Similar complications, implant survival, and function following modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur for primary bone tumors: a systematic review and meta-analysis

PURPOSE

There is a lack of consensus regarding the best type of reconstruction of the proximal femur following bone tumor resection. The objective of this study was to analyze the complication risks, implant survival, and functional outcomes following modular prosthesis (MP) and allograft-prosthesis composite (APC) reconstruction of the proximal femur after primary bone tumor resections.

METHODS

We performed a search in the PubMed and Scopus libraries, obtaining 1 843 studies. We included studies reporting functional outcomes, complications, and implant survival of proximal femur reconstruction with MP or APC following primary bone tumor resection with a 2-year minimum follow-up. We excluded studies analyzing metastatic patients or studies with pooled data in which it was impossible to separate the data of patients with primary bone tumors from those with bone metastases.

RESULTS

We analyzed 18 studies (483 patients) reporting on 234 (48%) patients with MP reconstruction and 249 (52%) patients with APC reconstruction. The risk of complications was similar in patients with MP reconstruction (29%; 95% CI [0.11; 0.47]) and APC reconstruction (36%; 95% CI [0.24; 0.47]) (p = 0.48). Implant survival following MP reconstruction ranged from 81 to 86% at 5 years, 75 to 86% at 10 years, and 82% at 15 years. Implant survival following APC reconstruction ranged from 86 to 100% at 5 years and 86% at 10 years, and 86% at 15 years. Functional outcomes following MP reconstruction and APC reconstruction ranged from 24.0 to 28.3 and from 21.9 to 27.8, respectively.

CONCLUSION

Patients with primary bone tumor of the proximal femur who underwent MP or APC reconstruction seem to have similar complication risks, implant survival, and functional outcomes.

Patterns and treatment outcomes of primary bone tumors in children treated at tertiary referral hospital, Ethiopia

BACKGROUND

Bone tumors account for approximately 6% of all cancers in children. Malignant bone tumors, commonly occurring in children and adolescents, are associated with high mortality and morbidity. The overall survival of children with primary malignant bone tumors is affected by the stage of disease, time of diagnosis, and treatment response. Despite advanced treatment modalities with chemotherapy, surgery, and radiotherapy, bone tumor is the third leading cause of death in children with malignancy. Patients with metastatic disease at diagnosis have poor outcomes compared to localized disease at presentation. The 5-year Overall Survival and event-free survival in children with primary malignant bone tumors were 85.2% and 69.2%. The study aimed to assess the clinicopathological profile and treatment outcomes of children with primary malignant bone tumors in our setup.

MATERIALS AND METHODS

A hospital-based cross-sectional study was conducted on 95 children who met the inclusion criteria through structured questionnaire. The collected data were analyzed using a statistical package for social sciences (SPSS) version 25. P-value < 0.05 was considered to be statistically significant. Kaplan Meier survival estimate was used for overall and event-free survival analysis.

RESULTS

A total of ninety-five patients met the study inclusion criteria and the median age at diagnosis with primary malignant bone tumors was 10 years, with an interquartile range of 8-12 years. The duration of the illness from the onset of symptoms to the oncologic treatment center ranges from three weeks to 2 years with a mean duration of five months. Swelling was the commonest presenting symptom accounting for 95.8% (n = 91). Lower extremity was the commonest primary site of involvement accounting for 55.8% (n = 53) of children with primary malignant bone tumors. Osteosarcoma was the commonest malignant bone tumor constituted 66.3% (n = 63), followed by Ewing sarcoma at 33.7% (n = 32). About 41.2% (n = 39) of children had metastatic disease at presentation and the lung was the commonest site of distant metastasis. The Kaplan Meier survival estimate analysis showed the 1-year and 5-year overall survival probabilities for all pediatric primary malignant bone tumor patients were 65% (95% CI: 0.3-0.56) and 38% (95% CI:0.19-0.47) respectively. The 1-year and 5-year event-free survival probabilities were 55% (95% CI: 0.32-0.73) and 33% (95% CI: 0.10-0.59). The stage of the disease at presentation had a significant association with the outcome (p = 0.023).

CONCLUSION

Our study showed the mean duration of the illness from the onset of symptoms to the oncologic treatment center was 5 months ranging from 3 weeks to 2 years. More than one-third of the presented with metastatic disease at presentation. The 1-year and 5-year overall survival (OS) probabilities of children with primary malignant bone tumors were low in our setup compared to other studies.

