Challenge of treating skeletal muscle metastasis during the COVID-19 pandemic in a low-resource setting.

BACKGROUND: The authors report on an extremely rare case of skeletal muscle metastasis from primary lung cancer that involved the radial nerve and humerus, which was 'over-treated' with wide tumour resection and frozen autograft reconstruction upon misdiagnosis of sarcoma by intraoperative frozen section, amid pressure of expediting hospital care in a low-resource setting during the coronavirus disease (COVID-19) pandemic. CASE PRESENTATION: A 61-year-old male living outside Metro Manila presented with painful mass in his left distal arm during the enhanced community quarantine, and requested admission upon testing negative for COVID-19. Imaging studies suggested a diagnosis of soft tissue sarcoma involving the radial nerve and humerus, and intending to prevent nosocomial severe acute respiratory syndrome coronavirus 2infection of patient, treatment was expedited by foregoing biopsy and opting for intraoperative frozen section prior to resection. Frozen section findings suggested malignancy intraoperatively, and surgical team proceeded with wide tumour resection and frozen autograft reconstruction of the humerus using plates and screws. However, permanent sections revealed metastatic carcinoma from primary non-small cell lung cancer, with positron emission tomography (PET) scan confirming lung mass in the right apical lobe. CONCLUSION: The report concludes that establishment of a definite tumour diagnosis by final histopathological analysis is indispensable, even when planning for emergent surgery in the time of the COVID-19 pandemic.

Evaluating Clinical Outcomes for Determining the Optimal Delay to Skin Incision under WALANT: A Prospective Series of 34 Patients from a Low-Resource Tertiary Setting.

BACKGROUND: Additional studies on clinical outcomes to determine the optimal time delay from injection of local anesthesia to skin incision for WALANT surgeries are needed. The authors aimed to propose the optimal time delay from local injection to skin incision for WALANT surgeries of the hand and wrist by analyzing intraoperative blood loss, postoperative pain scores, and complication rates. METHODS: Thirty-four patients were consecutively recruited and allocated by either 7-min or 30-min delay for skin incision from local injection of epinephrine with lidocaine. Intraoperative bleeding and postoperative pain scores were analyzed between both groups by Mann-Whitney U-test, while complication rates were compared using Fisher's exact test. RESULTS: The present study did not find significant differences in mean intraoperative blood loss (8 ± 5.8 mL vs. 5 ± 2.2 mL, p=0.074), complication rates (18% vs. 0%, p=0.227), and mean pain scores (1.2 ± 0.5 vs. 1.4 ± 0.5, p=0.307) between the 7-min and 30-min groups. CONCLUSION: The authors conclude that a waiting time of 7 min from the injection of local anesthesia is sufficient to achieve comparable clinical outcomes for minor hand and wrist surgeries under WALANT.

Factors Associated with Disease Stabilization of Desmoid-Type Fibromatosis.

BACKGROUND: Spontaneous disease stabilization of desmoid-type fibromatosis (DF) has been demonstrated in many reports, and the watchful waiting approach without any frontline treatment is becoming popular as an initial management strategy. In this study, we aimed to assess the disease stabilization rate and identify predictive factors for disease stabilization of DF in patients with conservative treatment. METHODS: We reviewed 76 patients with sporadic extra-abdominal DF who were managed with frontline conservative treatment in our institute. The minimum follow-up was 12 months. Stabilization was defined as radiological evidence of no change or continuous decrease in size of the tumor for six months or more. The primary endpoint was stabilization of DF. Possible patient-, disease-, and treatment-related factors predictive of disease stabilization were analyzed with multivariate analysis. RESULTS: At final follow-up, 54 of the 76 tumors (71%) were stable, and mean time to stabilization was 30.4 months (range, 7 to 112 months). On Kaplan-Meier survival analysis, the spontaneous stabilization rate was 25.4% at one year, 52.7% at two years, and 70.9% at three years. The mean time to spontaneous stabilization was longer in patients with ≤ 40 years of age (p = 0.022) or recurrence (p = 0.041). On multivariate analysis with the Cox proportional hazard method, recurrence (hazard ratio [HR], 1.79; p = 0.041) and younger age (HR, 2.04; p = 0.022) were identified as independent prognostic factors for longer time to disease stabilization. CONCLUSIONS: Frontline conservative treatment seems to be the optimal treatment for most patients with DF. Younger patients or those with recurrence may require longer time to spontaneous disease stabilization.

