Operative management of soft tissue sarcomas: impact of anatomic site

Operative management of soft tissue sarcomas begins with the surgical biopsy. Incisional biopsy of an undiagnosed soft tissue mass allows optimal later definitive resection, this resection including the entire biopsy wound, as well as accomplishing an "adequate" margin around the sarcoma. The principles employed for this resection are those that lead to adequate gross and microscopic margins of normal tissue around the sarcoma while considering the limitations, in terms of physical disability, from the procedure itself. This operative strategy is described for various anatomic locations, such as the extremities, trunk, retroperitoneum, and head and neck; special problems with each of these primary sites are discussed.     

Toxicologic studies of tin needles at the intrathoracic site of mice

Male Marsh mice which received a single intrathoracic injection of 4 mg of tin needles at 3 months of age were compared with controls given isotonic saline. The form and size of most of the tin needles were similar to those of asbestos needles which produced mesotheliomas and lung neoplasms in rodents. Water and food intake was markedly reduced for 24 hrs after the injection of tin. Survival rates (followed for 19 months), pathology of the bladder, liver, and kidney, as well as local and general cancer development were not adversely associated with the tin treatment as compared with the tin treatment as compared with controls. The local reaction to the tin included giant cell phagocytosis, nodular fibroplasia, and capillary formation. The failure of the tin needles to induce local neoplasms may relate to their high density as compared with silicates and/or their lack of the unique potential of the silicate particles to stimulate avascular fibrosis.     

Biocompatibility of silicon-based electrode arrays implanted in feline cortical tissue

The passive biocompatibility of silicon-based electrode arrays was studied in feline cortical tissue. Three types of arrays were used: uncoated, coated with polyimide, and coated with polyimide over an adhesion promoter. Fifteen arrays were implanted for 24 h to determine early tissue reaction to the implantation procedure, and twelve arrays were implanted for 6 months to determine structural and material biocompatibility. Edema and hemorrhage were present around the short-term implants, but involved less than 6% of the total area of the tissue covered by the array. With chronic implants, leukocytes were rarely present and macrophages were found around roughly one-third of the tracks. Remnants of foreign material from the electrodes could be identified in less than 10% of the tracks. Gliosis was found around all tracks, forming an annulus between 20 and 40 microns thick. A capsule was not always present, and never exceeded a thickness of 9 microns. These results suggest that the implantation procedure produces limited amounts of tissue damage, and that the arrays are biocompatible. However, the arrays insulated with polyimide over a primer had significantly greater involvement of macrophages, gliosis, and capsule formation than uncoated arrays and arrays insulated with polyimide without printer, perhaps indicating a reaction to aluminum oxide in the primer.     

Role of radiotherapy in soft tissue sarcoma

OBJECTIVE: To determine if the ammonia produced by Helicobacter pylori affects the phagocytic ability of human polymorphonuclear leucocytes as measured by the oxidative burst. METHODS: Interactions between opsonized urease-positive and -negative strains of H. pylori with polymorphonuclear leucocytes were studied in two series of experiments. In the first series of experiments, concentrations from 0 to 50 mM of NH4Cl were added to polymorphonuclear leucocytes. In the second series of experiments, bacteria were pre-incubated for 1 h with urea (0 to 50 mM) before addition of phagocytes. Luminol-dependent chemiluminescence was measured every 5 min over a 50-min period. The pH was verified in each treatment. RESULTS: Inhibition of chemiluminescence, increasing with concentration, was noted in all treatments when NH4Cl was added. When urea was added to urease-positive strains, chemiluminescence was significantly reduced when compared to the urease-negative strain and the zymosan control. This effect could not be attributed to a change in pH in the experiments using NH4Cl or urea at a concentration of 5 mM and 10 mM. CONCLUSION: Ammonia generated by H. pylori may contribute to the decreased activity of polymorphonuclear leucocytes in vivo.     

