Functional outcome in patients with osteosarcoma around the knee joint treated by minimised surgery. Int Orthop. 2008;32:63-68. [PMID: 18214479 DOI: 10.1007/s00264-006-0289-2]

Osteosarcoma in a Teenage Athlete With a Swollen Knee Joint

Osteosarcoma is a malignant mesenchymal tumour. This primarily manifests in the formation of immature osteoid cells by tumour cells. Osteosarcoma is the most common primary bone tumour in children and adolescents. It tends to occur in the metaphysis of long shafts, shows osteoblastic differentiation, and produces malignant osteoid material. We present the case of a 17-year-old male who presented to our clinic who had left knee pain for a few days. An initial radiograph of the knee joint revealed a lytic lesion in the proximal tibia and further imaging was advised. During a follow-up visit, the patient had worsening pain and had a computerized tomography scan of the left knee, confirming osteosarcoma on the lateral side of the left tibia. He was referred to the orthopaedic department, where a biopsy was performed, to confirm the diagnosis of osteosarcoma. The patient was commenced on chemotherapy due to metastatic disease and has so far tolerated therapy well.

The risk factors for mechanical complication in endoprosthetic reconstruction of knee osteosarcoma

BACKGROUND

The increased limb survival rates and higher functional demands have also increased the mechanical complication rates of megaprostheses. This study aimed to analyse possible risk factors which can predispose patients to mechanical complications.

METHODS

Patients with knee osteosarcoma referred to our clinic from 1992 to 2014 were investigated retrospectively. The patients who underwent surgical resection and endoprosthetic reconstruction with at least 5 years of follow up were analysed. The revision of the megaprosthesis due to a mechanical complication was accepted as an endpoint. The possible risk factors, including cement usage, implant material, joint mechanism, neoadjuvant radiotherapy, and anatomical localization of the lesion, were analysed for any association with mechanical complication rates.

RESULTS

A total of 118 patients were included for final analysis. The average age was 24.5 years (standard deviation ±10.1, range: 15-64). Mechanical complication rate was 22% which included 19 aseptic loosenings and seven implant failures. The average time to mechanical complication was 32.5 months. Overall, 5-year implant survival was 78%. Multiple regression analysis revealed that cement usage is an independent risk factor for mechanical complication (P = 0.007). Although the 5-year implant survival was higher in rotating hinge and titanium implants compared with fixed hinge and cobalt chrome, the multiple regression model did not yield a correlation with mechanical complication rates.

CONCLUSION

Cemented implants showed significantly higher mechanical complication rates compared with cementless ones in this series of knee osteosarcoma patients who underwent megaprosthetic reconstruction. Hinge mechanism and implant material did not have a significant effect on mechanical complication rates.

Plate-assisted bone segment transport: Novel application on distal tibia defect after tumour resection. A case report

Introduction

Reconstruction of a large bone defect of the distal tibia after limb salvage surgery is difficult. The options include custom-made ankle endoprosthetic replacement, arthrodesis, and biological or metallic intercalary reconstructions. This report introduces a technique that provides the patient with a long-lasting biological reconstruction while preserving the native ankle.

Presentation of case

We present the case of a 47-year-old man with osteosarcoma of the distal tibia. After neoadjuvant chemotherapy, wide excision was performed while preserving the ankle joint. Bone reconstruction by Plate-assisted bone segment transport (PABST) was performed with a non-invasive growing intramedullary nail. At 34 months of follow-up, there was solid union and the Musculoskeletal Tumour Society Score was 26/30.

Discussion

This is the first report of PABST after distal tibia tumour resection. It shows that this is a viable and safe method of reconstruction. Despite the use of adjuvant chemotherapy, regenerate was formed and union was achieved.

Conclusion

PABST is a useful tool in the armamentarium to tackle difficult large bone defects.

•

Large distal tibia bone defects are difficult to manage.

•

First report of Plate-assisted bone segment transport after distal tibia tumour resection

•

Regenerate was formed and bone union was achieved despite adjuvant chemotherapy.

•

Good outcome and function at 34 months of follow-up

•

Plate-assisted bone segment transport is a useful reconstructive technique.