Surveillance for lung metastasis from giant cell tumor of bone.

BACKGROUND AND OBJECTIVES: Literature on surveillance for lung metastasis from giant cell tumor of bone (GCTB) is scarce. We aimed to develop one by determining: (1) the optimal surveillance schedule by analyzing time-to-event data, taking into account the predictive factors, and (2) the effective diagnostic modality. METHODS: A total of 333 patients who underwent surgery for GCTB were followed for at least 2 years. All had chest radiography, and 169 had additional CT for surveillance. Time to lung metastasis and cumulative incidence were calculated, and diagnostic performance between chest radiography and CT was compared. RESULTS: Twenty-five (7.5%) of 333 patients developed lung metastasis, and local recurrence (LR) was the only predictive factor (RR = 6.54). Median interval from LR to metastasis was 15 months, and 17 (85%) of the 20 metastases with LR occurred within 3 years of LR. Cumulative post-LR incidences at 1, 3, and 5 years were 15.4%, 21.5%, and 21.5%, respectively. CT was more sensitive (100% vs 32%), and had higher positive predictive value (81% vs 57%) and accuracy (96% vs 93%). CONCLUSIONS: Intensified lung surveillance is warranted for GCTB patients with LR, especially for 3 years from diagnosis of LR. CT is effective for detecting lung metastasis from GCTB.

An unusual case of proximal humeral simple bone cyst in an adult from secondary cystic change.

BACKGROUND: Simple bone cysts (SBC) have been documented to occur in adults with closed physeal plates, most commonly affecting the calcaneus in this patient subset. Although most authors theorize an association to trauma, etiology of simple bone cysts remains an enigma up to now. CASE PRESENTATION: A 26-year-old kickboxing coach sought consult for a painful right shoulder which on radiographs and magnetic resonance (MR) imaging showed a proximal humeral lesion with signs of ossification. The patient was lost to follow-up but again sought consult after 3 years for the recurring complaint. On repeat radiographs, computed tomography (CT) scan, and MR images, tumor enlargement with cystic findings typical of simple bone cyst were documented. Diagnostic aspiration of the lesion was firstly done, revealing straw-colored fluid. The patient then underwent intralesional curettage with alpha-tricalcium phosphate cement reconstruction of the lytic defect. No perioperative complications were incurred, and on latest follow-up at 3 years postoperatively, Musculoskeletal Tumor Society (MSTS) and visual analog scale (VAS) pain scores were 30/30 and 0/10, respectively. CONCLUSIONS: The authors believe their report provides support to a possible association to trauma of simple bone cysts occurring in the adult population with closed physes and suggest this subset of patients may require a different treatment approach from that for juvenile simple bone cysts.

Solitary thoracic intramedullary spinal neurofibroma microsurgically extirpated via recapping T-saw laminoplasty.

We report the case of a 40-year-old female presenting with back pain that was complicated by a solitary intramedullary spinal cord mass at the T10-11 levels, confirmed by magnetic resonance imaging and computed tomography myelography. Microsurgical en bloc extirpation of the tumor approached through a recapping T-saw laminoplasty of T10 was done, and histopathology findings revealed a diagnosis of neurofibroma. Solitary spinal neurofibroma is one of the rarest tumors involving the spinal cord and is very adherent for the lack of a well-defined capsule, requiring careful dissection under microscope magnification for successful en bloc resection. Recapping T-saw laminoplasty affords both maximal exposure and anatomic reconstruction postextirpation, avoiding most postoperative spinal complications.

Pathogenesis of Osteosclerotic Change Following Treatment with an Antibody Against RANKL for Giant Cell Tumour of the Bone.

