CDK4 expression in chordoma: A potential therapeutic target

Chordomas are rare bone tumors and treatment is commonly based on a combination of surgery and radiotherapy. There is no standard chemotherapy treatment for chordoma. The aim of this study was to determine the expression of cyclin-dependent kinase 4 (CDK4) in chordoma and its therapeutic implications. We evaluated CDK4 expression both in chordoma cell lines and in chordoma tissues. Also, we investigated the functional roles of CDK4 in chordoma cell growth and proliferation. Furthermore, the therapeutic implications of targeting CDK4 in chordoma were evaluated. We found CDK4 highly expressed in chordoma cell lines and in a majority (97.7%) of chordoma tissues. Higher CDK4 expression correlated with metastasis and recurrence of chordoma. Treatment of chordoma cells using CDK4 inhibitor palbociclib could efficiently inhibit chordoma cells growth and proliferation. These data demonstrate that targeting CDK4 may be useful as a novel strategy in the treatment of chordoma. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1581-1589, 2018.

Diagnosis, Classification, and Management of Soft Tissue Sarcomas

BACKGROUND

Soft tissue sarcomas are challenging to oncologists due to their unique character, the infrequency of their occurrence, and the difficulties in predicting outcomes. Advances in imaging, as well as improvements in surgical techniques and adjunctive treatment methods, have improved care for patients with these unusual disorders.

METHODS

The various types of soft tissue tumors are defined, and the statistics for the Orthopaedic Oncology Group in relation to them are reviewed and compared with literature references.

RESULTS

The overall survival rate for 1,220 tumors treated at our institute from June 1972 to June of 2001 was 72%, with a wide range. Patients with leiomyosarcomas, clear cell sarcomas, and malignant fibrous histiocytomas had a poorer survival rate, while those with fibrosarcomas, liposarcomas, and neurofibrosarcomas fared better. Outcome was affected by patient age, tumor anatomic site, tumor stage, and a history of recurrence.

CONCLUSIONS

Competent imaging, predictive immunological and genetic studies, improved surgery, and newer methods of adjunctive and neoadjunctive treatment should result in improvements in outcomes for patients with these tumors.

Functional and oncological outcome after surgical resection of the scapula and clavicle for primary chondrosarcoma

PURPOSE

The scapula is a relatively common site for chondrosarcoma to develop in contrary to the clavicle, which is rarely affected by these tumors. The aim of this study is to determine the functional and oncological outcome for patients treated operatively for scapular or clavicular chondrosarcoma.

METHODS

In this single-center retrospective study, we included a sample of 20 patients that received the diagnosis of a primary chondrosarcoma of the scapula or clavicle. Of the surviving patients, the functional function was assessed using the DASH and the PROMIS Physical Function-Upper Extremity. Patients were longitudinally tracked for their oncological outcome.

RESULTS

All patients were followed for at least 2 years or until death. The mean age of the cohort was 47 years. Eighteen patients suffered from a chondrosarcoma of the scapula, and in 2 patients, the tumor was located in the clavicle. Metastasis, local recurrence and a higher tumor grade were all associated with a decreased overall survival. For the patients with a chondrosarcoma of the scapula, the average DASH score was 16 ± 16 and the mean PROMIS Physical Function-Upper Extremity score was 48 ± 10. Patients with both an intact rotator cuff and glenoid had a better physical function.

CONCLUSIONS

Upper extremity function after (partial) scapulectomy varied depending on whether the glenoid was spared and whether a functioning shoulder abductor remained. When the resection spared these structures, then excellent functional outcomes were reported. Oncologic outcomes depended upon the grade of the tumor and whether local recurrence and metastases occurred.

Evaluation of P-glycoprotein (Pgp) expression in human osteosarcoma by high-throughput tissue microarray

Survival of osteosarcoma patients is currently limited by the development of metastases and multidrug resistance (MDR). A well-established cause of MDR involves overexpression of P-glycoprotein (Pgp) in tumor cells. However, some discrepancies still exist as to the clinical significance of Pgp in osteosarcoma. We sought to elucidate further whether the Pgp expression correlated with clinical behavior in a series of patients with osteosarcoma via high-throughput tissue microarray (TMA) analysis. Immunohistochemical analysis of Pgp expression in a TMA of 114 specimens with a retrospective review of 70 osteosarcoma patients admitted to the Massachusetts General Hospital (MGH) was performed. High Pgp expression was correlated with metastasis development and poor response to pre-operative chemotherapy in osteosarcoma patients. Eighteen of the fifty-seven patients initially admitted with primary osteosarcoma showed high Pgp expression. Among these 18 patients with high Pgp expression, 13 of 18 (72%) patients eventually developed metastases. There was no significant clinical relevance between Pgp expression and osteosarcoma survival. These results support that high expression of Pgp is important, but cannot be assigned as, an individual predictor in the development of human osteosarcoma. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1606-1612, 2016.

A Follow-Up Study of "Dangerous Answers" in Four Medical Specialties

We undertook this study to obtain further validation of a latent trait for dangerousness, identified by Mankin, Lloyd, and Rovinelli (1987), on certification examinations for medical specialists. "Dangerousness " was defined as any act of omission, or commission, in treatment which could result in a patient's death or injury. The method we employed involved asking panels of experts to retrospectively evaluate items on specilty examinationsfor dangerous answers. We then analyzed candidates' choices of dangerous answers. Four specialties participated in the study, and data from each were analyzed separately. Our results failed to support a latent trait for dangerousness. Nevertheless, we suggest that future studies employing alternative evaluation methods could yield support for a dangerousness trait, but consideration must be given to the potential costs of these studies.

