Maximilian Zacherl

Elevated preoperative neutrophil/lymphocyte ratio is associated with poor prognosis in soft-tissue sarcoma patients.

Background:Recent data indicate that tumour microenvironment, which is influenced by inflammatory cells, has a crucial role in cancer progression and clinical outcome of patients. In the present study, we investigated the prognostic relevance of preoperative neutrophil/lymphocyte (N/L) ratio on time to tumour recurrence (TTR) and overall survival (OS) in soft-tissue sarcoma (STS) patients who underwent curative surgical resection.Methods:In all, 260 STS patients were included in this retrospective study. Kaplan–Meier curves and multivariate Cox proportional models were calculated for TTR and OS.Results:In univariate analysis, elevated N/L ratio was significantly associated with decreased TTR (hazard ratio (HR), 2.32; 95% confidence interval (CI), 1.30–4.14; P=0.005) and remained significant in the multivariate analysis (HR, 1.98; 95%CI, 1.05–3.71; P=0.035). Patients with elevated N/L ratio showed a median TTR of 77.9 months. In contrast, patients with low N/L ratio had a median TTR of 99.1 months. Regarding OS, elevated N/L ratio was also significantly associated with decreased survival in univariate analysis (HR, 2.90; 95%CI, 1.82–4.61; P=0.001) and remained significant in multivariate analysis (HR, 1.88; 95%CI, 1.14–3.12; P=0.014).Conclusion:In conclusion, our findings suggest that an elevated preoperative N/L ratio predicts poor clinical outcome in STS patients and may serve as a cost-effective and broadly available independent prognostic biomarker.

Accuracy of Multiphasic Helical Computed Tomography and Intraoperative Sonography in Patients Undergoing Orthotopic Liver Transplantation for Hepatoma: What is the Truth?

ObjectiveTo determine the real value of liver imaging in cirrhosis by macro- and histomorphologic examination of the entire organ after orthotopic liver transplantation for hepatocellular carcinoma (HCC). Summary Background DataIn comparative studies, a virtual sensitivity of up to 94% is described for helical computed tomography in HCC staging. The tumor detection rate of intraoperative ultrasonography (IOUS) is reported to be almost 100%. MethodsThis prospective observational study comprised 23 patients with HCC in cirrhosis admitted for orthotopic liver transplantation. Results of preoperative triphasic helical computed tomography (HCT) and IOUS were correlated with histopathologic results after 3-mm-slicing of the explanted liver. ResultsOverall, 179 liver segments were examined by HCT, IOUS, and MHM. Fifty-two malignant lesions and 10 dysplastic nodules were revealed by MHM. Using HCT, 13 HCCs could not be identified in 8 patients and 15 results were falsely positive in 10 patients. The detection rate of dysplastic nodes was 40% for HCT and 60% for IOUS. IOUS missed four HCCs in four patients and had six false-positive results in six patients. In a segment-based analysis, the overall accuracy of IOUS was significantly higher for IOUS (95.5%) versus HCT (89.9%). In the lesion-by-lesion analysis, the sensitivity was 92.3% for IOUS and 75.0% for HCT, with a significant difference. ConclusionsCorrelation of explanted liver pathologic results offers precise evaluation of imaging modalities. The data of this histopathologically based study confirm that IOUS is significantly superior in staging HCC in cirrhosis versus CT, even after technical refinements through enhanced multiphasic high-velocity helical scanning.

The influence of personality traits on the subjective outcome of operative hallux valgus correction

We studied prospectively the influence of personality traits on the subjective outcome of a chevron osteotomy in 42 patients with hallux valgus. The mean age of patients was 48.3 (20–70) years. Personality traits were evaluated by the means of the Freiburg Personality Inventory (FPI-R). Three months postoperatively 37 patients were satisfied, and five patients not satisfied with the operative procedure. The preoperative AOFAS Score improved from an average of 48.7 (30–65) points to 87.9 (50–100) points. A comparison of satisfied and dissatisfied patients revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angle was 12.2±7.8° and 13.4±8.3° (p=0.74) among satisfied and not satisfied patients, respectively, and the intermetatarsal angle (I–II) was 7.4±2.5° and 7.6±4° (p=0.89), respectively. The results suggest that the patient’s subjective result after the operative correction may be influenced by some individual, personality profiles.RésuméNous avons étudié l’influence des traits de la personnalité sur le résultat subjectif d’une ostéotomie en chevron chez 42 malades avec hallux valgus. L’âge moyen des malades était de 48,3 ans (20–70). Les traits de la personnalité ont été évalués au moyen de l’Inventaire de Personnalité de Fribourg (FPI-R). A trois mois postopératoires 37 malades étaient satisfaits de la procédure opératoire, et 5 ne l’étaient pas. Le Score préopératoire AOFAS a été amélioré d’une moyenne de 48,7 (30–65) points à 87,9 (50–100) points. Une comparaison de malades satisfaits et non satisfaits a révélé des différences statistiquement significatives dans le caractère agressif des traits de la personnalité (p=0,003), extraversion (p=0,001) et inquiétude sur sa santé (p=0,04). L’angle de l’hallux valgus postopératoire était respectivement de 12,2±7,8° et 13,4±8,3° (p=0,74) pour les malades satisfaites et les malades non satisfaits, et l’angle intermétatarsien (I–II) était de 7,4±2,5° et 7,6±4° (p=0,89) respectivement. Les résultats suggèrent que le résultat subjectif après la correction opératoire peut être influencé par le profil de personnalité du malade.

