Visual art therapy and its effects in older people with mild cognitive impairment: A systematic review

INTRODUCTION

Mild cognitive impairment (MCI) is a known risk factor for the development of dementia. The potential benefits on cognition from non-pharmacological measures such as art-based interventions are of increasing interest. This systematic review examines the evidence for the impact of one form of art-based intervention, visual art therapy (VAT), on the cognition and psychological wellbeing of older people with MCI.

METHODS

Randomised controlled and quasi-experimental trials evaluating the efficacy of VAT in older persons aged over 60 years with MCI were included. A search was performed on electronic databases: MEDLINE, CINAHL, Embase and PsycINFO. Joanna Briggs Institute critical appraisal and extraction tools were utilised for risk of bias assessment and data extraction, respectively. A narrative descriptive approach was used to outline the findings.

RESULTS

Seven studies were identified from 4311 articles screened. Improvement in cognition was reported in five studies, with two of these reporting sustained improvement at 6-9 months, while the remaining three studies showed improvement only at the immediate post-intervention period. A positive impact was reported in four of six studies that examined the effect of VAT on participant psychological wellbeing. The overall methodological quality of the studies ranged from moderate in four of five RCTs, to high in the quasi-experimental studies and one RCT. However, the low study power in the context of small sample sizes limits the applicability of these studies to the population of interest.

CONCLUSIONS

VAT is potentially an effective non-pharmacological intervention that may enhance cognition and provide benefits for psychological wellbeing in older persons with MCI. Given the limited studies available, with the majority emerging over the last 5 years, further research is required to confirm these reported benefits, as well as to determine whether VAT impacts on the progression of cognitive decline in MCI.

Evaluation of aerosol transmission risk during home quarantine under different operating scenarios: A pilot study

SARS-CoV-2 has been recognized to be airborne transmissible. With the large number of reported positive cases in the community, home quarantine is recommended for the infectors who are not severely ill. However, the risks of household aerosol transmission associated with the quarantine room operating methods are under-explored. We used tracer gas technique to simulate the exhaled virus laden aerosols from a patient under home quarantine situation inside a residential testbed. The Sulphur hexafluoride (SF₆) concentration was measured both inside and outside the quarantine room under different operating settings including, air-conditioning and natural ventilation, presence of an exhaust fan, and the air movement generated by ceiling or pedestal fan. We calculated the outside-to-inside SF₆ concentration to indicate potential exposure of occupants in the same household. In-room concentration with air-conditioning was 4 times higher than in natural ventilation settings. Exhaust fan operation substantially reduced in-room SF₆ concentration and leakage rate in most of the ventilation scenarios, except for natural ventilation setting with ceiling fan. The exception is attributable to the different airflow patterns between ceiling fan (recirculates air vertically) and pedestal fan (moves air horizontally). These airflow variations also led to differences in SF₆ concentration at two sampling heights (0.1 m and 1.7 m) and SF₆ leakage rates when the quarantine room door was opened momentarily. Use of natural ventilation rather than air-conditioning, and operating exhaust fan when using air-conditioning are recommended to lower exposure risk for home quarantine. A more holistic experiment will be conducted to address the limitations reflected in this study.

A review of occupancy-based building energy and IEQ controls and its future post-COVID

Occupancy schedules and density can have a substantial influence on building plug, lighting, and air conditioning energy usage. In recent years, the study related to occupancy and its impact on building energy consumption has gained momentum and is also promoted by ASHRAE as it has created a multi-disciplinary group to encourage a comprehensive study of occupant behaviour in buildings. Past studies suggest that building systems do not consume the same energy and provide similar Indoor Environmental Quality (IEQ) to their designed specifications due to inaccurate assumptions of occupants and their behaviour. Supplying ASHRAE 62.1 specified minimum required ventilation based on accurate occupancy may lead to significant air-conditioning energy savings. However, the same strategy is not suitable in the current time since minimum required ventilation may not be sufficient to mitigate the SARS-CoV-2 virus spread in confined spaces. High-temperature cooling augmented with elevated air movement across an acceptable range of velocity can maintain the health and comfort of occupants by providing higher ventilation and without an energy penalty. The analysis of the literature highlights strengths, weaknesses, and key observations about the existing occupancy monitoring and occupancy-based building system control methods to help in the direction of future occupancy-based research.

Stereological Estimation of Dopaminergic Neuron Number in the Mouse Substantia Nigra Using the Optical Fractionator and Standard Microscopy Equipment

In pre-clinical Parkinson's disease research, analysis of the nigrostriatal tract, including quantification of dopaminergic neuron loss within the substantia nigra, is essential. To estimate the total dopaminergic neuron number, unbiased stereology using the optical fractionator method is currently considered the gold standard. Because the theory behind the optical fractionator method is complex and because stereology is difficult to achieve without specialized equipment, several commercially available complete stereology systems that include the necessary software do exist, purely for cell counting reasons. Since purchasing a specialized stereology setup is not always feasible, for many reasons, this report describes a method for the stereological estimation of dopaminergic neuronal cell counts using standard microscopy equipment, including a light microscope, a motorized object table (x, y, z plane) with imaging software, and a computer for analysis. A step-by-step explanation is given on how to perform stereological quantification using the optical fractionator method, and pre-programmed files for the calculation of estimated cell counts are provided. To assess the accuracy of this method, a comparison to data obtained from a commercially available stereology apparatus was performed. Comparable cell numbers were found using this protocol and the stereology device, thus demonstrating the precision of this protocol for unbiased stereology.

Computer navigation and distal femoral reconstruction in the oncologic patient

OBJECTIVES

As adjuvant treatments for musculoskeletal malignancies improve expectations of preserved function increase. We questioned whether computer navigation for distal femoral reconstruction would improve outcomes.

METHODS

Twenty oncology patients were reviewed after distal femoral reconstruction using navigation. Outcomes included local recurrence, implant revision, patient function, patellofemoral complications and leg-length inequality.

RESULTS

Implant survivorship was 85% at 26 months. There were no local recurrences and 3 failures for aseptic loosening. Good functional outcomes were observed in remaining cases.

CONCLUSION

Computer navigation for distal femoral reconstruction resulted in acceptable functional outcomes and implant survivorship. Reduced local recurrence were observed at intermediate follow-up. Level of Evidence: Level IV.

