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Kantzos AJ, Fayad LM, Abiad JE, Ahlawat S, Sabharwal S, Vaynrub M, Morris CD. The role of imaging in extremity sarcoma surgery. Skeletal Radiol 2024; 53:1937-1953. [PMID: 38233634 DOI: 10.1007/s00256-024-04586-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
The surgical management of extremity bone and soft tissue sarcomas has evolved significantly over the last 50 years. The introduction and refinement of high-resolution cross-sectional imaging has allowed accurate assessment of anatomy and tumor extent, and in the current era more than 90% of patients can successfully undergo limb-salvage surgery. Advances in imaging have also revolutionized the clinician's ability to assess treatment response, detect metastatic disease, and perform intraoperative surgical navigation. This review summarizes the broad and essential role radiology plays in caring for sarcoma patients from diagnosis to post-treatment surveillance. Present evidence-based imaging paradigms are highlighted along with key future directions.
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Affiliation(s)
- Andrew J Kantzos
- Orthopedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Laura M Fayad
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | | | - Shivani Ahlawat
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Samir Sabharwal
- Orthopedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Max Vaynrub
- Orthopedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Carol D Morris
- Orthopedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.
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2
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Quirion JC, Johnson SR, Kowalski BL, Halpern JL, Schwartz HS, Holt GE, Prieto-Granada C, Singh R, Cates JMM, Rubin BP, Mesko NW, Nystrom LM, Lawrenz JM. Surgical Margins in Musculoskeletal Sarcoma. JBJS Rev 2024; 12:01874474-202403000-00003. [PMID: 38446910 DOI: 10.2106/jbjs.rvw.23.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
» Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.» There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.» Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.» Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.
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Affiliation(s)
- Julia C Quirion
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel R Johnson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brooke L Kowalski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer L Halpern
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Herbert S Schwartz
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ginger E Holt
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos Prieto-Granada
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reena Singh
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brian P Rubin
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Nathan W Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lukas M Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joshua M Lawrenz
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Huang M, Ma Z, Yu J, Lu Y, Chen G, Fan J, Li M, Ji C, Xiao X, Li J. Does joint-sparing tumor resection jeopardize oncologic and functional outcomes in non-metastatic high-grade osteosarcoma around the knee? World J Surg Oncol 2023; 21:185. [PMID: 37344861 DOI: 10.1186/s12957-023-03045-2] [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: 09/27/2022] [Accepted: 05/25/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND We previously reported joint-sparing tumor resection for osteosarcoma with epiphyseal involvement in which transepiphyseal osteotomy went through the in situ ablated epiphysis. However, we do not know whether this is a safe approach when compared with joint-sacrificed tumor resection. Our objective was to compare oncologic and functional outcomes between patients who underwent joint preservation (JP) and joint replacement (JR) tumor resection. Furthermore, we identified the risk factors of local recurrence, metastasis and survival. METHODS Eighty-nine patients with non-metastatic high-grade osteosarcoma around the knee were treated with limb-salvage surgery (JP in 47 and JR in 42). Age, gender, tumor location, pathologic fracture, plain radiographic pattern, limb diameter change, perivascular space alteration, surgical margin, local recurrence, metastasis, death, and the Musculoskeletal Tumor Society (MSTS)-93 scores were extracted from the records. Univariate analysis was performed to compare oncologic and functional outcomes. Binary logistic and cox regression models were used to identify predicted factors for local recurrence, metastasis, and survival. RESULTS Local recurrence, metastasis and overall survival were similar in the JP and JR group (p = 0.3; p = 0.211; p = 0.143). Major complications and limb survival were also similar in the JR and JP group (p = 0.14; p = 0.181). The MSTS score of 27.06 ± 1.77 in the JP group was higher than that of 25.88 ± 1.79 in the JR group (p = 0.005). The marginal margin of soft tissue compared with a wide margin was the only independent predictor of local recurrence (p = 0.006). Limb diameter increase and perivascular fat plane disappearance during neoadjuvant chemotherapy were independent predictors for metastasis (p = 0.002; p = 0.000) and worse survival (p = 0.000; p = 0.001). CONCLUSIONS Joint-sparing tumor resection with the ablative bone margin offers advantage of native joint preservation with favorable functional outcomes while not jeopardizing oncologic outcomes compared with joint-sacrificed tumor resection. Surgeon should strive to obtain adequate soft tissue surgical margin decreasing risk of local recurrence. Novel drug regimens might be reasonable options for patients with obvious limb diameter increase and perivascular fat disappearance during chemotherapy.
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Affiliation(s)
- Mengquan Huang
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Ziyang Ma
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Jie Yu
- Department of Orthopedics, 986 Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Yajie Lu
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Guojing Chen
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Jian Fan
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Minghui Li
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Chuanlei Ji
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Xin Xiao
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China.
| | - Jing Li
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China.
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Cederberg KB, Iyer RS, Chaturvedi A, McCarville MB, McDaniel JD, Sandberg JK, Shammas A, Sharp SE, Nadel HR. Imaging of pediatric bone tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e30000. [PMID: 36250990 PMCID: PMC10661611 DOI: 10.1002/pbc.30000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/08/2022]
Abstract
Malignant primary bone tumors are uncommon in the pediatric population, accounting for 3%-5% of all pediatric malignancies. Osteosarcoma and Ewing sarcoma comprise 90% of malignant primary bone tumors in children and adolescents. This paper provides consensus-based recommendations for imaging in children with osteosarcoma and Ewing sarcoma at diagnosis, during therapy, and after therapy.
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Affiliation(s)
- Kevin B. Cederberg
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ramesh S. Iyer
- Department of Radiology, Seattle Children’s Hospital, Seattle, WA
| | - Apeksha Chaturvedi
- Division of Pediatric Radiology, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - MB McCarville
- Department of Diagnostic Imaging, St Jude Children’s Research Hospital, Memphis, TN
| | - Janice D. McDaniel
- Department of Pediatric Interventional Radiology, Akron Children’s Hospital, Akron, OH and Department of Radiology, Northeast Ohio Medical University, Rootstown, OH
| | - Jesse K. Sandberg
- Department of Pediatric Radiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA
| | - Amer Shammas
- Division of Nuclear Medicine, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, OH, Canada
| | - Susan E. Sharp
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Helen R. Nadel
- Department of Pediatric Radiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA
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Stefanaki C, Paltoglou G, Mastorakos G, Chrousos GP. Chronic Stress and Steatosis of Muscles, Bones, Liver, and Pancreas: A Review. Horm Res Paediatr 2023; 96:66-73. [PMID: 35144259 DOI: 10.1159/000522540] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 02/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic stress is a recognized risk factor for poor health, body composition disequilibrium, impaired mental health, and deterioration of quality of life. Chronic stress-related cortisol oversecretion and circadian dysregulation and associated systemic low grade, injurious inflammation ("para-inflammation") contribute to steatosis in various metabolically active solid organs, affecting both their structure and function. The aim of this review was to summarize current knowledge on the impact of chronic stress and associated para-inflammation on skeletal muscle, bone, liver, and pancreas, leading to their steatosis. Current management of these maladaptive conditions is also included and underscored in this review. SUMMARY Steatosis of metabolically active solid organs is involved in various metabolic processes and considered a risk factor for chronic noncommunicable diseases, yet its role in chronic stress physiology and pathophysiology has been overlooked. KEY MESSAGES Chronic stress-associated steatosis of several solid organs is generally disregarded in current clinical practice. Physicians should be alert for these steatoses and should address them adequately so as to provide appropriate medical care. New guidelines generated by learned societies are needed, along with large observational studies, to offer novel solutions to this old problem.
