Efficacy of Extracorporeal Irradiation in Primary Malignant Bone Tumours: A Tertiary Cancer Centre Experience

Background: Limb-sparing approaches involving a combination of surgery, chemotherapy, and radiotherapy are preferred in primary malignant bone tumours whenever possible. The limb function can be maintained by performing reconstruction either using a prosthesis or bone graft. Extracorporeal irradiation is a novel and exciting technique in which the restoration is done using the patient’s own tumour bone. In this article, we present the local control, complications, and functional outcome of 49 cases of primary malignant bone tumours treated using the technique of extracorporeal irradiation. Materials and methods: 49 patients with primary malignant bone tumours were treated with extracorporeal irradiation between the year 2007 to 2015.En-bloc resection of the tumour and the involved bone along with soft tissues was performed about four weeks after the completion of three to four cycles of neoadjuvant chemotherapy. The bone segment was irradiated with 6MV linear accelerator to a dose of 50Gy. After extracorporeal irradiation, the bone was re-implanted using fixation devices. Local control, relapse-free survival, complications and functional outcome were studied. Results: Out of 49 patients, there were 33 males and 16 females. The median age was 19 years. Femur and tibia were the most common tumour locations with osteosarcoma being the most common histology (74%). The local control rate was 94%. The 8 year local recurrence-free survival and distant metastasis-free survival were 89% and 84% respectively. The overall complication rate was 20%. Infection was the most frequent complication, observed in 46% of the patients who developed complications. Out of 49 patients, 40 had reported a good range of movements. Conclusion: Extracorporeal irradiation and re-implantation is a convenient alternative to prosthesis from a health economics point of view, provided severe complications are managed and avoided so that functional results can be achieved.  

Brodie's Abscess of Posterior Ilium with Gluteal Syndrome, an Unusual Cause of Paediatric Low Back Pain: A Case Report

Brodie’s abscess is a variety of subacute osteomyelitis with a long duration of presentation and intermittent pain. It usually involves the metaphyseal region of long bones of the lower limbs. Brodie’s abscess of pelvic bone is very rare. Involvement of posterior ilium with gluteal syndrome is extremely unusual and can be easily missed or misdiagnosed. We present a 9-year old boy who reported to us with intermittent low back pain of three months duration without any other constitutional symptoms. Clinically, there was mild tenderness over the posterior ilium. Computed tomography showed a lytic lesion in the posterior ilium with a breach in the outer cortex. MRI and bone scan were suggestive of inflammatory pathology. Keeping infective, tubercular and benign bone tumors as differential diagnoses, open biopsy and curettage were done. Staphylococcus aureus was cultured and histopathology was suggestive of osteomyelitis. The patient received appropriate antibiotics for six weeks. He was asymptomatic till 18 months of follow up without any recurrence. We present this case because of its rarity and unusual presentation as gluteal syndrome and low back pain, and its resemblance to other pelvic and sacroiliac joint pathologies which are often missed or misdiagnosed in paediatric patients.

Evaluation of static and dynamic MRI for assessing response of bone sarcomas to preoperative chemotherapy: Correlation with histological necrosis

OBJECTIVES

Preoperative chemotherapy plays a key role in management of bone sarcomas. Postoperative evaluation of histological necrosis has been the gold standard method of assessing response to preoperative chemotherapy. This study was done to evaluate the efficacy of static and dynamic magnetic resonance imaging (MRI) for assessing response preoperatively.

MATERIALS AND METHODS

Our study included 14 patients (12 osteosarcomas and 2 malignant fibrous histiocytomas) with mean age of 21.8 years, treated with preoperative chemotherapy followed by surgery. They were evaluated with static and dynamic MRI twice, before starting chemotherapy and again prior to surgery. Change in tumor volume and slope of signal intensity - time curve were calculated and correlated with percentage of histological necrosis using Pearson correlation test.

RESULTS

The change in dynamic MRI slope was significant (P = 0.001). Also, ≥60% reduction in slope of the curve proved to be an indicator of good histological response [positive predictive value (PPV) =80%]. Change in tumor volume failed to show significant correlation (P = 0.071). Although it showed high negative predictive value (NPV = 85.7%), PPV was too low (PPV = 57.14%).

CONCLUSIONS

Dynamic MRI correctly predicts histological necrosis after administration of preoperative chemotherapy to bone sarcomas. Hence, it can be used as a preoperative indicator of response to neoadjuvant chemotherapy. On the other hand, volumetric assessment by static MRI is not an effective predictor of histological necrosis. This study proves the superiority of dynamic contrast-enhanced study over volumetric study by MRI.

