Chordoma arising from the coccygeal disc and mimicking a pilonidal cyst

Chordomas are rare, low-grade malignant tumors often found in the sacrococcygeal region and prone to local recurrence. We report an atypical presentation of a 40-year-old patient with a symptomatic midline retrococcygeal lesion that was presumptively treated as a pilonidal cyst due to its clinical and imaging features. After surgical pathology rendered the diagnosis of chordoma, the patient required salvage surgery in the form of partial sacrectomy with soft tissue flap coverage. In addition to the unusually predominant retrococcygeal location, surgical pathology identified an intervertebral disc origin rather than the typical osseous origin. To our knowledge, this presentation of chordoma with coccygeal intervertebral origin and a large subcutaneous mass at imaging has rarely been reported in the literature. We describe this case to raise awareness of atypical presentations of sacrococcygeal chordoma that may lead to erroneous presumptive diagnosis and treatment.

Outcomes of Second-Line Therapies in Patients With Metastatic de Novo and Treatment-Emergent Neuroendocrine Prostate Cancer: A Multi-Institutional Study

BACKGROUND

De novo neuroendocrine prostate cancer (NEPC) and treatment-emergent neuroendocrine prostate cancer (T-NEPC) are rare diseases with a poor prognosis. After first-line platinum chemotherapy, there is no consensus on second-line treatments.

PATIENTS AND METHODS

Patients with a pathologic diagnosis of de novo NEPC or T-NEPC between 2000 and 2020 who received first-line platinum and any second-line systemic therapy were selected and standardized clinical data was collected via the electronic health record at each institution. The primary endpoint was overall survival (OS) based on second-line therapy. Secondary endpoints included objective response rate (ORR) to second-line therapy, PSA response, and time on treatment.

RESULTS

Fifty-eight patients (32 de novo NEPC, 26 T-NEPC) from 8 institutions were included. At de novo NEPC or T-NEPC diagnosis, the overall cohort had a median age of 65.0 years (IQR 59.2-70.3) and median PSA of 3.0 ng/dL (IQR 0.6-17.9). Following first-line platinum chemotherapy, 21 patients (36.2%) received platinum chemotherapy, 10 (17.2%) taxane monotherapy, 11 (19.0%) immunotherapy, 10 (17.2%) other chemotherapy, and 6 (16.2%) other systemic therapy. Among 41 evaluable patients, the ORR was 23.5%. The mOS after start of second-line therapy was 7.4 months (95% CI 6.1-11.9).

CONCLUSIONS

In this retrospective study, patients with de novo NEPC or T-NEPC who received second-line therapy were treated with wide variety of treatment regimens, reflecting the lack of consensus in this setting. Most patients received chemotherapy-based treatments. Overall prognosis was poor and ORR was low in the second line regardless of treatment choice.

The enigma of Sir William Robert Wills Wilde (1815-1876)

William Wilde, father of Oscar Wilde, made a significant contribution to ophthalmology and otology. Qualified as a surgeon. educated in statistics and showing sympathy for the Irish population, Wilde was appointed a Commissioner for the 1851 Census, which covered the time of the Irish Famine (1845-1852). Wilde, steeped in Irish mythology, used his knowledge to develop a close rapport with the Irish peasantry. However, his life was a paradox; he supported the British Government's approach to the Famine and at the same time he showed humanity to the Irish peasantry. In his personal life he was implicated in an abortive libel case involving a young female patient who had accused him of rape. Wilde lived as though he had two separate lives: on the one hand the successful surgeon, famine Commissioner and cataloguer of Irish antiquities, and the other a countryman and disciple of Irish mythology. Wilde was highly preceptive especially in his views on the recording of medical data and outcomes in clinical practice. We argue that Wilde was probably unmatched in the variety of his talents but was also perplexing in the various actions he took during his life and that indeed Wilde was an enigma.

Geographic and Demographic Disparities in Colorectal Cancer: A Population-Based Study Using National Cancer Database

BACKGROUND AND OBJECTIVES

Area of residence may adversely affect survival and outcomes in many cancers. The objective of this study was to evaluate the impact of geographical and demographic disparities on survival of patients with colorectal cancer.

MATERIALS AND METHODS

Data were obtained from the National Cancer Database (NCDB) colon, rectosigmoid, and rectal datasets. Patients were categorized by area of residence, namely, metropolitan (MA), urban (UA), or rural (RA). Sociodemographic and tumor-related data were collected and analyzed to evaluate variables affecting overall survival (OS).

RESULTS

In total, 973,139 patients between 2004 and 2013 were included in the study, of which 83%, 15%, and 2% were MA, UA, and RA residents, respectively. RA and UA patients were mostly white male with low income and no comorbidities. In univariate analysis, OS was worse for RA (hazard ratio [HR] 1.10) and UA (HR 1.06) colorectal cancer patients than that for MA colorectal cancer patients. In multivariate analysis revealed significant association between OS and geographic residence, with worse OS for RA (HR 1.02, p = 0.04) and UA (HR 1.01, p = 0.003) patients. Black (HR 1.14) and Native American (HR 1.17) patients had worse outcomes, while Asians (HR 0.8), women (HR 0.88), and patients with higher income had improved OS (HR 0.88).

CONCLUSION

The differences in the OS for RA and UA patients with colorectal cancer were significantly driven by economic disparity. Area of residence represents an important factor independently limiting access to care, particularly in geographically isolated individuals.

Risk of Toxicity After Initiating Immune Checkpoint Inhibitor Treatment in Patients With Rheumatoid Arthritis

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are increasingly used to treat advanced cancer. Rheumatoid arthritis (RA) is associated with an increased risk of malignancies; however, patients with RA have been excluded from ICI trials. In this study, we evaluated risk of toxicity after initiation of ICI treatment in RA patients.

METHODS

We conducted a single-institution, medical records review analysis to assess the incidence of immune-related adverse events (irAEs) and autoimmune disease (AID) flares among patients with AIDs treated with ICIs from 2011 to 2018. A subgroup analysis for RA patients was performed with frequencies of irAEs and AID flares reported.

RESULTS

Twenty-two patients with RA who were treated with ICI for malignancy were identified. At the time of ICI initiation, 86% had inactive RA disease activity. Immune-related adverse events occurred in 7 (32%) of patients, with 2 (9%) developing grade 3 (i.e., severe) irAEs. Immune checkpoint inhibitors were temporarily discontinued because of irAEs in 5 patients (23%), and permanently in 1 patient. Rheumatoid arthritis flares occurred in 12 patients (55%). Of those, 10 (83%) received oral corticosteroids with an adequate treatment response.