Targeting EZH2-mediated methylation of H3K27 inhibits proliferation and migration of Synovial Sarcoma in vitro

Synovial sarcoma is an aggressive soft tissue sarcoma genetically defined by the fusion oncogene SS18-SSX. It is hypothesized that either SS18-SSX disrupts SWI/SNF complex inhibition of the polycomb complex 2 (PRC2) methyltransferase Enhancer of Zeste Homologue 2 (EZH2), or that SS18-SSX is able to directly recruit PRC2 to aberrantly silence target genes. This is of potential therapeutic value as several EZH2 small molecule inhibitors are entering early phase clinical trials. In this study, we first confirmed EZH2 expression in the 76% of human synovial sarcoma samples. We subsequently investigated EZH2 as a therapeutic target in synovial sarcoma in vitro. Knockdown of EZH2 by shRNA or siRNA resulted in inhibition of cell growth and migration across a series of synovial sarcoma cell lines. The EZH2 selective small-molecule inhibitor EPZ005687 similarly suppressed cell proliferation and migration. These data support the hypothesis that targeting EZH2 may be a promising therapeutic strategy in the treatment of synovial sarcoma; clinical trials are initiating enrollment currently.

MicroRNA-155 expression is independently predictive of outcome in chordoma

Background

Chordoma pathogenesis remains poorly understood. In this study, we aimed to evaluate the relationships between microRNA-155 (miR-155) expression and the clinicopathological features of chordoma patients, and to evaluate the functional role of miR-155 in chordoma.

Methods

The miRNA expression profiles were analyzed using miRNA microarray assays. Regulatory activity of miR-155 was assessed using bioinformatic tools. miR-155 expression levels were validated by reverse transcription-polymerase chain reaction. The relationships between miR-155 expression and the clinicopathological features of chordoma patients were analyzed. Proliferative, migratory and invasive activities were assessed by MTT, wound healing, and Matrigel invasion assays, respectively.

Results

The miRNA microarray assay revealed miR-155 to be highly expressed and biologically active in chordoma. miR-155 expression in chordoma tissues was significantly elevated, and this expression correlated significantly with disease stage (p = 0.036) and the presence of metastasis (p = 0.035). miR-155 expression also correlated significantly with poor outcomes for chordoma patients (hazard ratio, 5.32; p = 0.045). Inhibition of miR-155 expression suppressed proliferation, and the migratory and invasive activities of chordoma cells.

Conclusions

We have shown miR-155 expression to independently affect prognosis in chordoma. These results collectively indicate that miR-155 expression may serve not only as a prognostic marker, but also as a potential therapeutic target in chordoma.

Targeting CDK11 in osteosarcoma cells using the CRISPR-Cas9 system

Osteosarcoma is the most common type primary malignant tumor of bone. Patients with regional osteosarcoma are routinely treated with surgery and chemotherapy. In addition, many patients with metastatic or recurrent osteosarcoma show poor prognosis with current chemotherapy agents. Therefore, it is important to improve the general condition and the overall survival rate of patients with osteosarcoma by identifying novel therapeutic strategies. Recent studies have revealed that CDK11 is essential in osteosarcoma cell growth and survival by inhibiting CDK11 mRNA expression with RNAi. Here, we apply the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)-Cas9 system, a robust and highly efficient novel genome editing tool, to determine the effect of targeting endogenous CDK11 gene at the DNA level in osteosarcoma cell lines. We show that CDK11 can be efficiently silenced by CRISPR-Cas9. Inhibition of CDK11 is associated with decreased cell proliferation and viability, and induces cell death in osteosarcoma cell lines KHOS and U-2OS. Furthermore, the migration and invasion activities are also markedly reduced by CDK11 knockout. These results demonstrate that CRISPR-Cas9 system is a useful tool for the modification of endogenous CDK11 gene expression, and CRISPR-Cas9 targeted CDK11 knockout may be a promising therapeutic regimen for the treatment of osteosarcoma.

Schwannoma: a rare benign tumor of soft tissues

'Schwannomas are unusual benign tumors which arise from the surface of neural elements of the body or within the brain. They do not as a rule metastasize but may cause sometimes severe local problems on the nerves, blood vessels and adjacent bone. The tumors arise from the Sheath of Schwann, a structure on the surface of a nerve. The lesions may expand and cause considerable damage to adjacent tissues. They do not arise within bone since there are no Sheaths of Schwann within the osseous tissue but may cause local damage to the bony cortex and sometimes fractures. Rarely the lesions may metastasize and cause patients' death. The treatment is usually local resection, and most often is successful although may cause damage to the adjacent nerve.

