Primary bone tumors of the spine: a survey of the evaluation and treatment at the Istituto Ortopedico Rizzoli

Epidemiology of Surgically Treated Spinal Tumors: A Multicenter Surveillance Study of 9686 Patients from the German Spine Registry (DWG Register)

Tumors of the spine are challenging in terms of diagnoses and interdisciplinary treatment. This study was conducted to evaluate and characterize a large multicenter cohort of surgically treated spine tumor patients.Data of the German Spine Society (DWG) were used to characterize a cohort of all surgically treated spine tumor cases that were registered between 2017 and 2021. Subgroup analysis was performed for tumor entity, tumor localization, height of most severely affected segments, surgical treatment, and demographic parameters.In total, there were 9686 cases, of which 6747 were "malignant", 1942 were "primary benign", 180 were "tumor-like lesions", and 488 were "other" spinal tumors. Subgroups showed differences in number of affected segments as well as localization. There were further significant differences in surgical complication rates (p = 0.003), age (p < 0.001), morbidity (p < 0.001), and duration of surgery (p = 0.004).This is a representative study on spinal tumors from a large spine registry and allows for the epidemiological characterization of surgically treated tumor subgroups and quality control of registry data.

One-stage combined approach en bloc vertebrectomy for primary Ewing's sarcoma of mobile spine in an adult patient: 3 years following aggressive surgery for a rare entity

Key Clinical Message

Currently, there is no consensus on the optimal management of nonmetastatic Ewing's sarcoma of the mobile spine. However, associated to chemotherapy, aggressive surgery with en bloc wide resection seems to improve local control and survival.

Abstract

Primary Ewing's sarcoma (EWS) of non-sacral spine is extremely rare, especially in middle-age. Therapeutic strategy aims: to large tumor resection, to provide spine stability and to avoid recurrence through chemo and radiotherapy. We report a case of thoracic spine EWS in an adult treated by combined approach en bloc vertebrectomy.

Medium to long term follow-up of survival and quality of life in patients with primary tumors of the cervical spine: Experience From a large single center

Objectives

To evaluate the survival and medium to long term health-related quality of life (HRQoL) of patients with primary cervical spinal tumors in a cross-sectional study and to identify any significant associations with demographic or clinical characteristics.

Methods

Patients diagnosed with primary cervical spinal tumors were retrospectively enrolled and their clinical, radiologic, and follow-up data (specifically the EQ-5D questionnaire) were collected. Univariate and multivariate Cox time-dependent regression analyses were performed to examine the significance of certain variables on overall survival. Univariate and multivariate logistic regression analyses were conducted to identify variables significant for overall HRQoL and each dimension of the EQ-5D.

Results

A total of 341 patients were enrolled in the study with a mean follow-up of 70 months. The diagnosis was benign in 246 cases, malignant in 84, and unconfirmed in 11. The 5-year overall survival rate was 86% and the 10-year overall survival rate was 65%. Multivariate analysis suggested that surgical treatment (P = 0.002, hazard ratio [HR] = 0.431, 95% CI. [0.254, 0.729]), benign and malignant tumors [P < 0.001, HR = 2.788, 95% CI. (1.721, 4.516)], tumor and surrounding normal tissue boundary [P = 0.010, HR = 1.950, 95% CI. (1.171, 3.249)], and spinal instability [P = 0.031, HR = 1.731, 95% CI. (1.051, 2.851)] still had significant effects on survival.

Conclusions

In this cross-sectional study, we evaluated the survival period and medium and long-term health-related quality of life of patients with primary tumors of the cervical spine, and analyzed the significant related factors of tumor clinical characteristics. Surgery, myelopathy, malignancy, spinal pain relieved by lying down or supine position, and tumor infiltration on MRI were significant predictors for overall survival. Enneking stage and age were significant predictors for HRQoL.

Autologous mesenchymal stem cells in the treatment of spinal aneurysmal bone cyst

PURPOSE

We retrospectively analyzed a cohort of patients treated at our Centre with bone marrow concentrated (BMC) injection for aneurysmal bone cyst (ABC) of the spine, in order to propose this treatment as a valid alternative for the management of ABCs.

METHODS

Fourteen patients (6 male, 8 female) were treated between June 2014 to December 2019 with BMC injection for ABC of the spine. The mean age was 15.5 years. The mean follow up was 37.4 months (range 12-60 months). The dimension of the cyst and the degree of ossification were measured by Computed Tomography (CT) scans before the treatment and during follow-up visits.

