Evaluation and staging of musculoskeletal neoplasms

Orthopedic approaches for bone sarcoma: A bibliometric review of the 50 most cited papers

Background

Curative treatment of bone sarcoma is primarily based on operative management. The Orthopedic Oncology approach towards this disease has evolved greatly to the breakthrough in systemic treatment options as well as unique implant designs favoring limb salvage over amputations. The purpose of this study was to perform a bibliometric analysis of the top 50 most cited papers related to the orthopedic the approach to bone sarcomas.

Methods

We queried the ISI Web of Knowledge database in July 2022. Keywords utilized were: ""Bone Sarcoma" OR "Osteosarcoma" OR "Ewing Sarcoma" OR "Chondrosarcoma" OR "Chordoma". The top 50 articles pertaining to the orthopedic approach to bone sarcoma were included for analysis and included manuscript title, authors, citation count, journal and publication year.

Results

The mean number of citations are 187.06 (Range 125-400; SD 67.83). The average citations per year is 10.03 (Range 47.86-3.43; SD 8.05). Many articles were published from 2000 to 2009 (n = 20) and 1990-1999 (n = 13). The majority of the articles were published by institutions within the United States (n = 32). The most common level of evidence was level IV (n = 37). Majority of the articles focused on treatment outcome (n = 22).

Conclusion

This study offers a comprehensive review of the most cited literature regarding orthopedic approaches to bony sarcomas. Modern treatment approaches for bone sarcoma has resulted in an increased focus within the literature on achieving disease free survival wide tissue margins. Understanding the trends of available studies allows for physicians and researchers to target and innovate future areas of study.

Update in Imaging Evaluation of Bone and Soft Tissue Sarcomas

The evolution in imaging evaluation of musculoskeletal sarcomas contributed to a significant improvement in the prognosis and survival of patients with these neoplasms. The precise characterization of these lesions, using the most appropriate imaging modalities to each clinical condition presented, is of paramount importance in the design of the therapeutic approach to be instituted, with a direct impact on clinical outcomes. The present article seeks to update the reader regarding imaging methodologies in the context of local and systemic evaluation of bone sarcomas and soft tissues.

Updating on Bone and Soft Tissue Sarcomas Staging

Bone and soft tissue sarcomas consist of a heterogeneous group of malignant tumors of mesenchymal origin that can affect patients from any age. The precise staging of these lesions determines the best therapeutic strategies and prognosis estimates. Two staging systems are the most frequently used: the system proposed by the University of Florida group, led by Dr. William F. Enneking (1980) and adopted by the Musculoskeletal Tumor Society (MSTS), and the system developed by the American Joint Committee on Cancer (AJCC) (1977), currently in its 8 th edition (2017). This paper updates the reader on the staging of bone and soft tissue sarcomas affecting the musculoskeletal system.

The epidemiology, surgical management, and impact of margins in skull and mandibular osseous-site tumors

OBJECTIVE

The aim of the study was to characterize the epidemiology and treatment outcomes of head and neck (HN) osseous-site tumors.

METHODS

Descriptive analyses and multivariate Cox regressions were performed to analyze the effect of surgery on overall survival (OS) utilizing the National Cancer Database (2004-2016).

RESULTS

Of 2449 tumors, surgery was utilized in 84.5% of cases. OS was worse in osteosarcoma (5-year OS: 53.4% [SE: 2.5%]) compared with cartilage tumors (5-year OS: 84.6% [SE: 1.8%]) (log-rank P < .001). Treatment regimens that included surgery were associated with improved OS on multivariate analysis (hazard ratio [HR] 0.495 [95% CI: 0.366-0.670]). Positive margins were found in 40.8% of cases, and associated with decreased OS in osteosarcomas (HR 1.304 [0.697-2.438]).

CONCLUSION

Treatment that included surgery was associated with an increased OS within our cohort of HN osseous-site tumors, although the rates of positive margins were >40%. These findings may be limited by inherent selection bias in the database.

Predictors of Survival in Children with Osteogenic Sarcoma Undergoing Limb Salvage Surgery: Experience from a Tertiary Cancer Center in Rural India

Context: Osteogenic Sarcoma (OGS) is the fifth most common malignancy among adolescents aged 15–19. With multimodality therapy, the long-term survival has improved from 16% in the prechemotherapy era to around 70% in the postchemotherapy era. Aim: This study aims to determine the clinical profile and survival of children with OGS being treated with limb-salvage surgery (LSS). Subjects and Methods: This is a retrospective analysis of all cases of OGS (age ≤ 19) who underwent LSS at our center between June 2009 and February 2017. Baseline characteristics were noted and multivariate analysis was performed for various variables to identify predictors of survival. Results: Among 44 cases studied majority were boys (n = 27). Ninety-three percentage (n = 41) were adolescents. Stage 2 disease was 75% and Stage 3 disease was 25%. The estimated 3-year overall survival (OS) was 69% (95% confidence interval [CI] 55–86) and the estimated 3-year event-free survival (EFS) was 55% (95% CI = 41–74). OS was significantly improved in patients with >90% necrosis postneoadjuvant chemotherapy (NACT) when compared with <90% necrosis (3-year OS = 88% vs. 51%,P= 0.01) and in patients who received ≤4 cycles NACT versus >4 cycles (78% vs. 60%,P= 0.04). EFS was significantly better in patients without lung metastasis at presentation (61% vs. 29%,P= 0.04), Stage 2 disease (59% vs. 38%,P= 0.04) and >90% necrosis in the tumor post-NACT (69% vs. 35%,P= 0.02). Conclusion: Significant response to NACT predicted improved OS and EFS in children with OGS treated with LSS.

Diagnosis, Classification, and Management of Soft Tissue Sarcomas

BACKGROUND

Soft tissue sarcomas are challenging to oncologists due to their unique character, the infrequency of their occurrence, and the difficulties in predicting outcomes. Advances in imaging, as well as improvements in surgical techniques and adjunctive treatment methods, have improved care for patients with these unusual disorders.