Modification of the sensitivity of glucose sensor implanted into subcutaneous tissue

The mechanism of reducing the glucose sensitivity of sensors implanted into the subcutaneous tissue of the normal rat was evaluated (n = 10) by comparing sensitivities observed in vitro and in vivo. In vivo sensitivity was significantly lower than that observed in vitro before implantation (p < 0.005). Most interestingly, in vitro sensitivity immediately after explanation did not differ from that in vivo and increased progressively during rinsing (p < 0.02 after 30 min). These results demonstrate that the reduction of in vivo sensitivity was not due to a local factor or factors but to a reversible alteration of the glucose sensor characteristics induced in vivo by some local factor(s). This suggests that modifications of the outer sensor membrane, the nature of which remains to be determined, may prevent this effect and resolve the problem.     

Locally recurrent soft tissue sarcoma of the extremities

BACKGROUND: The management of locally recurrent extremity soft tissue sarcoma remains challenging. This study was undertaken to evaluate the long-term outcome after therapy for isolated locally recurrent soft tissue sarcoma (STS) of the extremity. METHODS: Between January 1, 1980, and December 31, 1990, 52 patients were treated at The University of Texas M. D. Anderson Cancer Center for locally recurrent extremity STS. The records of the subset of these patients (n = 36) with isolated local recurrence were examined to document clinicopathologic and treatment factors and to evaluate outcome using the end points of local recurrence-free, recurrence-free, and overall survival. RESULTS: Limb-sparing conservative surgery was possible in 24 patients (75%). Twelve (33%) of 36 patients were treated by surgery alone, 23 patients (64%) were treated with combined modality therapy (surgery plus radiation and/or chemotherapy), and 1 patient had radiotherapy only. Sixteen (44%) of 36 patients had no further recurrence of any type at a median follow-up of 58 months (range, 4 to 173 months). The 5-year actuarial local recurrence-free, recurrence-free, and overall survival rates were 72%, 45%, and 77%, respectively. CONCLUSIONS: Limb-sparing conservative surgery is possible in the majority of patients with isolated locally recurrent STS. Durable local control can be established with individualized local treatment strategies. These results support aggressive multimodality limb-sparing treatment approaches for these patients.     

Surgical aspects in the multidisciplinary treatment of soft tissue sarcomas

Sarcomas are rare malignant tumors with a large variety of histologic subtypes. The surgical approach depends more on the histologic grade, the size and the site of the tumor. Radiologic diagnosis relies predominantly on MR-imaging. Discernible improvements have taken place in soft tissue sarcoma patient survivorship and quality of life over the past 20 years, with overall 5-year survival currently at approximately 50-80%. The place of surgery in the treatment of soft-tissue sarcoma is defined in the light of a review of the recent literature. Radical surgical resection is the mainstay of therapy. Local recurrence is the most common type of failure. Local recurrence is resectable and limb preservations possible in the majority of patients. Survival after treatment of local recurrence is determined mainly by the grade and secondarily by the size of the tumor. The essential risk factor for local recurrence is the quality of surgical resection, defined by the definitive resection margins. A lateral safety margin of 5 cm and of 2 cm to the depth should be respected. In sarcoma of the extremity the compartment is defined based on clinical, radiographic, histopathologic and operative findings. The use of muscle flaps to fill the surgical defects can improve the functional result and reduce the complication rate. Only about 5% of the patients need amputation. Evaluation of functional results must be based on objective criteria. In retroperitoneal sarcoma the significant factors for determining prognosis are grade and completeness of exzision. Multidisciplinary treatment according to common protocols is essential. Shifts in treatment have taken place over the past decade, from single-modality treatment involving radical surgery with compartment resection to sophisticated limb-salvage strategies combined with radiation therapy. In case of inadequate surgery e.g. in a large tumor with positive margins in high-grade soft tissue sarcomas the addition of radiotherapy can improve local control, but cannot ensure that obtained by adequate surgery. Patients with large (greater than 5 cm), high grade soft tissue sarcoma are at high risk for distant recurrence and disease-related mortality. Investigations of combined modality therapy with newer chemotherapy agents and dose intensification treatment strategies are warranted.     

