sarcomas. In all tests, the significance level adopted was 5%. The SPSS version 25.0 software was used.

RESULTS

Of the 825 questionnaires distributed, 325 were returned. Educational sessions on sarcomas did not appear to significantly improve the student's knowledge. Only 29.5% of students identified the lack of pain as an indicator of potential malignancy in soft tissue sarcomas, while 73.8% correctly recognized pain as a symptom of bone sarcomas. Limb amputation as the optimal surgical method for patient recovery was incorrectly reported by 39.1% of the sample.

CONCLUSION

A great part of the surveyed population does not have adequate knowledge about the basic concepts associated with limb sarcomas. The minority of them are satisfied with the knowledge gained during their medical education about these tumors. Inadequate medical academic training may initially lead to the wrong clinical management of patients with bone and soft tissue tumor lesions. An educational effort is needed to enhance oncology education for medical students, especially concerning sarcomas.

Challenges in the Management of Complex Soft-Tissue Sarcoma Clinical Scenarios

With nearly 15,000 new cases of soft-tissue sarcoma (STS) in the United States each year, early diagnosis and therapeutic management is imperative for successful patient outcomes. Primary STS is conventionally treated with a combination of wide-margin resection, neoadjuvant or adjuvant radiation therapy, and, in specific cases, adjuvant chemotherapy. However, in situations of complex disease presentation, guidelines for treatment are less clearly outlined. Limited metastatic disease, local recurrence, fungating STSs, and unplanned or incomplete resections of STSs present unique challenges for the multidisciplinary care team. The management of complex STS clinical scenarios usually involves limb-salvage resection or amputation as well as some combination of radiation therapy and/or ablative interventional radiology techniques. As a result, a multidisciplinary team approach is essential for treating patients in these challenging scenarios, with a recent focus on the integration of plastic and reconstructive surgery into the treatment algorithm.

Prognostic Impact of Malignant Wounds in Patients With Head and Neck Cancer: Secondary Analysis of a Prospective Cohort Study

INTRODUCTION

Malignant wounds are lesions caused by metastasis from distant primary cancers or by direct invasion of the cutaneous structures of a primary cancer, and are most common in patients with breast or head and neck cancers. Malignant wounds not only cause physical symptoms, but also affect survival. Recognizing prognosis in terminal-stage cancer patients is necessary for both patients and health care providers. The prognostic impact of malignant wounds in patients with head and neck cancer has been poorly investigated.

METHODS

This is a secondary analysis of the results of a prospective cohort study that investigated the dying process in patients with advanced cancer in 23 palliative care units in Japan. The primary outcome of this study was the prognostic impact of malignant wounds in patients with head and neck cancer. The difference in survival between patients with head and neck cancer who had malignant wounds and those who did not was compared using the log-rank test.

RESULTS

Of 1896 patients admitted to palliative care units, 68 had head and neck cancer, and 29 of these had malignant wounds. Overall survival was significantly shorter in patients with malignant wounds than that in those without (median: 19.0 days vs 32.0 days, P = 0.046).

CONCLUSION

Patients with head and neck cancer who had malignant wounds had worse overall survival than those who did not.

Two simple-to-use web-based nomograms to predict overall survival and cancer-specific survival in patients with extremity fibrosarcoma

Background

Fibrosarcoma is a rare sarcoma of the soft tissue in adults, occurring most commonly in the extremities. This study aimed to construct two web-based nomograms to predict overall survival (OS) and cancer-specific survival (CSS) in patients with extremity fibrosarcoma (EF) and validate it with multicenter data from the Asian/Chinese population.

Method

Patients with EF in the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015 were included in this study and were randomly divided into a training cohort and a verification cohort. The nomogram was developed based on the independent prognostic factors determined by univariate and multivariate Cox proportional hazard regression analyses. The predictive accuracy of the nomogram was validated with the Harrell's concordance index (C-index), receiver operating curve, and calibration curve. Decision curve analysis (DCA) was utilized to compare the clinical usefulness between the novel model and the existing staging system.

Result

A total of 931 patients finally were obtained in our study. Multivariate Cox analysis determined five independent prognostic factors for OS and CSS, namely, age, M stage, tumor size, grade, and surgery. The nomogram and the corresponding web-based calculator were developed to predict OS (https://orthosurgery.shinyapps.io/osnomogram/) and CSS (https://orthosurgery.shinyapps.io/cssnomogram/) probability at 24, 36, and 48 months. The C-index of the nomogram was 0.784 in the training cohort and 0.825 in the verification cohort for OS and 0.798 in the training cohort and 0.813 in the verification cohort for CSS, respectively, indicating excellent predictive performance. The calibration curves showed excellent agreement between the prediction by the nomogram and actual outcomes. Additionally, the results of DCA showed that the newly proposed nomogram was significantly better than the conventional staging system with more clinical net benefits. The Kaplan-Meier survival curves showed that patients assigned into the low-risk group had a more satisfactory survival outcome than the high-risk group.