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Affiliation(s)
- Charikleia Stefanaki
- Unit of Endocrinology, Diabetes Mellitus, and Metabolism, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.,University Research Institute of Maternal and Child Health & Precision Medicine, and UNESCO Chair on Adolescent Health Care, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Paltoglou
- Unit of Endocrinology, Diabetes Mellitus, and Metabolism, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.,University Research Institute of Maternal and Child Health & Precision Medicine, and UNESCO Chair on Adolescent Health Care, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Mastorakos
- Unit of Endocrinology, Diabetes Mellitus, and Metabolism, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George P Chrousos
- University Research Institute of Maternal and Child Health & Precision Medicine, and UNESCO Chair on Adolescent Health Care, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
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The safe surgical margin in Ewing's sarcoma. Surg Oncol 2022; 41:101737. [PMID: 35358914 DOI: 10.1016/j.suronc.2022.101737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/23/2021] [Accepted: 03/03/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION There is recent evidence advocating the use of post-chemotherapy MRI for safe resection of primary bone sarcoma in providing a clear margin of disease. This paper challenges this view by providing evidence obtained from comparing surgical resection margin measurements calculated off the pre- and post-chemotherapy MRIs to the post-operative histological analysis. METHOD A retrospective patho-radiological analysis of 10 patients treated for long bone Ewing's sarcoma. The pre- and post-chemotherapy MRI radiological measurements were correlated with the post-operative gross and microscopic histological specimens with the principle aim of determining which represented the accurate histological extent of disease and therefore which image set should be used in determining the surgical resection margins. RESULTS In the 10 cases there was a discrepancy in the extent of pathological disease on comparative histological and radiological assessment. The mean age at presentation was 19.5years [4-45 years], with a female bias (n = 7/10). The lower limbs were more commonly involved than the upper limb (femur n = 2/10, tibia n = 3/10, fibula n = 2/10, humerus n = 2/10, ulna n = 1/10). There was no correlation between the percentage reduction in measured volume/length of pathological bone on sequential MRI and the percentage necrosis on histology. The average discrepancy between the length of pathological bone on histology and on MRI was 2.7 cm. Using the baseline pre-chemotherapy MRI to plan the surgical resection margins, 7/10 patients had their surgical resection margins through radiologically clear but pathologically abnormal bone (without histological evidence of residual tumour). Had the post-chemotherapy MRI been used a further 3 patients would have had their tumour resected through pathologically abnormal bone. No patients had or would have had tumour resected through residual tumour. CONCLUSIONS The use of the post-chemotherapy MRI for planning surgical resection margins increases the risk of resecting through histologically abnormal bone that may have been previously contaminated by tumour, without significant benefit of preserving sufficient bone to facilitate joint or physeal sparing surgery. The evidence from this study supports current guidelines recommending the use of pre-chemotherapy MRI to plan safe surgical resection margins in Ewing's sarcoma.
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Zhou L, Lin S, Zhu H, Dong Y, Yang Q, Yuan T. The blood pressure and use of tourniquet are related to local recurrence after intralesional curettage of primary benign bone tumors: a retrospective and hypothesis-generating study. BMC Musculoskelet Disord 2022; 23:201. [PMID: 35241034 PMCID: PMC8892695 DOI: 10.1186/s12891-022-05157-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 02/25/2022] [Indexed: 11/29/2022] Open
Abstract
Aims Intralesional curettage is a commonly used treatment for primary bone tumors. However, local recurrence of tumors after curettage remains a major challenge. Questions (1) Is blood pressure related to local recurrence after intralesional curettage for benign or intermediate bone tumors? (2) What’s the impact of tourniquet usage on the risk of recurrence from high blood pressure? Methods This retrospective study evaluated patients receiving intralesional curettage for primary bone tumors from January 2011 to January 2015. A total of 411 patients with a minimum five-year follow-up were included for analysis. Demographic and disease-related variables were first assessed in univariable analyses for local recurrence risk. When a yielded p-value was < 0.2, variables were included in multivariable analyses to identify independent risk factors for local recurrence. Patients were then stratified by tourniquet usage (use/non-use), and risk from high blood pressure was evaluated in both subgroups. Results At an average follow-up of 6.8 ± 1.0 years, 63 of 411 patients (15.3%) experienced local recurrence. In multivariable analyses, local recurrence was associated with age (OR, 0.96; 95% CI, 0.94–0.99; p = 0.005); tumor type; lesion size (> 5 cm: OR, 3.58; 95% CI, 1.38–9.33; p = 0.009); anatomical site (proximal femur: OR, 2.49; 95% CI, 1.21–5.15; p = 0.014; proximal humerus: OR, 3.34; 95% CI, 1.61–6.92; p = 0.001); and preoperative mean arterial pressure (> 110 mmHg: OR, 2.61; 95% CI, 1.20–5.67; P = 0.015). In subgroup analyses, after adjusting for age, tumor type, lesion size, and anatomical site, tourniquet use modified the preoperative mean arterial pressure - recurrence relationship: when tourniquet was not used, preoperative mean arterial pressure predicted local recurrence (95–110 mmHg, 4.13, 1.42–12.03, p = 0.009; > 110 mmHg, 28.06, 5.27–149.30, p < 0.001); when tourniquet was used, preoperative mean arterial pressure was not related to local recurrence (all p values > 0.05). Conclusions A high preoperative blood pressure was related to local recurrence after intralesional curettage for primary bone tumors in our study. Tourniquet usage and controlling blood pressure might be beneficial for reducing local recurrence in patients scheduled to receive intralesional curettage for primary bone tumor treatment. Level of evidence Level IV, hypothesis-generating study. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05157-4.
