Risk of local recurrence after deltoid-sparing resection for osteosarcoma of the proximal humerus

BACKGROUND

The anatomy of the shoulder poses special challenges with regard to limb-sparing surgery. Resection of the deltoid muscle is considered by some surgeons to be necessary to achieve adequate margins for osteosarcoma of the proximal humerus. However, this can compromise the functional results after reconstruction of the shoulder. The goal of the current study was to determine whether deltoid-sparing resection can be safely performed for osteosarcoma of the proximal humerus.

METHODS

Between 1978 and 2005, 23 consecutive patients with high-grade nonmetastatic osteosarcoma of the proximal humerus underwent limb-sparing surgery with preservation of the deltoid muscle. All patients received neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy. The mean follow-up was 90 months (range, 7 months-279 months).

RESULTS

The overall survival at 5 years was 77%. At the time of last follow-up, 14 (61%) of 23 of patients were alive without evidence of disease. Three (13%) patients developed local recurrence. Two of these patients had poor responses to chemotherapy, with tumor necrosis of 50% and 70%. The third patient had a pathologic fracture of the humerus. Positive surgical margins were associated with local recurrence, and 2 of 4 patients with a positive surgical margin developed local recurrence (P = .01).

CONCLUSIONS

Preservation of the deltoid muscle can be performed for carefully selected patients with osteosarcoma of the proximal humerus. Routine use of the procedure is not justified, because it may be associated with an elevated risk of recurrence. The risk of local recurrence appears to be related to positive surgical margins and possibly the percentage of tumor necrosis.

Therapeutic guidelines for the treatment of bone metastasis: a report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology

Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. Here we present both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.

Allograft-prosthetic composite reconstruction of the proximal part of the tibia. An analysis of the early results

BACKGROUND

Allograft-prosthetic composite reconstruction of the proximal part of the tibia is one option following resection of a skeletal tumor. Previous studies with use of this technique have found a high prevalence of complications, including fracture, infection, extensor mechanism insufficiency, and loosening. To address some of these problems, we adopted certain measures, including muscle flap coverage, meticulous tendon reconstruction, rigid implant fixation, and careful rehabilitation. The goal of the present study was to evaluate the functional outcome and complications in patients undergoing allograft-prosthetic composite reconstruction of the proximal part of the tibia.

METHODS

Twelve patients who underwent allograft-prosthetic composite reconstruction of the proximal part of the tibia after tumor resection were retrospectively evaluated at a median follow-up of forty-nine months. Clinical records and radiographs were reviewed to evaluate patient outcome, healing at the allograft-host junction, function, construct survival, and complications.

RESULTS

Nine patients had no extensor lag, and three patients had 5 degrees to 15 degrees of extensor lag. The mean amount of knee flexion was 103 degrees (range, 60 degrees to 120 degrees ). The mean Musculoskeletal Tumor Society score was 24.3 (81%) of a maximum of 30. Complete bone union occurred in nine patients, and partial union occurred in three patients. At the time of writing, no secondary bone-grafting procedures had been required to achieve union, and no revision or removal of the reconstruction had been performed. Rotational or free flaps provided satisfactory wound coverage in all patients. A deep infection occurred in one patient whose allograft and prosthesis were successfully retained after treatment with surgical débridement and intravenous antibiotics.

CONCLUSIONS

After osteoarticular resection of destructive tumors of the proximal part of the tibia, an allograft-prosthetic composite reconstruction can provide consistently good functional results with an acceptably low complication rate. Technical aspects of the procedure that may favorably affect outcome include soft-tissue coverage with muscle flaps and rigid fixation with a long-stemmed implant.

Analysis of the osteoinductive capacity and angiogenicity of an in vitro generated extracellular matrix

In this study, the osteoinductive potential of an in vitro generated extracellular matrix (ECM) deposited by marrow stromal cells seeded onto titanium fiber mesh scaffolds and cultured in a flow perfusion bioreactor was investigated. Culture periods of 8, 12, and 16 days were selected to allow for different amounts of ECM deposition by the cells as well as ECM with varying degrees of maturity (Ti/ECM/d8, Ti/ECM/d12, and Ti/ECM/d16, respectively). These ECM-containing constructs were implanted intramuscularly in a rat animal model. After 56 days, histologic analysis of retrieved constructs revealed no bone formation in any of the implants. Surrounding many of the implants was a fibrous capsule, which was often interspersed with fat cells. Within the pore spaces, the predominant tissue response was the presence of blood vessels and young fibroblasts or fat cells. The number of blood vessels on a per area basis calculated from a histomorphometric analysis increased as a function of the amount of ECM within the implanted constructs, with a significant difference between Ti/ECM/d16 and plain Ti constructs. These results indicate that although an in vitro generated ECM alone may not induce bone formation at an ectopic site, its use may enhance the vascularization of implanted constructs.

Functional outcome following endoprosthetic reconstruction of the proximal humerus

BACKGROUND

The proximal humerus is a common site for tumors, either metastatic or primary. Thus it is a frequent site of intervention in musculoskeletal oncology surgery. We looked at the use of endoprosthetic reconstructions in surgical intervention for tumors of the proximal humerus.

METHODS

A review of our database from 1990 to 2005 revealed 83 proximal humeral endoprosthetic reconstructions following an intra-articular, deltoid muscle, and axillary nerve sparing resection. Medical records and radiographs were reviewed to determine shoulder range of motion, MSTS scores, and any complications. The median patient age was 55 years (range, 13-80). The mean follow-up was 30 months (range, 1-199).

RESULTS

Mean active abduction was 41 degrees (range, 10-90 degrees) and mean active forward flexion was 42 degrees (range, 5-115 degrees). The mean MSTS score was 63% (range, 40-83%). Implant-related complications included 2 deep infections and 22 patients with proximal migration of the prosthesis. No prostheses loosened. Only 2 required removal (1 for infection and 1 for progression of metastatic disease).

CONCLUSIONS

A proximal humeral endoprosthesis provides a durable reconstruction with a relatively low complication rate. Although it provides a stable platform for elbow and hand function, actual shoulder function is limited.

Surgical management of primary osteosarcoma

Surgical strategies for the primary tumor for patients with extremity and pelvis osteosarcoma have evolved from the ablative to limb-sparing approaches over the past three decades. Favorable oncologic and functional outcomes with contemporary tissue-conserving techniques consistently observed in skeletally mature patients have prompted the application of similar approaches to a growing number of eligible skeletally immature patients. In response to emerging long-term outcome data, current strategies have focused principally on refining the nature and scope of surgical resection to preserve uninvolved tissues, and on the adoption of novel biological and nonbiological skeletal and soft-tissue reconstruction methods to optimize function. We focus on these clinical issues and discuss current efforts to advance the surgical management of the primary tumor and address the limitations of the definitive treatment of the primary tumor, including locally recurrent disease and complications of skeletal reconstructions.

Proximal femoral endoprosthesis for the treatment of metastatic

Traditional reconstructive options may not always be adequate to treat the extensive bone loss that can occur with metastatic disease of the proximal femur. Another method of treatment is resection of the proximal femur and reconstruction with an endoprosthesis. However, the more extensive surgery raises concern for a higher perioperative complication rate in this potentially medically unstable population. This study reviewed 57 patients with metastatic disease treated with 58 proximal femoral endoprostheses. The only perioperative complications were 2 symptomatic deep venous thromboses. Late complications included 3 dislocations, 2 deep venous thromboses, 1 pulmonary embolism, and 4 infections. Three deaths occurred during the perioperative period, all from underlying cancer. Proximal femoral endoprostheses offer a safe treatment option for patients with extensive metastatic disease.

Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas

OBJECTIVE

We conducted a prospective trial to define the local recurrence rates for selected patients with T1 soft tissue sarcomas (STS) treated by surgery alone.

