Postoperative drainage management and wound complications following resection of lower limb soft tissue tumors: a retrospective cohort study

PURPOSE

Postoperative wound complications are common in patients undergoing resection of lower extremity soft tissue tumors. Postoperative drainage therapy ensures adequate wound healing but may delay or complicate it. The aim of this study is to evaluate the incidence of postoperative wound complications and delayed or prolonged drainage treatment and to propose a standardized definition and severity grading of complex postoperative courses.

METHODS

A monocentric retrospective analysis of 80 patients who had undergone primary resection of lower extremity soft tissue tumors was performed. A new classification was developed, which takes into account postoperative drainage characteristics and wound complications. Based on this classification, risk factors and the prognostic value of daily drainage volumes were evaluated.

RESULTS

According to this new definition, regular postoperative course grade 0 (no wound complication and timely drainage removal) occurred in 26 patients (32.5%), grade A (minor wound complications or delayed drainage removal) in 12 (15.0%), grade B (major wound complication or prolonged drainage therapy) in 31 (38.8%), and grade C (reoperation) in 11 (13.7%) patients. Tumor-specific characteristics, such as tumor size (p = 0.0004), proximal tumor location (p = 0.0484), and tumor depth (p = 0.0138) were identified as risk factors for complex postoperative courses (grades B and C). Drainage volume on postoperative day 4 was a suitable predictor for complex courses (cutoff of 70 ml/d).

CONCLUSION

The proposed definition incorporates wound complications and drainage management while also being clinically relevant and easy to apply. It may serve as a standardized endpoint for assessing the postoperative course after resection of lower extremity soft tissue tumors.

RETROPERITONEAL PERIVASCULAR EPITHELIOID CELL NEOPLASM (PECOMA) RESPONSE TO MTOR KINASE INHIBITION. A CASE REPORT WITH LITERATURE REVIEW

Perivascular epithelioid cell tumors (PEComas) are a very rare group of neoplasms and were first reported in 1996. These tumors represent a family of mesenchymal neoplasms, related through activation of the mammalian target of rapamycin (mTOR) inhibitor signaling pathway. The objective of this case report is to demonstrate significant regression of the tumor after neoadjuvant treatment with an oral mTOR inhibitor, following surgical removal of the mass to avoid a multiorgan resection. We present a case of a 27-year-old female with retroperitoneal PEComa and evaluated the tumor with MRI and integrated 18F-FDG-PET/CT scans at presentation and serially during treatment with everolimus. After 6 months of treatment with everolimus the tumor showed a substantial size reduction. Therefore, a multiorgan resection could be omitted. The patient has not demonstrated any disease recurrence after nearly 2 years of follow-up. PEComas are tumors with unpredictable behavior. Our report indicates that treatment of PEComas with everolimus may achieve a significant clinical response. As indicated by our case and past reports, mTOR inhibitors may be one of the best treatment options for this disease.

[Advanced gastrointestinal stromal tumors : What role does surgery currently play in multimodal concepts?]

BACKGROUND

Gastrointestinal stromal tumors (GIST) have an incidence of 1-2/100,000 and thus constitute the most common mesenchymal neoplasm of the digestive tract. Their specific tumor biology with mutations in the protooncogenes c-KIT and PDGFR α acting as drivers of tumor growth facilitate targeted therapy with tyrosine kinase inhibitors. In this context, there are several specific indications for surgery in patients with advanced GIST.

OBJECTIVE

This article discusses the importance of surgery within multimodal therapeutic concepts for advanced GIST.

MATERIAL AND METHODS

The results of a selective literature search including own studies and case reports are presented.

RESULTS

For large GIST at unfavorable anatomical locations, which are not amenable to organ-sparing resection, neoadjuvant imatinib therapy is the standard upfront treatment prior to surgery in the case of imatinib-sensitive mutations in the c-KIT protooncogene. This usually reduces the extent of resection without increasing perioperative morbidity. In the metastatic setting, surgery can constitute a significant part of multimodal therapy in patients with a generalized response to drug therapy by resection of residual tumor masses, although there are no prospective studies to prove a beneficial effect on overall survival. In patients with focal progression on anti-proliferative therapy, local therapeutic measures can make an important contribution to multimodal tumor control. In patients with generalized progression, an operation should only be performed in highly selected cases with the goal of symptom control. Local ablative therapies, such as radiofrequency ablation (RFA), irreversible electroporation (IRE) and selective internal radiotherapy (SIRT) are a therapeutic option particularly for liver metastases.