Measurement of the acromiohumeral interval on standardized anteroposterior radiographs: a prospective study of observer variability.

BACKGROUND An acromiohumeral interval narrower than 6 mm has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study assessed interobserver and intraobserver variability in the radiographic measurement of the acromiohumeral interval. MATERIAL AND METHODS Five board-certified orthopedic surgeons independently reviewed 58 blinded, standardized anteroposterior shoulder radiographs. The acromiohumeral interval was measured in millimeters. The 5 investigators classified each image a second time in random order. RESULTS After the same 58 radiographs had been evaluated by the 5 investigators at both examination time points, no significant differences were noted in the interobserver and intraobserver measurements (P < .05). The respective maximum interobserver and intraobserver differences were 4 and 3 mm (range, 0-4 mm). CONCLUSION The assessment of the acromiohumeral interval using standardized anteroposterior radiographs is a reliable and reproducible method of measurement. LEVEL OF EVIDENCE Level 1; Investigating a diagnostic test.

Surgical treatment of pathologic fractures of the humerus and femur

The life expectancy of patients with malignant tumours and the incidence of osseous metastases have increased over the last decades. Operations for skeletal metastases of the extremities represent the most frequent surgery in orthopaedic oncology. The purpose of this study was to evaluate and compare the different operative treatment options for patients with pathologic fractures of the humerus and femur in terms of complications, postoperative recovery, and survival.From 2000 to 2005, 109 patients were surgically treated for pathologic fractures of the humerus (n=19) or femur (n=90). The study group consisted of 60 women and 43 men, with a mean age of 67 years (13-88). Breast carcinoma (36%) was the most common primary tumour, followed by kidney (17%) and bronchial (16%) carcinoma. Of all patients, 75 (73%) had numerous skeletal metastases, and 38 (37%) had visceral metastases.Wide or marginal resection was performed in seven fractures of the humerus and 14 fractures of the femur; intralesional resection was done in seven humeral and 73 femoral fractures; and stabilisation alone was done in five fractures of the humerus and three fractures of the femur. The median survival time for all patients was 6 months (0-102). The survival rate at 1 year was 25% (25% for both humeral and femoral fractures), 15% at 2 years (17% for humeral and 15% for femoral fractures), and 8% at 3 years (16% for humeral and 7% for femoral fractures). The overall complication rate was 11%, and revision surgeries were performed in seven patients (6.4%). The majority of patients (n=65; 60%), especially those with fractures close to the articular joint, were successfully treated with endoprosthetic replacement. Patients with fractures stabilised by intramedullary nails had shorter operating times, a shorter hospital stay, and fewer complications than patients treated with plating systems. Therefore, we recommend intralesional resection of the metastasis and stabilisation with intramedullary devices, supported by bone cement, as the treatment of choice for pathologic fractures of the diaphysis and metaphysis of the humerus and femur. Wide resection should be reserved for selected cases, such as solitary bone metastasis of kidney carcinoma.