SUMMARY BACKGROUND DATA

Retrospective data suggest that some patients with small STS can be safely treated by surgery alone. There are no defined criteria to select patients for such treatment.

METHODS

Patients with T1 primary STS were treated with function-preserving surgery and microscopic assessment of surgical margins. Postoperative external-beam radiation was employed selectively for patients with microscopically positive (R1) final surgical margins. Patients who underwent resection with microscopically negative (R0) final margins did not receive radiotherapy.

RESULTS

Eighty-eight eligible and evaluable patients were entered on this protocol between March 1996 and April 2002. Tumor sites included the extremities (n=60), and trunk (n=26). Fifty-one patients (58%) had high-grade STS; 60 (68%) had superficial (T1a) disease. Fourteen patients (16%) underwent R1 resection and were treated with postoperative radiation; 74 (84%) underwent R0 resection and were treated by surgery alone. The median follow-up was 75 months. Isolated local recurrences were observed in 11 patients (13%; 6 in R1 arm, 5 in R0 arm). In the R0 surgery-alone arm, the cumulative incidence rates of local recurrence at 5 and 10 years were 7.9% and 10.6%, respectively; and the 5- and 10-year sarcoma-specific death rates were 3.2% and 3.2%.

CONCLUSION

Selected patients with primary T1 STS of the extremity and trunk can be treated by R0 surgery alone with acceptable local control and excellent long-term survival.

Patient survival after surgery for osseous metastases from renal cell carcinoma

BACKGROUND

Skeletal metastases from renal cell carcinoma are highly destructive vascular lesions. They pose unique surgical challenges due to the risk of life-threatening hemorrhage and resistance to other treatments. The goal of this retrospective study was to evaluate factors that may affect survival after surgical treatment of metastases of renal cell carcinoma.

METHODS

We performed a retrospective review of a series of 295 consecutive patients who had been treated for metastatic renal cell carcinoma at one institution between 1974 and 2004. There were 226 men and sixty-nine women. A total of 368 metastases of renal cell tumors to the extremities and pelvis were treated. The surgical procedures included curettage with cementing and/or internal fixation (214 tumors), en bloc resection (117), closed nailing (twenty-seven), amputation (four), and other measures (six). Overall survival was calculated with Kaplan-Meier analysis. The log-rank test was used to evaluate the effect of different variables on overall survival.

RESULTS

The overall patient survival rates at one and five years were 47% and 11%, respectively. The metastatic pattern had a significant effect on the survival rate (p < 0.0001): patients with a solitary bone metastasis had the most favorable overall survival rate. Patients with multiple bone-only metastases had a better survival rate than patients with pulmonary metastases (p = 0.009). A clear-cell histological subtype was also associated with better survival (p < 0.0001). The tumor grade did not predict survival (p = 0.17). Fifteen patients (5%) died within four weeks after surgery. The causes included acute pulmonary failure (seven patients), multiorgan failure (six), cerebrovascular accident (one), and hypercalcemia (one). There were no deaths attributable to intraoperative hemorrhage.

DISCUSSION

Survival beyond twelve months is possible for a substantial proportion of patients with metastatic renal cell carcinoma. Patients with a clear-cell histological subtype, bone-only metastases, and a solitary metastasis have superior survival rates. The presence of pulmonary metastases does not predict early death in a reliable manner, and some patients may survive for years with pulmonary and systemic disease. The data are important for surgeons to consider when choosing treatment for these patients. For example, local control of disease and implant stability are important issues for patients with a potential for a long duration of survival.

The effects of medications on bone

Medications taken for the treatment of arthritis and psychotropic and epileptic disorders, as well as anticoagulants, antacids, bisphosphonates, corticosteroids, and antineoplastic drugs, can profoundly affect bone metabolism. In some scenarios (eg, osteoporosis), these effects are intended; in others (eg, rickets, osteomalacia secondary to antiepileptic drugs), potentially adverse side effects of medications on bone may occur. Nonsteroidal anti-inflammatory drugs appear to delay fracture healing and bone ingrowth, although these effects are reversible. Disease-modifying antirheumatic drugs do not appear to affect bone metabolism adversely when taken in the low dosages currently prescribed. Bisphosphonates are useful in restoring bone mass in cases of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, Paget's disease, and neoplastic conditions with bone loss and hypercalcemia. Corticosteroids and cancer chemotherapeutic agents generally affect bone adversely and increase fracture risk.

Bone cancer

Primary bone cancers are extremely rare neoplasms, accounting for less than 0.2% of all cancers. Primary bone cancers show wide clinical heterogeneity and, perhaps most importantly, are often curable. With current multimodality treatment, including multi-agent chemotherapy, approximately three quarters of all patients diagnosed with osteosarcoma are cured. Updates for 2007 include changes in recommendations for treating chondrosarcoma, Ewing's sarcoma, and osteosarcoma.

For the most recent version of the guidelines, please visit NCCN.org

Disease- and recurrence-free survival after surgical resection of solitary bone metastases of the pelvis

For patients with advanced cancer who present with or develop a bone lesion as the only focus of cancer beyond the primary site, en bloc resection of the metastasis may optimize local tumor control, provide durable pain relief, and possibly prolong patient survival. For patients with pelvic metastasis, however, this surgery can be associated with a high risk of complications. We analyzed fourteen consecutive patients with a solitary metastasis to the bony pelvis who underwent en bloc resection to determine if the benefits of surgery outweigh the surgical morbidity. The epicenter of the tumor was isolated to the ilium (four patients), the pubis (one patient), and the ischium (three patients), or to the periacetabular region (six patients). Surgical margins were negative for tumor in 13 of 14 patients. No local recurrence developed at last follow-up for six survivors (median 74.5 months) and eight non-survivors (median 53 months). Local pain relief was achieved in all patients. For patients with a solitary pelvic metastasis, the favorable median patient survival justifies consideration of a radical surgical approach to achieve pain palliation and tumor control.

Curettage of biopsy-diagnosed grade 1 periacetabular chondrosarcoma

Intralesional excision of intraosseous grade 1 periacetabular chondrosarcoma may seem an attractive alternative to the current recommendation of joint-sacrificing, en bloc resection. We report eight patients who initially underwent this treatment to identify if local tumor control can be achieved consistently. All patients had a percutaneous biopsy that was interpreted as grade 1 chondrosarcoma. The final histology after curettage indicated Grade 1 chondrosarcoma in five patients, Grade 2 in two, and dedifferentiated chondrosarcoma in one. Three of the five patients with true grade 1 chondrosarcoma have been free of disease at a median followup of 108 months. The other two patients with grade 1 chondrosarcoma on the curettage specimen recurred as higher-grade tumors. Three patients died of high-grade chondrosarcoma at a median of 23 months (range 17-72 months). Overall, the majority of patients in this cohort had either a misdiagnosis or recurrence of higher-grade disease. Based on these observations, in the absence of a predictable method to identify the true intraosseous grade 1 chondrosarcomas of the pelvis, curettage must be undertaken with the understanding that a percutaneous biopsy may misrepresent the histologic grade and that curettage may result in a higher risk of recurrence.

