Daniel C. Allison

A Meta-Analysis of Osteosarcoma Outcomes in the Modern Medical Era

Four decades ago, specialized chemotherapy regimens turned osteosarcoma, once considered a uniformly fatal disease, into a disease in which a majority of patients survive. Though significant survival gains were made from the 1960s to the 1980s, further outcome improvements appear to have plateaued. This study aims to comprehensively review all significant, published data regarding osteosarcoma and outcome in the modern medical era in order to gauge treatment progress. Our results indicate that published survival improved dramatically from 1960s to 1980s and then leveled, or in some measures decreased. Recurrence rates decreased in the 1970s and then leveled. In contrast, published limb salvage rates have increased significantly every recent decade until the present. Though significant gains have been made in the past, no improvement in published osteosarcoma survival has been seen since 1980, highlighting the importance of a new strategy in the systemic management of this still very lethal condition.

A Comparison of Fine-needle Aspiration, Core Biopsy, and Surgical Biopsy in the Diagnosis of Extremity Soft Tissue Masses

BackgroundBiopsy tissue can be obtained through a fine needle, a wider coring needle, or through an open surgical incision. Though much literature exists regarding the diagnostic yield of these techniques individually, none compare accuracy of diagnosis in the same mass.Questions/purposesWe asked how the diagnostic accuracy of fine-needle aspiration, core biopsy, and open surgical biopsy compare in regard to identifying malignancy, establishing the exact diagnosis, and guiding the appropriate treatment of soft tissue masses.Patients and MethodsWe prospectively studied 57 patients with palpable extremity soft tissue masses, performing fine-needle aspiration, followed by core biopsy, followed by surgical biopsy of the same mass.ResultsOpen surgical biopsy was 100% accurate on all accounts. With regard to determining malignancy, fine-needle aspiration and core biopsy had 79.17% and 79.2% sensitivity, 72.7% and 81.8% specificity, 67.9% and 76% positive predictive value, 82.8% and 84.4% negative predictive value, and an overall accuracy of 75.4% and 80.7%, respectively. In regard to determining exact diagnosis, fine-needle aspiration had a 33.3% accuracy and core biopsy had a 45.6% accuracy. With regard to eventual treatment, fine-needle aspiration was 38.6% accurate and core biopsy was 49.1% accurate.ConclusionsIn soft tissue mass diagnosis, core biopsy is more accurate than fine-needle aspiration on all accounts, and open biopsy is more accurate than both in determining malignancy, establishing the exact diagnosis, and the guiding appropriate treatment.Level of Evidence Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Microbiology of upper extremity soft tissue abscesses in injecting drug abusers.

Drug injection often results in upper extremity soft tissue infections. We determined the bacteriology of soft tissue abscesses in substance abusers who inject drugs to provide guidelines for empiric antibiotic therapy. We retrospectively studied 855 patients (638 men and 217 women; mean age, 41.5 years) with a history of injecting illicit drugs and a diagnosis of an upper extremity soft tissue abscess. In the 694 patients with positive cultures the most common organism was Staphylococcus aureus, identified in 359 of 694 patients (52%). An increase in the incidence of oxacillin-resistant S. aureus over time was observed. Oxacillin-resistant S. aureus comprised 5% of S. aureus infections in 1999, 50% in 2001, 56% in 2003, and 82% in 2005. Microaerophilic streptococci were present in 37% of culture-positive cases and other anaerobes in 10%. Infections were monomicrobial in 366 of 694 patients (53%) and polymicrobial in 328 of 694 patients (47%). S. aureus is the most common pathogen in soft tissue abscesses in injecting drug abusers with an increasing incidence of oxacillin-resistant S. aureus. In addition to surgical decompression of abscesses, broad-spectrum empiric antibiotic therapy is necessary. Level of Evidence: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