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Affiliation(s)
- Lenian Zhou
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Shanyi Lin
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Hongyi Zhu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Yang Dong
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Qingcheng Yang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Ting Yuan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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Personalized 3D-printed guide in malignant bone tumor resection and following reconstruction – 17 cases in pelvic and extremities. Surg Oncol 2022; 42:101733. [DOI: 10.1016/j.suronc.2022.101733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 02/11/2022] [Accepted: 03/01/2022] [Indexed: 11/18/2022]
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9
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Clemente EJI, Navarro OM, Navallas M, Ladera E, Torner F, Sunol M, Garraus M, March JC, Barber I. Multiparametric MRI evaluation of bone sarcomas in children. Insights Imaging 2022; 13:33. [PMID: 35229206 PMCID: PMC8885969 DOI: 10.1186/s13244-022-01177-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/07/2022] [Indexed: 12/22/2022] Open
Abstract
Osteosarcoma and Ewing sarcoma are the most common bone sarcomas in children. Their clinical presentation is very variable depending on the age of the patient and tumor location. MRI is the modality of choice to assess these bone sarcomas and has an important function at diagnosis and also for monitoring recurrence or tumor response. Anatomic sequences include T1- and T2-weighted images and provide morphological assessment that is crucial to localize the tumor and describe anatomical boundaries. Multiparametric MRI provides functional information that helps in the assessment of tumor response to therapy by using different imaging sequences and biomarkers. This review manuscript illustrates the role of MRI in osteosarcoma and Ewing sarcoma in the pediatric population, with emphasis on a functional perspective, highlighting the use of diffusion-weighted imaging and dynamic contrast-enhanced MRI at diagnosis, and during and after treatment.
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Affiliation(s)
- Emilio J Inarejos Clemente
- Department of Diagnostic Imaging. Hospital Sant Joan de Déu, Av. Sant Joan de Déu, 2, CP:08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Oscar M Navarro
- Department of Medical Imaging, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Maria Navallas
- Department of Diagnostic Imaging, Hospital 12 de Octubre, Madrid, Spain
| | - Enrique Ladera
- Department of Diagnostic Imaging. Hospital Sant Joan de Déu, Av. Sant Joan de Déu, 2, CP:08950, Esplugues de Llobregat, Barcelona, Spain
| | - Ferran Torner
- Department of Orthopaedics, Hospital Sant Joan de Déu. Av, Sant Joan de Déu, 2, CP:08950, Esplugues de Llobregat, Barcelona, Spain
| | - Mariona Sunol
- Department of Pathology, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Moira Garraus
- Department of Oncology, Hospital Sant Joan de Déu. Av, Sant Joan de Déu, 2, CP:08950, Esplugues de Llobregat, Barcelona, Spain
| | - Jordi Català March
- Department of Radiology, Instituto de Resonancia Magnetica Guirado, C/Muntaner, 531, CP:08022, Barcelona, Spain
| | - Ignasi Barber
- Department of Diagnostic Imaging. Hospital Sant Joan de Déu, Av. Sant Joan de Déu, 2, CP:08950, Esplugues de Llobregat, Barcelona, Spain
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Menendez N, Epelman M, Shao L, Douglas D, Meyers AB. Pediatric Osteosarcoma: Pearls and Pitfalls. Semin Ultrasound CT MR 2022; 43:97-114. [PMID: 35164914 DOI: 10.1053/j.sult.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Osteosarcoma is a malignant bone tumor most commonly presenting in children. It has a bimodal distribution with a peak incidence occurring during the ages of 10-14 years old and in adults greater than age 65. The first peak of osteosarcoma correlates with the increased proliferation of bone during the pubertal growth period. Osteosarcoma most frequently presents with localized bone pain, swelling, and an antalgic gait. The patient may attribute symptoms to trauma or strenuous exercise, causing the patient to be managed conservatively. In these cases, the pain persists and eventually leads to further evaluation. The most common type of osteosarcoma is the conventional high-grade osteosarcoma. For conventional osteosarcoma, the diagnosis is typically made or strongly suggested based upon the initial radiographic appearance. Other types of osteosarcomas include low grade central, telangiectatic, small-cell, surface and intracortical. Consequently, it is important for radiologists to be aware of these subtypes and the imaging features that differentiate them from other etiologies to prevent a delay in treatment.
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Affiliation(s)
- Nelson Menendez
- University of Central Florida College of Medicine, Orlando, FL; Department of Radiology, Nemours Children's Health System/Nemours Children's Hospital, Orlando, FL
| | - Monica Epelman
- University of Central Florida College of Medicine, Orlando, FL; Department of Radiology, Nemours Children's Health System/Nemours Children's Hospital, Orlando, FL
| | - Lei Shao
- University of Central Florida College of Medicine, Orlando, FL; Department of Pathology and Lab Medicine, Nemours Children's Health System/Nemours Children's Hospital, Orlando, FL
| | - Dorothea Douglas
- University of Central Florida College of Medicine, Orlando, FL; Department of Pediatrics, Nemours Children's Health System/Nemours Children's Hospital, Orlando, FL
| | - Arthur B Meyers
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Dept. of Radiology, Cincinnati, OH.
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11
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Katz TH, Hasan OH, Miller BJ. Accuracy of X-Ray and Magnetic Resonance Imaging in Defining the Tumor Margin in Primary Bone Sarcoma. THE IOWA ORTHOPAEDIC JOURNAL 2021; 41:27-33. [PMID: 34924867 PMCID: PMC8662927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Limb-salvage surgery for primary bone sarcomas are preceded by X-ray and MRI for surgical planning. However, the accuracy of X-ray and MRI predicted margins are not well described. Our study examined these questions: (1) How accurately do X-ray and MRI margin measurements reflect the true margin on pathology reports? (2) Do X-ray or MRI margin measurements have smaller differences compared to pathology reports? (3) How many X-ray or MRI margin measurement differences were greater than 1 cm, 2 cm, and 3 cm from pathology reports? (4) Is there an X-ray or MRI view that consistently results in a smaller difference from pathology reports? METHODS This retrospective chart review examined patients with primary bone sarcoma treated with limb-salvage surgery. Reviewers used electronic measurement tools to determine margins from X-ray or MRI based on the resection length of the pathologic specimen. Mean differences of margin measurements to pathology reports were calculated. We determined outliers of imaging margin measurements at 1 cm, 2 cm, and 3 cm differences to pathology reports. RESULTS In the total cohort of 39 patients, the mean difference of X-ray and MRI margins compared to pathology reports were 1.09 cm (st dev 0.79 cm) and 0.71 cm (st dev 0.70 cm), respectively. MRI margin measurements had smaller differences compared to pathology reports than X-ray in 32 of 38 cases (84%) with complete imaging. X-ray outliers at 1 cm, 2 cm, and 3 cm differences were 36, 14 and 2 respectively for 70 margin measurements and MRI outliers at 1 cm, 2 cm, and 3 cm differences were 17, 6, and 0 respectively for 66 margin measurements. The views with the smallest difference were anterior-posterior X-rays and MRI views with the closest predicted margin. CONCLUSION Electronic MRI margin measurements with the closest predicted margin provided the smallest differences with pathology reports and are therefore the most accurate for preoperative planning. When there is adequate residual diaphysis for reconstructive fixation, surgeons should plan for a 3 cm bone margin using MRI measurements to ensure complete removal of the intramedullary extent of sarcoma.Level of Evidence: IV.
