Ewing?s sarcoma and primitive neuroectodermal tumor of hand and forearm

Wide Resection of Primary Malignant Bone Tumors of the Hand in Children and Reconstruction Using Nonvascularized Fibular Bone Graft: Case Series and Literature Review

PURPOSE

Primary malignant bone tumors of the hand are rare in children. Resection and reconstruction of the digit are challenging and have been described in case reports. This retrospective study describes the functional and oncologic outcomes of resection and reconstruction using a nonvascularized fibular bone graft in a cohort of children.

METHODS

A total of 5 children were included. The mean age at diagnosis was 7.6 years (range, 1.6-12 years). Histologic diagnosis showed Ewing sarcoma in 3 and osteosarcoma in 2 patients. Four tumors were located in the metacarpal bones of the fingers, and 1 was located in the thumb. Four patients were treated with chemotherapy. All the patients were treated with wide resection and a cement spacer. This was followed by second stage reconstruction using a nonvascularized fibular bone graft. In tumors of the fingers, carpometacarpal joint fusion with a neighboring carpal bone was performed, whereas a pseudoarthrosis was created between the graft and the base of the proximal phalanx. In the thumb's case, the opposite was done, with fusion at the metacarpophalangeal joint and a pseudoarthrosis at the carpometacarpal joint.

RESULTS

The mean follow-up duration was 5.5 years (range, 2-9 years). Surgical margins were negative in all the patients. At their latest follow-up visit, none of the patients developed systemic or local recurrence. Two complications required a revision surgery, one due to graft subluxation and the other due to nonunion. At their final follow-up examination, the mean total arc of movement was 80° (range, 60°-100°), and all the patients were able to resume their grasping and writing capabilities.

CONCLUSIONS

The resection and reconstruction of primary malignant bone tumors of the metacarpals using a nonvascularized fibular bone graft in children can preserve the cosmesis and function of the digit without jeopardizing oncologic outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Diagnosis and management of primary malignant tumors in the upper extremity

Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.

Subungual Ewing sarcoma/PNET tumor family of the great toe: a case report

Ewing’s sarcoma is seen mainly in patients less than 18. This aggressive tumor generally affects the axial skeleton and only rarely involves the acral regions. Ewing’s sarcoma in the foot is inordinately scarce. Clinical features are uncertain and can imitate other common diseases. This paper presents a case of 62-year-old malewith complaints of pain and swelling of the subungual area of his right great toe. The lesion was excised, and histopathological diagnosis of Ewing’s sarcoma was made. Histopathological examination, supported by immunochemical methods, remains the mainstay of diagnosis. Surgical ablation along with chemotherapy is the therapy of choice. To our knowledge, this is the first report of Ewing’s sarcoma involving the nail bed of the great toe without bone erosion. The key messages of this case report is “Subungual Ewing sarcoma is a rare case, and Ewing’s sarcoma must be kept in mind for acral lesions, especially in the adult population.”

Reconstruction of the elbow and forearm for Ewing sarcoma of ulna: A new biological technique

Primary bone tumors around the elbow represent <1% of all the skeletal tumors. Surgery with or without adjuvant therapy (radiotherapy, chemotherapy) is the treatment of choice for malignant tumors. Reconstruction of the elbow and forearm in malignant tumors is challenging as it involves a complex interplay between multiple joints which need to be stabilized for the optimal functional outcome. We describe a new technique for the reconstruction of the elbow after resection of a proximal ulna tumor with articular radio-ulnar synostosis with the creation of a single bone forearm. We attempted to achieve a mobile elbow and stable wrist joint with the radio-ulnar union at the proximal articular surface of the ulna resulting in a single bone forearm. The procedure involves an oblique osteotomy preserving the olecranon process (after taking adequate margins based on oncological principles) and its articular cartilage along with the attachment of the triceps tendon. Then the radial head was partially denuded of its cartilage using a burr, leaving cartilage only on the volar side, and then fused to the remnant olecranon. Osteosynthesis was done using compression screw and tension band wiring. The advantages of this procedure are that the mobility at wrist and elbow are retained, it requires minimal hardware and allows for primary closure of the wound.

Ewing sarcoma of the proximal phalanx: case report

We report a case of primary Ewing sarcoma of the proximal phalanx of the right middle finger in an 18-year-old boy. He was treated with neoadjuvant chemotherapy, followed by ray amputation. To restore maximum function, the index ray was transferred to the base of the third metacarpal bone and fixed with a plate. The function of his right hand after the operation was excellent and the cosmetic appearance acceptable. There was no evidence of local recurrence or metastasis after 20 months follow up.