Orthopaedic metal devices coated with a novel antiseptic dye for the prevention of bacterial infections

Gendine is a novel antiseptic dye with broad-spectrum antimicrobial activity that may be used to coat plastics and metal devices. Our objective was to determine the efficacy of gendine-coated orthopaedic metal devices in preventing methicillin-resistant Staphylococcus aureus (MRSA) colonisation. Stainless steel and titanium Schanz rods were coated with gendine. The zone of inhibition (ZoI) around the rods with and without gamma-irradiation was determined by a modified Kirby-Bauer method. A previously published bioprosthetic biofilm colonisation model, modified Kuhn's method, was used to determine the adherence of MRSA to coated and uncoated rods, with and without irradiation, after insertion into bovine bone and after 3 months shelf life followed by 2 weeks of immersion in serum. The gendine-coated Schanz metal rods showed a net ZoI of 16 mm against MRSA before and after irradiation. Gendine-coated rods showed no biofilm formation (0 colony-forming units (CFU)), which was a significant reduction (P<0.001) compared with uncoated controls (>5000 CFU). Coated rods exposed to high-dose gamma-irradiation and coated rods drilled into bone also showed significant efficacy (P<0.001) in preventing biofilm adherence. After 2 weeks, gendine-coated rods maintained significant durability (P<0.01), resulting in 90% reduction in MRSA biofilm adherence compared with uncoated control rods. Results indicate that gendine-coated metal rods are highly efficacious in the prevention of MRSA biofilm.

Acetabular outcome after hip hemiarthroplasty in patients with tumors

Hip hemiarthroplasty is performed routinely on patients with tumors of the proximal femur, although the long-term effect on the native acetabulum is unknown. We measured the amount of femoral head migration that would occur with intermediate and long-term followup. We also measured the amount of groin pain experienced by patients with longer followup and the overall rate of conversion to total hip arthroplasty. From a surgical database, we identified 442 patients with tumors who had 447 hip hemiarthroplasties without or with an allograft composite. We reviewed the medical records and radiographs of 32 patients with at least 5 years followup (median followup, 10 years) to determine their clinical and radiographic outcomes. The median proximal and medial migration measurements were 3 mm (range, 0-24 mm) and 2 mm (range 0-20 mm), respectively. Thirty-one patients had minimal or no groin pain. Seven of the 447 arthroplasties (1.6%) were converted to total hip arthroplasties. Even patients with long-term followup usually had minimal pain and radiographic changes. The overall rate of conversion to total hip arthroplasty was low. Concern regarding excessive acetabular wear resulting in conversion to total hip arthroplasty in patients with tumors is not supported by our data.

Chemotherapy response is an important predictor of local recurrence in Ewing sarcoma

BACKGROUND

Local recurrence in Ewing sarcoma is associated with a poor prognosis. The purpose of the study was to determine the factors that predict local recurrence after surgical treatment of the primary tumor.

METHODS

Between 1990 and 2001, 64 patients underwent surgical resection of Ewing sarcoma. Surgical margins were assessed histologically and radiologically. Response to preoperative chemotherapy was determined by detailed specimen mapping. Local recurrence-free survival (LRFS) was calculated by Kaplan-Meier analysis. Multivariate analysis was performed with the Cox proportional hazards model.

RESULTS

A number of factors were found to be associated with local recurrence on univariate analysis. Patients with a good response to chemotherapy (> or = 90% tumor necrosis), had superior LRFS at 5 years (86% vs 51%, P = .015). Central site of disease was associated with an increased rate of recurrence. The LRFS at 5 years was 50% for the chest wall, 74% for pelvic/scapular, and 86% for extremity tumors (P = .083). Positive surgical margin was not a strong predictor of recurrence (P = .72). A critical analysis of minimal surgical margin based on preoperative magnetic resonance imaging (MRI) and computed tomography (CT) scans also failed to reveal an association between margin and local recurrence. In multivariate analysis, the 2 independent predictors of local recurrence were histological response to chemotherapy and central site of disease.

CONCLUSION

Local recurrence after surgical resection is a complex phenomenon. An important predictive factor is the response to chemotherapy. In the current study, this seems to have the largest impact. Central site of disease may be a second independent predictive factor.

Imaging Characteristics of Locally Recurrent Tumors of Bone

OBJECTIVE

The purpose of this article is the identification of recurrent tumor of bone utilizing radiography, CT, and MRI.

CONCLUSION

Radiography is frequently used to identify recurrence of treated bone tumors through findings such as osteolysis, cortical reactions, and characteristic matrix mineralization. CT can help evaluate the character of osseous and calcific abnormalities. Comparison with prior radiographs can be crucial for differentiation between postoperative alterations of bone and subtle signs of recurrence. MRI can identify soft-tissue masses and is useful for imaging patients with metallic hardware when it is optimized to decrease artifacts.

Periosteal margin in soft-tissue sarcoma

BACKGROUND

Soft-tissue sarcomas frequently rest in contact with bone. The purpose of the study was to evaluate the risk of local recurrence for sarcomas adjacent to bone and to determine whether the periosteum provides an adequate margin of resection.

METHODS

Fifty patients with soft-tissue sarcomas abutting bone were treated at a single institution between 1990 and 2004. All patients had high-grade, T2 (>5 cm), nonmetastatic disease in the lower extremity. Bone contact was verified by preoperative magnetic resonance imaging (MRI) and/or computed tomography (CT) scans. Forty-three of 50 patients received preoperative radiation with a mean dose of 50 Gy. In 11 cases a composite resection of bone and soft tissue was performed. In 39 cases the excision involved only soft tissue.

RESULTS

True bone invasion was verified by histopathologic examination in 3 of 50 cases (6%). Local recurrence in the soft tissues developed in 8 of 50 (16%) patients. In no case did the recurrence involve destruction of cortical bone or erosion into bone. The recurrent tumor resided against the region of previous bone contact in 1 of 8 cases. There was no statistically significant difference in local recurrence between patients who had composite bone resection and patients who had soft-tissue resection only (P = .87).

CONCLUSIONS

Relatively few sarcomas are able to penetrate cortical bone. Composite bone and soft-tissue resections are indicated primarily for frank bone invasion. In the absence of this, the periosteum is an adequate surgical margin for sarcomas treated with wide excision and radiation.

The effect of preoperative radiotherapy and reconstructive surgery on wound complications after resection of extremity soft-tissue sarcomas

BACKGROUND

Major wound complications (MWCs) are frequent after preoperative radiotherapy (RT) for extremity soft-tissue sarcoma (STS). We examined the rate of MWCs at a single institution with readily available reconstructive surgery.

METHODS

The medical records of consecutively treated extremity STS patients treated with preoperative external-beam RT and surgical resection from June 1996 through February 2003 were reviewed. Patients underwent RT (median 50 Gy), followed by resection 4-8 weeks later. Patients believed to be at higher risk for MWC underwent wound closure by the reconstructive surgery service (RSS). MWCs included secondary operation, invasive procedure, hospital readmission, or persistent deep packing or dressing changes.

RESULTS

A total of 173 patients underwent preoperative RT. Median age was 54 years; 51% were female; 80% had lower extremity STS. Wound closure was performed by the primary surgeon in 91 cases (53%). The RSS performed wound closure in the remaining 82 patients (47%). One or more MWCs occurred in 55 patients (32%). Wound complications were more likely in patients with lower extremity (49/138, 36%) than upper extremity (6/35, 17%) STS (P = 0.03). Among patients with lower-risk wounds closed by the primary surgical team, 29 (32%) experienced MWC, whereas in the higher-risk patients closed by the RSS, MWC occurred in 26 (32%).

CONCLUSIONS

MWCs are frequent after preoperative RT and occur more commonly in patients with lower extremity tumors. The MWC rate observed in a single-institution setting was comparable to that observed in the preoperative therapy arm of a multicenter Canadian trial. Patients believed to be at higher risk for MWCs undergoing RSS closure have MWC rates comparable to those with lower-risk wounds closed by the primary team.

