Applied Nanotechnology and Nanoscience in Orthopedic Oncology

Nanomedicine is based on the fact that biological molecules behave similarly to nanomolecules, which have a size of less than 100 nm, and is now affecting most areas of orthopedics. In orthopedic oncology, most of the in vitro and in vivo studies have used osteosarcoma or Ewing sarcoma cell lineages. In this article, tumor imaging and treatment nanotechnology applications, including nanostructure delivery of chemotherapeutic agents, gene therapy, and the role of nano-selenium-coated implants, are outlined. Finally, the potential role of nanotechnology in addressing the challenges of drug and radiotherapy resistance is discussed. [Orthopedics. 2016; 39(5):280-286.].

Total scapulectomy and constrained reverse total shoulder reconstruction for a Ewing's sarcoma

BACKGROUND

Total scapulectomy and intra-articular resection of the glenohumeral joint indicates the Malawer Type III shoulder girdle resection.

MATERIALS AND METHODS

The modified Tikhoff-Linberg total scapulectomy and constrained reverse total shoulder reconstruction for a Ewing's sarcoma of the scapula is presented. A combined approach has been used. The deltoid, trapezius, rhomboids, levator scapulae, latissimus dorsi, and serratus anterior were preserved. the tumor was removed en bloc by disarticulation of the acromioclavicular and the glenohumeral joints. The scapular prosthesis was suspended by the muscles. A constrained reverse humeral prosthesis was implanted after osteotomy of the humeral head.

RESULTS

There were no intraoperative or postoperative complications; surgical margins were clear. At 12 months postoperatively, the patient has a stable and painless shoulder.

CONCLUSION

The goal of shoulder reconstructions is to provide a stable and painless joint that allows positioning of the arm and hand in space. Compared to those patients left without a scapula reconstruction, prosthetic replacement of the scapula and shoulder partially restores abduction and external rotation and improves cosmesis.

Extraskeletal myxoid chondrosarcoma of the perineum

Extraskeletal myxoid chondrosarcoma is an aggressive tumor with significant metastatic potential. A 40-year-old man presented with an asymptomatic mass at the left ischial fossa. Magnetic resonance imaging showed a 9x6-cm mass with variable signal intensity and cystic formations. A computed tomography scan of the chest showed multiple pulmonary nodules. A computed tomography-guided core needle biopsy was consistent with low-grade extraskeletal myxoid chondrosarcoma. Despite the presence of lung metastases, wide resection of the primary tumor was performed. Wide resection included the perineal mass and the adjacent ischiopubic ramus. Postoperative recovery was uneventful. One month postoperatively, thoracotomy was performed, and approximately 20 pulmonary nodules were excised. Histological analysis of the excised specimens was consistent with extraskeletal myxoid chondrosarcoma metastases. Two years postoperatively, the patient is alive without evidence of local recurrence or distant disease. Extraskeletal myxoid chondrosarcoma is an unusual soft tissue sarcoma with ultrastructural and molecular features distinct from that of skeletal myxoid chondrosarcoma. The EWS-CHN gene fusion is highly specific to extraskeletal myxoid chondrosarcoma; the gene fusion is positive in >or=75% of cases. Treatment should include wide excision for local tumor control. Resection of the lung metastases is feasible. Because of the prolonged survival of patients with extraskeletal myxoid chondrosarcoma, long-term follow-up is recommended for early detection of local recurrence or distant metastases.

Ewing's sarcoma of the hip presenting as a benign cystic lesion

A 14-year-old girl with a Ewing's sarcoma of the left femoral head and neck is presented. The imaging features mimicked a benign cystic lesion. Biopsy and molecular analysis confirmed the diagnosis. The patient was treated with chemotherapy, wide tumor resection, and proximal femoral reconstruction using an allograft-prosthesis composite. Differential diagnosis, imaging, and pathologic features of Ewing's sarcoma are discussed.

Advances and challenges in diagnosis and management of skeletal metastases

The treatment of metastatic disease remains challenging. The number of patients who will be diagnosed with metastatic bone disease will continue to increase as survival from the primary cancer diagnosis continues to improve. Although it often is impossible to cure these patients, the task of maximizing their quality of life must be met with valiant efforts. Although a large number of medical and technological advances have occurred, perhaps the recognition of the importance of a well-qualified multidisciplinary team approach to treatment of these complex patients has done more to improve the field than any other single achievement. As basic science continues to further unravel potential treatment options, we must not forget this integrated approach and we must embrace "the bench" at the bedside.