[Total wrist fusion with vascularized fibula graft after tumor resection of the distal radius]

OBJECTIVE

Total tumor resection and defect resconstruction by vascularized fibula graft and total wrist fusion.

INDICATIONS

Primary extended bone tumors of the distal radius.

CONTRAINDICATIONS

Tumor infiltration of the whole carpus or of the neurovascular structures.

SURGICAL TECHNIQUE

En bloc resection of the tumor including the biopsy scar. Raising of a microvascular fibula graft including the peroneal vessels. Defect reconstruction using the fibula and stabilization of the total wrist fusion with a locking compression plate (LCP).

POSTOPERATIVE MANAGEMENT

Functional therapy of the fingers is possible, below elbow cast for 6 weeks. Weight bearing after 12 weeks according to bone healing.

RESULTS

The operation technique described for preservation of the extremity in primary extended bone tumors of the distal radius was performed in our clinic in 2 patients since 2009. Tumor-free and pain-free hand function was found at the 2.5-year follow-up examinations. The patients had free range of motion of the fingers and preserved sensorimotor function. The MSTS (Musculoskeletal Tumour Society) scores by Enneking were 80% and 70%.

Clinical management of Ewing sarcoma of the bones of the hands and feet: a retrospective single-institution review

BACKGROUND/PURPOSE

Bones of the hands and feet are uncommon sites for Ewing sarcoma. In this study, we reviewed our experience in the management of these tumors.

METHODS

We retrospectively reviewed clinical presentation, management, and outcome of patients with Ewing sarcoma of the bones of hands and feet treated at our institution (1981-2006).

RESULTS

The cohort included 6 males and 3 females (8 white, 1 African American; median age at diagnosis, 15 years). Primary tumor site was the hand in 6 and the foot in 3 patients. Three patients had distant metastatic disease at diagnosis (lung [n = 2]; ipsilateral axillary lymph node[(n = 1]). All patients had painful swelling at the primary site, and 2 (22%) had pathological fracture. All patients received chemotherapy and local control measures (surgery [n = 6], radiation [n = 2], surgery and radiation [(n = 1]). Three patients received radiotherapy for distant metastases. Three patients had systemic recurrence (lungs [n = 2], lung and brain [n = 1]); none had local tumor recurrence. Median follow-up was 5 years. Five patients (55.6%) are alive at last follow-up.

CONCLUSIONS

Chemotherapy and surgical excision of primary tumor are the mainstays of treatment. Radiotherapy is recommended for local control of lesions in the hand for patients declining excisional therapy.

Tumours of the hand: a review on histology of bone malignancies

Malignant bone tumours of the hands are uncommon. Although almost all lesions that occur in other parts of the skeleton can also affect the hands, their frequency, distribution and clinical characteristics differ. This review focusses on the histology of these tumours and gives an overview of the main differential diagnoses. Close correlation to radiologic and clinical features usually leads to the correct diagnosis.

Ewing's sarcoma of the hand

A retrospective case review was carried out to report the outcomes in a contemporary case series of Ewing's sarcoma originating in the hand. We identified five patients treated since 1995. All five had wide surgical excision, one by ray amputation. All were treated with chemotherapy. Four patients also received radiation therapy, two to treat metastases and two as an adjunct to local excision. There were no local recurrences. Two patients developed metastases. Both died of their disease. Neither of these two patients had received local postoperative radiation therapy; one did not receive chemotherapy before definitive surgery. The other three patients were alive and free of disease at last follow-up, 4 to 12 years after initial presentation.

Improved survival for sarcomas of the wrist and hand

PURPOSE

To evaluate survival characteristics of malignant hand tumors compared with those occurring in other musculoskeletal locations over a 30-year period.

METHODS

Patients were identified through a computerized database maintained at the authors' institution over the past 30 years. Each patient's records were reviewed retrospectively. Diagnoses were categorized and survival data for patients with hand malignancies were compared with those of patients having similar tumors in other musculoskeletal sites by using multivariate statistical analysis.

RESULTS

The most common malignancies were epitheloid sarcoma, synovial sarcoma, and malignant fibrous histiocytoma. Improved survival during the follow-up period was found for hand malignancies versus those occurring in other musculoskeletal sites as a whole, and this difference was statistically significant. No significant survival benefit was identified for individual tumors.

CONCLUSIONS

Patients presenting with primary malignancies of the hand may survive longer than those with similar tumors in other musculoskeletal locations

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level II.