Surgical downstaging in an open-label phase II trial of denosumab in patients with giant cell tumor of bone

Background

Surgical resection with curative intent for giant cell tumor of bone (GCTB) may be associated with severe morbidity. This interim analysis evaluated reduction in surgical invasiveness after denosumab treatment in patients with resectable GCTB.

Methods

Patients with primary or recurrent GCTB, for whom the initially planned surgery was associated with functional compromise or morbidity, received denosumab 120 mg subcutaneously every 4 weeks (additional doses on days 8 and 15 of the first cycle). Planned and actual GCTB-related surgical procedures before and after denosumab treatment were reported. Patients were followed for surgical outcome, adverse events, and recurrence following resection.

Results

Overall, 222 patients were evaluable for surgical downstaging (54 % were women; median age 34 years). Lesions (67 % primary and 33 % recurrent) were located in the axial (15 %) and appendicular skeleton (85 %). At the data cutoff date, most patients had not yet undergone surgery (n = 106; 48 %) or had a less morbid procedure (n = 84; 38 %) than originally planned. Median (interquartile range) time on denosumab was 19.5 (12.4–28.6) months for the 106 patients who had not undergone surgery and were continuing on monthly denosumab. Native joint preservation was 96 % (n = 24/25) for patients with planned joint/prosthesis replacement and 86 % (n = 30/35) for patients with planned joint resection/fusion. Of the 116 patients who had surgery (median postsurgical follow-up 13.0 [8.5–17.9] months), local recurrence occurred in 17 (15 %) patients.

Conclusion

For patients with resectable GCTB, neoadjuvant denosumab therapy resulted in beneficial surgical downstaging, including either no surgery or a less morbid surgical procedure.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4634-9) contains supplementary material, which is available to authorized users.

Myopericytoma: a unifying term for a spectrum of tumours that show overlapping features with myofibroma. A review of 14 cases

BACKGROUND

Myopericytoma (MPC) is a recently proposed term to describe a group of tumours that originate from perivascular myoid cells and show a range of histological growth patterns. Only a small number of series describing MPC have been reported. MPC is frequently misdiagnosed as a sarcoma.

AIMS

To document the clinical and histopathological findings of a series of MPCs, to describe the range of growth patterns and morphological spectrum, and to compare MPC with myofibroma (MF).

PATIENTS/METHODS

Fourteen patients with features of MPC and/or MF were identified from the archival files of the department of anatomical pathology, Royal Prince Alfred Hospital, Sydney, Australia.

RESULTS

There were six female and eight male patients. The mean and median patient ages were 37 and 35.5 years, respectively. The tumours were located in the skin, subcutis, or superficial soft tissues of the distal extremities (13 patients) or the head and neck region (one patient), and showed a spectrum of morphological appearances. They were divided into two groups based upon the predominant growth pattern corresponding to MPC (seven cases) and MF (seven cases). The feature most suggestive of MPC was the presence of a concentric perivascular arrangement of plump spindle shaped cells. The presence of a zonation/biphasic appearance was most characteristic of MF.

CONCLUSIONS

MPC exhibits a spectrum of growth patterns that overlap with MF. Tumours can be designated as MPC or MF depending on the predominant growth pattern.

En-bloc resection, extracorporeal irradiation, and re-implantation in limb salvage for bony malignancies

We treated 50 patients with bony malignancy by en-bloc resection, extracorporeal irradiation with 50 Gy and re-implantation of the bone segment.

The mean survivor follow-up was 38 months (12 to 92) when 42 patients were alive and without disease. There were four recurrences. The functional results were good according to the Mankin score (17 excellent, 13 good, nine fair, three failures), the Musculoskeletal Tumour Society score (mean 77) and the Toronto Extremity Salvage score (mean 81). There was solid union, but bone resorption was seen in some cases. The dose of radiation was lethal to all cells and produced a dead autograft of perfect fit.

Extracorporeal irradiation is a useful technique for limb salvage when there is reasonable residual bone stock. It allows effective re-attachment of tendons and produces a lasting biological reconstruction. There should be no risk of local recurrence or of radiotherapy-induced malignancy in the replanted bone.

