Effects of liquid nitrogen treatment on the proliferation of osteosarcoma and the biomechanical properties of normal bone

Thallium-201 scintigraphy for the assessment of long-term prognosis in patients with osteosarcoma

OBJECTIVE

The aim of this study was to confirm the prognostic value of (201)Tl scintigraphy in the midcourse of preoperative chemotherapy in patients with osteosarcoma.

METHODS

The 28 patients with biopsy-proven osteosarcoma were enrolled retrospectively in this study. Planar scintigraphy was performed 15 min after injection of 111 MBq (201)Tl before preoperative chemotherapy and after third course (midcourse) of chemotherapy in all patients. The (201)Tl uptake ratio was calculated by dividing the count density of the lesion by that of the contralateral normal area. The percentage reduction of the (201)Tl uptake ratio calculated by 100 × [(pre-chemotherapy ratio - mid-chemotherapy ratio)/pre-chemotherapy ratio] was compared with the histopathological response and long-term survival rate.

RESULTS

Good histopathological response was observed in 16 patients. Mean follow-up period was 58.0 ± 41 months. Both overall and event-free survival rates of histopathologically good responders were significantly higher than that of poor responders (P = 0.018 and P = 0.0076). There was also significant correlation between pre-chemotherapeutic effect evaluated with (201)Tl scintigraphy and overall and event-free survival rate in all patients (P = 0.045 and P = 0.017, respectively), and in patients without metastasis at initial diagnosis (P = 0.043 and P = 0.031, respectively).

CONCLUSION

(201)Tl scintigraphy performed in the middle of neoadjuvant chemotherapy can predict overall survival and event-free survival in patients with osteosarcoma.

Pedicle freezing with liquid nitrogen for malignant bone tumour in the radius: a new technique of osteotomy of the ulna

We describe a new technique of pedicle freezing of the distal radius with malignant bone tumour and osteotomy of the normal ulna. The distal radius was sufficiently elevated to enable freezing without damaging adjacent tissues by releasing the distal radio-ulnar and radio-carpal joint and cutting the middle third of the ulna. The distal radius (including the tumour) was soaked in liquid nitrogen and the defect filled with iliac grafts. The ulna was repaired with plate and screws and was united at month 2. There was no local recurrence and the postoperative function score was 93%. This technique decreases the risk of non-union of the osteotomy site of the tumorous bone.

Pedicle frozen autograft reconstruction in malignant bone tumors

BACKGROUND

Standardizing limb salvage surgery for malignant bone tumors should result in improved limb function after tumor excision and reconstruction. Recently, we developed and clinically applied a method of biological reconstruction using tumor-bearing autografts treated with liquid nitrogen. We report this newly modified technique using pedicle frozen autografts to save the continuity of anatomical structures.

METHODS

We treated 33 malignant bone tumor patients. Diagnoses of the tumors were 17 osteosarcomas, 11 metastatic tumors, 2 Ewing's sarcomas, 2 chondrosarcomas, and 1 undifferentiated pleomorphic sarcoma. The sites of the tumors were 23 femurs, 5 tibias, 4 humeri, and 1 calcaneus. Operative procedures consisted of exposing the tumor, performing one-site osteotomy or joint dislocation, rotating and freezing the tumor lesion in liquid nitrogen for 20 min, and reconstruction using intramedullary nailing, plates, or composite arthroplasty.

RESULTS

Postoperative function was excellent in 25 patients (75.7%), good in 5 patients (15.1%), and fair in 3 patients (9.0%). At the final follow-up, 8 patients had died at a mean of 17 months postoperatively, and 18 patients remained disease-free for a mean follow-up period of 30 months (range 7-69 months). Seven patients were alive but with disease. Complications were encountered in 12 patients, including 4 deep infections, 3 fractures, 3 local recurrences from surrounding soft tissue, 2 nonunions, and 1 collapse. All were managed successfully.

CONCLUSIONS

The pedicle frozen autograft, which was newly developed to solve drawbacks of previously reported free frozen autografts, achieved success for reconstruction of malignant bone tumors. This is a new, simple, effective surgical technique for biological reconstruction that is still investigated but has potential for development.

Cryoimmunologic antitumor effects enhanced by dendritic cells in osteosarcoma

BACKGROUND

We previously reported a limb-salvage technique by treating tumor-bearing bone with liquid nitrogen. We also reported systemic antitumor immunity was enhanced by cryotreatment in a murine osteosarcoma (LM8) model. We therefore combined the cryotreatment of tumor with dendritic cells to promote tumor-specific immune responses.

QUESTIONS/PURPOSES

We determined whether our technique could enhance systemic immune response and inhibit metastatic tumor growth in a murine osteosarcoma model.

MATERIALS AND METHODS

To evaluate activation of the immune response, we prepared six groups of C3H mice (80 mice total): (1) excision only, (2) dendritic cells without reimplantation of the cryotreated primary tumor, (3) reimplantation of the cryotreated primary tumor alone, (4) dendritic cells combined with reimplantation of the cryotreated primary tumor, (5) dendritic cells exposed to cryotreated tumor lysates without reimplantation of the cryotreated primary tumor, and (6) dendritic cells exposed to cryotreated tumor lysates with reimplantation of the cryotreated primary tumor. We then compared and verified the activation state of each group's antitumor immunity.

