Intraoperative near-infrared fluorescence guided surgery using indocyanine green (ICG) may aid the surgical removal of benign bone and soft tissue tumours.

BACKGROUND: Benign bone and soft tissue tumours encompass a broad, heterogenous range of tumours with varying clinical characteristics. These are often managed surgically with either curettage or marginal excision, but unfortunately have high rates of local recurrence. Indocyanine green (ICG) is a fluorescent dye which can be used to identify solid malignancies intraoperatively but its use is not yet established in benign bone and soft tissue tumours. This study aims to assess whether these tumours fluoresce when administered with ICG pre-operatively and whether this helps surgeons to identify tumour intra-operatively. PATIENTS AND METHODS: Patients with locally aggressive benign bone and soft tissue tumours were administered with 25-75 mg of ICG preoperatively at the induction of anaesthesia. Fluorescence was imaged intraoperatively using the Stryker SPY-PHI camera. RESULTS: Of the 12 patients included, 11 tumours fluoresced. The surgeons felt the fluorescence guided the procedure in 7 out of the 11 cases which fluoresced. It was felt to be particularly useful in the curettage of bone tumours, in which curettage could be repeated until the absence of fluorescence on imaging. After 12 months, no patients had local recurrence of the tumour. There were no adverse events recorded in this study and surgeons found the technology acceptable. CONCLUSIONS: The use of ICG for fluorescence guided surgery is a promising technology to improve outcomes of surgery for benign bone and soft tissue tumours. Further, longer term, study with a control arm is needed to identify whether it results in a reduction in the local recurrence rate.

What Is the Significance of Indeterminate Pulmonary Nodules in High-Grade Soft Tissue Sarcomas? A Retrospective Cohort Study.

BACKGROUND: Sarcomas are rare, aggressive cancers which frequently metastasise to the lungs. Following diagnosis, patients typically undergo staging by means of a CT scan of their chest. This often identifies indeterminate pulmonary nodules (IPNs), but the significance of these in high-grade soft tissue sarcoma (STS) is unclear. Identifying whether these are benign or malignant is important for clinical decision making. This study analyses the clinical relevance of IPNs in high-grade STS. METHODS: All patients treated at our centre for high-grade soft tissue sarcoma between 2010 and 2020 were identified from a prospective database. CT scans and their reports were reviewed, and survival data were collected from patient records. RESULTS: 389 suitable patients were identified; 34.4% had IPNs on their CT staging scan and 20.1% progressed into lung metastases. Progression was more likely with IPNs ≥ 5 mm in diameter (p = 0.006), multiple IPNs (p = 0.013) or bilateral IPNs (p = 0.022), as well as in patients with primaries ≥ 5 cm (p = 0.014), grade 3 primaries (p = 0.009) or primaries arising deep to the fascia (p = 0.041). The median time to progression was 143 days. IPNs at diagnosis were associated with an increased risk of developing lung metastases and decreased OS in patients with grade 3 STS (p = 0.0019 and p = 0.0016, respectively); this was not observed in grade 2 patients. CONCLUSIONS: IPNs at diagnosis are associated with significantly worse OS in patients with grade 3 STS. It is crucial to consider the primary tumour as well as the IPNs when considering the risk of progression. Surveillance CT scans should be carried out within 6 months.

Intraoperative Near-Infrared Fluorescence Guided Surgery Using Indocyanine Green (ICG) for the Resection of Sarcomas May Reduce the Positive Margin Rate: An Extended Case Series.

BACKGROUND: Sarcomas are rare, aggressive cancers which can occur in any region of the body. Surgery is usually the cornerstone of curative treatment, with negative surgical margins associated with decreased local recurrence and improved overall survival. Indocyanine green (ICG) is a fluorescent dye which accumulates in sarcoma tissue and can be imaged intraoperatively using handheld near-infrared (NIR) cameras, theoretically helping guide the surgeon's resection margins. METHODS: Patients operated on between 20 February 2019 and 20 October 2021 for intermediate to high grade sarcomas at our centres received either conventional surgery, or were administered ICG pre-operatively followed by intra-operative NIR fluorescence guidance during the procedure. Differences between the unexpected positive margin rates were compared. RESULTS: 115 suitable patients were identified, of which 39 received ICG + NIR fluorescence guided surgery, and 76 received conventional surgery. Of the patients given ICG, 37/39 tumours fluoresced, and surgeons felt the procedure was guided by the intra-operative images in 11 cases. Patients receiving ICG had a lower unexpected positive margin rate (5.1% vs. 25.0%, p = 0.01). CONCLUSIONS: The use of NIR fluorescence cameras in combination with ICG may reduce the unexpected positive margin rate for high grade sarcomas. A prospective, multi-centre randomised control trial is now needed to validate these results.

The importance of clear margins in myxofibrosarcoma: Improving local control by means of staged resection and reconstruction.

INTRODUCTION: Myxofibrosarcomas are associated with a locally infiltrative growth pattern, making a clear-margin resection margin challenging. This leads to high local recurrence rates. While immediate wound closure and adjuvant radiotherapy has been proposed to mitigate incomplete excisions, we present our experience treating myxofibrosarcomas with staged excisions until clear margins are obtained, prior to reconstruction. METHODS: All patients with myxofibrosarcomas treated with a curative intent at our centre between 2009 and 2019 were identified. Patient demographics, tumour characteristics, number of resections, method of reconstruction, adjuvant therapy, complications, local recurrence rates, length of hospital stay and overall survival were assessed. RESULTS: 97 consecutive eligible patients were identified. Forty-six (47%) had positive margins reported following a first resection. The median number of resections required to obtain clear margins was two and the median time from first excision to definitive wound closure was 15 days. Local recurrence rate for the whole cohort was 14%. Patients who had staged resection until clear margins were obtained had a significantly lower rate of local recurrence compared to those who had positive margins at time of reconstruction (p-value = 0.001). The estimated 5-year disease-specific survival for the whole cohort was 93%. DISCUSSION: Obtaining clear margins in myxofibrosarcoma via staged resections was associated with lower local recurrence rates for patients who had an initial resection with positive margins. The outcomes of performing staged resections are equivalent to patients for whom a clear margin were obtained in the first instance.

Surgical Advances in Osteosarcoma.

Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.

Getting off on the wrong foot doctor-patient miscommunication: a risk for wrong site surgery.

BACKGROUND: Miscommunication between surgeon and patient can have far reaching consequences including the potential for wrong-site surgery (WSS). In the course of routine foot and ankle clinics, particular inconsistencies were noted between the terms used by surgeons and patients to label individual toes with the potential for miscommunication. METHODS: To investigate this phenomenon 100 consecutive patients were asked to label their own toes. The first fifty labelled their left foot, the subsequent fifty their right. RESULTS: Errors in communication were common with an average frequency of greater than one in 10. Miscommunication was most likely when patients used numbers to label their toes, accounting for 93% of all errors. CONCLUSIONS: As a result we recommend that healthcare professionals avoid the use of numbers to label toes when communicating with patients to help avoid miscommunication.