Seungcheol Kang

Unplanned excision of soft tissue sarcoma: The impact of the referring hospital

BACKGROUND Unplanned excision of soft tissue sarcoma (STS) remains a common problem performed at various levels of hospitals, where clinical characteristics may differ. However, there is little literature describing the impact of the referring hospital on patient characteristics and/or outcome in unplanned excision of STS. This study examined the possible different patient characteristics and prognoses according to the level of referring hospitals where unplanned excision was performed. METHODS Patients referred to our institute after unplanned excision of STS on their extremities were reviewed. Referring hospitals were categorized into two groups according to their referral grades; tertiary hospitals (general hospitals with tertiary [highest] referral grade, n = 42) and non-tertiary hospitals (others, n = 79). RESULTS Patients referred from tertiary hospitals had significantly larger number of high-grade tumors (p = 0.019) but lower chance of finding a residual tumor at re-excision (p = 0.020) than non-tertiary hospitals. For oncological outcomes, referral from tertiary hospital was an independent factor for better local control (hazard ratio, 0.211; 95% confidence interval, 0.061-0.730). However, there was no difference in disease-specific death (p = 0.729) or metastasis (p = 0.978) between the two groups. CONCLUSIONS Despite having worse clinicopathologic characteristics, patients referred from tertiary hospitals had fewer local recurrences than patients from non-tertiary hospitals. The impact of the referring hospital on patient outcome and disease characteristics needs to be considered in unplanned excision of STS.

Post-metastasis survival in extremity soft tissue sarcoma: A recursive partitioning analysis of prognostic factors

BACKGROUND Recursive partitioning analysis (RPA) enables grouping of patients into homogeneous prognostic groups in a visually intuitive form and has the capacity to account for complex interactions among prognostic variables. In this study, we employed RPA to generate a prognostic model for extremity soft tissue sarcoma (STS) patients with metastatic disease. METHODS A retrospective review was conducted on 135 patients with metastatic STS who had undergone surgical removal of their primary tumours. Patient and tumour variables along with the performance of metastasectomy were analysed for possible prognostic effect on post-metastatic survival. Significant prognostic factors on multivariate analysis were incorporated into RPA to build regression trees for the prediction of post-metastatic survival. RESULTS RPA identified six terminal nodes based on histological grade, performance of metastasectomy and disease-free interval (DFI). Based on the median survival time of the terminal nodes, four prognostic groups with significantly different post-metastatic survival were generated: (1) group A: low grade/metastasectomy; (2) group B: low grade/no metastasectomy/DFI ⩾ 12 months or high grade/metastasectomy; (3) group C: low grade/no metastasectomy/DFI < 12 months or high grade/no metastasectomy/DFI ⩾ 12 months; and (4) group D: high grade/no metastasectomy/DFI < 12 months. The 3-year survival rates for each group were: group A, 76.1 ± 9.6%; group B, 42.3 ± 10.3%; group C, 18.8 ± 8.0%; and group D, 0.0 ± 0.0%. CONCLUSION Our prognostic model using RPA successfully divides STS patients with metastasis into groups that can be easily implemented using standard clinical parameters.

Outcomes of curettage and anhydrous alcohol adjuvant for low-grade chondrosarcoma of long bone

BACKGROUND Low-grade chondrosarcoma of long bones can be treated successfully with extended intralesional curettage using adjuvants. However, there is no study reporting the use of anhydrous alcohol as an adjuvant in the treatment of low-grade chondrosarcoma. We asked (1) whether intralesional curettage and anhydrous alcohol adjuvant for low-grade chondrosarcoma is associated with good oncologic outcomes; and we report (2) the complications of the procedure. METHODS Thirty-six patients (13 men, 23 women) with a mean age of 46 years (range, 18-67 years) were treated for low-grade chondrosarcoma and followed up for a median of 62 months (range, 24-169 months). After intralesional curettage, and additional burring, anhydrous alcohol was used as an adjuvant therapy. RESULTS At the time of last follow-up, there were no local recurrences or distant metastases. Six patients developed complications: 4 postoperative fractures (11%), 1 intra-articular loose body (3%) and 1 postoperative joint stiffness (3%). CONCLUSION Anhydrous alcohol is a reasonable adjuvant for the curettage of low-grade chondrosarcoma of long bones. A long-term follow-up study is necessary, considering the slow biological progression of low-grade chondrosarcoma.

Cross-cultural adaptation and validation of the Korean Toronto Extremity Salvage Score for extremity sarcoma

A Korean version of Toronto Extremity Salvage Score (TESS), a widely used disease‐specific patient‐reported questionnaire for assessing physical function of sarcoma patients, has not been developed.

