Meta-Analysis of the Diagnostic Accuracy of Primary Bone and Soft Tissue Sarcomas by 18F-FDG-PET

Impact of the COVID-19 on the surgical management of bone and soft tissue sarcoma: A systematic review

The aim of this study was to examine cases of malpractice litigation in primary sarcoma and metastatic bone disease inorthopedic oncology, to identify the areas in which orthopedic surgeons may be guilty of negligence, and to make them aware of this. A comprehensive examination was conducted on all closed medical malpractice cases involving bone and soft tissue malignant tumors from 2014 to 2024. Patient demographics, histopathological diagnosis, and malpractice claims made in a variety of specialties were recorded. The inclusion and exclusion criteria of the study resulted in the inclusion of 70 cases of primary bone and soft tissue sarcoma and 36 cases of metastatic bone disease. A total of 47 primary tumors were bone sarcoma and 23 were soft tissue sarcoma. A total of 11 patients with primary sarcoma were accepted for malpractice claims, representing 16% of all cases within this category. Nevertheless, no evidence of malpractice was identified among the patients with metastatic bone disease (p = 0.012). Orthopedists (44 of 85 defendants), pathologists (14 of 85 defendants), and radiologists (7 of 85 defendants) were the most common defendants in primary sarcoma malpractice cases. Surgeons other than orthopedists (21 of 49 defendants), medical oncologists (4 of 49 defendants), and radiation oncologists (4 of 49 defendants) were the most common defendants in metastatic bone disease malpractice cases. Analysis of our cases suggests that malpractice claims are more likely filed against orthopedic surgeons for the treatment of primary malignant bone and soft tissue tumors than for metastatic bone disease.

The incidence of postoperative venous thromboembolism (VTE)and wound complications is greater after sarcoma resection. We sought to identify differences in postoperative VTE and bleeding complications with direct oral anticoagulants (DOACs)versus low-molecular-weight heparin (LMWH)following resection of lower extremity primary bone or soft tissue sarcoma. We retrospectively identified 2083 patients from the PearlDiver database who underwent resection of primary bone or soft tissue sarcoma of the lower extremity from January 2010 to October 2021 and prescribed LMWH or DOAC within 90-days postoperatively. The primary outcomes were comparison of postoperative incidence and odds of deep venous thrombosis(DVT), pulmonary embolism(PE), and bleeding complications within 90-days following resection. Patients prescribed DOACs had a greater odds of DVT (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.06-2.41;p = 0.024) and PE (OR: 3.38;95% CI: 1.96-5.86;p < 0.001) within 90-days following resection of bone sarcoma when compared withthe LMWH cohort. Patients undergoing resection of soft tissue sarcomas also had greater odds DVT (OR: 1.65;95% CI: 1.09-2.49;p = 0.016) and PE (OR: 2.62;95% CI: 1.52-4.54;p < 0.001) in the DOAC cohort. There was no difference in the odds of bleeding complications. This study demonstrated an increased incidence and odds of VTE, but not bleeding complications, when using DOACs versus LMWH after primary bone or soft tissue sarcoma resection. Level III.

Background Primary bone and soft tissue sarcomas are rare tumors requiring wide surgical resection and reconstruction to achieve local control. Postoperative complications can lead to delays in adjuvant therapy, potentially affecting long-term oncologic outcomes. Understanding postoperative complication risks is essential; however, past studies are limited by small sample sizes. Purpose This study uses a large national registry to characterize the incidence of complications and mortality in the first thirty days following surgical management of primary bone and soft tissue sarcomas of the extremities. Methods A retrospective review of patients in the National Surgical Quality Improvement Program database was performed. Cases were identified using diagnosis codes for malignant neoplasm of soft tissue or bone and procedure codes for amputation and radical resection. The cohort was subdivided by bone versus soft tissue sarcoma, upper versus lower extremity, and amputation versus limb salvage. Results One thousand, one hundred eleven patients were identified. The most frequent complications were surgical site infections, sepsis, and venous thromboembolism. The overall incidence of complications was 14.0%. Unplanned readmission and reoperation occurred after 7.0% and 8.0% of cases, respectively. Thirty-day mortality was 0.3%, with one intraoperative death. Patient factors and complication rates varied by tumor location and surgical modality. Lower extremity cases were associated with higher rates of wound complications and infectious etiologies such as surgical site infections, urinary tract infections, and systemic sepsis. In contrast, patients undergoing amputation were more likely to experience major medical complications including acute renal failure, cardiac arrest, and myocardial infarction. Conclusion Approximately 1 in 7 patients will experience a complication in the first thirty days following surgery for primary bone and soft tissue sarcomas of the extremities. The unique risk profiles of lower extremity and amputation cases should be considered during perioperative planning and surveillance.

