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Dry SM. Dedifferentiation in bone and soft tissue sarcomas: How do we define it? What is prognostically relevant? Hum Pathol 2024; 147:139-147. [PMID: 38311185 DOI: 10.1016/j.humpath.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
Dedifferentiation traditionally is defined by descriptive criteria as a tumor showing an abrupt change in histology from a conventional, classic, low-grade appearing neoplasm to a tumor that is more cellular, pleomorphic and "high grade", with grading typically being performed by subjective criteria. The dedifferentiated areas range from areas with recognizable histologic differentiation which differs from the primary tumor (such as an osteosarcoma arising from a low-grade chondrosarcoma) to areas containing sarcomas without specific histologic differentiation (such as pleomorphic or spindle cell sarcoma). Many, but not all, dedifferentiated tumors are aggressive and associated with significantly shorter survival than their conventional counterparts, even grade 3 conventional tumors. As a result, dedifferentiated tumors are generally considered to be clinically aggressive and as a result, more aggressive surgery or the addition of (neo)adjuvant chemotherapy is often considered. However, long-term (greater than 20 year) survivors are reported in the most common dedifferentiated bone and soft tissue sarcomas. Moreover, use of mitotic criterion for defining dedifferentiation in dedifferentiated liposarcoma as well as grading (by the French system) have been found to be associated with survival. This paper reviews the literature on dedifferentiated chondrosarcoma, dedifferentiated liposarcoma, dedifferentiated chordoma and dedifferentiated parosteal osteosarcoma. As a result of that review, recommendations are advocated to identify evidence-based, objective diagnostic and grading criteria for dedifferentiation that are appropriate for each tumor type. Adding such criteria will improve consistency in diagnosis worldwide, allow easier comparison of clinical research performed on dedifferentiated tumors and help communicate (to patients and clinicians) the tumors with highest risk of clinically aggressive behavior, to allow appropriate and personalized treatment planning.
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Affiliation(s)
- Sarah M Dry
- Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, 13-222 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
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Kumar GR, Krishnan CK, Muralidharan K, Sundersingh S, Murugesan K, Raja A. Limb Salvage Surgery in a Rare Case of Recurrent Parosteal Osteosarcoma with Vascular Graft Thrombosis. Vasc Specialist Int 2023; 39:33. [PMID: 37927145 PMCID: PMC10626314 DOI: 10.5758/vsi.230058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
Recurrent parosteal sarcomas with vascular involvement are rare and present unique challenges in their diagnosis and management. We report the case of a 21-year-old woman with parosteal osteosarcoma of the left distal femur, encasing the popliteal vessels. En bloc transarticular resection of the distal femur and popliteal vessels was performed, followed by reconstruction using a modular prosthesis and a saphenous vein autograft for both the artery and vein. On the 1st postoperative day, the patient developed an arterial thrombus requiring reintervention with a jump polytetrafluoroethylene (PTFE) graft. Histopathology confirmed parosteal osteosarcoma. After a disease-free survival of 41 months, the patient experienced local recurrence involving the PTFE graft, leading to graft compression, erosion, and subsequent thrombosis. Despite these complications, limb salvage was possible due to adequate collateral blood supply. This case highlights the feasibility of limb salvage surgery in select cases of parosteal osteosarcoma with vascular involvement.
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Affiliation(s)
- Gaurav Ravi Kumar
- Department of Surgical Oncology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
| | - Chandra Kumar Krishnan
- Department of Surgical Oncology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
| | - Krishna Muralidharan
- Department of Vascular Surgery, Tamil Nadu Government Multi-Superspeciality Hospital, Omandurar Estate, Chennai, Tamil Nadu, India
| | - Shirley Sundersingh
- Departments of Onco-Pathology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
| | | | - Anand Raja
- Department of Surgical Oncology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
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Pacheco M, Guzmán R, Bonilla P. Dedifferentiated Low-Grade Osteosarcoma, Outcome with or Without Chemotherapy: A Systematic Review. Orthop Res Rev 2023; 15:79-89. [PMID: 37143718 PMCID: PMC10153403 DOI: 10.2147/orr.s404146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023] Open
Abstract
The treatment of low-grade osteosarcomas is surgical resection with wide margins. In instances of dedifferentiation, a therapeutic paradigm similar to that of conventional high-grade osteosarcoma has not been adequately evaluated in these neoplasms. The main objective of this review was to define whether the addition of chemotherapy to surgical treatment has an impact on the survival of patients with dedifferentiated low-grade osteosarcomas. Secondary objectives were to observe the degree of histological response to neoadjuvant chemotherapy and to describe the percentage of de novo dedifferentiation. A systematic search of articles including dedifferentiated low-grade osteosarcomas, published between 1980 and 2022 was carried out in the PubMed, Cochrane and Scielo databases. A qualitative synthesis of the results was performed. Twenty-three articles comprising 117 patients were included. The survival of patients treated with surgery alone and surgery with chemotherapy was not statistically significant between the two groups. A good histological response was seen in 20% of specimens treated with neoadjuvant chemotherapy. De novo dedifferentiation was seen in approximately a fifth of low-grade osteosarcomas. The evidence available suggests that the addition of chemotherapy does not have an impact on the survival of patients with low-grade dedifferentiated osteosarcomas.