MicroRNA-1 (miR-1) inhibits chordoma cell migration and invasion by targeting slug

Recent studies have revealed that expression of miRNA-1 (miR-1) is frequently down-regulated in several cancer types including chordoma. Identifying and validating novel targets of miR-1 is useful for understanding the roles of miR-1 in chordoma. We aimed to further investigate the functions of miR-1 in chordoma. Specifically, we assessed whether restoration of miR-1 affects cell migration and invasion in chordoma, and focused on the miR-1 potential target Slug gene. Migratory and invasive activities were assessed by wound healing and Matrigel invasion assays, respectively. Cell proliferation was determined by MTT assay. Slug expression was evaluated by Western blot, immunofluorescence, and immunohistochemistry. Restoration of miR-1 expression suppressed the migratory and invasive activities of chordoma cells. Transfection of miR-1 inhibited cell proliferation both time- and dose-dependently in chordoma. MiR-1 transfected cells showed inhibited Slug expression. Slug was over-expressed in chordoma cell lines and advanced chordoma tissues. In conclusion, we have shown that miR-1 directly targets the Slug gene in chordoma. Restoration of miR-1 suppressed not only proliferation, but also migratory and invasive activities, and reduced the Slug expression in chordoma cells. These results collectively indicate that miR-1/Slug pathway is a potential therapeutic target because of its crucial roles in chordoma cell growth and migration.

Liposarcoma: a soft tissue tumor with many presentations

Liposarcoma is an uncommon connective tissue tumor arising from lipoblast cells. The lesion is located in body soft parts and rarely arises from the bones. The tumors are variable in presentation ranging from benign well-differentiated tumors to myxoid and round cell-dedifferentiated and pleomorphic forms which can present with metastases. The lesions are most often treated by surgical resection. Chemotherapy and radiation may be added to the treatment of the more malignant variants with some success.

Malignant lymphoma of bone: a review of 119 patients

BACKGROUND

Lymphoma of bone is uncommon. As a result of this, many aspects of primary lymphoma of bone (PLB) are controversial: the definition, treatment strategies, response criteria, and prognostic factors.

QUESTIONS/PURPOSES

We sought to determine the following in an analysis from a single center over a four-decade period: (1) 5-year disease-free survival of patients with PLB as well as those with systemic lymphoma with bone involvement; and (2) whether prognostic factors (sex, site of tumor, age) were associated with 5-year survival.

METHODS

A total of 119 patients with lymphoma involving the musculoskeletal system were retrospectively evaluated. Among these, 94 patients who had a minimum followup of 6 months (mean, 67 months; range, 6 months to 34 years) were further analyzed for the skeletal site of involvement, the orthopaedic intervention(s) needed, and survival. The overall median age was 45 years (range, 7-87 years). The female-to-male ratio was 1:1.53. There were 70 (65 unifocal, five multifocal) patients with PLB. The femur was the most frequent site involved. Appendicular skeleton involvement was substantially higher in patients with PLB. Thirty-four (36%) patients had at least one surgical intervention. Fourteen patients (41%) needed more than one major surgical intervention.

RESULTS

The disease-free 5-year survival for patients with PLB was 81% and for the patients with systemic lymphoma with bone involvement, it was 44%. The disease-free 5-year survival of the patients with PLB younger than 60 years old and 60 years old or older was 90% and 62%, respectively. Age was the only prognostic factor on survival of patients with PLB.

CONCLUSIONS

Orthopaedic intervention was usually needed for pathologic fractures, avascular necrosis, spinal cord compression, or for the lesions of the weightbearing bones compromising stability or joint motion. The potential for long-term survival suggests the use of implants and techniques that have the best chance of long-term success.

Pleomorphic spindle cell sarcoma (PSCS) formerly known as malignant fibrous histiocytoma (MFH): a complex malignant soft-tissue tumor

A presentation defining the nature, characteristics, causation, treatment and outcome of patients with lesions formerly known as malignant fibrous histiocytoma and now as pleomorphic spindle cell sarcoma is clearly a very difficult subject. Many authors do not believe that the tumor exists and instead describe them as forms of fibrosarcomas, fibromyxoid lesions, dedifferentiated chondrosarcomas or even leiomyosarcomas. The reasons for this confusion are presumably related to the fact that the malignant pleomorphic spindle cell sarcoma does not seem to be a distinct type of lesion with specific histologic and genetic characteristics. Instead, the tumor has at least four separate histologic variations and no specific gene signature and in fact does not seem to be either familial or ethnic in presentation. In view of the fact that the tumor was traditionally the most frequently encountered malignant soft-tissue neoplasm, the world of orthopedic oncology is clearly distressed by the problems that these patients have and is joined by the radiation oncologists and chemotherapists in seeking new solutions.

Establishment and characterization of a novel chordoma cell line: CH22

Chordoma is a rare primary malignant bone tumor and there exist only a few established human chordoma cell lines. The scarcity of robust chordoma cell lines has limited the ability to study this tumor. In this report, we describe the establishment of a novel chordoma cell line and characterize its in vitro and in vivo behaviors. The tumor tissue was isolated from a patient with recurrent chordoma of the sacrum. After 6 months in culture, the chordoma cell line, referred here as CH22, was established. Microscopic analysis of two-dimensional culture confirmed that the CH22 cells exhibited a typical vacuolated cytoplasm similar to the well-established chordoma cell line U-CH1. Electron microscopy showed cohesive cells with numerous surface filopodia, pockets of glycogen and aggregates of intermediate tonofilaments in cytoplasm. Three-dimensional culture revealed that the CH22 cells could grow and form clusters by day 8. The MTT assays demonstrated that, compared with sensitive osteosarcoma cell lines, CH22 cells were relatively resistant to conventional chemotherapeutic drugs. Western blotting and immunofluorescence analysis confirmed that the CH22 cells expressed brachyury, vimentin, and cytokeratin. Finally, histological analysis of CH22 xenograft tumor tissues demonstrated the appearance of physaliphorous cells and positive staining of brachyury, cytokeratin, and S100. By CT and MRI, imaging xenografts showed the typical appearances seen in human chordomas. These findings suggest that the established novel human chordoma cell line CH22 and its tumorigenecity in SCID nude mice may serve as an important model for studying chordoma cell biology and the development of new therapeutic modalities.