Outcome of postradiation osteosarcoma does not correlate with chemotherapy response

Postradiation osteosarcoma is a rare tumor with a historically poor prognosis. Recent reports concerning the prognosis of the disease have been conflicting. We ascertained the long-term outcome of patients with this disease treated in the era of contemporary chemotherapy. Twenty-seven patients diagnosed with postradiation osteosarcoma and treated with chemotherapy and surgical resection from 1980-2003 were identified. Demographics, anatomic location, stage, chemo- therapy, necrosis rate, recurrence and metastatic rates were recorded; Kaplan-Meier survival rates were estimated. The median age was 54 years (range, 12-86 years). Nineteen patients were female and eight patients were male. Median followup was 39.2 months (range, 0-218 months). Twenty-two patients received induction chemotherapy for a mean of four cycles (range, 2-6 cycles). Mean tumor necrosis was 63.5%. Seven patients had 90% necrosis; four of these patients died of their disease. The mean survival was 23 months, and the 5-year disease free survival estimate was 27.2%. Histologic response to chemotherapy did not correlate with survival. Patients who had a latency of greater than 10 years after radiation had a better prognosis. Unlike conventional osteosarcoma, response to chemotherapy (necrosis) did not have prognostic significance. Current chemotherapy regimens fail to impact survival in postradiation osteosarcoma.

LEVEL OF EVIDENCE

Therapeutic study, level IV (retrospective comparative study).

Endoprosthetic and allograft-prosthetic composite reconstruction of the proximal femur for bone neoplasms

Reconstruction of the proximal femur after tumor resection can be achieved with either an endoprosthesis or an allograft-prosthetic composite. We compared the two modalities for complications, functional outcome, and construct survival. We retrospectively analyzed 52 patients with endoprostheses and 20 with allograft-prosthetic composite reconstructions between 1974 and 2002. Median followup was 146 months and 76 months, respectively. Both methods were associated with low rates of early complications. Infections occurred in two patients with endoprostheses and one patient with an allograft-prosthetic composite reconstruction. Aseptic loosening was the most common (10%) late complication for patients with endoprostheses. Nonunion was the most common (10%) complication for patients with allograft prosthetic composite reconstructions. All host-allograft junctions eventually healed after bone-grafting. The Musculo skeletal Tumor Society scores were similar for patients with endoprostheses (70%) and allograft-prosthetic composites (82%). The median hip abductor strength was greater for patients with allograft-prosthetic composite reconstructions (4.6 of 5) than for patients with endoprostheses (2.8 of 5). Kaplan-Meier survivorship of the implant was 86% for both groups at 10 years. The consistent restoration of abductor muscle strength combined with the low morbidity and high durability support the use of allograft-prosthetic composite reconstruction in patients with long life expectancy.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Complications of combined modality treatment of primary lower extremity soft-tissue sarcomas

BACKGROUND

Correlations between various patient, tumor, and treatment characteristics and complications in patients undergoing combined modality treatment for primary lower extremity soft-tissue sarcomas were investigated.

METHODS

Using the M. D. Anderson Radiation Oncology database, the records of the subset of patients treated with combined radiation and limb-sparing surgery for primary lower extremity soft-tissue sarcomas were retrospectively reviewed from the years 1960 to 2003.

RESULTS

In all, 412 patients were identified. With a median follow-up of 9.3 years, there were a total of 113 (27%) acute wound complications and 41 (13% at 20 years) chronic radiation-related limb complications. Preoperative radiation and tumor sizes >5 cm were associated with an increased risk of acute wound complications (34% preoperative vs. 16% postoperative, P < .001; and 31% >5 cm vs. 17% < or =5 cm, P = .005). At 20 years the radiation-related complication rate was higher in patients with a groin or thigh tumor location (16% vs. 4% other; P = .008), prior acute wound complications (20% vs. 10% no surgical complication), and a radiation dose > or =60 grays (Gy) (18% vs. 9% for dose < 60 Gy; P = .04). Five fractures occurred, resulting in a crude overall fracture rate of 1.2%.

CONCLUSIONS

Patients treated with preoperative radiation for larger tumors are more likely to have acute surgical wound complications. Acute wound complications followed by postoperative radiation are associated with chronic radiation-related limb problems, as are higher radiation dose and proximal tumor location. The fracture rate is so low that prophylactic fixation is not warranted.

Treatment and prognosis of chondroblastoma

Chondroblastoma is an aggressive tumor of bone with the capacity for recurrence and metastasis. We sought to determine the prognostic factors that affect survival and local recurrence with particular emphasis on surgical technique and the anatomic constraints of the open physis. It was hypothesized that an open growth plate would impact the local recurrence rate negatively and be a primary determinant of treatment outcome. We retrospectively reviewed 82 consecutive patients treated at one institution. Intralesional treatment with meticulous curettage and bone graft resulted in local control in the majority of patients. Four local recurrences developed between 5 and 51 months. An open growth plate was not found to correlate with local recurrence. In most cases, the open physis did not considerably impact surgical technique. Although the median age of the patients was 16 years, the majority of patients had a closed or closing physis. Few patients had substantial growth remaining. A physeal-sparing operation was done in six patients, and no local recurrences were observed in this group. The factors that seemed to affect local recurrence included inadequate surgery and biologic aggressiveness of the tumor. Inadequate surgery was likely to be the cause of local recurrence in patients who presented after previous treatment elsewhere. Three patients who developed local recurrence manifested increased biologic aggressiveness of disease. These patients subsequently developed metastatic disease and malignant transformation of disease. All three patients died from their disease. Pelvic tumors tend to be biologically more aggressive and more apt to recur locally and metastasize to distant locations.

LEVEL OF EVIDENCE

Therapeutic Study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Favorable long-term results of prosthetic arthroplasty of the knee for distal femur neoplasms

We evaluated implant survival, late complications prompting reoperation and functional outcome in long-term (> 5 years) survivors of bone neoplasms of the distal femur treated with osteoarticular resection and segmental rotating hinge total knee arthroplasty. We retrospectively reviewed 83 patients who survived more than 5 years after the first procedure. Seventy-four of the 83 patients have retained a mobile knee joint. At a median followup of 146 months (range, 62-252 months), 22 patients required 26 additional procedures for a prosthesis-specific event (n = 24) or tumor recurrence (n = 2) after reaching 5-year followup. Aseptic loosening (n = 7) and component breakage (n = 2) occurred between 5 and 10 years. Polyethylene wear (n = 12) occurred only after 10 years. One late tumor recurrence at 62 months prompted amputation. All other patients retained a mobile knee joint. Functional outcome was excellent with a median Musculoskeletal Tumor Society score of 88% and a median Toronto Extremity Severity Scale score of 94%. Patients with bone neoplasms who survive more than 5 years after limb salvage with a segmental rotating hinge total knee arthroplasty can expect to retain a mobile knee joint and function consistently at a high level.

LEVEL OF EVIDENCE

Therapeutic study, Level III-2 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Methods: A Comparative Analysis of Radiography, Microcomputed Tomography, and Histology for Bone Tissue Engineering

This study focused on the assessment of radiography, microcomputed tomography, and histology for the evaluation of bone formation in a 15.0-mm defect in the rabbit radius after the implantation of a tissue-engineered construct. Radiography was found to be useful as a noninvasive method for obtaining images of calcified tissue throughout the time course of the experiment. With this method, however, image quality was low, making it difficult to obtain precise information about the location and quantity of the bone formed. Microcomputed tomography was used to create three-dimensional reconstructions of the bone (25-microm resolution). These reconstructions allowed for greater spatial resolution than the radiography, but did not allow for imaging of the implanted scaffold material or the surrounding, nonmineralized tissue. To visualize all materials within the defect area at the cellular level, histology was used. Histological analysis, however, is a destructive technique that did not allow for any further analysis of the samples. Each technique examined here has its own advantages and limitations, but each yields unique information regarding bone regeneration. It is only through the use of all three techniques that complete characterization of the bone growth and tissue/construct responses after implantation in vivo.