METHODS

The various types of soft tissue tumors are defined, and the statistics for the Orthopaedic Oncology Group in relation to them are reviewed and compared with literature references.

RESULTS

The overall survival rate for 1,220 tumors treated at our institute from June 1972 to June of 2001 was 72%, with a wide range. Patients with leiomyosarcomas, clear cell sarcomas, and malignant fibrous histiocytomas had a poorer survival rate, while those with fibrosarcomas, liposarcomas, and neurofibrosarcomas fared better. Outcome was affected by patient age, tumor anatomic site, tumor stage, and a history of recurrence.

CONCLUSIONS

Competent imaging, predictive immunological and genetic studies, improved surgery, and newer methods of adjunctive and neoadjunctive treatment should result in improvements in outcomes for patients with these tumors.

Comparison of the AJCC, MSTS, and Modified Spanier Systems for Clinical and Pathologic Staging of Osteosarcoma

The prognostic performance of the 2 most commonly used staging systems for skeletal sarcoma (the American Joint Committee on Cancer [AJCC] and Musculoskeletal Tumor Society [MSTS] systems) have never been compared analytically. Another staging system originally proposed by Spanier has not yet been validated. Given the recent release of the 8th edition of the AJCC Cancer Staging Manual, this study was designed to directly compare these anatomic staging systems in a series of 153 high-grade, intramedullary osteosarcomas. Kaplan-Meier curves were plotted and pairwise comparisons between each stage category were performed. Predictive accuracy of each staging system for determining 5-year disease-free survival was evaluated by comparing areas under receiver-operating characteristic curves generated from logistic regression analysis. Multiple concordance indices were calculated using bootstrapping methods (200 replications). ρk and R were estimated as measures of the variation in survival outcomes explained by the regression models. The AJCC, MSTS, and a modified version of the Spanier staging systems showed similar discriminatory abilities and no significant differences in the levels of contrast between different tumor stages across staging systems. Addition of T-category information from each staging system contributed significant prognostic information compared with a Cox proportional hazard regression model consisting only of the presence or absence of metastatic disease as a measure of disease extent. Concordance indices and predictive accuracy for 5-year disease-free survival were not significantly different among the different staging systems either. Similar findings were observed after accounting for other important prognostic variables. Additional studies are necessary to determine performance parameters of each staging system for other types of skeletal sarcoma. Prognostic performance of osteosarcoma staging systems would also be improved by incorporating nonanatomic prognostic variables into staging algorithms.

EFFICACY OF THE ENNEKING STAGING SYSTEM IN RELATION TO TREATING BENIGN BONE TUMORS AND TUMOR-LIKE BONE LESIONS

Objective: To evaluate the efficacy of the Enneking staging system for determining the prognosis, planning surgical treatment and indicating adjuvant therapy for benign bone tumors (BBT) and tumor-like bone lesions (TBL). Methods: A retrospective multicenter, descriptive, nonrandomized study was carried out on a representative sample comprising a large series of 165 patients with a total of 168 benign bone tumors and tumor-like bone lesions. The patient sample was typical, and matched the literature in all respects. All the patients were classified according to the Enneking staging system, and the initial staging of each lesion was correlated with its behavior after either conservative or surgical treatment, in order to determine the efficacy of the system. The treatment options and complications were described and analyzed. Results: The results from the treatment provided 95.2% agreement with the Enneking staging system, with a 95% confidence interval of between 90.8 and 97.9%. Of the 168 tumors treated, only eight (4.8%) could not be controlled in relation to the initial treatment indicated by the Enneking staging system. Tumors classified as active were the most prevalent, comprising 73.2% of the lesions. Tumor recurrence was significantly more frequent (p < 0.001) in the aggressive stage. All the patients staged as latent evolved to cure. The study suggested that surgery with wide margins, for aggressive lesions, could provide better lesion control, with a lower recurrence rate (p > 0.001). For latent and active lesions, the study demonstrated the efficacy of both expectant treatment and excision, with or without autogenous bone graft. Conclusion: The results confirm that the Enneking staging system was very efficient in determining the prognosis, enabling surgical planning and indicating adjuvant therapy for treatment of BBT and TBL.

Multi-detector computed tomography in evaluating locally aggressive and malignant bone tumours

OBJECTIVE

To evaluate the ability of Multi-Detector Computed Tomography in preoperative evaluation of locally aggressive and malignant bone tumours in correlation with histopathological findings.

MATERIALS AND METHODS

Twenty patients suspected of malignant bone tumours on the basis of their clinical profile were selected. Following a plain radiograph evaluation, all of them were subjected to CT scan examination. Multi Planar Reconstruction (MPR) was done in sagittal and coronal planes and also three-dimensional Volume Rendering (VR) and Maximum Intensity Projection (MIP) images were obtained.

RESULTS

Of the 20 patients, 18 underwent surgery, and their histopathological findings were compared and correlated with MDCT findings. MDCT was 92.8% sensitive and 100% specific in determining the vascularity of the tumour and also can detect displacement/ encasement/ involvement of adjacent vessels. It has a sensitivity and specificity of 100% in determining cortical break, calcification and periosteal reaction. However, it is less sensitive in detecting joint involvement. Post contrast enhancement gives details of the extent of the soft tissue component.

CONCLUSION

Although MRI is a preferred modality in preoperative evaluation of bone tumours, CT may be used an alternative in case of non-availability of MRI, which has faster acquisition time and better resolution. Using three dimensional MPR imaging, the location and extent of the tumour can be studied. It is also useful in determining cortical discontinuity, periosteal reaction, and calcification. By virtue of MIP and VR imaging, vascularity of the tumour and its relationship with the adjacent vasculature can be established. However, it is inferior to MRI in soft tissue characterization and has poor sensitivity in detecting marrow and joint involvement.

Can a less radical surgery using photodynamic therapy with acridine orange be equal to a wide-margin resection?

BACKGROUND

Wide-margin resections are an accepted method for treating soft tissue sarcoma. However, a wide-margin resection sometimes impairs function because of the lack of normal tissue. To preserve the normal tissue surrounding a tumor, we developed a less radical (ie, without a wide margin) surgical procedure using adjunctive photodynamic therapy and acridine orange for treating soft tissue sarcoma. However, whether this less radical surgical approach increases or decreases survival or whether it increases the risk of local recurrence remains uncertain.