What's New in Musculoskeletal Tumor Surgery.

The lungs are the commonest site of metastasis for primary high-grade bone and soft tissue sarcoma, but current guidelines on the management of pulmonary nodules do not specifically cater for this group of patients. The current article reviews the literature from the past 20 years that has reported the CT features of pulmonary metastases in the setting of known primary bone and soft tissue sarcoma, with emphasis on osteosarcoma, chondrosarcoma, and trunk and extremity soft tissue sarcoma, the aim being to aid radiologists who report chest CT of musculoskeletal sarcoma patients in deciding which lesions should be considered metastatic, which lesions are indeterminate and require follow-up, and which lesions are of no concern.

BackgroundOxidative stress is characterised by an increased level of reactive oxygen species (ROS) that disrupts the intracellular reduction-oxidation (redox) balance and has been implicated in various diseases including cancer. Malignant tumors of connective tissue or sarcomas account for approximately 1% of all cancer diagnoses in adults and around 15% of paediatric malignancies per annum. There exists no information on the alterations of oxidant/antioxidant status of sarcoma patients in literature. This study was aimed to determine the levels of oxidative stress and antioxidant defence in patients with primary bone and soft tissue sarcoma and to investigate if there exists any significant differences in these levels between both the sarcomas.MethodsThe study cohort consisted of 94 subjects; 20 soft tissue sarcoma, 27 primary bone sarcoma and 47 healthy controls. Malondialdehyde (MDA) and protein carbonyls were determined to assess their oxidative stress levels while antioxidant status was evaluated using catalase (CAT), superoxide dismutase (SOD), thiols and trolox equivalent antioxidant capacity (TEAC).ResultsSarcoma patients showed significant increase in plasma and urinary MDA and serum protein carbonyl levels (p < 0.05) while significant decreases were noted in TEAC, thiols, CAT and SOD levels (p < 0.05). No significant difference in oxidative damage was noted between both the sarcomas (p > 0.05).ConclusionsIn conclusion, an increase in oxidative stress and decrease in antioxidant status is observed in both primary bone and soft tissue sarcomas with a similar extent of damage. This study offers the basis for further work on whether the manipulation of redox balance in patients with sarcoma represents a useful approach in the design of future therapies for bone disease.

Sarcomas are classified into two types, bone sarcoma and soft tissue sarcoma (STS), which account for approximately 1% of adult solid malignancies and 20% of pediatric solid malignancies. There exist more than 50 subtypes within the two types of sarcoma. Each subtype is highly diverse and characterized by significant variations in morphology and phenotypes. Understanding tumor molecular genetics is helpful in improving the diagnostic accuracy of tumors that have been difficult to classify based on morphology alone or that have overlapping morphological features. The different molecular characteristics of bone sarcoma and STS in China remain poorly understood. Therefore, this study aimed to analyze genomic landscapes and actionable genomic alterations (GAs) as well as tumor mutational burden (TMB), microsatellite instability (MSI), and programmed death ligand-1 (PD-L1) expression among Chinese individuals diagnosed with primary bone sarcomas and STS. This retrospective study included 145 patients with primary bone sarcomas (n = 75) and STS (n = 70), who were categorized based on the 2020 World Health Organization classification system. Patients diagnosed with bone sarcomas were significantly younger than those diagnosed with STS (p < 0.01). The top 10 frequently altered genes in bone sarcoma and STS were TP53, CDKN2A, CDKN2B, MAP3K1, LRP1B, MDM2, RB1, PTEN, MYC, and CDK4.The EWSR1 fusions exhibited statistically significant differences (p < 0.01) between primary bone sarcoma and STS in terms of their altered genes. Based on the actionable genes defined by OncoKB, actionable GAs was found in 30.7% (23/75) of the patients with bone sarcomas and 35.7% (25/70) of those with STS. There were 4.0% (3/75) patients with bone sarcoma and 4.3% (3/70) patients with STS exhibited high tumor mutational burden (TMB-H) (TMB ≥ 10). There was only one patient with STS exhibited MSI-L, while the remaining cases were microsatellite stable. The positive rate of PD-L1 expression was slightly higher in STS (35.2%) than in bone sarcoma (33.3%), however, this difference did not reach statistical significance. The expression of PD-L1 in STS patients was associated with a poorer prognosis (p = 0.007). Patients with STS had a better prognosis than those with bone sarcoma, but the observed difference did not attain statistical significance (p = 0.21). Amplification of MET and MYC genes were negatively correlated with clinical prognosis in bone tumors (p<0.01). In conclusion, bone sarcoma and STS have significantly different clinical and molecular characteristics, suggesting that it is vital to diagnose accurately for clinical treatment. Additionally, comprehensive genetic landscape can provide novel treatment perspectives for primary bone sarcoma and STS. Taking TMB, MSI, PD-L1 expression, and OncoKB definition together into consideration, there are still many patients who have the potential to respond to targeted therapy or immunotherapy.

