[Oncological outcomes and prognostic factors in surgically treated patients with synovial sarcoma]

INTRODUCTION

Synovial sarcoma is an unusual tumor with an incidence of 1-3 cases per million. It is more frequent in teenagers and young adults under 30. It develops anywhere, but the extremities are the most frequent place of appearance (80% extremities, 20% other locations: 8% trunk, 7% retroperitoneal/abdominal, 5% head and neck). Oncological results are different depending on the study. Survival rate free of local recurrence, survival rate free of events and global survival rate vary upon published studies. The same happens with the disease's prognostic factors.

METHODS

The objective was to analyze a group of 43 patients with diagnosis of synovial sarcoma of the extremities treated surgically and determine (1) global survival rate, (2) survival rate free of events, (3) local recurrence rate and (4) oncological risk factors.

RESULTS

The global survival rate at 2 years was 90% (IC95%: 76 - 96%) and 67% (IC95%: 49-80%) at 5 years. The survival rate free of events at 2 years was 68% (IC95% 51-80%) and 48% (IC95% 32-52%) at 5 years. The recurrence rate at 2 years was 9% (IC95% 3-25%) and 25% (IC95% 13-46%) at 5 years. The histological grade and metastatic presence were bad prognostic factors.

DISCUSSION

We can conclude that our oncological results are in line with those published in previous series and that there were two factors associated with poor prognosis.

Pseudomyogenic hemangioendothelioma with bone and soft tissue involvement with favorable response to pamidronate: a case report and systematic review of the literature

Pseudomyogenic hemangioendothelioma (PMH) can be a challenge for diagnosis and might be confused with other tumors, such as epithelioid sarcoma. Here we present a case and a systematic review of the literature to identify and discuss PMH treatment in primary bone involvement. A 25-year-old woman was referred for bone pain (10/10) in the left lower limb. Magnetic resonance imaging (MRI) showed multiple bone lesions (left femur, tibia, patella, ankle, and foot) with well-defined borders without signs of local aggressiveness. Positron Emission Tomography-Computed Tomography (PET-CT) showed multiple metabolic musculoskeletal lesions in the left lower limb. A CT scan-guided biopsy was performed. Histological and immunohistochemical findings confirmed the diagnosis of PMH. After treatment with intravenous pamidronate (90 mg/monthly), the patient had clinical improvement, mild pain 2/10 without the use of non-steroidal anti-inflammatory drugs or opiates. Follow-up was assessed by MRI and PET-CT. PET-CT showed metabolic resolution of most of the bone and muscular lesions and a significant improvement of the femoral lesion. MRI showed that the lesions in the left femur, tibia, and foot had a marked decrease in size without intravenous post-contrast enhancement and smaller lesions had disappeared. After a 3-year follow-up, PET-CT showed no metabolically active images. Literature review identified 31 records including 58 clinical cases of PMH with primary bone involvement and treatment description for qualitative analysis. Most lesions (69%) were treated by local excision or curettage. In addition, amputations were performed in a significant percentage of cases (20.7%). In the last years, mTOR inhibitors (n = 7) and anti-resorptive treatments (n = 4) were considered as alternative treatment options, especially in multifocal lesions.

Effects of Brief Guided Imagery on Female Patients Diagnosed with Fibromyalgia: An Exploratory Controlled Trial

OBJECTIVES

To evaluate the effect of Brief Guided Imagery (BGI) on patients suffering chronic, fibromyalgia-related pain.

BACKGROUND

Fibromyalgia is characterized by chronic pain and accompanied by fatigue, depression, sleep problems, decreased daily functioning, and a lack of energy, thus negatively impacting daily functions, mental and physical health, and quality of life.

DESIGN

An exploratory, controlled trial.

SETTING

The study was conducted at Clalit Health Services (CHS) Physiotherapy Institute, Jerusalem, Israel and approved by the CHS IRB (0015-com2-16).

METHODS

Thirty-seven female patients diagnosed with fibromyalgia were alternatively allocated to an intervention group 1 (IG1) including 18 patients, or a control group (CG) including 19 patients. Following the first BGI trial, the 16 remaining participants in CG became intervention group 2 (IG2), and 13 patients completed the trial.

OUTCOME MEASURES

All patients completed a Brief Pain Inventory pain questionnaire and an SF-36 satisfaction questionnaire, before and after the intervention.

RESULTS

The findings of this study are encouraging. Training in BGI was found to be related to significant improvement in pain management, general activity, mood, walking ability, routine work, relationships with others, sleep and enjoyment of life. Significant improvements were found for overall pain, as well as for mood and quality of life.

