John C. Neilson

Prognostic variables in patients with primary soft tissue sarcoma of the extremity and trunk treated with neoadjuvant radiotherapy or neoadjuvant sequential chemoradiotherapy

BackgroundNeoadjuvant radiotherapy (NRT) is an effective strategy to treat soft tissue sarcomas (STS). However, the role of neoadjuvant chemoradiotherapy (NCRT) remains to be determined.MethodsFrom May 1999 to July 2010, 112 patients with localized STS of the extremity and trunk who were treated with NRT or NCRT followed by surgery were retrospectively reviewed. Clinical outcomes including overall survival (OS), disease-free survival (DFS), and distant metastasis free survival (DMFS) were calculated using Kaplan-Meier survival analyses. Prognostic variables were determined by univariate (UVA) and multivariate analyses (MVA).ResultsMedian follow-up was 37 months. Median RT dose was 50 Gy. Forty-nine patients received NCRT. Overall limb-preservation rate was 99% and local control was 97%. The estimated 3-year OS, DFS, and DMFS were 86%, 68%, and 72%, respectively. Age was the only variable to predict for OS, DFS and DMFS on UVA. Age ≥ 70 predicted for poor OS, stage III disease predicted for poor DFS and DMFS, and the addition of chemotherapy predicted for improved DMFS on MVA.ConclusionsExcellent rates of local control and limb-preservation were observed in patients with primary STS treated with neoadjuvant therapy followed by surgery. Neoadjuvant sequential chemotherapy followed by radiotherapy may be considered for young patients with stage III STS.

Safety and Efficacy of Minimally Invasive Acetabular Stabilization for Periacetabular Metastatic Disease with Thermal Ablation and Augmented Screw Fixation

PURPOSE To evaluate minimally invasive acetabular stabilization (MIAS) with thermal ablation and augmented screw fixation for impending or minimally displaced fractures of the acetabulum secondary to metastatic disease. MATERIALS AND METHODS Between February 2011 and July 2014, 13 consecutive patients underwent thermal ablation, percutaneous screw fixation, and polymethyl methacrylate augmentation for impending or nondisplaced fractures of the acetabulum secondary to metastatic disease. Functional outcomes were evaluated before and after the procedure using the Musculoskeletal Tumor Society (MSTS) scoring system. Complications, hospital length of stay, and eligibility for chemotherapy and radiation therapy were assessed. RESULTS All procedures were technically successful with no major periprocedural complications. The mean total MSTS score improved from 23% ± 11 before MIAS to 51% ± 21 after MIAS (P < .05). The mean MSTS pain scores improved from 0% (all) to 32% ± 22 after MIAS (P < .05). The mean MSTS walking ability score improved from 22% ± 19 to 55% ± 26 after MIAS (P < .05). Two complications occurred; a patient had a minimally displaced fracture of the superior pubic ramus at the site of repair but remained ambulatory, and septic arthritis was diagnosed in another patient 12 months after repair. The average length of hospital stay was 2 days ± 3.6; six patients were discharged within 24 hours of the procedure. All patients were eligible for chemotherapy and radiation therapy immediately after the procedure. CONCLUSIONS MIAS is feasible, improves pain and mobility, and offers a minimally invasive alternative to open surgical reconstruction.

The effect of smoking and major vein resection on post-therapy lymphedema in soft tissue sarcomas treated with neoadjuvant radiation and limb-salvage surgery.

Background:Neoadjuvant therapy with radiation +/− chemotherapy is an accepted management for soft tissue sarcomas (STS). The incidence of post-therapy lymphedema is around 30%. The purpose of this study was to identify variables that predict for post-therapy lymphedema. Methods:From 2000 to 2010, 132 patients with STS were treated with neoadjuvant radiation +/− chemotherapy followed by resection. Patient variables and treatment outcomes were reviewed. Presence of lymphedema was determined by the treating physician. The Fisher exact test was used for univariate analysis and logistic regression was used for multivariate analysis. Results:Median follow-up was 3.1 years. Of the lower extremity STS, major veins were sacrificed in 34% of patients. Lymphedema occurred in 22.4% of patients. Smoking negatively predicted for lymphedema on univariate analysis (P=0.007), and sacrifice of a major vein was associated with an increased risk of lymphedema (P=0.02). On multivariate analysis, smoking (P=0.02, odds ratio 0.31) negatively predicted for and sacrifice of a major vein (P=0.03, odds ratio 2.7) positively predicted for lymphedema. Conclusions:There may be an association between smoking and decrease post-therapy lymphedema. Also, patients who undergo resection of a major vein seem to be more prone to post-therapy lymphedema.