BACKGROUND: Giant cell tumours (GCTs) of the bone are intermediate tumours that are locally aggressive. Denosumab, an antibody against receptor activator of nuclear factor kappa-B ligand (RANKL), was recently developed; however, it induces osteosclerotic change through an unknown mechanism. We determined whether osteosclerotic change could be induced by neoplastic stromal cells of giant cell tumours (GCTs). PATIENTS AND METHODS: Participants included four patients with GCT of the bone who were treated with neoadjuvant denosumab. Expression of alkaline phosphatase (ALP), osteocalcin (OCN), RANKL and histone H3K36 trimethylation were assessed through immunohistochemistry of biopsy and surgical specimens. RESULTS: OCN expression was significantly elevated after denosumab treatment, whereas ALP and RANKL expressions were not significantly elevated. Immunofluorescence staining revealed OCN expression and H3K36 trimethylation while their co-localisation was confirmed in the surgical specimens. CONCLUSION: Denosumab promoted OCN expression and might induce the osteogenic differentiation of GCT stromal cells.

Functional and radiological outcomes of a minimally invasive surgical approach to monostotic fibrous dysplasia.

BACKGROUND: Reports showing high recurrence rates for intralesional curettage and bone grafting have made the current treatment principle for fibrous dysplasia controversial. This study aimed to report the postoperative clinical outcomes from three minimally invasive surgical strategies we use for monostotic fibrous dysplasia (MFD). PATIENTS AND METHODS: Twelve patients with MFD presenting with no pathologic fracture or deformity and treated with one of three surgical strategies-plain open biopsy, plain alpha-tricalcium phosphate (ATP) reconstruction, and prophylactic bridge plating-were included. There were nine men and three women, with median age of 38 years. Mean follow-up was 88 weeks. Five cases involved the proximal femur, two each involved the femoral and tibial diaphyses, and one each involved the distal humerus, radial diaphysis, and proximal tibia. All cases were reviewed for functional and radiological outcomes. RESULTS: Median time to full activity was 1 day (range 1 to 3) for the plain open biopsy group, while the prophylactic bridge-plating and plain ATP reconstruction groups had longer median recovery times (59 days, range 3 to 143, and 52 days, range 11 to 192, respectively). Musculoskeletal Tumor Society scores at last follow-up were excellent for all the cases (mean 29.6, range 25 to 30). Radiological analysis using Gaski et al.'s criteria showed plain open biopsy resulted in partial resolution of proximal femoral lesions, while ATP reconstruction and prophylactic plating resulted in no change and progression in this lesion site, respectively. For femoral diaphyseal lesions, prophylactic plating resulted in partial resolution, while ATP reconstruction resulted in no change. In the tibial diaphysis, prophylactic plating resulted in partial resolution, while plain open biopsy resulted in no change. For the lesions involving the distal humerus and the proximal tibia, plain open biopsy resulted in partial resolution, while for the radial diaphyseal lesion, ATP reconstruction resulted in no change. Radiological progression was limited in 11 (92%) cases, and none had postoperative complications. CONCLUSION: Plain open biopsies for asymptomatic lesions; prophylactic bridge plating for symptomatic, large diaphyseal lytic lesions; and plain ATP reconstructions for both small and large nondiaphyseal symptomatic lytic lesions may be acceptable alternatives to curettage-incorporating procedures for MFD.

A case of infected schwannoma mimicking malignant tumor.

BACKGROUND: Infected schwannoma has been reported, this being one of the four cases published in the literature. Infected schwannoma has proven to be a tough diagnostic challenge to the treating tumor surgeon, mimicking infectious entities and most essentially, a malignant tumor. CASE PRESENTATION: The authors report the case of a 64-year-old male with a soft tissue mass in his right gluteal area that presented initially with right leg pain, then later with signs of inflammation on the tumor area. Magnetic resonance imaging (MRI), computed tomography (CT), and thallium-201 scintigraphy studies confirm the presence of soft tissue mass which had continuity with sciatic nerve, with subsequent serial MRI findings suggesting tumor enlargement with cystic degeneration. Increased level of C-reactive protein (CRP) was observed before surgery. During an open biopsy upon tissue sampling, exudates with necrotic tissue were seen. Increased level of CRP and necrotic change suggested the possibility of malignant tumor. Histopathological diagnosis was schwannoma, and group B Streptococcus was detected by culture. After the confirmation of infected schwannoma, enucleation of the tumor was performed. CONCLUSIONS: The report concludes that establishment of a benign pathology is essential when presented with similar clinical findings prior to definitive enucleation of an infected schwannoma.