Publications by authors named "Raimondo Piana"

31 Publications

Small Subcutaneous Soft Tissue Tumors (<5 cm) Can Be Sarcomas and Contrast-Enhanced Ultrasound (CEUS) Is Useful to Identify Potentially Malignant Masses.

Int J Environ Res Public Health 2020 11 28;17(23). Epub 2020 Nov 28.

Department of Orthopaedic, Traumatology and Rehabilitation, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, CTO Hospital, Via Zuretti 29, 10126 Torino, Italy.

Subcutaneous masses smaller than 5 cm can be malignant, in contrast with the international guidelines. Ultrasound (US) and magnetic resonance imaging (MRI) are useful to distinguish a potentially malignant mass from the numerous benign soft tissue (ST) lesions. Contrast-enhanced ultrasound (CEUS) was applied in ST tumors, without distinguishing the subcutaneous from the deep lesions. We evaluated CEUS and MRI accuracy in comparison to histology in differentiating malignant from nonmalignant superficial ST masses, 50% smaller than 5 cm. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) with their 95% confidence intervals (CI) were calculated. Of malignant cases, 44.4% measured ≤5 cm. At univariate analysis, no statistically significant differences emerged between benign and malignant tumors in relation with clinical characteristics, except for relationship with the deep fascia ( = 0.048). MRI accuracy: sensitivity 52.8% (CI 37.0, 68.0), specificity 74.1% (CI 55.3, 86.8), PPV 73.1% (CI 53.9, 86.3), and NPV 54.1% (CI 38.4, 69.0). CEUS accuracy: sensitivity 75% (CI 58.9, 86.3), specificity 37% (CI 21.5, 55.8), PPV 61.4% (CI 46.6, 74.3), and NPV 52.6% (CI 31.7, 72.7). CEUS showed a sensitivity higher than MRI, whereas PPV and NPV were comparable. Also, masses measuring less than 5 cm can be malignant and referral criteria for centralization could be revised.
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http://dx.doi.org/10.3390/ijerph17238868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730454PMC
November 2020

Electrochemotherapy and Simultaneous Photodynamic Bone Stabilization of Upper Limbs in Metastatic Renal Cancer Disease: Case Report and Literature Review.

Case Rep Med 2020 14;2020:8408943. Epub 2020 Oct 14.

Oncologic Orthopaedic Division, Department of Orthopaedic and Traumatology, Orthopaedic and Trauma Center, Città Della Salute e Della Scienza,Via Gianfranco Zuretti 29, 10126 Turin, Italy.

Introduction: Metastatic bone disease represents a systemic pathology that heavily affects the quality of life of oncologic patients causing pain and functional disability. . We present the case of a patient with a history of renal cell cancer presenting pathologic fractures of both humeri and proximal right radius.

Results: After a careful multidisciplinary approach, an adjuvant anticancer therapy and a photodynamic bone stabilization procedure were performed with a minimally invasive technique aiming to minimize pain and local disease progression, while restoring functional autonomy and improving the patient's quality of life. Electrochemotherapy was delivered on the lytic bone lesions with extraskeletal involvement of the proximal left humerus and the proximal right radius, and then polymeric bone stabilization was performed on both humeri. At two months of follow-up, the patient presented satisfactory functional scores (MSTS score: 12/30 bilaterally; DASH scores: 46.7/100 for the right side and 48.3/100 for the left one), and pain was well controlled with opioid analgesics. Radiographs showed good results in terms of ossification of lytic bone lesions and durability of polymeric stabilization. At four months of follow-up, the patient reported a stable clinical scenario. Six months after surgery, due to extremely poor prognosis after the progression of primary disease, the patient was referred to palliative care and died shortly thereafter.

Conclusion: Over the last decade, the management of metastatic bone disease has changed. Low-toxicity and minimally invasive procedures such as electrochemotherapy and polymeric bone stabilization might be performed concomitantly in selected patients, as an alternative to radiation therapy and to more demanding surgical procedures such as plating and adjuvant cementing.
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http://dx.doi.org/10.1155/2020/8408943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7582063PMC
October 2020

Gait analysis: Comparative evaluation of conventional total knee replacement and modular distal femoral megaprosthesis.

Knee 2020 Oct 2;27(5):1567-1576. Epub 2020 Sep 2.

Oncologic Orthopaedic Unit, Department of Orthopaedic and Traumatology, CTO Hospital Città della Salute e della Scienza, Turin, Italy.

Background: Gait alterations have been studied with computer-assisted gait analysis after megaprosthetic replacement for tumors around the knee. It has never been proven that megaprostheses affects gait more than total knee arthroplasty (TKA); this study aims to compare via gait analysis patients who underwent megaprosthesis with patients with TKA.

Methods: We analyzed 26 patients with a megaprosthetic replacement of the distal femur and 21 patients with a standard TKA. For each subject computerized gait analysis was performed. Range of motion (ROM) of the knee was recorded, Quality of Life and functional evaluation in the oncologic group were assessed with the Musculoskeletal Tumor Society (MSTS) questionnaire, while Short Form-36 (SF-36) scores were calculated for both groups.

Results: All patients walked slower than healthy people (P < 0.05). Gait analysis showed a lower cadence than in the healthy population but no significant difference between the two groups. A longer swing and a shorter stance phase were detected in the megaprosthetic sample. The osteoarthritis group showed greater flexion during the phase of loading response, even if this was lower than the contralateral limb or healthy population. There was a statically significant difference between the healthy limb and the operated one in both groups regarding ROM, but no significant difference was registered between the two implants. MSTS score and most of SF-36 parameters showed no significant differences compared with literature data.

Conclusions: Gait analysis shows little discrepancy between the two groups; gait pattern abnormalities do not affect patients with a megaprosthetic replacement more significantly than patients undergoing TKA.
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http://dx.doi.org/10.1016/j.knee.2020.08.004DOI Listing
October 2020

End-of-Life in Oncologic Patients' Dream Content.