Percutaneous Acetabuloplasty for Metastatic Lesions to the Pelvis

Metastatic lesions of the acetabulum can be painful and debilitating. First-line treatment is multimodal and consists of disease-specific chemotherapy, osteoclastic inhibitors, analgesics, and radiation therapy. When these therapies fail, surgical intervention usually is indicated and varies from regional defect stabilization to large periacetabular reconstructions that are demanding procedures with high rates of complications. Percutaneous cement augmentation (acetabuloplasty) of lesions in selected patients has been explored as a less invasive method of lesional control. This retrospective review included 11 patients with painful periacetabular lesions who underwent percutaneous acetabuloplasty using fluoroscopic guidance from 2007 to 2012, in addition to standard treatment with either radiation or chemotherapy, or a combination of both radiation and chemotherapy. Primary tumors included 4 multiple myeloma, 4 renal cell, and 3 breast malignancies. Mean procedure length was 58.4 minutes, and mean hospital stay was 1.4 days (range, 1-2 days). Mean blood loss was 33.4 mL, and there were no complications due to infection or cementation. Mean follow-up was 26.4 months (range, 3-36 months), with 2 patients dying from complications of underlying disease. All of the patients experienced pain relief following the procedure, with mean visual analog scale scores improving from 7.7 to 2.1 (P=.002). Postoperative Musculoskeletal Tumor Society and Oxford hip scores were obtained for 7 of 11 patients and demonstrated improvement. One patient underwent conversion to an acetabular reconstruction due to disease progression. This report demonstrates the effective use of a minimally invasive procedure to provide acute stability, pain relief, and good functional outcomes in patients with periacetabular metastatic lesions without pathologic fracture. [Orthopedics. 2017; 40(1):e170-e175.].

Do Surgical Margins Affect Local Recurrence and Survival in Extremity, Nonmetastatic, High-grade Osteosarcoma?

BACKGROUND

Long-term survival for all patients with osteosarcoma using current aggressive adjuvant chemotherapy and surgical resection is between 60% and 70%. In patients who present with nonmetastatic, high-grade extremity osteosarcoma of bone, limb salvage surgery is favored, when appropriate, over amputation to preserve the limb, because limb salvage may lead to a superior quality of life compared with amputation. However, concern remains that in the attempt to preserve the limb, close or microscopically positive surgical margins may have an adverse effect on event-free survival.

QUESTIONS/PURPOSES

(1) Does a positive or close surgical margin increase the likelihood of a local recurrence? (2) Does a positive or close surgical margin adversely affect the development of metastatic disease? (3) What is the relationship of surgical margin on overall survival?

METHODS

With institutional review board approval, we retrospectively evaluated 241 patients treated at our institution between 1999 and 2011. Exclusion criteria included nonextremity locations, metastatic disease at initial presentation, low- or intermediate-grade osteosarcoma, treatment regimens that did not follow National Comprehensive Cancer Network (NCCN) guidelines, incomplete medical records, and any part of treatment performed outside of Moffitt Cancer Center or All Children's Hospital. Fifty-one patients were included in the final analysis, of whom 31 (61%) had followup data at a minimum of 2 years or whose clinical status was known but had died before 2 years of followup. Margin status was defined as (1) microscopically positive; (2) negative ≤ 1 mm; and (3) negative > 1 mm. Margin status, histologic response (tumor percent necrosis), type of osteosarcoma, type of surgery, presence of local recurrence, metastatic disease, and overall survival were recorded for each patient. The mean age was 22 years (range, 12-74 years) and the mean followup was 3 years (range, 0.1-14 years). Margin status was positive in 10% (five of 51), negative ≤ 1 mm 26% (13 of 51), and negative > 1 mm 65% (33 of 51).

RESULTS

Local recurrence was noted to be 14% (seven of 51) at 3.4 years. After controlling for relevant confounding variables, the presence of a positive margin compared with a negative margin > 1 mm was the only independent predictor of local recurrence (hazard ratio [HR], 8.006; 95% confidence interval [CI], 1.314-48.781; p = 0.0241). At a mean of 3.4 years, 29% (15 of 51) of the patients developed metastatic disease with no difference with the numbers available in the probability of developing metastatic disease among the three margin groups (p = 0.614). Overall survival at 3.8 years was 75% (38 of 51). After controlling for relevant confounding variables, we found that patients with positive margins were more likely to die from disease than those with negative margins (HR, 6.26; 95% CI, 1.50-26.14; p = 0.0119); no other independent predictors of survival were identified.

CONCLUSIONS

With the numbers of patients we had, we observed that patients with extremity, nonmetastatic, high-grade osteosarcoma who had positive margins showed a higher probability of local recurrence in comparison to those with negative surgical margins. Given that positive margins appear to be associated with poorer survival in patients with high-grade osteosarcoma of the extremities, surgeons should strive to achieve negative margins, but larger studies are needed to confirm these findings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Chondroblastoma of bone in the extremities: a multicenter retrospective study

BACKGROUND

Chondroblastoma is a rare benign cartilage tumor that commonly occurs in children and adolescents. This study was designed to review the epidemiologic characteristics and outcomes of surgical management in a large series of patients with extremity chondroblastoma.

METHODS

We performed a multicenter retrospective analysis of 199 patients with extremity chondroblastoma. Clinical data, radiographic images, histological findings, treatment, and outcome were analyzed.

RESULTS

There were 145 male patients and fifty-four female patients with a mean age of 18.0 years. The most commonly involved bone was the proximal part of the tibia (fifty-five patients [27.6%]), followed by the proximal part of the femur (fifty-two patients [26.1%]) and the distal part of the femur (thirty-eight patients [19.1%]). Prior to presentation, 73.4% (146 of 199 patients) experienced pain. The mean duration of pain and other symptoms was 8.7 months. The physis was open in 25.7%, it was closing in 22.2%, and it was closed in 52.1% of the patients at the time of presentation. One hundred and twenty-six patients had at least twenty-four months of follow-up; their mean follow-up duration was 62.1 months (range, twenty-four to 190 months). Initial treatment was curettage for 119 patients (94.4%) and en bloc resection for seven patients (5.6%). The local recurrence rate was 5.0% after curettage and 0% after resection. The only significant factor related to recurrence was the location of the lesion in the proximal part of the humerus (p = 0.001).

CONCLUSIONS

Chondroblastoma occurs most frequently in the proximal part of the tibia and the proximal part of the femur with significant male predilection. In this series, recurrence was most frequent in the proximal part of the humerus. Our results suggest that curettage and bone-grafting provide favorable local control and satisfactory functional outcome for patients with this disease.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What are the results using the modified trapdoor procedure to treat chondroblastoma of the femoral head?

BACKGROUND

Treatment of chondroblastoma in the femoral head is challenging owing to the particular location and its aggressive nature. There is little published information to guide the surgeon regarding the appropriate approach to treating a chondroblastoma in this location. We developed a modified trapdoor procedure to address this issue. The primary modification is that the window surface of the femoral head is covered by the ligamentum teres rather than cartilage as in the traditional procedure.

QUESTIONS/PURPOSES

We assessed (1) the clinical presentation of chondroblastoma of the femoral head and treatment results with the modified trapdoor procedure in terms of (2) the frequency of local recurrence, (3) complications, and (4) functional outcomes using the Musculoskeletal Tumor Society (MSTS) score.

METHODS

Between 1999 and 2010, we treated 14 patients for chondroblastoma of the femoral head. All patients received the modified trapdoor procedure. Of those, 13 were available for followup at a minimum of 36 months (mean, 66 months; range, 36-117 months) and one patient was lost to followup. There were nine males and four females, with a mean age of 18 years (range, 9-29 years). Clinical features were ascertained by chart and radiographic review, and recurrence, complications, and functional outcomes (MSTS score) were recorded from chart review. Patterns of bone destruction were evaluated using the Lodwick classification, which ranges from IA (geographic appearance with sclerotic rim) to III (permeative appearance).