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Affiliation(s)
- Theodore H. Katz
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Obada H. Hasan
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Benjamin J. Miller
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
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12
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Campanacci DA, Scoccianti G. Benign and Malignant Tumors in Child Foot. Foot Ankle Clin 2021; 26:851-871. [PMID: 34752241 DOI: 10.1016/j.fcl.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bone tumors affecting pediatric foot are a rare occurrence. Most lesions are benign, but a thorough diagnostic evaluation must always be performed to rule out malignant tumors. Approach to benign lesions is conservative, from observation follow-up to curettage or mininvasive techniques. In malignant lesions, a wide resection must be performed and same protocols applied as in tumors affecting other skeletal sites. Reconstructive procedures should aim to mechanical stability and long-lasting results; joint motion restoring can be attempted when not negatively affecting stability. Amputation procedures should be considered as a still viable choice because of their good functional result in the foot.
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Affiliation(s)
- Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Largo Brambilla 3, Firenze 50134, Italy.
| | - Guido Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Largo Brambilla 3, Firenze 50134, Italy
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Zucchini R, Staals EL, Fiore M, Campanacci L, Giannini C, Manfrini M, Donati DM. Intercalary reconstruction of the distal femur with or without physeal preservation: results and impact on limb growth. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1651-1659. [PMID: 34674057 DOI: 10.1007/s00590-021-03149-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Allograft reconstruction with or without vascularized fibula can be a valuable solution to treat childhood intercalary tumours of the distal femur. We aimed to assess the oncological status, complication rate and survival of distal femur intercalary reconstruction after trans-metaphyseal (TMR) and trans-epiphyseal resection (TER). We also evaluated the impact of distal temporary graft fixation on skeletal growth after TMR. METHODS We retrospectively reviewed 23 skeletally immature patients affected by distal femur osteosarcoma (18) and Ewing sarcoma (5). Mean patients age was 10.3 years. In 11 cases, TMR was performed with physis preservation and temporary distal graft fixation. In 9 patients, TER was performed with growth plate sacrifice. The last 3 cases were treated with TMR and sliding plate fixation. RESULTS Mean follow-up was 8.4 years. No deaths occurred, but 3 patients presented lung metastasis and 2 cases presented local recurrence in soft tissues. 10 implant-related complications occurred, all surgically treated. At skeletal maturity, mean femoral dysmetria was 2.3 cm after TMR and temporary epiphysiodesis, and 3.1 cm after TER. In TMR group, a strong trend towards physeal recovery was observed after epiphyseal screws removal (p = 0.061), but valgus deformity in distal femur was more frequent (p = 0.049). MSTS score was good or excellent in all patients, with no statistically significant difference between TMR and TER. CONCLUSIONS Intercalary graft reconstruction after TMR and TER allows good local disease control and excellent functional results with long-term follow-up. Temporary distal fixation might reduce the final limb discrepancy after TMR, but valgus deformity could develop. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Riccardo Zucchini
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy
| | - Eric Lodewijk Staals
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy
| | - Michele Fiore
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy.
| | - Laura Campanacci
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy
| | - Claudio Giannini
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy
| | - Marco Manfrini
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy
| | - Davide Maria Donati
- 3rd Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Via G. C. Pupilli 1, 40136, Bologna, Italy
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Simon AL, Hallé A, Tanase A, Peuchmaur M, Jehanno P, Ilharreborde B. Is magnetic resonance imaging reliable for assessing osteosarcoma of the knee joint in children? Orthop Traumatol Surg Res 2021; 109:103086. [PMID: 34597827 DOI: 10.1016/j.otsr.2021.103086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/12/2020] [Accepted: 09/24/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The study of tumor extension in knee osteosarcomas is an essential diagnostic tool that helps determine the surgical approach. Magnetic resonance imaging (MRI) is the key component in this decision-making process, but the interpretation of signals can be difficult because peritumoral edema and inflammation may be mistaken for the tumor. HYPOTHESIS There is a discrepancy between MRI and histopathology findings in the assessment of joint involvement in pediatric osteosarcomas of the knee. MATERIALS AND METHODS All children who underwent an extra-articular resection for an osteosarcoma of the knee between 2007 and 2016 were included. This was indicated if there was at least one of the following MRI signs: presence of articular effusion, involvement of either the peripheral capsuloligamentous structures, central pivot or patella, or lesion abutting the articular cartilage. RESULTS Nine patients were operated on with a mean age of 13±2.7 years. There were at least two of the described signs, mainly the involvement of the peripheral capsuloligamentous structures (78%) and central pivot (56%). The histopathology confirmed that the resection margins were healthy in all cases, but the indication for extra-articular resection could have been avoided in 89% of them. DISCUSSION MRI is the current gold standard for assessing tumor extension, but the signs contraindicating the transarticular approach remain poorly defined. Joint effusion detected by clinical or radiological assessment is the least reliable one. It seems that the tumor's proximity to the articular cartilage, as long as there is no loss of continuity in the latter, or its extension into the central pivot should no longer be considered as relevant signs. The involvement of the peripheral capsuloligamentous structure remains an indication criterion because oncologic resection is otherwise impossible, and the risk of false-negative histopathologic diagnoses is higher. Other MRI sequences could better assess the true extension into the joint space. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Anne-Laure Simon
- Service de chirurgie infantile à orientation orthopédique, hôpital universitaire Robert-Debré, université de Paris, AP-HP, 48, boulevard Sérurier, 75019 Paris, France.