CONCLUSIONS

Our analysis suggests that irAEs following ICI treatment are not increased among RA patients compared with other cancer patients. Heightened RA disease activity during ICI treatment is common, but most adverse events are manageable with oral corticosteroids, and few require permanent ICI discontinuation. A close collaboration between the oncologist and rheumatologist is advisable when considering ICIs in patients with RA.

Recurrent loss of chromosome 22 and SMARCB1 deletion in extra-axial chordoma: A clinicopathological and molecular analysis

Extra-axial chordoma is a rare neoplasm of extra-axial skeleton and soft tissue that shares identical histomorphologic and immunophenotypic features with midline chordoma. While genetic changes in conventional chordoma have been well-studied, the genomic alterations of extra-axial chordoma have not been reported. It is well known that conventional chordoma is a tumor with predominantly non-random copy number alterations and low mutational burden. Herein we describe the clinicopathologic and genomic characteristics of six cases of extra-axial chordoma, with genome-wide high-resolution single nucleotide polymorphism array, fluorescence in situ hybridization and targeted next-generation sequencing (NGS) analysis. The patients presented at a mean age of 33 years (range: 21-54) with a female to male ratio of 5:1. Four cases were histologically conventional type, presented with bone lesions and three of them had local recurrence. Two cases were poorly differentiated chordomas, presented with intra-articular soft tissue masses and both developed distant metastases. All cases showed brachyury positivity and the two poorly differentiated chordomas showed in addition loss of INI-1 expression by immunohistochemical analysis. Three of four extra-axial conventional chordomas showed simple genome with loss of chromosome 22 or a heterozygous deletion of SMARCB1. Both poorly differentiated chordomas demonstrated a complex hyperdiploid genomic profile with gain of multiple chromosomes and homozygous deletion of SMARCB1. Our findings show that heterozygous deletion of SMARCB1 or the loss of chromosome 22 is a consistent abnormality in extra-axial chordoma and transformation to poorly differentiated chordoma is characterized by homozygous loss of SMARCB1 associated with genomic complexity and instability such as hyperdiploidy.

Durvalumab consolidation therapy in a patient with stage IIIB unresectable NSCLC harboring a MET exon 14 splice site alteration

BACKGROUND

Recent literature has identified significant benefit of consolidation durvalumab following chemoradiotherapy in patients with unresectable non-small cell lung cancer (NSCLC). However, immunotherapy has demonstrated modest benefit in patients harboring oncogene driver mutations. While standard of care in metastatic oncogenic driven tumors is targeted tyrosine kinase inhibitors (TKIs), there is little data to guide treatment for patients who present with earlier stage unresectable disease, receiving chemoradiotherapy and have both high PD-L1 expression as well as concomitant actionable driver mutations.

CLINICAL PRESENTATION

We report a patient who presented with stage IIIB lung adenocarcinoma with high PD-L1 expression (80%) for which she received definitive concurrent chemoradiotherapy with consolidation durvalumab. The patient quickly progressed and was found to harbor a MET exon 14 splice site alteration for which she received crizotinib and had a good response.

DISCUSSION

This case highlights the possibility that patients with non-metastatic, unresectable NSCLC with high PD-L1 expression and a concomitant driver mutation may benefit from targeted tyrosine kinase inhibitors rather than immune checkpoint inhibitor therapy.

The impact of in-service physical injury or illness on the mental health of military veterans

BACKGROUND

Each year approximately 2000 UK service personnel are medically discharged with physical and/or psychological injury or illness. While there is much research on both psychological injury and physical injury, the challenges of transition relating to the intersection between the two has received less attention. This article reports on the first phase of a 2-year funded study with the aim to understand the lived experiences of veterans who have been discharged from service with a physical injury or illness and the impacts of this on their mental health.

METHODS

Using a qualitative methodology, 22 veterans who had been discharged from service within the last 8 years were interviewed to identify key aspects of their experience of the transition process.

RESULTS

The article highlights two key themes: how some veterans adjusted to life with a physical injury or condition; and, the intersections that became apparent between physical injury and mental health. The challenges that veterans faced were shaped by the transition process and by the way in which the medical discharge process was conducted.

CONCLUSIONS

Consideration of improvements to the medical discharge process could influence better outcomes for those who have left with a physical injury or illness and later find themselves struggling with mental health issues.

Preemptive Versus Reactive Topical Clobetasol for Regorafenib-Induced Hand-Foot Reactions: A Preplanned Analysis of the ReDOS Trial

BACKGROUND

Hand-foot skin reaction (HFSR) is the most common regorafenib-induced adverse event and is in need of effective prevention and palliation.

MATERIALS AND METHODS

The Regorafenib Dose Optimization Study (ReDOS), a four-arm, previously published trial with a 1:1:1:1 randomization scheme, was analyzed in a manner in keeping with the original protocol to assess whether clobetasol 0.05% cream (a corticosteroid) applied to the palms and soles twice per day for 8 weeks was more effective when prescribed preemptively (before the development of HFSR) versus reactively (after the development of HFSR). Patients were assessed during the first two cycles of regorafenib.

RESULTS

Sixty-one patients received preemptive clobetasol, and 55 received reactive clobetasol. Groups were balanced on demographics. Over the first two cycles, no evidence of HFSR occurred in 30% with preemptive clobetasol versus 13% with reactive clobetasol (p = .03). During the first cycle, 54% and 45% of patients had no HFSR with preemptive and reactive clobetasol, respectively (p = .35). During the second cycle, 33% and 15% had no HFSR with preemptive and reactive clobetasol, respectively (p = .02). During the second cycle, rates of grade 1, 2, and 3 HFSR were 30%, 8%, and 3%, respectively, with preemptive clobetasol and 43%, 18%, and 7%, respectively, with reactive clobetasol (p = .12). Patient-reported outcomes showed HFSR compromised nearly all activities of daily living with worse quality of life in patients who received reactive versus preemptive clobetasol. No clobetasol-induced adverse events were reported.

CONCLUSION

Preemptive clobetasol might lessen regorafenib-induced hand-foot reactions compared with reactive therapy. Further confirmatory studies are needed in a larger patient cohort.