RESULTS

Mice that received dendritic cells exposed to cryotreated tumor lysates with reimplantation of the cryotreated primary tumor group had high serum interferon gamma, reduced pulmonary metastases, and increased numbers of CD8(+) T lymphocytes in the metastatic areas.

CONCLUSIONS

Combining tumor cryotreatment with dendritic cells enhanced systemic immune responses and inhibited metastatic tumor growth.

CLINICAL RELEVANCE

We suggest immunotherapy could be developed further to improve the treatment of osteosarcoma.

Histological examination of frozen autograft treated by liquid nitrogen removed after implantation

BACKGROUND

Several oncological sterilization methods involving autoclaving, irradiation, or pasteurization have been developed for limb reconstruction of large bone defects following tumor excision. Studies involving histological examinations of these autografts have all found that osteogenesis occurs slowly. We have used frozen autografts treated by liquid nitrogen for limb reconstruction and have achieved excellent results for bone union. To determine if frozen autografts exhibit early bone remodeling, we investigated the repair processes of the frozen bones.

METHODS

We analyzed frozen autografts treated by liquid nitrogen, retrieved at a mean of 19.1 months (2-75 months) after implantation because of complications or local tumor recurrence. The specimens were obtained from six patients with a mean age of 36.2 years (8-68 years). The six grafts comprised three osteoarticular grafts, two intercalary grafts, and one joint graft. We histologically reviewed the autograft-containing sections for tumor cell necrosis, evidence of cortical repair, the cortical junction, and joint cartilage.

RESULTS

Tumor cells were completely eradicated from the frozen bone in all cases. In a specimen retrieved 5 months after implantation, a small area of the bone showed active osteocytes and osteoblasts. In three cases retrieved more than 1 year after implantation, osteocytes and osteoblasts were observed in broad portions of the frozen bones, indicating the onset of osteogenesis in the frozen bone at an early stage. The cortical host-graft junction showed incorporation along with continuity of bone trabeculae. In addition, we were able to fi nd normal chondrocytes on the articular surface.

CONCLUSIONS

The frozen bone specimens in this study thus showed evidence of newly formed bone and earlier osteogenesis than has been previously reported. Our results suggest that frozen autografts may be considered one of the most useful recycled materials for biological reconstruction.

Reconstruction of the pelvis after resection of malignant bone tumours in children and adolescents

The predominant tumour of the pelvic region in children and adolescents is Ewing's sarcoma followed by osteosarcoma. Both tumours are treated by chemotherapy and the best chance of survival is offered by wide tumour resection. Compared to surgical treatment on the extremities, the resection and reconstruction of pelvic sarcomas remains challenging. Surgery of pelvic sarcomas shows higher rates of local recurrence and complications and a lower functional outcome than other localisations. Especially in children and adolescents the reconstruction methods have to focus additionally on the growing skeleton. According to the different types of pelvic resections and therefore the need of different reconstruction methods, the following article is based on Enneking's surgical classification of pelvic resections. Type I resections are best reconstructed with autografts implanted between the supracetabular osteotomy and the sacrum. Patients show the best functional results after this reconstruction. Periacetabular resections (type II) in small children do best with iliofemoral arthrodesis or pseudarthrosis; in larger adolescents the use of the pedestal Schoellner cup showed superior results over the prior saddle prosthesis. Type III resections are not reconstructed. Complete internal hemipelvectomy represents the most difficult situation, in children as well as in adults. High complication rates after allograft and endoprosthetic reconstruction have recently favoured the renaissance of a flail hip reconstruction or the hip transpositionplasty.

Methods of biological reconstruction for bone sarcoma: indications and limits

Therapy of bone sarcoma has dramatically changed over the past few decades. Several successful interdisciplinary treatment strategies have led to an increase of the survival rates from 20% to 60%-80%. Consequently new demands on the operative treatment of bone and soft tissue sarcoma have arisen. Nowadays limb salvage can be achieved in 80%-90% using tumour megaprostheses or biological reconstruction procedures. In this article we outline the indications and limitations of biological reconstruction procedures after bone tumour resection. We therefore introduce the different biological approaches such as free autologous bone grafting, reimplantation of extracorporeal devitalized autografts or distraction osteogenesis and summarize the currently available data on the individual procedures. Our analyses demonstrate a wide applicability of biological procedures in tumour situations. Although accompanied by considerable complications in the early postoperative phase, biological reconstructions clearly demonstrate the potential of having excellent long-term durability and functionality.

Re-implantation of tumour tissue treated by cryotreatment with liquid nitrogen induces anti-tumour activity against murine osteosarcoma

We evaluated the possible induction of a systemic immune response to increase anti-tumour activity by the re-implantation of destructive tumour tissue treated by liquid nitrogen in a murine osteosarcoma (LM8) model. The tumours were randomised to treatment by excision alone or by cryotreatment after excision. Tissue from the tumour was frozen in liquid nitrogen, thawed in distilled water and then re-implanted in the same animal. In addition, some mice received an immunological response modifier of OK-432 after treatment. We measured the levels of interferon-gamma and interleukin-12 cytokines and the cytotoxicity activity of splenocytes against murine LM8 osteosarcoma cells. The number of lung and the size of abdominal metastases were also measured.