CONCLUSION

Surgery plays an important role in the multimodal therapy of advanced GIST particularly in the neoadjuvant setting. Its role is more limited in metastatic stages where systemic treatment represents the frontline therapeutic approach.

Increased serum bone sialoprotein concentrations in patients with Crohn's disease

INTRODUCTION

Impaired calcium homeostasis and/or the administration of corticosteroids are considered to be among the factors contributing to the pathogenesis of osteopenia in patients with inflammatory bowel disease. There is an increasing evidence suggesting that certain pro-inflammatory cytokines may also directly influence the bone metabolism in these patients. Routine measurement of bone mass and loss usually include dual energy X-ray absorptiometry as well as urinary and serum assessment of collagen crosslinks. More recent studies include likewise the detection of bone sialoprotein into a specific diagnostics of bone turnover.

PATIENTS AND METHODS

We investigated 47 patients with inflammatory bowel disease (Crohn's disease N = 41, ulcerative colitis N = 6) and 17 healthy volunteers to assess and compare serum levels of bone sialoprotein and other routine parameters of bone turnover. Bone sialoprotein levels were measured by using a recently described radioimmunoassay.

RESULTS

In comparison to the control group, bone sialoprotein and urinary crosslinks were significantly increased only in patients with Crohn's disease, while other markers of bone turnover (e. g. alkaline phosphatase, carboxylterminal propeptide of typ I procollagen, urinary deoxypyridinoline, vitamin D, phosphate and calcium) did not differ significantly between the patients' groups.

CONCLUSION

According to these data, increased serum bone sialoprotein concentrations seem to be an additional valuable and sensitive marker of bone resorption in patients with Crohn's disease.

[Hepatocellular adenoma confirmed by Doppler ultrasonography and laparoscopy]

CASE REPORT

A 46-year-old female patient presented for further investigation of an isolated liver lesion that was diagnosed by her physician by abdominal ultrasound and computertomography. The Doppler ultrasound (including a signal amplifier) could not differentiate the lesion so that a laparoscopy was performed. A hepatic adenoma was found which was confirmed by the histological examination of a directed liver biopsy.

CONCLUSION

Signs and symptoms, diagnostic procedures and differential diagnostic options of a hepatic adenoma are discussed.

[Adult-onset Still's disease. Differential diagnosis in recurrent pharyngitis, fever of unknown original and excessive hyperferritinemia]

HISTORY AND PHYSICAL EXAMINATION

Six weeks before admission a 43-year old previously healthy woman got right-sided pharyngitis, accompanied with Herpes labialis and oral candidiasis. Two weeks later she travelled to a holiday in the Caribbean. During the first week of holiday she developed pharyngitis again, this time accompanied with fever and arthralgies. Therapeutic trial with antibiotics, antimalaric drugs and antiamoebics, given at the holiday resort, did not reduce fever. Immediately after return to Germany a therapeutic trial with imipenem was was attempted, without any apparent improvement. At admission, the patient was febrile, had pinky patchy exanthema and arthralgias.

EXAMINATIONS

At admission, abnormal findings included anaemia (Hb 8.8 mg/dl), severe leukocytosis (35.3/nl), increased ESR (43/89 mm), CRP (24.2 mg/dl) and ferritin (5751 micrograms/l). Ultrasound examination revealed mild splenomegaly. Computed tomography of the abdomen and chest were without apparent abnormalities.

TREATMENT AND CLINICAL COURSE

Infection, autoimmune diseases and neoplasia were ruled out. The diagnosis of adult onset Still's disease was established on the basis of a typical triad of symptoms (fever, exanthema, arthritis). Treatment with 100 mg/d prednisolon (started intravenously) was beneficial for fever and arthralgia, and resulted in the normalisation of laboratory findings. After gradual reduction in the corticosteroid dosage, maintenance treatment with 20 mg/d prednisolon was continued over following months.

CONCLUSION

Recurrent prodromal pharyngitis and excessive hyperferritinaemia are, in addition to the triad fever-exanthema-arthritis, further important diagnostic criteria of adult onset Still's disease.