Primary Fibular Sarcomas: Do They Behave Differently? An Institutional Review of 14 Patients

Surgical resection with wide margins is pivotal for sarcoma treatment but achieving the same for fibular sarcomas is a surgical challenge. Thus, we decided to evaluate our own institutional database of primary fibular sarcomas for surgical treatment, margins and pattern of relapse. From July 2014 to October 2018, we identified fourteen patients with histologically confirmed fibular sarcomas. Limb salvage surgery (LSS) was performed in thirteen patients included in our study. One patient treated with definitive radiotherapy was excluded from final survival and functional analyses. The proximal third fibula was the most common site of involvement (85.7%). Osteosarcoma was the histological diagnosis in eight (57.1%) and Ewing's in the remaining six (42.9%). All patients with proximal fibular tumours underwent Malawer type II resection. Margins were reported as free in twelve and involved in one case. The mean follow-up period was 37.15 months. In the operated group (n = 13), distant relapse occurred in 3 patients, combined relapse in 1 patient and 10 patients are alive and disease free until the last follow-up. The Kaplan-Meier survival analyses revealed the EFS (event-free survival-local/distant relapse) probability as 72.7% at 24 months and 53% at the end of 42 months. The OS (overall survival) probability at 24 months was 75.5% and 57.5% at the end of 42 months. Although it is difficult to achieve conventional wide margins in fibular sarcomas, our results suggest no increased incidence of local recurrence rates as compared to sarcomas at other common sites as reported in literature. Our series helps in understanding site-specific behaviour of sarcomas while contributing to the available data.

Long-term survival in a patient with Hutchinson-Gilford progeria syndrome and osteosarcoma: A case report

BACKGROUND

Hutchinson-Gilford progeria syndrome (HGPS) is an extremely rare disease characterized by the rapid appearance of aging with an onset in childhood. Serious cardiovascular complications can be life-threatening events for affected patients and the cause of early death. Herein we report a HGPS patient with osteosarcoma hat was successfully managed and is alive 13 years after the diagnosis. This is the first report describing the detailed surgical procedure and long-term follow-up of osteosarcoma in a patient with HGPS.

CASE SUMMARY

The patient was diagnosed with HGPS at 5 years of age with typical features and was referred to our department with a suspected bone tumor of the left proximal tibia at the age of 18. Open biopsy of the tibial bone tumor revealed a conventional fibroblastic osteosarcoma. We have developed and performed a freezing technique using liquid nitrogen for tumor reconstruction. This technique overcame the small size of the tibia for megaprosthesis and avoided amputation and limb salvage was achieved 13 years post-operatively. Although the patient had a number of surgical site complications, such as wound dehiscence, and superficial and deep infections due to vulnerable skin in HGPS, no recurrence or metastases were detected for 13 years, and she walks assisted by crutches. Her general health was good at the latest follow-up at 31 years of age.

CONCLUSION

A HGPS patient with osteosarcoma was successfully managed and she was alive 13 years after the diagnosis.

Clinical course of grafted cartilage in osteoarticular frozen autografts for reconstruction after resection of malignant bone and soft-tissue tumor involving an epiphysis

•

Frozen autograft of tumour-bearing bone using liquid nitrogen as a recycling autograft has various advantages.

•

This paper is the first report focusing on the fate of grafted cartilage in recycled autograft after bone tumour excision.

•

We found hemicondylar frozen autograft is promising reconstruction method.

There are several options for biological reconstruction after bone tumor resection. If the tumor invades an epiphysis, the reconstruction is far more complicated because there is no option to restore large joint cartilage using currently available medical techniques. Frozen autograft with liquid nitrogen has been used as recycled autologous bone graft and the purpose of the present study was to assess the outcome of grafted cartilage in osteoarticular frozen autografts used in the treatment of patients with bone and soft-tissue sarcoma. We have treated 27 patients with cases of bone tumor resection involving an epiphysis where frozen autografts were used for reconstruction. If the tumor was located in a limited part of the epiphysis, partial resection of the epiphysis was performed to preserve the healthy part of the cartilage in 4 cases. The survival of grafted frozen cartilage was assessed by X-ray imaging. The end point was defined as grade IV of the Kellgren and Lawrence osteoarthritis grading system and was recorded using the Kaplan–Meier method. In case of removal of grafted bone after the surgery, pathological findings were assessed by hematoxylin and eosin staining of sections of resected cartilage in available cases to observe the fate of grafted cartilage over time. The postoperative mean follow-up period was 94.0 months. Grade IV osteoarthritis occurred in 12 patients. All patients in the partial epiphyseal freezing group survived compared with only 1 patient in the total epiphyseal freezing group who had survived to the final follow up (p < 0.01). Resected specimens with grafted cartilage were examined histologically. A sample excised after 14 months had dead cartilage with empty lacunae and the surface of the cartilage had reactive fibrous tissue. Grafted cartilage of frozen osteoarticular autografts was worn out over time. However, intraepiphyseal resection preserving partial healthy cartilage resulted in excellent survival. This technique requires careful planning of the surgery but might be an alternative to megaprosthesis.