Impact severity of local recurrence in giant cell tumor of bone

We retrospectively reviewed 183 consecutive patients diagnosed with giant cell tumor at the three most common sites (distal femur, proximal tibia, and distal radius) to determine the pattern of local tumor recurrence and the impact severity of the recurrence on adjacent joint function. The primary tumor was treated in all patients with intralesional excision of tumor by curettage. Forty-five patients developed locally recurrent disease. Twenty-three of the patients had their first surgery at our institution, and 22 had been referred from other institutions after the development of local recurrence. The intrainstitutional recurrences were salvaged by a repeat curettage (n = 12) or en bloc osteoarticular resection (n = 10) for bone recurrences and wide local excision for soft tissue recurrence (n = 1). The prereferral recurrences were salvaged by a repeat curettage (n = 7) and en bloc osteoarticular resection (n = 15) for bone recurrences. Incomplete initial surgery, a delay in diagnosis of the recurrence of greater than 6 months, and subchondral recurrence of tumor were contributing factors in the failure to salvage the joint. Despite its benign histology, giant cell tumor of bone is an aggressive tumor that demands meticulous attention to surgical detail and close postoperative surveillance for successful local tumor control and durable, joint-preserving function.

LEVEL OF EVIDENCE

Therapeutic study, Level III-2 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Port-Site Metastasis: The Influence of Biology

OBJECTIVE

Several surgical and technical mechanisms have been proposed for the development of port-site metastasis, but the influence of tumor and host biologic factors has not been emphasized. We present a case of a pelvic chordoma that metastasized to a prior laparoscopic radical nephrectomy port-site.

METHODS

A 62-year-old woman underwent laparoscopic radical nephrectomy (LRN) for a pT1b grade 3 renal cell carcinoma, followed 6 weeks later by resection of a sacral chordoma. The incisions and areas of dissection for the two procedures were discontinuous.

RESULTS

Eight months following the LRN she developed a nodule in one of the laparoscopic port-sites. The port-site metastasis was treated with wide surgical resection, which was confirmed as metastatic chordoma on histologic examination.

CONCLUSION

Based on the chronological sequence and physical distance between surgical sites, only biological factors could have contributed to this port-site metastasis. This unusual case highlights the important role that tumor and host biologic mechanisms play in the development of port-site metastasis.

Chondrosarcoma of the scapula

BACKGROUND

Chondrosarcoma is the second most common primary sarcoma of bone. It often develops within flat bones, such as the pelvis, ribs, and scapula. In the current study, the authors reviewed the surgical experience and long-term oncologic outcomes of patients with chondrosarcoma arising in the scapula.

METHODS

The medical records of 29 consecutive patients with chondrosarcoma of the scapula were reviewed. The patients were treated between 1954 and 1994. All patients had localized disease at the time of presentation. The tumors were classified histologically as Grade 1 (10 patients), Grade 2 (10 patients), Grade 3 (7 patients), dedifferentiated (1 patient), and mesenchymal (1 patient) (using the criteria of Evans et al.). The mean maximal dimension of the tumors was 11 cm. Twenty-five patients underwent limb-sparing surgical resection and 4 patients underwent forequarter amputations. The median follow-up was 13 years (range, 1-35 years).

RESULTS

At last follow-up, 22 patients (76%) were free of disease and 7 patients (24%) had died of their disease. Local recurrence occurred in 4 patients at 7 months, 16 months, 40 months, and 43 months, respectively. The local recurrence-free survival rate was 86% at 5 years, 10 years, and 20 years. Disease-specific survival was 83% at 5 years, 74% at 10 years, and 74% at 20 years. Patients who had low-grade chondrosarcomas had better survival compared with patients who had high-grade chondrosarcomas (P = 0.07).

CONCLUSIONS

Patients who had localized chondrosarcoma of the scapula had a favorable long-term outcome, most likely due to the unique anatomic features that improved the likelihood of achieving wide surgical margins with limb-sparing surgery, despite the frequent presentation of locally advanced disease.

Phase I Trial of Preoperative Doxorubicin-Based Concurrent Chemoradiation and Surgical Resection for Localized Extremity and Body Wall Soft Tissue Sarcomas

Purpose

The primary objective of this phase I trial was to define the maximum-tolerated dose of continuous-infusion doxorubicin administered with standard preoperative radiation for patients with localized, potentially resectable soft tissue sarcomas of the extremities or body wall.

Patients and Methods

Twenty-seven patients with radiographically resectable intermediate- or high-grade soft tissue sarcomas were treated. Preoperative external-beam radiation was administered in 25 2-Gy fractions (total dose, 50 Gy). Concurrent continuous-infusion doxorubicin was administered by an initial bolus (4 mg/m2) and subsequent 4-day continuous infusion (12.5, 15.0, 17.5, or 20.0 mg/m2/wk). Radiographic restaging was performed 4 to 7 weeks after chemoradiation, and patients with localized disease underwent surgical resection.

Results

Chemoradiation was completed as an outpatient procedure in 25 patients (93%). The maximum-tolerated dose of continuous-infusion doxorubicin combined with standard preoperative radiation was 17.5 mg/m2/wk; at this dose level, seven (30%) of 23 patients had grade 3 dermatologic toxicity. Macroscopically complete resection (R0 or R1) was performed in all 26 patients who underwent surgery. Among 22 patients who were treated with doxorubicin 17.5/mg/m2/wk with concurrent radiation and subsequent surgery, 11 patients (50%) had 90% or greater tumor necrosis, including two patients who had complete pathologic responses.

Conclusion

Preoperative doxorubicin-based chemoradiation appears safe and feasible. The maximum-tolerated dose of continuous-infusion doxorubicin with standard preoperative radiation was 17.5 mg/m2/wk. Pathologic response rates with this regimen are encouraging.

A phase II study of cisplatin, doxorubicin, and ifosfamide with peripheral blood stem cell support in patients with skeletal osteosarcoma and variant bone tumors with a poor prognosis

BACKGROUND

The authors evaluated the efficacy and toxicity of cisplatin, ifosfamide, and doxorubicin with peripheral blood stem cell (PBSC) support in adult patients with osteosarcomas and variants with a poor prognosis.

METHODS

Between December 1994 and January 2001, 37 patients (20 males and 17 females) with a median age of 38 years (range, 18-63 years) entered the study. Ten patients had pelvic osteosarcomas (OS), 6 had malignant fibrous histiocytomas, 5 had metastatic OS, and 16 had miscellaneous histologies. The authors used doxorubicin (60-75 mg/m(2)) and ifosfamide (10 g/m(2)) followed by granulocyte-colony-stimulating factor (G-CSF) (5 microg/kg twice per day) for mobilization of PBSC, collected at a median of 12 days (range, 10-14 days). Three cycles with cisplatin (120 mg/m(2)), ifosfamide (10 g/m(2)), and doxorubicin (75 mg/m(2)), given 28 days apart, were planned followed by PBSC (2-4 x 10(6) CD34-positive cells/kg) infusion plus G-CSF.

RESULTS

Patients received a median of three cycles (range, one to three cycles) in addition to the mobilizing cycle. The median PBSC collection was 17.5 x 10(6)/kg (range, 13.2-90.8 x 10(6)/kg) with a median of 1 apheresis (range, 1-2 aphereses). Twenty-eight patients underwent surgery, 10 achieved 95-100% necrosis, and 4 achieved 90-94% necrosis. Six patients required early discontinuation of therapy due to toxicities, two patients developed progressive disease, and one patient was deemed unresectable. The median time to progression (TTP) and overall survival by Kaplan-Meier estimates for all 37 patients was 19 months and 49 months, respectively.

CONCLUSIONS

The authors accomplished the objective of improving the rate of necrosis with intensification of preoperative therapy. However, TTP and survival rates remained poor. The toxicity profile of this regimen is prohibitive and alternative strategies need to be investigated.