| | - Aurélien Hallé
- Service de chirurgie infantile à orientation orthopédique, hôpital universitaire Robert-Debré, université de Paris, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - Anca Tanase
- Service de radiologie pédiatrique, hôpital Robert-Debré, université de Paris, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - Michel Peuchmaur
- Service d'Anatomie et de Cytologie pathologiques, hôpital Robert-Debré, université de Paris, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - Pascal Jehanno
- Service de chirurgie infantile à orientation orthopédique, hôpital universitaire Robert-Debré, université de Paris, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - Brice Ilharreborde
- Service de chirurgie infantile à orientation orthopédique, hôpital universitaire Robert-Debré, université de Paris, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
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Saifuddin A, Santiago R, van Vucht N, Pressney I. Comparison of T1-weighted turbo spin echo and out-of-phase T1-weighted gradient echo Dixon MRI for the assessment of intra-medullary length of appendicular bone tumours. Skeletal Radiol 2021; 50:993-1005. [PMID: 33078239 DOI: 10.1007/s00256-020-03654-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/11/2020] [Accepted: 10/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Intra-medullary tumour length is accurately assessed on T1-weighted turbo spin echo (T1W TSE) MRI which can be relatively time consuming, whilst the gradient echo Dixon (T1W GrE Dixon) technique is a rapid sequence (imaging time ~ 30 s). The aim of this study was to determine if the out-of-phase Dixon (OP T1W GrE Dixon) sequence can produce equivalent measurements of intra-medullary tumour length compared to the T1W TSE sequence. MATERIALS AND METHOD Tumour length was assessed in 90 patients undergoing MRI for staging of primary bone tumours with both T1W TSE and OP T1W GrE Dixon MRI sequences at 3 T (n = 42) and 1.5 T (n = 48). Tumour length was measured independently by different observers allowing assessment of inter-observer correlation, and the correlation between measurements on T1W TSE and OP T1W GrE Dixon sequences was also determined. RESULTS There were 53 males and 37 females (mean age 36.4 years; range 2-77 years). Inter-observer correlation for tumour length on both the T1W TSE and T1W OP GrE Dixon sequences was very good (ICC = 0.94-0.98), and measurement of tumour length comparing T1W TSE and T1W GrE Dixon was also very good (ICC = 0.91-0.99). In 4 cases, tumour length was significantly overestimated on T1W TSE images due to extensive reactive marrow oedema, but more accurately determined on the OP sequence when compared to resection specimens. CONCLUSIONS The OP T1W GrE Dixon sequence is comparable to T1W TSE for assessment of the intra-medullary length of appendicular bone tumours, and more accurate in the presence of extensive reactive marrow oedema.
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Affiliation(s)
- A Saifuddin
- Department of Radiology, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - R Santiago
- Department of Radiology, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - N van Vucht
- Department of Radiology, University College Hospital, London, UK
| | - I Pressney
- Department of Radiology, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK.
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Zöllner SK, Amatruda JF, Bauer S, Collaud S, de Álava E, DuBois SG, Hardes J, Hartmann W, Kovar H, Metzler M, Shulman DS, Streitbürger A, Timmermann B, Toretsky JA, Uhlenbruch Y, Vieth V, Grünewald TGP, Dirksen U. Ewing Sarcoma-Diagnosis, Treatment, Clinical Challenges and Future Perspectives. J Clin Med 2021; 10:1685. [PMID: 33919988 PMCID: PMC8071040 DOI: 10.3390/jcm10081685] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
Ewing sarcoma, a highly aggressive bone and soft-tissue cancer, is considered a prime example of the paradigms of a translocation-positive sarcoma: a genetically rather simple disease with a specific and neomorphic-potential therapeutic target, whose oncogenic role was irrefutably defined decades ago. This is a disease that by definition has micrometastatic disease at diagnosis and a dismal prognosis for patients with macrometastatic or recurrent disease. International collaborations have defined the current standard of care in prospective studies, delivering multiple cycles of systemic therapy combined with local treatment; both are associated with significant morbidity that may result in strong psychological and physical burden for survivors. Nevertheless, the combination of non-directed chemotherapeutics and ever-evolving local modalities nowadays achieve a realistic chance of cure for the majority of patients with Ewing sarcoma. In this review, we focus on the current standard of diagnosis and treatment while attempting to answer some of the most pressing questions in clinical practice. In addition, this review provides scientific answers to clinical phenomena and occasionally defines the resulting translational studies needed to overcome the hurdle of treatment-associated morbidities and, most importantly, non-survival.
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Affiliation(s)
- Stefan K. Zöllner
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
| | - James F. Amatruda
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
| | - Sebastian Bauer
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Medical Oncology, Sarcoma Center, University Hospital Essen, 45147 Essen, Germany
| | - Stéphane Collaud
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Thoracic Surgery, Ruhrlandklinik, University of Essen-Duisburg, 45239 Essen, Germany
| | - Enrique de Álava
- Institute of Biomedicine of Sevilla (IbiS), Virgen del Rocio University Hospital, CSIC, University of Sevilla, CIBERONC, 41013 Seville, Spain;
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, 41009 Seville, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Jendrik Hardes
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Wolfgang Hartmann
- Division of Translational Pathology, Gerhard-Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany;
- West German Cancer Center (WTZ), Network Partner Site, University Hospital Münster, 48149 Münster, Germany
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute and Medical University Vienna, 1090 Vienna, Austria;
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - David S. Shulman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Arne Streitbürger
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Beate Timmermann
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre, 45147 Essen, Germany
| | - Jeffrey A. Toretsky
- Departments of Oncology and Pediatrics, Georgetown University, Washington, DC 20057, USA;
| | - Yasmin Uhlenbruch
- St. Josefs Hospital Bochum, University Hospital, 44791 Bochum, Germany;
| | - Volker Vieth
- Department of Radiology, Klinikum Ibbenbüren, 49477 Ibbenbühren, Germany;
| | - Thomas G. P. Grünewald
- Division of Translational Pediatric Sarcoma Research, Hopp-Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Translational Pediatric Sarcoma Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Core Center, 69120 Heidelberg, Germany
| | - Uta Dirksen
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
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Assessment of Resection Margins in Bone Tumor Surgery. Sarcoma 2020; 2020:5289547. [PMID: 33488268 PMCID: PMC7789471 DOI: 10.1155/2020/5289547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/24/2020] [Accepted: 11/27/2020] [Indexed: 11/17/2022] Open
Abstract
Limb salvage surgery is now the preferred procedure for bone tumor surgery. To decrease the risk of local recurrence, it is crucial to obtain adequate resection margins. The obtained margins must be evaluated postoperatively because they influence what treatment is given subsequently when margins are not adequate (e.g., surgical revision and radiotherapy). The study aims to evaluate margin assessment of tumor specimen by MRI compared to conventional histology (to establish the viability of using MRI) and assess the accuracy of a patient-specific instrument when narrow margins were aimed. The resection margins in 12 consecutive patients that were operated on for bone tumor resection were prospectively analyzed using three methods: MRI of the resection specimen, macroscopic evaluation of specimen slices, and microscopic pathological evaluation. The assessments were qualitative (R0, R1, and R2) and quantitative (distance in mm). MRI, macroscopic, and microscopic margins generated similar results for both the qualitative (all resections were R0) and quantitative assessments. The median error in safe margins was 2 mm with a surgical guide (PSI) and 5 mm without a surgical guide. Local recurrences were not detected after a mean follow-up period of 3.7 years (range, 2.1-5 years); however, four patients died during the study. In conclusion, MRI is a valuable tool for assessing safe margins. When specimens are not available for pathological assessment (e.g., extracorporeally irradiated autograft or autoclaved autograft), MRI could be used to evaluate margins. In particular, when tumor volume is high, MRI could also help to focus the pathological examination on areas of concern.