What are the Oncologic and Functional Outcomes After Joint Salvage Resections for Juxtaarticular Osteosarcoma About the Knee?

BACKGROUND

Joint salvage surgery for patients with juxtaarticular osteosarcoma remains challenging, especially when the tumor invades the epiphysis. Because patients are surviving longer with current chemotherapy regimens, it is advantageous to retain native joints if possible, especially in young patients. However, the results using joint-preserving tumor resections in this context have not been well characterized.

QUESTIONS/PURPOSES

(1) What are the functional outcomes after limb salvage surgery at a minimum of 3 years? (2) What are the oncologic outcomes? (3) Is joint salvage surgery for epiphyseal tumors associated with an increased risk of local recurrence compared with metaphyseal tumors not invading the epiphysis? (4) What are the complications associated with joint salvage surgery?

METHODS

Between 2004 and 2013, we treated 117 patients with juxtaarticular osteosarcoma; of those, 43 (38%) were treated with joint salvage surgery, and 41 (95%) of the 43 patients are included in our study. The other two (5%) were lost to followup before 3 years (mean, 4.4 years; range, 3-11 years,). During the period in question, we generally performed joint salvage surgery in these patients when they had a favorable response to chemotherapy, did not have a pathologic fracture or extrusion of the tumor into the joint, and did not have a whole-epiphyseal osteolytic lesion, a large mass, or obvious neurovascular involvement. This report is a followup of an earlier study; the current study includes an additional nine patients, and additional followup of a mean of 19 months for the patients included in the earlier report. We ascertained overall survival and survival free from local recurrence which was estimated using the Kaplan-Meier method, functional status of the limb which was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system, and recorded reconstructive complications including infection, fracture, skin necrosis, and nonunion. We compared oncologic and functional outcomes between patients with (n = 28) and without tumor extension to epiphysis (n =13). We also compared oncologic and functional outcomes among patients with different adjuvant treatments including microwave ablation (n = 11), cryoablation (n = 12), and navigation-assisted osteotomy (n = 5). Complications were tallied using records from our institutional database.

RESULTS

The overall Kaplan-Mayer survival rate was 82% (95% CI, 104-128 months) at 5 years. The overall Kaplan-Meier survivorship from local recurrence was 91% at 5 years (95% CI, 115-133 months). Three patients had a local recurrence, but none had local recurrence in or close to the remaining epiphysis. The MSTS scores ranged from 22 to 30 points, with a median of 28. There were no differences in survival rate, local recurrence, or MSTS scores between patients with a tumor that did not invade the epiphysis and those in whom the tumor did invade the epiphysis. There were differences in MSTS scores among patients with epiphyseal tumor extension in which different adjuvant techniques, including microwave ablation, cryoablation, and navigation-assisted osteotomy, were used. Additional surgical procedures were recorded for 10 patients (24%). Osteonecrosis of the residual epiphysis was detected 13 patients (31%).

CONCLUSIONS

Our findings suggest it is possible to salvage joints in selected patients with juxtaarticular osteosarcoma around the knee. The patients who have a favorable response to chemotherapy are the best candidates for this approach. Future studies might explore the role of adjuvant techniques of microwave ablation and cryoablation, particularly when the tumor invades the epiphysis, and whether resections can be facilitated with navigation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Distraction osteogenesis and arthrodesis as a new surgical option for chondrosarcoma in the distal tibia

Recent advances in the management of bone tumors have led to a significant increase in the survival rates of patients with malignant bone tumors. Thus, limb salvage surgery has gained importance for preserving limb function in the management of bone tumors. However, surgery presents unique difficulties in terms of the biomechanics and obtaining a soft-tissue cover, such as when the ankle is involved in the primary malignant bone tumor. We report a case of chondrosarcoma of the distal tibia treated with wide en bloc resection arthrodesis and reconstruction of the defect using distraction osteogenesis, which offers an effective alternative protocol for limb salvage. The patient has remained disease free for 3 years since the initial surgery and can maintain normal limb athletic function.

Tumour response of osteosarcoma to neoadjuvant chemotherapy evaluated by magnetic resonance imaging as prognostic factor for outcome

PURPOSE

This study evaluated the feasibility of computed magnetic resonance imaging (MRI) volumetry in conventional osteosarcomas. Secondly, we investigated whether computed volumetry provides new prognostic indicators for histological response of osteosarcomas after neoadjuvant chemotherapy.

METHODS

In a retrospective cohort study, data from the Vienna Bone Tumour Registry was used. MR images from 14 patients (male:female = 1.8, mean age 19 years) were analysed prior to and after neoadjuvant chemotherapy according to current therapy regimens. Histological response to chemotherapy was graded according to the Salzer-Kuntschik classification. Computed volumetry was performed for the intraosseous part, as well as the soft-tissue component and the tumour as a whole.