IMPLICATIONS FOR PRACTICE

Regorafenib causes hand-foot skin reactions. Preemptive clobetasol, a high-potency topical corticosteroid, appears to lessen the severity of this adverse event. Although further study is needed, the favorable adverse event profile of this intervention might prompt clinicians to discuss this option with their patients.

ctDNA applications and integration in colorectal cancer: an NCI Colon and Rectal-Anal Task Forces whitepaper

An increasing number of studies are describing potential uses of circulating tumour DNA (ctDNA) in the care of patients with colorectal cancer. Owing to this rapidly developing area of research, the Colon and Rectal-Anal Task Forces of the United States National Cancer Institute convened a panel of multidisciplinary experts to summarize current data on the utility of ctDNA in the management of colorectal cancer and to provide guidance in promoting the efficient development and integration of this technology into clinical care. The panel focused on four key areas in which ctDNA has the potential to change clinical practice, including the detection of minimal residual disease, the management of patients with rectal cancer, monitoring responses to therapy, and tracking clonal dynamics in response to targeted therapies and other systemic treatments. The panel also provides general guidelines with relevance for ctDNA-related research efforts, irrespective of indication.

Response to immune checkpoint inhibitor (ICI) rechallenge after high-grade immune related adverse events (irAE) in patients (pts) with metastatic melanoma (MM)

10045

Background: ICIs have transformed MM mortality. Pts receiving ICIs may experience high-grade irAEs that limit continuation of treatment per current guidelines. We aimed to evaluate the safety and response rate of ICI rechallenge. Methods: 551 MM pts treated with ICI were retrospectively reviewed from Jan 2014 to Jan 2020 after IRB approval. The incidence of a recurrent irAE in pts with ICI rechallenge within the same drug class after an initial high-grade (Grade III/IV) irAE was evaluated. Age, gender, irAEs, and outcomes were descriptively analyzed within the rechallenged cohort. Results: 32.7% of pts (180/551) experienced a high-grade irAE. 60.0% of these (108/180) pts were on combination therapy with at least one ICI. 50.6% (91/180) of pts were rechallenged with ICI within the same drug class. The rechallenged cohort had a median age of 63.8 [range: 28-86] years and 48.4% was female. The cohort’s initial irAE occurred at a median of 7.6 weeks from treatment onset with Grade 3/4 severity of 60.0% /40.0% (91). Toxicities included colitis 27.5% (25/91), hepatitis 23.1% (21/91), skin toxicity 22.0% (20/91), adrenal insufficiency 5.5% (5/91) hypophysitis 5.5% (5/91), neurological abnormality 4.4% (4/91), pancreatitis 3.3% (3/91), hematological abnormality 3.3% (3/91), arthralgia 3.3% (3/91), myalgia 3.3% (3/91), pneumonitis 2.2% (2/91), insulin dependent diabetes 1.1% (1/91), fatigue 1.1% (1/91), vasculitis 1.1% (1/91), and hyponatremia 1.1% (1/91). ICI rechallenge occurred at a median of 9.7 weeks from the first Grade 3/4 irAE. 51.8% (29/56) pts initially treated with combo were rechallenged with combo, while 48.2% (27/56) were rechallenged with single agent ICI. Of pts initially treated with single ICI, 60% (21/35) were rechallenged with single agent ICI and 40% (14/35) with combo. With a median follow-up of 21.1 months after rechallenge, irAEs occurred in 75.8% (69/91), with 44.9% of irAEs (31/69) presenting as a different type from the initial event and 31.9% (22/69) as high-grade events. There were no rechallenge irAE-related deaths. Within the rechallenge cohort, 39.6% (36/91) of pts had disease progression. Clinical benefit was achieved in 60.4% (55/91) of pts: 40.7% (37/91) complete response, 11.0% (10/91) partial response and 8.8% (8/91) stable disease. Conclusions: ICI rechallenge can be safely administered in pts with MM after recovery from an initial high-grade irAE. Rechallenge irAE’s did not always reflect initial irAE’s. Close monitoring for any type or grade of IRAE is recommended.

Salvage chemotherapy in the treatment of metastatic melanoma after progression on immunotherapy

e22019

Background: Immune-checkpoint inhibitors (ICI) have dramatically altered the prognosis of metastatic melanoma (MM); however, fifty percent of patients will not respond to ICI. For these patients, the next choice of treatment includes targeted therapy or a clinical trial if eligible. If these treatment choices have already been utilized or are not available to the patient, there may be value in attempting a course of salvage chemotherapy (CTX). Limited clinical trial evidence has demonstrated unexpected efficacy of CTX after prior progression on ipilimumab, offering higher disease control rates than expected from what is seen in first-line chemotherapy. The phenomenon of a “priming” effect of ICI on CTX efficacy has been shown in patients of various solid tumors after progression on anti-PD1/PD-L1 therapy. The purpose of this retrospective analysis is to evaluate the efficacy of salvage CTX after prior ICI therapy for patients with MM. Patients with ocular melanoma were excluded, as this tumor subtype is known to have reduced response to immunotherapy. Methods: By retrospective analysis, patients were included under an IRB approved waiver of consent. We identified patients with MM treated with ICI therapy between Jan, 2011 and July, 2019 who were subsequently treated with salvage CTX as a result of progression of disease (POD). Salvage CTX included dacarbazine, carboplatin, temozolomide, paclitaxel, or a combination. We assessed response rate, duration of response, and time to progression (TTP) from the onset of salvage CTX. Results: A total of 22 patients who satisfied the above criteria were identified. The majority of this population had a course of single agent ICI as well as a course of combination ICI prior to salvage CTX (72.7%, n = 16/22). 13 (59.1%) patients had POD on salvage CTX with a median TTP of 10.9 weeks. 9 (40.9%) patients responded to salvage CTX. 3 (13.6%) patients achieved a complete response, 4 (18.2%) patients achieved a partial response and 2 (9.1%) patients achieved stable disease. Mean durability of response was 53.6 weeks, ranging from 7-194 weeks. Conclusions: ICI “priming” prior to salvage CTX efficacy may improve disease responsiveness to CTX. This sequence of therapy may offer patients another reasonable treatment option. Despite the small sample size of this study, a prospective clinical trial in MM exploring CTX following ICI progression should be considered.