Clinical case seminar: Fibroblast growth factor 23: a new clinical marker for oncogenic osteomalacia

The phosphate-wasting condition, oncogenic osteomalacia, is problematic to diagnose and manage clinically due to difficulty in locating the causative tumor. Fibroblast growth factor 23 (FGF23) has recently been implicated in the pathogenesis of oncogenic osteomalacia. In this case the patient presented with clinical features typical of oncogenic osteomalacia. Removal of an angiolipoma from the thigh did not correct the clinical or biochemical abnormalities. Subsequent identification and removal of a benign giant cell tumor in the pubic ramus, however, did result in normalization of his symptoms and signs. Positive staining for FGF23 protein by immunohistochemistry was demonstrated in the giant cell tumor, but not in the angiolipoma. The serum concentration of FGF23 was elevated in preoperative serum, then normalized after removal of the giant cell tumor. Expression of both FGF23 mRNA and protein was demonstrated in the giant cell tumor tissue, and FGF23 mRNA expression and renal phosphate uptake inhibitory activity were also detected in cultured giant cell tumor cells. This case provides further evidence for the involvement of FGF23 in the pathogenesis of oncogenic osteomalacia and for the utility of serum FGF23 measurement and immunohistochemical detection of FGF23 in the diagnosis and clinical management of this condition.

Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery

Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96). There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)). Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%). The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035). A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading. Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur.

The effectiveness of robotic hip and knee arthroplasty on patient-reported outcomes: A systematic review and meta-analysis

PURPOSE

The purpose of the study is to determine the effectiveness of semi-active and active robotic hip and knee arthroplasty on post-operative patient-reported outcomes of function, pain, quality of life and satisfaction with surgery.

METHODS

PubMed, Medline, Embase and CENTRAL were searched. Included were comparative studies investigating the effectiveness of semi-active or active robotic hip or knee arthroplasty compared to any other surgical intervention on function, pain, quality of life and satisfaction with surgery. Risk of bias and the strength of the evidence were assessed using the Downs and Black tool and the GRADE system, respectively. Relative risks, mean differences and 95% CI were calculated using random-effects models.

RESULTS

Fourteen studies involving 1342 patients were included. All studies compared robotic to conventional surgery, with active robotic surgery evaluated in total hip or knee arthroplasty and semi-active robotic surgery in total hip or unicompartmental knee arthroplasty. Most studies presented some risk of bias, and the strength of evidence was rated as low to very low quality. Random-effects meta-analyses showed that post-operative functional outcomes were comparable between active robotic and conventional total hip and knee arthroplasty at the short-, medium- and long-term follow-up. No significant difference in pain, quality of life and satisfaction with surgery were reported in individual studies.

CONCLUSIONS

This systematic and meta-analyses indicates that functional outcomes for patients undergoing active robotic total hip and knee arthroplasty were comparable to conventional surgery. Whether semi-active or active robotic hip or knee arthroplasty is effective in improving post-operative pain, quality of life and satisfaction with surgery is unclear. PROSPERO Registration Number: CRD42017059932.

Surgical biopsy with intra-operative frozen section. An accurate and cost-effective method for diagnosis of musculoskeletal sarcomas

The most appropriate protocol for the biopsy of musculoskeletal tumours is controversial, with some authors advocating CT-guided core biopsy. At our hospital the initial biopsies of most musculoskeletal tumours has been by operative core biopsy with evaluation by frozen section which determines whether diagnostic tissue has been obtained and, if possible, gives the definitive diagnosis. In order to determine the accuracy and cost-effectiveness of this protocol we have undertaken a retrospective audit of biopsies of musculoskeletal tumours performed over a period of two years. A total of 104 patients had biopsies according to this regime. All gave the diagnosis apart from one minor error which did not alter the management of the patient. There was no requirement for re-biopsy. This protocol was more labour-intensive and 38% more costly than CT-guided core biopsy (AU$1804 vs AU$1308). However, the accuracy and avoidance of the anxiety associated with repeat biopsy outweighed these disadvantages.

A Robust Assay for Alternative Lengthening of Telomeres in Tumors Shows the Significance of Alternative Lengthening of Telomeres in Sarcomas and Astrocytomas

Purpose and Experimental Design: Telomeres of tumor cells may be maintained by telomerase or by alternative lengthening of telomeres (ALT). The standard ALT assay requires Southern analysis of high molecular weight genomic DNA. We aimed to establish and validate an ALT assay suitable for archived paraffin-embedded tumors and to use it to examine the prevalence and clinical significance of ALT in various types of tumors that are often telomerase negative.

Results: To assay for ALT, we detected ALT-associated promyelocytic leukemia (PML) bodies (APBs) by combined PML immunofluorescence and telomere fluorescence in situ hybridization. APBs are PML nuclear domains containing telomeric DNA and are a known hallmark of ALT in cell lines. The APB assay concurred with the standard ALT assay in 62 of 62 tumors and showed that 35% of 101 soft tissue sarcomas (STS), 47% of 58 osteosarcomas (especially younger patients), 34% of 50 astrocytomas, and 0% of 17 papillary thyroid carcinomas were ALT positive (ALT+). The prevalence of ALT varied greatly among different STS subtypes: malignant fibrous histiocytomas, 77%; leiomyosarcomas, 62%; liposarcomas, 33%; synovial sarcomas, 9%; and rhabdomyosarcomas, 6%. ALT correlated with survival in glioblastoma multiforme and occurred more often in lower-grade astrocytomas, but ALT+ and ALT− sarcomas were equally aggressive in terms of grade and clinical outcome.