A Comparison of Mineral Bone Graft Substitutes for Bone Defects

Synthetic bone graft substitutes have evolved in response to the downsides of autograft and allograft. This article consolidates the literature regarding the use of mineral bone graft substitutes in the treatment of cavitary bone defects. No level I studies regarding their use in the treatment of bone tumors have been performed, but the clinical studies that have been published indicate that calcium sulfate resorbs too quickly and incites inflammatory reaction and hydroxyapatite resorbs too slowly and blocks new bone ingrowth; tricalcium phosphate and mineral bone graft composites have the biochemical profile that is most compatible with new bone formation. These studies also indicate that mineral bone grafts are safe and may be as effective as other graft options; however, radiographic interpretation may be inaccurate and no evidence exists to suggest that mineral bone graft substitutes are superior to no graft at all. The trauma literature has yielded numerous level I studies that indicate that calcium phosphate cements result in increased metaphyseal fracture stability, but have not yet detected any improvement in healing. Prospective randomized clinical trials in the treatment of bone tumors are necessary to properly delineate the real indications for bone grafting and to demonstrate the graft’s efficacy in this regard.

Prognostic value of necrosis after neoadjuvant therapy for soft tissue sarcoma

While treatment‐induced tissue necrosis is a well‐documented predictor of patient survival in malignant bone tumors, its prognostic value in soft tissue sarcomas is controversial. A prior study from our institution did not find a prognostic value to tumor necrosis. We analyze a more extensive database of high‐grade soft tissue sarcomas treated with neoadjuvant chemotherapy, radiation therapy, or both to re‐evaluate if the degree of tumor necrosis alone can be used as a predictive factor for local recurrence, metastasis, and disease‐specific survival.

Bone grafting alternatives for cavitary defects in children

The surgical resection of benign bone tumors in children results in cavitary bone defects, which often are treated with a graft. Autologous cancellous bone has been considered the gold standard graft for this condition at the expense of significant morbidity. Allogenic bone grafts are most commonly used, with the downsides of antigenicity and limitations in supply. Synthetic bone graft substitutes have evolved in response to the downsides of autograft and allograft, also with their risks and benefits. This study consolidates the recent literature regarding the use of bone grafts for the treatment of surgically created, nonstructural, cavitary bone defects in children. Many studies describing various bone graft options alone, in combination, and in comparison to each other have been published. No single option has been demonstrated to be superior, and some studies indicate that no graft at all may be as effective as current graft options. High volume, prospective, randomized clinical trials in the treatment of bone tumors comparing graft options with each other and to no grafting at all are necessary to properly delineate the real indications for bone grafting and to demonstrate its efficacy.

Moving Beyond Response Criteria: New Measures of Success in the Treatment of Sarcomas

Opinion statementThere is an urgent need to develop new therapies for soft tissue sarcomas. Traditional cytotoxic therapies, such as doxorubicin and ifosfamide, have been the standard approach to this disease. However, newer paradigms are emerging that are less toxic while targeting dysregulated pathways, tumor hypoxia, and genetic translocations. These newer therapies require different measures of activity as standard response criteria may inaccurately measure their effectiveness. Serious consideration of select endpoints and measures of tumor response are crucial to make significant strides in the treatment of sarcomas. Current studies on soft tissue sarcomas are slowly abandoning response rates while employing progression-free survival and time to progression as improved endpoints. With time and data, our understanding of the relative activity of these agents will grow and lead to improved benefits for our patients.

Clavicular eosinophilic granuloma causing adult shoulder pain

Though rarely reported, neoplasms of the clavicle occur, and their symptoms can be mistaken for more common shoulder conditions. We present the case of a benign clavicular neoplasm, rarely seen in adults, presenting with pain, and eventual pathologic fracture in a 49 year-old. A 49 year-old male firefighter underwent arthroscopic rotator cuff repair for shoulder pain after magnetic resonance imaging revealed supraspinatus tendon tear. The patients pain persisted after surgery, and was described as routine until he developed severe pain after minor blunt trauma. A local Emergency Room performed the first x-rays, which revealed a pathologic fracture of the distal clavicle through a destructive lesion. The patient was referred to an orthopedic oncologist, who performed incisional biopsy, which initially diagnosed osteomyelitis. The patient was subsequently taken to surgery for debridement. Pathology then yielded the diagnosis of eosinophilic granuloma. The patient was taken back to surgery for formal curettage with open reduction and internal fixation. The patients pain resolved, the pathologic fracture fully healed, and the patient returned to full time work as a firefighter. Though workup for common shoulder conditions often identifies incidental benign lesions of bone, the converse can be true. Persistent pain despite intervention should raise concern for further investigation. An x-ray alone can reveal a destructive bone lesion as the source of shoulder pain.