Postoperative wound complications are challenging in patients with localized extremity soft-tissue sarcomas. Various factors have been associated with wound complications, but there is no ...individualized predictive model to allow providers to counsel their patients and thus offer methods to mitigate the risk of complications and implement appropriate measures.
We used data from multiple centers to ask: (1) What risk factors are associated with postoperative wound complications in patients with localized soft-tissue sarcomas of the extremity? (2) Can we create a predictive nomogram that will assess the risk of wound complications in individual patients after resection for soft-tissue sarcoma?
From 2000 to 2016, 1669 patients undergoing limb-salvage resection for a localized primary or recurrent extremity soft-tissue sarcoma with at least 120 days of follow-up at eight participating United States Sarcoma Collaborative institutions were identified. Wound complications included superficial wounds with or without drainage, deep wounds with drainage because of dehiscence, and intentional opening of the wound within 120 days postoperatively. Sixteen variables were selected a priori by clinicians and statisticians as potential risk factors for wound complications. A univariate analysis was performed using Fisher's exact tests for categorical predictors, and Wilcoxon's rank-sum tests were used for continuous predictors. A multiple logistic regression analysis was used to train the prediction model that was used to create the nomogram. The prediction performance of the datasets was evaluated using a receiver operating curve, area under the curve, and calibration plot.
After controlling for potential confounding factors such as comorbidities, functional status, albumin level, and chemotherapy use, we found that increasing age (odds ratio 1.02; 95% confidence interval, 1.00-1.03; p = 0.008), BMI (OR 1.05; 95% CI, 1.02-1.09; p = 0.004), lower-extremity location (OR 6; 95% CI, 2.87-12.69; p < 0.001), and neoadjuvant radiation (OR 2; 95% CI, 1.47-3.16; p < 0.001) were associated with postoperative wound complications (area under the curve 69.2% range 62.8%-75.6%).
We found that age, BMI, tumor location, and timing of radiation are associated with the risk of wound complications. Based on these factors, a validated nomogram has been established that can provide an individualized prediction of wound complications in patients with a resected soft-tissue sarcoma of the extremity. This may allow for proactive management with nutrition and surgical techniques, and help determine the delivery of radiation in patients with a high risk of having these complications.
Level III, therapeutic study.
Background
Prognostic nomograms for patients with resected extremity soft tissue sarcoma (STS) include the Sarculator and Memorial Sloan Kettering (MSKCC) nomograms. We sought to validate these two ...nomograms within a large, modern, multi-institutional cohort of resected primary extremity STS patients.
Methods
Resected primary extremity STS patients from 2000 to 2017 were identified across nine high-volume U.S. institutions. Predicted 5- and 10-year overall survival (OS) and distant metastases cumulative incidence (DMCI), and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated with Sarculator and MSKCC nomograms, respectively. Predicted survival probabilities stratified in quintiles were compared in calibration plots to observed survival assessed by Kaplan–Meier estimates. Cumulative incidence was estimated for DMCI. Harrell’s concordance index (C-index) assessed discriminative ability of nomograms.
Results
A total of 1326 patients underwent resection of primary extremity STS. Common histologies included: undifferentiated pleomorphic sarcoma (35%), fibrosarcoma (13%), and leiomyosarcoma (9%). Median tumor size was 8.0 cm (IQR 4.5–13.0). Tumor grade distribution was: Grade 1 (13%), Grade 2 (9%), Grade 3 (78%). Median OS was 172 months, with estimated 5- and 10-year OS of 70% and 58%. C-indices for 5- and 10-year OS (Sarculator) were 0.72 (95% CI 0.70–0.75) and 0.73 (95% CI 0.70–0.75), and 0.72 (95% CI 0.69–0.75) for 5- and 10-year DMCI. C-indices for 4-, 8-, and 12-year DSS (MSKCC) were 0.71 (95% CI 0.68–0.75). Calibration plots showed good prognostication across all outcomes.
Conclusions
Sarculator and MSKCC nomograms demonstrated good prognostic ability for survival and recurrence outcomes in a modern, multi-institutional validation cohort of resected primary extremity STS patients. External validation of these nomograms supports their ongoing incorporation into clinical practice.
Background and Objectives
Resection of primary retroperitoneal sarcomas (RPS) has a high incidence of recurrence. This study aims to identify patterns of recurrence and its impact on overall ...survival.
Methods
Adult patients with primary retroperitoneal soft tissue sarcomas who underwent resection in 2000‐2016 at eight institutions of the US Sarcoma Collaborative were evaluated.