Brain Sci 2020 Aug 1;10(8). Epub 2020 Aug 1.

Sleep Medicine Center, Department of Neuroscience, University of Torino, 10126 Torino, Italy.

Both non-rapid eye movements and rapid eye movements sleep facilitate the strengthening of newly encoded memory traces, and dream content reflects this process. Numerous studies evaluated the impact of diseases on dream content, with particular reference to cancer, and reported the presence of issues related to death, negative emotions, pain and illness. This study investigates death and illness experiences in 13 consecutive patients with sarcoma compared to paired controls, early after diagnosis, evaluating dream contents, fear of death, mood and anxiety, distress, and severity of disease perception (perceived and communicated). Ten patients and 10 controls completed the study. Dream contents were significantly different between patients and normative data (DreamSat) and patients and controls (higher presence of negative emotions, low familiar settings and characters and no success involving the dreamer). Illness and death were present in 57% of patients' dreams (0% among controls), but no differences emerged between patients and controls in regard to anxiety and depression, distress and fear of death, even if the severity of illness was correctly perceived. The appearance of emotional elements in dreams and the absence of conscious verbalization of distress and/or depressive or anxious symptoms by patients could be ascribed to the time required for mnestic elaboration (construction/elaboration phase) during sleep.
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http://dx.doi.org/10.3390/brainsci10080505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464967PMC
August 2020

A Preliminary Study on the Mechanical Reliability and Regeneration Capability of Artificial Bone Grafts in Oncologic Cases, With and Without Osteosynthesis.

J Clin Med 2020 May 8;9(5). Epub 2020 May 8.

Oncologic Orthopaedic Division, Department of Orthopaedic and Traumatology, Orthopaedic and Trauma Center, Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy.

Several bone grafts are available for clinical use, each with their own peculiar biological and mechanical properties. A new bone graft was obtained by combining mineral structures from natural bovine bones with bioresorbable polymers and cellular nutrients. The study aims to evaluate the clinical, biological and structural properties of this bone graft and its reliability in orthopedic oncology. 23 adult patients (age range 18-85 years) were treated between October 2016 and December 2018; the oncologicdiagnoses were heterogeneous. After surgical curettage and bone grafting, a clinical-radiological follow up was conducted. Radiographs were used to evaluate graft integration according to the usual bone healing and oncologic follow up. Local complications (infection, local recurrence, wound dehiscence, fracture or early reabsorption) were evaluated. The mean followup was of 18.34 ± 4.83 months. No fracture or infection occurred. One case of patellar Giant Cell Tumor (GCT) and one of proximal tibia low-grade chondrosarcoma recurred after about one year. Two wound dehiscences occurred (one required a local flap). Follow-up X-rays showed good to excellent graft integration in most patients (20 out of 21). The investigated graft has a mechanical and structural function that can allow early weight-bearing and avoid a preventive bone fixation (only needed in four patients in this series). The graft blocks are different for shapes and dimensions, but they can be customized by the producer or sawcut by the surgeon in the operating theatre to fit the residual bone cavity. The complication rate was low, and a rapid integration was observed with no inflammatory reaction in the surrounding tissues. Further studies are mandatory to confirm these promising results.
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http://dx.doi.org/10.3390/jcm9051388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291150PMC
May 2020

Prognostic role of PD-L1 and immune-related gene expression profiles in giant cell tumors of bone.

Cancer Immunol Immunother 2020 Sep 6;69(9):1905-1916. Epub 2020 May 6.

Department of Oncology, University of Turin, Turin, Italy.

Giant cell tumor of bone (GCTB) is a locally aggressive and rarely metastatic tumor, with a relatively unpredictable clinical course. A retrospective series of 46 GCTB and a control group of 24 aneurysmal bone cysts (ABC) were selected with the aim of investigating the PD-L1 expression levels and immune-related gene expression profile, in correlation with clinicopathological features. PD-L1 and Ki67 were immunohistochemically tested in each case. Furthermore, comprehensive molecular analyses were carried out using NanoString technology and nCounter PanCancer Immune Profiling Panel, and the gene expression results were correlated with clinicopathological characteristics. PD-L1 expression was observed in 13/46 (28.3%) GCTB (and in 1/24, 4.2%, control ABC, only) and associated with a shorter disease free interval according to univariate analysis. Moreover, in PD-L1-positive lesions, three genes (CD27, CD6 and IL10) were significantly upregulated (p < 0.01), while two were downregulated (LCK and TLR8, showing borderline significance, p = 0.06). Interestingly, these genes can be related to maturation and immune tolerance of bone tissue microenvironment, suggesting a more immature/anergic phenotype of giant cell tumors. Our findings suggest that PD-L1 immunoreactivity may help to select GCTB patients with a higher risk of recurrence who could potentially benefit from immune checkpoint blockade.
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http://dx.doi.org/10.1007/s00262-020-02594-9DOI Listing
September 2020

Wrist Arthrodesis and Osteoarticular Reconstruction in Giant Cell Tumor of the Distal Radius.

J Hand Surg Am 2020 Sep 17;45(9):882.e1-882.e6. Epub 2020 Apr 17.

Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Ortopedico Rizzoli, Bologna, Italy; Università degli Studi di Bologna, Bologna, Italy.

Purpose: The aim of this multi-institutional retrospective study was to compare osteoarticular graft reconstruction (OA) and wrist arthrodesis (WA) after distal radius resection for giant cell tumor.

Material And Methods: Sixty-seven patients affected by giant cell tumor of the distal radius underwent resection and reconstruction with OA (47 patients) or WA (20 patients). The mean age was 40 years (range, 13-74 years). Grafts included fresh-frozen allograft or nonvascularized fibular autograft. Complications requiring surgical revision were recorded. Clinical outcome was assessed with the Musculoskeletal Tumour Society Score (MSTS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Results: Fifteen patients developed a local recurrence after a median of 12 months (range, 6-137 months). Sixteen patients required revision surgery for complications. Of these, 10 were graft-related complications (7 in the OA group and 3 in the WA group). Among OA, 2 patients with painful instabilities and 4 with severe arthritis required conversion into WA after a mean of 26 months (range, 13-38 months) At a median follow-up of 105 months (range, 12-395 months), similar functional outcome (MSTS and DASH score) was observed between OA and WA.