RESULTS

Six patients received a single dose of BMC, five patients received two doses and in three patients three doses of BMC were administered. The mean ossification of the cyst (expressed in Hounsfield units) increased statistically from 43.48 ± 2.36 HU to 161.71 ± 23.48 HU during follow-up time and the ossification was associated to an improvement of the clinical outcomes. The mean ossification over time was significantly higher in patients treated with a single injection compared to patients treated with multiple injections. No significant difference in ossification was found between cervical and non-cervical localization of the cyst. Moreover, the initial size of the cyst was not statistically associated with the degree of ossification during follow-up CONCLUSIONS: Results of this paper reinforce our previous evidence on the use of BMC as a valid alternative for spinal ABC management when SAE treatment is contraindicated or ineffective.

Wide Surgery in the Cervical Spine: Indications, Results, and Complications in a Series of 30 Patients Affected by Primary Bone Tumors

BACKGROUND

En bloc surgery is the mainstay treatment for primary malignant bone tumors, as well as in the cervical spine. Unfortunately, literature on the topic is limited to case reports and small series.

METHODS

We reviewed all patients affected by primary cervical spine bone tumors treated with en bloc surgeries from 1996 to 2016 and identified 30 eligible cases. We evaluated the clinical presentation and tumor characteristics and reported surgical results, complications, recurrence, and survival rates.

RESULTS

Only 17 of 30 patients had not been previously treated at presentation. Osteosarcoma and chordoma were the most frequent tumors, and pain was reported in all cases. En bloc spondylectomy, hemispondylectomy, and posterior arch en bloc resection were performed in 16, 12, and 2 patients, respectively. The obtained margin was adequate (wide and marginal) in 60% of cases and intralesional in the remaining cases. Two deaths occurred in the immediate postoperative period. Neurological deterioration, dural tear, and dysphagia were the most frequent complications. The 5-year local recurrence-free survival was 70.4%. The recurrence rate was 38.5% and 11.7% in previously and non-previously treated patients, respectively (χ²: 2.94; P = 0.086). Overall survival at 5 years was 58% and 47% for all series and malignant tumors, respectively.

CONCLUSION

Primary cervical spine bone tumors present a difficult approach. Findings suggest that patients treated with en bloc surgery show recurrence and survival rates comparable to the same tumors located in the thoracolumbar spine.

Rod fracture and related factors after total en bloc spondylectomy

BACKGROUND CONTEXT

Several studies have reported favorable oncosurgical outcomes after total en bloc spondylectomy (TES) for treatment of primary malignant tumors or oligometastatic tumors. Considering that TES is indicated for patients with longer life expectancy, long-term instrumentation-related issues such as rod fracture needs to be addressed.

PURPOSE

To investigate delayed rod fracture and related factors after TES.

STUDY DESIGN

Multicenter, retrospective study.

PATIENT SAMPLE

Thirty-two patients who survived for more than 2 years after TES.

OUTCOME MEASURES

Rod fracture and related factors.

METHODS

The relationships between rod fracture and related factors were investigated using Kaplan-Meier survivorship analysis with log-rank test. The analyzed factors were sex, age (<60 or ≥60), tumor histology (primary or metastatic), location of resected tumor (thoracic [above T11], thoracolumbar [cases including T12-L1], or lumbar [below L2]), number of resected vertebrae (1, 2, or 3), anterior support method (expandable cage, mesh cage, or strut bone graft), rod diameter (5.5 mm or 6.0 mm), and history of radiotherapy including preoperative or postoperative radiotherapy.

RESULTS

The study population consisted of 18 men and 14 women, with a mean age of 49.0 years. Nineteen patients had primary tumors and 13 patients had metastatic tumors. The mean follow-up duration was 49.8 months (range, 24-166 months). Twelve of 32 patients (37.5%) experienced rod fractures at an average of 29.2 months (range, 8-93 months) after TES. Of these 12 patients, 8 underwent revision surgery caused by back pain aggravation (n = 7) or nonunion on computed tomography scan (n = 4). Location of resected tumor and history of radiotherapy were significantly associated with rod fracture (p = .004 and p = .019, respectively).

CONCLUSION

Rod fracture was not a rare complication after TES surgery. History of radiotherapy and TES at lumbar level were significant risk factors related to rod fracture. A robust strategy to obtain solid osseous fusion should be considered when planning TES.

