Presentation and outcome of primary tumors of the patella

Demographics, pathology, and outcomes of 7 patellar tumors, including 2 giant cell tumors, 2 chondroblastomas, 1 osteoid osteoma, 1 osteitis fibrosa cystica, and 1 case of myelomatous infiltration, are described. Five male and 2 female patients with a mean age of 42.5 years were followed for an average of 3.5 years. Anterior knee pain was the main presenting symptom. Two patients presented with pathologic fracture. One patient with chondroblastoma underwent curettage only; the second patient underwent curettage and bone grafting. Both patients with giant cell tumors underwent total patellectomy. Patients with osteoblastoma and osteitis fibrosa cystica underwent excision of the lesion. The patient with myeloma underwent radiotherapy. Patellar tumors represent special management problems because of their subcutaneous location, relationship to the extensor mechanism, and difficulties in interpretation of radiographs. A satisfactory outcome can be expected in the majority because of the predominantly benign nature of the lesions and straightforward operative intervention after diagnosis.

Poster - Thurs Eve-40: The potential of using SPECT ventilation information with IMRT for functional lung avoidance in radiotherapy of non small cell lung cancer

We have investigated the feasibility of using ventilation scans obtained from single photon emission computed tomography (SPECT) in intensity-modulated radiation therapy (IMRT) planning in lung cancer radiotherapy to avoid well functioning lung. We fused SPECT ventilation scans acquired at GE Hawkeye SPECT-CT of ten stage-III lung radiotherapy patients with planning CT in treatment planning system (Pinnacle v8.0, Philips Medical Systems). We automatically segment out 50% and 70% ventilated volumes. For each patient, we generated IMRT plans using nine equally spaced beams with and without avoiding well ventilated volume. They were compared with three beam IMRT plans with beam directions chosen to minimize the mean dose to the ventilated lung volumes, while keeping cord dose below tolerance and dose uniformity in the target. The plans generated using functional lung avoidance information reduces the doses to the functioning lung. With both IMRT avoidance plans, we could not obtain better functional avoidance or lower V-20Gy (volume receiving 20Gy or more) for total lung when the planning target volume (PTV) was surrounded by functional lung volumes. We were able to achieve better ventilated lung avoidance and lower total lung V-20Gy when the PTV is close to, but not surrounded by functioning lung volumes. For patients with the PTV that is far from 50% and 70% functional lung volumes, three-field IMRT spare the ventilated lung as well as nine-field IMRT ventilation avoidance plan, with a lower total lung V20-Gy.

Twentieth-century survival from osteosarcoma in childhood. Trends from 1933 to 2004

We have reviewed the data from our regional Bone Tumour Registry on patients with osteosarcoma diagnosed between 1933 and 2004 in order to investigate the relationship between survival and changes in treatment. There were 184 patients with non-metastatic appendicular osteosarcoma diagnosed at the age of 18 or under. Survival was calculated using Kaplan-Meier curves, and multivariate analysis was performed using the Cox regression proportional hazards model. The five-year survival improved from 21% between 1933 and 1959, to 62% between 1990 and 1999. During this time, a multi-disciplinary organisation was gradually developed to manage treatment. The most significant variable affecting outcome was the date of diagnosis, with trends in improved survival mirroring the introduction of increasingly effective chemotherapy. Our experience suggests that the guidelines of the National Institute for Clinical Excellence on the minimum throughput of centres for treatment should be enforced flexibly in those that can demonstrate that their historical and contemporary results are comparable to those published nationally and internationally.

Outcome of 17 pigmented villonodular synovitis (PVNS) of the knee at 6 years mean follow-up

Between January 1950 and December 2000, 16 patients were identified from Scottish Bone Tumour Registry with 17 histologically proven pigmented villonodular synovitis (PVNS) of the knee. The mean follow-up was 6 years (range, 1-14 years). A knee swelling of chronic duration with dull ache was the common presenting symptom. The mean duration of symptoms prior to presentation was 25 months (1-108 months), however it was much less (mean, 7 months) in four patients with a history of trauma. The mean age was 33 years (range, 16-58 years) with a slight male predominance. The lesion was predominantly anterior in nine patients, posterior in four, anterolateral in two, and medial and lateral in one each. Three patients (four knees) had localised disease and 13 diffuse. Anteroposterior and lateral radiographs of the knee revealed normal findings in 11 patients, features of gonarthrosis in four and a large suprapatellar loose body in one patient (both knees). Open (incisional-eight, excisional-eight) biopsy was carried out in all and all were histologically confirmed as PVNS. Removal of a localised synovial mass or loose body with surrounding partial synovectomy (four) was carried out for the localised variety, whilst open partial (three) or total (radical) synovectomy (10) was performed in all cases of diffuse PVNS. Three of seventeen knees had a recurrence, noted at 4, 6 and 8 years postoperatively (0% - localised, 23% - diffuse variety). A total (radical) synovectomy should be considered in diffuse PVNS in order to obtain optimal outcome.