Single and multiple metachronous osteosarcoma tumors after therapy

BACKGROUND

The objective of the current study was to determine the incidence, clinical and pathologic characteristics, and outcome of patients with conventional osteosarcoma who developed metachronous tumors after treatment for the primary tumor and prevention of pulmonary metastases.

METHODS

The medical records of 270 pediatric patients (younger than age 18 years) were reviewed. The prevention and absence of pulmonary metastases was confirmed by chest radiographs and computerized scans of the lungs. Radionuclide bone scans were used to confirm the absence of skeletal metastases.

RESULTS

Eleven patients with metachronous tumors were identified. Index primary tumors involved the femur (n = 8), the tibia (n = 2), and the radius (n = 1). Single metachronous tumors developed in the femur (n = 6), in the humerus (n = 1), and multifocal in multiple bones (n = 4). Two patients later developed second metachronous tumors. The interval between identification of the primary tumor to development of the single metachronous tumors varied from 11 months to 78 months and from 12 months to 42 months for synchronous multifocal tumors. Metachronous tumors were treated with single-agent cisplatin or ifosfamide. Only 1 patient experienced > 90% tumor necrosis. Pulmonary metastases were not detected in 10 of 11 patients at the time metachronous tumors were discovered. In the 11th patient, synchronous pulmonary metastasis with the metachronous tumor was noted. Three patients had a prior history of bilateral retinoblastoma. The Li-Fraumeni syndrome may have been present in another patient. Six patients died. Five patients have survived for 20+ to 50+ months after the appearance, treatment, and resection of metachronous tumors.

CONCLUSIONS

With improvement in the cure rate, metachronous osteosarcoma should be recognized as an important sequela in long-term survivors. The etiology of this disease is unknown. Speculation rests on a skeletal multicentric origin, which includes an inherited predisposition to develop osteosarcoma in retinoblastoma and in the Li-Fraumeni syndrome. Meticulous follow-up is required to permit early detection and successful therapeutic intervention.

Complex segmental elbow reconstruction after tumor resection

Twenty-three patients were reviewed retrospectively to determine their oncologic and functional outcomes after resection of 15 primary or eight metastatic tumors about the elbow between 1985 and 2000. The indications for resection were dictated by the histologic features of the tumor, location of the lesion, and extent of bone destruction. A total humeral reconstruction was done in 12 patients. Of this group, an endoprosthesis was used in seven patients and a total humeral allograft with a proximal humeral prosthesis and osteoarticular elbow reconstruction (allograft-prosthetic composite) was used in five patients. Eleven additional patients had a segmental total elbow replacement after resection of the distal humerus or proximal ulna. Local disease control was achieved in 17 patients (74%). Fourteen patients presented with (48%) or had (13%) distant metastasis develop, but only eight (35%) died of their disease. Periprosthetic lysis or allograft resorption was present in five patients (22%), and two (18%) humeral components of total elbow prostheses required revision for loosening. The mean Musculoskeletal Tumor Society functional score was 23 of 30 points (77%) in the 12 living patients followed up for a mean of 46 months (range, 24-124 months). It was 83% in patients with a segmental total elbow reconstruction and 71% in patients with a total humeral reconstruction. Aggressive limb salvage of the humerus or elbow or both provides a satisfactory functional outcome without jeopardizing overall survival.

Radiotherapy in the management of giant cell tumor of bone

PURPOSE

To evaluate the outcomes of patients with giant cell tumor of bone (GCTB) treated with radiotherapy (RT) with or without surgical resection.

METHODS AND MATERIALS

We performed a retrospective review of the records from 25 consecutive patients with pathologically confirmed GCTB who had undergone RT between 1956 and 2000.

RESULTS

Patients ranged in age from 11 to 69 years (median 32); 16 were female and 9 were male. The anatomic distribution of lesions was as follows: cervical spine, 3; temporal bone, 1; thoracic or lumbar spine, 9; sacrum, 8; ilium, 1, and humerus, radius, and thumb metacarpal, 1 each. Tumors ranged in size from 2 to 20 cm (median 9.5) at their maximal dimension. Thirteen patients had been referred for RT for primary GCTB and 12 had been referred with locally recurrent disease after having undergone one or more other treatments. Fourteen patients had undergone RT for gross disease, and the remaining 11 had been treated with RT after gross total resection. In 10 of these 11 patients, the treatment margins were positive or uncertain. Radiation doses ranged from 25 to 65 Gy (median 46). At a median follow-up of 8.8 years (range 0.67-34), 7 patients had developed isolated local recurrence, 2 had developed isolated distant recurrence, and 3 had developed both. The actuarial 5-year overall and disease-free survival rate was 91% and 58%, respectively, and the actuarial 5-year local control and distant metastasis-free survival rate was 62% and 81%, respectively. Univariate analysis suggested that treatment for recurrent disease correlated with a lower disease-free survival rate (83% vs. 33%, p = 0.06), distant metastasis-free survival rate (100% vs. 64%, p = 0.08), and local control rate (83% vs. 42%, p = 0.08) at 5 years. Of the 12 cases of recurrence, 7 were ultimately successfully treated with additional salvage therapy. In 4 of these patients, salvage therapy included interferon-alpha 2b.

CONCLUSION

RT should be considered an adjuvant to surgery or as alternative therapy in cases of GCTB that are unresectable or in which excision would result in substantial functional deficits. When RT is used as primary therapy, the rate of local control seems to be satisfactory. In heavily pretreated patients, however, RT delivered as it was in this series can result in poor local control, and alternative therapies should be considered.

Osteosarcoma of bone in apatient with primary hyperparathyroidism: a case report

A 69-year-old woman was diagnosed with a malignant tumor of the right proximal femur. She had primary hyperparathyroidism and chronic elevation of parathyroid hormone levels (PTH > 1,000 pg/ml). She underwent resection of the bone lesion; histological analysis showed a high-grade fibroblastic osteosarcoma. In addition, she underwent curative resection of a large left superior parathyroid adenoma. To our knowledge, this is the third reported clinical case of osteosarcoma arising in association with hyperparathyroidism.

Development of an injectable, in situ crosslinkable, degradable polymeric carrier for osteogenic cell populations. Part 2. Viability of encapsulated marrow stromal osteoblasts cultured on crosslinking poly(propylene fumarate)

The effect of temporary encapsulation of rat marrow stromal osteoblasts in crosslinked gelatin microparticles on cell viability and proliferation was investigated in this study for microparticles placed on a crosslinking poly(propylene fumarate) (PPF) composite over a 7 day time period. Encapsulated cells were seeded on crosslinking PPF composites at times up to 10 min following initiation of the crosslinking reaction, and also on fully crosslinked PPF composites and tissue culture polystyrene controls, with a cell seeding density of 5.3 x 10(4) cells/cm2. The crosslinked PPF composite exhibited an average gel point of 10.3 min and an average maximum crosslinking temperature of 47.5 degrees C. Cell viability and proliferation were assessed by DNA and 3H-thymidine assays and the results were compared with those for nonencapsulated cells. The results showed that the addition time of cells to a crosslinking PPF composite had a large effect on cell viability and proliferation for both encapsulated and nonencapsulated cells with more surviving cells added at later time points. Most importantly, the temporary encapsulation of cells significantly enhanced cell viability at earlier time points. The data indicate that the presence of gelatin microparticles does not affect the crosslinking of a PPF composite. They further suggest that the temporary encapsulation of cells in crosslinked gelatin microparticles may preserve the viability of cells contained in an actively crosslinking PPF composite used as an injectable polymeric scaffold serving also as a carrier for osteogenic cell populations.