CONCLUSIONS

We see a trend of improvement following BGI, but more research is needed to investigate this technique. Significant improvements were found for overall pain, as well as for mood and quality of life. We recommend adding BGI to treatment plans for patients suffering chronic, fibromyalgia-related pain. While other guided imagery methods last up to 20 minutes per session, BGI is innovative since only two minutes are required to obtain a positive effect on chronic pain and quality of life measures.

Nodular fasciitis, a forgotten entity

BACKGROUND

Nodular fasciitis is a benign pseudosarcomatous, self-limited, and reactive process. Based on its clinical and histological features - a fast-growing, solitary tumor with high cellularity and mitotic count - nodular fasciitis is considered to be a benign mimic of sarcoma.

METHODS

We present four cases of nodular fasciitis and a review of the literature.

RESULTS

The cases we present were initially misdiagnosed as sarcoma; two as dermatofibrosarcoma protuberans, one as atypical fibroxanthoma, and one as leiomyosarcoma.

CONCLUSION

Awareness of this entity among dermatologists is important as misdiagnosis may lead to unnecessary treatments associated with increased morbidity.

Foreign-Body Reaction and Osteolysis in Dorsal Lunate Dislocation Repair With Bioabsorbable Suture Anchor

Background: In recent years the use of biodegradable suture anchors for treating tendon and ligament pathology in hand surgery became popular. These materials are biocompatible, radiolucent, and load sharing, as they incrementally transfer load to surrounding bone during the resorption process. Despite these numerous advantages, polyglycolic (PGA) and poly-L-lactic acid (PLLA) have become a problem because of the potential risk for foreign body reactions. Methods: This article presents a case of an intraosseous foreign body reaction and massive osteolysis of the proximal carpal after dorsal lunate dislocation repair with bioabsorbable suture anchors. Results: Because of the persistent pain and the decreased strength, a proximal row carpectomy was performed 12-months after the initial trauma. Conclusions: Hand surgeons should be aware of the possibility of a late foreign body reaction, that could be especially severe in carpal bones.

A High-grade Sarcoma Arising in a Patient With Recurrent Benign Giant Cell Tumor of the Proximal Tibia While Receiving Treatment With Denosumab

BACKGROUND

A giant cell tumor of bone is a primary benign but locally aggressive neoplasm. Malignant transformation in a histologically typical giant cell tumor of bone, without radiotherapy exposure, is an uncommon event, occurring in less than 1% of giant cell tumors of bone. Although surgery is the standard initial treatment, denosumab, a monoclonal antibody drug that inhibits receptor activator of nuclear factor-κB ligand (RANKL), has shown considerable activity regarding disease and control of symptoms in patients with recurrence, unresectable, and metastatic giant cell tumors of bone.

CASE DESCRIPTION

We report the case of a 20-year-old woman with a recurrent benign, giant cell tumor of bone, who had a bone sarcoma develop while receiving denosumab treatment.

LITERATURE REVIEW

To our knowledge, there have been no reports of infection or malignancy with low-dose denosumab administration for osteoporosis. However, while there are relatively few reported side effects, the safety of denosumab and adverse events seen with higher doses, as used in treatment of giant cell tumors of bone are not well defined.

CLINICAL RELEVANCE

Denosumab has become a valuable adjunct for treatment of recurrent or unresectable giant cell tumor of bone. It is not clear if our patient's malignant transformation of a giant cell tumor of bone while receiving denosumab treatment was caused by denosumab, but it is important to be aware of the possibility if more cases occur. Future studies should focus on the safety of high-dose denosumab administration in patients with a benign unresectable giant cell tumor of bone.

Head injury and loss of consciousness raise the likelihood of developing and maintaining PTSD symptoms

Mild traumatic brain injury has been associated with higher prevalence of posttraumatic stress disorder (PTSD). The extent to which head injury or loss of consciousness predicts PTSD is unknown. To evaluate the contribution of head injury and loss of consciousness to the occurrence of PTSD, we made a longitudinal evaluation of 1,260 road accident survivors admitted to the emergency department with head injury (n = 287), head injury and loss of consciousness (n = 115), or neither (n = 858). A telephone-administered posttraumatic symptoms scale inferred PTSD and quantified PTSD symptoms at 10 days and 8 months after admission. The study groups had similar heart rate, blood pressure, and pain levels in the emergency department. Survivors with loss of consciousness and head injury had higher prevalence of PTSD and higher levels of PTSD symptoms, suggesting that patients with head injury and loss of consciousness reported in the emergency department are at higher risk for PTSD.