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Affiliation(s)
- Marina Pacheco
- Department of Pathology, Complejo Hospitalario Metropolitano CSS, Social Security Fund, Panama, Panama
- Sistema Nacional de Investigación; Secretaria Nacional de Ciencia, Tecnologia e Innovación, Panama, Panama
- Correspondence: Marina Pacheco, Departamento de Patología, Complejo Hospitalario Metropolitano Dr. Arnulfo Arias Madrid CSS, Avenida José de Fábrega y Simón Bolivar, Bella Vista, Panama, Panama, Tel +507 503 6219, Email
| | - Rodolfo Guzmán
- Department of Pathology, Hospital San Juan de Dios CCSS, San Jose, Costa Rica
| | - Patricia Bonilla
- Department of Orthopedics, Hospital del Niño Dr. José Renán Esquivel, Panama, Panama
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Aparisi Gómez MP, Righi A, Errani C, Facchini G, Gambarotti M, Picci P, Vanel D, Donati DM, Bazzocchi A. Inflammation and infiltration: can the radiologist draw a line? MRI versus CT to accurately assess medullary involvement in parosteal osteosarcoma. Int J Biol Markers 2020; 35:31-36. [PMID: 32079463 DOI: 10.1177/1724600819900516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cancer causes inflammation as it progresses through healthy tissue. The differentiation of tumoral growth from the surrounding inflammatory change is paramount in planning surgeries seeking to preserve function. This retrospective study aims at illustrating how a careful use of imaging (computed tomography (CT)/magnetic resonance imaging (MRI)) can help to draw the line between infiltration and inflammation. Out of 72 cases of parosteal osteosarcoma in our institution we selected 22 which had pretreatment imaging, and out of those, 14 that had both MRI and CT. Using Fisher's exact test, we evaluated the performance of each technique on accurately diagnosing medullary tumor infiltration, using histological analysis as a gold standard. All cases (14/14) demonstrated medullary abnormality on MRI, but only 6/14 (42.9%) demonstrated abnormality on CT. The 8/14 cases with MRI abnormality but no CT abnormality (57.1%) showed inflammation with no tumoral cells present on histological analysis. In the cases where the two examinations showed medullary abnormality (6/14) histology demonstrated tumoral infiltration. MRI demonstrated high sensitivity and negative predictive value, but low specificity and low positive predictive value and accuracy (P=1). CT demonstrated high sensitivity, specificity, high positive and negative predictive values and accuracy (P = 0.000333). MRI is highly sensitive for the detection of medullary abnormality but lacks specificity for tumor invasion. Correlation with CT is recommended in all cases of positive MR to add specificity for tumors. The adequate use of the two imaging methods allows to differentiate between inflammatory change and tumoral infiltration in POS, relevant for surgical planning.
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Affiliation(s)
- Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand.,Department of Radiology, Hospital Vithas Nueve de Octubre, Valencia, Spain
| | - Alberto Righi
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Gambarotti
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Piero Picci
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Daniel Vanel
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Maria Donati
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Parosteal Osteosarcoma: A Benign-Looking Tumour, Amenable to a Variety of Surgical Reconstruction. Int J Surg Oncol 2020; 2020:4807612. [PMID: 32550023 PMCID: PMC7275216 DOI: 10.1155/2020/4807612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/27/2020] [Indexed: 12/01/2022] Open
Abstract
Osteosarcoma arising from cortical surface is classified into parosteal, periosteal and high-grade surface osteosarcoma. Along the spectrum, parosteal osteosarcoma occupies the well-differentiated end. It is a relatively rare disease entity, comprised only 4% of all osteosarcomas and barely reported in the literature. The objective of this study is to describe cases of parosteal osteosarcoma as well as a variety of treatment options amenable to such entity. Six cases of parosteal osteosarcoma were identified based on histopathological reports in a tertiary referral hospital in Jakarta, Indonesia between January 2001 and December 2019. The mean age was 29.8 years old; four of them (66.7%) were male. Distal end of femur was the most commonly involved bone (five cases, 83.3%). The patients were treated with wide excision followed by several different reconstruction methods: replacement with endoprosthesis, extracorporeal irradiation, knee arthrodesis, or prophylactic fixation. One of our patients presented with dedifferentiated component, and therefore was treated by limb ablation. While two cases died of pulmonary metastasis, other patients reported fair to excellent functional outcome.