Immunotherapy to treat malignancy in patients with pre-existing autoimmunity

In the past 10 years, immune checkpoint inhibitors (ICIs) have become an additional pillar of cancer therapy by activating the immune system to treat a number of different malignancies. Many patients receiving ICIs develop immune-related adverse events (irAEs) that mimic some features of classical autoimmune diseases. Unfortunately, patients with underlying autoimmune conditions, many of whom have an increased risk for malignancy, have been excluded from clinical trials of ICIs due to a concern that they will have an increased risk of irAEs. Retrospective data from patients with autoimmune diseases and concomitant malignancy treated with ICIs are encouraging and suggest that ICIs may be tolerated safely in patients with specific autoimmune diseases, but there are no prospective data to guide management. In this manuscript, we review the relationship between pre-existing autoimmune disease and irAEs from checkpoint inhibitors. In addition, we assess the likelihood of autoimmune disease exacerbations in patients with pre-existing autoimmunity receiving ICI.

Long-term outcomes of high-dose single-fraction radiosurgery for chordomas of the spine and sacrum

OBJECTIVE

The current treatment of chordomas is associated with significant morbidity, high rates of local recurrence, and the potential for metastases. Stereotactic radiosurgery (SRS) as a primary treatment could reduce the need for en bloc resection to achieve wide or marginal margins. Spinal SRS outcomes support the exploration of SRS's role in the durable control of these conventionally radioresistant tumors. The goal of the study was to evaluate outcomes of patients with primary chordomas treated with spinal SRS alone or in combination with surgery.

METHODS

Clinical records were reviewed for outcomes of patients with primary chordomas of the mobile spine and sacrum who underwent single-fraction SRS between 2006 and 2017. Radiographic local recurrence-free survival (LRFS), overall survival (OS), symptom response, and toxicity were assessed in relation to the extent of surgery.

RESULTS

In total, 35 patients with de novo chordomas of the mobile spine (n = 17) and sacrum (n = 18) received SRS and had a median post-SRS follow-up duration of 38.8 months (range 2.0-122.9 months). The median planning target volume dose was a 24-Gy single fraction (range 18-24 Gy). Overall, 12 patients (34%) underwent definitive SRS and 23 patients (66%) underwent surgery and either neoadjuvant or postoperative adjuvant SRS. Definitive SRS was selectively used to treat both sacral (n = 7) and mobile spine (n = 5) chordomas. Surgical strategies for the mobile spine were either intralesional, gross-total resection (n = 5) or separation surgery (n = 7) and for the sacrum en bloc sacrectomy (n = 11). The 3- and 5-year LRFS rates were 86.2% and 80.5%, respectively. Among 32 patients (91%) receiving 24-Gy radiation doses, the 3- and 5-year LRFS rates were 96.3% and 89.9%, respectively. The 3- and 5-year OS rates were 90.0% and 84.3%, respectively. The symptom response rate to treatment was 88% for pain and radiculopathy. The extent or type of surgery was not associated with LRFS, OS, or symptom response rates (p > 0.05), but en bloc resection was associated with higher surgical toxicity, as measured using the Common Terminology Criteria for Adverse Events (version 5.0) classification tool, than epidural decompression and curettage/intralesional resection (p = 0.03). The long-term rate of toxicity ≥ grade 2 was 31%, including 20% grade 3 tissue necrosis, recurrent laryngeal nerve palsy, myelopathy, fracture, and secondary malignancy.

CONCLUSIONS

High-dose spinal SRS offers the chance for durable radiological control and effective symptom relief with acceptable toxicity in patients with primary chordomas as either a definitive or adjuvant therapy.

Oncologist uptake of comprehensive genomic profile guided targeted therapy

We describe the extent to which comprehensive genomic profiling (CGP) results were used by oncologists to guide targeted therapy selection in a cohort of solid tumor patients tested as part of standard care at Roswell Park Comprehensive Cancer Center June 2016-June 2017, with adequate follow up through September 2018 (n = 620). Overall, 28.4% of CGP tests advised physicians about targeted therapy use supported by companion diagnostic or practice guideline evidence. Post-test targeted therapy uptake was highest for patients in active treatment at the time of order (86% versus 76% of treatment naïve patients), but also took longer to initiate (median 50 days versus 7 days for treatment naïve patients), with few patients (2.6%) receiving targeted agents prior to testing. 100% of patients with resistance variants did not receive targeted agents. Treatment naïve patients received immunotherapy as the most common alternative. When targeted therapy given off-label or in a trial was the best CGP option, (7%) of patients received it. Our data illustrate the appropriate and heterogeneous use of CGP by oncologists as a longitudinal treatment decision tool based on patient history and treatment needs, and that some patients may benefit from testing prior to initiation of other standard treatments.

Systemic therapy for hepatocellular carcinoma: beyond sorafenib

Hepatocellular carcinoma (HCC) remains the second leading cause of cancer mortality worldwide and the fifth leading cause of cancer-related deaths in the United States. In 2007, sorafenib became the first Food and Drug Administration (FDA) approved first line systemic treatment for HCC, however, it confers only modest benefit in median overall survival (mOS) and comes with significant side effects. This review article will explore systemic treatments for incurable HCC beyond sorafenib. It will pay particular emphasis to various kinase inhibitors, immunotherapies, and new data on combination therapies.

Treatment recommendations to cancer patients in the context of FDA guidance for next generation sequencing

Background

Regulatory approval of next generation sequencing (NGS) by the FDA is advancing the use of genomic-based precision medicine for the therapeutic management of cancer as standard care. Recent FDA guidance for the classification of genomic variants based on clinical evidence to aid clinicians in understanding the actionability of identified variants provided by comprehensive NGS panels has also been set forth. In this retrospective analysis, we interpreted and applied the FDA variant classification guidance to comprehensive NGS testing performed for advanced cancer patients and assessed oncologist agreement with NGS test treatment recommendations.

Methods

NGS comprehensive genomic profiling was performed in a CLIA certified lab (657 completed tests for 646 patients treated at Roswell Park Comprehensive Cancer Center) between June 2016 and June 2017. Physician treatment recommendations made within 120 days post-test were gathered from tested patients’ medical records and classified as targeted therapy, precision medicine clinical trial, immunotherapy, hormonal therapy, chemotherapy/radiation, surgery, transplant, or non-therapeutic (hospice, surveillance, or palliative care). Agreement between NGS test report targeted therapy recommendations based on the FDA variant classification and physician targeted therapy treatment recommendations were evaluated.

Results

Excluding variants contraindicating targeted therapy (i.e., KRAS or NRAS mutations), at least one variant with FDA level 1 companion diagnostic supporting evidence as the most actionable was identified in 14% of tests, with physicians most frequently recommending targeted therapy (48%) for patients with these results. This stands in contrast to physicians recommending targeted therapy based on test results with FDA level 2 (practice guideline) or FDA level 3 (clinical trial or off label) evidence as the most actionable result (11 and 4%, respectively).