RESULTS

The symptoms at diagnosis were pain in nine patients and discomfort in four. The mean duration of symptom was 11 months (range, 1-36 months). The physis was open in two patients, closing in one, and closed in 10. The patterns of bone destruction were evaluated as Lodwick Class IA in six patients, Lodwick Class IB in five, and Lodwick Class IC in two. At latest followup, no local recurrence was observed. Two patients had postoperative complications. One had avascular necrosis of the femoral head and was treated with prosthesis replacement. The other had asymptomatic heterotopic ossification in the surgical field. The mean MSTS score was 29.6 (range, 28-30).

CONCLUSIONS

Based on this small series, we believe our modified trapdoor procedure is a safe, effective means of treating a chondroblastoma in the femoral head, but additional clinical evaluation with more patients is necessary to confirm our findings.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Cutaneous leiomyosarcoma: treatment and outcomes with a standardized margin of resection

BACKGROUND

Cutaneous leiomyosarcoma is primarily a low-grade malignancy that affects elderly male Caucasians. It is a rare dermal-based tumor for which treatment algorithms have been poorly defined.

METHODS

We retrospectively reviewed the use of a median 1-cm margin for resection to treat patients with cutaneous leiomyosarcoma referred for treatment between 2005 and 2010.

RESULTS

Thirty-three patients with cutaneous leiomyosarcoma were treated. Of these, 76% were male, 97% were Caucasian (median age: 63.5 years), and 67% of tumors were located on the extremities. Preoperative staging was negative for distant metastasis in all patients. A majority of the tumors (88%) were low grade (median size: 1.3 cm). All of the tumors were positive for smooth-muscle actin. A total of 94% of patients underwent primary surgical resection with a median margin of 1 cm. Final resection margin was negative in 97% of patients. Adjuvant radiotherapy was used in 15%. No metastatic spread or recurrences were present, and 100% of patients were alive at last follow-up (median: 15.5 months).

CONCLUSIONS

Good oncological control and excellent outcomes are possible with a 1-cm resection margin in most cases of cutaneous leiomyosarcoma.

Biomechanical analysis of impending femoral neck fractures: the role of percutaneous cement augmentation for osteolytic lesions

BACKGROUND

Management of impending pathologic femoral neck fractures includes internal fixation, arthroplasty and megaprostheses. The study aim was to determine the augmentative effect of cement injection for minimally invasive treatment of femoral neck lesions.

METHODS

Twenty-seven cadaveric femora received a simulated osteolytic lesion previously shown to decrease the femur's failure load by 50%. Specimens were allocated to three groups of nine and loaded to failure in simulated single-leg stance: (1) percutaneous cementation + internal fixation (PCIF); (2) percutaneous cementation (PC); and (3) internal fixation (IF). Lesion-only and augmented finite element models were virtually loaded and stresses were queried adjacent to the lesion.

FINDINGS

PCIF resulted in the largest failure load though the increase was not significantly greater than the PC or IF groups. Inspection of the PC and PCIF specimens indicated that the generation of a cement column that spanned the superior and inferior cortices of the femoral neck increased failure loads significantly. Finite element analysis indicated that IF and PCIF constructs decreased the stress adjacent to the lesion to intact femur levels. Cementation without superior-to-inferior femoral neck cortical contact did not restore proximal femoral stress toward the intact condition.

INTERPRETATION

Internal fixation alone and internal fixation with or without cementation produce similar levels of mechanical augmentation in femora containing a high-risk lesion of impending fracture. A cement injection technique that produces a cement column contacting the superior and inferior femoral neck cortices confers the highest degree of biomechanical stability, should percutaneous cementation alone be performed.

Bone cancer

Primary bone cancers are extremely rare neoplasms, accounting for fewer than 0.2% of all cancers. The evaluation and treatment of patients with bone cancers requires a multidisciplinary team of physicians, including musculoskeletal, medical, and radiation oncologists, and surgeons and radiologists with demonstrated expertise in the management of these tumors. Long-term surveillance and follow-up are necessary for the management of treatment late effects related to surgery, radiation therapy, and chemotherapy. These guidelines discuss the management of chordoma, giant cell tumor of the bone, and osteosarcoma.

Cutaneous angiosarcoma: a single-institution experience

BACKGROUND

Cutaneous angiosarcoma (CAS) is a rare, aggressive vascular sarcoma with a poor prognosis, historically associated with 5-year overall survival (OS) rates between 10 and 30 %.

METHODS

This is a single-institution retrospective review of patients treated for CAS from 1999-2011. Demographics, primary tumor characteristics, treatment, and outcomes were analyzed.

RESULTS

A total of 88 patients were identified (median age 70 years and 57 % female). Median tumor size was 3 cm. Median follow-up was 22 months. The 5-year OS and recurrence-free survival (RFS) were 35.2 and 32.3 %, respectively; median was 22.1 months. Also, 36 patients (41 %) received surgery alone, 7 (8 %) received XRT alone, and 41 (47 %) received surgery and XRT. Of the 67 of 88 patients who were disease-free after treatment, 33 (50 %) recurred (median of 12.3 months). Surgery alone had the highest 5-year OS (46.9 %) and RFS (39.9 %) (p = ns). Four presentation groups were identified: (1) XRT-induced, n = 30 (34 %), 26 of 30 occurred in females with a prior breast cancer, (2) sporadic CAS on head and neck (H/N), n = 38, (3) sporadic CAS on trunk/extremities, n = 13, and (4) Stewart-Treves n = 7. Those with trunk/extremity CAS had the highest 5-year OS (64.8 %), with H/N CAS having the worst 5-year OS (21.5 %). On MV analysis, only tumor size <5 cm correlated with improved OS (p = 0.014).

DISCUSSION

In this large series, there appears to be a better overall prognosis than historically reported, especially in Stewart-Treves and CAS on trunk or extremities. While surgery alone was associated with better OS and RFS compared with other treatment modalities, this was not statistically significant. Tumor size was a significant prognostic factor for OS.

Biomechanical model of a high risk impending pathologic fracture of the femur: lesion creation based on clinically implemented scoring systems

BACKGROUND

Multiple classifications combine objective and subjective measures to predict fracture risk through a metastatic lesion. In our literature review, no studies have attempted to validate this predicted fracture risk from a biomechanical perspective. The study goal was to evaluate proximal femur strength after creating osteolytic defects. We report a standardized technique to re-create a metastatic lesion.

METHODS

Eight femoral matched pairs were procured and a standardized technique was used to create an osteolytic femoral neck defect in one femur with the contralateral specimen serving as the control. Femurs were loaded to failure in a material testing machine at 2 mm/s. Failure load (N) and location of failure were documented. 3D finite element (FE) femur models with and without the lesions were developed to predict von Mises stresses in the femoral neck and compare between the two models.

FINDINGS

Femurs containing the osteolytic defect failed at significantly lower loads than the intact specimens in a reproducible manner (intact: 10.69 kN (3.09 SD); lesion: 5.56 kN (2.03 SD), p<0.001). The average reduction in failure load was 48%, and the fracture pattern was consistent in all specimens. FE model comparison similarly predicted significantly higher von Mises stress at the lesion.