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18
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Luna R, Fritz J, Del Grande F, Ahlawat S, Fayad LM. Determination of skeletal tumor extent: is an isotropic T1-weighted 3D sequence adequate? Eur Radiol 2020; 31:3138-3146. [PMID: 33179165 DOI: 10.1007/s00330-020-07394-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To test the hypothesis that an accelerated, T1-weighted 3D CAIPIRINHA SPACE sequence with isotropic voxel size offers a similar performance to conventional T1-weighted 2D TSE (turbo spin echo) for the evaluation of bone tumor extent and characteristics. METHODS Thirty-four patients who underwent 3-T MRI with 3DT1 (CAIPIRINHA SPACE TSE) and 2DT1 (TSE) were included. Sequence acquisition time was reported. Two radiologists independently evaluated each technique for tumor location, size/length, tumor-to-joint distance, signal intensity, margin/extraosseous extension, and signal-to-noise (SNR) and contrast-to-noise (CNR) ratios. RESULTS Tumors were located in long (20/36, 55.5%) and pelvic (16/36, 44.4%) bones. 3DT1 sequence required an average acquisition time of 235 s (± 42 s, range 156-372), while two plane 2DT1 sequences combined (coronal and axial) had an average acquisition time of 381 s (± 73 s, range 312-523). There was no difference in the measurements of tumor length and tumor-to-joint distance (p = 0.95) between 3DT1 and 2DT1 images. Tumors were hypointense (17/36, 47.2% vs 17/36, 47.2%), isointense (12/36, 33.3% vs 12/36, 33.3%), or hyperintense (7/36, 19.4% vs 7/36, 19.4%) on 3DT1 vs 2DT1, respectively. Assessment of tumor margins and extraosseous extension was similar, and there was no difference in tumor SNR or CNR (p > 0.05). CONCLUSIONS An accelerated 3D CAIPIRINHA SPACE T1 sequence provides comparable assessments of intramedullary bone tumor extent and similar tumor characteristics to conventional 2DT1 MRI. For the assessment of bone tumors, the isotropic volume acquisition and multiplanar reformation capability of the 3DT1 datasets can obviate the need for 2DT1 acquisitions in multiple planes. KEY POINTS • 3DT1 offers an equivalent performance to 2DT1 for the assessment of bone tumor characteristics, with faster and higher resolution capability, obviating the need for acquiring 2DT1 in multiple planes. • There was no difference in the measurements of tumor length and tumor-to-joint distance obtained on 3DT1 and 2DT1 images. • There was no difference in signal-to-noise ratio (SNR) or contrast-to-noise ratio (CNR) measures between 3DT1 and 2DT1.
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Affiliation(s)
- Rodrigo Luna
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | - Jan Fritz
- Grossman School of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Filippo Del Grande
- Servizio si Radiologia del Sottoceneri, Ospedale Regionale di Lugano, Lugano, Ticino, Switzerland
| | - Shivani Ahlawat
- Division of Musculoskeletal Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | - Laura M Fayad
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA.
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McColl M, Fayad LM, Morris C, Ahlawat S. Pelvic bone tumor resection: what a radiologist needs to know. Skeletal Radiol 2020; 49:1023-1036. [PMID: 32072185 DOI: 10.1007/s00256-020-03395-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 02/02/2023]
Abstract
Pelvic bone tumors present a diagnostic and therapeutic challenge. Due to the deep anatomic location and resultant late clinical presentation, pelvic bone tumors tend to be large and located in close proximity to pelvic viscera as well as vital neurovascular structures. Operative management of pelvic bone tumors is indicated for a variety of orthopedic oncologic conditions. In general, limb-sparing pelvic resection rather than hemipelvectomy with amputation of the ipsilateral limb is considered when a functional limb can be preserved without compromising the surgical margins. There are various options for pelvic resection and reconstruction, and the selection depends on tumor histology, anatomic location, and extent. The decision regarding choice of surgical procedure and reconstruction method for a pelvic bone tumor requires a thorough knowledge of the pelvic anatomy, and careful inspection of the anatomic extent. The surgical plan must strike a balance between acceptable functional outcome and acceptable morbidity. In this review, we describe the different types of pelvic resection techniques, and the vital role preoperative imaging plays in defining the anatomic extent of a pelvic bone tumor and subsequent surgical planning.
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Affiliation(s)
- Michael McColl
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD, 21287, USA
| | - Laura M Fayad
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD, 21287, USA
| | - Carol Morris
- Division of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, 21287, MD, USA
| | - Shivani Ahlawat
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD, 21287, USA.
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The sensitivity, specificity, and diagnostic accuracy of whole-bone MRI for identifying skip metastases in appendicular osteosarcoma and Ewing sarcoma. Skeletal Radiol 2020; 49:913-919. [PMID: 31900513 DOI: 10.1007/s00256-019-03364-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Pre-operative whole-bone MRI is required to assess intra-osseous tumour extent and to identify skip metastases in cases of bone sarcoma. The current study aims to determine the sensitivity, specificity, and diagnostic accuracy of whole-bone MRI for the identification of skip metastases. MATERIALS AND METHOD Review of 162 patients with long bone osteosarcoma or Ewing sarcoma who had undergone whole-bone MRI to assess intra-osseous tumour length and identify skip metastases. Comparison was made with post-chemotherapy MRI to look for a change in the appearance of suspected skip metastases, and resection specimens were assessed for the presence of skip metastases. The presence of local osseous recurrence was determined at final follow-up. RESULTS There were 112 males and 50 females (mean age 18.8 years), with 119 osteosarcomas and 43 Ewing sarcomas. Skip metastases were diagnosed on whole-bone MRI in 23 cases (14.2%). In 2 cases, pre-operative needle biopsy diagnosed enchondromata, resulting in false positive diagnoses. Skip metastases were diagnosed in the resection specimens in 3 cases, and based on comparison with post-chemotherapy MRI in 12. There was no evidence of local osseous recurrence in 160 patients, while late recurrence occurred in 2 patients. Sensitivity was calculated as 88.2%, specificity as 97.6%, and diagnostic accuracy as 96.7%. CONCLUSION Whole-bone MRI has a high sensitivity, specificity, and diagnostic accuracy for the identification of skip metastases in osteosarcoma and Ewing sarcoma. The possibility of false positive skip lesions and late local osseous recurrence is also highlighted.