RESULTS

In a setting of appropriate radiological equipment, the method has been considered to be well implementable into clinical routine. The mean tumour volume prior to chemotherapy was 321 (±351) ml. In good responders (n = 6), overall tumour volume decreased by 47% (p = 0.345), whereas poor responders (n = 8) showed a 19% decrease (p = 0.128). Neoadjuvant multidrug therapy remarkably changed the tumour composition. This is seen in a decrease of the mean ratio of soft-tissue to intraosseous tumour volume from 8.67 in poor responders and 1.15 in good responders to 1.26 and 0.45 (p = 0.065), respectively. Interestingly, the bony compartment of good responders showed a volume increase during neoadjuvant chemotherapy (p = 0.073). However, we did not find prognostic markers for histological tumour response to pre-operative chemotherapy.

CONCLUSIONS

Separated volumetry of tumour segments revealed interesting insights into therapy-induced growth patterns. If verified in a larger study population, these results should be taken into account when planning ablative surgery.

Marginal resection for osteosarcoma with effective neoadjuvant chemotherapy: long-term outcomes

BACKGROUND

We report the long-term outcomes of patients with osteosarcoma who underwent effective preoperative chemotherapy and subsequently underwent marginal resection.

METHODS

We reviewed the records of 50 patients with osteosarcoma who underwent marginal resection following effective preoperative chemotherapy; 18 were treated with the MMIA (high-dose methotrexate (HD-MTX), adriamycin (ADR), ifosfamide (IFO)) and cisplatin (DDP), and 32 patients were treated with the DIA (DDP, ADR and IFO). protocol. The functions of the affected limb were evaluated using the revised MSTS93 system. The Kaplan-Meier method was used for survival analysis.

RESULTS

After a median follow-up of 5.5 years, the rates were: overall 5-year cumulative survival 61.7%, event-free survival 57.7%, recurrence 8.5%, pulmonary metastases 42.6%, and excellent to good function of the affected limb 57.7%.

CONCLUSIONS

Our results showed that marginal resection can be performed in patients with osteosarcoma who obtain clinically favorable responses to chemotherapy. Patients had a good clinical course and there was no negative effect on rates of survival or local recurrence.

Postural assessment of patients with non-conventional knee endoprosthesis

Objective:

To investigate the correlation between the sagittal and frontal alignment and possible postural asymmetries found in patients submitted to total knee stent placement for osteosarcoma.

Methods:

Twenty two individuals were divided into two groups according to tumor location: femur group (13 patients) and tibia group (nine patients), who were evaluated through postural analysis software (SAPO).

Results:

No statistically significant difference was found between groups, supporting previous result showing that both groups present the same postural asymmetries.

Conclusion:

We conclude that both groups have the same postural imbalances, especially the knee of the affected limb that presents hyperextension and center of gravity shifted anteriorly and laterally to the non-affected limb, indicating changes in weight bearing and influencing the gait pattern and balance. Level of Evidence II, Prospective Comparative Study.

Treatment including anthracyclines versus treatment not including anthracyclines for childhood cancer

BACKGROUND

One of the most important adverse effects of anthracyclines is cardiotoxicity. A well-informed decision on the use of anthracyclines in the treatment of childhood cancers should be based on evidence regarding both antitumour efficacy and cardiotoxicity. This review is the second update of a previously published Cochrane review.

OBJECTIVES

To compare antitumour efficacy (survival and tumour response) and cardiotoxicity of treatment including or not including anthracyclines in children with childhood cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 6), MEDLINE (1966 to July 2013) and EMBASE (1980 to July 2013). In addition, we searched reference lists of relevant articles and conference proceedings, the International Society for Paediatric Oncology (SIOP) (from 2002 to 2012) and American Society of Clinical Oncology (ASCO) (from 2002 to 2013). We have searched for ongoing trials in the ISRCTN register and the National Institute of Health register (both screened August 2013) (http://www.controlled-trials.com).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing treatment of any type of childhood cancer with and without anthracyclines and reporting outcomes concerning antitumour efficacy or cardiotoxicity.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection, risk of bias assessment and data extraction. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We identified RCTs for seven types of tumour, acute lymphoblastic leukaemia (ALL) (three trials; 912 children), Wilms' tumour (one trial; 316 children), rhabdomyosarcoma and undifferentiated sarcoma (one trial; 413 children), Ewing's sarcoma (one trial; 94 children), non-Hodgkin lymphoma (one trial; 284 children), hepatoblastoma (one trial; 255 children) and acute myeloid leukaemia (AML) (one trial; 394 children). All studies had methodological limitations. For ALL no evidence of a significant difference in antitumour efficacy was identified in the meta-analyses, but in most individual studies there was a suggestion of better antitumour efficacy in patients treated with anthracyclines. For both Wilms' tumour and Ewing's sarcoma a significant difference in event-free and overall survival in favour of treatment with anthracyclines was identified, although for Wilms' tumour the significant difference in overall survival disappeared with long-term follow-up. For rhabdomyosarcoma and undifferentiated sarcoma, non-Hodgkin lymphoma and hepatoblastoma no difference in antitumour efficacy between the treatment groups was identified. The same was true for AML, with the exception of overall survival in a post hoc analysis in a subgroup of patients with relapsed core binding factor (CBF)-AML in which patients treated with anthracyclines did better. Clinical cardiotoxicity was evaluated in four RCTs; no significant difference between the treatment groups was identified, but in all individual studies there was a suggestion of a lower rate of clinical cardiotoxicity in patients who did not receive anthracyclines. None of the studies evaluated asymptomatic cardiac dysfunction. No RCTs were identified for other childhood cancers.