Conclusions

We found an appropriate “dose-response” relationship between the strength of clinical evidence supporting biomarker-directed targeted therapy based on application of FDA guidance for NGS test variant classification, and subsequent treatment recommendations made by treating physicians. In view of recent changes at FDA, it is paramount to define regulatory grounds and medical policy coverage for NGS testing based on this guidance.

Association of Clinicopathologic and Molecular Markers on Stage-specific Survival of Right Versus Left Colon Cancer

BACKGROUND

Previous studies have shown that variability in molecular markers correlates with poorer survival outcomes in patients with right-sided colon cancer (RCC) compared with left-sided colon cancer (LCC). However, several studies have shown conflicting results when examined stage for stage. We examined RCC and LCC to assess for differences in histopathologic features and overall survival (OS).

MATERIALS AND METHODS

The National Cancer Database was used to identify patients with RCC and LCC from 2004 to 2013. A propensity-adjusted analysis evaluating the association between the primary site and OS was performed.

RESULTS

Of the 422,443 patients identified, 54.7% had RCC and 45.3% had LCC. For all stages, the patients with RCC were older, had more poorly differentiated tumors, and had a greater degree of microsatellite instability compared with those with LCC. Patients with RCC also had more KRAS mutations than did those with LCC. RCC patients had poorer 3- and 5-year OS at all stages, especially stage 3 (62% vs. 73% and 50% vs. 62%, respectively; P < .001). The median OS was 77.5 months for LCC and 62.3 months for RCC (P < .001).

CONCLUSION

The present study is one of the largest studies demonstrating that RCC and LCC are different biologic entities. Patients with RCC had significantly greater rates of microsatellite instability for all stages, which has been previously shown to be prognostically advantageous. However, the results of the present study showed poorer OS at every disease stage for RCC compared with LCC. These factors have important implications for the further use of targeted therapies in the treatment of advanced colon cancer.

Escaping the professional silo: an escape room implemented in an interprofessional education curriculum

Communication skills among healthcare professionals are a necessary component in ensuring quality outcomes for patients. This report describes the design and curricular implementation of an interprofessional escape room, an innovative way to promote communication and positive team dynamics among students. In this interactive, serious game, teams of approximately eight interprofessional participants were provided with a fictitious patient case in a simulated hospital environment. Within a 45-minute time limit, students needed to use objects in the room to solve a series of puzzles to successfully complete the room by addressing all the patient's needs. A facilitated debrief following the activity allowed participants to reflect on their communication skills and teamwork during the experience. A total of thirty students across seven professions piloted the activity, and 181 students across five professions participated in the activity as part of an academic course. Feedback from students was collected on a seven-point Likert scale and revealed the value of an interprofessional escape room in academia. This report, which describes what appears to be the first interprofessional health care escape room within an IPE curriculum, demonstrates the value of the escape room in encouraging teamwork, facilitating communication, and promoting interprofessionalism.

Age-related rates of colorectal cancer and the factors associated with overall survival

Background

The purpose of this study was to identify differences in both demographic and pathologic factors associated with the age-related rates of colorectal cancer (CRC) and overall survival (OS).

Methods

The National Cancer Data Base (NCDB), 2004-2013, was queried for patients with CRC. Patients were stratified by age (≤50 vs. ≥60 years). Multivariable analysis was performed to identify factors associated with OS.

Results

A total of 670,030 patients were included; 488,121 with colon, and 181,909 with rectal or rectosigmoid cancer. For colon cancer, patients ≤50 years had higher proportions of pathologic stage III and IV disease than patients ≥60 (III: 33.7% vs. 28.6%, IV: 25.5% vs. 14.3%, respectively; P≤0.001). Similar differences were found for patients with rectal cancer (III: 35.8% vs. 28.6%, IV: 16.5% vs. 11.6%, respectively for age ≤50 and ≥60 years; P≤0.001). More aggressive pathologic factors were identified in the ≤50 cohort and were associated with worse OS, including higher tumor grade, lymphovascular invasion (LVI), perineural invasion (PNI), and elevated serum carcinoembryonic antigen (CEA). Disparities associated with OS were also identified for both colon and rectal cancer. For patients ≤50 with CRC, African-American and Hispanic race, lower income and lower education were associated with increased risk of mortality compared to the ≥60 cohort.

Conclusions

There are clear differences in biological factors and in racial and socioeconomic disparities of patients with early onset CRC. Earlier screening should be seriously considered in patients under 50 years who are African-American and Hispanic, as these populations present with more aggressive and advanced disease.

Undifferentiated pleomorphic sarcoma: indolent, tail-like recurrence of a high-grade tumor

Recurrence of a soft tissue sarcoma typically manifests as a round or oval mass at imaging, and recurrent high-grade soft tissue sarcomas generally enlarge relatively rapidly. We present a case of high-grade undifferentiated pleomorphic sarcoma in the calf of a 48-year-old male that recurred as a thin, curvilinear "tail" of enhancing tissue at magnetic resonance imaging (MRI), with extremely indolent growth over a 7-year period. The unusual imaging finding of a slowly enlarging "tail" should not be dismissed as postoperative changes, even for a high-grade soft tissue sarcoma.

A phase II trial of erlotinib monotherapy in advanced pancreatic cancer as a first- or second-line agent

INTRODUCTION

Pancreatic adenocarcinoma carries a grim prognosis. In 2007, gemcitabine with erlotinib emerged as an appropriate treatment option for patients with advanced inoperable or metastatic disease (APC). In this phase II trial we sought to evaluate the efficacy of erlotinib monotherapy in patients with APC who had disease refractory to or ineligibility for gemcitabine-based therapy.

METHODS

Eligible patients who had received 0 or 1 non-EGFR inhibitor containing gemcitabine-based chemotherapy for APC were recruited prospectively and treated with erlotinib 150 mg orally daily until unacceptable toxicity or disease progression. Primary endpoint was progression-free survival (PFS). Correlations of clinical response with smoking, rash, steady-state concentration of erlotinib and its metabolite (OSI-420) as well as the nicotine metabolite cotinine were performed.

RESULTS

The trial was terminated early for futility. Eighteen of the 34 planned subjects were recruited. Median PFS and OS were 42 and 95 days, respectively. Best response was stable disease (21%). There was a trend for improved PFS and OS in never smokers compared to current and past smokers (128.5, 39, 42 days and 173, 100, 88 days, respectively). Past/current smokers had lower steady-state concentrations of erlotinib and OSI-420 compared to never smokers. There was evidence of recent smoking exposure in 30% of patients self-identified as past smokers. Rash was infrequent, with no cases of grade III/IV rash and it was not related to treatment outcomes.