An Approach to Primary Tumors of the Upper Cervical Spine With Spondylectomy Using a Combined Approach: Our Experience With 19 Cases

STUDY DESIGN

A retrospective study.

OBJECTIVE

To examine the link between major complications, surgical techniques, and perioperative care in the intralesional spondylectomy of the upper cervical spine.

SUMMARY OF BACKGROUND DATA

Spondylectomy has been demonstrated to prolong cancer-free survival in many patients with locally aggressive spinal tumors. However, the challenging nature of this surgical procedure and the potential for severe complications often limit its application in the upper cervical spine.

METHODS

Nineteen patients with primary upper cervical tumors were treated with spondylectomy from March 2005 to August 2009, using either the anterior-posterior or posterior-anterior approach. Anterior procedures were transmandibular, transoral, or high retropharyngeal. Anterior reconstructions were performed in plates with iliac crest strut grafts, plates with mesh cages, and Harms mesh cages alone. Occipitocervical fixation was performed with Halo-vest application for postoperative immobilization.

RESULTS

Vertebral artery injuries occurred unilaterally in 5 cases intraoperatively: 4 occurred in the anterior approach of anterior-posterior procedures. Fusion was achieved in 9 patients with intact internal instrumentation. Fusion with the anterior construct in a tilted position occurred in 3 patients, all of whom underwent anterior-posterior procedures with Halo-vest immobilization for less than 1 month. Nonunion occurred in 3 cases after the posterior-anterior procedure because of anterior bone graft absorption. Prolonged Halo-vest immobilization maintained postoperative stability. Failure of internal instrumentation occurred in 3 cases. Anterior construct dislocation and severe tilting occurred in 2 cases after the anterior-posterior procedure. Five patients had a local recurrence. All recurrent lesions were malignant tumors and occurred in regions where surgical exposure was inadequate with incomplete excision.

CONCLUSION

The order of the surgical approach is a critical determinant of complications, fusion rates, choice of surgical technique, and reconstruction methods. The postoperative use of a Halo-vest is recommended. Local recurrence is associated with tumor malignancy and inadequate excision margin.

LEVEL OF EVIDENCE

4.

Epidemiological characteristics of primary spinal osseous tumors in Eastern China

BACKGROUND

Primary spinal osseous tumors are rare, yet they represent a difficult treatment paradigm because of the complexities of tumor resection and significant resistance to chemotherapy and radiation therapy. The geographic distribution of primary spinal osseous tumors throughout the world appears to be quite variable, with a very low incidence reported in Asian countries.

METHODS

Data on 1209 cases of primary spinal osseous malignant and benign tumor cases diagnosed during the 20-year period of 1995 through 2015 in eastern China were analyzed.

RESULTS

In 780 cases (64.5%), the lesion was benign and in 429 (35.5%) was malignant. The commonest primary malignant tumors were chordoma (9.8% of all cases) followed by plasma cell myeloma (8.5% of all cases). The most common benign tumor was hemangioma (28.1% of all cases) followed by giant cell tumor of bone (15.7% of all cases) and osteoblastoma (4.4% of all cases). The benign tumors affected men in 33.8% of cases and women in 30.7% of cases, the malignant tumors affected men in 23.7% of cases and women in 11.8%. The mean age (mean ± SD) in the benign group was 34.7 ± 19.8 years and in the malignant group was 47.4 ± 16.5 years. Related symptoms were pain (54.4%), radiculopathy (12.9%), cord compression (9.2%), mass (5.7%), pathological fracture (4.7%), deformity (2.1%), and weight loss (1.9%). The anatomical locations included almost every vertebra of the spine. The thoracic spine (38.1%) was the most common location of the tumors, followed by the cervical spine (27.4%) and lumbar spine (18.4%).

CONCLUSIONS

Compared with other similar series reported in the literature from the other countries, our results obtained in a developing country were different in some degree. This large series of primary spinal osseous tumors may reflect fairly well their real incidence and provide a sufficiently detailed perspective on epidemiologic studies of primary spinal osseous tumors in eastern China.

Single-Stage Posterolateral Transpedicular Approach With 360-Degree Stabilization and Vertebrectomy in Primary and Metastatic Tumors of the Spine

OBJECTIVE

Currently, anterior, posterior, or combined approaches are used in various spinal disorders; however, a single-stage posterolateral transpedicular approach with 360° stabilization and vertebrectomy provides better results for spinal tumors.