Conclusion: The APB assay for ALT is suitable for paraffin-embedded tumors. It showed that a substantial proportion of STS, osteosarcomas, and astrocytomas, but not papillary thyroid carcinomas use ALT. APB positivity correlated strongly with survival of patients with astrocytomas.

Extracorporeal irradiation for malignant bone tumors

PURPOSE

Extracorporeal irradiation (ECI) has been used selectively in the management of primary malignant bone tumors since 1996. We report our techniques for ECI and the short-term oncologic and orthopedic outcomes.

METHODS AND MATERIALS

Sixteen patients with primary malignant bone tumors were treated with ECI from 1996 to 2000. The median age was 14 years. The histologic diagnoses were Ewing's sarcoma (11), osteosarcoma (4) and chondrosarcoma (1). The treated sites were femur (7), tibia (4), humerus (2), ilium (2), and sacrum (1). Following induction chemotherapy in Ewing's sarcomas and osteosarcoma, en bloc resection of the tumor and tumor-bearing bone was performed. A single dose of 50 Gy was delivered to the bone extracorporeally using either a linear accelerator (9 cases) or a blood product irradiator (7 cases). The orthopedic outcome was recorded using a standard functional scale.

RESULTS

At a median follow-up of 19.5 months, there were no cases of local recurrence or graft failure. One patient required amputation due to chronic osteomyelitis. For the 10 patients with follow-up greater than 18 months, the functional outcomes were graded good to excellent.

CONCLUSION

The short-term oncologic and orthopedic results are encouraging and suggest that ECI provides a good alternative for reconstruction in limb conservative surgery in selected patients. This technique should only be used in a multidisciplinary setting, where careful follow-up is available to assess the long-term outcomes.

Isolated limb infusion for advanced soft tissue sarcoma of the extremity

BACKGROUND

Isolated limb infusion (ILI) is a minimally invasive technique for delivering high-dose regional chemotherapy. We report our experience with ILI for the treatment of soft tissue sarcoma (STS).

METHODS

From our prospective database, 21 patients with STS of the limb treated with ILI between 1994 and 2007 were identified. In all patients, a high-dose cytotoxic drug combination was used.

RESULTS

There were 14 men, and the median age was 60 years (range, 18-85 years). Eighteen patients (86%) had lower limb tumors. All patients had advanced local disease. The procedure was well tolerated. Fourteen patients (67%) received ILI before definitive surgery. The overall response rate was 90% (complete response [CR] rate 57%, partial response rate 33%). The disease-specific overall survival was 61.9% (median follow-up, 28 months). Only American Joint Committee on Cancer stage was associated with overall survival. The local recurrence rate was 42%. CR and malignant fibrous histiocytoma tumor subtype were associated with a lower local recurrence rate. A lower initial skin temperature (median 35.8 degrees C) was associated with a CR (P = .033). Patients who had a steep increase in intramuscular temperature during the procedure were more likely to have a CR (P = .055). Classification tree analysis identified patients with an initial PaO(2) of >/=194 mmHg as being more likely to have a CR. Ultimately, the overall limb salvage rate was 76%.

CONCLUSION

The outcomes after ILI are comparable to those achieved by conventional isolated limb perfusion. ILI is a minimally invasive alternative to isolated limb perfusion for patients with advanced STS of the extremity.

Free Vascularized Fibula Grafts in Limb-Salvage Surgery

The authors review the outcome of a consecutive series of 24 free vascularized fibular grafts performed as part of a limb-salvage procedure following tumor excision. There were 15 women and nine men with a mean age of 26 years (range: 6 to 52 years). The minimum follow-up was 12 months. The mean length of the graft was 13.1 cm. (range: 4.5 to 25 cm). Fifteen grafts were used in the upper limb, eight in the lower limb, and one in the pelvis. Bony union was achieved in 21/24 patients at a mean of 9.3 months. Complications occurred in 13/24 patients of whom 11 required a second operation. Four patients died of metastatic disease. The mean Musculoskeletal Tumor Society (MSTS) functional score in the remaining 20 was 84.5 percent, with 16 patients having a good or excellent outcome. Free vascularized fibula grafts offer a reliable method of reconstruction after excision of bone tumors. Although the incidence of complications appears high, they are relatively easy to correct, bony union is achieved in the majority, and functional outcome is good.

Programmed cell death-1 blockade in recurrent disseminated Ewing sarcoma

Background

Ewing sarcoma (EWS) is a malignant tumour of bone and soft tissue, and although many patients are cured with conventional multimodal therapy, those with recurrent or metastatic disease have a poor prognosis. Genomic instability and programmed cell death ligand-1 (PD-L1) expression have been identified in EWS, providing a rationale for treatment with agents that block the programmed cell death-1 (PD-1) receptor.