Cervical extraskeletal Ewing's sarcoma: case report demonstrating radiological features and management

BACKGROUND

Extraskeletal Ewing's sarcoma is a rare tumour of mesenchymal origin, which is histologically similar to primary osseous Ewing's sarcoma. The majority of cases have been reported in the lower limb and paravertebral region, with a few cases reported in the neck.

METHODS

We report a patient with extraskeletal Ewing's sarcoma presenting with a right-sided neck mass, vocal fold palsy and T1 nerve root involvement. The detection of characteristic features on computed tomography and magnetic resonance imaging scans, in conjunction with histological analysis, was required to make the diagnosis.

RESULTS

Radiological imaging demonstrated that the tumour was infiltrating through the neural exit foramina of the lower cervical nerve roots, with encasement of the vertebral artery. The patient was managed with combination chemotherapy for systemic control and irradiation for local control.

CONCLUSION

Extraskeletal Ewing's sarcoma has a propensity to occur in a paravertebral location, being found rarely in the cervical region, and has a predilection to infiltrate through neural exit formina. Computed tomography and magnetic resonance imaging are helpful in the diagnosis of this rare tumour.

The prevalence and incidence of end-stage renal disease in Native American adults on the Navajo reservation

Whereas members of the Navajo Nation are at high risk for diabetes mellitus, there are no recent published estimates of the burden of end-stage renal disease (ESRD), an important sequela of diabetes, on the Navajo Nation, a 16 million acre area in Arizona, New Mexico, and Utah with more than 200 000 tribal members. We used data from the US Renal Data System to estimate the prevalence and incidence of ESRD among Native American adults (>/=18 years) living on the Navajo Nation. For comparison, we estimated the prevalence and incidence of ESRD among all adults in the US, all Native American adults in the US, and Native American adults living in Arizona, New Mexico, Utah, and Colorado excluding those living on the Navajo Nation. The age-adjusted prevalence of ESRD in the Native American adults on the Navajo Nation was 0.63%, which was higher than in the US adults (0.19%, P<0.0001) and among the Native American adults in the US (0.36%, P<0.0001), but lower than among the other Native American adults in the Southwest (0.89%, P<0.0001). The age-adjusted incidence of ESRD in the Native American adults on the Navajo Nation was 0.11%, which was also higher than in the US adults (0.045%, P<0.0001) and among the Native American adults in the US (0.073%, P<0.0009), but lower than among the other Native American adults in the Southwest (0.17%, P<0.0003). The reasons behind these disparities merit further study.

Can haematological indices predict positive findings at endoscopy in anaemic patients?

INTRODUCTION

Patients with anaemia are commonly referred for bidirectional endoscopy. The aim of this study was to determine if any haematological parameters could predict positive findings at endoscopy.

PATIENTS AND METHODS

A total of 209 patients had bidirectional endoscopies performed for anaemia between September 2002 and March 2004. The endoscopy reports, histology and full blood count results (haemoglobin [Hb], red blood cells [RBCs], packed cell volume [PCV], mean cell volume [MCV] and mean cell haemoglobin [MCH]) were then reviewed. Statistical analysis was performed using non-parametric tests.

RESULTS

Overall, 197 patients had successful bidirectional endoscopies with 12 requiring completion barium enema. In 48 (23%) of these patients, a cause of anaemia was found with 15 (7.2%) carcinomas detected (2 upper GI and 13 lower GI). There was a significant difference in haemoglobin (9.2 g/dl versus 10.1 g/dl; P = 0.0044), RBCs (3.56 x 10(12)/l versus 3.83 x 10(12)/l; P = 0.0325) and PCV (0.279 l/l versus 0.31 l/l; P = 0.0112) between patients with positive findings at endoscopy and those with a normal investigation. Cancer patients had significantly lower haemoglobin (8.65 g/dl versus 10.1 g/dl; P = 0.0103), RBCs (3.45 x 10(12)/l versus 3.83 x 10(12)/l; P = 0.0179) and PCV (0.27 l/l versus 0.31 l/l; P = 0.0298) compared with patients with normal endoscopies. There was no significant difference in the other haematological parameters between those found to have positive findings and those that had normal endoscopies.

CONCLUSIONS

Based on this study, the yield of bidirectional endoscopy is low, with haemoglobin and PCV being the most useful haematological indices of significant pathology. Ferritin and MCV did not predict the likelihood of finding a gastrointestinal cause for the anaemia.