METHODS

We evaluated the age, sex distribution, presenting symptoms, neurologic examination findings according to the pre- and postoperative Frankel classification, pre- and postoperative VAS pain scores, preoperatively administered medical therapies, pre- and postoperative corset use, level of the lesion, levels of previous surgical interventions, root ligation (if performed), results of the primary disease, hospitalization duration (after the operation), postoperative complications (if any), postoperative follow-up duration, and postoperative survival duration of 22 patients.

RESULTS

We observed that primary bone tumors were localized in the lumbar (75%) and thoracic regions (25%) and that metastatic tumors were localized in the thoracic (77.78%) and lumbar regions (22.22%). The VAS and Frankel scores of the 22 patients who were included in the study revealed that this surgical treatment modality was associated with statistically significant improvements in test scores (P < 0.001). No ribcage dislocation was observed. In 1 patient (4.54%), a neurologic deficit developed. Two patients (9.09%) required revision because of screw malposition.

CONCLUSIONS

In spinal tumors, 360° fusion performed via a posterolateral approach is a less risky, relatively safe, and less invasive method. This method, which reduces the risks of anesthesia and internal problems and decreases cost, is an essential technique for decreasing hospitalization duration, improving pain levels, and achieving faster mobilization and faster initiation of radiotherapy and chemotherapy.

Spinal tumor surgery: management and the avoidance of complications

BACKGROUND

Complication avoidance is paramount to the success of any surgical procedure. In the case of spine tumor surgery, the risk of complications is increased because of the primary disease process and the radiotherapy and chemotherapeutics used to treat the disease. If complications do occur, then life-saving adjuvant treatment must be delayed or withheld until the issue is resolved, potentially impacting overall disease control.

METHODS

We reviewed the literature and our own best practices to provide recommendations on complication avoidance as well as the management of complications that may occur. Appropriate workup of suspected complications and treatment algorithms are also discussed.

RESULTS

Appropriate patient selection and a multidisciplinary workup are imperative in the setting of spinal tumors. Intraoperative complications may be avoided by employing proper surgical technique and an understanding of the pathological changes in anatomy. Major postoperative issues include wound complications and spinal reconstruction failure. Preoperative surgical planning must include postoperative reconstruction. Patients undergoing spinal tumor resection should be closely monitored for local tumor recurrence, recurrence along the biopsy tract, and for distant metastatic disease. Any suspected recurrence should be closely watched, biopsied if necessary, and promptly treated.

CONCLUSIONS

Because patients with spinal tumors are normally treated with a multidisciplinary approach, emphasis should be placed on the recognition of surgical complications beyond the surgical setting.

En bloc resections for primary spinal tumors in 20 years of experience: effectiveness and safety

BACKGROUND CONTEXT

Many studies have demonstrated that en bloc surgical resection of primary spinal tumors with adequate margins results in improved local disease control and survival compared with intralesional excision. Nevertheless, the use of this procedure is under debate because most of the current evidence is provided by small and heterogeneous series of cases.

PURPOSE

To validate the application of en bloc resection for the treatment of aggressive benign and primary malignant spinal tumors.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

From August 1990 to March 2010, 103 consecutive patients affected by primary spinal tumors were enrolled in the study. All patients were submitted to the same clinical and imaging workup.

OUTCOME MEASURES

Analysis of local recurrence (LR) and tumor-related mortality, reliability of preoperative surgical planning, and morbidity and mortality. In addition, the effects of possible predictors of these events were studied.

METHODS

The parameters for the effectiveness and safety of en bloc resections performed on primary spinal tumors were considered as primary end points of this study, and two research questions were formulated. The analysis of the procedure effectiveness considered the identification of possible predictors of LR and tumor-related mortality. Information about safety is collected so as to clarify the possibility to respect the preoperative planning and to identify possible predictors of morbidity and mortality. Data from clinical and imaging examination were collected in a database and were used to answer the proposed research questions.