Conclusions: Our results did not show any advantage of OA or WA over the other technique. A patient-by-patient decision should be taken both regarding the type of reconstruction (OA or WA) and the type of graft (allograft or autograft). The reconstructive choice should also consider the patient's functional expectations.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2020.03.005DOI Listing
September 2020

Fibulo-scapho-lunate fusion after resection of the distal radius: Case series, review of the literature and critical analysis of bone fixation.

Injury 2020 Dec 9;51(12):2893-2899. Epub 2020 Mar 9.

Orthopaedic Oncology Center, ASST Gaetano Pini, CTO, Milan, Italy.

Fibulo-scapho-lunate fusion is a technique that allows residual movement in the wrist in case of wide bone resection replacing the distal radius by a vascularised fibular transfer. Some authors have used this technique with favourable results but the distal synthesis seems to not be standardised at all, many different osteosynthesis methods have been proposed. This paper reports a complete review of the present day literature about this subject and, evaluating the different proposed osteosynthesis techniques referred in literature, suggests a standardization of the synthesis methods with dorsal plating. We report some technical considerations and results of three cases operated with a stable dorsal osteosynthesis (twice with a double plate and once with a long plate). We evaluate the time of healing and the clinical result.
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http://dx.doi.org/10.1016/j.injury.2020.03.017DOI Listing
December 2020

Femoropatellar Osteoarthritis and Trochlear Femoral Bone Defect due to Giant Cell Tumor of the Knee: A Selected Patellofemoral Joint Arthroplasty and Reconstructive Technique: A Case Report.

JBJS Case Connect 2020 Jan-Mar;10(1):e0378

AOU Città della Salute e della Scienza di Torino-Ospedale CTO, Department of Oncological and Reconstructive Orthopaedics, Torino, Italy.

Case: A 35-year-old man with a giant cell tumor involving the lateral condyle and trochlea of the right distal femur underwent curettage of the lesion and cement grafting, which resulted in symptomatic patellofemoral osteoarthritis after more than 4 years. A standard follow-up excluded recurrence, whereas infection was ruled out while investigating the symptoms. Finally, a patellofemoral resurfacing prosthesis was implanted while filling the bone defects with tantalum cones.

Conclusion: A "tailored" surgical technique with a selected patellofemoral joint arthroplasty could be used in oncologic setting to save further bone stock for possible revisions while permitting full and quick clinical recovery.
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http://dx.doi.org/10.2106/JBJS.CC.19.00378DOI Listing
January 2021

Validation process of Toronto Exremity Salvage Score in Italian: A quality of life measure for patients with extremity bone and soft tissue tumors.

J Surg Oncol 2020 Mar 19;121(4):630-637. Epub 2020 Jan 19.

Health Care and Outcome Research, Krembil Research Institute, University Health Network, University of Toronto, MP11-322, 399 Bathurst Street, Toronto, Canada.

Background And Objectives: Limb salvage surgery remains the standard treatment in bone and soft tissue tumors. Toronto Extremity Salvage Score (TESS) is the most used quality of life measure. Our objective was to perform cross-cultural adaptation and validation in Italian, testing test-retest reliability, construct validity, and responsiveness.

Methods: We interviewed patients already treated for content validity. A total of 124 patients completed TESS and other questionnaires presurgery, at 3 months, 3 months + 2 weeks, and 6 months follow-up. We calculated intraclass correlation coefficients (ICCs) for reliability, associations with Pearson's r, and change over time with paired T tests.

Results: A new item regarding touch-screen devices was added to the upper extremity (UE) questionnaire. ICC resulted of 0.99 for lower extremity (LE) and 0.98 for UE patients, Pearson's r between TESS and Musculoskeletal Tumor Society was .66 and .64, EuroQol-5D-5L r was .62 and .61, and r between TESS and short form-36 physical function subscale was .76 and .71 for LE and UE groups, respectively. Paired T test results were statistically significant to detect change over time (0.03, 0.04, and 0.04 for LE groups and 0.03, 0.01, and 0.04 for UE groups).

Conclusion: The Italian version of TESS can be used for the bone and soft tissue sarcoma population in clinical trials in Italy and with Italian speaking patients abroad to ensure patients' perspectives for efficacy and efficiency of treatments.
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http://dx.doi.org/10.1002/jso.25849DOI Listing
March 2020

The intraoperative use of aortic balloon occlusion technique for sacral and pelvic tumor resections: A case-control study.

Surg Oncol 2020 Mar 20;32:69-74. Epub 2019 Nov 20.

Oncologic Orthopaedic Surgery Division, CTO Hospital - AOU Città della Salute e della Scienza di Torino, Italy.

Introduction: Pelvic and sacral tumor surgery is traditionally characterized by several major complications. Bleeding is probably the most feared and dreadful complication. The aim of the study was to evaluate whether the intraoperative use of the intra-aortic balloon occlusion technique could decrease the perioperative blood loss. A secondary aim was to assess aortic balloon-related complications.

Materials And Methods: From January 2014 to December 2017 15 patients (Group 1) treated with intra-aortic balloon inflation were prospectively enrolled and compared to a historical control group (Group 2) of 11 patients with similar surgeries. Number of blood units transfused, perioperative hemoglobin values, hours spent in intensive care unit (ICU), length of inpatient stay, and perioperative complications were evaluated.

Results: Intraoperatively, a mean of 6.1 blood units per patient (BUPP) was used in Group 1 and 16.2 BUPP in Group 2. Postoperatively the averages were 2,8 and 5,4 BUPP in Group 1 and 2, respectively. Patients in Group 1 had a faster recovery in hemoglobin values, as well as a shorter length of overall inpatient stay (28,9 vs 59 days) and of ICU stay (33.9 vs 74.6 h). The most relevant complications observed in Group 1 were two thrombosis at the incannulation site that required a surgical arterial thrombectomy.