INTERPRETATION

Our methods and pathologic fracture model represent the clinical parameters of metastatic bone disease and suggest a significant reduction in structural integrity of the lesion-containing femur. Prophylactic surgical fixation may be warranted clinically to reduce the risk of pathologic fracture. Our model technique is reproducible and may be used in future studies.

Adult soft tissue sarcoma local recurrence after adjuvant treatment without resection of core needle biopsy tract

BACKGROUND

Core needle biopsies of sarcomas allow a diagnosis in a high percentage of patients with few complications. However, it is unclear whether the tract needs to be excised to prevent recurrences.

QUESTIONS/PURPOSES

We therefore determined the rates of recurrence and metastases in patients with Stage III extremity sarcomas, who underwent wide local resection without excision of the needle tract and also received adjuvant treatment.

METHODS

We retrospectively reviewed 59 adult patients with deep, larger than 5 cm, high-grade soft tissue sarcomas of the upper or lower extremity treated between January 1999 and April 2009. All the patients underwent a core needle biopsy. Resection was performed with wide margins. The biopsy tract was not resected during the definitive surgery. Fifty-seven patients (97%) received preoperative and/or postoperative radiation, whereas 49 patients (83%) received chemotherapy. Local recurrence and distant recurrence rates were determined. The minimum followup was 24 months (median, 56 months; range, 24-122 months).

RESULTS

The local recurrence rate was 9%. Fifteen patients (25%) developed metastasis after diagnosis. Seven of the 59 patients (12%) had microscopic positive margins at resection.

CONCLUSIONS

Our data demonstrate no increase in local recurrence rates or rates of metastatic disease compared with previously published studies when resection of the core biopsy tract was not performed.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The use of isolated limb infusion in limb threatening extremity sarcomas

This paper reports a single-institution experience with the use of isolated limb infusion for limb salvage in locally advanced, unresectable, recurrent limb threatening soft tissue sarcomas.

BACKGROUND

Locally advanced, limb threatening soft tissue sarcomas (STS) pose a significant treatment challenge. We report our experience using isolated limb infusion (ILI) in patients with unresectable extremity STS.

METHODS

A total of 22 patients with extremity STS underwent 26 ILIs with melphalan and dactinomycin. Patient characteristics, intra-operative parameters and toxicity were recorded. Outcome measures included limb-salvage and in-field response rates.

RESULTS

Of the 19 lower and 7 upper extremity ILIs, Wieberdink grade III toxicity or less was observed in all. Median followup was 11 months. A total of 17 patients were evaluable at 3 months post-ILI with an overall response rate of 42%. Four (24%) had complete response (CR), three (18%) partial response (PR), three (18%) stable disease (SD) and seven (41%) progressive disease (PD). Twelve of 17 (71%) underwent successful limb preservation at a median of 9 months post-ILI. Two (12%) were downstaged to resectable disease and remain showing no evidence of disease (NED) after surgery at 30 and 22 months post-ILI.

CONCLUSIONS

ILI is an attractive modality that provides regional disease control and limb preservation in patients with limb threatening sarcoma. Although short-term results appear encouraging, long-term follow-up is needed to fully assess the role of ILI in unresectable extremity STS.

Differential gene expression in liposarcoma: Insight into pathways for dedifferentiation?

10048

Background: Liposarcoma (LPS) dedifferentiation signifies conversion to a clinically aggressive phenotype, but the biologic processes required for this change have not been determined. We describe differential gene expression patterns between well-differentiated (WD) and dedifferentiated (DD) tumors to determine pathways involved in LPS dedifferentiation. Methods: From 1999 to 2006, 121 fatty tumors were resected at a single institution. Twenty tumors, consisting of atypical lipomatous tumors (ALT), WD LPS or DD LPS, were randomly selected and clinicopathologic characteristics were retrospectively reviewed. Gene expression profiling was performed on extracted RNA using the Affymetrix GeneChip platform. Differentially expressed genes were obtained and gene network analysis was done using GeneGO by MetaCore. Results: Median age was 59 years and 70% of cases were male. WD tumors, consisting of 3 ALT and 6 WD LPS, were compared with 11 DD LPS. After a median follow-up of 64 months, 7 patients had died of whom 6 had DD LPS. DD histology was associated with lower overall survival (p<0.05). Significance Analysis of Microarrays for WD tumors vs. DD LPS using a 0% false discovery rate showed differential expression of 188 genes. Network analysis of genes from WD tumors vs. DD LPS showed significant (p<0.001) differential regulation of glucose-activated transcription factor ChREBP (carbohydrate response element binding protein), a key element involved in lipogenesis, gluconeogenesis and glycolysis. There was also significant differential regulation of insulin signaling, PI3K-dependent and PKA signal transduction pathways and of amino acid, fatty acid and glucose metabolism pathways (p<0.05). These pathways, based on Gene Ontology cellular processes, mapped to gene networks primarily involved in lipid metabolism (p<0.05). Conclusions: Differential expression of genes involved in lipid metabolism networks is seen in DD LPS and changes in lipid metabolism may be associated with dedifferentiation. These differential gene expression patterns may help identify fatty tumors potentially at risk for progressing to a malignant or DD state and provide prognostic factors and therapeutic targets for patients with LPS.

Multimodality therapy for pulmonary metastasis in sarcoma patients: Results of a single institution

10070

Background: Pulmonary metastasectomy (PM) for sarcoma can result in significant long term survival in carefully selected patients (pts). We report our experience with pulmonary metastasectomy. Methods: After IRB approval, 120 pts who underwent PM for sarcoma at Moffitt Cancer Center from 1999 to 2011 were reviewed. Survival was calculated according to the Kaplan-Meier method with Cox proportional hazard univariate (UV) and multivariate (MV) models used to analyze relationships between clinicopathologic variables and overall survival (OS). P-value < 0.05 was considered significant. Results: Median age was 51 yrs, 95(79%) pts had soft tissue sarcomas with pleomorphic being most common. Of the 25(21%) osseous sarcomas, osteosarcoma was most common. 20(15%) had synchronous metastasis (mets); of the pts with local disease only, median time to recurrence from primary resection was 13 months (mo). OS from initial resection was 55 mo for pts with local disease only vs. 27 mo for pts with synchronous mets. On UV analysis, use of radiation, number of index lesions, presence of synchronous mets and time to recurrence achieved significance. On MV analysis, only shorter time to recurrence (p=.03) and presence of synchronous mets (p=.04) were independent predictors of poor survival. 63(52%) pts [26(22%) neoadjuvant, 19(16%) adjuvant, 18(15%) both] received chemotherapy for the primary tumor, while 57(48%) did not. There was a trend towards poor survival in pts receiving chemotherapy compared to pts receiving no chemotherapy (p=0.06, HR 1.59). In addition 40(34%) pts received chemotherapy prior to PM with no difference in OS compared to pts who did not get chemotherapy (p=0.1, HR 1.55). 71(59%) had 1 PM, 32(27%) had 2 and 17(14%) had 3 or more PM with OS being 17 mo, 37 mo and 34 mo in each group, respectively. A higher number of PM was associated with improved survival (p=.01). Conclusions: Pts with a shorter disease free interval have a decreased OS as do pts with synchronous mets. Pts undergoing multiple PM have a survival benefit likely resulting from favorable disease biology. Failure of chemotherapy to show a survival benefit may be a result of selection bias for patients with aggressive disease being treated with chemotherapy.