Comorbidity is Independently Associated with Poor Outcome in Extremity Soft Tissue Sarcoma

Background Comorbidity has not been examined as an independent prognostic factor in soft tissue sarcoma (STS). We examined the prognostic impact of comorbidity on oncologic outcome in STS with an adjustment for possible confounding factors. Methods A retrospective review was performed on 349 patients who had undergone surgery for high-grade localized STS of extremity at our institute. Conditions known to alter the risk of mortality, as defined in the Charlson comorbidity index, were classified as comorbidities and 43 patients (12%) had at least one comorbidity at the time of surgery. The association of comorbidity and oncologic outcomes of local recurrence-free survival (LRFS) and disease-specific survival (DSS) were tested with adjustment for confounding factors. Results Comorbidity was associated with old age, high tumor grade, and large tumor size. The presence of comorbidity was independently associated with poor LRFS and DSS, even after adjusting for confounding factors including age and treatment variables. Conclusions Our data suggest that the presence of comorbidity is an independent prognostic factor for extremity STS.

Preoperative Embolization for Bone Metastasis From Hepatocellular Carcinoma

Preoperative transcatheter arterial embolization for hypervascular bone tumors is now widely accepted as a safe and effective procedure for reducing intraoperative blood loss and surgical morbidity. However, few studies have reported the use of preoperative transcatheter arterial embolization for nonspine bone metastases from hepatocellular carcinoma. The goal of this study was to assess the effect of preoperative embolization on blood loss and clinical outcomes in surgery for nonspine bone metastasis from hepatocellular carcinoma. Seventy-five patients with metastases from hepatocellular carcinoma to the pelvis and extremities were reviewed retrospectively. The study population consisted of 62 men and 13 women, with a mean age of 64.6 years (range, 40.0-80.1). The average follow-up period was 8.2 months (range, 0.3-66.1). Twenty-two patients underwent transcatheter arterial embolization for preoperative devascularization (group A), and 53 patients underwent operative treatment only (group B). The proportion of pelvis metastases was significantly higher (P<.001) and operative time was longer (P=.006) in group A than in group B. However, a significantly smaller decrease in hemoglobin level before and after surgery was seen in group A (P=.017). No significant differences were seen in intraoperative estimated blood loss, perioperative hemoglobin level, number of allogeneic transfusions, or length of hospitalization between the 2 groups. Preoperative transcatheter arterial embolization is an effective means to reduce bleeding during surgery for nonspine metastases from hepatocellular carcinoma. In general, surgical procedures that included transcatheter arterial embolization took longer and were more extensive.

Incidence and Treatment Pattern of Extremity Soft Tissue Sarcoma in Korea, 2009-2011: A Nationwide Study Based on the Health Insurance Review and Assessment Service Database.

Purpose We conducted a nationwide study to assess the incidence and treatment patterns of extremity soft tissue sarcoma (STS) in South Korea. Materials and Methods The nationwide incidence and treatment patterns of extremity STS were assessed using two nationwide databases, the Korea National Cancer Incidence (KNCI) database and the Health Insurance Review and Assessment Service (HIRA) database. Results A total of 1,236 patients were newly diagnosed with extremity STS during the 3-year study period, from 2009 to 2011. The annual incidence of extremity STS in the Korean population was approximately 0.9 per 100,000 people with a male bias that increased with age and was especially pronounced amongst individuals aged > 80 years. Approximately 7% of patients did not receive any treatment, and surgical excision was performed for 85% of those who were treated. Conclusion This is the first nationwide study of the incidence and treatment patterns of extremity STS in Korea using two national databases (KNCI and HIRA), which include the entire Korean population. The results of this study may be useful for future planning and management of STS, at the national level.