CONCLUSIONS

Overall, erlotinib monotherapy failed to improve outcomes compared to historical controls in patients with APC after 0-1 prior systemic therapies. There was a trend for improved PFS and OS in never smokers.

Disparities in the Age-Related Rates of Colorectal Cancer in the United States

The incidence of colorectal cancer (CRC) among Americans under the age of 50 years is increasing. The purpose of this study was to identify racial and socioeconomic disparities associated with this trend. The National Cancer Data Base was used to identify patients with CRC from 1998 to 2011. Patients were stratified by age (<50 versus >60 years), with ages 50 to 60 years omitted from the analysis to minimize overlapping trends between the two age groups. Relative frequencies (RFs) by year were plotted against demographic variables. Changes in RF over time and intervals from diagnosis to treatment (including surgery and chemotherapy) were compared. A total of 1,213,192 patients were studied; 885,510 patients with colon cancer and 327,682 with rectal or rectosigmoid cancer. Patients <50 years had higher RF for stage III/IV CRC compared with >60 years, with the highest rate of increase in stage III colon cancer (0.198% per year). Patients <50 years had higher RF for CRC if they were African-American or Hispanic. Hispanic patients <50 years had the highest rates of increase for both colon (RF = 0.300% per year) and rectal cancer (RF = 0.248% per year). Compared with race, other variables including education and income were not found to have as strong an association on age-related rates of CRC. No clinically significant differences were observed for time from diagnosis to treatment in either age group. Important racial disparities are associated with differences in age-related CRC rates, warranting further investigation to develop improved strategies for the earlier detection of CRC in these populations.

Clinical outcomes following resection of giant spinal schwannomas: a case series of 32 patients

OBJECTIVE

The objective of this study was to review clinical outcomes following resection of giant spinal schwannomas.

METHODS

The authors conducted a retrospective review of a case series of patients with giant spinal schwannomas at a tertiary cancer hospital.

RESULTS

Thirty-two patients with giant spinal schwannomas underwent surgery between September 1998 and May 2013. Tumor size ranged from 2.5 cm to 14.6 cm with a median size of 5.8 cm. There were 9 females (28.1%) and 23 males (71.9%), and the median age was 47 years (range 23–83 years). The median follow-up duration was 36.0 months (range 12.2–132.4 months). Three patients (9.4%) experienced recurrence and required further treatment. All recurrences developed following subtotal resection (STR) of cellular or melanotic schwannoma. There were 3 melanotic (9.4%) and 6 cellular (18.8%) schwannomas included in this study. Among these histological variants, a 33.3% recurrence rate was noted. In 1 case of melanotic schwannoma, malignant transformation occurred. No recurrence occurred following gross-total resection (GTR) or when a fibrous capsule remained due to its adherence to functional nerve roots.

CONCLUSIONS

Resection is the treatment of choice for symptomatic or growing giant schwannomas, frequently requiring anterior or combined approaches, with the goals of symptom relief and prevention of recurrence. In this series, tumors that underwent GTR, or where only capsule remained, did not recur. Only melanotic and cellular schwannomas that underwent STR recurred.

Abstract 3058: Oxidative phosphorylation-dependent regulation of cancer cell apoptosis in response to anticancer agents

Although cancer cells develop resistance to multiple types of anticancer agents, whether they adopt similar or differential mechanisms to evade cell death in response to a broad spectrum of cancer therapeutics is not fully defined. We show differential sensitivity, caspase activation, and cytokines/chemokines release in response to multiple anticancer agents. We demonstrated that DNA-damaging agents (etoposide and doxorubicin), ER stressor (thapsigargin), and histone deacetylase inhibitor (apicidin) target oxidative phosphorylation (OXPHOS) for apoptosis induction, whereas other anticancer agents including staurosporine, taxol, and sorafenib induced apoptosis in OXPHOS-independent manner. DNA-damaging agents induced mitochondrial biogenesis accompanied by increased production of cellular and mitochondrial ROS. Mitochondrial biogenesis upregulated both mitochondrial protein-folding machinery and unfolded protein response. Induction of mitochondrial biogenesis occurred in a caspase activation-independent mechanism but was reduced by autophagy inhibition and p53-deficiency. Abrogation of complex-I blocked DNA damage-induced caspase activation, whereas inhibition of complex II or gross complexes did not modulate the caspase activity. Interestingly, DNA damaging agent doxorubicin showed strong binding to mitochondria, which was disrupted upon OXPHOS complex I-deficiency but not by OXPHOS complex II-deficiency. Thapsigargin-induced caspase activation was reduced upon abrogation of complex-I or gross-complexes whereas a reverse trend was observed with apicidin. Together, our findings define the specific targets of apoptosis induction in response to a broad range of anticancer therapeutics, which provide a new strategy for differential mitochondrial targeting for cancer therapy.

Citation Format: Sandeep Kumar, Neelu Yadav, Tim Marlowe, Ajay Chaudhary, Jianmin Wang, Jordan O'Malley, Patrick Boland, Srinivas Jayanthi, Thallapuranam Krishnaswamy Suresh Kumar, Nagendra Yadava, Dhyan Chandra. Oxidative phosphorylation-dependent regulation of cancer cell apoptosis in response to anticancer agents. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3058. doi:10.1158/1538-7445.AM2015-3058

Successful imatinib therapy for neuroendocrine carcinoma with activating Kit mutation: a case study

Neuroendocrine tumors (NET) and gastrointestinal stromal tumors (GIST) are believed to originate from the cells of Cajal that are randomly dispersed along the aerodigestive tract. Despite their distinct morphologic appearance, NET and GIST may share oncogenic mechanisms. Often presenting in the metastatic setting, treatment options for patients with NET are limited. This case report presents a patient with refractory metastatic NET that did not respond conventional chemotherapy. The patient was treated with a KIF11 inhibitor in a phase I clinical trial and experienced a prolonged and clinically meaningful partial response. On progression at 20 months, the patient's tumor was sequenced to reveal a KIT exon 11 mutation. Institution of imatinib therapy achieved a rapid and sustained antitumor effect with profound clinical benefit. Despite previously reported KIT expression in NET, this is the first documented case of an activating KIT mutation in NET and of successful treatment with both a KIF11 inhibitor and imatinib, each of which was elucidated through molecular profiling of the patient's tumor. Imatinib may be a valuable therapy in NET harboring activating KIT mutations.