Results
Four hundred and ninety‐eight patients were analyzed, with 56.2% (280 of 498) having recurrences. There were 433 recurrences (1‐8) in 280 patients with 126 (25.3%) being locoregional, 82 (16.5%) distant, and 72 (14.5%) both locoregional and distant. Multivariate analyses revealed the following: Patient age P = .0002), tumor grade (P = .02), local recurrence (P = .0003) and distant recurrence (P < .0001) were predictors of disease‐specific survival. The 1‐, 3‐, and 5‐year survival rate for patients who recurred vs not was 89.6% (standard error SE 1.9) vs 93.5% (1.8), 66.0% (3.2) vs 88.4% (2.6), and 51.8% (3.6) vs 83.9% (3.3), respectively, P < .0001. Median survival was 5.3 years for the recurrence vs 11.3+ years for the no recurrence group (P < .0001). Median survival from the time of recurrence was 2.5 years.
Conclusions
Recurrence after resection of RPS occurs in more than half of patients independently of resection status or perioperative chemotherapy and is equally distributed between locoregional and distant sites. Recurrence is primarily related to tumor biology and is associated with a significant decrease in overall survival.
Background
The role of neoadjuvant chemotherapy (NCT) for high-risk soft tissue sarcoma (STS) is questioned. This study aimed to define which patients may experience a survival advantage with NCT.
...Methods
All the patients from the U.S. Sarcoma Collaborative database (2000–2016) who underwent curative-intent resection of high-grade, primary truncal/extremity STS size 5 cm or larger were included in this study. The primary end points were recurrence-free survival (RFS) and overall survival (OS).
Results
Of the 4153 patients, 770 were included in the study. The median tumor size was 10 cm, and 669 of the patients (87%) had extremity tumors. The most common histology was undifferentiated pleomorphic sarcoma (UPS), found in 42% of the patients. Of the 770 patients, 216 (28%) received NCT. The patients who received NCT had deeper, larger tumors (
p
< 0.001). Of the patients with tumors 5 cm or larger and 8 cm or larger, NCT was not associated with improved RFS or OS. However for the patients with tumors 10 cm or larger, NCT was associated with improved 5-year RFS (51% vs 40%;
p
= 0.053) and 5-year OS (58% vs 47%;
p
= 0.043). By location, the patients with extremity tumors 10 cm or larger but not truncal tumors had improved 5-yearr RFS (54% vs 42%;
p
= 0.042) and 5-year OS (61% vs 47%;
p
= 0.015) with NCT. According to histology, no subtype had improved RFS or OS with NCT, although the patients with UPS had a trend toward improved 5-year RFS (56% vs 42%;
p
= 0.092) and 5-year OS (66% vs 52%;
p
= 0.103) with NCT.
Conclusion
For the patients with high-grade STS, NCT was associated with improved RFS and OS when tumors were 10 cm or larger and located in the extremity. However, no histiotype-specific advantage was identified. Future studies assessing the efficacy of NCT may consider focusing on these patients, with added focus on histology-specific strategies.
Backgrounds and Objectives
This investigation described clinicopathological features and outcomes of extraskeletal myxoid chondrosarcoma (EMC) patients.
Methods
EMC patients were identified from the ...United States Sarcoma Collaborative database between 2000 and 2016. Overall survival (OS) and recurrence‐free survival (RFS) were calculated, and prognostic factors were analyzed.
Results
Sixty individuals with a mean age of 55 years were included, and 65.0% (n = 39) were male. 73.3% (n = 44) had a primary tumor. A total of 41.6% (n = 25) developed tumor relapse following resection. The locoregional recurrence rate was 30.0% (n = 18/60), and mean follow‐up was 42.7 months. The 5‐year OS was 71.0%, while the 5‐year RFS was 41.4%. On multivariate analysis for all EMC, chemotherapy (hazard ratio HR, 6.054; 95% confidence interval CI, 1.33−27.7; p = 0.020) and radiation (HR, 5.07, 95% CI, 1.3−20.1; p = 0.021) were independently predictive of a worse RFS. Among patients with primary EMC only, the 5‐year OS was 85.3%, with a 30.0% (n = 12) locoregional recurrence rate, though no significant prognostic factors were identified.
Conclusions
Long‐term survival with EMC is probable, however there exists a high incidence of locoregional recurrence. While chemotherapy and radiation were associated with a worse RFS, these findings were likely confounded by recurrent disease as significance was lost in the primary EMC‐only subset.
Background
Surgical resection for sarcoma lung metastases has been associated with improved overall survival (OS).
Methods
Patients who underwent curative‐intent resection of sarcoma lung metastases ...(2000–2016) were identified from the US Sarcoma Collaborative. Patients with extrapulmonary metastatic disease or R2 resections of primary tumor or metastases were excluded. Primary endpoint was OS.