Outcome of lower-limb preservation with an expandable endoprosthesis after bone tumor resection in children

BACKGROUND

The optimal treatment of malignant pediatric lower-extremity bone tumors is controversial. Expandable endoprostheses allow limb preservation, but the revision rate and limited function are considered barriers to their use. This study investigated the functional, emotional, and oncologic outcomes of thirty-eight patients treated with an expandable endoprosthesis.

METHODS

A retrospective chart review was performed, and surviving patients were asked to complete the Musculoskeletal Tumor Society (MSTS) outcomes instrument and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional data including the range of hip and knee motion, limb-length discrepancy, and total lengthening were also obtained.

RESULTS

Thirty-eight patients were treated with an expandable endoprosthesis, and twenty-six of these patients were alive at the time of the study. The mean global MSTS score was 26.1, and the mean global PODCI score was 85.8. The mean emotional acceptance and happiness subscores were high. The mean sagittal-plane hip motion in patients who had undergone replacement of the proximal aspect of the femur was 103°. The mean knee motion in patients who had undergone replacement of the proximal aspect of the femur, the distal aspect of the femur, or the proximal aspect of the tibia was 127°, 97°, and 107°, respectively. The mean lengthening at the time of skeletal maturity was 4.5 cm, and the mean limb-length discrepancy was 0.7 cm. Forty-two percent of the patients experienced complications, with ten patients requiring prosthesis revision and two of these patients requiring amputation.

CONCLUSIONS

Current technology does not offer a single best reconstruction option for children. Previous studies and the present series have indicated that physical and emotional functioning in patients treated with an expandable endoprosthesis are good but that complication rates remain high. Amputation and rotationplasty are alternative treatments if patients and their families are amenable to these procedures. The literature supports no single superior treatment among these three options with regard to physical or emotional health.

Biology, classification, and management of recurrent myxofibrosarcoma 21 years after resection

Soft-tissue sarcomas (STSs) are a heterogenous group of rare malignancies that have significant lifelong implications. Accepted management options include limb-sparing surgical resection and adjuvant radiation therapy. Here we present the case of a myxoid malignant fibrous histiocytoma, now termed a myxofibrosarcoma, which recurred 21 years after primary surgical resection. To our knowledge, this is the longest documented interval between initial management and recurrence of an STS. Significant changes have been made in classification guidelines and diagnostic methods over this 2-decade period. The pathogenesis of remote recurrence of STSs remains controversial and is discussed in this report.

Limb preservation with isolated limb infusion for locally advanced nonmelanoma cutaneous and soft-tissue malignant neoplasms

OBJECTIVE

To demonstrate the efficacy of isolated limb infusion (ILI) in limb preservation for patients with locally advanced soft-tissue sarcomas and nonmelanoma cutaneous malignant neoplasms.

BACKGROUND

Locally advanced nonmelanoma cutaneous and soft-tissue malignant neoplasms, including soft-tissue sarcomas of the extremities, can pose significant treatment challenges. We report our experience, including responses and limb preservation rates, using ILI in cutaneous and soft-tissue malignant neoplasms.

METHODS

We identified 22 patients with cutaneous and soft-tissue malignant neoplasms who underwent 26 ILIs with melphalan and dactinomycin from January 1, 2004, through December 31, 2009, from 5 institutions. Outcome measures included limb preservation and in-field response rates. Regional toxic effects were measured using the Wieberdink scale and serum creatinine phosphokinase levels.

RESULTS

The median age was 70 years (range, 19-92 years), and 12 patients (55%) were women. Fourteen patients (64%) had sarcomas, 7 (32%) had Merkel cell carcinoma, and 1 (5%) had squamous cell carcinoma. The median length of stay was 5.5 days (interquartile range, 4-8 days). Twenty-five of the 26 ILIs (96%) resulted in Wieberdink grade III or less toxicity, and 1 patient (4%) developed grade IV toxicity. The median serum creatinine phosphokinase level was 127 U/L for upper extremity ILIs and 93 U/L for lower extremity ILIs. Nineteen of 22 patients (86%) underwent successful limb preservation. The 3-month in-field response rate was 79% (21% complete and 58% partial), and the median follow-up was 8.6 months (range, 1-63 months). Five patients underwent resection of disease after an ILI, of whom 80% are disease free at a median of 8.6 months.

CONCLUSIONS

Isolated limb infusion provides an attractive alternative therapy for regional disease control and limb preservation in patients with limb-threatening cutaneous and soft-tissue malignant neoplasms. Short-term response rates appear encouraging, yet durability of response is unknown.

Computer-assisted navigation and musculoskeletal sarcoma surgery

BACKGROUND

Despite advances in medical, surgical, and radiation oncology, deep-seated bone sarcomas that require large osseous resections continue to present resection and reconstructive challenges to musculoskeletal surgeons.

METHODS

We describe our experience with computer navigation techniques combined with complex pelvic resections and limb-preserving surgeries.

RESULTS

Computer-assisted navigation has shown promise in aiding in optimal preoperative planning and in providing more accurate and precise feedback during surgery.

CONCLUSIONS

Computer-assisted navigation offers precise instrumentation, technology-oriented imaging systems, and powerful information processing, all of which can assist in decision making, preoperative planning, and surgical accuracy.

Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques

BACKGROUND

Improved understanding and advances in treatment regimens have led to increased longevity among patients diagnosed with extremity soft tissue sarcomas. Limb salvage techniques and implants have improved and continue to evolve to accommodate the increasing demands and survival of these patients.

METHODS

The current report is a review of the literature for recent advancements in techniques, implant design, and outcomes in the field of limb salvage therapy using segmental megaprostheses for the treatment of extremity sarcomas. We report on our experience in this field utilizing a classification system of failure mechanisms to outline to discuss current controversies in management.

RESULTS

Five mechanisms of failure have been identified: soft-tissue failure, aseptic loosening, structural failure, infection, and tumor progression. Infection was the most common mode of failure in our series, accounting for 34% of cases. Soft-tissue failure occurred most commonly in the joints that depend heavily on periarticular muscles and ligaments for stability due to their high degree of functional range of motion. We observed a 28% soft-tissue failure rate about the shoulder and hip, aseptic loosening accounted for 19% of implant failures, and structural failure was seen in 17% of cases. Seventeen percent of cases failed due to tumor progression, an etiology that is defined by biological factors, surgical technique, and adjuvant therapies.

CONCLUSIONS

Surgical techniques and megaprosthesis designs are constantly changing in order to meet the challenge of increasing functional demands and longevity in this unique patient population. A classification system defined by treatment failure etiologies provides the framework for discussion of current controversies in limb salvage therapy as well as a guide for advancement and potential solutions in this challenging arena.