Early PTSD symptom trajectories: persistence, recovery, and response to treatment: results from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS)

Context

Uncovering heterogeneities in the progression of early PTSD symptoms can improve our understanding of the disorder's pathogenesis and prophylaxis.

Objectives

To describe discrete symptom trajectories and examine their relevance for preventive interventions.

Design

Latent Growth Mixture Modeling (LGMM) of data from a randomized controlled study of early treatment. LGMM identifies latent longitudinal trajectories by exploring discrete mixture distributions underlying observable data.

Setting

Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity.

Participants

Adult survivors of potentially traumatic events consecutively admitted to the hospital's emergency department (ED) were assessed ten days and one-, five-, nine- and fifteen months after ED admission. Participants with data at ten days and at least two additional assessments (n = 957) were included; 125 received cognitive behavioral therapy (CBT) between one and nine months.

Approach

We used LGMM to identify latent parameters of symptom progression and tested the effect of CBT on these parameters. CBT consisted of 12 weekly sessions of either cognitive therapy (n = 41) or prolonged exposure (PE, n = 49), starting 29.8±5.7 days after ED admission, or delayed PE (n = 35) starting at 151.8±42.4 days. CBT effectively reduced PTSD symptoms in the entire sample.

Main Outcome Measure

Latent trajectories of PTSD symptoms; effects of CBT on these trajectories.

Results

Three trajectories were identified: Rapid Remitting (rapid decrease in symptoms from 1- to 5-months; 56% of the sample), Slow Remitting (progressive decrease in symptoms over 15 months; 27%) and Non-Remitting (persistently elevated symptoms; 17%). CBT accelerated the recovery of the Slow Remitting class but did not affect the other classes.

Conclusions

The early course of PTSD symptoms is characterized by distinct and diverging response patterns that are centrally relevant to understanding the disorder and preventing its occurrence. Studies of the pathogenesis of PTSD may benefit from using clustered symptom trajectories as their dependent variables.

Role of Oxygen Precipitation Processes in Defect Formation and Evolution in Oxygen Implanted Silicon-on-Insulator Material

The role of precipitation processes in defect development in high temperature implanted single and multiple implant/anneal SIMOX was studied by transmission electron microscopy. The differences in defect type, density and location were compared. The dominant defects in single implanted and annealed material are pairs of narrow stacking faults (NSFs) at a density of ∼ 106 cm−2 while stacking fault pyramids (SFPs) at a similar density dominate multiple implant/anneal material. However, SFPs are confined to the buried oxide interface and thus the density of through-thickness defects is about two orders of magnitude lower in multiple implant (<104 cm−2) than in single implant material (∼106 cm−2). SFPs are formed from a collection of four NSFs pinned to residual oxide precipitates. This transformation is energetically possible only below a critical NSF length which is dictated by the relative location of the residual precipitates. In turn, the residual precipitate location is determined by the location of as-implanted defects on which SiO2 preferentially nucleates and grows. Thus, the synergistic interaction between precipitation and defect formation and evolution processes plays a key role in determining the final defect microstructure of SIMOX.

Breast cancer and the stromal factor. The "prometastatic healing process" hypothesis

The correlation between axillary status and several histological features of breast carcinomas has been well established, however stromal changes have rarely been analyzed. Detailed clinicopathological review of 1803 patients with infiltrating breast carcinoma was performed. Stromal myxoid changes (SMC), size (T2-T3: > 2 cm, T1c: 1-2 cm, T1 a-b: < 1cm), fibrotic focus, age, lymphovascular embolizations, tumor infiltrating lymphocytes (TIL), multifocality, histological grade (G), estrogen receptors (ER), progesterone receptors (PR) and HER2 were semi-quantitated in two or three grades and correlated to axillary status. SMC3 followed by T2-T3, G3, fibrotic focus, T1c, embolizations, SMC2, TIL2, G2 and multifocality were strongly associated with positive axillary nodes; an inverse association was found with ER+++ and PR+++. Our findings support a critical role of the peritumoral stroma in the development of metastases. These stromal alterations should be remarked in routine pathology reports as they can be easily assessed and provide important information about tumor biology and aggressiveness. They could also become, in a future, the target of novel therapeutics.

The use of antipsychotics for dementia

Clinical dilemma: In the Emergency Room you are asked to examine a patient diagnosed with dementia. You diagnose active psychosis, and contemplate whether to prescribe antipsychotic (AP) medication?