Hand and foot abnormalities associated with genetic diseases

INTRODUCTION

The small bones and soft tissues of the hands and feet can be affected by systemic disorders, and frequently, the findings are quite unique and virtually diagnostic for some genetic or metabolic disorders.

MATERIALS AND METHODS

Photographs and imaging studies for the hands and feet are available in a digitized system, which has been approved by our hospital institutional review board. Examination of these and their description can establish a relationship with some degree of certainty to a series of highly variable and uncommon clinical disorders.

RESULTS

Description of the clinical, physiologic and genetic characteristics, and illustrations of hand and foot abnormalities are provided for an array of diseases, including Ellis-van Creveld syndrome, fibrodysplasia ossificans progressiva, achondroplasia, Kniest dysplasia, pseudo- and pseudo-pseudohypoparathyroidism, acromegaly, nail-patella syndrome, Marfan's disease, cartilage-hair hypoplasia, and several forms of mucopolysaccharidosis.

CONCLUSIONS

The findings support the concept that many genetic disorders can often be diagnosed by clinical and imaging examination of the patient's hands and feet.

Extra-abdominal desmoid tumors: a report of 234 cases

BACKGROUND/OBJECTIVES

To report on the clinical presentation and outcome for 234 patients with extra-abdominal desmoids tumors.

METHODS

Since 1977, the authors have treated 234 patients with extra-abdominal desmoid tumors. The patients had an average age of 36.7 and 61% were female. The tumors arose adjacent to muscles or bones and the largest number were in the foot, shoulder thigh and calf. All of the patients were treated by primary surgery. Thirty-seven had additional radiation and eight had chemotherapy.

RESULTS

Local recurrence occurred in 39 patients and 23% of the patients required additional surgery. Of great concern were 24 patients who developed multiple sites metachronously, which required further surgery and in many cases caused disability. None of the patients died of disease but 5 required amputations.

CONCLUSIONS

The authors concluded that despite the benign nature of the disease, these patients are difficult to treat and the results are sometimes considerably less than optimal.

Proximal femoral allograft: prognostic indicators

Between 1972 and 1999, the Orthopedic Oncology Service treated 150 patients with resection and allograft transplantation of the proximal femur. Of the group, 121 patients had malignant tumors of the proximal femur and 29 had benign disorders. Four types of allografts were used: osteoarticular (46 patients), allograft-prosthesis (73), intercalary (20), and allograft-arthrodesis (5). Only 16% of the patients died of disease and 3% required amputation. The overall success rate for the series was 77% with the best results for the allograft prosthetic (82%) and intercalary procedures (87%). Graft infection (15 patients), allograft fracture (26 patients), and local recurrence (11 patients) most markedly affected outcome. With the exception of deaths of disease, no significant outcome difference occurred between the patients with malignant and benign disorders. In conclusion, allograft implantation especially for aggressive or malignant tumors of the proximal femur appears to be a competent system for therapy.

Osteosarcoma of the spine: experience in 26 patients treated at the Massachusetts General Hospital

BACKGROUND CONTEXT

Because of the low incidence, treatment recommendations for spinal osteosarcoma are guided by the results of small series and case reports. Many include patients who presented for treatment over the course of three to four decades.

PURPOSE

The goal of this investigation was to report the treatments, results, and overall survivorship of 26 patients treated for osteosarcoma of the spine at a single institution.

STUDY DESIGN

Retrospective prognostic series (Level III evidence).

PATIENT SAMPLE

Twenty-six patients treated at a single center for osteosarcoma of the spine over a 26-year period.

OUTCOME MEASURES

Estimation of patient survival, local recurrence, and the presence of metastatic disease.

METHODS

We performed a retrospective review of cases of osteosarcoma involving the spine treated at our institution between 1982 and 2008. Medical charts, radiology reports, pathology reports, and operative notes were reviewed for all patients. Available imaging studies were also reviewed. The log-rank test was used to compare baseline differences between groups. Survivorship analysis was performed using Kaplan-Meier methodology. The effect of Paget osteosarcoma, type of resection, presence of local recurrence, tumor size, surgical margins, and metastases on overall survival were also investigated using the log-rank test.

RESULTS

Twenty-six patients were included for review in this study. Twenty individuals were treated surgically, and 24 were treated with radiation with a mean dose of 62.2 Gy (range 20-84.7 Gy). Twenty-five patients received chemotherapy. Of those treated surgically, seven received en bloc resection. The median overall survival for all patients in our series was 29.5 months (standard error 14.7, 95% confidence interval 0.6-58). Local recurrence developed in 7 patients (27%), and metastasis occurred in 16 individuals (62%). Patients with Paget osteosarcoma had worse overall survival (p<.001).