The role of radical amputations for extremity tumors: a single institution experience and review of the literature

BACKGROUND

Major amputations are indicated for advanced tumors when limb-preservation techniques have been exhausted. Radical surgery can result in significant palliation and possible cure.

METHODS

We identified 40 patients who underwent forequarter (FQ) or hindquarter (HQ) amputations between May 2000 and January 2011. Patient demographics, tumor-related factors, and outcomes were reviewed.

RESULTS

There were 30 FQ and 10 HQ amputations. The most common diagnoses were sarcoma (55%) and squamous cell carcinoma (25%). Patients presented with primary tumors (35%), regional recurrence (57.5%), or unresectable limb metastatic disease (7.5%). Presenting symptoms included fungating wounds (35%), intractable pain (78%), and limb dysfunction (65%). Operations were performed with curative intent (10%), curative/palliative intent (70%), or palliation alone (20%). Wound complications occurred in 35%. Pain was improved in 78% of patients following surgery. Despite a 91% negative margin rate, 79% of patients recurred either locally or distantly. Median overall survival was 10.9, 13.2, and 3.4 months in the curative, curative/palliative, and palliative groups, respectively.

CONCLUSIONS

In the absence of conservative options, major amputations are indicated for the management of advanced tumors. These operations can be performed safely, resulting in effective palliation of debilitating symptoms. While recurrence rates remain high, some patients can achieve prolonged survival.

Combination of external beam radiotherapy (EBRT) with intratumoral injection of dendritic cells as neo-adjuvant treatment of high-risk soft tissue sarcoma patients

PURPOSE

The goal of this study was to determine the effect of combination of intratumoral administration of dendritic cells (DC) and fractionated external beam radiation (EBRT) on tumor-specific immune responses in patients with soft-tissue sarcoma (STS).

METHODS AND MATERIAL

Seventeen patients with large (>5 cm) high-grade STS were enrolled in the study. They were treated in the neoadjuvant setting with 5,040 cGy of EBRT, split into 28 fractions and delivered 5 days per week, combined with intratumoral injection of 10(7) DCs followed by complete resection. DCs were injected on the second, third, and fourth Friday of the treatment cycle. Clinical evaluation and immunological assessments were performed.

RESULTS

The treatment was well tolerated. No patient had tumor-specific immune responses before combined EBRT/DC therapy; 9 patients (52.9%) developed tumor-specific immune responses, which lasted from 11 to 42 weeks. Twelve of 17 patients (70.6%) were progression free after 1 year. Treatment caused a dramatic accumulation of T cells in the tumor. The presence of CD4(+) T cells in the tumor positively correlated with tumor-specific immune responses that developed following combined therapy. Accumulation of myeloid-derived suppressor cells but not regulatory T cells negatively correlated with the development of tumor-specific immune responses. Experiments with (111)In labeled DCs demonstrated that these antigen presenting cells need at least 48 h to start migrating from tumor site.

CONCLUSIONS

Combination of intratumoral DC administration with EBRT was safe and resulted in induction of antitumor immune responses. This suggests that this therapy is promising and needs further testing in clinical trials design to assess clinical efficacy.

Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review

BACKGROUND

Massive endoprostheses provide orthopaedic oncologists with many reconstructive options after tumor resection, although failure rates are high. Because the number of these procedures is limited, failure of these devices has not been studied or classified adequately. This investigation is a multicenter review of the use of segmental endoprostheses with a focus on the modes, frequency, and timing of failure.

METHODS

Retrospective reviews of the operative databases of five institutions identified 2174 skeletally mature patients who received a large endoprosthesis for tumor resection. Patients who had failure of the endoprosthesis were identified, and the etiology and timing of failure were noted. Similar failures were tabulated and classified on the basis of the risk of amputation and urgency of treatment. Statistical analysis was performed to identify dependent relationships among mode of failure, anatomic location, and failure timing. A literature review was performed, and similar analyses were done for these data.

RESULTS

Five hundred and thirty-four failures were identified. Five modes of failure were identified and classified: soft-tissue failures (Type 1), aseptic loosening (Type 2), structural failures (Type 3), infection (Type 4), and tumor progression (Type 5). The most common mode of failure in this series was infection; in the literature, it was aseptic loosening. Statistical dependence was found between anatomic location and mode of failure and between mode of failure and time to failure. Significant differences were found in the incidence of failure mode Types 1, 2, 3, and 4 when polyaxial and uniaxial joints were compared. Significant dependence was also found between failure mode and anatomic location in the literature data.

CONCLUSIONS

There are five primary modes of endoprosthetic failure, and their relative incidences are significantly different and dependent on anatomic location. Mode of failure and time to failure also show a significant dependence. Because of these relationships, cumulative reporting of segmental failures should be avoided because anatomy-specific trends will be missed. Endoprosthetic design improvements should address failure modes specific to the anatomic location.

Hip abductor moment arm--a mathematical analysis for proximal femoral replacement

Background

Patients undergoing proximal femoral replacement for tumor resection often have compromised hip abductor muscles resulting in a Trendelenberg limp and hip instability. Commercially available proximal femoral prostheses offer several designs with varying sites of attachment for the abductor muscles, however, no analyses of these configurations have been performed to determine which design provides the longest moment arm for the hip abductor muscles during normal function.

Methods

This study analyzed hip abductor moment arm through hip adduction and abduction with a trigonometric mathematical model to evaluate the effects of alterations in anatomy and proximal femoral prosthesis design. Prosthesis dimensions were taken from technical schematics that were obtained from the prosthesis manufacturers. Manufacturers who contributed schematics for this investigation were Stryker Orthopaedics and Biomet.

Results

Superior and lateral displacement of the greater trochanter increased the hip abductor mechanical advantage for single-leg stance and adduction and preserved moment arm in the setting of Trendelenberg gait. Hip joint medialization resulted in less variance of the abductor moment arm through coronal motion. The Stryker GMRS endoprosthesis provided the longest moment arm in single-leg stance.

Conclusions

Hip abductor moment arm varies substantially throughout the hip's range of motion in the coronal plane. Selection of a proximal femur endoprosthesis with an abductor muscle insertion that is located superiorly and laterally will optimize hip abductor moment arm in single-leg stance compared to one located inferiorly or medially.

Enhancing soft tissue ingrowth in proximal femoral arthroplasty with aortograft sleeve: a novel technique and early results

Hip abductor function is critical to joint stability after proximal femoral arthroplasty. Normal soft tissue relationships are often violated during this procedure for complete tumor resection. Abductor insufficiency leads to abnormal gait mechanics and poor function. To improve soft tissue stability about a metallic proximal femoral endoprosthesis, we devised a novel use of vascular graft material. Two patients received a proximal femoral arthroplasty using this technique. These patients were followed for an average of 26.5 months. They demonstrated mean active hip abduction of 48°, hip flexion of 90°, mean Musculoskeletal Tumor Society score of 24 (80%), and Toronto Extremity Salvage Score of 80. We believe that this technique may be useful in achieving soft tissue stability about a metal endoprosthesis and may facilitate better function in patients undergoing this surgery.