Re-implantation of tumour tissue after cryotreatment activated immune responses and inhibited metastatic tumour growth. OK-432 synergistically enhanced the anti-tumour effect. Our results suggest that the treatment of malignant bone tumours by reconstruction using autografts containing tumours which have been treated by liquid nitrogen may be of clinical value.

Bone transport using hydroxyapatite loaded with bone morphogenetic protein in rabbits

The feasibility of bone transport with bone substitute and the factors which are essential for a successful bone transport are unknown. We studied six groups of 12 Japanese white rabbits. Groups A to D received cylindrical autologous bone segments and groups E and F hydroxyapatite prostheses. The periosteum was preserved in group A so that its segments had a blood supply, cells, proteins and scaffold. Group B had no blood supply. Group C had proteins and scaffold and group D had only scaffold. Group E received hydroxyapatite loaded with recombinant human bone morphogenetic protein-2 and group F had hydroxyapatite alone.

Distraction osteogenesis occurred in groups A to C and E which had osteo-conductive transport segments loaded with osteo-inductive proteins. We conclude that scaffold and proteins are essential for successful bone transport, and that bone substitute can be used to regenerate bone.

Functional outcome in patients with osteosarcoma around the knee joint treated by minimised surgery

The functional results of prostheses and osteoarticular grafts for osteosarcoma around the knee joint are not satisfactory because of poor durability and gross distortion of the normal anatomy. We have investigated the functional outcome of intentional marginal excision for osteosarcoma around the knee joint in conjunction with caffeine-potentiated chemotherapy. Twenty-one patients with AJCC stage IIB high-grade osteosarcoma around the knee joint were given three to five preoperative courses of intra-arterial cisplatin and caffeine with or without doxorubicin. The histological response in these 21 patients to preoperative chemotherapy was grade IV (no viable cells) in 19 patients and grade III (only scattered foci of viable cells) in 2. The patients were separated into three groups on the basis of patterns of tumour excision. The first group underwent marginal excision of the proximal fibula, the second underwent epiphysis preservation followed by distraction osteogenesis, and the third underwent joint resection and reconstruction. The mean functional evaluations were 100, 95, and 88%, respectively. No local tumour recurrence was seen at mean follow-up of 97 months. Marginal excision of the proximal fibula resulted in excellent function. Preservation of the epiphysis leads to better function than joint resection.

Bone transport with frozen devitalized bone: an experimental study using rabbits and a clinical application

We evaluated the feasibility of bone transport with frozen devitalized bone in the tibia of 20 adult female rabbits. A 1.5-cm segmental defect was created, followed by proximal tibial transverse osteotomy to remove a 2.5-cm segment to be transported after devitalization with liquid nitrogen. The proximal and distal tibia and the devitalized autogenous bone each were fixed with two half-pins. After 2 weeks, transport of the devitalized segment was initiated at 1 mm/day. In a control group, callus formed at proximal and distal osteotomy sites, and distracted callus gradually maturated. The docking site fused and the medullary canal reappeared by 8 weeks after completing distraction. In the frozen-bone group, bone formation proceeded from the proximal tibial end, and the distraction callus slowly matured. The transported segment remained nonviable until revascularization proceeded from its periphery, evident 8 weeks after completion of distraction. Docking sites fused well without infection at pin sites. There was no sign of infection around the pin sites of the devitalized bone. We finally describe similar successful treatment of a 13-year-old girl with tibial deformity resulting from osteofibrous dysplasia who was treated successfully with this procedure. Therefore, bone transport using frozen devitalized bone can regenerate living bone. This experimental model represents the development of a new reconstruction technique of bone transport with devitalized bone.

Reconstruction using an autograft containing tumour treated by liquid nitrogen

We describe a method of reconstruction using tumour-bearing autograft treated by liquid nitrogen in 28 patients. The operative technique consisted of en bloc excision of the tumour, removal of soft tissue, curettage of the tumour, drilling and preparation for internal fixation or prosthetic replacement before incubation for 20 minutes in liquid nitrogen, thawing at room temperature for 15 minutes, thawing in distilled water for ten minutes, and internal fixation with an intramedullary nail, plate or composite use of prosthetic replacement. Bone graft or cement was used to augment bone strength when necessary. The limb function was rated as excellent in 20 patients (71.4%), good in three (10.7%), fair in three (10.7%), and poor in two (7.1%). At the final follow-up six patients had died at a mean of 19.8 months after the operation, while 21 remained free from disease with a mean follow-up of 28.1 months (10 to 54). One patient is alive with disease. Bony union was seen at a mean of 6.7 months after the operation in 26 patients. Complications were encountered in seven patients, including three deep infections, two fractures, and two local recurrences. All were managed successfully. Our results suggest that this is a simple and effective method of biological reconstruction.