Background: We previously reported on the real world treatment and outcomes of 423 angiosarcoma pts in Asia. In this current report, we focus on the 173 pts with V-AS and evaluate the treatment patterns and prognostic factors associated with this disease subset. Methods: This is a retrospective chart review of V-AS pts seen at 8 Asian academic study sites. Survival analysis is measured from date of presentation to the study site. Results: Median study follow-up was 8.7 mths. Median age 52 yrs; 86% of pts presented with primary disease to study site. 42% (n = 73) had localized disease and 56% (n = 97) had locally advanced/unresectable or metastatic disease; disease status was unknown for 3 pts. Distribution of primary site as follows, liver (n = 38, 22%), cardiovascular system (n = 30, 17%), breast (n = 25, 14%), spleen (n = 18, 10%) and others (n = 62, 36%) from a myriad of organ systems each representing <10% of cases. More pts with breast AS presented with localized disease. For pts with localized disease, primary treatment was surgery in 74% (n = 54) of pts. Of 38 pts with known margins, R0 and R1 were achieved in 71% and 21% respectively. In pts who had surgery, 43% developed subsequent disease relapse/progression with a median PFS of 9.5 mths. Of 97 pts with advanced/unresectable disease, 59% of pts received chemotherapy as part of treatment while 22% and 20% had surgery/radiation only or supportive care only respectively. 46% of chemotherapy-treated pts had 1 line of treatment while 35% and 19% had 2 or > 3 lines of treatment respectively. The most common first line chemotherapy used was paclitaxel (53%) followed by liposomal doxorubicin (18%). Median OS was 11.9 mths in the overall V-AS cohort, with median OS 29.2 mths and 6.3 mths in the localized and advanced/unresectable cohort respectively. In the univariate analysis of pts with unresectable/metastatic disease, only ECOG was associated with OS. Conclusions: This study highlights the heterogeneity and treatment challenges of visceral angiosarcoma. Overall prognosis is poor, in particular in pts with advanced/unresectable disease. Legal entity responsible for the study: National Cancer Centre Singapore Funding: None Disclosure: R. Quek: Grants/research support: Novartis, Pfizer, Janssen, Bayer and Eisai. Honoraria/consultation fees: Novartis, Bayer, BMS, Merck, Roche and Eisai. Participation in a company sponsored speaker's bureau: Novartis, Bayer, Merck and Eisai. All other authors have declared no conflicts of interest.

guide to sizing and should be used as an adjunct to other techniques. It is important to recognise and account for magnification errors on imaging. Endoscopic-assisted local intralesional curettage and excision of intraosseous lesions in the talus CJ Pearce, Y Chen, EM Puhaindran National University Hospital, Division of Foot and Ankle Surgery, Singapore National University Hospital, Department of Orthopaedic Surgery, 1E, Kent Ridge Road, NUHS Tower, Block, Level 11, Singapore 119228 National University Hospital, Division of Musculoskeletal Oncology, Singapore