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Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas. Sarcoma 2019; 2019:7385470. [PMID: 31885489 PMCID: PMC6914948 DOI: 10.1155/2019/7385470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/24/2019] [Accepted: 11/06/2019] [Indexed: 01/29/2023] Open
Abstract
In today's era, limb salvage surgery is the procedure of choice and current standard of care in appropriately selected patients of bone sarcomas. For adequate oncologic clearance, preoperative evaluation of the extent of tumor is mandatory. The present study was done to compare measurements of bone sarcomas (osteosarcoma, Ewing's sarcoma, and chondrosarcoma) as determined by magnetic resonance imaging (MRI) with the histopathological extent seen on resected specimens. We prospectively evaluated 100 consecutive patients with a diagnosis of bone sarcoma who underwent limb salvage surgery between May 2014 and December 2014. The maximum longitudinal (cranio-caudal) dimension of tumor on the noncontrast T1-WI sequence of MRI (irrespective of whether it was pre/postchemotherapy) was compared with the gross dimensions of the tumor on histopathology. The arithmetic mean difference, Wilcoxon signed-rank test, and Spearman's correlation analysis were used to test the differences and correlation between groups. Mean tumor size on MRI based on the largest extent on MRI was 12.1 ± 4.85 cm (mean ± standard deviation), while it was 10.77 ± 4.6 cm (mean ± standard deviation) on histopathology. In 79 cases, MRI overestimated the extent of disease; the mean was 1.79 cm with a standard deviation of 1.56 cm. When the disease extent was underestimated on MRI (13 cases), the mean was 0.58 cm with a standard deviation of 0.43 cm. In 8 cases (osteosarcoma (7), Ewing's sarcoma (1)), MRI measurement was equal to histopathology. The Spearman correlation analysis showed a high correlation of tumor length on histopathology with the MRI for all patients (R = 0.948, P < 0.0001). We thus conclude that MRI is accurate in delineating the extent of bone sarcomas. A margin of 2 cm from the maximum tumor extent is adequate to ensure appropriate surgical resection.
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Vieth V. [The importance of radiology in bone sarcoma diagnostics : Initial and advanced diagnostics]. DER ORTHOPADE 2019; 48:727-734. [PMID: 31392388 DOI: 10.1007/s00132-019-03786-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reliable diagnostic assessment of malignant bone lesions remains a challenge in all the medical disciplines involved. The high incidence of benign (mainly pediatric) bone lesions needs to be distinguished from the rare malignant counterparts. If clinical presentation and patient history are unable to exclude a malignant tumour, adequate imaging of the affected region is necessary. OBJECTIVES This article focuses on giving implementable advice in dealing with problems and questions arising in the diagnostic process of treating patients with suspected or confirmed bone sarcoma. Also, follow-up recommendations from a radiological point of view are presented. METHODS Review and discussion of relevant literature against personal experiences in the medical imaging of patients with bone sarcomas. RESULTS Interpretation of projection radiographic images usually succeeds in assessing a bone tumour's dignity by evaluating periosteal reaction, the formation of a tumour matrix and consideration of the Lodwick classification. A current adaptation of the classic Lodwick classification incorporates diagnostic possibilities of more recent imaging techniques (magnetic resonance imaging (MRI), positron emission tomography (PET)) and is presented in this article. Plain radiographs are superseded by MRI as the primary imaging performed when depicting bone lesions with increasing frequency. The role of MRI in terms of primary diagnostics, staging, planning of biopsy tracts and tumour resections, evaluation of treatment response and follow-up are discussed. All diagnostic imaging techniques, including whole-body imaging methods, relevant in the diagnosis and therapy of bone sarcomas are presented in the sequence in which they appear during treatment. CONCLUSIONS Radiological imaging and expertise are important pillars in diagnosis and treatment of bone sarcomas. A variety of complementing imaging techniques provide a treatment-relevant basis significant for all medical disciplines involved.
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Affiliation(s)
- Volker Vieth
- Klinik für Radiologie, Klinikum Ibbenbüren, Große Straße 41, 49477, Ibbenbüren, Deutschland.
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23
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Cannavò L, Albano D, Messina C, Corazza A, Rapisarda S, Pozzi G, Di Bernardo A, Parafioriti A, Scotto G, Perrucchini G, Luzzati A, Sconfienza L. Accuracy of CT and MRI to assess resection margins in primary malignant bone tumours having histology as the reference standard. Clin Radiol 2019; 74:736.e13-736.e21. [DOI: 10.1016/j.crad.2019.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/23/2019] [Indexed: 11/25/2022]
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24
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Gomez-Brouchet A, Mascard E, Siegfried A, de Pinieux G, Gaspar N, Bouvier C, Aubert S, Marec-Bérard P, Piperno-Neumann S, Marie B, Larousserie F, Galant C, Fiorenza F, Anract P, Sales de Gauzy J, Gouin F. Assessment of resection margins in bone sarcoma treated by neoadjuvant chemotherapy: Literature review and guidelines of the bone group (GROUPOS) of the French sarcoma group and bone tumor study group (GSF-GETO/RESOS). Orthop Traumatol Surg Res 2019; 105:773-780. [PMID: 30962172 DOI: 10.1016/j.otsr.2018.12.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Standardized reports are essential to meeting the bone sarcoma reference center certification requirements of the French National Cancer Institute (INCa). The usual classifications of the Musculoskeletal Tumor Society (MSTS), the American Joint Committee on Cancer (AJCC/IUCC) TNM R classification and the American College of Pathologists, are inexact inasmuch as they fail to include chemotherapy impact on tumor cells in assessing surgical margins. This leads to inconsistent interpretation by teams managing bone sarcoma. The present literature analysis sought to assess the limitations of existing classifications for purposes of standardized reporting of the management of surgical specimens from patients with osteosarcoma or Ewing sarcoma receiving neoadjuvant chemotherapy, by addressing the following questions: 1) What is the prognostic value of margins and chemotherapy response in the classifications? 2) What are the histologic changes induced by chemotherapy, with what impact on interpretation of margins? METHOD A PubMed literature analysis was performed, targeting the prognostic value of resection margin assessment, in September 2018. French bone pathology group (Groupe français des pathologistes osseux) and international guidelines on bone specimen management were referred to so as select items for a standardized report. Eight of the 523 articles retrieved met the study eligibility criteria. RESULTS Minimal distance between tumor and surgical margin, with a>2mm threshold, seemed to be the optimal parameter for predicting local recurrence. Good chemotherapy response and appendicular skeletal location were associated with lower risk of local recurrence. None of the available classifications take into account the microscopic changes induced by chemotherapy in interpreting resection margins. DISCUSSION To standardize practice, GROUPOS developed a standardized report for bone sarcoma specimens, considering the histopathologic changes in the tumor after neoadjuvant chemotherapy. The TNM R system was adapted and a threshold of>2mm was chosen as an acceptable limit to qualify surgical resection as safe (R0). R1 status (≤2mm) was subdivided into subgroups a, b and c, to include margin measurement in relation to the post-chemotherapy scar: R1a, resection within the scar; R1b, resection in healthy tissue,≤2mm from the scar and/or residual viable cells; and R1c, resection within the lesion in contact with viable cells or within coagulation necrosis areas. The GROUPOS members drew up this standardized report so as to ensure a common language, improving bone sarcoma management in specialized centers. Reliable data can thus be established for national and international multicenter studies. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anne Gomez-Brouchet
- Département de pathologie, IUCT-oncopole, CHU de Toulouse and université de Toulouse, 1, avenue Irène Joliot Curie, 31059 Toulouse cedex 9, France.
