Treatment for local control of retroperitoneal and pelvis sarcomas: A review of the literature

Retroperitoneal and pelvis sarcomas are uncommon tumors for which complete surgical resection is the mainstay of treatment. However, achieving complete gross resection with microscopically negative margins is challenging, and local recurrence rates can be high. Patients often succumb to uncontrolled local disease. Radiation therapy offers a potential means for sterilizing microscopic residual disease, although its use continues to be controversial. Chemotherapy alone or in combination with radiation continues to be investigated as an adjunct to surgery, along with immunotherapy and targeted therapies. In this review, we discuss the current management of retroperitoneal and pelvis sarcomas, focusing on studies of surgery and radiation therapy to maximize local control.     

Fluoroscopy: An essential diagnostic modality in the age of high-resolution cross-sectional imaging

The importance of fluoroscopy as an imaging modality has been minimized relative to other cross-sectional modalities, including high-resolution computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Fluoroscopy examinations have decreased in clinical practice due to reduced appreciation of its usefulness, insufficient training of residents, fewer staff with adequate expertise, and poor reimbursements relative to other modalities. We revisit and build upon the prior literature and history of this decreased utilization. We then seek to prove continued value, through categorized examples and within multiple subspecialties, wherein fluoroscopy plays an integral part toward clinical diagnoses as well as optimizing patient outcomes. This is particularly true for motility and esophageal disorders, where structure and function with real-time evaluation is essential.  We additionally show several post-operative cases where the synergy of fluoroscopy with CT and endoscopy is apparent.  The fluoroscopic radiologist also has the unique ability to vary patient positioning, as opposed to traditional CT or MRI, where orthogonal views are employed without positional or temporal changes. We turn attention to the modern era, with synergistic and novel cases demonstrating that fluoroscopy remains instrumental toward achieving a diagnosis alongside other modalities. Our cases stress the need to maintain expertise in fluoroscopy skill, and underline its continued importance in residency training programs.  We conclude that fluoroscopy is a relatively inexpensive modality that is often under-appreciated in diagnostic radiology. We suggest that competency in fluoroscopy is crucial for future generations of radiologists to both work with their peers, as well as to aid clinicians in the optimal treatment of patients.     

Current strategies for the restoration of adequate lordosis during lumbar fusion

Not restoring the adequate lumbar lordosis during lumbar fusion surgery may result in mechanical low back pain, sagittal unbalance and adjacent segment degeneration. The objective of this work is to describe the current strategies and concepts for restoration of adequate lordosis during fusion surgery. Theoretical lordosis can be evaluated from the measurement of the pelvic incidence and from the analysis of spatial organization of the lumbar spine with 2/3 of the lordosis given by the L4-S1 segment and 85% by the L3-S1 segment. Technical aspects involve patient positioning on the operating table, release maneuvers, type of instrumentation used (rod, screw-rod connection, interbody cages), surgical sequence and the overall surgical strategy. Spinal osteotomies may be required in case of fixed kyphotic spine. AP combined surgery is particularly efficient in restoring lordosis at L5-S1 level and should be recommended. Finally, not one but several strategies may be used to achieve the need for restoration of adequate lordosis during fusion surgery.     

Paediatric gonad shielding in pelvic radiography: A systematic review and meta-analysis

IntroductionThe British Institute of Radiology (BIR) and American Association of Physicists in Medicine (AAPM) have recommended that gonad shielding is no longer used during pelvic X-ray examinations. The BIR guidance states that shielding may still be considered for use on males, but should not be used on females. This paper aimed to evaluate if this decision was supported by evidence from practice, by comparing the accuracy of gonad shield placement in paediatric males and females.MethodsA systematic review of databases including EMBASE, MEDLINE and PubMed was performed in February 2021. Studies were considered eligible if they provided data on the use of gonad shielding during pelvic X-ray examinations on male and female patients under the age of 18. Nine studies met the inclusion criteria and data extraction was performed. Quality appraisal was undertaken, and a meta-analysis of shielding accuracy was performed on seven studies.ResultsThe results from the meta-analysis (2187 total radiographs) demonstrated that female patients were significantly more likely (OR 1.38, 95% CI 0.88–1.87) than males to have gonad shields placed inaccurately (p value < 0.001).ConclusionGonad shield placement on paediatric female patients is significantly less accurate than on males, and so the results support the AAPM and BIR guidance to stop the practice for females. Shield application may also be frequently inaccurate for males, but the review does not provide clear evidence for or against continuing the practice for males.Implications for practiceDiscontinuing the use of gonad shields in paediatric pelvic radiography on female patients is supported. Any continued use on male patients, or for reasons such as psychological reassurance, should be subject to enhanced training and audit to ensure benefits outweigh any risks.     

Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients

ObjectivesHistorically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients.MethodsA prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2–4 weeks, and 3, 6 and 12 months after fracture.Results102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2–4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0–8) vs. 5 (0–10), p = 0.19) and ADL scores (85 (25–100) vs. 78.6 (5–100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%.ConclusionsThe vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.     