Sacroplasty for Cancer-Associated Insufficiency Fractures

BACKGROUND:

Tumor-associated sacral insufficiency fractures (SIF) present a significant clinical challenge. As survival increases for many malignancies, sacral fractures associated with metastases, sacral or extended pelvic radiation, and paraneoplastic osteoporosis are increasingly common and yet remain difficult to treat in the setting of the potentially significant morbidity of open sacral surgery.

OBJECTIVE:

To describe our prospective experience with sacroplasty for tumor-associated lesions, including the largest series to date of radiation-induced SIF.

METHODS:

Twenty-five patients with symptomatic SIF underwent 31 percutaneous fluoroscopy-guided sacroplasties with a median 5.8 mL of polymethyl methacrylate or a ceramic-resin composite under fluoroscopic guidance and with concurrent biopsy acquisition. Eighteen patients had fractures related to previous sacral or pelvic radiation; 4 had viable lytic lesions; and 2 had oncology-related osteoporosis. Postoperative pain reduction, procedural morbidity, and functional outcomes were recorded.

RESULTS:

Twenty of 25 patients (80%) had reduction in their visual analog pain score at a median follow-up of 6.5 months; no patients worsened. The mean visual analog scale score decreased from 8.8 to 4.7 postprocedurally (P &lt; .001), with significant reductions regardless of the underlying pathology (P &lt; .001 to P &lt; .05). Six of 13 patients with pretreatment ambulatory impairment required fewer ambulatory aids and 3 were newly ambulatory. Extravertebral cement migration was noted in 18 procedures; however, no instance was clinically relevant. Six repeat or contralateral procedures were performed. No morbidity was encountered.

CONCLUSION:

Sacroplasty is a safe and effective option for the palliation of sacral fractures in the oncologic population.

A pathway to empowerment: evaluating a cancer education and support programme in New Zealand

Support programmes often benefit cancer patients and their families. This study evaluates how the Living Well Cancer Education Programme (LWCEP), from the Cancer Society of New Zealand, meets the needs of its clients. A purposeful sample of 21 participants representing the normal range of demographic characteristics (age, gender, diagnosis and geographical location) for the programme, participated in semi-structured interviews. Demographic data were subjected to a frequency analysis. Main data were collected and analysed using a constructivist grounded theory approach regarding the experiences of the participants with being on the programme and recommendations for future development. Of the 21 participants, 14 were cancer patients (eight women and six men) and seven were support people (five women and two men). The LWCEP was described as a safe, supportive and stimulating environment, provided a powerful sense of belonging, empowered participants to gain perspective, enhance their confidence and communication skills and make increasingly informed choices. Consistent with a previous evaluation focussing on the facilitators of the LWCEP, there was a strong desire for better promotion of the programme to the wider community, establishment of a better referral pathway and the potential to offer two separate programmes depending on the stage of a patient's journey.

Innate immunity to influenza virus: implications for future therapy

Innate immunity is critical in the early containment of influenza virus infection. The innate response is surprisingly complex. A variety of soluble innate inhibitors in respiratory secretions provide an initial barrier to infection. Dendritic cells, phagocytes and natural killer cells mediate viral clearance and promote further innate and adaptive responses. Toll-like receptors 3 and 7 and cytoplasmic RNA sensors are critical for activating these responses. In general, the innate response restricts viral replication without injuring the lung; however, the 1918 pandemic and H5N1 strains cause more profound, possibly harmful, innate responses. In this review, we discuss the implications of burgeoning knowledge of innate immunity for therapy of influenza.

Benign Notochordal Cell Tumors of the Spine

BACKGROUND:

Notochord-related lesions of the spinal column include benign notochordal cell tumors (BNCTs), ecchordosis physaliphora, both generally considered benign lesions, and chordomas, which represent malignant tumors. The histological similarity of these lesions to the notochord and each other and their strong predilection to the axial skeleton have led to the hypothesis that these lesions represent a continuum of malignant transformation from notochordal remnants, BNCTs, and finally chordomas.

OBJECTIVE:

To present a cohort of biopsy-proven BNCTs with a description of radiographic features, histology, and follow-up to help elucidate the optimal management of these lesions.

METHODS:

A retrospective chart review identified 13 patients with notochordal rest lesions confirmed by histology. Histologic inclusion criteria included notochordal features without evidence of septation, myxoid matrix, nuclear atypia, or mitotic figures. Tumors exhibiting evidence of cortical expansion or destruction were excluded. The natural history and histological and radiographic features were examined.

RESULTS:

Sixteen spinal lesions from 8 patients met the diagnostic criteria for BNCTs, identified on imaging after the patient presented with back pain. Radiographically, all lesions were hypointense on T1-weighted magnetic resonance imaging sequences and hyperintense on T2-weighted and short T1 inversion recovery. The median radiographic follow-up was 21.6 months (range, 8.5-71.2 months). None of the lesions exhibited radiographic or symptomatic progression.

CONCLUSION:

Although limited by short follow-up, our series confirms that these lesions may be safely observed without evidence of malignant transformation, which emphasizes the importance of distinction of BNCT from chordoma at diagnosis and the possibility of close follow-up for these lesions instead of aggressive treatment indicated in patients with chordomas.

Enhancement of antiviral activity of collectin trimers through cross-linking and mutagenesis of the carbohydrate recognition domain

Surfactant protein D (SP-D) plays important roles in innate defense against respiratory viruses [including influenza A viruses (IAVs)]. Truncated trimers composed of its neck and carbohydrate recognition domains (NCRDs) bind various ligands; however, they have minimal inhibitory activity for IAV. We have sought to find ways to increase the antiviral activity of collectin NCRDs. Cross-linking of the SP-D NCRD with nonblocking monoclonal antibodies (mAbs) markedly potentiates antiviral activity. In the present report, we demonstrate that F(ab')2 [but not F(ab')1] fragments of a cross-linking mAb have similar effects. Hence, cross-linking activity, but not the Fc domain of the mAb, is needed for increased antiviral activity. In contrast, the Fc domain of the mAb was important for increasing viral uptake or respiratory burst responses of human neutrophils. Our NCRD constructs contain an S protein binding site. Herein, we show that a multivalent S protein complex caused cross-linking and also increased the antiviral activity of NCRDs. NCRDs of conglutinin and CL43 had greater intrinsic antiviral activity than those of SP-D or mannose-binding lectin. Based on motifs found in these serum collectins, we have constructed mutant versions of the human SP-D NCRD that have increased antiviral activity. These mutant NCRDs also had potentiated activity after cross-linking with F(ab')2 fragments or S protein complexes. Hence, the antiviral activity of NCRDs can be increased by 2 distinct, complementary strategies, namely cross-linking of NCRDs through various means and mutagenesis of CRD residues to increase viral binding. These findings may be relevant for antiviral therapy.