Clinical and haematological predictors of acute hematogenous Methicillin Resistant Staphylococcus aureus (MRSA) osteomyelitis & septic arthritis

INTRODUCTION

In the present study, we observed differences in the clinical and haematological parameters in patients of MRSA and non MRSA acute osteoarticular infection.

METHODOLOGY

For the patients of acute haematogenous osteomyelitis/septic arthritis, clinical features, haematological parameters and blood & aspirate cultures were recorded.

RESULTS

Of 81 patients enrolled in the study, 61 were culture positive (22% MRSA). Statistically significant difference was found only in CRP (P < 0.001). ROC curve analysis shows that CRP levels of >13.9 mg/L, MRSA bone and joint infection could be predicted with 92.9% sensitivity and 79.1% specificity (AUC = 89.1).

CONCLUSION

Estimation of serum CRP levels at the time of presentation can aid in distinguishing MRSA osteomyelitis from non MRSA one.

Tumor(s) induced osteomalacia--a curious case of double trouble

CONTEXT

We report a case of tumor-induced osteomalacia with evidence of synchronous multifocal fibroblast growth factor 23 (FGF23) production.

OBJECTIVE

The aim is to present a case of tumor-induced osteomalacia and to highlight the fact that incomplete removal of multifocal FGF23-producing tumors, which are not entirely picked up by functional imaging, could be the cause of treatment failure.

SETTING

The patient was treated in the Department of Endocrinology of a tertiary care center in India.

PATIENT

We report the case of a 42-year-old male with tumor-induced osteomalacia.

INTERVENTION

We treated the tumor-induced osteomalacia with staged surgery of the two tumors. The 18F-fluorodeoxyglucose (FDG)-avid lesion (considered the sole culprit lesion after functional imaging) was resected first, followed by the non-FDG-avid lesion. The sequential removal of both tumors resulted in complete cure.

RESULTS

The patient had hypophosphatemia and hyperphosphaturia. C-Terminal FGF23 level was elevated. Positron emission tomography-computed tomography showed two lesions-an FDG-avid lesion in the right leg, and a non-avid lesion in the left thigh. After removal of the FDG-avid lesion, the hypophosphatemia persisted, and the FGF23 level showed only modest reduction. The patient had complete clinical and biochemical resolution only after removal of the second non-FDG-avid tumor.

CONCLUSIONS

We present the case of a tumor-induced osteomalacia whose biochemical parameters did not improve after removal of the FDG-avid tumor initially. The possibility of multifocal FGF23 production was considered, and the second, non-FDG-avid lesion was resected, which resulted in complete cure. Thorough clinical examination and meticulous follow-up with documentation of the biochemical resolution are necessary for management of all patients with this rare disorder.

Calcium sulfate as bone graft substitute in the treatment of osseous bone defects, a prospective study

BACKGROUND

Calcium sulfate belongs to synthetic ceramic group of bone graft substitutes having an osteoconductive property. Calcium sulfate is an easily available, economic bone graft substitute. It is a bio-inert material which over a period of weeks get resorbed and fibrovascular tissue takes its place which eventually allows neovascularisation and bone formation within the area. Use of calcium sulfate as a bone graft substitutes avoids the complications and morbidity associated with autograft like infection, second surgery, and finite amount of graft.

MATERIAL AND METHODS

A total of 15 patients with benign bone lesions and chronic osteomyelitis were operated and the osseous defects were filled with calcium sulfate which was comprehensively sterilized. Patients were followed with serial radiographs at six week intervals. Calcium sulfate resorption and new bone formation was studied.

RESULTS

Thirteen cases out of 15 showed calcium sulphate resorption and new bone incorporation. Calcaium sulphate resorption occurred at an average of 14.5 weeks (range,13-18weeks) whereas new bone incorporation occurred at an average of 6months ( range,5-7months). Thirteen patients out of these 15 cases returned to full activities of daily living. One patient had pathological fracture at the osseous defect postoperatively. One patient with GCT of distal end of tibia had recurrence of tumor and had to undergo second surgery.

CONCLUSION

Although autogenous bone graft is the gold standard for bone grafting, it has limitations like finite amount, additional surgery and donor site morbidity. Calcium sulphate is safe, efficient and easily available bone graft substitute in the treatment of osseous defects. Most common complication encountered was aseptic serous discharge. Functional results were favorable in most of the cases.