Purse-string capsule repair to reduce proximal femoral arthroplasty dislocation for tumor--a novel technique with results

Hip joint dislocation is the most common complication after proximal femoral arthroplasty with a large endoprosthesis. Average dislocation rates are around 15%. In an attempt to decrease dislocations after proximal femoral arthroplasty for tumor resections, we devised a novel closure of the hip capsule. This technique uses a 3-mm cottony Dacron suture placed about the hip capsule in a circumferential, purse-string manner. Thirty-nine patients received hip hemiarthroplasty with purse-string capsular closure. Seven patients were lost to follow-up, leaving 36 patients available for analysis. One patient dislocated (2.8%). We believe this technique is useful in preventing dislocation in patients undergoing proximal femoral arthroplasty for oncologic disease.

Abstract 2411: Intratumoral dendritic cell vaccine as neo-adjuvant immunotherapy of high-risk soft tissue sarcoma patients undergoing external beam radiation therapy (EBRT): Prospective phase I/II clinical trial

Cell death inducing external beam radiation (EBRT) combined with experimental intratumoral injection of dendritic cells (DC) showed promise by initiating anti-autologous tumor-cell immune responses in mice. Here we performed first clinical trial testing this hypothesis in patients with large high-grade soft tissue sarcomas (STS). This type of cancer has a significant (&gt;50%) risk of progressing to distant metastases. Patients with clinical stage T2N0M0 or T3N0M0 high-grade STS of the extremity/trunk/chest wall were treated with standard neo-adjuvant EBRT 5040 cGy / 180 cGy coordinated with experimental DC therapy consisting of DC progenitor apheresis, ex-vivo expansion and culture, and 4 × intratumoral injections of 10 million DC. Autologous DC product was performed according to standardized GMP laboratory procedures. T cell function was assessed by EliSpot (measuring IFN-γ production) and proliferation (thymidine uptake) in addition to phenotyping of peripheral blood mononuclear cells by flow cytometry.

Clinically, targeted accrual was reached with eighteen patients completing neo-adjuvant EBRT with experimental intratumoral DC therapy. All patients have completed full immunologic assessment. Ten patients (56%) were induced to produce significant immune responses against autologous tumor cell lysates or/and survivin antigens as determined using ELISPOT assays or cell proliferation. Interestingly, some of these responses persisted even 30 weeks after start of treatment. Extensive post treatment T cell infiltration was detected within tumors. No clinical toxicity has been observed. Suggestive clinical outcome on 14 patients followed 1 year reveal progress in 1/7 patients with robust response (detected at more than one time point), and 4/7 patients with weak (detected at one time point at the beginning of the study) or no response respectively. Thus, this data is promising for planning future combined treatment approaches as radiation therapy/immunotherapy.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2411.

Giant cell tumor of the anterior rib masquerading as a breast mass: a case report and review of current literature

INTRODUCTION

Giant cell tumor (GCT) is an aggressive, but usually benign bone neoplasm most commonly arising in the metaphysis/epiphyses of long bones. While they are categorized as benign tumors, they can be locally aggressive and clinically have metastatic potential. The most common locations of this tumor include the distal femur, proximal tibia, and distal radius. We report a GCT arising in an atypical location and mimicking a breast mass.

CASE PRESENTATION

This case was diagnosed at a large cancer center in Florida. Pertinent clinical findings were obtained from chart review and inter-departmental consultation. Radiologically, the initial impression included a deep-seated breast cancer with local chest wall invasion. Further evaluation revealed the mass to be an expansile rib lesion with extraosseous soft tissue invasion. Histological examination of the biopsy specimen showed bland multi-nucleated giant cells and mononuclear cells whose nuclei were morphologically similar. No necrosis, pleomorphism or mitotic activity was identified. No chondroid or osseous elements were present.

CONCLUSION

The histological features of bland mononuclear and multinucleated giant cells along with the lack of any additional mesenchymal elements led to the diagnosis of giant cell tumor. Resection of tumor was performed. The patient is disease free as of the last follow-up visit. This case is important as it shows where the physician must keep this diagnosis in mind whenever a deeply located breast mast is present.

Extraskeletal myxoid chondrosarcoma: rare presentation in the knee joint space

Extraskeletal myxoid chondrosarcoma is a malignant cartilage tumor that rarely presents in the joint space. This article presents a case of a man who presented with a 1-year history of continuous growth of a mass over the medial aspect of his right knee. Radiographs demonstrated osteoarthritis, and arthroscopy was performed for degenerative joint disease. At the time of surgery, an intra-articular mass was encountered and an unplanned biopsy was performed. Pathological analysis revealed the mass to be a primary extraskeletal, intra-articular chondrosarcoma. He had no history of malignancy. He underwent extra-articular resection of the lesion and reconstruction with endoprosthesis. The patient's clinical course required multiple re-operations, and pulmonary metastases developed. A gastrocnemius flap was performed for wound coverage in proximity to the resected arthroscopy portals. This case emphasizes the importance of proper preoperative imaging and planning for lesion biopsies. Proper initial management may have led to lesser overall morbidity. Review of the literature reveals that this is the only reported case of a primary intra-articular extraskeletal myxoid chondrosarcoma.

Practical Issues of Intraoperative Frozen Section Diagnosis of Bone and Soft Tissue Lesions

Background

Intraoperative pathologic diagnosis of bone and soft tissue lesions is an important yet challenging tool in clinical musculoskeletal oncology practice. There is limited information in the literature addressing the practical issues commonly encountered regarding intraoperative frozen section of musculoskeletal lesions.

Methods

A literature review and retrospective review of practical experience in intraoperative pathology consultation at our institute's sarcoma program were conducted to investigate the pitfalls and limitations of frozen section and potential solutions to overcome these problems.

Results

Frozen section evaluation is an essential and reliable procedure for guiding intraoperative decisions. Intraoperative cytology as an adjunct to frozen section enhances the accuracy of diagnosis of bone and soft tissue lesions. Cytology can accurately diagnose certain entities alone and is superior to frozen section for certain tumor types and for evaluating bone marrow margins. It is also invaluable in triaging cases for ancillary studies and for tumor banking. Practical working protocols can be developed to optimize the usefulness of intraoperative pathologic consultation.

Conclusions

Intraoperative pathology consultation should be done in an interdisciplinary approach by correlating clinical, radiologic, and pathologic information. As an adjunct to frozen section, cytology and gross examination enhance the accuracy of diagnosis of musculoskeletal lesions.

Orthopedic Surgery Options for the Treatment of Primary Osteosarcoma

Background

Osteosarcoma is the most common malignant primary neoplasm of bone. Orthopedic procedures are essential components in the multidisciplinary treatment of osteosarcoma. Limb-salvaging procedures offer adequate disease control comparable to the results obtained by amputations. This review discusses the advantages and disadvantages of the various types of amputations and the limb-salvaging techniques for the treatment of osteosarcoma.

Methods

The authors analyzed the characteristics of limb-salvaging procedures and amputations for osteosarcoma. Qualitative and quantitative studies published in the English language that are listed in the National Library of Medicine were used as the basis for this review. In addition, a review of an expandable prosthesis is included.

