Complete tumor necrosis after neoadjuvant chemotherapy defines good responders in patients with Ewing sarcoma

BACKGROUND

Survival in patients who have Ewing sarcoma is correlated with postchemotherapy response (tumor necrosis). This treatment response has been categorized as the response rate, similar to what has been used in osteosarcoma. There is controversy regarding whether this is appropriate or whether it should be a dichotomy of complete versus incomplete response, given how important a complete response is for in overall survival of patients with Ewing sarcoma. The purpose of this study was to evaluate the impact that the amount of chemotherapy-induced necrosis has on (1) overall survival, (2) local recurrence-free survival, (3) metastasis-free survival, and (4) event-free survival in patients with Ewing sarcoma.

METHODS

In total, 427 patients who had Ewing sarcoma or tumors in the Ewing sarcoma family and received treatment with preoperative chemotherapy and surgery at 10 international institutions were included. Multivariate Cox proportional-hazards analyses were used to assess the associations between tumor necrosis and all four outcomes while controlling for clinical factors identified in bivariate analysis, including age, tumor volume, location, surgical margins, metastatic disease at presentation, and preoperative radiotherapy.

RESULTS

Patients who had a complete (100%) tumor response to chemotherapy had increased overall survival (hazard ratio [HR], 0.26; 95% CI, 0.14-0.48; p < .01), recurrence-free survival (HR, 0.40; 95% CI, 0.20-0.82; p = .01), metastasis-free survival (HR, 0.27; 95% CI, 0.15-0.46; p ≤ .01), and event-free survival (HR, 0.26; 95% CI, 0.16-0.41; p ≤ .01) compared with patients who had a partial (0%-99%) response.

CONCLUSIONS

Complete tumor necrosis should be the index parameter to grade response to treatment as satisfactory in patients with Ewing sarcoma. Any viable tumor in these patients after neoadjuvant treatment should be of oncologic concern. These findings can affect the design of new clinical trials and the risk-stratified application of conventional or novel treatments.

Navigated multiplanar osteotomies for spinal primary bone tumors

Background:

Establishing the proper diagnosis and rendering appropriate treatment of spinal primary bone tumors (SPBT) can result in definitive cures. Notably, malignant, or benign SPBT (i.e., with aggressive local behavior) generally require en bloc resection. Osteotomies of the vertebral body in more than 1 plane may avoid critical structures, preserve nerve functions, and reduce the volume of healthy bone resected. Here, our objective was to report how we planned and performed navigated multiplanar osteotomies for en bloc resection of 14 SPBT.

Methods:

We performed a retrospective analysis of 14 patients with malignant or locally aggressive benign SPBT operated on consecutively between 2014 and 2019 utilizing preoperative 3D planning/navigation. Tumors were resected in an en bloc fashion utilizing multiplanar osteotomies. Patients were followed for a minimum of 12 postoperative months.

Results:

Diagnoses included three benign but locally aggressive bone tumors (i.e., all osteoblastomas) and 11 primary sarcomas (i.e., six chordomas and five chondrosarcomas). Eleven tumors involved the sacrum and the other three, the thoracic spine. In 12 patients, the en bloc margins were classified as marginal (<1 cm), and in two patients, as wide (>1 cm). Intraoperative navigation facilitated the performance of 40 osteotomies in 14 patients (median = 2.9, range = 2–6).

Conclusion:

Navigated multiplanar osteotomies increased the precision and safety of en bloc resections for 14 primary spinal bone tumors SPBT that included 11 malignant and three benign/locally aggressive lesions.

Modular prosthesis reconstruction after tumour resection, evaluation of failures and survival

OBJECTIVE

To analyze a series of patients with bone tumours reconstructed with modular prostheses and to evaluate: 1) Survival of the implant. 2) Causes of failure. 3) Complication rates. 4) Limb salvage overall survival. 5) Functional results and full weight bearing.

MATERIALS AND METHODS

A retrospective study from longitudinally maintained oncology databases was undertaken. All patients with bone tumours reconstructed with endoprosthesis were analysed. A toal of 106patients matched the inclusion criteria. They were divided into groups: group 1, primary bone tumours; group 2, bone metastasis; group 3, osteoarticular allograft reconstruction revisions. The type of failures were classified according to Henderson et al. (2014) and functional results assessed by the Musculoskeletal Tumor Society (MSTS). Demographic analysis, survival and the differences between groups were recorded.