Conclusion: The intra-aortic balloon occlusion is an effective technique to control bleeding during the resections of huge pelvic and sacral tumors. A proper training of a multidisciplinary team and an accurate patient selection are required to prevent major complications.
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http://dx.doi.org/10.1016/j.suronc.2019.11.003DOI Listing
March 2020

Letter to the Editor Regarding "Intraneural Ewing Sarcoma of Fibular Nerve: Case Report, Radiologic Findings and Review of Literature".

World Neurosurg X 2019 Apr 1;2:100017. Epub 2019 Feb 1.

Oncologic and Orthopaedic Surgery - AOU Città della Salute e della Scienza Torino, Turin, Italy; and Regional Reference Centre for Bone and Soft Tissue Sarcomas, Turin, Piedmont, Italy.

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http://dx.doi.org/10.1016/j.wnsx.2019.100017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580878PMC
April 2019

Management of Paprosky type three B acetabular defects by custom-made components: early results.

Int Orthop 2019 01 16;43(1):117-122. Epub 2018 Oct 16.

Orthopaedic Department, Città della Salute e della Scienza, University of Turin, Viale 25 Aprile 137 int 6, 10133, Turin, Italy.

Purpose: Our study aims at the evaluation of the recently introduced Lima Promade custom-made acetabular device for the treatment of complex acetabular Paprosky 3B defects.

Methods: Between 2016 and 2018, eight patients with major acetabular osteolysis and multiple revisions history were treated with a custom-made implant in a single centre and by a single surgeon. We assessed patients' demographics, peri-operative data, and complications and a specific questionnaire was submitted to the surgeon after each procedure.

Results: All the devices were correctly positioned. In two over eight cases, a post-operative dislocation occurred, where extensive soft tissue impairment was present. The questionnaire showed a good pre-operative and intra-operative experience of the surgeon.

Conclusions: The Promade custom-made acetabular system showed encouraging results for complex defects and the entire procedure was positively rated. Further analysis with a higher number of cases and a longer follow-up should be performed for a complete clinical and cost-effective evaluation.
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http://dx.doi.org/10.1007/s00264-018-4203-5DOI Listing
January 2019

Trabectedin and olaparib in patients with advanced and non-resectable bone and soft-tissue sarcomas (TOMAS): an open-label, phase 1b study from the Italian Sarcoma Group.

Lancet Oncol 2018 10 11;19(10):1360-1371. Epub 2018 Sep 11.

Medical Oncology-Sarcoma Unit, Istituto di Candiolo-Fondazione del Piemonte per l'Oncologia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Candiolo, Italy; Department of Oncology, University of Torino, Regione Gonzole, Orbassano, Italy.

Background: Trabectedin is an alkylating drug with a unique mechanism of action causing single-strand and double-strand DNA breaks that activate DNA damage-response pathways. Based on our preclinical data, we hypothesised that poly(ADP-ribose) polymerase 1 (PARP1) inhibitors might be an ideal partner of trabectedin and aimed to assess the safety, identify the recommended phase 2 dose, and explore preliminary signs of activity of trabectedin and olaparib combination treatment in patients with bone and soft-tissue sarcoma.

Methods: We did an open-label, multicentre, phase 1b study, recruiting patients from the national Italian sarcoma network aged 18 years and older with histologically confirmed bone and soft-tissue sarcoma progressing after standard treatments with Eastern Cooperative Oncology Group performance status of 1 or less. In a classic 3 + 3 design, patients received a 24 h infusion of trabectedin on day 1 and olaparib orally twice a day in 21-day cycles across six dose levels (trabectedin 0·675-1·3 mg/m every 3 weeks; olaparib 100-300 mg twice a day from day 1 to 21). Intermediate dose levels were permitted to improve safety and tolerability. The primary endpoint was determination of the recommended phase 2 dose (the maximum tolerated dose). Safety and antitumour activity were assessed in all patients who received at least one dose of the study drugs. We report the results of the dose-escalation and dose-expansion cohorts. The trial is still active but closed to enrolment, and follow-up for patients who completed treatment is ongoing. This trial is registered with ClinicalTrials.gov, number NCT02398058.

Findings: Between Nov 17, 2014, and Jan 30, 2017, of 54 patients assessed for eligibility, we enrolled 50 patients: 28 patients in the dose-escalation cohort and 22 patients in the dose-expansion cohort. Patients received a median of four cycles of treatment (IQR 2-6; range 1-17 [the patients who received the highest number of cycles are still on treatment]) with a median follow-up of 10 months (IQR 5-23). Considering all dose levels, the most common grade 3-4 adverse events were lymphopenia (32 [64%] of 50 patients), neutropenia (31 [62%]), thrombocytopenia (14 [28%]), anaemia (13 [26%]), hypophosphataemia (20 [40%]), and alanine aminotransferase concentration increase (9 [18%]). No treatment-related life-threatening adverse events or deaths occurred. One (2%) patient interrupted treatment without progression without reporting any specific toxicity. Observed dose-limiting toxicities were thrombocytopenia, neutropenia for more than 7 days, and febrile neutropenia. We selected intermediate dose level 4b (trabectedin 1·1 mg/m every 3 weeks plus olaparib 150 mg twice a day) as the recommended phase 2 dose. Seven (14%; 95% CI 6-27) of 50 patients achieved a partial response according to Response Evaluation Criteria In Solid Tumors 1.1.

Interpretation: Trabectedin and olaparib in combination showed manageable toxicities at active dose levels for both drugs. Preliminary data on antitumour activity are encouraging. Two dedicated phase 2 studies are planned to assess activity of this combination in both ovarian cancer (EudraCT2018-000230-35) and soft-tissue sarcomas.

