Combined modalities approach for localized adult extremity soft-tissue sarcoma

Extremity soft-tissue sarcomas are a heterogeneous group of rare neoplasms, characterized by a broad spectrum of biological aggressiveness and a uniform tendency for local failure if not adequately treated. Surgery is the mainstay of therapy, and the availability of multidisciplinary surgical skills allows adequate margins with acceptable morbidity to be obtained. Local therapies, such as radiation therapy or isolated limb perfusion, alone or in combination with systemic agents, may help to further improve local control, especially in difficult presentations. The possible impact of systemic treatment on survival is still a matter of debate, and the agents used so far have not provided a major breakthrough, even in selected populations at high risk of disease spread. Nevertheless, soft-tissue sarcomas are no longer considered a unique disease. More than 50 different histotypes can now be well recognized, with distinct biological and molecular characteristics, which lead to different clinical behavior and a potentially different sensitivity to targeted agents. Therefore, it is more essential than ever for treatment of these patients to be delivered in referral centers, where a dedicated multidisciplinary team is able to administer histology and clinically driven approaches. The employment of combined modalities will be able to maximize the chance of local cure even in difficult presentations, and possibly improve survival, especially in high-risk disease.     

Patient-reported Upper Limb Function After Sentinel Lymph Node Biopsy for Breast Cancer: A Prospective Observational Study

IntroductionSentinel lymph node biopsy (SLNB) is the standard procedure for axillary staging in breast cancer. There is a lack of consistency in studies reporting on upper limb morbidity after SLNB. We present a prospective study evaluating upper limb function after SLNB using the validated quickDASH questionnaire.Materials and MethodsConsecutive patients who underwent wide local excision and SLNB were included in the study. Arm function was assessed using the quickDASH questionnaire at 3 time points – prior to surgery and 2 weeks and 3 months after SLNB. The scores obtained were labeled as A, B, and C respectively. The mean and median scores were compared using the paired t test and Wilcoxon signed rank test.ResultsNinety-nine patients met all inclusion criteria and were included in the final analysis. The mean A, B, and C scores were 8.46, 16.05, and 13.36. The median A, B, and C scores were 2.27, 7.5, and 4.54. There was a statistically significant difference between mean and median A and B scores, B and C scores, and A and C scores. A similar trend was observed in patients with better preoperative upper limb function. Patients with a higher body mass index had significantly worse B and C scores.ConclusionThere is a significant deterioration in upper limb function following SLNB. This improves at 3 months but does not reach baseline levels. Larger studies with long-term follow-up are required to establish the extent of upper limb functional morbidity and natural course of functional recovery after SLNB.     

Isolated limb perfusion is an effective treatment modality for locally advanced Kaposi sarcoma of the extremities

IntroductionKaposi sarcoma (KS) is a rare soft tissue sarcoma. In case of locally advanced disease, mutilating surgery such as amputations or major reconstructive procedures are sometimes inevitable. The aim of this study was to evaluate the effectiveness of isolated limb perfusion (ILP) in patients with locally advanced KS of the extremities.Material and methodsAll patients who underwent ILP for KS between 1996 and 2018 at Erasmus MC, Rotterdam were identified. Clinical data was obtained from either a prospectively maintained database or retrospective assessment of patient files.ResultsA total of 14 primary ILP's were performed in 11 patients. Median follow-up from primary ILP was 30 months (range, 5–98). The overall response rate of primary ILP was 100%, with a complete response (CR) rate of 50%. Only minimal local toxicity (Wieberdink I-III) was observed. Local progressive disease occurred after eight primary ILP's (57%) with a median local progression free survival (PFS) of 18 months (95% confidence interval [CI]: 7.0–28.9). Subsequently, four (46%) patients received a total of 5 recurrent ILP's. After the recurrent ILP on the same leg, the overall response rate was 75% and a CR-rate of 50%. One patient needed amputation post-operatively resulting in a limb salvage rate of 91%. One (9%) patient developed metastases four months after ILP.ConclusionsILP is a highly effective treatment modality with very limited morbidity rates for patients with locally advanced KS of the extremity. ILP should be considered as a treatment modality for locally advanced KS of the extremities.     

Effect of sentinel lymph node biopsy on upper limb function in women with early breast cancer: A systematic review of clinical trials

PurposeAxillary surgery is still essential in the management of early breast cancer. Conservative procedures like sentinel lymph node biopsy (SLNB) are less invasive than the traditional axillary node dissection (ALND). However, some extent of ipsilateral upper limb dysfunction might still occur. This systematic review aimed to describe the incidence of lymphedema, pain, sensory, and motor disorders after SLNB in women with early breast cancer.MethodsWe conducted a systematic review of randomized controlled trials. The search was performed on Pubmed, EMBASE, CINAHAL, and Web of Science. The search was based on the following concepts: breast cancer, sentinel lymph node biopsy, axillary dissection, upper limb complications. The risk of bias was evaluated using the Cochrane Rob 2.0 toll.ResultsWe obtained 979 unique registries from the primary search and 381 additional records from the included articles’ reference lists. Fifty-one articles were assessed as full text. Nine studies were included in the review. A total of 5161 patients undergone SLNB, and 4110 patients were assessed for ipsilateral arm complications. Six months after the surgery, 0–11% of patients presented lymphedema, 11–16% pain, 2–22% sensory disorders, and 0–9% motor disorders.ConclusionsSLNB was associated with persistent postoperative complications. The burden of complications, although lower when compared to ALND, should not be ignored.Protocol registrationPROSPERO registration number CRD42018090540, registered July 09, 2018.     