Conclusion

In this study, we constructed two nomograms and web-based survival calculators including five independent prognostic factors for the survival prediction of patients with EF, which could help clinicians make personalized clinical decisions.

Outcome of Surgery as Part of Palliative Care of Patients with Symptomatic Advanced or Metastatic Extra-Abdominal High-Grade Soft Tissue Sarcoma

Background

The modern multimodal treatment of malignant tumors has increased disease-specific survival and decreased the burden of tumor-associated complications. The main focus of palliative surgery is not based primarily on quantitative success parameters of tumor response but is instead mainly on the question of quality of life.

Aim

The current study was conducted to analyze the clinical and oncological outcomes of palliative patients with soft tissue sarcoma.

Design

Of 309 patients with extra-abdominal high-grade soft tissue sarcoma treated between August 2012 and December 2014, our retrospective analysis revealed 33 palliative patients for this study. All patients were evaluated and managed by a multidisciplinary team with expertise and experience in sarcoma treatment. The survival analysis was made using the Kaplan-Meier method.

Results

The main sarcoma symptoms were pain (27.3%) and ulcerated tumors or shortly before ulceration (24.2%). Thirteen patients (39.4%) were operated on with negative margins, 15 (45.5%) with positive margins, 2 with tumor debulking (6.1%), and 3 patients (9.1%) were treated only with palliative hyperthermic isolated limb perfusion. Ten pedicle flaps were performed after sarcoma resection. The median operation time was 85 minutes (range, 37-216 minutes). The median hospitalization stay was 9.5 days (range, 3-27 days). No patients died during hospitalization. Twelve-month disease-free survival was 48.5% (95% confidence interval: 45.4-51.6).

Conclusions

Palliative surgery of metastatic or advanced soft tissue sarcoma can improve the wound care and quality of life. Closed noninfected wounds enable further treatment options, such as chemotherapy, immunotherapy, and radiotherapy. This surgery should be considered during the discussion on interdisciplinary tumor boards.

Tumor-skin invasion is a reliable risk factor for poor prognosis in superficial soft tissue sarcomas

Introduction

Superficial soft tissue sarcomas are often left untreated unless they invade the skin and skin ulcers manifest. Progressive sarcomas frequently result in dismal oncological outcomes despite multidisciplinary treatment. This study aimed to identify prognostic factors for superficial soft tissue sarcomas.

Materials and methods

This study retrospectively analyzed the clinicopathological data of 82 patients with superficial soft tissue sarcomas treated between August 2003 and December 2020 at our institution. A superficial soft tissue sarcoma was defined if the percentage of the area occupied by the tumor in the assessed region (skin, subcutaneous) was more than 50%. Age, sex, location, tumor size, tumor-skin invasion, tumor grade, and distant metastasis at initial diagnosis were evaluated as potential prognostic factors. Cox proportional hazards regression models were used to identify the prognostic factors. Five-year survival rates were assessed by the Kaplan-Meier method.

Results

The mean follow-up time was 60.1 months. The 5-year overall survival, 5-year local recurrence-free survival, and 5-year metastasis survival rates were 76.4%, 60.6%, and 71.0%, respectively. Univariate analysis showed significant relationships between poor prognosis and tumor size ≥5 cm, distant metastasis at initial diagnosis, and tumor-skin invasion. In the multivariate analysis, only the tumor-skin invasion was associated with worse overall survival.

Conclusions

Superficial soft tissue sarcomas have biologically been considered a separate category due to their better prognosis. In this study, the tumor-skin invasion was the only significant factor associated with a poor prognosis. Therefore, all superficial soft tissue sarcomas without tumor-skin invasion should be treated as early as possible.

