Excisional biopsy of impalpable soft tissue tumors US-guided preoperative localization in 12 cases

We present a technique to facilitate excisional biopsy of impalpable soft tissue tumors. A modified Kopans localization needle is positioned preopera-tively under ultrasound-guidance (7.5 MHz). The needle contains a hookwire with an over-bent hook that springs open when protruded beyond the needle tip and anchors the wire in the lesion. The technique was used in 12 patients and facilitated excisional biopsy in all of them.     

Intraoperative O-arm-navigated resection in musculoskeletal tumors

Background

Although emerging evidence has suggested that computer-assisted navigation allows surgeons to plan the optimal level of resection without compromising the surgical margins, the precise accuracy of the procedures has been unclear. The aim of this study was to investigate the accuracy and safety of the musculoskeletal tumor resection using O-arm/Stealth intraoperative navigation assistance.

血管成像技术在骨科软组织肿瘤诊断中的应用

血管成像技术已经成为影像诊断技术的重要组成部分,在临床上主要用于诊治脑血管疾病(特别是脑动脉瘤)、冠状动脉疾病、外周血管疾病等.在肿瘤的诊断和术前评估方面有初步应用.随着影像设备及技术的进步和发展,以及对血管成像技术认识的提高,在临床的应用范围正逐步扩大.本文就数字减影血管造影、CT血管造影及磁共振血管造影成像三种技术在骨科软组织肿瘤临床应用现状、优点和不足作一综述.     

Occlusive dressing for large soft tissue defects following soft tissue tumor excision

Background  Reconstructive surgery using pedicles or free muscle-skin flaps and skin grafting reduces wound complications and promotes favorable limb function; however, the sacrifice of normal tissue remains problematic and complicated. Occlusive dressings are widely employed for management of injuries, burns, and surgical wounds. However, their effectiveness for treating soft tissue defects following a soft tissue tumor excision has not been fully elucidated. The purpose of this study was to evaluate the effectiveness and safety of an occlusive dressing treatment method for soft tissue defects following soft tissue tumor excisions. Methods  We retrospectively reviewed eight patients (three men, five women) whose wounds were treated with polyurethane foam occlusive dressings to allow reconstruction of the soft tissue defect following soft tissue tumor excision. Their mean age was 64.5 years (range 23–83 years), and the mean size of the defect was 60.1 cm² (range 20–144 cm²). The wound was covered with a hydrophilic polyurethane dressing material. The treatment periods, incidence of complications, and ultimate outcomes were evaluated. Results  Seven defects were completely healed by secondary intention without the requirement of any additional surgery. Mean treatment periods were 21.6 weeks (range 13.5–44.0 weeks). Mean follow-up periods were 33.1 months (range 15.8–48.6 months). One patient with a recurrent malignant fibrous histiocytoma (MFH) who had a history of radiotherapy required a posterior thigh flap 44 weeks after the surgery. Recurrence due to a positive surgical margin was observed in only one patient with recurrent MFH. None of the patients exhibited clinical evidence of superficial or deep infection. Conclusions  This treatment method is simple, safe, and reliable. We concluded that the highly favorable indications of this treatment are ideal for patients who wish to avoid sacrificing their normal tissue, have no history of radiotherapy before surgery, and do not require chemotherapy or radiotherapy after the operation.     

Malignant soft tissue tumors

This article is a survey of actual aspects. With regard to frequency, the malignant fibrous histocytoma comes first, followed by lipo- and fibrosarcoma, synovial sarcoma, malignant schwannoma, malignant tumours proceeding from arteries and veins and the unstriated musculature. Staging and grading of these tumours are difficult. Until now their overall TNM-classification was not possible due to insufficient hard criteria.     

Chemotherapy of soft tissue tumors

The use of chemotherapy in the treatment of patients with advanced soft tissue sarcoma and as adjuvant and neoadjuvant therapy is reviewed. In advanced disease a response rate of up to 35% can be achieved with combination chemotherapy, but these are mainly partial remissions; few complete remissions are attained. The median survival for patients in partial remission is 2 years. The most active cytotoxic drug is adriamycin, with a remission rate of 30%. The addition of dacarbazine can increase the remission rate; however, this has no significant impact on survival and the toxicity is more pronounced. The activity of neoadjuvant or adjuvant chemotherapy is still controversial. Some studies indicate a positive effect on disease-free or overall survival with adriamycin-containing regimens. Other studies have not confirmed these results. More controlled trials with adequate numbers of patients stratified for tumor subtype, tumor localization and grading are needed to define the value of adjuvant or neoadjuvant chemotherapy in soft tissue sarcomas. Optimal interdisciplinary treatment can only be realized at specialized centers.     

