Robert Turcotte's research while affiliated with McGill University Health Centre and other places

Introduction We aimed to determine if hypofractionated radiotherapy (HYPO-RT) delivering 30Gy in 5 fractions yields similar tumour necrosis compared to conventional radiotherapy (CONV-RT) with 50Gy in 25 fractions in STS, and its clinical significance in regard to loco-regional recurrence-free survival (LRFS), distant disease-free survival (DDFS) and overall survival (OS). Method Patients with localised STS who had CONV-RT and HYPO-RT followed by definite surgery were included. Good response is defined as tumour necrosis ≥ 90% and poor response as < 90%. Tumour characteristics including histological subtype, grading, and necrosis were reviewed. Independent sample median t-test was used to compare the median tumour necrosis. Chi-squared analysis was used for categorical variables. LRFS, DDFS and OR were estimated using Kaplan-Meier survival function. Results 74 patients had CONV-RT and 54 patients had HYPO-RT. Overall, 82 (64.1%) of patients were male. Median tumour size was 7.0 cm. Lower extremity was the most common location, n = 77 (60.2%). The most common histology across both groups was myxofibrosarcoma (32.8%) followed by myxoid liposarcoma (14.8%), and undifferentiated pleomorphic sarcoma (11.7%). The median time from completion of pre-operative radiotherapy to surgery for both groups was 35 days. There was a significant difference in median tumour necrosis percentage between CONV-RT and HYPO-RT (40.0% vs 60.0%, p = 0.011). Utilising a cut off of 90% necrosis, patients treated with the HYPO-RT of had a significantly higher percentage of tumour necrosis compared to the CONV-RT (37.0% vs 16.2%, p = 0.007). During an overall median follow up of 32 months, twelve patients (9.4%) developed loco-regional recurrence, 24 patients (18.8%) developed distant failure, and 19 patients (14.8%) died of metastatic disease. Patients with < 90% necrosis had higher loco-regional failure (12.5% vs 0%, p=0.037) and distant failure rates (24.0% vs 3.1%, p=0.009) compared to patients with ≥ 90% necrosis. The 3-year LRFS rate was 85.5% (95% CI, 77.3% - 92.3%) in patients with < 90% necrosis and 100% in those with ≥ 90% necrosis (p=0.051). The 3-year DDFS rate was 74.6% (95% CI, 65.3% - 82.1%) for those with < 90% necrosis and 96.9% (CI, 78.4 - 99.7%) for ≥ 90% necrosis (p = 0.013). The 3-year OS rate was 80.0% (CI, 69.0% - 86.5%) % for patients with < 90% necrosis and 88.9% % (CI, 61.0% - 96.8%) for ≥ 90% necrosis (p = 0.161). Conclusion Necrosis ≥90% was strongly associated with reduced risk of developing distant metastasis with a trend for reduced risk of loco-regional failure as well. HYPO-RT to a dose of 30Gy in 5 fractions was associated with higher rate of tumour necrosis compared to CONV-RT using 50Gy in 25 fractions.

To assess the clinical impact of regular whole-body magnetic resonance imaging (WBMRI) surveillance in myxoid liposarcoma patients. This was a retrospective cohort study of myxoid liposarcoma patients who underwent at least one WBMRI at our institution between October 2006 and December 2020. The effect of WBMRI on clinical management, namely treatment modification or additional diagnostic investigations was studied. A standardised WBMRI surveillance protocol was instituted in 2015. We compared patient outcomes for the metastatic patients who had and had not received regular WBMRI surveillance and performed survival analysis for both subgroups. Of the 56 patients (60.7% male, median age: 48.1 years) who underwent 345 WBMRI, 17 (30.3%) had metastases, and 168 WBMRI were performed in this group. The median imaging follow-up for the entire cohort was 35 months; the metastatic group had a median follow-up of 42 months. WBMRI changed the clinical management in 13 (76.5%) metastatic patients, with 33 instances of treatment modification. Thirty-five lesions were labelled ‘indeterminate,’ 16 (45.7%) had additional investigations/interventions, and 4 (11.4%) were confirmed to be metastatic. Twenty-one metastatic lesions were missed initially on WBMRI and confirmed on subsequent WBMRI, of which 5 (23.8%) were clinically significant. The 5-year survival since the detection of metastasis was better in the regular surveillance subgroup (85.7% vs. 45%), but this was not statistically significant (p = 0.068). Five patients (8.9%) developed their first metastasis more than 5 years after diagnosing the primary lesion. Regular WBMRI surveillance of myxoid liposarcoma patients considerably impacts clinical management by frequently influencing treatment decisions. WBMRI has been recently recommended as an imaging option for the staging and surveillance of myxoid liposarcoma patients. Our study highlights the impact of regular WBMRI surveillance on the clinical management of these patients and how it affects their survival.

Case A 38-year-old man with congenital pain insensitivity underwent bilateral below-knee amputations. After his subsequent bilateral osseointegration (OI) limb replacements, he rapidly developed severe bilateral knee arthritis and varus deformity. In lieu of performing bilateral above-knee amputations, he underwent bilateral staged total knee arthroplasties (TKA) with excellent clinical and radiographic evaluation at 1-year follow-up. Conclusion To address both the limited bone stock and OI implant stem location, TKA after OI limb replacement in congenital pain insensitivity patients can be successfully achieved with a nonkeeled cementless tibial component and augmentation with a tibial cone.