| | - Eric Mascard
- Département de chirurgie orthopédique pédiatrique, hôpital-Necker, 149, rue de Sèvres, 75015 Paris, France
| | - Aurore Siegfried
- Département de pathologie, IUCT-oncopole, CHU de Toulouse and université de Toulouse, 1, avenue Irène Joliot Curie, 31059 Toulouse cedex 9, France
| | - Gonzague de Pinieux
- Service d'anatomie et cytologie pathologiques et université de Tours, CHRU de Tours, Avenue de la République, 37170 Chambray-lès-Tours, France
| | - Nathalie Gaspar
- Département de cancérologie de l'enfant et l'adolescent, Gustave-Roussy cancer campus, 114, rue Edouard Vaillant, 94800 Villejuif, France
| | - Corinne Bouvier
- Département de pathologie, CHU la Timone, 278, rue Saint-Pierre, 13005 Marseille, France
| | - Sébastien Aubert
- Université de lille - institut de pathologie, centre de biologie pathologie, 1, rue Philippe Marache, 59000 Lille, France
| | - Perrine Marec-Bérard
- Département d' oncologie pédiatrique, IHOPe/Centre Léon Bérard, 28, promenade Léa et Napoléon Bullukian, 69008 Lyon, France
| | | | - Béatrice Marie
- Département de Pathologie, CHU Nancy, 25, rue Lionnois, 54000 Nancy, France
| | - Frédérique Larousserie
- Service de pathologie et université Paris Descartes, AP-HP, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Christine Galant
- Service d'anatomie pathologique des cliniques universitaires Saint-Luc, 10, avenue Hippocrate, 1200 Brussels, Belgium
| | - Fabrice Fiorenza
- Département de chirurgie orthopédique, CHU de Limoges, 2, avenue Martin Luther King, 87000 Limoges, France
| | - Philippe Anract
- Département de chirurgie orthopédique, CHU de Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Jérôme Sales de Gauzy
- Département de chirurgie orthopédique pédiatrique, hôpital-Mère-Enfant, CHU Toulouse, 330, avenue de Grande Bretagne, 31300 Toulouse, France
| | - François Gouin
- Centre Léon-Bérard, CHU Nantes, Nantes/Inserm, UMR 1238, Phy-Os, université de Nantes, 28, rue Laennec, 69008 Lyon France
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25
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Pennington Z, Ahmed AK, Cottrill E, Westbroek EM, Goodwin ML, Sciubba DM. Systematic review on the utility of magnetic resonance imaging for operative management and follow-up for primary sarcoma-lessons from extremity sarcomas. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:225. [PMID: 31297390 DOI: 10.21037/atm.2019.01.59] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary sarcomas of the vertebral column affect roughly 5 in every million persons annually, of which half to one-third are malignant. Treatment of these lesions requires multimodal management, often employing attempts at en bloc resection of the lesion with negative margins. This may be facilitated using magnetic resonance imaging for preoperative margin planning, but current literature is lacking regarding the use of such imaging to accurately predict planned surgical margins. Here we review prior studies describing the use of magnetic resonance imaging for en bloc resection of sarcomas of the extremities to identify learning points for application to the treatment of spinal neoplasms. We conducted a systematic review of the PubMed and EMBASE literature. Included studies described the accuracy of MRI for preoperative evaluation of tumor margins, intraoperative guidance for en bloc resection, or post-operative evaluation of residual or recurrent disease. All included studies described patients treated for osseous or soft tissue sarcoma of the limbs. We found 1,705 unique references of which 27 met criteria for inclusion. Seven studies reported MR had an overall diagnostic accuracy of 93.6-96% for preoperative margin evaluation with non-contrast T1 most accurately reflecting true margins. In the nine articles reporting results of MR-guided resection, negative margins were achieved in 88.8-100% of cases with a closest margin of 2-4 mm. Eleven articles combined reported the accuracy of MR for residual disease or local recurrence, with a mean sensitivity and specificity of 71.7% and 79.3%, respectively for residual disease and 87.9% and 85.9%, respectively for local recurrence. The current literature for appendicular musculoskeletal sarcoma suggests that MR is highly accurate for defining tumor margins preoperatively, guiding osteotomy cuts intraoperatively, and documenting recurrence or residual disease. Further evidence is necessary to evaluate the degree to which it can accurately guide osteotomy planning for en bloc resection of vertebral primaries.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Saifuddin A, Sharif B, Gerrand C, Whelan J. The current status of MRI in the pre-operative assessment of intramedullary conventional appendicular osteosarcoma. Skeletal Radiol 2019; 48:503-516. [PMID: 30288560 DOI: 10.1007/s00256-018-3079-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/08/2018] [Accepted: 09/16/2018] [Indexed: 02/08/2023]
Abstract
Osteosarcoma is the commonest primary malignant bone tumour in children and adolescents, the majority of cases being conventional intra-medullary high-grade tumours affecting the appendicular skeleton. Treatment is typically with a combination of neo-adjuvant chemotherapy, tumour resection with limb reconstruction and post-operative chemotherapy. The current article reviews the role of magnetic resonance imaging (MRI) in the pre-operative assessment of high-grade central conventional osteosarcoma.
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Affiliation(s)
- Asif Saifuddin
- Department of Imaging, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Ban Sharif
- Department of Imaging, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
| | - Craig Gerrand
- Department of Orthopaedic Oncology, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Jeremy Whelan
- Medical Oncology, University College London Hospital, 235 Euston Rd, London, NW1 2BU, UK
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