Does an excision of needle bone biopsy tract affect the prognosis in patients with primary bone tumor?

Background

Opinion remains divided as to whether excision of needle biopsy tract is beneficial and affect the prognosis. The aim of the study was to compare the outcomes in patients of primary malignant bone tumor who had undergone surgery with or without biopsy tract excision.

Methods

From January 2017 to June 2020, 240 patients with primary malignant bone tumors who underwent percutaneous needle biopsy followed by surgery were included. We categorized patients into Biopsy tract excision (Group1:185 patients) and Non Biopsy tract excision (Group 2:55 patients). Median follow-up of patients was 58.6 months (range; 12-61.8months).

Results

Demographics, histopathological type, tumor location, type of surgery were similar in biopsy tract excision and non excision group. We found biopsy tract seeding in two cases out of 185 (1.1 %). Local recurrence in biopsy tract excision and non excision group was observed in 3.2 % and 1.8 % respectively with p value 0.58. The mean local recurrence free survival rate in group 1 and 2 was 60 and 44 months respectively. Limb salvage was performed in 71.6 % and in amputation in 28.3 % cases. The local recurrence in limb-salvage and amputation group was observed in 3.4 % (6/172) and 1.4 % (1/68) respectively.

Conclusion

There was no significant difference in the rate of local recurrence between patients who were treated by biopsy tract excision or non tract excision. Percutenous needle bone biopsy tract leads to minimal risk of tumor seeding during surgical resection of primary bone tumors.We recommend the further multi centre studies with more number of patients to reach a consensus on resection of needle biopsy tract during surgical management of primary bone tumors.

Primary and Metastatic Bone Tumors of the Patella: Literature Review and Institutional Experience

BACKGROUND

Patellar tumors are rare but certainly must be considered in the differential diagnosis in patients with knee pain. Diagnosis can be challenging as often patellar neoplasms are confused with benign conditions and their clinical presentation is usually not specific. We performed an institutional and a literature review to determine what are the most common tumors affecting the patella and what is the best management.

METHODS

This is a case series from our institution including all patients with benign, malignant, and metastatic patellar neoplasms. Charts were reviewed for patient demographics, clinical presentation, pathology characteristics, radiographic classification, and oncologic and functional outcomes.

RESULTS

Twenty-four patients were identified; twelve patients had benign lesions, 10 metastatic and 2 primary malignant tumors. Chondroblastoma and Giant Cell Tumor were the most common tumors. Management of benign lesions with intralesional curettage and packing with bone graft or cement demonstrated excellent results with no local recurrence. In terms of malignant tumors, the spectrum of treatment is variable; it could range from medical management alone or in combination with surgical procedures to total patellectomy with reconstruction of the extensor mechanism.

CONCLUSION

Patellar tumors should be part of the differential in patients with chronic knee pain that does not respond to initial conservative interventions. Recurrence rate with intralesional curettage and bone grafting or cement packing is very low and therefore should be the treatment of choice for benign intraosseous neoplasms. Resection with negative margins in malignant neoplasms or bone metastasis decreases local recurrence but only in the former group there is a potential impact in survival.

An Epidemiological Study of Primary Bone Tumors of the Fibula

Background

Relatively low incidence has led to an under-rating of fibula tumors. This study aimed to evaluate fibula tumors as a whole and to give detailed information based on histological types according to the anatomic location of the tumors in the fibula.

Methods

Evaluation was made of all the primary bone tumors of the fibula recorded in our bone tumor registry and institute of pathology from 2007 to 2018. Of these, 62 cases were identified. Analysis included assessment of age, gender, tumor localization, the presenting symptoms, the duration of symptoms, and treatment methods.

Results

There were 48 (77.4%%) benign and 14 (22.6%) malignant tumors. The most commonly found benign tumors were non-ossifying fibroma (12/48; 25%) and aneurysmal bone cyst (12/48; 25%), and the malignant tumors were chondrosarcoma (3/14; 21.4%) and chondroblastic osteosarcoma (3/14; 21.4%). The most common location for both benign and malignant tumors (58.3%, 71.4%) are the proximal fibula, followed by the distal fibula (27.1%, 28.6%) and the diaphysis (14.6%, 0%). Six (9.7%) patients presented with pathological fibula fractures.

