Osteosarcoma of the diaphysis of long bones: clinicopathologic features and treatment of 51 cases

Does the Clinical Presentation of Secondary Osteosarcoma in Patients Who Survive Retinoblastoma Differ From That of Conventional Osteosarcoma and How Do We Detect Them?

BACKGROUND

Osteosarcoma is the most common secondary malignancy among survivors of retinoblastoma. Most previous reports on secondary malignancy of retinoblastoma included all types of secondary malignancies without a focus on osteosarcoma, owing to its rarity. In addition, there are few studies suggesting tools for regular surveillance for early detection.

QUESTIONS/PURPOSES

(1) What are the radiologic and clinical characteristics of secondary osteosarcoma after retinoblastoma? (2) What is the clinical survivorship? (3) Is a radionuclide bone scan a reasonable imaging modality for early detection in patients with retinoblastoma?

METHODS

Between February 2000 and December 2019, we treated 540 patients for retinoblastoma. Twelve patients (six male, six female) subsequently developed an osteosarcoma in the extremities; two of these patients had two sites of osteosarcoma (10 femurs, four tibiae) . A Technetium-99m bone scan image was examined annually in all patients for regular surveillance after the treatment of retinoblastoma as per our hospital's policy. All patients were treated with the same strategy as that used for primary conventional osteosarcoma, namely neoadjuvant chemotherapy, wide excision, and adjuvant chemotherapy. The median follow-up period was 12 years (range 8 to 21 years). The median age at the time of diagnosis of osteosarcoma was 9 years (range 5 to 15 years), and the median interval from retinoblastoma diagnosis to osteosarcoma diagnosis was 8 years (range 5 to 15 years). Radiologic characteristics were assessed with plain radiographs and MRI, while clinical characteristics were assessed through a retrospective review of medical records. For clinical survivorship, we evaluated overall survival, local recurrence-free survival, and metastasis-free survival. We reviewed the results of bone scans and clinical symptoms at the time of diagnosis for osteosarcoma after retinoblastoma.

RESULTS

In nine of 14 patients, the tumor had a diaphyseal center, and five of the tumors were located at the metaphysis. The femur was the most common site (n = 10), followed by the tibia (n = 4). The median tumor size was 9 cm (range 5 to 13 cm). There was no local recurrence after surgical resection of the osteosarcoma, and the 5-year overall survival rate after the diagnosis of osteosarcoma was 86% (95% CI 68% to 100%). In all 14 tumors, the Technetium bone scan showed increased uptake in the lesions. Ten of 14 tumors were examined in clinic because of patient complaints of pain in the affected limb. Four patients showed no clinical symptoms detected by abnormal uptake on bone scan.

CONCLUSION

For unclear reasons, secondary osteosarcomas in patients who were alive after the treatment of retinoblastoma had a slight predilection for the diaphysis of the long bone compared with patients with spontaneous osteosarcoma in other reports. The clinical survivorship of osteosarcoma as a secondary malignancy after retinoblastoma may not be inferior to that of conventional osteosarcoma. Close follow-up with at least yearly clinical assessment and bone scans or other imaging modalities appears to be helpful in detecting secondary osteosarcoma after the treatment of patients with retinoblastoma. Larger multi-institutional studies will be needed to substantiate these observations.Level of Evidenc e Level IV, therapeutic study.

Onlay vascularized fibular grafting as a salvage procedure for the management of nonunion after reconstruction of the femur following tumor resection

PURPOSE

The femur is prone to nonunion after biologic reconstruction following tumor resection, due to high bending forces. Nonunion at the host-graft junction is difficult to treat since the graft is in an avascular state. We aimed to investigate the clinical and radiographic results of an onlay free vascularized fibular grafting (VFG) as a salvage procedure for nonunion management after biologic reconstruction of the femur following bone tumor resection.

METHODS

We retrospectively reviewed 10 patients (8 men and 2 women, median age: 15.5 years, range: 10-47) who underwent an onlay VFG for nonunion after intercalary reconstruction of the femur using an allograft ( n = 7) or pasteurized autograft ( n = 3), following tumor resection. The median follow-up period after VFG was 85.7 (24.6-163.5) months.