AUTHORS' CONCLUSIONS

At the moment no evidence from RCTs is available which underscores the use of anthracyclines in ALL. However, 'no evidence of effect', as identified in this review, is not the same as 'evidence of no effect'. For Wilms' tumour, rhabdomyosarcoma and undifferentiated sarcoma, Ewing's sarcoma, non-Hodgkin lymphoma, hepatoblastoma and AML only one RCT was available for each type and, therefore, no definitive conclusions can be made about the antitumour efficacy of treatment with or without anthracyclines in these tumours. For other childhood cancers no RCTs were identified and therefore no conclusions can be made about the antitumour efficacy of treatment with or without anthracyclines in these tumours.

Cisplatin inhibits bone healing during distraction osteogenesis

Osteosarcoma (OS) is the most common malignant bone tumor affecting children and adolescents. Many patients are treated with a combination of chemotherapy, resection, and limb salvage protocols. Surgical reconstructions after tumor resection include structural allografts, non-cemented endoprostheses, and distraction osteogenesis (DO), which require direct bone formation. Although cisplatin (CDP) is extensively used for OS chemotherapy, the effects on bone regeneration are not well studied. The effects of CDP on direct bone formation in DO were compared using two dosing regimens and both C57BL/6 (B6) and tumor necrosis factor receptor 1 knockout (TNFR1KO) mice, as CDP toxicity is associated with elevated TNF levels. Detailed evaluation of the five-dose CDP regimen (2 mg/kg/day), demonstrated significant decreases in new bone formation in the DO gaps of CDP treated versus vehicle treated mice (p < 0.001). Further, no significant inhibitory effects from the five-dose CDP regimen were observed in TNFR1KO mice. The two-dose regimen significantly inhibited new bone formation in B6 mice. These results demonstrate that CDP has profound short term negative effects on the process of bone repair in DO. These data provide the mechanistic basis for modeling peri-operative chemotherapy doses and schedules and may provide new opportunities to identify molecules that spare normal cells from the inhibitory effects of CDP.

A novel method to apply osteogenic potential of adipose derived stem cells in orthopaedic surgery

Background

A number of publications have reported that adipose derived stem cells (ADSCs) have the capacity to be induced to differentiate into osteoblasts both in vitro and in vivo. However, it has been difficult to use separate ADSCs for cortical bone regeneration and bone reconstruction so far. Inspired by the research around stromal stem cells and cell sheets, we developed a new method to fabricate ADSCs sheets to accelerate and enhance the bone regeneration and bone reconstruction.

Purpose

To fabricate ADSCs sheets and evaluate their capacity to be induced to differentiate to osteoblasts in vitro.

Methods

Human adipose derived stem cells (hADSCs) were employed in this research. The fabricating medium containing 50 µM ascorbate-2-phosphate was used to enhance the secretion of collagen protein by the ADSCs and thus to make the cell sheets of ADSCs. As the separate ADSCs were divided into osteo-induction group and control group, the ADSCs sheets were also divided into two groups depending on induction by osteogenesis medium or no induction. The osteogenic capacity of each group was evaluated by ALP staining, Alizarin Red staining and ALP activity.

Results

The ADSCs sheets were fabricated after one-week culture in the fabricating medium. The ALP staining of ADSCs sheets showed positive results after 5 days osteo-induction and the Alizarin Red staining of ADSCs sheets showed positive results after 1 week osteo-induction. The ALP activity showed significant differences between these four groups. The ALP activity of ADSCs sheets groups showed higher value than that of separate ADSCs.