Background Metastatic/unresectable angiosarcoma (AS) is a disease with poor prognosis. Median survival is generally less than 12 mths. Single agent taxane or anthracycline are commonly used agents. However optimal 1st line systemic treatment remains to be defined. Methods We undertook a retrospective chart review of AS pts seen in 8 sarcoma academic centres across Asia. Pts with complete clinical, treatment and follow up data were enrolled. Results 271 metastatic/unresectable AS pts were included into this study. Median age was 64 yrs. 64% of pts presented with metastatic/unresectable disease at time of initial diagnosis while 36% developed metachronous metastatic disease at a median of 7.6 mths following initial diagnosis. Primary origin of tumor was from a cutaneous site in 55% vs a visceral site in 45% of pts; the most common visceral site being the liver. 52% of these pts received systemic chemotherapy, of whom 55%, 25% and 20% of these pts received 1 line, 2 lines and >3 lines of chemotherapy respectively. Of pts who received systemic chemotherapy, the most common 1st line regimen used was paclitaxel in 47% and liposomal doxorubicin in 19%. At a median follow-up of 7.2 mths after diagnosis of metastatic/unresectable disease, overall survival (OS) was 8.3 mths, 11.5 mths in those who received at least 1 line of palliative chemotherapy vs 4.4 mths (p < 0.01) in those who did not receive palliative chemotherapy. Comparing between pts who received single agent paclitaxel vs anthracycline, progression-free survival (PFS) as defined by investigator was 4.7 mths for paclitaxel vs 2.8 mths for anthracycline (HR = 0.75, p = 0.2). Notably PFS to 1st line chemotherapy and OS were not significantly different between pts whose tumors developed from a primary cutaneous vs visceral site, (PFS: 3.8 mths vs 3.2 mths (HR = 0.87, p = 0.4); OS: 12.1 mths vs 9.5 mths (HR = 0.96, p = 0.8)). Evaluation of prognostic factors in this cohort of pts would be presented subsequently. Conclusions This study confirms the poor prognosis of pts with metastatic/ unresectable angiosarcoma AS. First line treatment with single agent taxane or anthracycline appears comparable. Legal entity responsible for the study National Cancer Centre Singapore Funding N/A Disclosure V. Sriuranpong: Corporate sponsored research: Novartis, MSD, Astra Zeneca, Roche, Lilly, Sanofi, Pfizer, BMS. R. Quek: Grants/research support: Novartis, Pfizer, Janssen, Bayer and Eisai Honoraria or consultation fees: Novartis, Bayer, BMS, Merck, Roche and Eisai Participation in a company sponsored speaker's bureau: Novartis, Bayer, Merck and Eisai. All other authors have declared no conflicts of interest

Background Angiosarcoma is an uncommon form of soft tissue sarcoma. Presentation and treatment are heterogeneous. We undertook a multicenter study evaluating the epidemiology, treatment and outcomes of AS pts in 8 sarcoma academic centres across Asia. Methods This is a retrospective chart review of AS pts seen at the study sites. Results In total 423 pts were included into study. Median follow-up was 12.4 mths. 59% and 41% had cutaneous (C-AS) and visceral AS (V-AS) respectively. Median age was 67 yr [74 yr vs 54 yr in C-AS vs V-AS, p < 0.001]. 58% presented with localized disease while 41% had locally advanced/metastatic disease. The most common primary site in pts with C-AS and V-AS was scalp and liver respectively. In pts with localized C-AS, primary treatment was surgery, chemotherapy and radiotherapy in 55%, 21% and 17% respectively. While in localized V-AS, primary treatment patterns included surgery, chemotherapy and best supportive care (BSC) in 73%, 11% and 8% respectively. In pts with localized disease for which surgery was performed and margin status known (n = 114), R0 margin was achieved in 69%, 66% vs 75% in C-AS vs V-AS (OR = 0.65, p = 0.3). In pts with locally advanced/metastatic disease (n = 173), 27%, 14% and 6% received 1, 2 and 3 lines of chemotherapy respectively; 7% of pts received >3 lines of chemotherapy. The most common first line chemotherapy regimen was paclitaxel (54%)followedbyliposomaldoxorubicin(15%).InptswithlocalizedASwhohad undergoneprimarysurgery,relapse-freesurvivalwas10.9mths,12.9vs8.1mthsinpts withC-ASvsV-AS(HR1.10,P=0.6).Medianoverallsurvival(OS)was23.7mths,24.0 mthsinC-ASvs23.0mthsinV-AS(HR1.22,P=0.3). Inptswithlocallyadvanced/ metastatic AS, median OS on BSC was 1.7 mths vs 17.1 mths for those who received at least1 lineofchemotherapy(HR5.30,P<0.001).MedianOSinptswithlocally advanced/metastaticC-ASvsV-ASwas11.5mthsvs8.3mthsinpts(HR0.94,P=0.7). Conclusions: This large observational study in AS is the first collaborative study by the ASC. This study highlights the complexity of AS and heterogeneity of treatment across Asia. Prognosis is poor and optimal treatment remains to be defined. Legal entity responsible for the study National Cancer Centre Singapore Funding N/A Disclosure R. Quek: Grants/research support: Novartis Pfizer, Janssen, Bayer and Eisai Honoraria or consultation fees: Novartis, Bayer, BMS, Merck, Roche, Eisai Participation in a company sponsored speaker's bureau: Novartis, Bayer, Merck, Eisai. V. Sriuranpong: Corporate sponsored research: Novartis, MSD, Astra Zeneca, Roche, Lilly, Sanofi, Pfizer, BMS. All other authors have declared no conflicts of interest.