QUESTIONS/PURPOSES

We determined the survival, local recurrence, and limb function outcomes in patients treated with a less radical approach and adjunctive acridine orange therapy compared with those who underwent a conventional wide-margin resection.

METHODS

We treated 170 patients with high-grade soft tissue sarcoma between 1999 and 2009. Fifty-one of these patients underwent acridine orange therapy. The remaining 119 patients underwent a conventional wide-margin resection for limb salvage surgery. We recorded the survival, local recurrence, and functional score (International Society of Limb Salvage [ISOLS]) score) for all the patients.

RESULTS

The 10-year overall survival rates in the acridine orange therapy group and the conventional surgery group were 68% and 63%, respectively. The 10-year local recurrence rate was 29% for each group. The 5-year local recurrence rates for Stages II, III, and IV were 8%, 36%, and 40%, respectively, for the acridine orange group and 13%, 27%, and 33%, respectively, for the conventional surgery group. The average ISOLS score was 93% for the acridine orange group and 83% for the conventional therapy group.

CONCLUSION

Acridine orange therapy has the potential to preserve limb function without increasing the rate of local recurrence. This therapy may be useful for eliminating tumor cells with minimal damage to the normal tissue in patients with soft tissue sarcoma.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of the levels of evidence.

Evaluation of prognostic factors and survival among patients with osteosarcoma attended at a philanthropic hospital in Teresina, Piauí, Brazil

Objective

Make an analysis of the factors that influence their survival and prognosis of patients with osteosarcoma treated at a Charity Hospital in Teresina-PI.

Methods

We analyzed medical records of 32 patients diagnosed with osteosarcoma in the period January 2005 to December 2010.

Results

Patients were aged between 6 and 73 years, with 56.2% men and 43.7% women. The prevailing color was black, with 62.5% of cases. With regard to histological subtype, the majority were osteoblastic type (71.8%). The anatomical location of the tumor was prevalent region of the knee (distal femur and proximal tibia). Regarding the size of the tumor, tumors were 43.8% bigger than 15 cm. Degree of necrosis Huvos concentrated primarily among the types I and II, 53.1% and 25% respectively. The overall survival at two and four years was 45.5% and 39% respectively and event- free survival at two and four years was 39.8% and 19.9% respectively.

Conclusion

We considered the worst prognosis, the presence of metastases at diagnosis and tumors larger than 15 cm. And the criteria of Huvos did not reach statistical significance for the prognosis of patients.

Imaging review of skeletal tumors of the pelvis--part I: benign tumors of the pelvis

The osseous pelvis is a well-recognized site of origin of numerous primary and secondary musculoskeletal tumors. The radiologic evaluation of a pelvic lesion often begins with the plain film and proceeds to computed tomography (CT), or magnetic resonance imaging (MRI) and possibly biopsy. Each of these modalities, with inherent advantages and disadvantages, has a role in the workup of pelvic osseous masses. Clinical history and imaging characteristics can significantly narrow the broad differential diagnosis for osseous pelvic lesions. The purpose of this review is to familiarize the radiologist with the presentation and appearance of some of the common benign neoplasms of the osseous pelvis and share our experience and approach in diagnosing these lesions.

Comparison of phenol and argon beam coagulation as adjuvant therapies in the treatment of stage 2 and 3 benign-aggressive bone tumors

Argon beam photocoagulation has gained popularity as an adjuvant therapy for the treatment of giant cell tumors of bone and other stage 2 or 3 benign-aggressive bone tumors. Although argon beam photocoagulation has been considered a safe and reasonable adjuvant treatment with acceptable recurrence rates, it has never been directly compared with the commonly described phenol as adjuvant. The purpose of this study was to determine whether argon beam photocoagulation is as effective as phenol in preventing recurrence without affecting functional outcome as an adjuvant to surgical curettage. We retrospectively reviewed 93 consecutive patients with a minimum 10-month follow-up between 1992 and 2007 who were treated with curettage and either phenol or argon beam photocoagulation. Functional outcomes and complications were recorded. Overall, 16 (17.2%) of 93 patients who were initially treated with 1 of the adjuvants had pathologically confirmed recurrences. No additional recurrences were noted after retreatment, leading to an overall recurrence rate of 17.1% with phenol and 14.8% with argon beam photocoagulation (P=.726). While avoiding the toxic effects of phenol, argon beam photocoagulation provides for statistically equivalent recurrence rates, functional outcomes, and complication rates in the treatment of benign-aggressive bone tumors.

Vacuum-assisted minimally invasive biopsy of soft-tissue tumors

BACKGROUND

Although exact histological characterization of soft-tissue tumors is essential for determining the appropriate therapy, the quality of the histological assessment is often limited by the size of the tissue samples. Incisional biopsy and core needle biopsy have been the most effective techniques for obtaining tissue samples from soft-tissue tumors. This study was performed to investigate whether vacuum-assisted biopsy can serve as a new diagnostic tool for soft-tissue neoplasms.

METHODS

This retrospective study compared the characterization made with use of vacuum-assisted biopsy of soft-tissue tumors in seventy-five patients between 2004 and 2006 and the characterization made with use of incisional biopsy of tumors in a comparison group of seventy-four patients between 2000 and 2005 with the final characterization made after radical tumor excision. All vacuum-assisted and incisional biopsies were performed by the same experienced surgeons and evaluated by the same experienced pathologists at a single tumor center. The sensitivity, specificity, positive and negative predictive values, and accuracy of the preliminary characterization made with use of each method were calculated on the basis of the final characterization made after excision.