Results

Limb-salvaging techniques have acceptable rates of disease control. However, amputation remains a valid procedure in selected cases of osteosarcoma in most parts of the world. Orthopedic oncology surgeons have various materials, procedures, and techniques available to achieve disease control and improve function in patients with osteosarcoma.

Conclusions

The surgical management of patients with osteosarcoma is challenging. No difference in survival has been shown between amputations and adequately performed limb-salvaging procedures. Optimal tumor resection and a functional residual limb with increased patient survival are the goals of modern orthopedic oncology.

Differential expression of Hox A5 in human colon cancer cell differentiation: a quantitative study using real-time RT-PCR

Fifteen different homeobox genes were identified from normal colon mucosa, untreated COLO 205 and herbimycin A treated COLO 205 cells in a degenerate primer RT-PCR screen. Several of the homeobox genes, including Cdx-1, Cdx-2, Pdx-1 and Hox A5, showed a trend toward differential expression in normal colon mucosa, and undifferentiated COLO 205 cells. Hox A5 was recently shown to suppress growth and induce p53-dependent apoptosis. To determine if Hox A5 was differentially expressed in differentiation of colon epithelial cells, we quantified Hox A5 expression by real-time quantitative RT-PCR. Expression of Hox A5 was 5.3- and 4.8-fold higher in normal colon mucosa compared to COLO 205 and HT-29 cells, respectively, suggesting that Hox A5 expression was higher in differentiated compared to undifferentiated colon epithelial cells. To avoid the complexity of tissue specimens and the influence of individual variation in Hox A5 expression, the effect of differentiation on Hox A5 expression was studied in COLO 205 cells treated with herbimycin A. The quantitative study showed that Hox A5 expression was increased when COLO 205 cells were induced to differentiate. The expression of Hox A5 was about 2-fold higher in the cells treated for 48 h compared to the untreated poorly-differentiated cells. The present study shows that Hox A5 may be involved in intestinal cell differentiation, in addition to its role in apoptosis.

Ribosomal protein L7a gene is up-regulated but not fused to the tyrosine kinase receptor as chimeric trk oncogene in human colorectal carcinoma

Ribosomal protein L7a (rp L7a) was identified in a subtractive hybridization screen as a gene up-regulated in human colorectal cancer. Expression of rp L7a was greater than 2-fold higher in tumors compared to adjacent normal mucosa in 72% of the patients studied (n=36). rp L7a was also up-regulated in concomitant polyps. The number of patients with rp L7a T/N ratio of >2 was significantly higher in the female (16/18) than in the male (10/18). rp L7a expression was also significantly higher in females with lymph node involvement compared to males. These results indicate that rp L7a expression is related to tumor growth in colorectal cancer especially in females, where it may also be related to tumor spread. There was no correlation of rp L7a expression with tumor cell differentiation. We also show that rp L7a does not exist as a fusion oncogene (trk-2h) in colorectal cancer.

Effect of unilateral breathing exercises on regional lung ventilation

We investigated the effect of a unilateral thoracic expansion exercise (TEE), a breathing manoeuvre used by physiotherapists, on regional lung ventilation. Nine trained physiotherapists aged 22-37 years completed the study. Technegas lung ventilation scans were used to determine the effect of a right unilateral TEE performed when sitting. This was compared with a maximal deep breath. Total radioactivity in each lung was determined. Each lung was sectioned into three equal zones (upper, middle and lower) and the ratio of radioactivity for each of the corresponding lung zones calculated. Ventilation was preferentially distributed to the right lung in all participants during both breathing manoeuvres. The mean (+/- S.E.M.) radioactivity ratios (right/left lung) were greater during a unilateral TEE (1.17 +/- 0.02) than during a deep breath (1.07 +/- 0.01). Seven participants achieved significantly greater ventilation to the right middle (1.15 +/- 0.03, P = 0.02) and lower zones (1.34 +/- 0.03, P = 0.02) during a unilateral TEE than to the corresponding zones on the left; this was evident soon after the initiation of the breath. The findings of this study show that relative regional ventilation to the ipsilateral lung can be increased during a unilateral TEE in trained individuals.

Heparin/heparan sulfate interacting protein gene expression is up-regulated in human colorectal carcinoma and correlated with differentiation status and metastasis

We applied a subtractive hybridization strategy to obtain genes that are differentially expressed in colorectal carcinoma. Heparin/heparan sulfate interacting protein (HIP) was shown to be up-regulated in colorectal carcinoma. A study of 53 patients with documented colorectal carcinoma showed that 70% of the tumors had HIP tumor-to-normal ratios (expression in tumor tissue compared to expression in normal mucosa) of >2. In six patients with concomitant polyps, HIP expression in the polyps was similar to the carcinoma, showing that up-regulation of HIP may be an early event in tumorigenesis. A significant inverse correlation between HIP levels and the presence of distant metastasis (Duke's stage D) was noted. Similarly, HIP expression was also related to differentiation status in human colorectal carcinoma cell lines. HIP expression was lower in the poorly differentiated COLO 205 cell line compared to the well-differentiated HT-29 cell line. The correlation was further strengthened by studies in COLO 205 cells that were induced to differentiate with herbimycin A treatment. HIP expression was significantly higher when the cells were induced to differentiate. Withdrawal of herbimycin A resulted in a reversal of morphological changes associated with differentiation and an associated decrease in HIP expression. These studies indicate that HIP is an important molecule for cell-cell and cell-extracellular matrix adhesion. The up-regulation of HIP may be an early event in tumorigenesis, and its increased expression may facilitate growth and local invasion. A lower expression of HIP in tumors results in decreased cell adhesion, favoring metastasis. HIP is a candidate marker of abnormal cell growth in the colon and a prognostic marker for colorectal carcinoma.

Skin stapled bowel anastomosis in a canine model

AIM OF STUDY

The aim of this study is to compare the safety and cost effectiveness of the use of staples designed for skin closure in the construction of colonic anastomoses.

METHOD

Twenty healthy dogs were prospectively randomised to either skin stapled or sutured anastomosis. The ascending colon was transected and reanastomosed. This segment was excised and used to test early bursting strength. There was no significant difference between the two groups. The ends of the colon were reanastomosed.

RESULTS

The time taken to perform the anastomosis and the cost of the suture or staples were noted. The time taken for the stapled anastomosis was significantly faster (p < 0.001) with a mean of 7.95 minutes versus a mean of 23.5 minutes for the handsewn anastomosis. The cost was also significantly less (p = 0.18) with a mean of SGD17.85 compared to a mean of SGD21.15 for the handsewn anastomosis. Two weeks later, the dogs were sacrificed and the late bursting pressures were tested and no significant difference was found between the two groups. The anastomotic site was then sent for histological examination. The four animals, one in the handsewn group and 3 in the skin stapled group, dying prior to sacrifice, were subjected to post-mortem.

CONCLUSION

The results show that skin stapled anastomoses are easy to learn and perform and may constitute a viable alternative to hand suture techniques.