Evaluation of the indirect effects of a pneumococcal vaccine in a community-randomized study

When a sufficiently high proportion of a population is immunized with a vaccine, reduction in secondary transmission of disease can confer significant protection to unimmunized population members. We propose a straightforward method to estimate the degree of this indirect effect of vaccination in the context of a community-randomized vaccine trial. A conditional logistic regression model that accounts for within-randomization unit correlation over time is described, which models risk of disease as a function of community-level covariates. The approach is applied to an example data set from a pneumococcal conjugate vaccine study, with study arm and immunization levels forming the covariates of interest for the investigation of indirect effects.

Paget sarcoma of the spine: Scottish Bone Tumor Registry experience

STUDY DESIGN

Retrospective case study of 13 cases of Paget sarcoma of the spine accrued from a prospectively collected Tumor Registry database.

OBJECTIVES

To analyze the clinical, radiologic, and histologic features of Paget sarcoma of the spine and to determine the factors influencing the prognosis.

SUMMARY OF BACKGROUND DATA

Paget disease of bone is a common disorder with the spine being involved in over 50% of patients. However, sarcomatous degeneration in the vertebral column is an extremely rare complication. There is very little in the literature with regard to clinical presentation and prognosis of patients with Paget sarcoma affecting the vertebral column.

METHODS

Between January 1944 and December 2003, 89 patients were registered with a diagnosis of Paget sarcoma in the Scottish Bone Tumor Registry. Thirteen patients with Paget sarcoma of the spine were analyzed with regard to their clinical, radiologic, and histopathologic features along with the prognostic predictors.

RESULTS

The mean age was 66.9 years (range: 56-79 years). There were 10 males and three females. There were seven cases involving the sacral spine (63.6%), three cases involving lumbar vertebrae, two affecting the dorsal spine, and one with diffuse dorsolumbar involvement (D11-L3). The mode of presentation was progressively increasing low back pain (in all 13), unilateral sciatica (six; left-sided, five; right-sided, one), bilateral sciatica (two), lower limb weakness (eight), and autonomic dysfunction (four). Ten of 13 cases (76.9%) were osteosarcoma. The rest were chondrosarcoma (n = 1), fibrosarcoma (n = 1), and malignant fibrous histiocytoma (n = 1). Decompression laminectomy was performed in three patients with progressive neurologic deficit. Eight patients had received radiotherapy. The mean survival was 4.22 months.

CONCLUSIONS

This series confirmed that Paget sarcoma of the spine has a very poor prognosis. We found a constellation of symptomatology in patients with sarcomatous Paget spine resulting from radiculomedullary compression, primarily lumbosacral involvement and predominantly osteosarcomatous histology. There was no significant difference observed on the overall prognosis of the patients with Paget sarcoma of the spine in the last 6 decades.

Guidelines for the diagnosis and management of carcinoid tumours. Part 1: the gastrointestinal tract. A statement from a Canadian National Carcinoid Expert Group

Carcinoid tumours are relatively rare and, in general, slow growing. They can be "non-functioning" tumours, presenting as a tumour mass, or "functioning" tumours secondary to the production of several biopeptides leading to the carcinoid syndrome. Though these tumours represent 0.25% of an oncology practice, a proper understanding of the clinical course of the disease and of the importance of appropriate diagnostic and therapeutic measures is very important. Proper patient management can lead to cure, particularly if the tumour can be fully resected, or to long-term palliation with medical treatment or cytoreductive surgery, or both, with significant prolongation of survival. A good understanding of the use of somatostatin analogues to achieve effective symptomatic control and of the importance of adequate follow-up and cardiac monitoring to prevent or effectively treat cardiac complications can contribute significantly to optimal control of this complex disease, ultimately improving the quality of life of affected patients. This article, developed by a group of Canadian experts, provides a framework that will assist clinicians in taking an optimal approach to managing their patients with carcinoid tumour.

Value of biopsy in the assessment of a retroperitoneal mass

AIMS

A retroperitoneal mass arising outside a specific organ usually gives rise to diagnostic uncertainty. Because of this, many clinicians request a radiologically guided biopsy. The aim of this study was to compare clinical and radiologic assessment with and without biopsy in patients undergoing surgical resection of a large abdominal mass.

METHODS

All patients undergoing resection of a large retroperitoneal mass under the care of one surgeon between 1994 and 2004 were included in this study.

RESULTS

One hundred and twenty-one patients underwent resection of a large retriperitoneal mass, of whom 84 had primary disease (median size 20cm, range 7cm-40cm). Thirty-six had clinical and radiologic assessment with biopsy while 48 had no biopsy. In the biopsy group four patients had a false negative result while two had a false positive result for a malignant tumour. Three patients had incorrect malignant histology on biopsy which led to an error in management in two. In addition, two adverse events related to biopsy were observed. One patient in the no biopsy group had an error in management. Sensitivity for diagnosis of a soft tissue tumour was 80.8% (95% CI 69.5%-92.1%) for clinical and radiologic assessment alone versus 91.6% (95% CI 82.6%-100%) when biopsy was added.