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Mogler C, Knebel C, Boxberg M, von Eisenhart-Rothe R, Wörtler K, Specht K. [Parosteal low-grade osteosarcoma with focal differentiation]. DER ORTHOPADE 2020; 49:273-276. [PMID: 31919554 DOI: 10.1007/s00132-019-03849-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This case study deals with the case of a 16-year-old male patient with a low-grade parosteal osteosarcoma of the distal femur with focal differentiation. Case history, disease course, and surgery as well as the pathological workup with final diagnosis are presented. Relevant radiologic and pathologic differential diagnoses und diagnostic pitfalls are explained in detail and discussed. Additionally, postoperative treatment options are illustrated.
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Affiliation(s)
- Carolin Mogler
- Institut für Pathologie, Technische Universität München, München, Deutschland
| | - Carolin Knebel
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, München, Deutschland.
| | - Melanie Boxberg
- Institut für Pathologie, Technische Universität München, München, Deutschland
| | | | - Klaus Wörtler
- Institut für Radiologie, Klinikum rechts der Isar, München, Deutschland
| | - Katja Specht
- Institut für Pathologie, Technische Universität München, München, Deutschland
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Zhao SC, Zhang CQ, Zhang CL. Custom-made intercalary endoprosthetic reconstruction for a parosteal osteosarcoma of the femoral diaphysis: A case report. Oncol Lett 2016; 10:3279-3285. [PMID: 26722326 DOI: 10.3892/ol.2015.3627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 07/30/2015] [Indexed: 11/06/2022] Open
Abstract
The present report describes a case of a 44-year-old female patient who presented with a palpable mass of the left thigh. A diagnosis of parosteal osteosarcoma (POS) at the femoral diaphysis was made following a diagnostic workup. Previous reports of long bone diaphyseal POS are rare. A long diaphyseal segment of the femur containing the tumor was resected along with a healthy margin of soft tissues, and the damaged bone was reconstructed with a custom-made intercalary endoprosthesis. Subsequent pathological examination of the surgical sample confirmed the diagnosis of POS. No local recurrence or distant metastasis was observed, and the patient had a positive Musculoskeletal Tumor Society score of 28/30 (93.3%) at the 28-month post-surgery follow-up. The present study describes the clinical, radiological, and pathological features of this rare type of osteosarcoma.
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Affiliation(s)
- Shi-Chang Zhao
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, P.R. China
| | - Chang-Qing Zhang
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, P.R. China
| | - Chun-Lin Zhang
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, P.R. China
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Shimoyama T, Yamamoto Y, Kuroda M, Takakuwa Y, Washimi Y, Ishimura D, Yamada H. Cortical Bone Remodeling in Parosteal Osteosarcoma Mimicking Medullary Involvement: A Case with the Difficulty in Pre-Surgical Staging. TOHOKU J EXP MED 2014; 233:165-9. [DOI: 10.1620/tjem.233.165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Tetsuo Shimoyama
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University
| | - Yasuhiro Yamamoto
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University
| | - Makoto Kuroda
- Department of Pathology, School of Medicine, Fujita Health University
| | - Yasunari Takakuwa
- Department of Pathology, School of Medicine, Fujita Health University
| | - Yuki Washimi
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University
| | - Daisuke Ishimura
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University
| | - Harumoto Yamada
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University
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Liu JJ, Liu S, Wang JG, Zhu W, Hua YQ, Sun W, Cai ZD. Telangiectatic osteosarcoma: a review of literature. Onco Targets Ther 2013; 6:593-602. [PMID: 23745051 PMCID: PMC3671797 DOI: 10.2147/ott.s41351] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Telangiectatic osteosarcoma is a rare variant of osteosarcoma and hence its occurrence, presentation, and prognosis are poorly understood. With advancements in technology and available treatment options, the scenario of its diagnosis, management, and outcome has changed. Chemotherapy with surgery was challenged previously, but has now been proved to be beneficial. We reviewed the available literature and compared results to define the characteristics of the disease, its presentation, radiographic and pathologic features, optimal treatment, and prognosis.