Conclusion

The experiments demonstrated that ADSCs sheets have better capacity than separate ADSCs to be induced to differentiate into osteoblasts. This indicates that it is possible to use the ADSCs sheets as a source of mesenchymal stem cells for bone regeneration and bone reconstruction.

Osteosarcoma around the knee treated with neoadjuvant chemotherapy and a custom-designed prosthesis

This article describes a novel approach using high-dose neoadjuvant chemotherapy with wide tissue resection and a specially designed artificial joint in 104 patients with stage IIB osteosarcoma near the knee. Sixty-four lesions were located at the distal femur, 39 at the proximal tibia, and 1 invaded the proximal tibia from the distal femur. Pathological fracture was present in 9 patients. Three courses of high-dose methotrexate, doxorubicin, and ifosfamide were administered preoperatively, and 6 courses were administered postoperatively. Preoperative radiographs and magnetic resonance images were obtained to determine the required tumor resection range and prosthesis size. Osteotomy of 3 cm of normal bone outside the tumor and wide resection of normal peripheral soft tissue were performed. Reconstruction with a rotary hinge or simple hinge prosthesis, as appropriate, was then performed. The Musculoskeletal Tumor Society 93 scoring system was used to evaluate limb function 6 months postoperatively. At final follow-up, recurrence, complication, survival, and amputation rates were 4%, 18%, 85%, and 4%, respectively. No recurrences were observed at the ends of amputated bones. Complications included infection (6%), nerve injury (3%), and prosthesis-related events (2% dislocation, 3% breakage, and 1% dislocation-related). Mean Musculoskeletal Tumor Society 93 score was 28 points, which indicated an excellent functional outcome. The low recurrence rate is attributed to the efficacy of the chemotherapy and the accuracy of the margin of resection.Effective chemotherapy reduces the risk of tumor metastasis and clarifies the tumor margin. Accurate identification of the resection margin reduces the risk of local recurrence.

Complex biological reconstruction after wide excision of osteogenic sarcoma in lower extremities

Wide margin resection of extremity tumor sometimes leaves a huge soft tissue and bony defects in limb salvage surgery. Adequate management of these defects is an absolute requirement when aiming for functional limb. Multidisciplinary management in such cases is an answer when complex biologic reconstruction is desired. We aim to present cases of osteogenic sarcoma of lower extremity requiring combined surgical approach to achieve effective musculoskeletal reconstruction. Patients and Methods. From 2006 to 2010 ten patients were operated on for osteogenic sarcoma of lower extremity requiring complex musculoskeletal reconstruction. Results. Six patients had pathology around knee joint, whereas one each with mid tibia, mid femur, proximal femur, and heel bone. Locking compression plate was used in 7 patients including six with periarticular disease. Eight out of ten patients underwent biologic reconstruction using autograft; endoprosthetic reconstruction and hindquarter amputation were done in the remaining two patients. Vascularized fibula was done in five patients, sural artery flap which was primarily done in three patients, spare part fillet flap, free iliac crest flap, and Gastrocnemius flap was done in one patient each. Secondary hemorrhage, infection, nonunion, wound dehiscence, and flap failure were notable complications in four patients. The Average Musculoskeletal Tumor Society score was 89%. Conclusion. Combined surgical approach results in cosmetically acceptable and functional limb.

Over 10-year follow-up of functional outcome in patients with bone tumors reconstructed using distraction osteogenesis

BACKGROUND

The aim of this study was to investigate the long-term functional capabilities of patients who underwent bone distraction for the treatment of bone defects caused by bone tumor excision.

METHODS

Bone distraction was indicated for patients with stage IIB malignant bone tumors when chemotherapy was judged to be effective and an epiphysis could be preserved or for patients with low-grade or aggressive benign bone tumors. Twenty-two patients who underwent reconstruction with bone distraction and were followed up for at least 10 years were retrospectively investigated. Patients included 8 males and 14 females, with a mean age of 25.3 years. Tumor types included seven osteosarcomas, two osteofibrous dysplasias, one Ewing's sarcoma, five low-grade osteosarcomas, two adamantinomas, and five giant cell tumors. Chemotherapy was performed during bone distraction in 8 cases. Bone transport was used in 17 cases, while shortening distraction was used in 5 cases.

RESULTS

The mean distraction length was 8.1 cm, and the mean external fixation period was 301 days. The average Musculoskeletal Tumor Society score (used to measure functional outcome) was 91.5 % at mean follow-up of 202 months. Fourteen patients were able to play sports without any difficulty.

CONCLUSIONS

Epiphyseal preservation and reconstruction by bone distraction require both time and effort, but can provide excellent long-term outcomes, resulting in a stable reconstruction that functionally restores the natural limb.