We investigated whether the presence of a pathological fracture increased the risk of local recurrence in patients with a giant cell tumour (GCT) of bone. We also assessed if curettage is still an appropriate form of treatment in the presence of a pathological fracture. We conducted a comprehensive review and meta-analysis of papers which reported outcomes in patients with a GCT with and without a pathological fracture at presentation. We computed the odds ratio (OR) of local recurrence in those with and without a pathological fracture. We selected 19 eligible papers for final analysis. This included 3215 patients, of whom 580 (18.0%) had a pathological fracture. The pooled OR for local recurrence between patients with and without a pathological fracture was 1.05 (95% confidence interval (CI) 0.66 to 1.67, p = 0.854). Amongst the subgroup of patients who were treated with curettage, the pooled OR for local recurrence was 1.23 (95% CI 0.75 to 2.01, p = 0.417). A post hoc sample size calculation showed adequate power for both comparisons. There is no difference in local recurrence rates between patients who have a GCT of bone with and without a pathological fracture at the time of presentation. The presence of a pathological fracture should not preclude the decision to perform curettage as carefully selected patients who undergo curettage can have similar outcomes in terms of local recurrence to those without such a fracture.

Opinion remains divided as to whether the development of pathological fracture affects the prognosis of patients with an osteosarcoma of the extremities. We conducted a comprehensive systematic review and meta-analysis of papers which reported the outcomes of osteosarcoma patients with and without a pathological fracture. There were eight eligible papers for final analysis which reported on 1713 patients, of whom 303 (17.7%) had a pathological fracture. The mean age for 1464 patients in six studies was 23.2 years old (2 to 82). The mean follow-up for 1481 patients in seven studies was 90.1 months (6 to 240). The pooled estimates of local recurrence rates in osteosarcoma patients with and without pathological fractures were 14.4% (8.7 to 20.0) versus 11.4% (8.0 to 14.8). The pooled estimate of relative risk was 1.39 (0.89 to 2.20). The pooled estimates of five-year event-free survival rates in osteosarcoma patients with and without a pathological fracture were 49.3% (95% CI 43.6 to 54.9) versus 66.8% (95% CI 60.7 to 72.8). The pooled estimate of relative risk was 1.33 (1.12 to 1.59). There was no significant difference in the rate of local recurrence between patients who were treated by amputation or limb salvage. The development of a pathological fracture is a negative prognostic indicator in osteosarcoma and is associated with a reduced five-year event-free survival and a possibly higher rate of local recurrence. Our findings suggest that there is no absolute indication for amputation, as similar rates of local recurrence can be achieved in patients who are carefully selected for limb salvage.

We read this short report letter with interest. The author reports a case of an early rupture of a repaired flexor pollicis longus (FPL) tendon in a 42-year-old lady, supposedly attributed to an anomalous intertendinous connection between the FPL and index finger flexor digitorum profundus (FDP) tendon, namely the Linburg-Comstock anomaly. We would like to share our own similar experience in support of the highly important relation between the healing of repaired FPL tendon and the presence of the anomaly, and both the operative and rehabilitative implications. Nonetheless, the author unfortunately failed to note that this relation has already been reported and detailed in the past. The author did not cite nor discuss our case report published in the Journal of Hand Surgery (Am.) in 2005 (Stahl et al., 2005). We described a case of an early failure of FPL tendon repair in a young woman caused by an anomalous connection between the tendons of the FPL and index finger FDP following forceful flexion of the unrestricted index finger and, hence, applying a tensile force that was transmitted through the anomalous band to the repaired site and resulted in repair failure. During re-exploration for repairing the FPL rupture, the incision was extended proximally and the anomalous band that served as a mechanical shortcut was visualized and ablated. Because the Linburg and Comstock anomaly reportedly is common (Linburg and Comstock, 1979) and may jeopardize the healing process after FPL repair, we emphasized the importance of the preoperative evaluation to look for clues suggesting the presence of the anomaly and recommended postoperative immobilization of both the thumb and index finger throughout the recovery period. We provided an alternative approach through surgical excision of the tethering anomalous connections. References