Asymmetrical Fracture Dislocation of Shoulder - A Case Report and Review of Literature

INTRODUCTION

A bilateral shoulder dislocation is an extremely rare injury with only a few reported cases in English literature, and most of these cases have occurred following a seizure episode or an electric shock. We present the first ever reported case of simultaneous bilateral anterior and posterior fracture dislocation of shoulders and its unique mechanism of injury in a 48 year old diabetic male.

CASE REPORT

A 48 year old male presented to our emergency department with pain and restriction of movements involving both shoulders following a fall. The patient was standing by the side of a two wheeler when he had a sudden syncopal attack and toppled on the other side of the vehicle. On examination there was flattening of deltoid contour with a positive Dugas test in both sides. Humeral head was palpable posteriorly on the right side and anteriorly on the left side. Plain radiograph anteroposterior view of both shoulders showed posterior dislocation of right shoulder with a fracture of greater tuberosity and anterior dislocation of left shoulder with a greater tuberosity fracture. Closed reduction was achieved for both shoulders under general anaesthesia. After a couple of weeks, complete range of motion exercises was started. X-ray of bilateral shoulders, at 3 months, showed complete union of the fracture.

CONCLUSION

Bilateral shoulder dislocation is suspected only following a violent mechanism of injury, however, we would like to point out, giving an example of our case that this injury may also occur after a trivial fall. And if associated with a fracture sometimes, the characteristic attitude of the limb may not be seen leading to a missed diagnosis. However a thorough clinical examination and the knowledge that such injuries may occur after a simple fall will help prevent missing these injuries.

Serum Procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis

BACKGROUND

Early diagnosis of Acute Osteomyelitis (OM) and Septic Arthritis (SA) is of vital importance to avoid devastating complications. There is no single laboratory marker which is sensitive and specific in diagnosing these infections accurately. Total Count, ESR and CRP are not specific as they can also be elevated in non pyogenic causes of inflammation. Pus Culture and sensitivity is not a true gold standard due to its varied positivity rates (40 - 70%). Serum Procalcitonin (PCT), at 0.5 ng/ml is found to be an accurate marker for pyogenic infections. The objectives of this study were to show that PCT is an accurate marker in differentiating Acute Osteomyelitis and Septic Arthritis from viral and non infective inflammatory bone and joint conditions.

METHODS

Patients of all age groups (n = 82) with suspected Acute Osteomyelitis and Septic Arthritis were prospectively included in this study. All patients were subjected to TC, CRP, PCT, IgM Dengue, IgM Chikungunya, pus and blood culture and sensitivity. At the end of the study, patients were classified into 3 groups: Group 1 = Confirmed Pyogenic (n = 27); Group 2 = Presumed Pyogenic (n = 21); Group 3 = Non - infective inflammatory (n = 34).

RESULTS

Group 1 has higher mean PCT levels than Group 2 and 3 (p < 0.05). PCT, at 0.4 ng/ml, was 85.2% sensitive and 87.3% specific in diagnosing Septic Arthritis and Acute Osteomyelitis. In comparison, PCT at conventional cut - off of 0.5 ng/ml is 66.7% sensitive and 91% specific.

CONCLUSION

Serum Procalcitonin, at a cut - off of 0.4 ng/ml, is a sensitive and specific marker in the diagnosis of Septic Arthritis and Acute Osteomyelitis.

Congenital insensitivity to pain and anhydrosis: a report of two cases

We report on 2 patients with congenital insensitivity to pain and anhydrosis. The first one was a 7-month-old boy who presented with non-traumatic, haematogenous septic dislocation of the right elbow with physeal separation of the distal humerus. The second one was a 3-year-old girl suspected to have Job syndrome with an altered immunological profile.

Acute osteomyelitis caused by Rhodococcus equi in an immunocompetent child

Rhodococcus equi is an unusual pathogen causing infections mostly in immunocompromised patients, particularly in those with human immunodeficiency virus (HIV). It has rarely been reported to affect immunocompetent hosts, where it usually presents as an isolated extrapulmonary lesion. We report a case of osteomyelitis caused by this organism in an immunocompetent host.

Hodgkins disease in relapse presenting as bone tumor

A 10-year-old male child presented with multiple lymph node swellings. A diagnosis of Hodgkins disease was made on histopathological examination. The patient developed relapse six months after his last chemotherapy as a solitary bone tumor, which is rare. Immunohistochemical evaluation helped for the correct typing of Hodgkins disease.

Management of charles bonnet syndrome in the elderly

The case of an 82 year old lady who suffered from vivid episodic complex visual pseudohallucination is presented. The alleviation of symptoms with carbamazepine monotherapy is highlighted. Correction of visual defect as another aspect of the management of Charles Bonnet syndrome in elderly patients is recommended.