Marginal resection for osteosarcoma with effective preoperative chemotherapy

OBJECTIVE

To present the clinical results of marginal resection with effective preoperative chemotherapy for treatment of osteosarcoma.

METHODS

Thirty-eight patients (20 male and 18 female, average age 17 years), underwent marginal resection after confirmation of effective preoperative chemotherapy between 1999 and 2008 and the results were analyzed retrospectively. The distal femur was involved in 22 cases, proximal tibia in 11, proximal humerus in 4, and proximal fibula in 1. Thirty-seven patients were stage IIB and one IIIB. Twenty-nine patients were treated with the DIA, and 9 with the MMIA protocol. Twenty-one patients underwent tumor resection and bone allograft transplantation. The epiphysis was preserved in 9 patients, and not in the other 12. Eleven patients underwent tumor resection and prosthetic replacement, and 4 tumor resection with autograft implantation. One patient underwent tumor resection and allograft with preservation of the epiphysis; another underwent marginal tumor resection only.

RESULTS

All patients received effective preoperative chemotherapy. At a median follow-up of 52 months, local recurrence had developed in one patient (2.6% local recurrence rate). Pulmonary metastases developed in 9 patients (23.7%). Five patients died of metastases, one died of intracranial hemorrhage due to thrombocytopenia caused by postoperative chemotherapy. The overall 2-year survival rate was 87.3%, and event-free survival rate 75.5%. The overall 5-year survival rate was 74.7%, and event-free survival rate 60.8%. Excellent to good function of affected limbs was achieved in 60.5%.

CONCLUSIONS

With careful preoperative evaluation and effective preoperative chemotherapy marginal resection of osteosarcoma can produce good results. Marginal resection of osteosarcoma should be performed by an experienced surgeon who is familiar with the limb salvage rules for osteosarcoma.

High-grade osteosarcoma treated with hemicortical resection and biological reconstruction

BACKGROUND AND OBJECTIVES

Wide excision with a 2-3 cm safe margin is widely-accepted in treating high-grade osteosarcoma. However, a wider margin sacrifices more healthy bone and may jeopardize joint function. We hypothesize that our innovative hemicortical resection for such tumors leads to better joint function without higher recurrence rate.

METHODS

Between August 2002 and April 2007, six patients of high-grade osteosarcoma were treated with hemicortical resection and biological reconstruction.

RESULTS

Five tumors were located around the knee and one was located in the distal tibia. The mean tumor size was 20.5 cm(3). The bone defects were reconstructed using recycled autograft in four cases (one by extracorporeal irradiation; three by liquid nitrogen) and structural allograft in two. In an average follow-up of 52 months (24-96), all patients survived without local recurrence or metastasis. All bone grafts incorporated well without mechanical failure or infection. The average Musculoskeletal Tumor Society score was 97.7%.

CONCLUSIONS

Hemicortical resection for high-grade osteosarcomas located eccentrically in the long bones may be a reliable technique leading to good joint function by preserving surrounding healthy tissues. The functional outcome was encouraging, although long-term follow-up is mandatory to validate. With the advancement of chemotherapy and radiographic three-dimensional imaging, the safe margin in wide excision of high-grade osteosarcoma may be narrowed down in light of joint surface preservation.

Impact of close surgical margin on local recurrence and survival in osteosarcoma

PURPOSE

Whether neoadjuvant chemotherapy safely allows close margins in osteosarcoma patients is still unknown. This study investigates the impact of close margins on local recurrence (LR) and overall survival (OS) for osteosarcoma patients treated with neoadjuvant chemotherapy.

METHODS

We retrospectively reviewed 47 cases of conventional osteosarcoma who were treated at our institution. Patient and treatment factors such as age, gender, MSTS stage, tumour site, surgery type, pathological type, tumour size, surgical margin, tumour necrosis rate, chemotherapy regimens and cycles were recorded. A close margin was defined as tumour present less than 5 mm from the closest resection margin. The average followup was 87.6 months (range, 25-135 months).

RESULTS

Twenty-five patients were alive, 22 patients had died, and eight had LR. Twenty-eight patients had wide margins, seven had positive margins and 12 had close margins. Positive margins had a greater risk of LR (57.1%) than wide margins and close margins. There was no difference in LR (8.3% vs 10.7%) between close margins and wide margins. Margin status was not correlated with OS.

CONCLUSION

Compared with wide margins, close margins did not lead to increased local recurrence in our study group. Whether close margins, as defined in our study, are just as acceptable as wide margins in terms of patient outcomes for osteosarcoma patients with neoadjuvant chemotherapy needs to be further confirmed in the future.

