Clinicopathologic characteristics, metastasis-free survival, and skeletal-related events in 628 patients with skeletal metastases in a tertiary orthopedic and trauma center.

BACKGROUND: Skeletal-related events (SREs) due to bone metastases (BM) significantly impact the morbidity and mortality of cancer patients. The present study sought to investigate clinicopathological characteristics, metastasis-free survival (MFS), and SREs in patients referred to a tertiary orthopedic and trauma center. METHODS: Data were retrieved from electronic health records (n=628). Survival curves were estimated utilizing the Kaplan-Meier method. The Cox regression model was used to determine factors influencing MFS based on estimated hazard ratios (HRs). RESULTS: Breast (55.8%) and lung (18.2%), and lung (32.9%) and prostate (16.8%) cancer were the most common cancer types in our cohort in women and men, respectively. Fifteen percent of patients presented with BM as the first manifestation of tumor disease, 23% had metastasis diagnosis on the same day of primary tumor diagnosis or within 3 months, and 62% developed BM at least 3 months after primary tumor diagnosis. Osteolytic BM were predominant (72.3%) and most commonly affecting the spine (23%). Overall median MFS was 45 months (32 (men) vs. 53 (women) months). MFS was shortest in the lung (median 15 months, 95% CI 8.05-19) and longest in breast cancer (median 82 months, 95% CI 65.29-94). Age (≥ 60 vs. < 60 years) and primary cancer grading of ≥2 vs. 1 revealed prognostic relevance. CONCLUSION: Women with breast or lung cancer, men with lung or prostate cancer, age ≥60 years, male sex, and primary cancer grading ≥2 are associated with increased risk for MBD. Intensified follow-up programs may reduce the risk of SREs and associated morbidity and mortality.

Adamantinomatous tumors: Long-term follow-up study of 20 patients treated at a single institution.

BACKGROUND AND OBJECTIVES: Adamantinomas are primary, low-grade malignant tumors of the bone that have metastatic potential to the lungs, lymph nodes, and other regions. The rarity of this disease and its nonspecific symptoms complicate diagnosis. MATERIALS AND METHODS: Records for 20 patients who underwent treatment for adamantinoma from 1975 to 2018 were reviewed for demographic, clinical, and pathological data, treatment details, postoperative complications, and outcomes. RESULTS: Patients presented at a median age of 22 years (1-79 years): 14 patients had a localized primary tumor, three presented with local recurrence, and three with metastatic disease. Median tumor size was 5.7 cm (0.5-15.5 cm). Wide excision was performed primarily in 15 cases; the remaining five patients underwent intralesional curettage. At a median follow-up of 7.3 years, 14 patients had no evidence of disease; two patients were alive with disease, and four patients died from the disease. Local recurrence and distant metastasis occurred at a median of 11.4 years (6 month-19 years) and 15.8 years (4 month-23 years) after diagnosis. CONCLUSIONS: Adequate histopathological diagnosis is crucial to avoid misdiagnosis of this rare tumor. Local and distant recuAbs_Para_meprrence can occur more than 20 years after the initial diagnosis. Life-long follow-up with clinical examination and imaging is required.

Sentinel lymph node biopsy predicts systemic recurrence in digital papillary adenocarcinoma.

BACKGROUND AND OBJECTIVES: Digital papillary adenocarcinoma (DPA) is a rare, aggressive neoplasm of sweat gland origin. It can recur at local, regional, or distant sites. There is limited knowledge about the role of sentinel lymph node biopsy (SLNB) in predicting recurrence in these patients. We present our experience with this uncommon tumor to evaluate the role of SLNB in predicting outcome. METHODS: Medical records of all patients who underwent surgical treatment for biopsy-proven upper extremity DPA at the study institution were reviewed. Descriptive statistics and Fisher's exact test were used to analyze data. RESULTS: Twenty-one patients were identified. Most patients were male (71%), and the median age was 51 years. SLNB was performed in 18 patients; three were positive for nodal metastatic disease (17%). At a median follow-up of 53 months, there were no local recurrences and two cases of systemic recurrence. No patient with a negative sentinel lymph node has evidence of metastasis or recurrence. Fisher's exact test demonstrated a significant association between a positive SLNB and recurrence (P = .02). CONCLUSION: SLNB revealed metastatic disease in 17% of patients with DPA and appears to predict systemic recurrence in this small series.