Funding: Italian Association for Cancer Research, Italian Sarcoma Group, Foundation for Research on Musculoskeletal and Rare Tumors, and Italian Ministry of Health.
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http://dx.doi.org/10.1016/S1470-2045(18)30438-8DOI Listing
October 2018

The surgical treatment of acromioclavicular joint injuries.

EFORT Open Rev 2017 Oct 19;2(10):432-437. Epub 2017 Oct 19.

CTO Hospital Turin, Italy.

Acromioclavicular joint (ACJ) injuries are common, but their incidence is probably underestimated. As the treatment of some sub-types is still debated, we reviewed the available literature to obtain an overview of current management.We analysed the literature using the PubMed search engine.There is consensus on the treatment of Rockwood type I and type II lesions and for high-grade injuries of types IV, V and VI. The treatment of type III injuries remains controversial, as none of the studies has proven a significant benefit of one procedure when compared with another.Several approaches can be considered in reaching a valid solution for treating ACJ lesions. The final outcome is affected by both vertical and horizontal post-operative ACJ stability. Synthetic devices, positioned using early open or arthroscopic procedures, are the main choice for young people.Type III injuries should be managed surgically only in cases with high-demand sporting or working activities. Cite this article: 2017;2:432-437. DOI: 10.1302/2058-5241.2.160085.
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http://dx.doi.org/10.1302/2058-5241.2.160085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5702953PMC
October 2017

Carbon-fiber reinforced intramedullary nailing in musculoskeletal tumor surgery: a national multicentric experience of the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group.

Injury 2017 Oct;48 Suppl 3:S55-S59

The Italian Orthopaedic Society (SIOT), Rome, Italy.

Introduction: Carbon fiber reinforced (CFR) implants have been proposed for the treatment of fractures or impending fractures of the long bones in the oncology patient. Aim of this study is to present the largest cohort of oncology patients operated by CFR nailing by the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group.

Methods: 53 adult oncology patients were operated on with a CFR-PEEK nail. All the data from adjuvants therapies were collected. Bone callus formation, response to radiotherapy, relapse or progression of the osteolysis were recorded. Hardware survival and failure, breakage and need for implant revision were also analysed.

Results: Anatomical implantation of nails include humerus (n = 35), femur (n =11) and tibia (n = 7). The most frequent tumors affecting the bone were myeloma (n = 13), breast (n = 11), lung (n = 8), and renal cell cancer (n = 7). Acrylic cement reinforcement was used in 2 patients. One patient was subjected to electrochemotherapy after nail insertion. Intraoperative and early postoperative complications occurred in 13.2% and 7.54% of patients respectively. Eight patients had local progression and one developed a stress fracture proximally to the distal static screw. Radiographic union occurred in 14 patients; one screw loosening was recorded.

Discussion: There is currently a lack of solid evidence on the clinical use of CFR nails in oncologic patients. This is the first and largest study of CFR nailing, with the longest available follow up.

Conclusions: Implant related complications and surgery-related morbidity should be taken into account in the decision-making process for the surgical management of these patients. These data can improve the surgeon-patient communication and guide further studies on patients' survival and complications with respect to surgery.
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http://dx.doi.org/10.1016/S0020-1383(17)30659-9DOI Listing
October 2017

Diffusion-weighted imaging for the cellularity assessment and matrix characterization of soft tissue tumour.

Radiol Med 2017 Nov 8;122(11):871-879. Epub 2017 Jul 8.

Dipartimento di Radiologia, Azienda Ospedaliera Città della Salute e della Scienza, Centro Traumatologico Ortopedico, Via Zuretti 29, 10126, Torino, Italy.

Purpose: To evaluate whether apparent diffusion coefficient (ADC) of diffusion-weighted imaging (DWI) is able to investigate the histological features of soft tissue tumours.

Methods: We reviewed MRIs of soft tissue tumours performed from 2012 to 2015 to calculate the average ADCs. We included 46 patients (27 male; mean age: 57 years, range 12-85 years) with histologically proven soft tissue tumours (10 benign, 2 intermediate 34 malignant) grouped into eight tumour type classes. An experienced pathologist assigned a semi-quantitative cellularity score (very high, high, medium and low) and tumour grading. The t test, ANOVA and linear regression were used to correlate ADC with clinicopathological data. Approximate receiver operating characteristic curves were created to predict possible uses of ADC to differentiate benign from malignant tumours.

Results: There was a significant difference (p < 0.01) in ADCs between these three groups excluding myxoid sarcomas. A significant difference was also evident between the tumour type classes (p < 0.001), grade II and III myxoid lesions (p < 0.05), tumour grading classes (p < 0.001) and cellularity scores classes (p < 0.001), with the lowest ADCs in the very high cellularity. While the linear regression analysis showed a significant relationship between ADC and tumour cellularity (r = 0.590, p ≤ 0.05) and grading (r = 0.437, p ≤ 0.05), no significant relationship was found with age, gender, tumour size and histological subtype. An optimal cut-off ADC value of 1.45 × 10 mm/s with 76.8% accuracy was found to differentiate benign from malignant tumours.

Conclusions: DWI may offer adjunctive information about soft tissue tumours, but its clinical role is still to be defined.
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http://dx.doi.org/10.1007/s11547-017-0787-xDOI Listing
November 2017

Management of the first episode of traumatic shoulder dislocation.

EFORT Open Rev 2017 Feb 13;2(2):35-40. Epub 2017 Mar 13.

Oncology and Reconstructive Department, CTO Hospital, AOU Citta' della Salute e della Scienza, Turin, Italy.