Fistula carcinoma in chronic soft tissue infection

Squamous cell carcinoma without accompanying osteomyelitis is a rare complication in chronic soft tissue inflammation. We report on a patient with soft tissue squamous cell carcinoma developing only two years after a war accident.     

Ion induced deformation of soft tissue

In this paper the effects of changing the ion concentration in and around a sample of soft tissue are investigated. The triphasic theory developed by Lai et al. (1990, Biomechanics of Diarthrodial Joints, Vol. 1, Berlin, Springer-Verlag) is reduced to two coupled partial differential equations involving fluid ion concentration and tissue solid deformation. These equations are given in general form for Cartesian, cylindrical and spherical geometries. After solving the two equations quantities such as fluid velocity, fluid pressure, chemical potentials and chemical expansion stress may be easily calculated. In the Cartesian geometry comparison is made with the experimental and theoretical work of Myers et al. (1984, ASME J. biomech. Engng, 106, 151-158). This dealt with changing the ion concentration of a salt shower on a strip of bovine articular cartilage. Results were obtained in both free swelling and isometric tension states, using an empirical formula to account for ion induced deformation. The present theory predicts lower ion concentrations inside the tissue than this earlier work. A spherical sample of tissue subjected to a change in salt bath ion concentration is also considered. Numerical results are obtained for both hypertonic and hypotonic bathing solutions. Of particular interest is the finding that tissue may contract internally before reaching a final swollen equilibrium state or swell internally before finally contracting. By considering the relative magnitude, and also variation throughout the time course of terms in the governing equations, an even simpler system is deduced. As well as being linear the concentration equation in the new system is uncoupled. Results obtained from the linear system compare well with those from the spherical section. Thus, biological swelling situations may be modelled by a simple system of equations with the possibility of approximate analytic solutions in certain cases.     

Therapy of soft tissue injuries--biological strategies

The traumatic soft tissue injury plays a central role in fracture healing. The knowledge of pathophysiological mechanisms has completely changed the management and therapy of injuries accompanied by soft tissue lesions. Treatment is aiming for prevention of the circle of hypoxia, microvascular perfusion disturbance, increased membrane permeability and potential infections. General therapeutic principles are decontamination, debridement, revascularisation and decompression. Modern methods of soft tissue treatment take these principles into consideration.     

Clinical diagnosis of soft tissue tumors

At the secretory stage of tooth enamel formation the majority of the organic matrix is composed of amelogenin proteins that are believed to provide the scaffolding for the initial carbonated hydroxyapatite crystals to grow. The primary objective of this study was to investigate the interaction between amelogenins and growing apatite crystals. Two in vitro strategies were used: first, we examined the influence of amelogenins as compared to two other macromolecules, on the kinetics of seeded growth of apatite crystals; second, using transmission electron micrographs of the crystal powders, based on a particle size distribution study, we evaluated the effect of the macromolecules on the aggregation of growing apatite crystals. Two recombinant amelogenins (rM179, rM166), the synthetic leucine-rich amelogenin polypeptide (LRAP), poly(L-proline), and phosvitin were used. It was shown that the rM179 amelogenin had some inhibitory effect on the kinetics of calcium hydroxyapatite seeded growth. The inhibitory effect, however, was not as destructive as that of other macromolecules tested. The degree of inhibition of the macromolecules was in the order of phosvitin > LRAP > poly(L-proline) > rM179 > rM166. Analysis of particle size distribution of apatite crystal aggregates indicated that the full-length amelogenin protein (rM179) caused aggregation of the growing apatite crystals more effectively than other macromolecules. We propose that during the formation of hydroxyapatite crystal clusters, the growing apatite crystals adhere to each other through the molecular self-association of interacting amelogenin molecules. The biological implications of this adherence effect with respect to enamel biomineralization are discussed.     