BackgroundChest wall sarcomas are rare and pose significant technical challenges in surgical management, particularly in patients with advanced disease. In this study, we examined the extent of resection, reconstruction techniques, and oncological outcomes of patients with chest wall soft tissue and bone sarcomas.MethodsThis retrospective single-center series included patients who underwent surgery at our center between May 2014 and February 2022 for deep-seated/subfascial primary and recurrent soft tissue or bone sarcomas of the chest wall requiring significant resection and extensive reconstruction. We analyzed clinical and operative data, including extent of resection, reconstruction techniques, and oncological outcomes. Additionally, we compared survival outcomes between patients with primary and recurrent tumors, and examined how these were influenced by clinical factors using Cox proportional hazards regression analysis.ResultsOf the 38 patients included, 22 were treated for primary or recurrent soft tissue sarcoma (STS) and 16 for bone sarcoma. En bloc microscopic radical resection (R0) was achieved in 95.45% and 93.75% of patients with soft tissue and bone sarcomas, respectively. Nonetheless, local recurrence or distant metastases occurred in 40%, 58.33%, and 40% of patients with primary soft tissue, recurrent soft tissue, and bone sarcomas, respectively. Adherence to clinical guidelines and treatment in the reference center was high for bone sarcoma (93.75%), but notably low for STS, resulting in 54.55% of these patients requiring re-resection. Compared with those who underwent only one surgery, patients who underwent re-resection had poorer postoperative outcomes, more severe complications, and longer hospital stay.ConclusionsChest wall sarcomas often require extensive resection and complex reconstruction. Although surgical treatment at reference sarcoma centers has significantly improved oncological and clinical outcomes, the prognosis of these patients remains guarded, necessitating further related research and continued refinement in surgical techniques, adjuvant therapies, and follow-up strategies.

To evaluate the clinical effects of transcatheter arterial embolization (TAE) on malignant bone and soft tissue tumors. TAE was performed in 10 patients with primary bone and soft tissue sarcomas and in 31 patients with metastatic bone tumors. The embolized arteries were the internal iliac artery in 30 cases, the intercostal artery in six cases, the lumbar artery in five cases, the suprascapular artery in three cases, and the iliolumbar artery, the internal pudendal artery, and the lateral sacral artery in one case each. The embolized material was gelatin sponge particles. The chemotherapeutic drugs were usually 20-40 mg of doxorubicin for primary and metastatic tumors and 50-100 mg of cisplatin only for primary tumors. In addition, 50-60 Gy of 10-MV radiotherapy with or without radiofrequency (RF)-capacitive hyperthermia in four sessions was administered before TAE for primary tumors only. Even though the pain score increased immediately after TAE, 30 of 38 (79%) patients with pain (8 of 9 with primary tumors, and 22 of 29 with metastases) achieved pain control after TAE. A necrotic low-density area shown by computed tomography (CT) after TAE was found in 31 of 41 (76%) tumors [8 of 10 (80%) with primary tumors, and 23 of 31 (74%) with metastatic tumors]. The tumor size decreased in 14 of 25 (56%) primary and metastatic tumors after 3 months. Osteosclerotic changes appeared in two cases of metastatic tumors after 6 months. In five tumors resected after TAE, large areas of necrosis within the tumor were confirmed histologically. Transient local pain and numbness appeared after TAE, but were relieved by drug treatment within 1 week. No severe complications except a case of gluteal muscle necrosis were encountered after TAE. The 1-year survival rate of the patients with primary tumors was 38.1%, and the median survival was 18 months. The longest survival was 84 months. The 1-year survival rate of the patients with metastatic bone tumors was 38.9%; the median survival was 12 months. The longest survival was 24 months. TAE could be an effective treatment for pain control and local control of malignant bone and soft-tissue tumors.

Level III, therapeutic study.