RESULTS

The vacuum-assisted biopsy procedure was performed successfully in seventy-four (99%) of the seventy-five patients. The accuracy of vacuum-assisted biopsy (96%) was comparable with that of incisional biopsy (99%). Vacuum-assisted biopsy correctly characterized the tumor as benign or malignant in 96% (95% confidence interval [CI], 92% to 100%) of the seventy-five patients compared with 99% (95% CI, 96% to 100%) of the seventy-four patients who underwent incisional biopsy. Vacuum-assisted biopsy correctly characterized the tumor diagnosis in 95% (95% CI, 90% to 100%) of the patients compared with 95% (95% CI, 89% to 100%) for incisional biopsy. Vacuum-assisted biopsy correctly characterized the tumor grade in 89% (95% CI, 82% to 96%) of the patients compared with 88% (95% CI, 80% to 95%) for incisional biopsy. The sensitivity of vacuum-assisted biopsy was 93% (95% CI, 71% to 100%), the specificity and the positive predictive value were both 100%, and the negative predictive value was 91% (95% CI, 85% to 98%). The overall accuracy of vacuum-assisted biopsy was 96% (95% CI, 92% to 100%).

CONCLUSIONS

Vacuum-assisted biopsy appears to be safe and provides a new tool for the diagnosis of soft-tissue tumors. One advantage of vacuum-assisted biopsy is that it can be performed with use of local anesthesia in an outpatient setting.

Expression of an exogenous human Oct-4 promoter identifies tumor-initiating cells in osteosarcoma

We explored the nature of the tumor-initiating cell in osteosarcoma, a bone malignancy that predominately occurs in children. Previously, we observed expression of Oct-4, an embryonal transcriptional regulator, in osteosarcoma cell cultures and tissues. To examine the relationship between Oct-4 and tumorigenesis, cells from an osteosarcoma biopsy (OS521) were stably transfected with a plasmid containing the human Oct-4 promoter driving a green fluorescent protein (GFP) reporter to generate the transgenic line OS521Oct-4p. In culture, only approximately 24% of the OS521Oct-4p cells were capable of activating the transgenic Oct-4 promoter; yet, xenograft tumors generated in NOD/SCID mice contained approximately 67% GFP(+) cells, which selectively expressed the mesenchymal stem cell-associated surface antigens CD105 and ICAM-1. Comparison of the tumor-forming capacity of GFP-enriched and GFP-depleted cell fractions revealed that the GFP-enriched fractions were at least 100-fold more tumorigenic, capable of forming tumors at doses of <300 cells, and formed metastases in the lung. Clonal populations derived from a single Oct-4/GFP(+) cell were capable of forming tumors heterogeneous for Oct-4/GFP expression. These data are consistent with the cancer stem cell model of tumorigenesis in osteosarcoma and implicate a functional link between the capacity to activate an exogenous Oct-4 promoter and tumor formation. This osteosarcoma tumor-initiating cell appears highly prolific and constitutes a majority of the cell population in a primary xenograft tumor, which may provide a biological basis for the particular virulence of this type of cancer.

Resection and reconstruction of an osteochondroma of the hallux: a review of benign bone tumors and a description of an unusual case

Osteochondroma, which is also known as exostosis, is the most common benign bone tumor. Although foot and hand surgeons frequently encounter the subungual exostosis, exostoses commonly localize to other areas of the skeleton as well. In this review, we describe the clinical and diagnostic imaging characteristics of benign bone tumors and, in particular, the osteochondroma and its surgical management. We also report the case of a patient who experienced an unusual pedal digital osteochondroma-like lesion.

LEVEL OF CLINICAL EVIDENCE

4.

Renal cell carcinoma metastases to bone after a 33-year remission

Renal cell carcinoma accounts for 2% of all cancers. Metastases to bone occur 35% to 40% of the time, second in prevalence of metastases only to the lungs. These metastases are highly destructive, hypervascular tumors known to be difficult to manage. This article reports a unique case in which a patient was disease free for 33 years from initial nephrectomy for treatment of primary renal cell carcinoma to discovery of metastatic disease to the pelvis. Search for an unknown primary was performed, consisting of a complete blood count, chemistry, alkaline phosphatase, calcium, serum and urine protein electrophoresis, immunoglobulin levels, prostate specific antigen, liver function tests, bone scan, and chest, abdomen, and pelvis computed tomography scans. This workup was negative for any other primary source of malignancy, and the patient's remaining kidney was found to be free from any tumor burden. The patient successfully underwent excisional biopsy of the lesion, which proved to be vascular in nature, consistent with the final pathology of renal cell carcinoma. The longest amount of time from completion of treatment for the primary renal cell carcinoma to discovery of the first metastatic disease has previously been reported at 22.3 years. Mean interval between primary treatment and discovery of metastases has been defined as 3.0+/-5.4 years. This article highlights the need for advanced medical workup as well as maintaining a high clinical suspicion in patients with remote histories of primary malignancies who present with bony lesions.

Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses

AIM

To evaluate the efficacy of ultrasound as a first-line investigation in patients with a clinical soft-tissue mass.

METHODS

Three hundred and fifty-eight consecutive patients (155 male, 203 female, mean age 48 years) referred from primary and secondary care with soft-tissue masses underwent ultrasound evaluation. Five radiologists performed ultrasound using a 10-15 MHz linear transducer and recorded the referrer diagnosis, history, lesion size, anatomical location and depth, internal echogenicity, external margins (well-defined rim or infiltrative), and vascularity on power Doppler (absent or present, if present the pattern was listed as either linear or disorganized). A provisional ultrasound diagnosis was made using one of eight categories. Benign categories (categories 1-5) were referred back to a non-sarcoma specialist or original referrer for observation. Indeterminate or possible sarcomas (categories 6-8) were referred for magnetic resonance imaging (MRI) within 14 days. Additionally category 8 lesions were referred to the regional sarcoma service. Institutional and regional database follow-up was performed.

RESULTS

Two hundred and eighty-four of the 358 (79%) lesions were classified as benign (categories 1-5). On follow-up 15 of the 284 patients were re-referred but none (284/284) had a malignancy on follow-up (24-30 months). Overall at ultrasound 33 lesions were larger than 5 cm, 42 lesions were deep to deep fascia with 20 showing both features. In this subgroup of 95 patients there were six malignant tumours with the rest benign. Seventy-three of the 358 patients underwent MRI; the results of which indicated that there were 60 benign or non-tumours, 10 possible sarcomas, and three indeterminate lesions. Overall six of 12 (6/358, 1.68% of total patients) lesions deemed to represent possible sarcomas on imaging were sarcomas.