A novel nanofibrous construct for promoting peripheral nerve repair was fabricated and tested in a rat sciatic nerve defect model. The conduit is made out of bilayered nanofibrous membranes with the nanofibers longitudinally aligned in the lumen and randomly oriented on the outer surface. The intra-luminal guidance channel is made out of aligned nanofibrous yarns. In addition, biomolecules such as laminin and nerve growth factor were incorporated in the nanofibrous nerve construct to determine their efficacy in in vivo nerve regeneration. Muscle reinnervation, withdrawal reflex latency, histological, axon density and electrophysiology tests were carried out to compare the efficacy of nanofibrous constructs with an autograft. Our study showed mixed results when comparing the artificial constructs with an autograft. In some cases, the nanofibrous conduit with aligned nanofibrous yarn as an intra-luminal guidance channel performs better than the autograft in muscle reinnervation and withdrawal reflex latency tests. However, the axon density count is highest in the autograft at mid-graft. Functional recovery was improved with the use of the nerve construct which suggested that this nerve implant has the potential for clinical usage in reconstructing peripheral nerve defects.

We examined the little finger in 402 normal subjects for the presence or absence of the flexor digitorum superficialis. All subjects also had their grip strength measured. No statistically significant difference was seen in the grip strength measurements between subjects who had a flexor digitorum superficialis tendon to the little finger and those who did not. This study demonstrates that absence of the flexor digitorum superficialis to the little finger is not associated with decreased grip strength. The implications of this in terms of repair of the flexor digitorum superficialis of the little finger are considered.

Infections of the hand are commonly encountered in general practice. Delay in diagnosis increases the risk of tissue loss and functional impairment. Staphyloccocal infections are most common, but polymicrobial infections are often seen in immunocompromised patients. In this pictorial essay, important and common conditions are illustrated to demonstrate key points and pitfalls in diagnosis and management.

Most standard textbooks of hand surgery quote the prevalence of absence of palmaris longus at around 15%. However, this figure varies considerably in reports from different ethnic groups. We studied 329 Chinese men and women and found palmaris longus to be absent unilaterally in 3.3%, and bilaterally in 1.2%, with an overall prevalence of absence of 4.6%. There was no significant difference in its absence with regard to the body side or the sex. Our literature review revealed a low prevalence of absence in Asian, Black and Native American populations and a much higher prevalence of absence in Caucasian populations. It is clear that a standard prevalence of absence of the palmaris longus cannot be applied to all populations.

High pressure injection injuries are well known to cause significant injury to the hand, with high amputation rates and poor functional outcome. Surgical treatment consists of early aggressive debridement followed by secondary closure. Flap reconstruction is a reconstruction option which can increase the chance of digit salvage, as well as give an acceptable functional and cosmetic result. We review three cases of flap reconstruction following high pressure injection injuries, and discuss their role in the treatment of these injuries.

Palsies involving the anterior interosseous nerve comprise less than 1% of all upper extremity nerve palsies. Patients often present initially with acute pain in the proximal forearm, lasting several hours to days. The pain subsides, to be followed by paresis or total paralysis of the pronator quadratus, flexor pollicis longus and the radial half of the flexor profundus, either individually or together. Patients with a complete lesion will have a characteristic pinch deformity. We report a case of anterior interosseous syndrome in a 42-year-old male. The patient was admitted initially for chronic osteomyelitis of the left calcaneum. He had a peripherally inserted central catheter (PICC) line inserted into a brachial vein for the administration of intravenous antibiotics, and developed anterior interosseous nerve palsy as a complication of this procedure. The catheter was subsequently removed and a new line was placed on the other side, and his neurological deficit has been improving since. This case highlights the potential hazards of venupuncture or arterial puncture of the brachial vein or artery respectively, even under controlled conditions with the benefit of ultrasound guidance. It also serves as a reminder to look out for the complications of these common procedures, and to be able to react appropriately when they arise.