Development of an injectable, in situ crosslinkable, degradable polymeric carrier for osteogenic cell populations. Part 3. Proliferation and differentiation of encapsulated marrow stromal osteoblasts cultured on crosslinking poly(propylene fumarate)

This study investigated the effect of temporary encapsulation of rat marrow stromal osteoblasts in crosslinked gelatin microparticles on long-term cell proliferation and phenotypic expression for microparticles placed on crosslinking poly(propylene fumarate) (PPF) composites using N-vinyl pyrollidinone (N-VP) as a crosslinking agent over a 28 day time period. Encapsulated cells (ECs) were seeded on actively crosslinking PPF composites 6 min after initiation of the crosslinking reaction, and also on fully crosslinked PPF composites and tissue culture polystyrene controls, with a cell seeding density of 5.3 x 10(4) cells/cm2. Composites prepared with three PPF:N-VP ratios were examined: 1:0.5, 1:0.1, and 1:0.05. Samples were taken at specified time points and analyzed by DNA, 3H-thymidine, alkaline phosphatase, osteocalcin, and calcium assays, and the measurements were compared with those for nonencapsulated cells (NCs). The results showed that encapsulated marrow stromal cells exhibited much higher viability, proliferation, and phenotypic expression when placed on crosslinking PPF composites than NCs. The assay results for ECs on crosslinking PPF composites were also similar to those on fully crosslinked PPF composites. The data further demonstrated that the PPF:N-VP ratio had no effect on the viability, proliferation, or phenotypic expression of the ECs. These results suggest that cells encapsulated in crosslinked gelatin microparticles may be part of an injectable, in situ crosslinkable, biodegradable polymeric composite for bone tissue engineering applications.

Development of an injectable, in situ crosslinkable, degradable polymeric carrier for osteogenic cell populations. Part 1. Encapsulation of marrow stromal osteoblasts in surface crosslinked gelatin microparticles

This study investigated the temporary encapsulation of rat marrow stromal osteoblasts in surface crosslinked gelatin microparticles. Cells were encapsulated in uncrosslinked gelatin microparticles of average diameter of 630 microm containing approximately 53 cells. Gelatin microparticles were crosslinked to shell thicknesses of approximately 75 microm via exposure to 1 mM dithiobis(succinimidylpropionate) (DSP) solution for 15 min or 5 mm DSP solution for 5 min for the production of microparticles dispersing approximately 60 min after placement into a physiologic fluid at 37 degrees C. Formed microparticles were placed into culture wells at a cell seeding density of 5.3 x 10(4) cells/cm2 and, following the degradation and/or dissolution of gelatin, the cells were cultured in the presence of osteogenic supplements for 28 days. Samples were taken at specified time points and analyzed by a DNA assay for cell number and a 3H-thymidine incorporation assay for proliferative potential. Samples were also obtained and analyzed at several time points by alkaline phosphatase, osteocalcin, and mineralization assays for early and late phenotypic expression markers of osteoblastic differentiation. The measurements from the different assays for encapsulated cells (EC) in uncrosslinked and crosslinked gelatin microparticles were normalized with the cell numbers from the DNA assay and compared with those for nonencapsulated control cells. The results demonstrated that the marrow stromal cells survived the encapsulation procedure in uncrosslinked gelatin microparticles and also retained their proliferative potential and osteoblastic phenotype over a 28 day period, although at a slightly lower level than the nonencapsulated cells. The results further showed that the marrow stromal cells survived the encapsulation in crosslinked gelatin microparticles prepared via exposure to 5mm DSP for 5 min and also retained their proliferative potential and osteoblastic phenotype over a 28 day period, but at a slightly lower level than the EC in uncrosslinked gelatin microparticles. In contrast, exposure to 1 mM DSP for 15 min led to severely limited cell viability and phenotypic expression probably due to the increased crosslinking time. These results suggest that temporary encapsulation of cells in gelatin microparticles may protect cells from short-term environmental effects such as those associated with the crosslinking of an injectable polymeric carrier for bone tissue engineering.

Giant cell tumor of bone

Giant cell tumor of bone is an enigmatic osseous neoplasm that is histologically benign but clinically shows local aggression and metastatic potential. The absence of clinical, radiographic, or pathologic features that are predictive of tumor behavior and patient outcome has resulted in recent attention to the pathobiology of giant cell tumor of bone. In this report, the clinicopathologic features of and current treatment approaches to giant cell tumor of bone are reviewed. Recent investigations of the specific role of the cell populations present in giant cell tumor of bone that influence tumor proliferation, bone resorption, and its clinical behavior are described.

Long-term follow-up of patients with giant cell tumor of the sacrum treated with selective arterial embolization

BACKGROUND

Giant cell tumors of the bone can behave as aggressive and sometimes lethal tumors. In the sacrum, the tumor can be extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. The goal of this study is to evaluate the long-term outcome of selective arterial embolization as an alternative treatment modality.

METHODS

From 1975 to 2001, 18 patients were treated with selective intraarterial embolization. The embolization method was a combination of Gelfoam particles and coils for peripheral and central occlusions, respectively. The number of embolizations was based on clinical symptoms, radiographic response, and the vascularity of the tumor. Nine patients received intraarterial cisplatin as part of their treatment. The median follow-up was 105 months.

RESULTS

Of 18 patients, 14 responded favorably to embolization with improvement in pain and neurologic symptoms. Computed tomographic and magnetic resonance imaging scans showed reossification and stabilization of tumor size. Arteriograms showed diminished vascularity. With long-term follow-up, three patients developed late disease recurrences within the sacrum. Kaplan-Meier analysis showed that the risk of local recurrence is 31% at 10 years and 43% at 15 and 20 years. The long-term outcome was not affected by intraarterial cisplatin. There was one death that occurred 1 day after embolization.

CONCLUSIONS

Most patients demonstrate an objective early radiographic response to embolization. Long-term follow-up shows that the response is durable in approximately one half of the patients. Given the potential morbidity of other treatments, embolization should be included in the armamentarium of treatment for this difficult disease. Embolization may be used alone or in conjunction with other therapy. Long-term follow-up is recommended for all patients because late disease recurrence or sarcomatous change can occur.

Surgical management of soft tissue sarcomas of the hand and foot

BACKGROUND

Soft tissue sarcomas of the hand and foot present unique management challenges. The purpose of the current study study was to determine oncologic outcome, particularly with respect to factors affecting local recurrence, distant recurrence, and disease-specific survival.

METHODS

A retrospective study was performed on 115 patients with soft tissue sarcomas of the hand or foot who were evaluated, treated, and followed at the authors' institution between 1980 and 1998. The medical records and radiographs were reviewed. Kaplan-Meier analysis was used to assess patient survival.

RESULTS

Most patients (95%) were referred after previous surgery. The majority of tumors (75%) were T1 lesions (less than 5 cm), and most tumors (81%) were high grade. Patients who were treated by definitive, wide re-excision (n = 43) had a 10 year local recurrence-free survival of 88%, which was significantly better than the corresponding rate of 58% for patients who did not have re-excision (n = 40, P = 0.05). Radiation improved local control in patients who did not undergo re-excision (n = 17, P = 0.02). However, radiation did not improve local control in patients who had definitive re-excision with negative margins (n = 13, P = 0.51). The disease-specific survival at 5 and 10 years was 76% and 65%, respectively, for patients who presented with localized disease. Disease-specific patient survival was significantly worse for patients who had regional or distant metastasis. Radical amputation as initial surgical treatment did not decrease the likelihood of regional metastasis and did not improve disease-specific patient survival. The presence of distant metastasis at presentation was an independent predictor of local recurrence.