Veno-accompanying artery fasciocutaneous flaps following wide excision of soft tissue tumors in the lower legs

BackgroundSoft tissue defects following wide excision of malignant soft tissue tumors (STTs) are sometimes too large for primary closure, especially in the lower legs where available soft tissue is limited. This study aimed to determine the clinical outcomes of reconstruction of a defect after wide excision of an STT with a veno-accompanying artery fasciocutaneous (VAF) flap in the lower leg.MethodsThis study comprised 9 patients with malignant STTs who had undergone reconstructive surgeries using VAF flaps after wide excisions, between October 2010 and September 2017. We retrospectively reviewed and collected data involving age, sex, follow-up period, histological diagnosis, surgical procedures, size and location of defects, size and location of the flaps, venous source of the flaps, direction of the pedicles, closing of donor sites, perioperative chemotherapies, postoperative complications, and the presence of postoperative local recurrence and metastasis.ResultsThe median follow-up period was 91.5 (range, 15.5–189.0) months. Four patients had defects located around the knee, 3 patients had defects located on the calf, and 2 patients had defects located around the ankle. The mean flap size was 95.6 × 119.4 (range, 50 × 100–130 × 140) mm. Six patients had venous sources from the small saphenous vein and 3 patients had venous sources from the great saphenous vein. The pedicles were proximally based in 4 patients and distally based in 5 patients. All flaps remained viable without any complications.ConclusionsOur findings showed that the VAF flap was easily elevated and reliable. Furthermore, it was effective in reconstructing soft tissue defects following wide excisions of STTs in the lower leg.     

Ultrasonic diagnosis of soft tissue tumors

Ultrasonography is relatively simple to manage, has no known risks to be patient, and is quickly available, all of which makes it a valuable tool, among the imaging techniques, in the primary diagnosis and initial work-up of soft-tissue tumors. Ultrasonography can reveal the extent of a tumor. Preoperative examination of a tumor in any number of planes gives the clinician a spatial idea of its size. Additionally, the internal architecture and structure of the tumor can be assessed. Sonography can distinguish whether lesions are predominantly cystic, solid, or more complex. Calcium deposits or foreign bodies can be demonstrated in some cases. It is difficult to delineate the margins of a tumor by sonography. Expanding and displacing tumor growth or infiltration cannot be diagnosed with certainty. Perifocal edema can make tumors appear larger than they in fact are. Ab type-specific differences of soft tissue tumors are demonstrable by sonography. Tissue differentiation is not possible.     

Clinical diagnosis of soft tissue tumors

In the clinical diagnosis of a soft tissue tumor, it is important to determine whether the lesion is malignant as soon as possible. To establish such a diagnosis we perform aspiration cytology and needle biopsy simultaneously with computed radiography (CR) and echosonogram at the first visit. After the first day's investigations, it is usually possible to select the surgical procedures based on the working diagnosis in almost all patients. When the lesion is clearly benign by diagnosis, excision can be performed. For large lesions or lesions that are suspected to be malignant, CT, magnetic resonance imaging , isotope-investigation, and arteriography are also performed, effectively providing precision in an already established diagnosis. These imaging findings are useful for establishing a surgical plan by anticipating the surgical line of the safety margin. For these few patients in whom the diagnosis still remains uncertain or when preoperative treatment is planned, an incisional or excisional biopsy may be necessary to establish the final diagnosis. When preoperative treatment is performed, the effectiveness of this treatment can be evaluated by medical imaging. Received for publication on Nov. 16, 1997     

Intraoperative ultrasound localization to guide surgical excision of nonpalpable breast carcinoma.