CONCLUSION

Ultrasound is an effective diagnostic triage tool for the evaluation of soft-tissue masses referred from primary care.

The role of intra-operative pathological evaluation in the management of musculoskeletal tumours

A tissue biopsy is usually a critical aspect in guiding appropriate initial management in patients with musculoskeletal tumours. We have previously outlined the role of intra-operative frozen section in both the determination of adequacy of a biopsy and for its diagnostic utility. In this article, the options and techniques for intra-operative pathological evaluation, namely frozen section, fine needle aspiration cytology and touch imprint cytology are reviewed. Frozen section examination may be applicable in the following Sections, including (1) at core biopsy, (2) at surgical margins, (3) at confirming diagnosis prior to definitive treatment or to evaluate tumour spread, and (4) at establishing a diagnosis of a metastasis prior to intramedullary nailing. There are also situations in which frozen section is inappropriate. Pitfalls associated with frozen sections are also highlighted. There are also cost implications, which we have quantified, of performing frozen sections. In our experience that the use of intra-operative pathological evaluation reduces the non-diagnostic rate of bone and soft tissue sarcoma biopsies, eliminates the need for re-biopsy hence alleviating stress, and is a useful addition to the armamentarium in evaluating musculoskeletal tumours.

MRI of soft-tissue masses: the relationship between lesion size, depth, and diagnosis

AIMS

To identify the relationship between depth and size of soft-tissue mass lesions relative to histological diagnosis in a range of malignant neoplastic, benign neoplastic, and non-neoplastic conditions on magnetic resonance imaging (MRI).

METHOD

The MRI findings of 571 consecutive patients referred to a supra-regional orthopaedic oncology unit with a suspected soft-tissue neoplasm were reviewed and included in the study. The patient age, histological diagnosis, lesion size, anatomical location, and lesion depth (superficial or deep to fascia) were recorded.

RESULTS

There were 288 males and 283 females (mean age 48 years, age range 2-92 years). The mean age was 54.1 years for malignant neoplastic lesions compared with 40.1 years for benign neoplastic and 45.4 years for non-neoplastic conditions. There was a significant age difference when malignant lesions were compared with benign neoplastic and non-neoplastic lesions (p<0.001). No significant relationship was present between lesion depth (480 deep, 91 superficial) and diagnosis (288 malignant neoplastic, 197 benign neoplastic and 86 non-neoplastic lesions). However, a significant relationship was identified between lesion size and diagnosis (p<0.001). Furthermore, a significant relationship was identified when lesion size greater than 5 cm, lesion depth, and diagnosis were analysed.

CONCLUSION

Current guidelines suggest the most important variables for assessing risk of malignancy in a soft-tissue lesion include size, depth in relation to the fascia, increasing size, and pain. The current study suggests that relationship to fascia is less important as a predictor of malignant potential in a patient cohort treated at a supra-regional centre. Significant risk factors include increasing patient age and lesion size greater than or equal to 5 cm.

Achondrogenesis Type IA (Houston-Harris): a still-unresolved molecular phenotype

Achondrogenesis type IA (Houston-Harris) is an extremely rare lethal chondrodysplasia with a characteristic severe disarrangement of endochondral ossification. The growth plate cartilage completely lacks columnar-zone formation and shows chondrocyte expansion due to intracellular vacuoles. This article on a new case of achondrogenesis type IA confirms these findings and demonstrates, on the ultrastructural level, the retention of fine fibrillar material within the rough endoplasmic reticulum (rER). Molecular analysis in the presented case of achondrogenesis type IA did not reveal mutations in the COL2A1 and SLC26A2 genes, which are known to cause achondrogenesis types IB and type II. Although the extracellular cartilage matrix was severely altered, all of the investigated matrix molecules (collagens, aggrecan, matrilins, cartilage oligomeric protein [COMP]) showed a normal distribution pattern. The only exception was type-X collagen, which was significantly reduced. Overall, our study suggests a disturbance in cartilage matrix assembly in the present case due to the retention of some sort of matrix component within the rER. Presumably, as a consequence of this event, processes of chondrocyte maturation and differentiation and endochondral bone formation are severely affected in this case of achondrogenesis type IA.

Intraoperative Radiation for Limb Sparing of the Distal Aspect of the Radius Without Transcarpal Plating in Five Dogs

OBJECTIVES

To evaluate intraoperative irradiation (IORT) as a method of limb spare with preservation of the radiocarpal joint.

STUDY DESIGN

Prospective case series.

ANIMALS

Dogs (n=5) with stage II sarcoma of the distal aspect of the radius.

METHODS

A bone segment containing the tumor was isolated surgically, treated by IORT, reimplanted, and secured by internal fixation. In 1 dog, the postradiation tumor bed was curetted and filled with bone cement. Dogs were administered alternating adriamycin and carboplatin starting 2 weeks after IORT and monitored at regular intervals.

RESULTS

Four dogs had osteosarcoma and 1 had undifferentiated sarcoma. Implant failure (n=3), deep tissue infection (3), and pathologic fracture (3) resulted in amputation (3) or pancarpal plating (2). The dog with undifferentiated sarcoma was euthanatized because of suspected tumor recurrence 4 months postoperatively. Osteotomy healing was documented by radiography (1), histopathology (2), or by direct observation (2).

CONCLUSIONS

A technique for limb-sparing surgery of the distal portion of the radius in dogs using IORT had advantages include healing of the autograft and a source for a perfectly fitting autograft but did not appear to offer any advantage with respect to infection rate. Long-term preservation of the radiocarpal joint was not successful.

CLINICAL RELEVANCE

It was not possible to preserve the function of the radiocarpal joint and so this technique cannot be recommended currently. Further study is needed to evaluate whether or not IORT can be considered in combination with pancarpal plating and possibly curettage and cementation of the tumor to prevent subchondral bone collapse.