Survivorship analysis in patients with periosteal chondrosarcoma

To investigate outcome and identify prognostic factors, we retrospectively reviewed 24 consecutive patients with periosteal chondrosarcomas. There were 17 males and seven females with a mean age of 37.6 years (range, 15-73 years). The femur was involved in 12 patients, the proximal humerus in five, the tibia in two, and the distal fibula, ilium, pubis, metatarsal, and rib in one patient each. The mean greatest dimension of the lesions was 8.1 cm (range, 1.5-27 cm). Based on the histologic pattern, there were 18 Grade 1 tumors and six Grade 2 tumors. All patients were treated surgically. Two patients had intralesional excisions, five patients had marginal excisions, and 17 patients had wide resections. With a mean followup of 17 years (range, 28 months-47 years), seven of 24 patients (29%) had one or more local recurrences. The 5-year local recurrence-free survival was less in patients treated with intralesional or marginal excisions (25%) than for patients treated with wide resections (93%). At the latest followup, six of 24 patients (25%) had died of pulmonary metastases. The overall 5-year metastasis-free survival was 83%. The 5-year metastasis-free survival was less for patients with Grade 2 tumors (50%) than for patients with Grade 1 tumors (94%).

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.

Current trends in the management of extra-abdominal desmoid tumours

Extra-abdominal desmoid tumours are slow-growing, histologically benign tumours of fibroblastic origin with variable biologic behaviour. They are locally aggressive and invasive to surrounding anatomic structures. Magnetic resonance imaging is the modality of choice for the diagnosis and the evaluation of the tumours. Current management of desmoids involves a multidisciplinary approach. Wide margin surgical resection remains the main treatment modality for local control of the tumour. Amputation should not be the initial treatment, and function-preserving procedures should be the primary treatment goal. Adjuvant radiation therapy is recommended both for primary and recurrent lesions. Chemotherapy may be used for recurrent or unresectable disease. Overall local recurrence rates vary and depend on patient's age, tumour location and margins at resection.

Lateral malleolus en bloc resection and ankle reconstruction for malignant tumors

Four children and six adults required en bloc resection of the lateral malleolus for malignant tumors. There were four osteosarcomas, three chondrosarcomas, two Ewing's sarcomas, and one adamantinoma. Surgical margins were wide in seven patients, marginal in two, and intralesional in one. A primary ankle arthrodesis was done in four adults and bracing without any reconstruction was done in four children and two adults. During a mean followup of 14.5 years (range, 3-30 years), there were two local recurrences (two of 10 patients) after a marginal excision and an intralesional excision. One patient had reoperation for a skip osteosarcoma lesion in the proximal fibula. Other complications included chronic osteomyelitis, a lateral talus subluxation and cavovarus deformity, and recurrent ankle instability and degenerative changes of the ankle. At the latest followup, all 10 patients showed no evidence of disease. Five patients who had primary or late ankle arthrodesis had a Musculoskeletal Tumor Society and International Society of Limb Salvage functional score of 28 points (92%), and two adolescents who had postoperative bracing alone had a functional score of 24 points (80%). The three remaining patients had a salvage amputation.

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.

Minimally invasive techniques in orthopedic oncology: radiofrequency and laser thermal ablation

Image-guided percutaneous thermal ablation is a safe and effective method to reduce pain in patients with painful bone tumors. Computed tomography-guided radiofrequency or laser ablation is the modality of choice for most osteoid osteomas. Radiofrequency or laser thermal ablation also offers an alternative method for palliation of localized, painful osteolytic metastatic lesions. Pain can be reduced and neural damage prevented, improving the quality of life for patients with cancer who often have multimorbid conditions and limited life expectancy. A multidisciplinary approach that includes orthopedic surgeons, neurosurgeons, medical and radiation oncologists, and interventional radiologists is essential to manage these patients.

Use of a vaccine strain of measles virus genetically engineered to produce carcinoembryonic antigen as a novel therapeutic agent against glioblastoma multiforme

Despite the most aggressive medical and surgical treatments, glioblastoma multiforme remains incurable with a median survival of <1 year. We investigated the antitumor potential of a novel viral agent, an attenuated strain of measles virus (MV), derived from the Edmonston vaccine lineage, genetically engineered to produce carcinoembryonic antigen (CEA). CEA production as the virus replicates can serve as a marker of viral gene expression. Infection of a variety of glioblastoma cell lines including U87, U118, and U251 at MOIs 0.1, 1, and 10 resulted in significant cytopathic effect consisting of excessive syncycial formation and massive cell death at 72-96 h from infection. terminal deoxynucleotidyltransferase-mediated nick end labeling assays demonstrated the mechanism of cell death to be predominantly apoptotic. The efficacy of this approach in vivo was examined in BALB/c nude mice by using both s.c. and intracranial orthotopic U87 tumor models. In the s.c. U87 model, mice with established xenografts were treated with a total dose of 8 x 10(7) plaque forming units of MV-CEA, administered i.v. Mice treated with UV light inactivated MV, and untreated mice with established U87 tumors were used as controls. There was statistically significant regression of s.c. tumors (P < 0.001) and prolongation of survival (P = 0.007) in MV-CEA treated animals compared with the two control groups. In the intracranial orthotopic U87 model, there was significant regression of intracranial U87 tumors treated with intratumoral administration of MV-CEA at a total dose of 1.8 x 10(6) plaque forming units as assessed by magnetic resonance image (P = 0.002), and statistically significant prolongation of survival as compared with mice that received UV-inactivated virus and untreated mice (P = 0.02). Histological examination of brains of MV-CEA-treated animals revealed complete regression of the tumor with the presence of a residual glial scar and reactive changes, mainly presence of hemosiderin-laden macrophages. In addition, CEA levels in the peripheral blood in both the s.c. and orthotopic models increased before tumor regression, indicating viral gene expression, and returned to normal when the tumors regressed. Ifnar(ko) CD46 Ge transgenic mice, susceptible to MV infection, were used to assess central nervous system toxicity of MV-CEA. Intracranial administration of MV-CEA into the caudate nucleus of Ifnar(ko) CD46 Ge did not result in clinical neurotoxicity. Pathologic examination demonstrated limited microglial infiltration surrounding the injection site. In summary, MV-CEA has potent antitumor activity against gliomas in vitro, as well as in both s.c. and orthotopic U87 animal models. Monitoring CEA levels in the serum can serve as a low-risk method of detecting viral gene expression during treatment, and could allow dose optimization and individualization of treatment.