CONCLUSIONS

Results presented here confirm a poor prognosis for patients with spinal osteosarcoma. Although combination therapies, including surgery, chemotherapy, and high-dose radiation, achieve adequate short-term survival, the 5-year mortality rate remains high.

p53 overexpression in Ewing's sarcoma/primitive neuroectodermal tumour is an uncommon event

Aim-To determine the presence of p53 overexpression in Ewing's sarcoma/primitive neuroectodermal tumours (ETs) and to assess whether p53 accumulation has any prognostic value.Methods-From a prospectively compiled database of 76 patients with ETs, suitable tumour tissue was available for 38. The monoclonal antibody pAb1801 was used to detect p53 nuclear protein overexpression. Results-Nuclear staining was detected in the tumours of three (8%) of the 38 patients. Where tumours stained positively, over 10% of the tumour nuclei were postively stained. All three patients whose tumours overexpressed p53 died and in a relatively short time compared with the patients who did not overexpress p53 (mean 3.7 months compared with a mean of 38.7 months in the p53 negative group).Conclusion-Overexpression of p53 in ETs is an uncommon event. Overexpression of p53 has repeatedly been shown to correlate closely with p53 point missense mutations and therefore this oncogenic event appears not to be of primary pathogenic importance in ETs. There is a tentative indication that those uncommon ETs in which p53 overexpression can be detected may be-have more aggressively.

Diverse cross-resistance phenotype to ET-743 and PM00104 in multi-drug resistant cell lines

PURPOSE

ET-743 (Yondelis, trabectedin) and PM00104 (Zalypsis) are marine derived compounds which demonstrate anti-tumor activity. The present study was performed to elucidate the relationship between the expression of ABCB1/MDR1 and ABCC1/MRP1 with resistance to either ET-743 or PM00104.

METHODS

We evaluate the association between expression of Pgp1, MRP1, and BCRP proteins and ET-743 or PM00104 resistance in a large panel of multi-drug resistant cell lines derived from histologically unrelated human tumors that were selected with paclitaxel, doxorubicin, cisplatin, mitoxantrane, or gemcitibine.

RESULTS

Paclitaxel selected resistant cell lines expressed high levels of ABCB1 (but not ABCC1 or ABCG2/BCRP) did not demonstrate cross-resistance to either ET-743 or PM00104. In contrast, the doxorubicin selected resistant cell lines also expressed high level of ABCB1 (but not ABCC1 or ABCG2) but did demonstrate significant cross-resistance to both ET-743 and PM00104. The paclitaxel selected cell lines demonstrated cross-resistance to doxorubicin, vincristine, and mitoxantrane, while most of the above doxorubicin selected cell lines demonstrated cross-resistance to paclitaxel and vincristine, but not to mitoxantrane. On the contrary, cisplatin and gemcitabine selected cell lines demonstrated no cross-resistance to paclitaxel, doxorubicin, ET-743, or PM00104. siRNA down-regulation of ABCB1 expression in doxorubicin selected cell lines caused partial sensitization to both doxorubicin and paclitaxel but not to either ET-743 or PM00104.

CONCLUSIONS

These results indicate that cell lines selected for resistance to either paclitaxel or doxorubicin are cross-resistant to many other drugs and that, for these cell lines, ABCB1 over-expression is not necessary to confer resistance to either ET-743 or PM00104. Diversity of cross-resistance observed in these multi-drug resistant cell lines are associated with the initial drug used for in vitro selection, but not to ABCB1 expression. This study suggests that a common molecular pathway other than ABCB1 may be involved in the mechanism of resistance to ET-743 or PM00104.

Non-ossifying fibroma, fibrous cortical defect and Jaffe-Campanacci syndrome: a biologic and clinical review

Non-ossifying fibroma of bone (NOF) is a common entity, more frequently found in male children and consisting of a solitary eccentric, lytic expanded lesion in the metaphysis of a long bone. The disorder is benign and most often asymptomatic but may result in a fracture requiring therapy. Of some importance is to distinguish NOF from another very similar but smaller lesion, fibrous cortical defect, which is almost always asymptomatic and eccentrically located. Even more striking is a very rarely encountered lesion known as Jaffe-Campanacci syndrome, which also occurs in children who present with typical non-ossifying fibromatous tumors but in multiple sites. In addition, these patients have some systemic and dermal findings resembling those seen in patients with Type 1 neurofibromatosis.

Metabolic bone disease: a review and update

Understanding the structure and formation of bone and the metabolic diseases that cause intrinsic biochemical alterations and ultimate damage to the skeletal system is an essential part of orthopaedic education and knowledge. Metabolic bone diseases such as rickets, osteomalacia, renal osteodystrophy, hyperparathyroidism, and osteoporosis often lead to subtle alterations in the patient's clinical status and to severe and disabling changes in the patient's bone structure. It is essential that orthopaedists recognize these conditions, provide a correct diagnosis, and use appropriate preventive and therapeutic treatments.