CONCLUSIONS

Biopsy adds no value to clinical and radiologic assessment of the patient with a resectable large retroperitoneal mass.

Chondromyxoid fibroma of the foot and ankle: 40 years' Scottish bone tumour registry experience

Ten cases of histologically proven chondromyxoid fibroma (CMF) of the foot and ankle with a mean follow-up of 6.1 years were retrospectively reviewed using the Scottish Bone Tumour Registry. The patients' mean age was 19 years; there were six males and four females. The anatomical locations were five phalangeal, three metatarsal, one tarsal affecting body of os calcis and one distal tibial. The median delay in presentation was 4.5 months. The modes of presentation were pain only (n=4), painful lump (n=4) and painless lump (n=2). The typical radiological finding was an expansile, lobulated, cystic lesion. Cortical erosion was documented in 80% patients. In four cases, curettage alone was carried out, while five patients underwent curettage along with autogenous bone grafting. One patient with distal phalangeal CMF had a primary toe amputation. Two patients had recurrences 9 and 16 months after their initial curettage. Both of them were males with proximal phalangeal CMF, associated with cortical erosion. Foot and phalangeal CMF initially treated with curettage only should be closely followed up, as we observed a 20% recurrence rate within a 2-year period. Cases featuring cortical erosion require thorough curettage and may require autogenous bone grafting to prevent fracture.

Scapulo-humeral Paget's sarcoma: Scottish Bone Tumour Registry experience

This study aimed to analyse the clinical, radiological and histological features of 16 scapulo-humeral Paget's sarcoma cases accrued from Scottish Bone Tumour Registry between January 1950 and December 2000. The mean age was 61.5 (range, 44-77) years with 12 men and 4 women. There were three scapular cases and 13 humeral (1 whole length, 5 upper humeral, 5 lower humeral and 2 mid-humeral). These patients presented with progressively increasing pain in the shoulder, arm or elbow (n = 5), a painful mass associated with a pathological fracture (n = 4), a pathological fracture with progressively worsening pain (n = 3), a painful mass (n = 3) and a painless mass associated with wrist drop (n = 1). Histology showed predominantly osteosarcoma (n = 12), followed by pleomorphic sarcoma (n = 2), malignant fibrous histiocytoma (n = 1) and fibrosarcoma (n = 1). Overall, the median survival period was 4.5 months. In summary, Paget's sarcoma of the scapulo-humeral area presents with progressively worsening pain, a painful mass with or without a pathological fracture, predominantly lytic in humeral and purely sclerotic in scapular lesions, osteosarcoma-dominant histology, primarily treated with an early limb ablative surgery and associated with a poor 1-year survival (12.5%) and 5-year survival (6.2%) rate.

Sarcomatous change in the Pagetoid tibiae

We reviewed 13 cases of tibial Paget's sarcoma constituting 14% of all registered Paget's sarcoma cases of the Scottish Bone Tumour Registry between January 1947 and June 2004. Eleven patients were male, and in ten patients the tumour involved the upper half of the tibia. In all cases, the main presenting feature was progressively worsening pain followed by a mass in six, a pathological fracture in five and tibial bowing in four. In nine patients, a lytic lesion was seen radiologically. Histologically, there were three osteosarcomas and ten malignant fibrous histiocytomas. Limb ablation was carried out in 11 patients, of whom nine had trans-femoral amputation. Six patients received adjuvant radiotherapy and/or chemotherapy. Post-operative complications included stump revision in two cases, non-union of a pathological fracture of the tibial tuberosity and a stress fracture. The median survival was 17 months.

Dysregulation of sphingolipid and sterol metabolism by ApoE4 in HIV dementia

BACKGROUND

Polymorphisms in apolipoprotein E have been associated with worse prognoses in numerous neurodegenerative conditions, including HIV dementia (HIVD). Despite these correlative observations, there has been little evidence suggesting a mechanism whereby the expression of ApoE4 renders neurons susceptible to insult.

METHODS

Electrospray ionization tandem mass spectrometry was used to quantify levels of sphingolipids and sterols in brains of HIVD patients. Data were stratified according to APOE genotype.

RESULTS

The authors found evidence of dysregulated lipid and sterol metabolism in HIVD patients with an APOE4 genotype. They also found elevations of sphingomyelin, ceramide, and cholesterol in the medial frontal cortex, parietal cortex, and cerebellum of HIVD patients with an APOE3/4 or APOE4/4 genotype compared with HIVD patients with an APOE3/3 genotype. There was no difference in the number of astrocytes or activated microglia in any brain region of the two patient populations, suggesting that modification of lipid metabolism in HIVD patients with an APOE4 genotype was not the result of increased CNS inflammation.

CONCLUSIONS

HIV dementia patients with an APOE4 genotype may be sensitized to neural insults because of dysregulations in lipid metabolism.