Bone primary sarcomas undergone unplanned intralesional procedures - the possibility of limb salvage and their oncologic results

BACKGROUND: It is quite rare but some primary sarcomas of the bone can be misdiagnosed as benign and be treated using intralesional procedures. An unplanned surgical excision occurs when tumors are removed without the appropriate preoperative evaluation and consideration for the need to obtain tumor-free margins. Residual tumor tissue as a result of unplanned excision of soft tissue sarcoma is a risk factor for local recurrence. METHODS: Twenty-five patients, undergone unplanned intralesional procedures of lower extremities, were enrolled in this study. There were 22 (88%) cases of osteosarcomas, 2 (8%) MFH of bone and 1 (4%) adamantinoma. Twenty-two (88%) cases had a limb salvage and among them, 4 (18%) cases had local recurrences. Three cases (12%) had amputation without any local event. RESULTS: Lung metastasis developed in 6 (24%) cases. The CDF 5 year survival for 22 osteosarcoma cases was 65%(confidence interval: 52-82%). DISCUSSION: Despite the high recurrence rate, the CDF survival of osteosarcoma cases was comparable to the primary one. Limb salvage procedures are worthwhile in cases whose initial radiographic findings simulate benign lesions, showing favorable response to neoadjuvant chemotherapy. The relative contraindication to the limb salvage is cases with a history of a pathologic fracture and extensive operative fixation.     

医学生心电图各波时间、P─R间期、Q─T间期的研究

为了探讨青年人心电图各波时间与少儿（青春期少年，下同）及成人正常值的区别，我们通过对140名医学生（17～20岁）正常心电图各渡时间及P－R间期、Q－T间期的侧量和统计学处理，发现上述各量与少儿和成年人比较均有显著差别。医学生心电图P波时间、P－R问期的平均值及变化范围介于少儿和成人正常值之间；QRS波时间95％上下限比少儿正常值上下限高，下限比成人正常值下限低。结果证明，正常心电图各波时间、P－R间期随年龄增长而延长或有增加趋势。     

Leg ulceration and ethnicity: a study in west London

Little is known of the influence race has on the development of leg ulceration, with most studies being performed in almost exclusively white populations. As part of a wider audit of leg ulcer services, health care professionals were contacted to give details of age, sex and ethnic background of all patients who attended for treatment of leg ulceration over a one year period in an area of west London. West London Health Care Trust provides services to a population of 275000 of whom 53000 have an ethnic background from the Indian subcontinent (South Asian).In all, 280 patients were identified, of whom 264 (94%) had details of age and sex. This gave a crude ascertainment rate of 1.02 per 1000 population. Of the 264 patients, five were classified as South Asians, with one patient classified as Afro-caribbean. The Mantel Haenzsel test demonstrated a significantly higher proportion of whites suffering from leg ulceration than South Asians, giving an odds ratio of 4.43, with 95% confidence intervals between 1.94 and 10.13 (P=0.0004). The expected frequency of South Asian patients should be 23, based on rates from the white population, of which 13 would be women and 10 men. Only five South Asian men were identified, and no Asian women with leg ulceration.Reasons for this low ascertainment are two-fold. Either there is a real difference between the white and South Asian populations, or South Asian patients are not presenting for treatment. Further work must be performed to determine whether this is an effect of low prevalence, or unmet need in the community.     

脑心通治疗下肢深静脉血栓临床观察

目的观察脑心通治疗下肢深静脉血栓的临床疗效及其对血液流变学、血脂、血糖的影响。方法将36例下肢深静脉血栓患者随机分为治疗组20例和对照组16例。治疗组用脑心通联合低分子肝素钠治疗,对照组用低分子肝素钠治疗,10天为一疗程,共2个疗程。对2组临床疗效、治疗前后实验室指标进行比较、统计学分析。结果2个疗程后,2组患者在临床疗效、实验室指标均有明显改善,但治疗组改善更明显,优于对照组。结论脑心通联合低分子肝素钠治疗下肢深静脉血栓疗效显著,且能明显改善患者血液流变学、血脂、血糖指标。     

Doppler US with perfusion software and contrast medium injection in the early evaluation of isolated limb perfusion of limb sarcomas: prospective study of 49 cases.

BACKGROUND: The aim of this study was to prospectively evaluate the use of Doppler ultrasonography with perfusion software and contrast agent injection (DUPC) during isolated limb perfusion (ILP) with high-dose chemotherapy and TNF-alpha(biochemotherapy) in patients with locally advanced extremity soft tissue sarcoma (STS). PATIENTS AND METHODS: Fifty-two patients were prospectively included in this monocentric imaging trial. Three were excluded because the study was incomplete in two patients and one tumour did not exhibit any contrast uptake. DUPC was performed before ILP and on days 1, 7, 15, 30 and 60 after ILP. A total of 292 DUPC were performed on 55 target lesions in 49 evaluable patients. The percentage of contrast uptake was evaluated at each tumour site by two radiologists. The criterion tested was a decrease of more than 50% in intra-tumour contrast uptake compared to the pre-ILP examination. Results were compared with both MRI and histological analysis after resection of residual disease. RESULTS: According to MRI and the histological analysis, 25 (51%) patients were good responders (no difference between the four treatment arms) with tumour necrosis exceeding 90% and 24 (49%) were poor responders. As of day +1, the accuracy of DUPC in predicting tumour response was 82% (18/25 good responders and 22/24 poor responders) increasing to 91% at day +7, 95% at day +15 and 96% at day +30. At day +15, DUPC was predictive of a good response in 100% of the cases. CONCLUSION: DUPC is a simple technique, allowing early prediction of tumour response after ILP. A new treatment planning scheme can be proposed based on the results of this study.