INJURIES OF THE HAND AND FOREARM—Treatment of Damaged Soft Tissues

Successful primary repair of soft tissue injuries of the hand and forearm holds the ultimate disability to a minimum. The kinds of trauma and the resultant soft tissue damage may be classified. Attention to details and technique in carrying out the primary reparative operation on the injured hand largely obviates a crippling deformity or the need for much reconstruction later.     

Vascular endothelial growth factor-D is a key molecule that enhances lymphatic metastasis of soft tissue sarcomas

Studies on lymph node metastasis of soft tissue sarcomas are insufficient because of its rarity. In this study, we examined the expressions of vascular endothelial growth factor (VEGF)-C and VEGF-D in soft tissue sarcomas metastasized to lymph nodes. In addition, the effects of the two molecules on the barrier function of a lymphatic endothelial cell monolayer against sarcoma cells were analyzed. We examined 7 patients who had soft tissue sarcomas with lymph node metastases and who had undergone neither chemotherapy nor radiotherapy before lymphadenectomy. Immunohistochemistry revealed that 2 of 7 sarcomas that metastasized to lymph nodes expressed VEGF-C both in primary and metastatic lesions. On the other hand, VEGF-D expression was detected in 4 of 7 primary and 7 of 7 metastatic lesions, respectively. Interestingly, 3 cases that showed no VEGF-D expression at primary sites expressed VEGF-D in metastatic lesions. Recombinant VEGF-C at 10(-8) and VEGF-D at 10(-7)and 10(-8)g/ml significantly increased the random motility of lymphatic endothelial cells compared with controls. VEGF-D significantly increased the migration of sarcoma cells through lymphatic endothelial monolayers. The fact that VEGF-D induced the migration of fibrosarcomas through the lymphatic endothelial monolayer is the probable reason for the strong relationship between VEGF-D expression and lymph node metastasis in soft tissue sarcomas. The important propensities of this molecule for the increase of lymph node metastases are not only lymphangiogenesis but also down-regulation of the barrier function of lymphatic endothelial monolayers, which facilitates sarcoma cells entering the lymphatic circulation.     

Primary intramuscular infestation of Echinococcus granulosus misdiagnosed as a soft tissue tumor: a case report

BACKGROUND: The occurrence of a primary intramuscular infestation of Echinococcus granulosus is extremely rare. CASE: A 70-year-old woman with primary skeletal muscle hydatidosis initially presented with a soft tissue mass. Clinical and radiologic examination revealed a huge cystic mass in the right quadriceps muscle without any visceral organ involvement. Since the differential diagnosis included a soft tissue tumor, fine needle aspiration cytology was performed, and a diagnosis of hydatid disease was made. CONCLUSION: This very rare case of primary intramuscular infestation of E granulosus was clinically misdiagnosed as a soft tissue tumor. Hydatid disease, albeit rare, should be considered in the differential diagnosis of a soft tissue mass.     

Establishment of a primary human sarcoma model in athymic nude mice

Improvement of soft tissue sarcoma patient outcome requires well-characterized animal models in which to evaluate novel therapeutic options. Xenograft sarcoma models are frequently used, but commonly with established cell lines rather than with primary human sarcoma cells. The objective of the present study was to establish a reproducible xenograft model of primary human soft tissue sarcoma in athymic nude mice. Primary soft tissue sarcoma cells from four resected human sarcomas were isolated, cultured until the third passage and injected subcutaneously into athymic nude mice. The sarcoma xenograft was further analyzed by histological and immunohistochemical staining. In two out of four sarcomas tumor growth could successfully be established leading to solid tumors of up to 540 mm³ volume. Histological and immunohistochemical staining confirmed the mouse xenograft as identical sarcoma compared with the original patient’s tissue. In the present study a reproducible xenograft model of primary human soft tissue sarcoma in athymic nude mice was established. This animal model is of great interest for the study of sarcomogenesis and therapy.     

Evaluation of P-glycoprotein expression in soft tissue sarcomas of the extremities

Soft tissue sarcomas comprise a heterogeneous group of mesenchymal tumors accounting for less than one-percent of adult neoplasms. In the last few years, the use of adjuvant chemotorapy has been proposed for the treatment of these lesions in order to obain a better systemic control, but its usefulness is still controversial. In this study, we evaluated whether P-glycoprotein, a membrane protein strictly associated with multidrug resistance, is overexpressed in soft tissue sarcomas. By using human multidrug resistant sarcoma cell lines as controls, we analyzed P-glycoprotein expression in 34 primary and in 23 relapsed soft tissue sarcomas of the extremities. Overexpression of P-glycoprotein was found in 6 out of 34 primaries (18%) and in 8 out of 23 relapses (35%). In particular, in malignant fibrous histiocytoma, the most frequent soft tissue sarcoma of adults, P-glycoprotein overexpression was found in 23% of primary untreated cases, in agreement with the reported relapse rate of this tumor after surgery and chemotherapy. These data suggest that, in soft tissue sarcomas, overexpression of P-glycoprotein may be of prognostic value and that the assessment of P-glycoprotein expression may be useful for the design of chemotherapy protocols.Abbreviations MDR multidrug-resistance - STS soft tissue sarcomas     