CONCLUSION

Limb sparing treatment is possible in many patients with soft tissue sarcomas of the hand and foot. Re-excision to achieve microscopically negative surgical margins is an effective method of achieving a high rate of local control in appropriately selected patients who present after unplanned excision of the primary tumor. There does not appear to be a survival benefit to immediate radical amputation, which should be reserved for cases where surgical excision or re-excision with adequate margins cannot be performed without sacrifice of functionally significant neurovascular or osseous structures.

Extraosseous osteosarcoma: response to treatment and long-term outcome

PURPOSE

To evaluate the clinicopathologic features of extraosseous osteosarcoma (EOO), a rare soft tissue form of osteosarcoma, and to examine its response to multimodality therapy.

PATIENTS AND METHODS

The medical records of all patients with EOO evaluated at The University of Texas M.D. Anderson Cancer Center between 1960 and 1999 were reviewed for clinicopathologic factors, treatment, and outcome.

RESULTS

Sixty consecutive patients with EOO were identified, including 38 patients with localized (American Joint Committee on Cancer stages I to III) disease. The majority of patients presented with T2 tumors (n = 35, 58%), and 90% of tumors were located beneath the investing fascia. Twenty-seven patients with measurable and assessable disease were treated with doxorubicin-based chemotherapy (median doxorubicin starting dose, 75 mg/m(2); median number of cycles, four). The overall response rate was 19%, with two complete and three partial responses; one (6%) of 18 doxorubicin-treated patients who underwent subsequent surgery had a pathologic complete response. For the subset of 30 patients with localized disease treated at M.D. Anderson, the 5-year actuarial local recurrence-free, distant recurrence-free, event-free, and disease-specific survival rates were 82% (95% confidence interval [CI], 70% to 98%), 64% (95% CI, 43% to 93%), 47% (95% CI, 30% to 70%), and 46% (95% CI, 26% to 80%), respectively.

CONCLUSION

EOO should be considered clinically and therapeutically distinct from osseous osteosarcoma. Radiographic response rates and pathologic complete response rates to doxorubicin-based systemic therapy are low.

Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution

BACKGROUND

Alveolar soft part sarcoma (ASPS) is a rare form of soft tissue sarcoma. Brain metastases have been reported to be a common feature of Stage IV ASPS, and recent practice guidelines recommend routine intracranial imaging as part of the staging evaluation in all patients who present with ASPS.

METHODS

The authors performed a comprehensive retrospective review of the clinical presentation, treatment, outcome, and patterns of failure in a consecutive series of patients with localized (American Joint Committee on Cancer [AJCC] Stages II/III) or metastatic (AJCC Stage IV) ASPS who presented to a tertiary care cancer center between 1959 and 1998.

RESULTS

Seventy-four patients were identified from the database searches. The anatomic distribution of their primary tumors included: extremities, 44 patients (60%); trunk, 15 patients (20%); head and neck, 9 patients (12%); and retroperitoneum, 6 patients (8%). The median tumor size was 6.5 cm (range, 1.2-24 cm). The AJCC stage at presentation was Stage II or III in 35% of the patients and Stage IV in 65% of the patients. The 5-year actuarial local recurrence free, distant recurrence free, disease free, and overall survival rates among the 22 patients with localized ASPS were 88%, 84%, 71%%, and 87%, respectively. At a median follow-up of 9 years, 2 of 22 patients with localized disease had developed local recurrences and 3 had developed metastatic disease (all to the lung only). Brain metastases were noted in 9 of 48 patients who presented with Stage IV (M1) disease (19%) and always were noted in association with metastasis to other sites. The median survival of patients with M1 disease was 40 months, with a 5-year survival rate of 20%.

CONCLUSIONS

Long term follow-up of patients with localized ASPS reveals a relatively indolent clinical course with relatively low rates of local and distant recurrence. In patients with Stage IV ASPS, brain metastases were observed only as part of more disseminated disease. The observations of the current study do not support current practice guidelines for the staging of patients with ASPS and suggest that selective rather than routine intracranial imaging should be used in patients presenting with ASPS.

Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution

BACKGROUND

Alveolar soft part sarcoma (ASPS) is a rare form of soft tissue sarcoma. Brain metastases have been reported to be a common feature of Stage IV ASPS, and recent practice guidelines recommend routine intracranial imaging as part of the staging evaluation in all patients who present with ASPS.

METHODS

The authors performed a comprehensive retrospective review of the clinical presentation, treatment, outcome, and patterns of failure in a consecutive series of patients with localized (American Joint Committee on Cancer [AJCC] Stages II/III) or metastatic (AJCC Stage IV) ASPS who presented to a tertiary care cancer center between 1959 and 1998.

RESULTS

Seventy-four patients were identified from the database searches. The anatomic distribution of their primary tumors included: extremities, 44 patients (60%); trunk, 15 patients (20%); head and neck, 9 patients (12%); and retroperitoneum, 6 patients (8%). The median tumor size was 6.5 cm (range, 1.2-24 cm). The AJCC stage at presentation was Stage II or III in 35% of the patients and Stage IV in 65% of the patients. The 5-year actuarial local recurrence free, distant recurrence free, disease free, and overall survival rates among the 22 patients with localized ASPS were 88%, 84%, 71%%, and 87%, respectively. At a median follow-up of 9 years, 2 of 22 patients with localized disease had developed local recurrences and 3 had developed metastatic disease (all to the lung only). Brain metastases were noted in 9 of 48 patients who presented with Stage IV (M1) disease (19%) and always were noted in association with metastasis to other sites. The median survival of patients with M1 disease was 40 months, with a 5-year survival rate of 20%.

CONCLUSIONS

Long term follow-up of patients with localized ASPS reveals a relatively indolent clinical course with relatively low rates of local and distant recurrence. In patients with Stage IV ASPS, brain metastases were observed only as part of more disseminated disease. The observations of the current study do not support current practice guidelines for the staging of patients with ASPS and suggest that selective rather than routine intracranial imaging should be used in patients presenting with ASPS.

Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution

BACKGROUND

Alveolar soft part sarcoma (ASPS) is a rare form of soft tissue sarcoma. Brain metastases have been reported to be a common feature of Stage IV ASPS, and recent practice guidelines recommend routine intracranial imaging as part of the staging evaluation in all patients who present with ASPS.

METHODS

The authors performed a comprehensive retrospective review of the clinical presentation, treatment, outcome, and patterns of failure in a consecutive series of patients with localized (American Joint Committee on Cancer [AJCC] Stages II/III) or metastatic (AJCC Stage IV) ASPS who presented to a tertiary care cancer center between 1959 and 1998.

RESULTS

Seventy-four patients were identified from the database searches. The anatomic distribution of their primary tumors included: extremities, 44 patients (60%); trunk, 15 patients (20%); head and neck, 9 patients (12%); and retroperitoneum, 6 patients (8%). The median tumor size was 6.5 cm (range, 1.2-24 cm). The AJCC stage at presentation was Stage II or III in 35% of the patients and Stage IV in 65% of the patients. The 5-year actuarial local recurrence free, distant recurrence free, disease free, and overall survival rates among the 22 patients with localized ASPS were 88%, 84%, 71%%, and 87%, respectively. At a median follow-up of 9 years, 2 of 22 patients with localized disease had developed local recurrences and 3 had developed metastatic disease (all to the lung only). Brain metastases were noted in 9 of 48 patients who presented with Stage IV (M1) disease (19%) and always were noted in association with metastasis to other sites. The median survival of patients with M1 disease was 40 months, with a 5-year survival rate of 20%.

CONCLUSIONS

Long term follow-up of patients with localized ASPS reveals a relatively indolent clinical course with relatively low rates of local and distant recurrence. In patients with Stage IV ASPS, brain metastases were observed only as part of more disseminated disease. The observations of the current study do not support current practice guidelines for the staging of patients with ASPS and suggest that selective rather than routine intracranial imaging should be used in patients presenting with ASPS.