Treatment including anthracyclines versus treatment not including anthracyclines for childhood cancer

BACKGROUND

One of the most important adverse effects of anthracyclines is cardiotoxicity. A well-informed decision on the use of anthracyclines in the treatment of childhood cancers should be based on evidence regarding both antitumour efficacy and cardiotoxicity.

OBJECTIVES

To compare antitumour efficacy of treatment including or not including anthracyclines in children with childhood cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2), MEDLINE (1966 to March 2010) and EMBASE (1980 to March 2010). In addition, we searched reference lists of relevant articles, conference proceedings and ongoing trials databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing treatment of any type of childhood cancer with and without anthracyclines and reporting outcomes concerning antitumour efficacy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed the study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We identified RCTs for six types of tumour: acute lymphoblastic leukaemia (ALL) (three trials; 912 children), Wilms' tumour (one trial; 316 children), rhabdomyosarcoma/undifferentiated sarcoma (one trial; 413 children), Ewing's sarcoma (one trial; 94 children), non-Hodgkin lymphoma (one trial; 284 children) and hepatoblastoma (one trial; 255 children). All studies had methodological limitations. For ALL no evidence of a significant difference in antitumour efficacy was identified in the meta-analyses, but in most individual studies there was a suggestion of better antitumour efficacy in patients treated with anthracyclines. For both Wilms' tumour and Ewing's sarcoma a significant difference in event-free and overall survival in favour of treatment with anthracyclines was identified, although for Wilms' tumour the significant difference in overall survival disappears with long-term follow-up. For rhabdomyosarcoma/undifferentiated sarcoma, non-Hodgkin lymphoma and hepatoblastoma no difference in antitumour efficacy between the treatment groups was identified. Clinical cardiotoxicity was evaluated in three RCTs: no significant difference between both treatment groups was identified, but in all individual studies there was a suggestion of a lower rate of clinical cardiotoxicity in patients who did not receive anthracyclines. None of the studies evaluated asymptomatic cardiac dysfunction. For other childhood cancers no RCTs were identified.

AUTHORS' CONCLUSIONS

At the moment no evidence from RCTs is available which underscores the use of anthracyclines in ALL. However, "no evidence of effect", as identified in this review, is not the same as "evidence of no effect". For Wilms' tumour, rhabdomyosarcoma/undifferentiated sarcoma, Ewing's sarcoma, non-Hodgkin lymphoma and hepatoblastoma only one RCT was available and, therefore, no definitive conclusions can be made about the antitumour efficacy of treatment with or without anthracyclines in these tumours. For other childhood cancers no RCTs were identified and therefore, no conclusions can be made about the antitumour efficacy of treatment with or without anthracyclines in these tumours.

Impact of serum caffeine monitoring on adverse effects and chemotherapeutic responses to caffeine-potentiated chemotherapy for osteosarcoma

BACKGROUND

Caffeine can safely enhance the cytocidal effects of anticancer drugs through its DNA repair-inhibiting effect. We have demonstrated in several studies that caffeine-potentiated chemotherapy induces a high complete response rate in patients with osteosarcoma. The present study focused on monitoring and adjusting serum caffeine levels during caffeine-potentiated chemotherapy to reduce adverse effects.

METHODS

We utilized a method for rapidly determining caffeine concentration by high-performance liquid chromatography. The maximum caffeine concentration was predicted from the measured concentrations at 24 and 48 h after the beginning of caffeine administration. The caffeine infusion rate was then modified accordingly to prevent the expected final concentration from exceeding 80 microg/ml. The study involved 22 American Joint Committee on Cancer (AJCC) stage IIB high-grade osteosarcoma patients treated with caffeine-potentiated chemotherapy. Nine patients underwent monitoring of their serum caffeine levels (monitoring group), and the remaining 13 patients were not monitored (nonmonitoring group). Toxicities were graded according to the Japan Clinical Oncology Group Toxicity Criteria.

RESULTS

Hematological toxic events were well tolerated in both groups. Grade 4 leukocyte toxicity events occurred in both groups. In the nonmonitoring group grade 2 or higher toxicities included 5 elevated aspartate aminotransferase/alanine aminotransferase level events and 17 hyponatremia events versus 1 hyponatremia event in the monitoring group. Histological examination of excised tumor samples after preoperative chemotherapy revealed that chemotherapeutic efficacy in the monitoring group was as good as in the nonmonitoring group. The median follow-up period in all patients was 72 months. Event-free survival was 76%, and overall survival was 100%.

CONCLUSIONS

Monitoring and adjusting caffeine levels were achieved without apparent loss of chemotherapeutic efficacy.