Crystals in hand

A genetic association of the ENPP1 gene with primary hand osteoarthritis was recently reported in this journal. ENPP1 encodes an enzyme that regulates soft tissue calcification. The study as it stands is far from complete because the actual causal variant(s) within ENPP1 has not been identified and no functional study on the activity of the enzyme in hand osteoarthritis was presented. Nevertheless, the study stimulates interest and will encourage others in the field to test ENPP1 as a possible osteoarthritis susceptibility gene in their cohorts. The genetic basis of osteoarthritis is slowly being uncovered, and this report constitutes another interesting find.     

Primary giant cell tumor of soft tissue. Report of a case with fine needle aspiration cytologic and histologic findings

BACKGROUND: So-called primary giant cell tumor of soft tissue of low malignant potential is the rare soft tissue analogue of giant cell tumor of bone, occurring primarily in superficial soft tissue. To our knowledge, the cytologic findings in bulky giant cell tumor of deep soft tissue were described only once, and no further report on the subcutaneous giant cell tumor could be retrieved from the literature. CASE: A 58-year-old woman presented with a well-demarcated, 1.5-cm-diameter dermal tumor. Fine needle aspiration smears contained numerous osteoclastlike giant cells and mononuclear cells showing bland and vesicular nuclei. A small fragment of branching vasculature and 1 mitosis were found. Those cytologic findings were enough to suggest a diagnosis of giant cell tumor of soft tissue, confirmed as a deep dermal giant cell on surgical resection. CONCLUSION: Primary giant cell tumor of soft tissue of low malignant potential should be considered in the differential diagnosis of bland-looking giant cell-rich lesions. Awareness of its existence and knowledge of its cytologic features are important for a correct preoperative cytologic diagnosis.     

Computational modelling and optimisation of soft tissue outcome in cranio-maxillofacial surgery planning

Cranio-maxillofacial (CMF) surgery operations are associated with rearrangement of facial hard and soft tissues, leading to dramatic changes in facial geometry. Often, correction of the aesthetical patient's appearance is the primary objective of the surgical intervention. Due to the complexity of the facial anatomy and the biomechanical behaviour of soft tissues, the result of the surgical impact cannot always be predicted on the basis of surgeon's intuition and experience alone. Computational modelling of soft tissue outcome using individual tomographic data and consistent numerical simulation of soft tissue mechanics can provide valuable information for surgeons during the planning stage. In this article, we present a general framework for computer-assisted planning of CMF surgery interventions that is based on the reconstruction of patient's anatomy from 3D computer tomography images and finite element analysis of soft tissue deformations. Examples from our clinical case studies that deal with the solution of direct and inverse surgical problems (i.e. soft tissue prediction, inverse implant shape design) demonstrate that the developed approach provides a useful tool for accurate prediction and optimisation of aesthetic surgery outcome.     

Fine needle aspiration cytology of primary soft tissue tumors. Morphologic analysis of the most frequent types.

We reviewed 98 cases of fine needle aspiration of soft tissue tumors with histologic confirmation performed during an eight-year period and propose a working morphologic classification based on the most prominent cytologic features. Six main tumor groups are recognized: myxoid, round cells, spindle cells, pleomorphic cells, polygonal cells and well differentiated. We believe that this classification allows recognition of the most common soft tissue tumors while helping with the differential diagnosis of other neoplasia, primary or secondary, with similar morphology and a similar presentation.     

Role of fine needle aspiration cytology in the diagnosis of soft tissue tumours

Fine needle aspiration cytology (FNAC) is a widely accepted safe, simple and rapid diagnostic procedure used in the examination of neoplastic and non‐neoplastic lesions of various locations. Since its introduction, FNAC has developed into an effective diagnostic tool practiced in a large majority of medical centres evaluating and treating oncological patients. The role of FNAC has been limited in the examination of primary soft tissue lesions, however, as many physicians working in this area recommended against using FNAC. An increasing use of minimally invasive diagnostic procedures in the last decade has resulted in a better acceptance of FNAC as a first‐line approach or as a complementary tool to core needle biopsy in the diagnosis of musculoskeletal lesions. This review discusses the role and value of FNAC in the evaluation and treatment of soft tissue tumours based on the experience gathered over the course of 48 years at the Sarcoma Center in Lund, Sweden. FNAC reports most often provide diagnostic information allowing the initiation of treatment or, when definitive diagnosis cannot be rendered from a cytological examination, guiding the continued diagnostic investigation. The main advantages of soft tissue FNAC are good sensitivity and specificity, low morbidity, speed of diagnosis, and low cost/benefit ratio. The most important disadvantages stem from limited experience in cytological diagnosis of soft tissue tumours and a lack of standardised and uniform reporting system for soft tissue FNAC.     