RESULTS

All patients were followed for a minimum of 24 months or until death. At the final assessment, 69 patients resulted with no evidence of disease with a mean follow-up of 100 months. Among the 103 patients, tumor recurred in 22 cases with a mean follow-up period of 39 months after surgery. A Cox regression multivariate analysis shows that marginal and intralesional resections are independent predictors of LR (hazard ratio [HR] 9.45, 95% confidence interval [CI] 1.06-84.47 and HR 38.62, 95% CI 4.67-319.21, respectively, compared with wide resection) and tumor-related mortality (in particular, HR 17.10, 95% CI 3.80-77.04 for intralesional resection compared with the wide one). The same analysis demonstrates that en bloc resection performed in recurrent cases or patients previously submitted to open biopsy (nonintact cases) have a LR risk higher than intact cases (HR 3.45, 95% CI 1.38-8.63). The success rate of en bloc resections in achieving adequate margins is 82.4%, and Weinstein-Boriani-Biagini surgical staging can also predict the margins in a high percentage of cases (75.7%). Complications occurred in 41.7% of patients with a higher rate observed in the nonintact group and for surgery with a double-approach or multisegmental resections. The mortality rate related to surgery complications was 1.9%, whereas tumor-related mortality was 15.5%.

CONCLUSIONS

Statistical analysis of the long-term results referred to 103 patients affected by aggressive benign and malignant primary spine tumors indicates that an en bloc resection is associated with a high rate of complications. Nevertheless, it decreases the risk of LR and tumor-related mortality. En bloc resection is a highly demanding procedure but can be performed to an acceptable degree of safety.

Primary Spine Tumors: Diagnosis and Treatment

Background

Primary tumors are rare and those localized to a single location offer the potential for cure. To achieve this, early recognition of the primary tumor and proper workup and treatment are essential.

Methods

The authors reviewed the literature and best practices to provide recommendations on primary spine tumor treatment. Appropriate workup of primary spine tumors and treatment algorithms are also discussed.

Results

Patients suspected of a primary spine tumor should undergo fine-needle aspirate biopsy following consultation with the surgical team to ensure the biopsy tract is surgically resectable should the need arise. Once pathology is confirmed, metastatic workup should be performed to guide the level of treatment. If a localized lesion with poor radiation and chemotherapeutic response is diagnosed, then en bloc resection may be required for cure. If en bloc resection is not feasible or metastatic lesions are present, then radiation and medical oncology specialists must work in conjunction with the surgical team to determine the best treatment options.

Conclusions

Patients with suspected primary tumors of the spine should be treated in a multidisciplinary fashion from the outset. With thoughtful management, these lesions offer the opportunity for surgical cure.

Aneurysmal bone cyst of the mobile spine: the therapeutic role of embolization

PURPOSE

Our aim is to define the role of embolization in the treatment of aneurysmal bone cyst of the spine in order to include this option in the decision making process.

METHODS

From April 2004 to November 2009, seven patients with primary aneurysmal bone cyst of the mobile spine treated by embolization have been prospectively followed-up. All clinical presentations and imagings were recorded. There are many options of embolic agent and techniques used, but all aim to devascularize the tumor. The therapeutic protocol includes: embolization repeated every 8 weeks until the appearance of radiographic signs of healing. Complications, rate of healing and clinical outcome were analyzed.

RESULTS

The number of embolizations varied from one to a maximum of seven without related intra- or post-operative complications. One patient, after four selective arterial embolizations, underwent direct percutaneous injection of embolic agents into the cyst. A clinical and radiographical response was achieved in all patients who were found alive and completely free of disease at mean follow-up of 46 months after last treatment and nobody crossed to surgical option.

CONCLUSION

Embolization seems to be the first option for spinal aneurysmal bone cyst treatment because of the best cost-to-benefit ratio. It is indicated in intact aneurysmal bone cyst, when diagnosis is certain, when technically feasible and safe and when no pathologic fracture or neurologic involvements are found. If embolization fails, other options for treatment would still be available.

Combined Percutaneous and Endovascular Treatment of Symptomatic Aneurysmal Bone Cyst of the Spine: Clinical Six Months. Follow-up of Six Cases