Image-guided percutaneous biopsy of musculoskeletal lesions in children

BACKGROUND

Percutaneous core needle biopsy (PCNB) of musculoskeletal lesions can provide early and definitive diagnosis and guide decisions on management. The technique is less invasive than open biopsy and has a low complication rate.

OBJECTIVES

The purpose of this study was to assess the diagnostic accuracy and safety of image-guided PCNB of musculoskeletal lesions in children.

MATERIALS AND METHODS

Retrospective review of the medical records of patients referred for PCNB of musculoskeletal lesions was performed. Data collected included tumor type and complication rates. Lesion "hit" or "missed", and core adequacy and ability to reach a definitive pathological diagnosis were reviewed and used to determine whether the biopsy was overall successful or unsuccessful.

RESULTS

A total of 127 biopsies were performed in 111 patients. Of the 127 PCNB procedures, 114 "hit" the lesion and 13 "missed," and 120 of the cores provided for analysis were deemed adequate for pathological interpretation and 7 were deemed inadequate. A definitive pathological diagnosis was possible in 97 of the 127 PCNB preocedures and not possible in 30. Overall 76% of the PCNB procedures were successful. The diagnostic success of biopsy in primary malignant tumors was significantly higher (92%) than in primary benign tumors (65%; P=0.008). Six minor complications resulted from PCNB.

CONCLUSION

This study showed that PCNB is accurate and safe for the diagnosis of musculoskeletal lesions in pediatric patients, and its results are comparable to those in adult studies.

Soft tissue sarcomas of the popliteal fossa: outcome and risk factors

BACKGROUND

Limb salvage surgery of popliteal soft tissue sarcomas may be hampered due to the incomplete anatomical containment of this region and the vicinity of neurovascular structures. The scope of this study was to determine outcome and to define risk factors.

PATIENTS AND METHODS

27 patients (53.3+/-15.8 y; 16/27 male) with popliteal soft tissue sarcomas were assessed. Mean follow-up was 40.9+/-33.8 months (48.5+/-36.7 months in surviving patients). 9/27 patients were included after prior treatment elsewhere (5 after intralesional resections and 4 local recurrences). The lesions were staged IB in 8/27 patients, IIB in 17/27 and III in 2/27. Immediate amputations were performed in 7/27 patients. 15/27 patients were subjected to radiation therapy (preoperative in 6/15 cases), 8/27 patients received chemotherapy (5/8 preoperatively).

RESULTS

Overall survival and disease-free survival at 5 y was 63.0% and 59.5%. Local recurrence occurred in 2 patients. 8/27 patients developed metastatic disease after 28.9+/-9.8 months. Survival (p=0.397) and disease-free survival (p=0.113) did not differ in patients after amputations vs limb salvage. Application of radiation therapy was associated with a better survival (p=0.003). Complications related to the surgical intervention were recorded in 2/27 patients, complications related to radiation therapy occurred in 6/15 patients.

DISCUSSION

Despite being extra-compartmental, popliteal sarcomas can be treated with a high rate of limb salvage while equal safety compared to amputations is maintained. Irradiation improved survival in our patient population. In cases with involvement of neurovascular structures, preoperative down-staging with radio or chemo-therapy may prevent amputation.

Staging of bone tumors: a review with illustrative examples

OBJECTIVE

The radiologist plays an important role in the workup and staging of bone tumors. The purpose of this article is to review that role and to discuss recent changes to the primary malignant bone tumor staging system developed by the American Joint Committee on Cancer.

CONCLUSION

Knowledge of staging parameters for the diagnosis and management of bone tumors will help the radiologist to generate meaningful reports for the referring physician.

Accuracy of computed tomography guided core needle biopsy of musculoskeletal tumours

BACKGROUND

The accurate diagnosis of musculoskeletal tumours is important for successful treatment. Image guided biopsy is gaining increasing acceptance for obtaining tissue for diagnosis. The aim of the present study is to assess the accuracy of computed tomography (CT)-guided core needle biopsy of musculoskeletal tumours.

METHODS

This is a retrospective study on a series of 127 patients with a musculoskeletal tumour. The biopsies were performed over a 4-year period from 1998 to 2001. The accuracy of the CT-guided core needle biopsy was determined by comparing the histology of the biopsy with the final histology of the specimen obtained at open biopsy or surgical resection of the tumour. The effective accuracy was determined by the accuracy of the biopsy to distinguish between a benign and malignant tumour.

RESULTS

Computed tomography guided core needle biopsy in the present series has an overall accuracy of 80.3%. The effective accuracy as determined by a malignant versus benign lesion was 89%. There were 86 malignant tumours with a biopsy accuracy of 81.4% and there were 41 benign tumours with a biopsy accuracy of 78%. The positive predictive value (PPV) of a malignant tumour is 98.9% and the PPV of benign tumour 90.2%. The most common site of biopsy was from the femur and thigh, together accounting for 39.4% of the tumours. The most common tumours in this series were liposarcoma (n = 12), osteosarcoma (n = 11) and giant cell tumour (n = 11). There were no reported complications arising from the biopsy.

CONCLUSION

Computed tomography guided core needle biopsy is a safe and effective procedure that is important in the diagnosis and management of musculoskeletal tumours. It should be performed in a specialized institution with a multidisciplinary musculoskeletal tumour team.

The surgical management of primary tumorsof the spine: initial results of an ongoing prospective cohort study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To prospectively validate the application of appendicular surgical oncology principles to the treatment of primary bone tumors of the spine at a quaternary care spine center using local recurrence, survival, and health-related quality of life as outcome measures.

SUMMARY OF BACKGROUND DATA

There is clear evidence that violating the margins of a sarcoma or other malignancy during surgical resection will risk local recurrence and diminish overall survival. Previous publications have retrospectively demonstrated this oncologically sound approach to spine tumor management to be internally valid. The external validity or limited generalizability has not been assessed.