Salvage of proximal humeral amputations with a remnant forearm flap

Spare-part surgery of upper extremity avulsions may facilitate primary soft-tissue healing and prosthetic rehabilitation. This procedure also may be applicable to the management of analogous proximal lower extremity avulsions where a short femoral stump and a shortage of soft tissue exist.     

马来酸桂哌齐特与腹部带蒂皮瓣对上肢烧伤组织缺损的修复效果

目的：探讨马来酸桂哌齐特联合腹部带蒂皮瓣治疗手及前臂皮肤软组织烧伤缺损的临床效果。方法：选取我院2011 年2 月 -2013 年2 月收治的68 例手及前臂皮肤软组织烧伤缺损患者作为观察组,行马来酸桂哌齐特结合腹部带蒂皮瓣治疗,另选择同 期接受股前外侧皮瓣修复治疗的50 例患者为对照组。观察并比较两组患者皮瓣修复效果以及神经功能烧伤缺损评分。结果：观 察组患者皮瓣存活率高于对照组,差异具有统计学意义(P<0.05);观察组皮瓣感染率低于对照组,差异具有统计学意义(P<0.05); 观察组皮瓣断蒂时间及神经功能烧伤缺损评分均低于对照组,差异具有统计学意义(P<0.05)。结论：马来酸桂哌齐特结合腹部带 蒂皮瓣治疗具有皮瓣存活率高、神经功能恢复良好,术后恢复快等特点,值得临床推广应用。     

The compressive material properties of the plantar soft tissue

The plantar soft tissue is the primary means of physical interaction between a person and the ground during locomotion. Dynamic loads greater than body weight are borne across the entire plantar surface during each step. However, most testing of these tissues has concentrated on the structural properties of the heel pad. The purpose of this study was to determine the material properties of the plantar soft tissue from six locations beneath: the great toe (subhallucal), the 1st, 3rd and 5th metatarsal heads (submetatarsal), the lateral midfoot (lateral submidfoot) and the heel (subcalcaneal). We obtained specimens from these locations from 11 young, non-diabetic donors; the tissue was cut into 2 cm x 2 cm blocks and the skin was removed. Stress relaxation experiments were conducted and the data were fit using the quasi-linear viscoelastic (QLV) theory. To determine tissue modulus, energy loss and the effect of test frequency, we also conducted displacement controlled triangle waves at five frequencies ranging from 0.005 to 10 Hz. The subcalcaneal tissue was found to have an increased relaxation time compared to the other areas. The subcalcaneal tissue was also found to have an increased modulus and decreased energy loss compared to the other areas. Across all areas, the modulus and energy loss increased for the 1 and 10 Hz tests compared to the other testing frequencies. This study is the first to generate material properties for all areas of the plantar soft tissue, demonstrating that the subcalcaneal tissue is different than the other plantar soft tissue areas. These data will have implications for foot computational modeling efforts and potentially for orthotic pressure reduction devices.     

拇指背侧皮神经营养血管皮瓣修复对拇指远端软组织缺损的效果观察

目的:探讨拇指背侧皮神经营养血管皮瓣修复拇指远端软组织缺损的临床效果。方法:选取我院2014年1月至2016年12月收治的拇指远端软组织缺损患者100例,随机分为对照组和观察组。对照组采取腹部皮瓣对拇指远端软组织缺损进行修复,观察组采取拇指背侧皮神经营养血管皮瓣对其进行修复。通过随访患者,记录分析皮瓣的生存状况、感觉指标、外观以及手部功能的DASH评分比较两组的修复效果。结果:观察组50例患者皮瓣全部成活。对照组50例皮瓣全部成活。与对照组相比,观察组在触觉、温度觉、单丝、两点辨别觉、瘢痕挛缩方面明显优于对照组(P0.05),臃肿发生率明显低于对照组(P0.05)。观察组DASH评分为29.56±2.14分,对照组为38.13±3.12分,观察组的DASH评分明显低于对照组(P0.05)。结论:拇指背侧皮神经营养血管皮瓣修复拇指远端软组织缺损手术不破坏主要血管神经,对供区影响小,操作简单,修复的指腹感觉,拇指外形较佳,是较为理想的选择。     

Identification of primary tumors of brain metastases by SIMCA classification of IR spectroscopic images