Giant Cell Tumor of the Pelvis: a Systematic Review

This is a systematic review of articles concerning the morbidity, recurrence rate, treatment and treatment complications of pelvic giant cell tumors (GCTs). The key words “giant cell tumor, pelvis” were used to identify articles which included data on patients with pelvic GCTs in English and Chinese databases of published reports from 1949–2012. The articles were filtered by title, abstract and full text. Thirty‐eight articles and 165 patients were identified for this review. Data on all identified patients were studies; data in different articles on the same patients was not used repeatedly. The following patient data were collected where possible and subjected to systematic analysis; age, location of GCT, treatment, follow‐up, complications, recurrence and whether alive or dead. The mean age of onset was 33.2 years (range, 14–73 years), the peak ages of onset being between 21 and 40 years. A pronounced sex difference was identified, the male : female ratio being 1:1.7. The acetabulum was the commonest area for pelvic GCTs. Forty‐eight tumors were primarily located in the iliac, 60 in the acetabular and 31 in the ischiopubic area. Twenty‐seven patients experienced complications of treatment. Patients who had been treated by wide resection had the most complications; these included incisional infection and delayed healing of incisions. Local recurrence was common, having occurred in 39/158 patients (24.6%), comprising 24/72 (33.3%) who had undergone intralesional surgery only; 9/20 (45.0%) who had undergone radiotherapy only; 1/51 (2.0%) who had undergone wide resection; and 5/14 patients (35.7%) who had undergone radiation therapy or cryotherapy plus intralesional surgery. Mortality was low (3.2%, 5/158). Pelvic GCT is not common, the acetabular area appears to the most frequent site and the peak age is the third and fourth decades. Although the recurrence rate is high for all pelvic GCTs, the mortality is low. Treatment has a critical influence on recurrence. In spite of the associated complications, the lower local recurrence rate makes wide resection a reasonable option for patients with extensive and/or aggressive GCTs.     

Urinary endometriosis: MR Imaging appearance with surgical and histological correlations

ObjectivesThe goals of the study were to describe the MR imaging features of endometriosis of the urinary tract and identify those that suggest intrinsic involvement of ureteric wall.Materials and methodsThirty-five women with proven urinary tract endometriosis and who had preoperative MR imaging between 2001 and 2011 were included retrospectively. MR images were intrepreted by one junior and one senior radiologists. To characterize the intrinsic parietal involvement, the ureteric circumference involved by the lesion of endometriosis was noted.ResultsThirty-eight ureteric and 13 bladder lesions were analyzed. They were found in association in nine women. Ureteric lesions were bilateral in seven women. Of the 38 ureteric lesions, 27 were extrinsic and 11 intrinsic at histopathological analysis. Sixteen women with extrinsic lesions and 10 with intrinsic ones were correctly identified on MR imaging. When the ureter was included less than 360° in the lesion, extrinsic involvement was confirmed in 80% of cases.ConclusionMR imaging appears to be more sensitive (91%vs 82%) but less specific (59% vs 67%) than surgery for the diagnosis of intrinsic form of ureteric location.     

改良Stoppa入路手术治疗双侧耻骨支骨折

目的:探讨改良Stoppa入路手术治疗骨盆双侧耻骨支骨折的临床疗效。方法:自2010年1月至2014年1月,采用改良Stoppa入路手术治疗双侧耻骨支骨折患者16例,其中男11例,女5例;年龄17～59岁,平均40.5岁。按Tile骨折分类法:A型8例,B型6例,C型2例。16例中单独使用改良Stoppa入路11例,联合髂窝入路4例,联合后路1例。观察患者的手术切口长度、手术时间、术中出血量及术后并发症情况,并采用Matta影像学骨折复位评价标准和Majeed功能评分系统对骨折复位及术后功能进行评价。结果:改良Stoppa手术入路切口长度为8～10 cm,平均9 cm;手术时间75～135 min,平均95 min;术中出血量400～900 ml,平均600 ml.16例术后均获随访,时间7～18个月,平均12.5个月。所有患者获骨性愈合,愈合时间2.7～5个月,平均3.1个月。术后无伤口化脓感染、异位骨化,无螺钉松动、钢板断裂,无腹壁疝发生。根据Matta影像学骨折复位标准,耻骨支骨折复位优9例,良6例,可1例。术后6个月Majeed功能评分,总分85.32±8.50,其中优8例,良6例,一般2例。结论:改良Stoppa手术入路具有切口方便直接、手术视野清晰、易于复位、并发症少和恢复快等特点,是治疗双侧耻骨支骨折一个理想的手术入路。     

退变性腰椎侧凸脊柱-骨盆矢状位影像学特点

目的 :观察退变性腰椎侧凸(DLS)患者脊柱-骨盆矢状位影像学特点,探讨脊柱-骨盆矢状位参数变化对DLS发生的影响。方法:回顾性分析103例DLS患者术前资料,男36例,女67例,年龄62.6±7.4(43~78)岁,并选取139例正常青年人群作为正常青年对照组,145例单纯颈椎病患者作为成年对照组,在脊柱全长正侧位X线片上测量各组冠状位、矢状位参数,包括L3倾斜角、侧凸Cobb角、冠状位平衡(CVA)、腰椎前凸角(LL)、矢状位平衡(SVA)、胸椎后凸角(TK)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)等,采用独立样本t检验比较DLS组与两对照组的各矢状位参数,并用Pearson相关分析DLS组各参数间相关性。结果:DLS组PI为50.4°±10.2°,显著高于正常青年对照组(45.1°±9.6°,P0.01)和成年对照组(46.9°±9.1°,P0.01)。与青年及成年对照组相比,DLS组LL、SS较小(P0.01),PT、SVA较大(P0.01);TK小于成年对照组(P0.01)。DLS组中合并退变性腰椎滑脱者37例(占35.9%),PI为53.1°±8.8°;无退变性腰椎滑脱者66例,PI为48.9°±10.6°,二者相比有统计学差异且均显著高于正常青年对照组(P0.05)。DLS组侧凸Cobb角与PT显著相关(P0.05),余冠状位参数与矢状位参数间未发现相关性;LL、PI、SS、PT两两之间显著相关(P0.01),LL、PT与TK显著相关(P0.01),SS与TK显著相关(P0.05),LL与SVA显著相关(P0.01)。结论 :DLS患者PI高于正常青年及颈椎病患者,高PI可能参与了DLS的发病机制;DLS患者退变、侧凸的腰椎仍存在调节矢状位平衡的能力。