METHODS

Included were all patients who underwent en bloc surgical resection of a primary tumor of the spine between January 1994 and November 2003, at the authors' institution. Patients were uniformly staged before surgery and baseline demographic and surgical variables were recorded, as well as a cross-sectional evaluation of generic health-related quality of life.

RESULTS

Twenty-six patients (12 males and 14 females) were eligible for the study. Average age was 42 (range 16 to 70). There were 19 malignant tumors and 7 benign. There are 20 surviving patients with an average follow-up of 41.5 months (range 6 to 111 months), 15 of whom had malignant tumors. None of these patients have evidence of local recurrence, and one has evidence of systemic disease. The health-related quality of life, using the SF-36, shows acceptable morbidity of these procedures (physical component summary = 37.73 +/- 11.52, MCS = 51.69 +/- 9.54).

CONCLUSIONS

Principles of wide surgical resection, commonly applied in appendicular oncology, can and should be used for the treatment of primary bone tumors of the spine with anticipated acceptable morbidity and satisfactory survival.

Quantification of SSX mRNA expression in human bone and soft tissue tumors using nucleic acid sequence-based amplification

The SSX family proteins have been considered new members of the cancer/testis antigens because of the restricted expression in testis among normal tissues and the activation in a wide range of cancers. Thus, they would be potential molecular targets for immunotherapeutic strategies. We have developed a competitive nucleic acid sequence-based amplification (NASBA) assay to analyze SSX mRNA expression in 211 bone and soft tissue tumors. The copy numbers of SSX mRNA per mug of total RNA in tumor tissues were widely distributed, ranging logarithmically from 0.6 to 6.6. We found that malignant tumors showed significantly higher expression of SSX mRNA than benign tumors (P < 0.0001). Further, SSX mRNA expression in stage III tumors was significantly higher than that in stage I or II tumors (P < 0.005). This NASBA assay was also more sensitive compared to immunohistochemistry using newly affinity-purified polyclonal antibody against SSX. Collectively, these results suggest that the SSX quantitative NASBA assay could provide useful information to select eligible patients for SSX-specific cancer vaccines.

Intercalary Bone Grafts for Joint and Limb Preservation in 17 Dogs with High-Grade Malignant Tumors of the Diaphysis

OBJECTIVE

To evaluate postoperative complications, limb function, and tumor control after intercalary resection and reconstruction for preservation of limb and joint function in dogs with high-grade malignant tumors of diaphyseal bone.

STUDY DESIGN

Retrospective study.

ANIMALS

Seventeen client-owned dogs.

METHODS

The bone tumor database and medical records were reviewed (1986-2002) for dogs with diaphyseal tumors treated with intercalary resection and reconstruction with either an allograft or irradiated autograft. Clinical presentation, diagnostic findings, surgical management, and outcome were determined from medical records and telephone interviews with veterinarians and owners. Statistical analyses included chi2 to test associations between intra- and postoperative variables with complications, and Kaplan-Meier survival analysis for disease-free interval, metastasis-free interval (MFI), and median survival time.

RESULTS

Intercalary limb-sparing surgery was performed in 17 dogs with diaphyseal tumors: osteosarcoma (OSA) (15), histiocytic sarcoma (1), and solitary metastasis from a pulmonary adenocarcinoma (1). One dog was excluded from further analysis when the spared limb was amputated 4 days postoperatively because of incomplete tumor resection. In 16 dogs, limb function was good to excellent. Complications occurred in 5 dogs (31.3%) and included superficial infection in 2 dogs (12.5%) and implant failure in 4 dogs (25%). All implant failures occurred in the ulna and there was a significant association between implant failure and non-cemented allografts (P=.042). Non-union of 1 or both osteotomies was diagnosed in 10 dogs (83.3%) and, despite lack of clinical signs in all cases, was significantly associated with the use of intracavitary locally released cisplatin (P=.046) and cemented intercalary grafts (P=.046). Local tumor recurrence was diagnosed in 1 dog (6.3%) and metastatic disease in 12 dogs (75.0%), including 10 dogs with OSA. The median MFI was 137 days. The local disease-free and overall limb-salvage rate was 94% and 100%, respectively. Overall median survival time was 393 days and the median survival time for dogs with OSA was 449 days.

CONCLUSION

Intercalary limb-sparing surgery results in better postoperative limb function with fewer and less severe complications than historical reports of dogs treated with non-intercalary limb-sparing surgery.

CLINICAL RELEVANCE

In dogs with diaphyseal tumors, intercalary limb-sparing surgery preserves normal joint function and results in good to excellent limb use with few complications and good local tumor control.

Intraoperative Extracorporeal Irradiation for Limb Sparing in 13 Dogs

OBJECTIVE

To evaluate extracorporeal intraoperative radiation therapy (IORT) as a treatment method for limb and joint sparing in dogs with appendicular sarcomas in sites other than the distal aspect of the radius.

STUDY DESIGN

Retrospective study.

ANIMALS

Thirteen client-owned dogs.

METHODS

The bone tumor database and medical records (1998-2002) were reviewed for dogs with primary appendicular bone tumors treated with IORT limb-sparing surgery and adjuvant chemotherapy. The segment of bone containing the tumor was isolated from adjacent soft tissue and an osteotomy performed distant to the tumor. The bone segment was exteriorized, irradiated (70 Gy single fraction), and then stabilized with internal fixation. Adjuvant chemotherapy was administered. Lameness was graded and local and distant tumor control was determined. Associations between intra- and postoperative variables with complications and Kaplan-Meier survival analysis for median disease-free interval and survival time were calculated.

RESULTS

Limb function was good or excellent in 10 dogs (77%). Postoperative complications (9 dogs, 69%) included deep infection, fracture of the irradiated bone, and implant failure. Surgical failure was more likely if a single implant was used to stabilize the osteotomized bone and if deep infection developed postoperatively. In 3 dogs, tumors recurred locally within bone in the radiation field. The disease-free and overall success rates of extracorporeal IORT for limb and joint preservation were 46% and 54%, respectively.