Clinicopathologic features, diagnosis, and treatment of fibrosarcoma of bone

Fibrosarcoma of bone is a relatively rare tumor; it accounts for less than 5% of bone sarcomas. The anatomical sites most commonly involved are the metaphyses of long tubular bones. Local pain, swelling, limitation of motion, and pathologic fracture are the common clinical signs and symptoms. Typical imaging findings include eccentrically located lytic lesions, with a geographic, moth-eaten, or permeative pattern of bone destruction, and extension into adjacent soft tissues. Surgery is the treatment of choice. The type of surgical procedure depends mainly on histologic grade, local conditions, and tumor location. With a high probability of metastases (>70%) after surgical treatment, perioperative adjuvant treatment modalities should be considered for high-grade tumors. The most important prognostic factors affecting survival include tumor grade, patient's age, and tumor location.

Vertebra plana of the lumbar spine caused by an aneurysmal bone cyst: a case report

The patient was a 15-year-old girl who had a lesion of the fourth lumbar vertebra. Plain radiographs suggested vertebra plana, with complete collapse of the body of the fourth lumbar vertebra and no involvement of the intervertebral disk spaces. The presumptive diagnosis was eosinophilic granuloma. Progressive neurologic symptoms required surgical excision of the lesion, decompression, and fusion. Histopathologic examination of the operative specimen confirmed the diagnosis of an aneurysmal bone cyst.

Prosthetic hip replacement for pathologic or impending pathologic fractures in myeloma

The authors retrospectively reviewed 53 hip replacements performed in 50 patients (mean age, 65 years) for plasmacytoma (four lesions) or multiple myeloma (49 lesions) of the hip region. Perioperatively, 49 patients received chemotherapy. Twenty-four hip lesions had radiation therapy. Within a mean followup period of 32.6 months, 15 (28%) complications occurred. Late deep infection, dislocation, and aseptic loosening with medial migration of the acetabular component occurred in one patient each. Three patients died during the first postoperatively month. All of the remaining patients postoperatively regained their previous ambulatory status; hip pain relief was achieved in 98% of patients. At the time of the latest followup evaluation, 84% of the patients had died (median survival time, 18 months) and 16% were still alive (median survival time, 76 months). Patients with plasmacytoma had longer survival than did patients with multiple myeloma (median survival, 6.3 years versus 18 months, respectively). No significant association was found between patient survival and the stage of disease at diagnosis, age, gender, type or location of the myeloma lesion, or the type of implant used. Because of the relatively long survival time, prosthetic replacement is indicated for extensive hip lesions in patients with plasmacytoma or multiple myeloma.

Total joint arthroplasty in orthotopic liver transplant recipients

Eight total hip and two total knee arthroplasties were performed from 1986 to 1991 in eight patients who had orthotopic liver transplantation. The indications for joint arthroplasty were avascular necrosis of the femoral head in five hips, pathologic femoral neck fracture caused by osteopenia in three hips, avascular necrosis of femoral and tibial condyles in one knee, and posttraumatic arthritis in one knee. Six patients (75%) had significant osteopenia. The mean interval between liver transplantation surgery and hip or knee joint arthroplasty was 2 years (8-48 months). The patients who had hip arthroplasty were followed for a mean of 4.85 years (2-8 years), and those who had a knee arthroplasty after a hip arthroplasty, for a mean of 3.5 years (2-5 years) after the knee arthroplasty. In the patients who had hip arthroplasty, the mean Harris hip score was improved from 34 to 82 points. In the two patients who had a knee arthroplasty, the mean score was improved to 100 points both for pain and function of the knee and for overall function from mean preoperative knee scores of 49 and 25 points, respectively. Radiographs did not reveal any loosening of the components. None of the patients required reoperation and there were no serious postoperative complications.