We describe the usefulness of endovascular and direct percutaneous treatment as a therapy option for aneurysmal bone cysts (ABCs) of the spine. From January 2007 to December 2008, we treated six consecutive patients with symptomatic ABCs resistant to continuous medical management or with acute clinical onset of paraparesis at cervical, thoracic and lumbar spine level. Two patients were treated after emergency laminectomy. All patients were studied with an MRI protocol and multidetector CT with MPR reconstructions followed by angiographic control before treatment. The procedure was performed under general anaesthesia for all patients. Under CT or fluoroscopy guidance, percutaneous treatment was performed either by direct injection of Glubran(®) diluted at 30% with Lipiodol(®) only, or combined with endovascular treatment by Onyx® injection. Clinical and X-ray follow-up was performed at three and six months. Combined endovascular and percutaneous treatment for ABCs was successful and led to an excellent outcome in five out of six patients with clinical improvement. There were no periprocedural or subsequent clinical complications and the glue resulted in successful selective permanent occlusion with intralesional penetration. Direct sclerotherapy resulted in immediate thrombosis of the malformation with no progression of symptoms. Complete healing was observed in five out of six aggressive lesions. No major complications were noted. At six month follow-up the symptoms had completely resolved and X-ray control showed a partial or total sclerotic reaction of the lesion with stable clinical results (no partial or clinical abnormalities). One patient had a recurrence of the ABC with spinal cord cervical clinical symptomatology. Combined endovascular and percutaneous treatment or direct percutaneous sclerotherapy with glue alone are important, safe, effective therapy options for symptomatic aneurysmal bone cyst. Results are stable and confirmed by clinical and X-ray follow-up six months after treatment.

An assessment of the reliability of the Enneking and Weinstein-Boriani-Biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group

STUDY DESIGN

Reliability analysis based on expert panel case series review and grading per the Enneking and Weinstein-Boriani-Biagini classification systems.

OBJECTIVE

To assess the reliability of the Enneking and Weinstein-Boriani-Biagini classification systems.

SUMMARY OF BACKGROUND DATA

The Enneking and Weinstein-Boriani-Biagini (WBB) classifications were developed to stage and facilitate treatment planning in patients with primary spine tumors. To date, their interobserver and intraobserver reliability has not been assessed-a fundamental step in facilitating broader clinical and research use.

METHODS

Clinical information, imaging studies, and biopsy results were compiled from 15 selected patients with primary spinal tumors. Eighteen spine surgeons independently estimated and scored the cases for Enneking grade, tumor and metastasis categories, Enneking stage, Enneking-recommended surgical margin, WBB zones and layers, and WBB-recommended surgical procedures, with a second assessment performed after random resorting of cases. Interobserver and intraobserver reliability of each category were assessed by percent agreement or proportional overlap. The Fleiss, Cohen, and Mezzich kappa statistics (kappa) were then applied, determined by the type of variable analyzed.

RESULTS

The kappa statistics for interobserver reliability were 0.82, 0.22, 0.00, 0.57, 0.47, 0.31, 0.58, and 0.54 for the fields of Enneking grade, tumor and metastasis categories, Enneking stage, Enneking-recommended surgical margin, WBB zones and layers, and WBB-recommended surgical procedures, respectively. The kappa statistics for intraobserver reliability were 0.97, 0.53, 0.47, 0.82, 0.67, 0.63, 0.79, and 0.79 for the same respective fields. According to Landis and Koch, the ranges of kappa values of 0.00 to 0.20, 0.21 to 0.40, 0.41 to 0.60, 0.61 to 0.80, and >0.80 imply slight, fair, moderate, substantial, and near-perfect agreement, respectively.

CONCLUSION

Results indicate moderate interobserver reliability and substantial and near-perfect intraobserver reliability for both the Enneking and WBB classification in terms of staging and guidance for treatment, despite a less than moderate interobserver reliability in interpreting the Enneking local tumor extension and WBB sector. Before incorporating the classifications in the clinical practice and research studies, further work is required to investigate the validity of the classifications.

Primary bone and metastatic tumors of the cervical spine

Cervical spine tumors, whether primary bone tumors or metastatic tumors, are rare. The possibility of tumors existing must be considered in the differential diagnosis of patients with persistent neck pain, with or without neurologic symptoms, particularly in those with significant pain at night. The clinical presentation is extremely variable, though a history of malignancy should always raise the concern for recurrence. The evaluation and diagnostic assessment includes a thorough physical examination. Radiographic imaging is usually initiated with plain radiographs and additional advanced imaging obtained as indicated. Using appropriate biopsy principles and techniques, tissue is obtained for histologic determination of the suspected lesion before surgical intervention. Treatment options are extremely variable and depend on many factors, including tumor type, location, and patient preference. Treatment warrants a multidisciplinary approach from experienced physicians and is most successfully accomplished in referral centers. Oncologic staging using the Enneking staging system, followed by surgical staging using the Weinstein, Boriani, Biagini system, will aid in the accurate characterization of the tumor load, maximize surgical goals, assure use of appropriate terminology, and provide optimal communication among treatment centers regarding tumor characteristics, treatment efforts, and results.