Postoperative Day 1 Glucose May Be Associated With Wound Complications in Sarcomas Treated With Preoperative Radiation

Background Uncontrolled blood glucose impacts key phases of the wound healing process. Various factors have been associated with postoperative wound complications in soft tissue sarcomas; however, the association of postoperative early morning blood glucose with wound complications, if any, remains to be determined. Because blood glucose levels may be modified, understanding whether glucose levels are associated with wound complications has potential therapeutic importance. Questions/purposes The purposes of this study were (1) to evaluate if postoperative early morning blood glucose is associated with the development of wound complications in soft tissue sarcomas; (2) to determine a blood glucose cutoff that may be associated with an increased risk of wound complications; and (3) to evaluate if patients with diabetes have higher postoperative blood glucose and an associated increased risk of wound complications. Methods From 2000 to 2015, 298 patients with Stage I to III soft tissue sarcomas of the extremity or chest wall were treated with preoperative radiation ± chemotherapy followed by limb-sparing resection. Of those, 191 (64%) patients had demographic, treatment, and postoperative variables and wound outcomes available; these patients’ results were retrospectively evaluated. None of the 191 patients were lost to followup. Early morning blood glucose levels on postoperative day (POD) 1 were available in all patients. Wound complications were defined as those resulting in an operative procedure or prolonged wound care for 6 months postresection. Variables that may be associated with wound complications were evaluated using logistic regression for multivariate analysis. Receiver operative curve (ROC) analysis was used to assess the early morning blood glucose level that best was associated postoperative wound complications. Results After controlling for potentially relevant confounding variables such as patient comorbidities, tumor size, and location, lower extremity soft tissue sarcomas (p = 0.002, odds ratio [OR], 6.4; 95% confidence interval [CI], 1.97-20.84) and elevated POD 1 early morning blood sugars (p < 0.001; OR, 1.1; 95% CI, 1.04-1.11) were associated with increased wound complications postoperatively. ROC analysis revealed that early morning POD 1 blood glucose of > 127 mg/dL was associated with postoperative wound complications with a sensitivity of 89% (area under the curve 0.898, p < 0.001). Median POD 1 early morning blood glucose in patients without diabetes was 118 mg/dL and 153 mg/dL in patients with diabetes (p = 0.023). However, with the numbers available, there was no increase in wound complications in patients with diabetes compared with those without it. Conclusions Our study provides preliminary information suggesting that POD 1 early morning blood glucose in patients with soft tissue sarcomas may be associated with a slightly increased risk of postoperative wound complications. An early morning blood glucose of > 127 mg/dL may be a threshold associated with this outcome. Although patients with diabetes had higher POD 1 early morning blood glucose levels, diabetes itself was not associated with the development of wound complications. We cannot conclude that better glycemic control will reduce wound complications in patients who receive preoperative radiation, but our data suggest this should be further studied in a larger, prospective study. Level of Evidence: Level III, therapeutic study.

Multivitamin Use may Improve Disease-free and Distant Metastasis-freeSurvival in Patients with Soft Tissue Sarcomas of the Extremity and Chestwall

Introduction: Multivitamins (MVT) are used for their potential benefit by patients diagnosed with cancer. There is a paucity of data correlating their use and outcomes in rarer malignancies. Thus, the aim of this study was to correlate MVT use with survival in patients with soft tissue sarcomas (STS). Materials and methods: Between 2000-2012, 185 patients with stage I-III STS underwent treatment. Variables were retrospectively analyzed relating to overall (OS), disease-free (DFS), and distant-metastasis free survival (DMFS). Univariate analysis (UVA) was performed using the log-rank test. Multivariate analysis (MVA) was performed using the Cox proportional hazards model. Results: Median follow-up was 3.6 years. 34% had record of taking a MVT at the time of diagnosis. Of these, 10% developed metastasis compared to 39% who were not taking a MVT at the time of their diagnosis. On UVA, MVT was associated with an improved DFS (p=0.001) and DMFS (p=0.001). On MVA for DFS and DMFS, smoking (p<0.01), stage III tumors (p<0.01), and statin use (p<0.01) were negative predictors, however MVT use (p<0.001 was associated with improved DFS and DMFS. Conclusions: Patients taking a MVT at the time of diagnosis had improved DFS and DMFS in our cohort. This may suggest that MVT use prevents distant metastasis.

Preoperative Radiation Therapy Followed by Reexcision May Improve Local Control and Progression-Free Survival in Unplanned Excisions of Soft Tissue Sarcomas of the Extremity and Chest-Wall

Background. The management for unplanned excision (UE) of soft tissue sarcomas (STS) has not been established. In this study, we compare outcomes of UE versus planned excision (PE) and determine an optimal treatment for UE in STS. Methods. From 2000 to 2014 a review was performed on all patients treated with localized STS. Clinical outcomes including local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) were evaluated using the Kaplan-Meier estimate. Univariate (UVA) and multivariate (MVA) analyses were performed to determine prognostic variables. For MVA, Cox proportional hazards model was used. Results. 245 patients were included in the analysis. 14% underwent UE. Median follow-up was 2.8 years. The LR rate was 8.6%. The LR rate in UE was 35% versus 4.2% in PE patients (p < 0.0001). 2-year PFS in UE versus PE patients was 4.2 years and 9.3 years, respectively (p = 0.08). Preoperative radiation (RT) (p = 0.01) and use of any RT for UE (p = 0.003) led to improved PFS. On MVA, preoperative RT (p = 0.04) and performance status (p = 0.01) led to improved PFS. Conclusions. UEs led to decreased LC and PFS versus PE in patients with STS. The use of preoperative RT followed by reexcision improved LC and PFS in patients who had UE of their STS.