CONCLUSIONS

Extracorporeal IORT provides a novel alternative to traditional techniques for preservation of joint and limb function in dogs with primary appendicular sarcomas. A minimum of 2 implants and intramedullary bone cement should be used to stabilize the osteotomized bone to minimize postoperative complications. Extracorporeal IORT should be used with caution in dogs with tumors of the distal tibia because of a high complication rate. Dogs with tumors in areas of good soft-tissue coverage, such as the humerus and femur, may be good candidates for limb and joint-sparing surgery using extracorporeal IORT.

CLINICAL RELEVANCE

Extracorporeal IORT is a surgical technique that can be used for limb and joint salvage in dogs with primary appendicular sarcomas in sites usually not amenable to traditional limb-sparing techniques.

Imaging evaluation of patients with soft tissue sarcoma

Imaging provides the clinician with crucial information in the diagnosis, staging, treatment planning, treatment evaluation, and post-treatment assessment of patients with soft tissue sarcoma. MRI, including contrast-enhanced sequences, usually is preferred for evaluating the primary site in extremity sarcomas and lesions of the head and neck. CT generally is preferred for imaging of the chest, abdomen, and pelvis, either in the evaluation of the primary site in those regions or for identifying metastatic disease. The experienced radiologist often can suggest a specific diagnosis or narrow differential diagnosis from the imaging characteristics, particularly with MRI. It is imperative that imaging be performed in a manner specific for the evaluation of soft tissue masses, and before biopsy or surgery, to provide the most accurate preoperative assessment and treatment planning [56, 57].

Primary bone tumors of the lower extremities

The key to adequate and accurate evaluation, diagnosis, and treatment of bone tumors is an organized and integrated approach involving the surgeon, radiologist, and pathologist. The radiologist plays not only a valuable role in the diagnosis and preoperative staging of bone tumors but may also play a role in biopsy and treatment. Despite the wide variety of imaging modalities available today, radiographs remain the mainstay in the evaluation of osseous neoplasms. Advanced imaging is. however. very useful for staging purposes and for characterization of the internal characteristics of tumors and may aid significantly in limiting the differential diagnosis. Although a detailed discussion of all ofthe various bone tumors of the lower extremities is beyond the scope of this article, an attempt is made to provide a framework for a rational and comprehensive approach to these complicated but relatively uncommon lesions. Certain lesions with unique characteristics are discussed to facilitate the diagnostic process.

Ultrastructural localization of type VI collagen in normal adult and osteoarthritic human articular cartilage

OBJECTIVE

Type VI collagen is a major component of the pericellular matrix compartment in articular cartilage and shows severe alterations in osteoarthritic cartilage degeneration. In this study, we analysed the exact localization of type VI collagen in its relationship to the chondrocyte and the (inter)territorial cartilage matrix. Additionally, we were interested in its ultrastructural appearance in normal and osteoarthritic cartilage.

DESIGN

Distribution and molecular appearance was investigated by conventional immunostaining, by multilabeling confocal scanning microscopy, conventional transmission, and immunoelectron microscopy.

RESULTS

Our analysis confirmed the pericellular concentration of type VI collagen in normal and degenerated cartilage. Type VI collagen formed an interface in between the cell surface and the type II collagen network. The type VI collagen and the type II collagen networks appeared to have a slight physical overlap in both normal and diseased cartilage. Additionally, some epitope staining was observed in the cell-associated interterritorial cartilage matrix, which did not appear to have an immediate relation to the type II collagen fibrillar network as evaluated by immunoelectron microscopy. In osteoarthritic cartilage, significant differences were found compared with normal articular cartilage: the overall dimension of the lacunar volume increased, and a significantly increased type VI collagen epitope staining was observed in the interterritorial cartilage matrix. Also, the banded isoform of type VI collagen was found around many chondrocytes.

CONCLUSIONS

Our study confirms the close association of type VI collagen with both, the chondrocyte cell surface and the territorial cartilage matrix. They show severe alterations in type VI collagen distribution and appearance in osteoarthritic cartilage. Our immunohistochemical and ultrastructural data are compatible with two ways of degradation of type VI collagen in osteoarthritic cartilage: (1) the pathologically increased physiological molecular degradation leading to the complete loss of type VI collagen filaments from the pericellular chondrocyte matrix and (2) the transformation of the fine filaments to the band-like form of type VI collagen. Both might implicate a significant loss of function of the pericellular microenvironment in osteoarthritic cartilage.

Clinical and radiographic evaluation of bone tumors

Timely diagnosis of osseous tumors is essential in providing proper management. Appropriate imaging studies are essential to this process, however, if inconclusive, they can be superceded by information obtained through the patient history and physical examination.

Imaging of benign and malignant soft tissue tumors of the neck

Soft tissue tumors of the neck are a heterogeneous group of neoplasms arising from adipose, muscular, and fibrous tissue. With the exception of lymphomas, they account for only a small fraction of neck masses. Nevertheless, accurate diagnosis is important since the behavior of these neoplasms differs markedly from each other and from other head and neck masses. Noninvasive imaging, usually with CT and MR imaging, plays an important role in diagnostic evaluation and treatment planning for these tumors. In some cases, imaging features may be suggestive of a single entity. In most cases, imaging is needed to assess the location and extent of the tumor prior to biopsy or excision. This article discusses imaging techniques used for such assessment, the imaging features that help to separate these neoplasms from other head and neck tumors, and the behavior and imaging features of each of the more common benign and malignant soft tissue tumors that occur in the neck.

Optimal radiologic imaging of soft tissue sarcomas

Radiologic evaluation of the patient with soft tissue sarcoma may include conventional radiography, scintigraphy, ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging. The radiologist also plays a critical role in the evaluation of the patient with soft tissue sarcoma by guiding and performing aspiration biopsies. This review discusses the use of radiological techniques to evaluate the primary lesion and to detect recurrences. In adults, soft tissue sarcoma most commonly occurs in the extremities, and this review emphasizes the role of MR imaging in the pre- and post-treatment evaluation of extremity soft tissue sarcomas. The role of imaging studies in the evaluation of soft tissue sarcomas in the abdomen, thorax, and the head and neck region is also discussed.