Combination of PI3K/mTOR inhibition demonstrates efficacy in human chordoma

BACKGROUND

Chordomas are rare tumors of the axial skeleton for which surgical resection remains the most reliable means of cure. PI-103 is a inhibitor of PI3K/AKT and mTOR activation. This study aims to determine whether the PI3K/mTOR pathway was active in chordomas and whether their inhibition could lead to decreased proliferation and increased apoptosis.

MATERIALS AND METHODS

Thirteen human chordoma were tested for activation of the PI3K/mTOR pathway. The human chordoma cell line UCH-1 was treated with increasing doses of PI-103. Inhibition of AKT and mTOR was examined and assays assessing proliferation and apoptosis were performed.

RESULTS

The chordoma specimen demonstrated activation of the PI3K/mTOR pathway. PI-103 inhibited the AKT and mTOR activation in the UCH-1 cell line. PI-103 inhibited proliferation and induced apoptosis in UCH-1.

CONCLUSION

The PI3K/AKT and mTOR signaling pathway is constitutively activated in chordoma. PI-103 decreases proliferation and induces apoptosis in the UCH-1 via inhibition of the PI3K/mTOR pathway.

Iliac hematoma mimicking neoplasm in adolescent athletes

Traumatic injuries of the hip and pelvis are common in child athletes and typically require minimal treatment. However, the presentation of such injuries can at times be clinically indistinguishable from the onset of a benign or malignant neoplastic process. In these circumstances, the orthopedic surgeon relies on modern diagnostic tools including imaging-predominantly magnetic resonance imaging (MRI) and computed tomography-and pathology studies. This article presents the cases of 2 adolescent boys with traumatic injuries to the hip, in which the threat of neoplasm could not be ruled out by in both initial imaging studies. In one case, biopsy could not conclusively rule out malignancy. In both cases, serial MRIs to monitor changes in lesion size proved valuable in determining treatment approach. The authors recommend a diagnostic algorithm to approach the differentiation of iliac hematoma from neoplasm and address the issue of waiting time in the diagnostic process. Early-and if necessary repeated-biopsy to rule out these conditions is advised, as conclusive pathologic findings are the only evidence that can rule out Ewing's sarcoma or an aneurysmal bone cyst. Given the morbidity of these conditions, the authors advocate this course of action to minimize distress to the patient and family members. Careful observation in combination with radiographic findings can yield a successful diagnosis, but the orthopedic surgeon must carefully weigh the increased risk of tumor growth against the need for biopsy.

Posterior stabilization strategies following resection of cervicothoracic junction tumors: review of 90 consecutive cases

Object

In this retrospective analysis the authors describe the assessment and outcomes of 90 patients who underwent placement of posterior instrumentation at the cervicothoracic junction following the resection of a primary or metastatic tumor during a 10-year period.

Methods

All patients underwent a posterolateral laminectomy including uni- or bilateral facetectomy, and 44 patients additionally required vertebral body resection and reconstruction. In patients who underwent C-6 or C-7 decompression, the posterior instrumentation strategies changed from the use of lateral mass plate systems (LMPSs) to lateral mass screw/rod systems (LMSRSs). Similarly, for T1–3 tumor decompression, the strategy shifted from sublaminar hook/rod systems (SHRSs) to the use of pedicle screw systems (PSSs) in which the surgeon used either a 6.25-mm rod or dual-diameter rods with or without a connector.

Results

The overall surgical complication rate was 19% including fixation failure in 11 patients (12%), 6 of whom required reoperation. Fixation failure rates for cervical decompression decreased from 2 (29%) of 7 patients in the LMPS group to 0 (0%) of 8 in the LMSRS group (p = 0.2). The fixation failure rates for thoracic decompression were 7 (15%) of 48 patients in the SHRS group, and there was a decrease to 2 (7%) of 27 in the PSS group (p = 0.48). Neurological and functional outcomes including American Spinal Injury Association, Eastern Cooperative Oncology Group, and Medical Research Council muscle strength and pain scores remained stable or improved in 94, 96, 100, and 96% of patients, respectively.

Conclusions

Current posterior instrumentation strategies involving LMSRSs and PSSs provide excellent and safe stabilization of the cervicothoracic junction following resection of primary or metastatic tumors.

Reconstruction of Extremity Long Bone Defects after Sarcoma Resection with Vascularized Fibula Flaps: A 10-Year Review

BACKGROUND

Limb-sparing wide excision has become as effective as amputation in treating extremity sarcoma. Limb reconstruction has traditionally involved allografting. The authors evaluated reconstruction of extremity long bone defects after tumor resection using fibula free flaps.

METHODS

A retrospective chart review (1991 to 2002) was performed of 25 consecutive patients at Memorial Sloan-Kettering Cancer Center who underwent reconstruction with free fibula flaps after limb-sparing resection of extremity sarcomas. Timing of reconstruction, complications, metastasis, survival, bone union, and functional outcome were analyzed. Functional assessment was based on the 1987 Musculoskeletal Tumor Society Score/Enneking classification.

RESULTS

Twenty-five patients (14 male patients and 11 female patients) were treated. Osteosarcoma (n = 8), Ewing's sarcoma (n = 8), and chondrosarcoma (n = 6) accounted for the majority of the cases. Reconstructed areas included tibia (n = 9), radius (n = 5), humerus (n = 6), femur (n = 4), and ulna (n = 1). All flaps survived (100 percent). One patient required emergent reexploration (4 percent), one suffered partial flap skin loss (4 percent), and three experienced postoperative infections (12 percent). In patients followed over 6 months, uncomplicated bony union was achieved in 11 of 14 patients (78 percent). After secondary procedures, bony union was ultimately achieved in 13 of 14 patients (93 percent), all of whom had good functional outcomes. Eight patients suffered local recurrences or metastases (32 percent); six died during the study period.

CONCLUSIONS

The microvascular free fibula flap has a lower infection rate than traditional allograft reconstruction. There is a high rate of bone union, and functional outcome is good. Thus, the authors recommend the microvascular fibula transfer as the technique of choice for reconstructing large, complex long bone defects resulting from tumor extirpation.