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Affiliation(s)
- Jun-Jian Liu
- Department of Orthopedic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Encinas-Ullán C, Ortiz-Cruz E, Barrientos-Ruiz I, Valencia-Mora M, González-López J. Parosteal osteosarcomas: Unusual findings. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2012.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Encinas-Ullán CA, Ortiz-Cruz EJ, Barrientos-Ruiz I, Valencia-Mora M, González-López JM. [Parosteal osteosarcomas: unusual findings]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012; 56:281-5. [PMID: 23594846 DOI: 10.1016/j.recot.2011.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 11/07/2011] [Accepted: 11/14/2011] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To study and evaluate the unusual findings in the natural history of parosteal osteosarcomas. Parosteal osteosarcomas are well-differentiated tumours of low grade malignancy, but may dedifferentiate into a more aggressive lesion. MATERIAL AND METHODS We reviewed 7 parosteal osteosarcomas treated in La Paz Hospital between 2005 and 2009 (3 were dedifferentiated parosteal osteosarcomas). The authors analysed the clinical and radiological features, histology, treatment and outcomes in this patient group. RESULTS There were 5 men and 2 women, with a mean age of 32.14 years, range 24-47 years. Three of seven tumours (42.8%) were dedifferentiated osteosarcomas. All three patients received chemotherapy. One patient presented with pulmonary metastases. No patient died. CONCLUSIONS It is important to understand that the biological phenomenon of dedifferentiation can occur in parosteal osteosarcomas. The prognosis, treatment and survival changes radically.
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Affiliation(s)
- C A Encinas-Ullán
- Unidad de Tumores Musculoesqueléticos, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Paz, Madrid, España
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Papathanassiou ZG, Alberghini M, Thiesse P, Gambarotti M, Bianchi G, Tranfaglia C, Vanel D. Parosteal osteosarcoma mimicking osteochondroma: A radio-histologic approach on two cases. Clin Sarcoma Res 2011; 1:2. [PMID: 22613734 PMCID: PMC3372285 DOI: 10.1186/2045-3329-1-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 07/25/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Parosteal osteosarcoma is a well-differentiated variant of osteosarcoma that affects the surface of the bone. The imaging pattern is very typical. We report two cases mimicking an osteochondroma, radiologically and histologically and propose an explanation. METHODS The review of 86 parosteal osteosarcomas of bone revealed this atypical pattern only once. A consultation case was received in the same time, and added to ours. Patients were 28 years old and 56 years old females. Imaging studies included two radiographs, two CTscans, one MRI examination and one bone scan and the results were compared to histology. RESULTS On imaging, both lesions presented as ossified lobulated masses attached with a broad base to the underlying cortex. No radiolucent cleft separated the masses and the host bone and cortex continuity between the mass and the femur was seen, with medullary communication. The marrow of the mass had a different density and intensity compared to normal marrow. So, there were features of an osteochondroma (cortex and medullary continuity) and of a parosteal osteosarcoma (ossified marrow). Pathological assessment on the final specimen confirmed the presence of low-grade parosteal osteosarcomas, after an erroneous diagnosis of osteochondroma on the initial biopsy. CONCLUSIONS Parosteal osteosarcoma can be rarely confused with osteochondroma. A radiologic-pathologic correlation is essential. Cortex continuity is the most misleading imaging feature that may occur in parosteal osteosarcomas. A knowledge of this misleading pattern will help diagnose the lesion from the beginning.
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Funovics PT, Bucher F, Toma CD, Kotz RI, Dominkus M. Treatment and outcome of parosteal osteosarcoma: biological versus endoprosthetic reconstruction. J Surg Oncol 2011; 103:782-9. [PMID: 21240982 DOI: 10.1002/jso.21859] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 12/03/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Due to its good prognosis despite local recurrence, more and less invasive methods for surgical treatment of parosteal osteosarcoma (POS) have been described. Aim of this retrospective single-center study was to investigate differences in outcome after biological and prosthetic reconstruction. METHODS A total of 28 patients with POS, 14 females, 14 males, mean age of 27 years (median, 24 years; range 15-59 years), mean follow-up of 130 months (median, 104 months; range, 9-383 months), underwent wide tumor resection and prosthetic reconstruction (12 patients, 42.9%), less extensive resection and biological reconstruction (11 patients, 39.3%), rotationplasty (three patients, 10.7%), or amputation (two patients, 7.1%). RESULTS There were two cases of local recurrence in patients with biological reconstruction and three cases of pulmonary metastases, leading to death of disease in two. Ten-year disease-specific survival was 91.1%. There was no significant difference between prosthetic and biological reconstruction in terms of local recurrence, metastasis, or functional outcome (mean MSTS Score, 85%). There were significantly more revisions in prosthetic reconstructions. CONCLUSIONS Given that the resection of the tumor has clear margins, both prosthetic and biological reconstruction show similar results; prostheses allow better local tumor control, however, require more revisions over time.
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Affiliation(s)
- Philipp T Funovics
- Department of Orthopaedic Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
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Parosteal osteosarcoma dedifferentiating into telangiectatic osteosarcoma: importance of lytic changes and fluid cavities at imaging. Skeletal Radiol 2010; 39:69; author reply 71. [PMID: 19826810 DOI: 10.1007/s00256-009-0814-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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