Results
Three hundred and fifty‐two patients met inclusion criteria. Location of primary tumor was truncal/extremity in 85% (n = 270) and retroperitoneal in 15% (n = 49). Forty‐nine percent (n = 171) of patients had solitary and 51% (n = 180) had multiple lung metastasis. Median OS was 49 months; 5‐year OS 42%. Age ≥55 (HR 1.77), retroperitoneal primary (HR 1.67), R1 resection of primary (HR 1.72), and multiple (≥2) lung metastases (HR 1.77) were associated with decreased OS(all p < 0.05). Assigning one point for each factor, we developed a risk score from 0 to 4. Patients were then divided into two risk groups: low (0–1 factor) and high (2–4 factors). The low‐risk group (n = 159) had significantly better 5‐year OS compared to the high‐risk group (n = 108) (51% vs. 16%, p < 0.001).
Conclusion
We identified four characteristics that in aggregate portend a worse OS and created a novel prognostic risk score for patients with sarcoma lung metastases. Given that patients in the high‐risk group have a projected OS of <20% at 5 years, this risk score, after external validation, will be an important tool to aid in preoperative counseling and consideration for multimodal therapy.
Abstract Background Intracranial pressure (ICP) monitoring is a standard of care in severe traumatic brain injury when clinical features are unreliable. It remains unclear, however, whether elevated ...ICP or decreased cerebral perfusion pressure (CPP) predicts outcome. Methods This is a prospective observational study of patients sustaining severe blunt head injury, admitted to the surgical intensive care unit at the Los Angeles County and University of Southern California Medical Center between January 2010 and December 2011. The study population was stratified according to the findings of ICP and CPP. Primary outcomes were overall in-hospital mortality and mortality because of cerebral herniation. Secondary outcomes were development of complications during the hospitalization. Results A total of 216 patients met Brain Trauma Foundation guidelines for ICP monitoring. Of those, 46.8% (n = 101) were subjected to the intervention. Sustained elevated ICP significantly increased all in-hospital mortality (adjusted odds ratio 95% confidence interval: 3.15 1.11, 8.91, P = .031) and death because of cerebral herniation (adjusted odds ratio 95% confidence interval: 9.25 1.19, 10.48, P = .035). Decreased CPP had no impact on mortality. Conclusions A single episode of sustained increased ICP is an accurate predictor of poor outcomes. Decreased CPP did not affect survival.
Abstract Background The traditional theory that pulmonary emboli (PE) originate from the lower extremity has been challenged. Methods All autopsies performed in Los Angeles County between 2002 and ...2010 where PE was the cause of death were reviewed. Results Of the 491 PE deaths identified, 36% were surgical and 64% medical. Venous dissection for clots was performed in 380 patients; the PE source was the lower extremity (70.8%), pelvic veins (4.2 %), and upper extremity (1.1%). No source was identified in 22.6% of patients. Body mass index (adjusted odds ratio AOR 1.044, 95% confidence interval CI 1.011 to 1.078, P = .009) and age (AOR 1.018, 95% CI 1.001 to 1.036, P = .042) were independent predictors for identifying a PE source. Chronic obstructive pulmonary disease (AOR .173, 95% CI .046 to .646, P = .009) was predictive of not identifying a PE source. Conclusions Most medical and surgical patients with fatal PE had a lower extremity source found, but a significant number had no source identified. Age and body mass index were positively associated with PE source identification. However, a diagnosis of chronic obstructive pulmonary disease was associated with no PE source identification.
Subtotal cholecystectomy (SC) is an alternative to open total cholecystectomy (OTC) when variable anatomy or other intraoperative findings preclude safe dissection of Calot's triangle. The objective ...of this study was to compare the outcomes between SC and OTC in patients with complicated cholecystitis, cases that could not be completed with the original surgical approach and required intraoperative conversion to either SC or OTC. All cases of cholecystectomy converted to SC or OTC from January 2008 to December 2012 were retrospectively identified. Preoperative laboratory values, imaging studies, and clinical demographics were compared between the two groups. The outcome variables analyzed included hospital and intensive care unit length of stay as well as intraoperative complications. In this study, 214 cases of complicated cholecystitis were analyzed; 63 SC and 151 laparoscopic converted to OTC. From the SC group, 46 (73%) were converted to open, 12 (19%) were primary open, and five (8%) were done laparoscopically. There were no statistically significant differences in demographics, preoperative serologic markers, or intraoperative findings (P > 0.05). Five (3.3%) common bile duct (CBD) injuries occurred in the OTC group, whereas none occurred in the SC group. Overall there were 23 (15.2%) complications in the OTC group and nine (14.3%) in the SC group. The aggregate severe complication rate (CBD injury, vascular injury, gastrointestinal injury) was significantly higher in the OTC group (0.0 to 7.9%, P = 0.036). In conclusion, SC may be considered as a safe alternative in complicated cholecystitis.
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