Osteoarticular and total elbow allograft reconstruction with severe bone loss

Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Our consecutive series consisted of 18 patients with tumors and one patient with trauma. Reconstruction consisted of 16 hemiarticular allografts and three total elbow osteoarticular allografts; patients had a minimum followup of 2 years (mean, 9.9 years; range, 2-12 years). For patients who had hemiarticular allografts, 14 of 16 were able to return to their preoperative level of occupational function, with one patient experiencing failure of the allograft from infection. For the three patients who had total elbow allograft reconstructions, all had degenerative changes develop after surgery and two of the allografts failed. Complications occurred in six of 19 patients. Hemiarticular elbow allograft reconstruction is useful for limb salvage with massive bone loss. Total elbow allograft reconstructions have a high failure rate in the mid-term.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Imaging of pseudoneoplastic masses associated with allografts

OBJECTIVE

The objective of this study is to describe the imaging features of non-neoplastic masses suspected of being tumor recurrences adjacent to allografts. The allografts were utilized for the treatment of various musculoskeletal tumors.

MATERIALS AND METHODS

We reviewed the medical records and imaging studies of 56 patients who were suspected of having recurrent tumors following surgical resection and allograft replacement treatment for a variety of musculoskeletal neoplasms. The imaging modalities included radiographs, CT, and MRI.

RESULTS

There were 47 cases of recurrent tumors. All tumor recurrences were in the soft tissues of the surgical bed (41 patients), or in the native bone adjacent to the host/allograft junction (6 patients). None of the recurrences originated in the allografts. Nine patients suspected of having recurrences were discovered to have non-neoplastic masses. Five of these were very closely related to the allograft, wrapping around parts of the allograft, and the other 4 were in the surgical bed, 2 of which were abscesses and two were seromas.

CONCLUSION

Most masses arising in the vicinity of allografts implanted following resection of musculoskeletal tumors represent recurrent neoplasms. A minority are reactive processes or abscesses or fluid collections. These "pseudoneoplasms," specifically those closely related to the allografts, have specific imaging characteristics that help distinguish them from recurrent tumors.

Radiation therapy for control of soft-tissue sarcomas resected with positive margins

PURPOSE

Positive margins (PM) remain after surgery in some soft-tissue sarcoma (STS) patients. We investigated the efficacy of radiation therapy (RT) in STS patients with PM.

METHODS AND MATERIALS

A retrospective chart review was performed on 154 patients with STS at various anatomic sites with PM, defined as tumor on ink, who underwent RT with curative intent between 1970 and 2001. Local control (LC), disease-free survival (DFS), and overall survival (OS) rates were evaluated by univariate (log-rank) and multivariate analysis of prognostic and treatment factors.

RESULTS

At 5 years, actuarial LC, DFS, and OS rates were: 76%, 46.7%, and 65.2%, respectively. LC was highest with extremity lesions (p < 0.01), radiation dose >64 Gy (p < 0.05), microscopically (vs. grossly visible) positive margin (p = 0.03), and superficial lesions (p = 0.05). Patients receiving >64 Gy had higher 5-year LC, DFS, and OS rates of 85%, 52.1%, and 67.8% vs. 66.1%, 41.8%, and 62.9% if < or =64 Gy, p < 0.04. OS was worse in patients with G2/G3 tumors with local failure (LF), p < 0.001. Other known prognostic factors, including grade, stage, size, and age (>50), also significantly influenced OS. By multivariate analysis, the best predictors of LC were site (extremity vs. other), p < 0.01 and dose (>64 vs. < or =64 Gy), p < 0.05; the best predictors for OS were size, p < 0.001, gross vs. microscopic PM, p < 0.05, and LF, p < 0.01.

CONCLUSION

Local control is achieved in most PM STS patients undergoing RT. Doses >64 Gy, superficial location, and extremity site are associated with improved LC. OS is worse in patients with tumors with lesions >5 cm, grossly positive margins, and after local failure.

Soft tissue sarcoma resection volume associated with wound-healing complications

Limb-salvage surgery has become the standard of care for most soft tissue sarcomas. While primary closure is often possible, it is frequently complicated by wound-healing complications in the setting of previously irradiated tissue and surgical wounds closed under tension. We sought to identify a relationship between the volume of resected soft tissue and the rate of wound-healing complications. We retrospectively reviewed 108 patients who were treated over a 17-month period for soft-tissue sarcomas using limb-salvage methods. Of these, 87 patients were treated with primary wound closure and 21 patients underwent primary muscle flap closure at the time of wide surgical excision. Of the 87 patients treated with primary wound closure, the mean volume of resected tissue in the group with wound-healing complications was greater than that the group that healed without complications. The mean volume of resected tissue in the group with wound-healing complications was 919 cm3 +/- 1173 cm3 and the mean volume of resected tissue in the group without wound-healing complications was 456 cm3 +/- 704 cm3. Mean volume of resected tissue in the group of patients treated with primary flap coverage was 1908 cm3, over twice as large as the mean volume of resected tissue in the group of patients treated with primary closure.

Clear cell sarcoma of soft tissues

Clear cell sarcoma (CCS) is a rare but highly malignant tumor of soft tissues often appearing as a small tender mass in the deep tissues of the distal extremities. We have studied 17 patients with such lesions treated since 1986 and have a high incidence of local recurrence and metastasis with a survival rate of only 47% despite surgery and for many of the patients, adjuvant therapy. The purpose of this article is to warn the readers of the dangers related to treating this seemingly benign lesion and urge them to perform wide surgery and utilize adjuvant therapy.