Shoulder joint dislocation is the most common joint dislocation seen in the emergency department.Traumatic dislocation may cause damage to the soft-tissues surrounding the shoulder joint and sometimes to the bone. The treatment, which aims at restoration of a fully functioning, pain-free and stable shoulder, includes either conservative or surgical management preceded by closed reduction of the acute dislocation.Conservative management usually requires a period of rest, generally involving immobilisation of the arm in a sling, even though it is still debated whether to immobilise the shoulder in internal or external rotation.Operative management, with no significant differences in term of re-dislocation rates between open and arthroscopic repair, incorporates soft-tissue reconstructions and/or bony procedures and is recommended in young male adults engaged in highly demanding physical activities.At our institution, non-operative management is favoured particularly for patients with multi-directional instability or soft-tissue laxity. Conservative measures are often preferred in older patients or younger patients that are not actively engaged in overhead activities. Immediate surgery on all first-time dislocations may subject many patients to surgery who would not have had any future subluxation.For these reasons, initially we will always try physical therapy and activity modification for the vast majority of our patients. Cite this article: 2017;2:35-40.DOI: 10.1302/2058-5241.2.160018.
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http://dx.doi.org/10.1302/2058-5241.2.160018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367571PMC
February 2017

Adipose Derived-Mesenchymal Stem Cells Viability and Differentiating Features for Orthopaedic Reparative Applications: Banking of Adipose Tissue.

Stem Cells Int 2016 29;2016:4968724. Epub 2016 Nov 29.

Skin Bank, Department of General and Specialized Surgery, A.O.U. Città della Salute e della Scienza, Torino, Italy.

Osteoarthritis is characterized by loss of articular cartilage also due to reduced chondrogenic activity of mesenchymal stem cells (MSCs) from patients. Adipose tissue is an attractive source of MSCs (ATD-MSCs), representing an effective tool for reparative medicine, particularly for treatment of osteoarthritis, due to their chondrogenic and osteogenic differentiation capability. The treatment of symptomatic knee arthritis with ATD-MSCs proved effective with a single infusion, but multiple infusions could be also more efficacious. Here we studied some crucial aspects of adipose tissue banking procedures, evaluating ATD-MSCs viability, and differentiation capability after cryopreservation, to guarantee the quality of the tissue for multiple infusions. We reported that the presence of local anesthetic during lipoaspiration negatively affects cell viability of cryopreserved adipose tissue and cell growth of ATD-MSCs in culture. We observed that DMSO guarantees a faster growth of ATD-MSCs in culture than trehalose. At last, ATD-MSCs derived from fresh and cryopreserved samples at -80°C and -196°C showed viability and differentiation ability comparable to fresh samples. These data indicate that cryopreservation of adipose tissue at -80°C and -196°C is equivalent and preserves the content of ATD-MSCs in Stromal Vascular Fraction (SVF), guaranteeing the differentiation ability of ATD-MSCs.
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http://dx.doi.org/10.1155/2016/4968724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5153503PMC
November 2016

Accuracy and role of contrast-enhanced CT in diagnosis and surgical planning in 88 soft tissue tumours of extremities.

Eur Radiol 2016 Jul 8;26(7):2400-8. Epub 2015 Oct 8.

Department of Imaging, Azienda Ospedaliera Città della Salute e della Scienza, CTO Hospital, Via Zuretti 29, 10126, Torino, Italy.

Objectives: Soft tissue tumours (STT) require accurate diagnosis in order to identify potential malignancies. Preoperative planning is fundamental to avoid inadequate treatments. The role of contrast-enhanced computed tomography (CT) for local staging remains incompletely assessed. Aims of the study were to evaluate CT accuracy in discriminating active from aggressive tumours compared to histology and evaluate the role of CT angiography (CTA) in surgical planning.

Materials And Methods: This retrospective cohort series of 88 cases from 1200 patients (7 %) was locally studied by contrast-enhanced CT and CTA in a referral centre: 74 malignant tumours, 14 benign lesions. Contrast-enhancement patterns and relationship of the mass with major vessels and bone were compared with histology on surgically excised samples. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were evaluated in discriminating active from aggressive tumours.

Results: Sensitivity in differentiating aggressive tumours from active lesions was 89 %, specificity 84 %, PPV 90 %, NPV 82 %. The relationship between mass and major vessels/bone was fundamental for surgical strategy respectively in 40 % and in 58 % of malignant tumours.

Conclusion: Contrast-enhanced CT and CTA are effective in differentiating aggressive masses from active lesions in soft tissue and in depicting the relationship between tumour and adjacent bones and major vessels.

Key Points: • Accurate delineation of vascular and bony involvement preoperatively is fundamental for a correct resection. • CT plays a critical role in differential diagnosis of soft tissue masses. • Contrast-enhanced CT and CT angiography are helpful in depicting tumoral vascular involvement. • CT is optimal for characterization of bone involvement in soft tissue malignancies.
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http://dx.doi.org/10.1007/s00330-015-4047-yDOI Listing
July 2016

Index Finger Pollicization for Functional Preservation of the Hand After Giant Liposarcoma Resection of the Thenar Eminence.

J Hand Microsurg 2015 Jun 9;7(1):216-9. Epub 2015 Jan 9.

Microsurgery Unit, Department of Orthopaedics and Traumatology, Orthopaedic and Trauma Center CTO, Via Zuretti 29, Turin, Italy.

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http://dx.doi.org/10.1007/s12593-014-0169-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461646PMC
June 2015

How do we estimate survival? External validation of a tool for survival estimation in patients with metastatic bone disease-decision analysis and comparison of three international patient populations.

BMC Cancer 2015 May 22;15:424. Epub 2015 May 22.

The Italian Orthopaedic Society Bone Metastasis Study Group, Via Nicola Martelli, 3, 00197, Rome, Italy.

Background: We recently developed a clinical decision support tool, capable of estimating the likelihood of survival at 3 and 12 months following surgery for patients with operable skeletal metastases. After making it publicly available on www.PATHFx.org , we attempted to externally validate it using independent, international data.

Methods: We collected data from patients treated at 13 Italian orthopaedic oncology referral centers between 2010 and 2013, then applied to PATHFx, which generated a probability of survival at three and 12-months for each patient. We assessed accuracy using the area under the receiver-operating characteristic curve (AUC), clinical utility using Decision Curve Analysis (DCA), and compared the Italian patient data to the training set (United States) and first external validation set (Scandinavia).