Operative Versorgung von pathologischen Humerus- und Femurfrakturen

The life expectancy of patients with malignant tumours and the incidence of osseous metastases have increased over the last decades. Operations for skeletal metastases of the extremities represent the most frequent surgery in orthopaedic oncology. The purpose of this study was to evaluate and compare the different operative treatment options for patients with pathologic fractures of the humerus and femur in terms of complications, postoperative recovery, and survival.From 2000 to 2005, 109 patients were surgically treated for pathologic fractures of the humerus (n=19) or femur (n=90). The study group consisted of 60 women and 43 men, with a mean age of 67 years (13-88). Breast carcinoma (36%) was the most common primary tumour, followed by kidney (17%) and bronchial (16%) carcinoma. Of all patients, 75 (73%) had numerous skeletal metastases, and 38 (37%) had visceral metastases.Wide or marginal resection was performed in seven fractures of the humerus and 14 fractures of the femur; intralesional resection was done in seven humeral and 73 femoral fractures; and stabilisation alone was done in five fractures of the humerus and three fractures of the femur. The median survival time for all patients was 6 months (0-102). The survival rate at 1 year was 25% (25% for both humeral and femoral fractures), 15% at 2 years (17% for humeral and 15% for femoral fractures), and 8% at 3 years (16% for humeral and 7% for femoral fractures). The overall complication rate was 11%, and revision surgeries were performed in seven patients (6.4%). The majority of patients (n=65; 60%), especially those with fractures close to the articular joint, were successfully treated with endoprosthetic replacement. Patients with fractures stabilised by intramedullary nails had shorter operating times, a shorter hospital stay, and fewer complications than patients treated with plating systems. Therefore, we recommend intralesional resection of the metastasis and stabilisation with intramedullary devices, supported by bone cement, as the treatment of choice for pathologic fractures of the diaphysis and metaphysis of the humerus and femur. Wide resection should be reserved for selected cases, such as solitary bone metastasis of kidney carcinoma.

A New Fine-Needle Aspiration System

Background. The main reasons for fine needle aspiration (FNA) failure are insufficient number of cells in the sample, nonrepresentative samples, and contamination of samples. The aim of this study was to measure the number of cells harvested by a new needle system with an aeration aperture (Thyrosampler) in comparison with a conventional FNA system (C-FNA). Methods. Under a double-blind setting, 30 aspirations, 15 with each system (C-FNA, Thyrosampler), were done in randomized order and recorded. Results. The median total number of cells was 59 680 cells/mL with C-FNA and 396 400 cells/mL with Thyrosampler. The needle system with the aeration aperture led to a significantly higher cell amount (564% more cells than the conventional system; P < .005) in needle aspiration biopsy. Conclusion. The new system with the vacuum release feature leads to a significantly higher cell amount in needle aspiration biopsy, which is a well-defined benefit.

Revision of inadequately treated soft-tissue sarcoma is associated with increased need for plastic or reconstructive surgery

ZusammenfassungGRUNDLAGEN: Weichteilsarkome (WTSA) sind seltene mesenchymale Tumore des Stütz- und Bewegungsapparates mit einer hohen Inzidenz an primären Fehldiagnosen und Therapie außerhalb bestehender Richtlinien. Im Zuge dieser retrospektiven Kohortenanalyse wurde der Einfluss von primär inadäquater chirurgischer Therapie vor Transferierung an ein Tumorzentrum analysiert. METHODIK: Prospektiv geplante Fünfjahresbeobachtung an einem tertiären Zentrum für Tumore des Stütz- und Bewegungsapparates. ERGEBNISSE: 116 Patienten wurden im Zeitraum zwischen 1998 und 2003 wegen eines WTSA operiert. 59 (51 %) Patienten(d) wurden vor ihrer Transferierung andernorts inadäquat chirurgisch behandelt. 54 (92 %) Patienten von diesen wurden ohne vorangegangene Biopsie operiert und zeigten eine signifikant höhere Rate an intraläsionalen Resektionsgrenzen (p < 0,0001), einen geringeren mittleren Tumordurchmesser (p = 0,007), eine höhere Rate an plastisch chirurgischen Deckungen bei erfolgter Definitivresektion (p = 0,009) und einen längeren mittleren Zeitraum bis zur Zuweisung an ein Zentrum (p < 0,0001) als Patienten, die primär adäquat chirurgisch behandelt wurden. Es war kein Einfluss auf Überleben, Lokalrezidivrate oder Metastasierungsrate erkennbar. SCHLUSSFOLGERUNGEN: Es besteht die Notwendigkeit zur Reduktion inadäquater chirurgischer Therapie von Patienten mit Weichteilsarkomen.SummaryBACKGROUND: Soft-tissue sarcomas (STS) of the extremities are frequently misdiagnosed at initial presentation with a high rate of treatment not in accordance with clinical practice guidelines. The purpose of this study was to detect clinical influence of inadequate surgery prior to referral to a tumour centre. METHODS: Five-year single institution review of patients operated for STS of the extremities in a tertiary referral unit. RESULTS: A total of 116 patients underwent curative surgery for STS between 1998 and 2003. A total of 59 (51%) patients were operated contrary to current clinical guidelines before referral (group B). A total of 54 (92%) of these patients were operated without previous biopsy. Group B had a significantly higher rate of intralesional margins (p < 0.001), a smaller diameter of primary lesion (p = 0.007), a higher rate of additional plastic surgery after re-resection (p = 0.009) and a longer period before referral (p < 0.001) than patients treated according to treatment guidelines (group A). There was no influence on survival, local recurrence or metastasis. CONCLUSIONS: There is a need for the reduction of inadequate surgery for STS.