Orthopaedic Case of the Month: Lower Leg Pain in a 41-year-old Woman

A 41-year-old-woman presented with a 10-year history of left lower leg pain distributed from the midportion of the lower leg to the foot and ankle. She had no history of relevant trauma or constitutional symptoms suggesting systemic illness. Shortly after the pain began she was seen at another hospital; no radiographs were taken but she had an MR scan (Fig. 1). The MR scan showed cortical thickening and bone marrow edema, suggesting chronic inflammation. The patient experienced little relief of her leg pain with 4 weeks of rest. The patient tolerated the pain for 8 years, then her leg pain worsened and she underwent an open biopsy of the bone at the midshaft of the left tibia at another hospital. The bone biopsy reportedly revealed chronic inflammation and osteoporosis. She was diagnosed as having low-grade osteomyelitis at the time. After biopsy the pain immediately subsided. However, the pain recurred 1 year after the biopsy and subsequently progressed. She presented to us 1 year later (2 years after the initial biopsy). There was no relevant familial history. A physical examination showed no swelling, redness, or warmth. There was localized tenderness over the anterior midshaft of the left tibia. The ranges of motion of bilateral hips, knees, and ankles were full. Other than a hemoglobin level of 10.6 g/dL, she had normal laboratory findings. No leukocytosis was evident, and the erythrocyte sedimentation rate (ESR) was 20 mm/ hour (normal range, 0–20 mm/hour), C-reactive protein was 0.01 mg/dL (normal range, 0–0.5 mg/dL), and serum alkaline phosphatase (ALP) was 41 IU/L (normal range, 30–115 IU/L). Plain radiographs, MRI, and technetium-99 bone scan (Tc-99 MDP bone scan) were obtained (Figs. 1–6). Based on the history, physical examination, laboratory studies, and imaging studies, what is the differential diagnosis at this point?

Outcomes of Hemiepiphyseal Stapling for Genu Valgum Deformities in Patients With Multiple Hereditary Exostoses: A Comparative Study of Patients With Deformities of Idiopathic Cause.

Background: Patients with multiple hereditary exostoses (MHE) frequently present with a genu valgum deformity. Temporary hemiepiphysiodesis, such as hemiepiphyseal stapling, is a relatively safe surgical method to correct angular deformities in skeletally immature patients, but its outcomes for genu valgum deformity in MHE patients have not been extensively reported. We investigated the outcomes of hemiepiphyseal stapling in MHE patients (MHE group) and compared those with the outcomes in patients with idiopathic deformities (idiopathic group) after adjusting for potential bias. Methods: Data from 70 limbs with genu valgum deformity (15 MHE and 55 idiopathic), which had undergone hemiepiphyseal stapling, were retrospectively reviewed. The outcomes were focused on the achievement of satisfactory correction and the velocity of correction. The independent effects of each characteristic on each outcome were investigated using multivariate analyses. The outcomes between the groups were also compared after 1:2 matching using propensity score analysis. Results: The mean valgus angle of the MHE group was 7.4±4.1 degrees at stapling and was corrected to 1.3±3.0 degrees at staple removal. The rate of satisfactory corrections was not different between the MHE and idiopathic groups (67% and 70%, respectively, P=0.820). However, the correction velocity was significantly lower in the MHE group than in the idiopathic group on both multivariate analysis (P=0.001) and matching comparison (4.4 vs. 7.9 degrees/y, P<0.001). The duration of correction was longer in the MHE group than in the idiopathic group by approximately half a year (1.5±0.6 vs. 0.9±0.3 y, respectively, P=0.003). Conclusions: In MHE patients with genu valgum deformity, satisfactory correction can be achieved by hemiepiphyseal stapling and is comparable with that seen in idiopathic patients. However, the MHE group showed lower correction velocity and required a longer time by about one half year for correction compared with the idiopathic group. Temporary hemiepiphysiodesis should be considered at an earlier age for patients with MHE compared with those with idiopathic deformity. Level of Evidence: Level III—prognostic study.

Non-Spine Bone Metastasis as an Initial Manifestation of Cancer in Korea

Non-spine bone metastasis accounts for approximately 20% of all skeletal metastases, but little data have been published that focused on bone metastasis to the pelvis and extremities as an initial manifestation of cancer. We determined 1) clinicopathologic characteristics of patients who presented with non-spine bone metastasis of unknown primary malignancy, and 2) process by which the diagnosis of primary cancer was made. We retrospectively reviewed 84 patients with bone metastasis of unknown primary cancer site at the time of presentation. The study population consisted of 56 men and 28 women, with a mean age of 59.1 yr (17.5-85.6 yr). The average follow-up period was 20.8 months (1-120 mo). Primary cancer site was identified in 79 patients (94.0%), and was determined to be the lung (46.4%), kidney (13.1%), liver (9.5%), thyroid (8.3%), and prostate (4.8%). Five-year overall survival rate was 28.0%. Multiple bone metastases, distant organ metastasis, and multiple bone with organ metastases were the significant prognostic factors in univariate analysis. Multiple bone metastases remained significant after multivariate analysis (P = 0.008). Lung cancer is the most common site of primary cancer, and patients with multiple bone metastases have a poor prognosis, possibly due to disseminated cancer and a greater tumor burden. Graphical Abstract