Occurrence, risk factors, and outcomes of bone cement implantation syndrome after hemi and total hip arthroplasty in cancer patients.

BACKGROUND AND OBJECTIVES: Patients undergoing cement fixation for hip arthroplasty are at increased risk of developing bone cement implantation syndrome (BCIS). We sought to determine: what is the occurrence of BCIS in patients with cancer after hip arthroplasty? What are the risk factors in patients with cancer for the development of this syndrome? What is the outcome for patients with cancer having BCIS? METHODS: We identified 374 patients with cancer who underwent cemented hip arthroplasty between 2010 and 2014. Patient characteristics, operative variables, and outcomes were collected. RESULTS: BCIS occurred in 279 (75%) patients. A total of 353 (94%) patients had bone metastases and 179 (48%) patients had lung metastases at the time of surgery. Age greater than 60 (hazard ratio [HR] 2.09, P = .02) and the presence of lung metastases (HR 1.77, P = .019) were associated with increased risk of BCIS. Increased perioperative use of vasopressors (HR 1.72, P = .023) and increased hospital stay beyond 10 days (HR 2.67, P = .003) was associated with BCIS. CONCLUSIONS: BCIS is a frequent clinical event in patients with cancer undergoing femoral cemented arthroplasty with increased risk for patients over age 60 and those with compromised lung function due to lung metastases and lung cancer. Patients who develop BCIS are more likely to require longer postoperative hospitalization. Careful preoperative assessment and intraoperative communication are crucial steps to reduce the consequences of BCIS.

Chronic recurrent multifocal osteomyelitis-case report of two patients and review of literature.

BACKGROUND: Chronic Recurrent Multifocal Osteomyelitis (CRMO) is an autoinflammatory skeletal disease characterized by unifocal or multifocal nonbacterial inflammatory bone lesions in the metaphysis of long bones. Common sites of CRMO are tibia, pelvis, proximal femur, clavicle, calcaneum and vertebrae. However, unifocal presentation or presentation in adults, atypical locations, and absence of recurrence have also been reported. METHODS AND FINDINGS: We describe two cases of female patients with unifocal presentation of nonbacterial inflammatory bone lesions in the upper and lower extremity. Furthermore, a review of literature is presented. CONCLUSION: Although CRMO is seen primarily in children and adolescents, and usually occurs in a multifocal pattern, our cases illustrate that this disease can arise in adult patients and in a single location. The diagnosis of CRMO should be made in a multi-disciplinary approach amongst orthopedic surgeons, radiologists and pathologists.

Is revisional surgery mandatory when an unexpected sarcoma diagnosis is made following primary surgery?

BACKGROUND: Soft tissue sarcomas (STS) are often diagnosed unexpectedly after surgery, and many excisions are incomplete. As histopathological assessments are challenging, patients later referred to comprehensive cancer centers (CCC) often come with an unclear status. This can make treatment planning problematic. We investigated the reliability of primary histopathological assessments, whether revisional surgery improved resection status, and the prognostic value of residual tumor at re-excision. METHODS: We analyzed the demographic and clinical characteristics of all patients referred to our CCC between 2003 and 2013. We compared patients treated exclusively at our CCC with those who had primary surgery elsewhere, and focused on resection margins, re-excision type, residual tumor, resection status after re-excision, and oncological outcome. RESULTS: Over half (n = 110) of all patients (n = 204) were referred from elsewhere. Seventy-one had undergone an excision without suspicion of malignancy. Resection status in referred patients was significantly inferior to the CCC group (p < 0.0001), although the latter had significantly more serious tumors and advanced disease stages (p < 0.05). The residual tumor rate was 53.13%, with a significantly higher probability in an upper extremity (p = 0.001). Initial histopathological classification was misleading in 46.9% of cases. Re-excision improved resection status in 69% of cases. Residual tumor presumably leads to higher rates of local recurrence (p = 0.057) and significantly shorter times to recurrence (p < 0.05). CONCLUSIONS: Re-excision should always follow unplanned STS excisions. Resection margins and histopathological assessments from referring institutions are often unreliable and unsuitable for treatment planning. Residual tumor is a risk factor for earlier and more likely local recurrence.