Effect of bacterium in the malignant wounds of soft tissue sarcoma

Malignant wounds (MWs) are rare skin lesions, which accompany ulceration, necrosis and infection caused by infiltration or damage by malignant tumor. The present study aimed to investigate the bacterial etiology implicated in MW in soft tissue sarcoma (STS), and the effectiveness of culture-guided perioperative antibacterial administration. A retrospective evaluation was conducted on medical records of patients who presented with MW between 2006 and 2020. A total of seven patients were included in the present study, in whom all tumors were relatively large (>5 cm) and high-grade. Subsequently, five patients underwent limb-sparing surgery, and three patients had distant metastases with a 5-year overall survival of 71%. Preoperative microbiological sampling from the wound identified 11 different bacterial strains in five patients. The infections were polymicrobial with an average of 2.6 strains isolated per patient (1 aerobic, 1.6 anaerobic bacteria). They were predominantly methicillin-sensitive Staphylococcus aureus. Patients with MWs from STS reported symptoms, including bleeding (71%), exudation (71%) and malodorous wound (43%) at the initial presentation; these completely resolved after surgery. All but one patient reported pain at the MW site with an average numeric rating scale of 4.4 at presentation that decreased to 1.4 (P=0.14) and 0.6 (P=0.04) one and two weeks after surgery, respectively. The patients had elevated C-reactive protein (71%), anemia (57%), low albumin (86%) and renal/liver dysfunction (14–29%). One patient was diagnosed with sepsis. Surgical resection afforded symptomatic relief and resolution of abnormal laboratory values. Although selected antibiotics were administered in four patients based on the preoperative antibiotic sensitivity test, surgical site infection (SSI) occurred in three patients. Therefore, the effectiveness of the selected antibiotics based on the results of the preoperative culture in preventing SSI needs to be investigated in the future. In conclusion, physicians should keep in mind that although surgical resection can improve the symptoms and abnormal values in laboratory examination form MW, it is accompanied with a high rate of SSI and poor prognosis.

Impact of Limb Salvage on Prognosis of Patients Diagnosed With Extremity Bone and Soft Tissue Sarcomas

Background

Although clinicians and patients with extremity bone and soft tissue (EBST) are increasingly interested in limb salvage surgery (LSS), because of the minimal damage to physical appearance and function, however, there is still a lack of large-scale population studies on whether LSS improves the prognosis of patients.

Purpose

The aim of this study was to compare the survival of patients with EBST sarcomas after receiving LSS and amputation.

Methods

To conduct the population-based study, we identified 6,717 patients with a histologically diagnosed bone sarcoma and 24,378 patients with a histologically diagnosed soft tissue sarcoma from the Surveillance, Epidemiology, and End Results database. We analyzed overall survival (OS), cancer-specific survival (CSS), and non-sarcoma survival (NSS) using the Kaplan-Meier method, log-rank test or Gray test, Cox regression model, propensity score-matched analysis, and landmark analysis.

Results

LSS could improve the prognosis in patients with most EBST subtypes, except for Ewing sarcomas and MPNST. However, in the subgroup without distant metastases, limb salvage increased CSS only for patients with osteosarcoma, Ewing sarcoma, and leiomyosarcoma, as well as NSS for patients with chondrosarcoma and synovial sarcoma. Landmark analysis further demonstrated that sarcoma survivors surviving <10 years could benefit from LSS but not for long-term survivors ≥10 years. Moreover, for patients with distant metastases, LSS could improve survival of osteosarcoma patients but worsen CSS among patients with MPNST. Landmark analysis further demonstrated that LSS improved survival among osteosarcomas patients with distant metastases only within 1 year after surgery. Moreover, patients receiving LSS and those receiving amputation had a high risk of dying from different non-sarcoma diseases during the postoperative follow-up.

Conclusions

The impact of limb salvage on the prognosis of patients depends on the pathological subtype and stage of EBST sarcomas.

Nutritional Predictors of Wound Infection in Patients with Lower Extremity Soft Tissue Sarcoma

BACKGROUND

Soft tissue sarcoma (STS) frequently requires high-risk surgery that predisposes patients to complex wounds. Past studies have identified a variety of tumor characteristics as risk factors for wound infection (WI); however, physiologic characteristics have not yet been studied in this population. Thus, the objective of this study is to identify any nutritional indicators and physiologic characteristics associated with the development of WI.

PATIENTS AND METHODS

633 patients from a large tertiary care center institution were identified with lower extremity STS removed from 1992 to 2017. The primary outcomes of interest were WI at patient's surgical site within 90 days of surgery and additional procedure due to wound infection. Patients' laboratory values, comorbidities, and other characteristics were assessed using multivariable analysis to determine risk factors for WI. Receiver operator characteristic (ROC) curves were used for analysis of plasma glucose and albumin levels to determine a useful risk threshold. Significance was determined to be p < 0.05.

RESULTS

Postoperative plasma glucose levels were significantly higher among patients with WI compared with those without (p < 0.001) and showed predictivity in ROC analysis (AUC 0.77, 95% CI 0.72-0.82). Preoperative albumin (p < 0.001) and prognostic nutritional index score (p = 0.002) were significantly lower among patients with WI. Partial thromboplastin time (PTT), international normalized ratio (INR), white blood cell count (WBC), and platelet count values had no effect on WI. Smoking elevated risk for WI (OR 1.64, p < 0.01). Significant risk factors were the same when assessed for those with WI undergoing additional procedures.

CONCLUSIONS

Postoperative plasma glucose levels, preoperative albumin levels, and smoking status are useful nutritional variables in predicting WI in STS excisional procedures.