BACKGROUND: This report describes a technique of intraoperative tumor localization by ultrasound without the use of a needle or wire to guide the excision of nonpalpable breast cancers. The results of our experience with pathologic margin status are reviewed. STUDY DESIGN: From 1994 to 1998, 65 breast cancers in 62 patients with biopsy-proved nonpalpable breast cancer were excised using intraoperative ultrasound localization. The pathologic status of the margins from the initial surgical excision specimen and any further excisions, either at the first operation or later procedures, was recorded. The distance from the tumor to the closest margin of excision was also determined. RESULTS: The overall success in achieving pathologically negative excision margins at first operation was 97% (63 of 65 cancers). Three patients underwent a second operative procedure, two for positive margins and one for a margin less than 1 mm (second operation = 4.8% of patients). After completion of the first operative procedure, the mean distance to the closest margin of excision was 0.8 cm. CONCLUSIONS: Intraoperative ultrasound localization for excision of nonpalpable breast cancers is feasible and gives results, in terms of pathologic margins, that are comparable with those achieved by standard needle-wire-guided excisions.     

Diagnosis and treatment of soft tissue tumors

In the management of soft-tissue tumors, accurate diagnosis, using a combination of clinical, radiographic, and histological data, is critical in optimizing outcome. Radiographic diagnoses can be useful, but they cannot accurately predict histology or whether a lesion is benign or malignant. Therefore, all soft lumps that persist or grow should be biopsied if possible. Fine-needle aspiration biopsy is useful in differentiating benign from malignant lesions. Core-needle biopsies can yield a histological diagnosis when the sample is sufficiently large. When open biopsy is required, the skin incision must be carefully placed so that the biopsy site can be completely excised if the lesion is subsequently found to be malignant. Excisional biopsy should be used only for small lesions or when the surgeon is confident that the lesion is benign. If, following excision, the lesion is found to be malignant or desmoid, additional surgery with an adequate excision margin should be performed. In the resection of high-grade sarcomas treated by surgery alone or resistant to preoperative adjuvant therapies, a "curative (wide) margin" must be achieved. We occasionally use preoperative radiation with or without hyperthermia for malignant lesions in the vicinity of neurovascular structures where adequate surgical margins are unlikely to be achieved. The use of chemotherapy is justified only in small-cell sarcomas in which metastasis occurs frequently and chemotherapy is known to be effective. For high-grade spindle-cell or pleomorphic sarcomas, the value of adjuvant chemotherapy remains controversial and needs investigation. Received for publication on June 9, 1998     

The human umbilical vein: a novel scaffold for musculoskeletal soft tissue regeneration

The umbilical cord is a biological tissue that is readily available and is usually discarded. In this study, we investigate the potential of making use of part of the human umbilical cord, in particular the umbilical vein, as a functional tissue engineering scaffold. Previous studies suggested the use of the human umbilical vein (HUV) as an acellular vascular grafting material. We propose taking advantage of the longitudinal mechanical properties of the HUV to use it as a scaffold material for musculoskeletal soft tissue regeneration. HUVs were mechanically dissected from 8.5-cm sections of fresh human umbilical cords. The sections were inverted such that the luminal side formed the exterior surface. HUVs were then decellularized, and filled with mesenchymal stem cells (MSCs) suspended in a type I collagen hydrogel. Seeded HUVs were cultured for periods of up to 2 weeks. After 2 weeks of culture, results showed a significant increase in cell number reaching almost three times the original inoculation density. Histological analysis revealed cell integration and migration into the HUV scaffold and extensive remodeling of extracellular matrix. Mechanically, the ultimate tensile stress doubled, and elastic modulus values were almost 2.7-fold higher. Given the differentiation capacity of the MSCs, along with the appropriate biochemical and biomechanical environment, the seeded HUV has a potential for ligament or tendon regeneration.     

Pathologic fractures after surgery and radiation for soft tissue tumors

Twenty pathologic fractures occurred in 285 patients with soft tissue tumors that were treated with radiation therapy and surgery. Twelve of these fractures occurred in 11 patients from a subpopulation of 163 patients with 168 soft tissue tumors of the thigh (155 soft tissue sarcomas and 13 aggressive fibromatosis). The fractures occurred at a mean of 40.5 months after treatment and were not associated with significant trauma. Risk factors associated with the development of fracture included tumor location within the anterior compartment of the thigh, extensive surgical periosteal stripping, and a marginal or intralesional margin of resection. The dose, timing, and fractionation of radiation therapy were not related to the risk of fracture. A high rate of complications was seen with this series, including fracture nonunion (45%) and deep infection (20%). Prophylactic intramedullary fixation of the femur should be considered for patients undergoing resection of large tumors in the anterior compartment of the thigh requiring extensive periosteal stripping and adjuvant radiation therapy.