Results: The Italian dataset contained 287 records with at least 12 months follow-up information. The AUCs for the three-month and 12-month estimates was 0.80 and 0.77, respectively. There were missing data, including the surgeon's estimate of survival that was missing in the majority of records. Physiologically, Italian patients were similar to patients in the training and first validation sets. However notable differences were observed in the proportion of those surviving three and 12-months, suggesting differences in referral patterns and perhaps indications for surgery.

Conclusions: PATHFx was successfully validated in an Italian dataset containing missing data. This study demonstrates its broad applicability to European patients, even in centers with differing treatment philosophies from those previously studied.
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http://dx.doi.org/10.1186/s12885-015-1396-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443666PMC
May 2015

Midfoot reconstruction with serratus anterior-rib osteomuscular free flap following oncological resection of synovial sarcoma.

J Orthop Traumatol 2015 Dec 3;16(4):347-50. Epub 2015 Apr 3.

Microsurgery Unit, Department of Orthopaedics and Traumatology, Orthopaedic and Trauma Center, Turin, Italy.

During recent decades, the concept of surgical treatment of malignant bone and soft tissue sarcomas has evolved, with the aim of preserving limb function. In this paper we report a case of metatarsal reconstruction by means of serratus and rib free flap after excision of a synovial sarcoma located in the dorsal aspect of the midfoot. Five years after the operation, the patient was free from recurrence and recovered full foot function. Amputation has been widely used in the past and this procedure still remains a valuable option when limb salvage is not possible. Nevertheless, in selected cases, reconstruction by means of composite free flaps may be successfully used for limb preservation in the treatment of malignant foot tumors after surgical excision.
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http://dx.doi.org/10.1007/s10195-015-0341-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4633423PMC
December 2015

Perfusion pattern and time of vascularisation with CEUS increase accuracy in differentiating between benign and malignant tumours in 216 musculoskeletal soft tissue masses.

Eur J Radiol 2015 Jan 29;84(1):142-150. Epub 2014 Oct 29.

Department of Imaging, Azienda Ospedaliera Città della Salute e della Scienza, CTO Hospital, Via Zuretti 29, 10126 Torino, Italy. Electronic address:

Introduction: Musculoskeletal Soft Tissue Tumours (STT) are frequent heterogeneous lesions. Guidelines consider a mass larger than 5 cm and deep with respect to the deep fascia potentially malignant. Contrast Enhanced Ultrasound (CEUS) can detect both vascularity and tumour neoangiogenesis. We hypothesised that perfusion patterns and vascularisation time could improve the accuracy of CEUS in discriminating malignant tumours from benign lesions.

Materials And Methods: 216 STT were studied: 40% benign lesions, 60% malignant tumours, 56% in the lower limbs. Seven CEUS perfusion patterns and three types of vascularisation (arterial-venous uptake, absence of uptake) were applied. Accuracy was evaluated by comparing imaging with the histological diagnosis. Univariate and multivariate analysis, Chi-square test and t-test for independent variables were applied; significance was set at p<0.05 level, 95% computed CI.

Results: CEUS pattern 6 (inhomogeneous perfusion), arterial uptake and location in the lower limb were associated with high risk of malignancy. CEUS pattern has PPV 77%, rapidity of vascularisation PPV 69%; location in the limbs is the most sensitive indicator, but NPV 52%, PPV 65%. The combination of CEUS-pattern and vascularisation has 74% PPV, 60% NPV, 70% sensitivity. No correlation with size and location in relation to the deep fascia was found.

Conclusion: US with CEUS qualitative analysis could be an accurate technique to identify potentially malignant STT, for which second line imaging and biopsy are indicated in Referral Centers. Intense inhomogeneous enhancement with avascular areas and rapid vascularisation time could be useful in discriminating benign from malignant SST, overall when the lower limbs are involved.
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http://dx.doi.org/10.1016/j.ejrad.2014.10.002DOI Listing
January 2015

Lower Limb Core Scale: a new application to evaluate and compare the outcomes of bone and soft-tissue tumours resection and reconstruction.

Biomed Res Int 2014 3;2014:652141. Epub 2014 Aug 3.

U.O.C Muscoloskeletal Traumatology, U.O.D. Microsurgery, AO Città Della Salute e Della Scienza, C.T.O. Hospital, via Zuretti 29, 10100 Torino, Italy.

Several methods are used to evaluate the functional outcome of tumour resections and reconstructions in the lower limb. However, one of their most common limitations is that they are specifically developed to evaluate only oncological patients. We introduced the Lower Limb Core Scale (LLCS) to overcome this limitation. The aim of this study was to evaluate the functional and subjective results in the lower limb and to evaluate the use of the LLCS. We conducted a retrospective cohort study using various tools to investigate the outcomes. The results of the LLCS were correlated with the results of other functional tests. A total of 44 patients were included in the study. None of the demographic variables correlated with the functional or health-related quality of life (QoL) scores except for gender, whereby male patients had an increased functional score. The correlation between LLCS and other scores was positive (r (2) = 0.77). The satisfactory QoL scores, and functional outcomes scores indicated the LLCS to be a reliable option for general and specific evaluation of lower limb reconstructions. We suggest using the LLCS for comparisons of oncological reconstructions with lower limb reconstructions in different disciplines.
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http://dx.doi.org/10.1155/2014/652141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137603PMC
May 2015

Management of long bone metastases: recommendations from the Italian Orthopaedic Society bone metastasis study group.

Expert Rev Anticancer Ther 2014 Oct 25;14(10):1127-34. Epub 2014 Aug 25.

CTO - Ospedale Careggi, Florence, Italy.