Treatment of proximal humeral chondrosarcoma with resection and allograft

Chondrosarcoma of the proximal humerus is an uncommon malignant bone tumor, and limited information is available about treatment. We retrospectively reviewed 31 patients treated by resection and replacement with allograft implants during the past 24 years. The patients were followed up for an average of more than 16 years. Despite some allograft complications, the overall success rate for the grafts was 77%, and patient survival was 96%. Only 1 patient died. Two patients required amputation for local recurrences, and the remainder did reasonably well despite some functional problems. On the basis of this study and by comparison data, we believe that proximal humeral chondrosarcomas are less malignant than chondrosarcomas in other sites. In comparing them against 26 metallic implants, we believe that resection and allograft implantation remains a generally successful treatment, although the improvement of the metallic devices over the years has made this technique more available and acceptable.

Treatment and outcome of 82 patients with angiosarcoma

BACKGROUND

Angiosarcomas are an uncommon type of malignancy that are generally thought to behave usually in a locally aggressive fashion; they often metastasize to distant sites.

METHODS

Patients with a diagnosis of angiosarcoma treated at our institution between 1980 and 2006 were analyzed for patient demographics, tumor characteristics, multimodality treatment, and outcomes.

RESULTS

A total of 82 patients were divided into those with primary and advanced disease. Overall, the median age was 65 (range, 22-91) years, and 44% of patients were women. Median size of tumors was 3.8 cm, and 76% of tumors were intermediate or high grade. Tumors were located throughout the body: 32 cutaneous, 22 deep soft tissues or organs, 10 radiation or lymphedema field, 8 bone, and 7 nonirradiated breast. Of 46 patients with primary disease, all patients underwent surgical resection, 67% received radiotherapy, and 27% received chemotherapy. Five-year disease-specific survival was 60%, and negative prognostic factors included intermediate or high grade, and tumors arising in a radiated or lymphedema field. Of 36 patients with advanced disease, 36% underwent a palliative operation, 78% received radiation, and 58% received chemotherapy. Median survival was just 7.3 months, and cutaneous tumors predicted a better prognosis compared with other sites.

CONCLUSIONS

Primary angiosarcomas treated with aggressive surgical resection and the addition of radiation for close margins or worrisome pathologic features can result in long-term survival in most patients. The role of adjuvant chemotherapy is unclear. Patients with advanced disease have a poor prognosis, but there can be dramatic responses to chemotherapy in a minority of patients.

Locking versus standard plates for allograft fixation after tumor resection in children and adolescents

PURPOSE

This investigation was undertaken to assess the performance of locking plates in comparison to standard compression plates for allograft fixation after resection of malignant primary skeletal tumors.

METHODS

Using a computerized database, patients younger than 18 years who had undergone resection of malignant skeletal tumors with allograft reconstruction from January 1998 through June 2004 were identified. Demographic, oncological, surgical, and follow-up data were collected, and comparison of outcomes with regard to allograft-host junction healing between locking and standard compression plates was undertaken.

RESULTS

Thirty-nine patients meeting the inclusion criteria were identified. Homogeneity of the study group with regards to age, sex, diagnosis, adjuvant therapy, and presence of metastases allowed for evaluation of allograft-host union as a relatively independent variable. Nine patients in the locking plate group (75%) united after the index procedure at an average of 13.1 months. Fifteen patients (55.6%) with compression plates healed after the initial reconstruction at an average of 14.6 months. Complications and secondary procedures were noted.

CONCLUSIONS

Results of this investigation suggest that use of locking plates for allograft-host junction fixation is associated with improved union rates and less need for additional operations when compared with standard compression plates.

Improved survival for sarcomas of the wrist and hand

PURPOSE

To evaluate survival characteristics of malignant hand tumors compared with those occurring in other musculoskeletal locations over a 30-year period.

METHODS

Patients were identified through a computerized database maintained at the authors' institution over the past 30 years. Each patient's records were reviewed retrospectively. Diagnoses were categorized and survival data for patients with hand malignancies were compared with those of patients having similar tumors in other musculoskeletal sites by using multivariate statistical analysis.

RESULTS

The most common malignancies were epitheloid sarcoma, synovial sarcoma, and malignant fibrous histiocytoma. Improved survival during the follow-up period was found for hand malignancies versus those occurring in other musculoskeletal sites as a whole, and this difference was statistically significant. No significant survival benefit was identified for individual tumors.

CONCLUSIONS

Patients presenting with primary malignancies of the hand may survive longer than those with similar tumors in other musculoskeletal locations

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level II.

Advantage of limb salvage over amputation for proximal lower extremity tumors

Although function after lower extremity amputation and limb salvage has been compared, no study has assessed individual functional variables by surgical level. Our aim was to determine whether risks of long-term psychologic and physical limitations were associated with amputation or limb salvage at four levels: below-knee, above-knee, hip, and pelvis. We included 408 patients with sarcomas and postoperative followup of 2 years or greater who had completed a quality-of-life self-report questionnaire. The mean length of followup was 8.91 +/- 5.15 years (range, 2-27 years). Relative risk analysis was done on 12 dichotomous general health, psychologic, and physical function variables. At the below-knee level, outcomes were similar after both procedures. At the above-knee level, amputation was associated with increased risk of limp (RR = 1.6), walking aid use (RR = 2.1), anxiety (RR = 2.4), and inability to drive (RR = 3), and decreased risk of muscle weakness (RR = 0.57). At the hip and pelvic levels, outcomes were descriptively compared because of the small number of amputations. At these higher levels, limitations were more common after amputation. The difference in results between the below-knee and above-knee levels supports the importance of distinguishing surgical levels. Limb salvage offers a functional advantage at proximal tumor locations.