Introduction: The role of positron-emission tomography/computed-tomography (PET/CT) in the management of sarcomas and as a prognostic tool has been studied. However, it remains unclear which metric is the most useful. We aimed to investigate if volume-based PET metrics (Tumor volume (TV) and total lesions glycolysis (TLG)) are superior to maximal standardized uptake value (SUVmax) and other metrics in predicting survival of patients with soft tissue and bone sarcomas. Materials and Methods: In this retrospective cohort study, we screened over 52′000 PET/CT scans to identify patients diagnosed with either soft tissue, bone or Ewing sarcoma and had a staging scan at our institution before initial therapy. We used a Wilcoxon signed-rank to assess which PET/CT metric was associated with survival in different patient subgroups. Receiver-Operating-Characteristic curve analysis was used to calculate cutoff values. Results: We identified a total of 88 patients with soft tissue (51), bone (26) or Ewing (11) sarcoma. Median age at presentation was 40 years (Range: 9–86 years). High SUVmax was most significantly associated with short survival (defined as <24 months) in soft tissue sarcoma (with a median and range of SUVmax 12.5 (8.8–16.0) in short (n = 18) and 5.5 (3.3–7.2) in long survival (≥24 months) (n = 31), with (p = 0.001). Similar results were seen in Ewing sarcoma (with a median and range of SUVmax 12.1 (7.6–14.7) in short (n = 6) and 3.7 (3.5–5.5) in long survival (n = 5), with (p = 0.017). However, no PET-specific metric but tumor-volume was significantly associated (p = 0.035) with survival in primary bone sarcomas (with a median and range of 217 cm3 (186–349) in short survival (n = 4) and 60 cm3 (22–104) in long survival (n = 19), with (p = 0.035). TLG was significantly inversely associated with long survival only in Ewing sarcoma (p = 0.03). Discussion: Our analysis shows that the outcome of soft tissue, bone and Ewing sarcomas is associated with different PET/CT metrics. We could not confirm the previously suggested superiority of volume-based metrics in soft tissue sarcomas, for which we found SUVmax to remain the best prognostic factor. However, bone sarcomas should probably be evaluated with tumor volume rather than FDG PET activity.

BackgroundBiopsy is a crucial step within the diagnostic cascade in patients with suspected bone or soft tissue sarcoma. Open biopsy is still considered the gold standard. However, recent literature suggests similar results for percutaneous biopsy techniques. Therefore, the aim of this retrospective analysis was to compare open and percutaneous core needle biopsy (CNB) regarding their accuracy in diagnosis of malignant musculoskeletal lesions.MethodsFrom January 2007 to December 2009, all patients with suspected malignant primary bone or soft tissue tumour undergoing a percutaneous CNB or open biopsy and a subsequent tumour resection at our department were identified and enrolled. Sensitivities, specificities, positive predictive values (PPV), negative predictive values (NPV) and diagnostic accuracy were calculated for both biopsy techniques and compared using Fisher’s exact test.ResultsA total of 77 patients were identified and enrolled in this study. Sensitivity, specificity, PPV, NPV and diagnostic accuracy were 100% for CNB in bone tumours. Sensitivity (95.5%), NPV (91.7%) and diagnostic accuracy (93.3%) for open biopsy in bone tumours showed slightly inferior results without statistical significance (p > 0.05). In soft tissue tumours favourable results were obtained in open biopsies compared to CNB with differences regarding sensitivity (100% vs. 81.8%, p = 0.5), NPV (100% vs. 50%, p = 0.09) and diagnostic accuracy (100% vs. 84.6%, p = 0,19) without statistical significance. The overall diagnostic accuracy was 92.9% for CNB and 98.0% for open biopsy (p = 0.55). A specific diagnosis could be obtained in 84.2% and 93.9%, respectively (p = 0.34).ConclusionIn our study we found moderately inferior results for the percutaneous biopsy technique compared to open biopsy in soft tissue tumours whereas almost equal results were obtained for both biopsy techniques for bone tumours. Thus, CNB is a safe, minimal invasive and cost-effective technique for diagnosing bony lesions. In soft tissue masses, the indication for percutaneous core needle biopsy needs to be made carefully by an experienced orthopaedic oncologist with respect to the suspected entity, size of necrosis and location of the lesion to avoid incorrect or deficient results.

The modified Glasgow prognostic score in patients undergoing surgery for bone and soft tissue sarcoma

Limb salvage is a key goal of tumor management around the knee, with surgical, medical, and radiologic treatment options. Primary bone and soft tissue sarcomas are optimally treated in specialist tertiary centers; however, metastatic disease is encountered in all aspects of radiologic practice, with overlap in the management strategies. Both specialist and generalist radiologists therefore need to be familiar with the expected normal appearances following these therapies and be able to recognize potential complications. This review article describes the techniques available for imaging the knee following treatment of bone and soft tissue tumors, with particular reference to artifact reduction. The therapeutic options for managing bone and soft tissue lesion are discussed, with emphasis on imaging appearances. Surgical, medical, and radiologic treatments are described. Complications and their imaging appearances are reviewed including local recurrence of tumor, infection, complications related to metallic implants, postradiation changes, and amputation. Normal imaging appearances and complications following radiologic treatment (namely radiofrequency ablation) of bone and soft tissue tumors are presented.