RESULTS

The median time to union between the host bone and the VFG osteotomy sites was 3.5 (2.8-4.5) months. The median time to union at the host-graft junctions was 10.6 (6.6-12.7) months. Two postoperative complications requiring revision surgery occurred in two patients: one graft fracture and one deep infection with synchronous graft fracture. Internal fixation was required in the patient with graft fracture. The patient with the infection and synchronous graft fracture was treated using debridement, antibiotics, and an external fixator. The median Musculoskeletal Tumor Society functional score was 88% (60-97%) at the final follow-up.

CONCLUSION

Onlay VFG as a salvage procedure for nonunion of a biologic intercalary reconstruction of the femur after tumor resection is a useful treatment option.

Efficacy of a Modified Scoring System to Facilitate Surgical Decision-making for Diaphyseal Malignancies: When is Devitalized Tumor-bearing Autograft of Value?

Objectives

To evaluate the validity of a modified scoring system (MSS) for inferring the bony quality of tumor‐bearing diaphyses and predicting the risk of reconstructive failure after devitalized bone replantation (DBR).

Methods

In this retrospective cohort study, we reviewed the records of 30 patients surgically treated for diaphyseal malignancies between 1996 and 2015. There were 18 male and 12 female subjects; the average age was 34.0 ± 24.5 years (8–82 years). Tumor locations comprised the femur (21), the humerus (4), the tibia (3), the radius (1), and the fibula (1). Histological diagnoses included osteosarcoma (13), metastases (4), Ewing sarcoma (3), chondrosarcoma (3), malignant fibrohistiocytoma (2), periosteal osteosarcoma (1), Langerhans cell sarcoma (1), lymphoma (1), rhabdomyosarcoma (1), and malignant giant cell tumor (1). All primary tumors were rated as stage IIB. Twenty patients underwent DBR. Prosthetic procedures and segmental autografting/allografting were performed in 7 and 3 cases, respectively. MSS (comprising 5 elements: pain, tumor location, bone destruction, localized dimension, and longitudinal dimension) for each patient was calculated in accordance with their preoperative presentations. Outcome measurements included oncological results, outcomes of reconstructions, complications, and functional preservation, presented using the musculoskeletal tumor society (MSTS) scale.

Results

Follow up was available in 29 cases for an average duration of 61.0 ± 49.9 months (12–152 months). Infection occurred in 2 patients (6.9%), primary nonunion in 6 (27.3%), metastases in 9 (31.9%), recurrences in 4 (13.8%), and deaths in 7 (24.1%); 1 subject underwent amputation due to recurrence following endoprosthetic replacement (3.4%). In the DBR group, fractures occurred in 4 cases (21.1%) and nonunion in 5 (25%); internal fixation was related to nonunion (nails, 44.4% vs plates, 9.1%, P = 0.02). MSS was associated with fractures of devitalized autografts (11.0 ± 1.2 vs 8.3 ± 1.8, P = 0.01); the system was efficacious in predicting chances of fractures of these grafts (P = 0.02). MSS ≥ 10 (with false positive rate ≤ 6.7%) suggested increased fracture probability (≥22.7%) after DBR; therefore, 10 was considered a cutoff value.

Conclusions

Diaphyseal malignancies with MSS ≥10 may contraindicate DBR for increased chances of reconstructive failure. In this situation, alternative procedures are advisable. Further investigations are warranted to assess the efficacy of MSS in implying the validity of DBR for diaphyseal malignancies.

The vascularised fibular graft for limb salvage after bone tumour surgery

Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour.

The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195).

In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients.

In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%).

VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated.

Cite this article: Bone Joint J 2015;97-B:853–61.

Diaphyseal osteosarcomas have distinct clinical features from metaphyseal osteosarcomas

AIMS

The aim of this study was to clarify the clinical features and outcomes of diaphyseal osteosarcoma.

METHODS

Patients with newly-diagnosed high-grade osteosarcoma occurring in the long bone were eligible for this retrospective study. Clinicopathological information was collected from our database and compared with 36 diaphyseal, 405 proximal and 519 distal metaphyseal, and 14 whole bone osteosarcoma patients. Additionally, case-control study matching by age, gender, site, and metastatic status at diagnosis with 1:3 ratio of 36 diaphyseal to 108 metaphyseal osteosarcomas patients was also conducted.