LEVEL OF EVIDENCE

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

A questionnaire study for 128 patients with Gaucher disease

Gaucher disease is an uncommon autosomal recessive disorder characterized by lysosomal storage of glucosyl ceramide, a material released during cell degradation. Patients with Gaucher disease often have significant hematologic, bone structural, and visceral problems which sometimes greatly affect their health and life style. Based on some extraordinary scientific discoveries over the past 45 years, a treatment system has evolved which consists of administration of an enzyme, which destroys the lysosome-stored material and to some extent restores the patients to good health. There are still some problems for these patients; however, and the purpose of the study is to define some of the clinical, sociologic, and psychologic problems with a specially designed questionnaire. Questionnaire data was collected for 128 patients from two institutions with complete anonymity, and the information compared against data from a National Health Interview Survey. The results show that many of the patients still have fairly extensive problems, which could possibly be helped by some alterations in treatment protocols.

Guidance on the use of miglustat for treating patients with type 1 Gaucher disease

Type 1 Gaucher disease (GD) is a progressive lysosomal storage disorder due to an autosomal recessive deficiency of glucocerebrosidase. Clinical manifestations include anemia, thrombocytopenia, hepatosplenomegaly, and bone and pulmonary disease. Intravenous enzyme replacement (ERT) with imiglucerase is the accepted standard for treatment of symptomatic patients. More than 3,500 patients worldwide have received ERT with well-documented beneficial effects on the hematological, visceral, skeletal, and pulmonary manifestations, and with resultant improvement in health-related quality of life. Miglustat, an imino sugar that reversibly inhibits glucosylceramide synthase and reduces intracellular substrate burden, is an oral treatment for patients with type 1 GD that was recently approved in the United States for symptomatic patients with mild to moderate clinical manifestations for whom ERT is not an option. Because responses to miglustat are slower and less robust than those observed with ERT, and because miglustat is associated with significant side effects, clinicians who care for patients with GD should become familiar with the limited indications for miglustat use and the circumstances when it may be prescribed appropriately. This review article and position statement represents the current opinion of American physicians with extensive expertise in GD regarding patient management in the context of the availability of standard imiglucerase treatment and the recent introduction of miglustat.

Aneurysmal bone cyst: a review of 150 patients

PURPOSE

We have reviewed a series of 150 aneurysmal bone cysts treated over the last 20 years.

PATIENTS AND METHODS

The lesions were principally located in the tibia, femur, pelvis, humerus, and spine and, in most cases, presented the imaging appearance originally described by Jaffe and Lichtenstein as a blowout with thin cortices.

RESULTS

Only one of the patients was believed to have an osteoblastoma of the spine with secondary development of an aneurysmal bone cyst, and none of the patients developed additional lesions. The patients were treated primarily with curettage and implantation of allograft chips or polymethylmethacrylate, but some patients were treated with insertion of autografts or allografts. The local recurrence rate was 20%, which is consistent with that reported by other centers.

CONCLUSION

Aneurysmal bone cysts are enigmatic lesions of unknown cause and presentation and are difficult to distinguish from other lesions. Overall, the treatment is satisfactory, but it is possible that newer approaches, such as improved magnetic resonance imaging studies, may help diagnose the lesions and allow the physicians to plan for more effective treatment protocols.

Chondromyxoid fibroma: a rarely encountered and puzzling tumor

Chondromyxoid fibroma is an uncommon bone neoplasm, accounting in our series for less than 1% of all connective tissue tumors. The tumor is more common in males, and located mostly in the metaphyseal areas of the lower extremity. The tumor is benign and there have been no reports of metastases. The method of treatment that has been used since the initial identification of the tumor has been curettage, which has a 20-25% recurrence rate. In our 30 patients, the average length of followup was 11 years (range, 1-29 years. Most of the tumors were in the pelvis, proximal tibia, distal femur, and foot. Tumors that were treated with curettage alone did less well than those that were packed with allograft bone or polymethylmethacrylate. Tumors treated by excision did not recur. The most difficult problem with chondromyxoid fibroma is pathologic identity because it often is confused with more aggressive tumors that may metastasize.

Treatment of giant cell tumors with allograft transplants: a 30-year study

We retrospectively reviewed 144 patients with giant cell tumors who had resection and implantation of cadaveric allografts from 1971-2001. Most procedures were done in the distal femur, proximal tibia, proximal femur, and proximal humerus. Seventy-eight percent of patients have retained their grafts and remain functional, but with limitations. Tumor complications included local recurrences (eight patients, none required an amputation) and metastases (three patients). None of the patients died. Allograft fracture occurred in 30 (21%) of the 144 patients, nonunion occurred in 12 (8%) patients, and infection occurred in 12 (8%) patients. Only patients with infection had a marked decline in outcome. Four patients required amputations, and only two of the eight patients with infection (17%) retained a functional graft. Eighty of the 144 patients (56%) had no complications, with a 94% success rate for the procedure. There have been fewer grafts done with the advent of burring, phenolization, and insertion of polymethylmethacrylate. However, based on our data and the good outcome for more extensive and destructive tumors, allograft implants can be used for treatment of patients with aggressive tumors, tumors that have caused fractures, or tumors that have recurred after conservative treatment.