Brain metastases are secondary intracranial lesions which occur more frequently than primary brain tumors. The four most abundant types of brain metastasis originate from primary tumors of lung cancer, colorectal cancer, breast cancer and renal cell carcinoma. As metastatic cells contain the molecular information of the primary tissue cells and IR spectroscopy probes the molecular fingerprint of cells, IR spectroscopy based methods constitute a new approach to determine the origin of brain metastases. IR spectroscopic images of 4 by 4 mm2 tissue areas were recorded in transmission mode by a FTIR imaging spectrometer coupled to a focal plane array detector. Unsupervised cluster analysis revealed variances within each cryosection. Selected clusters of five IR images with known diagnoses trained a supervised classification model based on the algorithm soft independent modeling of class analogies (SIMCA). This model was applied to distinguish normal brain tissue from brain metastases and to identify the primary tumor of brain metastases in 15 independent IR images. All specimens were assigned to the correct tissue class. This proof-of-concept study demonstrates that IR spectroscopy can complement established methods such as histopathology or immunohistochemistry for diagnosis.     

Identification of primary tumors of brain metastases by SIMCA classification of IR spectroscopic images

Brain metastases are secondary intracranial lesions which occur more frequently than primary brain tumors. The four most abundant types of brain metastasis originate from primary tumors of lung cancer, colorectal cancer, breast cancer and renal cell carcinoma. As metastatic cells contain the molecular information of the primary tissue cells and IR spectroscopy probes the molecular fingerprint of cells, IR spectroscopy based methods constitute a new approach to determine the origin of brain metastases. IR spectroscopic images of 4 by 4 mm² tissue areas were recorded in transmission mode by a FTIR imaging spectrometer coupled to a focal plane array detector. Unsupervised cluster analysis revealed variances within each cryosection. Selected clusters of five IR images with known diagnoses trained a supervised classification model based on the algorithm soft independent modeling of class analogies (SIMCA). This model was applied to distinguish normal brain tissue from brain metastases and to identify the primary tumor of brain metastases in 15 independent IR images. All specimens were assigned to the correct tissue class. This proof-of-concept study demonstrates that IR spectroscopy can complement established methods such as histopathology or immunohistochemistry for diagnosis.     

Feasibility of chemosensitivity testing in soft tissue sarcomas

BACKGROUND: Soft tissue sarcomas comprise less than 1% of all solid malignancies. The presentation and behavior of these tumors differs depending on location and histological characteristics. Standard therapy consists of complete surgical resection in combination with adjuvant radiotherapy. The role of chemotherapy is not clearly defined and is largely restricted to clinical trials. Only a limited number of agents have proved to be effective in soft tissue sarcomas. The use of doxorubicin, epirubicin and ifosfamide allowed response rates of more than 20%. In addition, recent chemotherapy trials did not demonstrate any significant differences in efficacy for various histological subtypes. METHODS: The objective of this study was to gain additional information about the chemosensitivity of soft tissue sarcomas to seven 7 different chemotherapy agents as single drugs and 4 combinations. Therefore we used an established ATP based in-vitro testing system and examined 50 soft tissue sarcomas. Chemosensitivity was assessed using a luciferin-luciferase-based luminescence assay providing individual chemosensitivity indices for each agent tested. RESULTS: The sensitivity varied widely according to the histological subtypes. The tumors state of cellular dedifferentiation played a crucial role for the efficiency of the chemotherapeutic agents. The sensitivity also depended on the presentation of the sarcoma as a primary or recurrent tumor. The highest sensitivity was demonstrated for actinomycin D as a single agent, with 74% of the tumor samples exhibiting a high-grade sensitivity (20% low sensitivity, no resistance). The combination of actinomycin D and ifosfamide yielded a high sensitivity in 76% (2% resistance). Doxorubicin as a mono-therapy or in combination with ifosfamide achieved high sensitivity in 70% and 72%, respectively, and resistance in 6% of the samples. CONCLUSION: Chemosensitivity testing is feasible in soft tissue sarcomas. It can be used to create sensitivity and resistance profiles of established and new cytotoxic agents and their combinations in soft tissue sarcomas. Our data demonstrate measurable discrepancies of the drug efficiency in soft tissue sarcomas, sarcoma subtypes and tumor recurrencies. However, current therapeutic regime does not take this in consideration, yet.     

Muscular metastasis, a rare presentation of non-small-cell lung cancer

A 71-year-old man presented with a 2-week history of pain and swelling of his left arm. Subsequent investigations revealed an intramuscular lesion, suggestive of soft tissue sarcoma. Histologic analysis was surprisingly consistent with metastasis from a primary squamous cell lung cancer. Skeletal muscle metastasis as a mode of presentation of primary lung cancer is an unusual phenomenon. A brief literature review accompanies this report.