Influence of Prereferral Surgery in Soft Tissue Sarcoma: 10 Years’ Experience in a Single Institution

Soft tissue sarcomas are a group of rare mesenchymal neoplasms comprising 0.8% of all malignant tumors. Workup should include medical history, physical examination, magnetic resonance imaging, biopsy, and thoracoabdominal computed tomography scan, in that order. Centralized multimodality treatment in a cross-disciplinary setting is mandatory. Treatment not according to current clinical practice guidelines is a common problem before referral to a specialized institution. The purpose of this 10-year, single-institution review was to investigate the influence of curative surgery on outcome, with a special emphasis on surgery before referral. A cohort of 266 patients who underwent curative surgery for soft tissue sarcoma between 1998 and 2008 was analyzed. One hundred thirty-one (49%) patients underwent surgery contrary to current clinical guidelines before referral, most (73%) at primary care units. One hundred thirteen (86%) of these patients underwent surgery without previous biopsy with a higher rate of intralesional margins (P<.001), a smaller mean diameter of primary lesion (P<.001), a higher rate of subcutaneous situs (P<.001), a lower mean American Joint Committee on Cancer score (P=.008), a higher rate of additional plastic surgery after re-resection (eg, flap surgery) (P<.001), and a longer period before referral (P<.001). No influence on survival, local recurrence, or metastasis existed. Prereferral surgery necessitating re-resection has no influence on survival but leads to an unfavorable clinical course. More effort should be made to improve awareness and referral modalities for general practitioners and physicians at community hospitals.

Liposarcomas: treatment and outcome, a retrospective single-center study

ZusammenfassungGRUNDLAGEN: Grading, Histopathologie, Größe und Art der chirurgischen Resektion sind wichtige prognostische Faktoren im biologischen Verhalten von Liposarkomen. METHODIK: In Hinblick auf Rezidiv, Metastasen und Überleben wurden 80 Patienten mit Liposarkom auf klinische und histologische Charakteristika nachuntersucht. ERGEBNISSE: Die Fünf-Jahres-Rate ohne Ereignis (Metastasen, Rezidiv oder Tod durch die Erkrankung) war 82 %. Stärkster prognostischer Faktor war das Tumorgrading. Patienten mit Alter über 60 Jahren zum Zeitpunkt der Diagnose hatten eine schlechtere Prognose. Bei 13,1 % (95% CI von 2,9 % bis 22,2 %) der Patienten kam es innerhalb von fünf Jahren zu Metastasen. Die durchschnittliche Zeit zwischen Erstdiagnose und Auftreten von Metastasen war 27 Monate (0 bis 63 Monate). Lokalrezidive traten nur bei Patienten auf, bei denen die primäre Behandlung nicht in einem Tumorzentrum durchgeführt wurde und das chirurgische Vorgehen inadäquat war (fünf Patienten mit LS G II und einem Patienten mit LS G I). SCHLUSSFOLGERUNGEN: Die Prognose von Liposarkomen ist gut, wenn das chirurgische Vorgehen adäquat ist und die Resektionsränder tumorfrei sind. Patienten mit suspektem Liposarkom sollten spezialisierten Sarkomzentren zugewiesen werden.SummaryBACKGROUND: In liposarcoma (LS), tumor-grade, histopathologic subtype, size, and completeness of resection are important prognostic factors. METHODS: We analyzed 80 patients with LS in an unselected patient sample concerning local recurrence, metastases, and survival in relation to clinicopathological characteristics and treatment. RESULTS: The five-year event-free rate was 82%. The strongest predictive prognostic factor was tumor grading. There was a significant influence of age over 60 showing a worse prognosis. Within 5 years after diagnosis, metastases were diagnosed in 13.1% (95% CI from 2.9% to 22.2%). The mean interval from first diagnosis to metastases was 27 months (0 to 63 months). Local recurrence occurred just in patients, who were not primary treated in a tumor-center and first resection was inadequate (five LS G II and one LS G I). CONCLUSIONS: Prognosis of LS is good if surgical treatment is adequate and resection performed with clear margins. Patients with suspected LS should be referred to specialized tumor-centers.