RESULTS

Five-year overall survival and metastasis-free survival of the three groups including diaphyseal, metaphyseal, and whole bone osteosarcoma patients showed significant difference (P = .029 and P = .013, respectively), although there is no difference for the survivals between proximal and distal metaphyseal osteosarcoma patients. Case-control study showed that patients with diaphyseal osteosarcomas had a significantly larger tumour (mean 13.5 cm vs 10 cm, P = .026), and demonstrated higher pathologic fracture rate (28% vs 12%, P = .033), superior 5-year metastasis-free survival (74% vs 40%, P = .0068), and slightly better 5-year overall survival (68% vs 46%, P = .074). Prognostic factor analysis showed that a pathologic fracture significantly decreased the survival of the patients with diaphyseal osteosarcoma.

CONCLUSIONS

The current study showed that diaphyseal osteosarcoma has distinct clinical features from metaphyseal osteosarcoma having an increased risk of pathologic fractures but with favorable survival outcome.

The clinical outcomes of extracorporeal irradiated and re-implanted cemented autologous bone graft of femoral diaphysis after tumour resection

PURPOSE

We report the outcome of intercalary resection of the femoral diaphysis and extracorporeal irradiated autologous bone graft reconstruction, without the use of vascularized fibular graft.

METHODS

Six patients with Ewing sarcoma of the mid-shaft femur who were treated by limb sparing tumour resection and reconstruction with extracorporeal irradiated autologous bone graft with intramedullary cement between 2002 and 2010 were studied.

RESULTS

Mean age at the time of surgery was ten years (range, four-23). The length of resected femoral bone averaged 23 cm (15-32 cm). The ratio of bone resection length to total femoral length averaged 60 % (56-66 %). The patients had been followed up for between 16 and 79 months (mean, 41 months) at the time of the study. There was no infection nor fracture in this series. Primary union of the distal and proximal osteotomy sites was achieved in three patients. Delayed union of the proximal osteotomy site occurred in one patient that was successfully treated with iliac crest bone grafting. One patient developed non-union at the distal osteotomy site which failed to heal with bone grafting and was therefore converted to endoprosthetic replacement, and another patient was converted to rotationplasty at five months post-surgery because of contaminated margins. Function was excellent in all patients with surviving re-implanted bone. Local recurrence arose in one patient.

CONCLUSION

Our experience suggests that cement augmentation of extracorporeal irradiated and re-implanted bone autografts offer a useful method of reconstructing large femoral diaphyseal bone defects after excision of primary malignant bone tumours.

Biological reconstruction after excision, irradiation and reimplantation of diaphyseal tibial tumours using an ipsilateral vascularised fibular graft

The purpose of this study was to assess the outcome of 15 patients (mean age 13.6 years (7 to 25)) with a primary sarcoma of the tibial diaphysis who had undergone excision of the affected segment that was then irradiated (90 Gy) and reimplanted with an ipsilateral vascularised fibular graft within it.

The mean follow-up was 57 months (22 to 99). The mean time to full weight-bearing was 23 weeks (9 to 57) and to complete radiological union 42.1 weeks (33 to 55). Of the 15 patients, seven required a further operation, four to obtain skin cover. The mean Musculoskeletal Society Tumor Society functional score at final follow-up was 27 out of 30 once union was complete. The functional results were comparable with those of allograft reconstruction and had a similar rate of complication.

We believe this to be a satisfactory method of biological reconstruction of the tibial diaphysis in selected patients.

How can survival be improved in localized osteosarcoma?

Despite numerous chemotherapy trials and the introduction of novel agents, survival in localized osteosarcoma, which plateaued in the mid-1980s, has been recalcitrant to our best efforts. The authors considered that a review of previous and current strategies that target survival might provide a direction for research efforts. Here, the focus is placed mainly on the reappraisal of previous mass chemotherapy trials and prognostic factors, in the hope of contriving a strategy to overcome the current stasis.