Purpose We aimed to describe the level of agreement between patients and physicians on the ratings of daily functioning and pain in a cohort of sarcoma patients and assess how (dis)agreement and its change over time predicted patient-reported outcomes in survivorship. Method We performed secondary analysis of longitudinal data from a sarcoma-specialty clinic in Montreal, Canada. Demographics, clinical characteristics and patient-physician agreement were summarized descriptively. Linear mixed models were used to assess the effects of time, baseline agreement, change in agreement over time, interaction of time and change in agreement and 12-month daily functioning, quality of life, and fatigue. Results Data were available for 806 patients (57.7% male, x̄ = 53.3 years) who completed at least one questionnaire. Patient-physician disagreement was common on the level of function (43.4%) and pain (45.7%). Baseline physician-patient agreement was associated with better 12-month outcomes. Improvement in agreement on function over time was significantly associated with daily functioning (F(2, 212) = 3.18, p = 0.043) and quality of life (F(2, 212) = 3.17, p < 0.044). The pattern was similar though less pronounced for the agreement on pain. Conclusions Our study offers novel insights into the importance of patient-physician agreement and communication’s role in long-term patient-reported outcomes in sarcoma. Implications for Cancer Survivors The results emphasize the importance of mutual understanding of symptoms and patients’ needs and suggest that further consultation in cases of discordance of ratings and opinions might be beneficial for optimal survivorship.

The health‐related quality of life of patients with extremity soft tissue sarcoma (STS) is not precisely captured by current patient‐reported outcome measures. Although functional impairment is central to their concerns, multiple sources of distress, emotional restoration, coping strategies, and somatic symptoms are crucial in approaching patients with extremity STS.

Achieving bone fixation during megaprosthesis revision presents a formidable challenge in view of the substantial bone loss. We report treatment of a failed revision distal femoral replacement in an active 36-year-old male mechanic remotely treated for osteosarcoma. A custom stem and cone were manufactured to augment fixation and preserve bone stock within a short segment of the remaining proximal femur. The patient returned to regular function without the need for assistive devices. Follow-up imaging demonstrated stable implant fixation at 1-year follow-up. While cones and sleeves have vastly improved fixation in revision knee arthroplasty, a custom-made cone for the proximal femur was used to augment fixation of a revision megaprosthesis and obviate the use of a total femoral replacement.

Simple Summary A solitary fibrous tumor (SFT) is a fibroblastic mesenchymal tumor with the hallmark of an NAB2–STAT6 gene fusion and an intermediate tendency to metastasize. Based on the lack of a histologic-based grading system for extra-meningeal SFTs, we defined the prognostic value of histologic features that predict the risk of developing distant metastases. Moreover, our study revealed the histologic alterations to recurrent SFTs that affect the biological behavior of the tumor. Abstract Histology has not been accepted as a valid predictor of the biological behavior of extra-meningeal solitary fibrous tumors (SFTs). Based on the lack of a histologic grading system, a risk stratification model is accepted by the WHO to predict the risk of metastasis; however, the model shows some limitations to predict the aggressive behavior of a low-risk/benign-appearing tumor. We conducted a retrospective study based on medical records of 51 primary extra-meningeal SFT patients treated surgically with a median follow-up of 60 months. Tumor size (p = 0.001), mitotic activity (p = 0.003), and cellular variants (p = 0.001) were statistically associated with the development of distant metastases. In cox regression analysis for metastasis outcome, a one-centimeter increment in tumor size enhanced the expected metastasis hazard by 21% during the follow-up time (HR = 1.21, CI 95% (1.08–1.35)), and each increase in the number of mitotic figures escalated the expected hazard of metastasis by 20% (HR = 1.2, CI 95% (1.06–1.34)). Recurrent SFTs presented with higher mitotic activity and increased the likelihood of distant metastasis (p = 0.003, HR = 12.68, CI 95% (2.31–69.5)). All SFTs with focal dedifferentiation developed metastases during follow-up. Our findings also revealed that assembling risk models based on a diagnostic biopsy underestimated the probability of developing metastasis in extra-meningeal SFTs.

Study design: A systematic review of the literature and pooled data analysis of treatment outcomes of primary sarcomas of the spine. Objective: To examine the current literature and treatment options for primary sarcomas of the spine. Summary of background data: A paucity of literature exists on treatment outcomes of primary sarcomas of the spine. Materials and methods: Two authors searched PubMed to identify articles for review, and a pooled data analysis was performed to determine overall survival for each type of surgical resection on spine sarcomas. Results: In total, 1776 articles were identified, and 11 met our inclusion criteria for review. In chondrosarcoma, overall survival was significantly higher with en bloc excision when compared with piecemeal resection (HR for piecemeal resection: 4.11; 95% CI: 2.08-8.15). Subgroup analysis showed that the addition of radiation therapy after piecemeal excision increased overall survival to 60 months from 48 months with piecemeal excision alone. In osteosarcoma, there was no significant difference in overall survival between en bloc and piecemeal resection (HR for piecemeal resection: 1.76; 95% CI: 0.776-3.99). In Ewing's sarcoma, overall survival was significantly higher when a successful en bloc resection was achieved and coupled with chemotherapy and radiation therapy for local control (HR for piecemeal resection: 7.96; 95% CI: 2.12-20.1). Interestingly, when a successful en bloc resection could not be achieved, chemotherapy and radiation therapy alone had significantly higher survival than piecemeal resection (HR for piecemeal resection: 2.63; 95% CI: 1.01-6.84). A significantly higher number of local recurrences were associated with the piecemeal resection group in all types of spine sarcomas. Conclusion: This review and pooled data seem to favor en bloc excision for local control as the treatment of choice in primary sarcomas of the spine.