Conclusion

Fibular tumors are rarely encountered in clinical practice but are mostly benign, with malignancy determined in approximately a quarter of patients. However, as most benign tumors are asymptomatic, and therefore remain undetected, the actual proportion of malignant tumors will be much lower.

Does facility volume influence survival in patients with primary malignant bone tumors of the vertebral column? A comparative cohort study

BACKGROUND CONTEXT

Facility volume has been correlated with survival in many cancers. This relationship has not been established in primary malignant bone tumors of the vertebral column (BTVC).

PURPOSE

To investigate whether facility patient volume is associated with overall survival in patients with primary malignant BTVCs.

STUDY DESIGN

Retrospective comparative cohort.

PATIENT SAMPLE

Adult patients with chordomas, chondrosarcomas, or osteosarcomas of the mobile spine.

OUTCOME MEASURES

Five-year survival.

METHODS

We retrospectively analyzed 733 patients with primary malignant BTVCs in the national cancer database from 2004 through 2015. Univariate and multivariate analyses were used to correlate specific outcome measures with facility volume. Volume was stratified based on cumulative martingale residuals to determine the inflection point of negative to positive impact on survival based on the patient cohort. Long-term survival was compared between patients treated at high and low volume using the Kaplan-Meier method. Only patients with malignant primary tumors were considered eligible for inclusion; patients with incomplete treatment data or benign tumors were excluded.

RESULTS

Patients treated at high-volume centers (HVCs) were younger (p=.0003) and more likely to be insured (p<.0001). There were no significant differences in tumor characteristics. Patients treated at high-volume facilities had improved 5-year survival of 71% versus 58% at low-volume centers (p<.0001). Patients treated at HVCs were more likely to receive surgical treatment (91% vs. 80%, p<.0001); if surgery was performed, they were more likely to undergo an en bloc resection (48% vs. 30%, p<.0001). However, there were no differences in margin status or utilization of radiotherapy or chemotherapy between HVCs and low-volume centers. In a multivariate analysis, facility volume was independently associated with improved survival overall (HR 0.75 [0.58-0.97], p=.03).

CONCLUSIONS

Primary malignant BTVCs are rare, even for HVCs. Despite this, patient survival was significantly improved when treatment was performed at HVCs.

Sustained long-term complete regression of a giant cell tumor of the spine after treatment with denosumab

BACKGROUND CONTEXT

Although giant cell tumors (GCTs) are histologically benign, they may become locally aggressive bone tumors. As these lesions tend to respond poorly to radio- and chemotherapy, currently the standard surgical paradigm for the treatment of spinal GCTs involves en bloc surgical resection. Denosumab is a newly developed monoclonal antibody designed to inhibit the receptor activator of nuclear factor kappa-B ligand (RANKL) which has already been demonstrated to induce marked radiographic responses on GCTs of the appendicular skeleton. Nevertheless, the role of denosumab in the treatment algorithm of GCTs of the spine has not yet been defined.

PURPOSE

To describe the first case of sustained long-term complete clinical and radiographic regression of a GCT of the spine after treatment with the new RANKL antibody denosumab.

STUDY DESIGN

Case report and literature review.

METHODS

The authors describe the case of 22-year-old female patient, harboring a GCT involving the C2 vertebral body and odontoid process, who was treated in monotherapy with denosumab, resulting in complete long-term clinical and radiographic tumor remission.

RESULTS

There were no major side effects associated with the long-term pharmacological treatment with denosumab. From the clinical standpoint, the patient demonstrated complete remission of the disease while under treatment. The 16-month radiographic follow-up demonstrated complete disappearance of the osteolytic process and intense new cortical bone formation with restoration of the bone integrity of the C2 vertebral body.

CONCLUSIONS

This is the first report of sustained long-term complete clinical and radiographic regression of a GCT of the spine after treatment with the new RANKL antibody denosumab. Although future long-term follow-up studies are still necessary to establish important key points regarding the best therapeutic protocol with such a new drug (such as the optimal time frame to keep the patient under treatment), denosumab promises to bring major changes to the current therapeutic paradigm for GCTs of the spine, which, up to now, has strongly relied on en bloc surgical resection.