The purpose of this article is to outline the current approach to patients affected by metastasis to the long bones and to present a clinical and surgical algorithm available for clinicians and for future research. A modern approach to patients affected by long bone metastasis in fact requires a multidisciplinary contest where oncologists, radiotherapists, surgeons and physical therapists cooperate with a shared vision, in order to provide the best possible integrated treatments available. The authors of this article constitute the Bone Metastasis Study Group of the Italian Orthopaedic Society (SIOT): a national group of orthopedic tumor surgeons who are dedicated to studying the approach, techniques and outcomes of surgery for metastatic tumours of the musculoskeletal system.
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http://dx.doi.org/10.1586/14737140.2014.947691DOI Listing
October 2014

The management of soft tissue sarcomas.

Surgeon 2012 Feb 3;10(1):25-32. Epub 2011 Dec 3.

James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk NR31 6LA, United Kingdom.

Background: Soft tissue sarcomas are a rare and heterogenous group of malignancies that are derived from the mesenchymal cell lines. In the last few decades, the management of these lesions has been improved by the introduction of dedicated Multi Disciplinary Teams (MDTs) where most bone and soft tissue tumours are now treated.(1) Following the recent changes to management outlined by the NICE/IOGs, we believe it is pertinent to review the current thinking on soft tissue tumour management.(2) We also discuss the principles of diagnosis and treatment and the role of adjuvant therapy.

Methods: This is a retrospective review. In the preparation of this paper, we have referred to recent NICE guidelines in this field and have performed a Medline search of the existing literature.

Results: The key to the success is early and appropriate patient referral. Whilst the responsibility for performing surgery has shifted away from the generalist and towards the super specialist, improvements in survivability can be achieved by promoting basic knowledge within the medical profession as a whole.

Conclusions: Both excision and biopsy of a soft tissue sarcoma by a non-specialist surgeon have been shown to increase the risk of tumour recurrence and all invasive procedures should now be performed within the MDT setting.
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http://dx.doi.org/10.1016/j.surge.2011.09.006DOI Listing
February 2012

Rugby players' awareness of concussion.

J Craniofac Surg 2011 Nov;22(6):2053-6

Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, 10126 Torino, Italy.

Purpose: Concussion is a common issue in most contact sports, such as rugby, being one of the most troublesome injuries facing the sports medicine physician. The aim of this article was to survey the knowledge and beliefs concerning concussion in a sample of young rugby athletes in the northwest of Italy.

Methods: The athletes of 4 amateur rugby teams completed a questionnaire about their knowledge about the signs and symptoms of concussion and of return-to-play strategies and protocols.

Results: Twenty-five athletes reported that they had not been informed by anyone about symptoms of concussion and its consequences. Among these, 7 players thought they could return to play immediately after a concussion during the very same match.

Conclusions: The surveyed group in this study presented a general lack of knowledge of concussion. Rugby athletes and coaches must be made aware about signs and symptoms of concussion to suspect this injury. It would be desirable that rugby players are educated regarding the potential risks of playing while symptomatic.
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http://dx.doi.org/10.1097/SCS.0b013e318231988dDOI Listing
November 2011

Rugby athletes' awareness and compliance in the use of mouthguards in the North West of Italy.

Dent Traumatol 2012 Jun 4;28(3):210-3. Epub 2011 Oct 4.

Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Corso Dogliotti 14, Turin, Italy.

Background: The prevention of dental injuries during full-contact sports such as rugby is extremely important. Wearing a mouthguard can significantly reduce the frequency and severity of orofacial injuries, but it is not always used as athletes find it difficult to tolerate. The purpose of the present study was to determine the awareness and the extent of mouthguard use in a sample of young rugby athletes in the North West of Italy.

Material And Methods: The athletes of four amateurs rugby teams based in the Province of Turin, Italy completed a questionnaire about playing history, current use and type of mouthguards, disturbs associated with mouthguard use, and general attitudes towards mouthguards.

Results: Only 53.85% of the subjects reported wearing their mouthguard all the time both during training and games. The most commonly reported problem associated with using a mouthguard was the discomfort on speech, followed by difficulty in closing lips, adversely affected breathing, adversely affected swallowing and slipping sensation. A statistically significant association between patients <22 years and non-use of mouthguards was observed.

Conclusion:  Limited knowledge about oral injury prevention and limited use of mouthguards were observed. The present study suggests that educational courses for rugby players and coaches to promote the use of mouthguards would be extremely important to reduce common complaints about these devices and increase their usage.
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http://dx.doi.org/10.1111/j.1600-9657.2011.01067.xDOI Listing
June 2012

Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours.

Eur Radiol 2010 Nov 27;20(11):2740-8. Epub 2010 Jun 27.

Department of Imaging, AO CTO/Maria Adelaide, Via Zuretti, 29, 10126, Turin, Italy.

Objective: Percutaneous biopsies are gaining acceptance in the diagnosis of soft-tissue tumours. Sampling in the most representative area is not easy in sarcomas of huge dimension. We hypothesised that ultrasound (US) contrast medium could identify the representative area for focus core-needle biopsy (CNB) METHODS: This is a retrospective cohort series of 115 soft-tissue masses treated from January 2007 to November 2008. Accuracy of US-guided CNB after contrast-enhanced US (CEUS) was determined by comparing the histology of the biopsy with the definitive diagnosis in 105 surgically excised samples (42 benign, 63 malignant) and with the expected outcome in the remaining ten malignant cases not surgically treated. A myxoid component was present in 21 sarcomas (34.4%).

Results: Of samples, 94.8% were adequate for diagnosis with 97.1% sensitivity and 92.5% specificity. Sensitivity and specificity in specific histopathological subgroupings were 100%, and in grading definition they were 100% and 96.8%.

Discussion: US-guided CNB is safe and effective. US contrast medium depicts tumour vascular supply and identifies the representative area(s) for sampling. Sensitivity and specificity are also high in subgrouping and grading, including myxoid types. Discussion about biopsy is part of the essential multidisciplinary strategy for these tumours.
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http://dx.doi.org/10.1007/s00330-010-1847-yDOI Listing
November 2010