Chemotherapy of metastatic soft tissue sarcoma

The chemosensitivity of bone sarcomas contrasts sharply with the comparative initial chemoresistance of soft tissue sarcomas. The lack of new effective cytotoxic agents, delayed treatment due to a clinical presentation which is often innocuous and the absence of a consensus about the role of adjuvant chemotherapy after adequate surgery account for the slow progress achieved in the treatment of these tumours and for such an appalling prognosis. Chemotherapy is still purely palliative except for certain specific metastatic lesions, and median overall survival is more often than not below 12 months. However, the optimization of the therapeutic index of the most active antimitotic drugs, the ever-increasing acceptance of the concept of a dose-effect for the majority of these lesions, the particularly promising objective response rates with intensive drug combinations and a better understanding of the development process of certain lesions and histologic subtypes make it possible to envisage a rapid improvement in their still far too dismal prognosis.     

Therapeutic use of carminomycin in soft tissue sarcomas

Under endoscopic control, biopsy specimens were taken from the oxyntic gland area of the stomach before and after administration of pentagastrin, synthetic secretin, and 13-norleucine motilin (13-nle-motilin), respectively. In 29 volunteers, the basal rate of 14C-leucine incorporation into mucosal protein averaged 41.2 +/- 7.7 X 103 cpm/mg protein (mean +/- S.D.). One and 4 hours after s.c. administration of pentagastrin (6 mug/kg body weight), values were significantly increased (p less than 0.05) by 18.9 and 21.8%, respectively, with respect to the basal level. One hour after an intravenous shot of 2 CU per kg body weight of secretin, gastric mucosal protein synthetis was not substantially inhibited, whereas a 1-hour continuous i.v. infusion of 13-nle-motilin (0.4 mug/kg body weight, hr) significantly decreased 14C-leucine incorporation rates by 17.5% (p less than 0.05). In contrast to rats, 1 hour after s.c. pentagastrin, protein synthesis in human duodenal mucosa was not altered. From these results it may be concluded that pentagastrin has a trophic influence on gastric mucosa in man. Moreover, the data presented are compatible with the hypothesis that gastrin and motilin may be involved in the regulation of human gastric mucosal protein synthesis.     

Granulation tissue polyposis associated with carcinoid tumours of the small intestine

We report two patients with ileal carcinoid tumours which were associated with polyps due to mucosal granulation tissue proliferation. In both cases the tumours had extensively infiltrated the small bowel wall and mesentery, and one had hepatic metastases. The mucosal surface of each specimen showed numerous, pale brown, sessile polyps which were restricted to the intestinal segment involved by carcinoid tumour, although not always closely related to neoplastic cells. The polyps were formed by the proliferation of capillaries, smooth muscle cells and myofibroblasts as demonstrated by immunohistochemistry and electronmicroscopy.     

Malignant giant cell tumors of soft tissue

Clinco-morphological characteristics of malignant giant cell tumours of soft tissues in 31 patients are presented. Microscopically, the tumours consisted of histiocyte-like mononuclear cells possessing a phagocytic capacity, stretched out fibroblast-like cells forming collagen fibres, multinuclear giant cells of the type of osteoclasts. Three morphological variants were singled out: 1/ predominantly round-polygonal-cellular (histiocyte-like), 2/ predominantly spindle cell (fibroblast-like) and 3/ mixed. Clinically the tumours were divided into 2 groups: superficial (in 8 patients) and deep ones (in 23 patients) developed in skeletal musculature, deep fasciae and tendons, retroperitoneally, as well as in the mammary gland, mesentery of the small intestine, the stomach. The superficial tumours were characterized by relatively low malignancy. Prognosis in the majority of patients with deep tumours of soft tissues was unfavourable. The authors share the opinion of the investigators who consider these tumours to be a malignant variant of giant cell tumours of vagina tendinis and, bearing in mind the unestablished histogenesis of these tumours, think it expedient to retain the term "malignant giant cell tumours of soft tissues".