RESULT

The mean follow-up of the patients was 68 months. Mean age was 43 years. Overall implant survival was 86.4% at 2 years (95% CI: 79-94) and 73% at 5 years (95% CI: 60-80). Nineteen patients (18%) developed a prosthetic failure. The limb salvage overall survival was 96% at 5 years (95% CI: 91-99). The mean functional results according to the MSTS was 24 and mean time to full weight bearing was 2.3 weeks.

CONCLUSIONS

Limb conservation surgery and endosprosthetic reconstruction is a valid option for patients with bone tumours with failure rates similar to other reconstruction methods.

Analysis of the order-implantation relationship for musculoskeletal tissue transplantation

OBJECTIVE

To analyze orders requested from a musculoskeletal tissue bank and to evaluate the percentage of tissue implantation.

MATERIAL AND METHODS

Two hundred and sixty-five orders for musculoskeletal tissue were analyzed over the course of a year.

EXCLUSIONS

5 duplications and 5 orders for which there was no availability to cover the need. We analyzed the number of surgeries in which the graft was finally used.

RESULTS

Of a total of 255 orders, the graft was used in 178 (70%), and the graft was not used in 77 (30%). Of the 178 used, there was a partial refund in 23 (10%). Of the 77 orders not used, surgery was performed in 32 (13%) without the use of bank tissue, while surgery was discontinued in the remaining 45 (17%).

DISCUSSION

A non-utilization rate of 30% was identified, of which 17% was from surgery that was not performed and 13% from surgery that was performed, but the tissue was returned to the tissue bank, because it was not required. In a further 10% there was partial return of the tissue. Based on this analysis, we consider that it is important to have direct confirmation of the surgery to avoid sending tissue for discontinued surgeries, since in addition to the economic impact, the bank must ensure adequate temperature maintenance during transportation and storage in the transplantation centre, to avoid discarding said tissue if it is returned.

[Survival and complications analysis of 97 patients with bone metastases treated surgically]

BACKGROUND

The purpose of this paper is to assess the survival and the different factors predisposing to increased local and overall complications in a group of patients treated surgically for bone metastases.

MATERIAL AND METHODS

A total of 97 patients were included in our study, 45 females and 52 males. Mean age was 59 years (range 22-81) and the mean follow-up was 23 months (range 3-76). Were performed 104 surgical interventions. Patient survival was estimated with the Kaplan-Meier method. Complications, recurrences and the most significant factors were analyzed.

RESULTS

Overall patient survival was 73% at one year, 47% at 2 years, and 6% at 5 years. Patient survival was greater in patients with a histologic diagnosis of metastatic renal cancer (p > 0.05) and a higher incidence of local relapses (p > 0.05). Intralesional surgery significantly affected the relapses.

CONCLUSIONS

Patients with metastatic renal cancer had the greatest survival rate. However, they were associated with a higher rate of local relapses and postoperative failure.

Locking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures

BACKGROUND

Fractures occurring at or near the distal tip of a hip prosthesis with a stable femoral stem (Vancouver type-B fractures) are associated with many complications because of the inherently unstable fracture pattern. Locking compression plates use screws that lock into the plate allowing multiple points of unicortical fixation. Such unicortical fixation may lower the risk of damage to the cement mantle or a stable femoral stem during the treatment of a periprosthetic femoral fracture. The purpose of this study was to analyze clinically and radiographically a group of patients with a Vancouver type-B1 periprosthetic femoral fracture treated with open reduction and internal fixation with use of a locking compression plate.

METHODS

Fourteen consecutive patients (fourteen hips) with a Vancouver type-B1 periprosthetic femoral fracture were treated with a locking compression plate. There were five men and nine women with an average age of sixty-eight years at the time of fracture. All of the fractures occurred after a total hip arthroplasty performed with cement, and eleven of the arthroplasties were revisions. In addition to the plate, cortical strut allografts were used to stabilize five fractures. The patients were assessed clinically and radiographically.

RESULTS

The average duration of follow-up was twenty months. Eight fractures healed uneventfully at an average of 5.4 months. Three treatment constructs failed with fracture of the plate within twelve months after surgery. An additional three constructs also failed because of plate pullout. All failures except one occurred in constructs in which a cortical strut allograft had not been utilized.

CONCLUSIONS

On the basis of the high failure rate in this series of patients, locking compression plates do not appear to offer advantages over other types of plates in the treatment of type-B1 periprosthetic femoral fractures. Despite the potential to preserve the cement mantle, the locked screws did not appear to offer good pullout resistance in this fracture type. We believe that supplementation with strut allografts should be used routinely if this type of locking compression plate is selected to treat these fractures.