Case presentation

In this report, we describe a heavily pre-treated patient with recurrent metastatic EWS who achieved a clinical and radiological remission with PD-1 blockade.

Conclusions

To our knowledge, this is the first reported case demonstrating efficacy of PD-1 blockade in EWS. This warrants further investigation in particular given the poor prognosis in patients with recurrent or metastatic disease.

Reconstruction of the proximal humerus with a composite of extracorporeally irradiated bone and endoprosthesis following excision of high grade primary bone sarcomas

INTRODUCTION

Functional reconstruction of the shoulder joint following excision of a malignant proximal humeral tumour is a difficult proposition.

METHOD

Eleven patients with primary osteosarcoma or Ewing's sarcoma underwent reconstruction with a composite of extra-corporeally irradiated autograft with the addition of a long stemmed hemiarthroplasty. At a mean follow-up of 5.8 years two patients had died from disseminated disease and one patient had undergone amputation for local recurrence. The eight patients with a surviving limb were examined clinically and radiographically.

RESULT

The mean Toronto Extremity Salvage Score was 74 and Musculo-Skeletal Tumour Society score 66. Rotation was well preserved but abduction (mean 32 degrees ) and flexion (40 degrees ) were poor. There was a high rate of secondary surgery, with five out of eleven patients requiring re-operation for complications of reconstruction surgery. Radiographic estimate of graft remaining at follow up was 71%. There were no infections, revisions or radiographic failures.

CONCLUSION

Whilst the reconstructions were durable in the medium term, the functional outcome was no better than with other reported reconstructive methods. The composite technique was especially useful in subtotal humeral resections, allowing preservation of the elbow joint even with very distal osteotomy. Bone stock is restored, which may be useful for future revision surgery in this young group of patients.

Pulmonary metastasectomy for bone and soft tissue sarcoma in Australia: 114 patients from 1978 to 2008

AIMS

The aim of this study is to analyze the prognostic factors for overall and relapse-free survival that may help select patients for pulmonary metastasectomy and inform their prognosis.

METHODS

From 1978 to 2008 130 patients underwent pulmonary metastasectomy for bone (osteosarcoma, chondrosarcoma and Ewing's sarcoma) and soft tissue sarcomas. Outcome measures analyzed were time to death and relapse and Cox regression models analyzed the association of prognostic factors.

RESULTS

In total 114 patients were analyzed. The 5-year post-metastasectomy overall survival rate was 43%. The 5-year relapse-free survival rate was 19%. In the multivariate analysis, an incomplete surgical resection (P = 0.02) was associated with an increased risk of death. There was weak evidence that a diameter of the largest resected metastasis ≥ 1.8 cm (P = 0.07) and a disease-free interval of ≤ 18 months (P = 0.08) were associated with an increased risk of death.

CONCLUSION

Poor prognostic factors for overall survival after a pulmonary metastasectomy are an incomplete surgical resection, a large diameter of the biggest resected metastasis and a short disease-free interval. The role of perioperative chemotherapy is uncertain.

Osteosarcoma and pulmonary metastases: 15-year experience from a single institution

BACKGROUND

The outcome of management in patients with osteosarcoma and pulmonary metastases at a Sydney teaching hospital was reviewed.

METHODS

A retrospective review was undertaken of all patients diagnosed with osteosarcoma and treated by the Bone and Soft Tissue Unit and the Medical Oncology Department, Royal Prince Alfred Hospital between 1979 and January 1995. Information was collected on demographics, tumour site, tumour histology, primary management including surgery and adjuvant therapy, and the subsequent development and management of pulmonary metastases.

RESULTS

A total of 56 patients with localized osteosarcoma was seen. Overall survival and survival following pulmonary metastases was assessed. There were 33 (59%) males and 23 (41%) females, with a median age of 27 years. Survival at 5 years, for patients with non-axial osteosarcoma was 60% (95% CI, 44-77%). Pulmonary metastases without other metastatic disease being apparent, developed in 22 patients, of whom 12 underwent surgical resection. The median disease-free interval of these latter patients was 20 months (95% CI, 8-32 months). Median survival among patients not undergoing surgical resection was 5 months from detection of metastases. Patients undergoing resection of pulmonary metastases had a median survival of 17 months following detection of pulmonary metastases (95% CI, 7-27 months). Actuarial 5-year survival was 16% (95% CI, 0-42%).

CONCLUSIONS

A small proportion of patients with resectable pulmonary metastases from osteosarcoma achieve long-term disease-free survival following surgical resection. It is not possible to accurately identify these patients prospectively.

Biopsy of musculoskeletal tumours - beware

BACKGROUND

Biopsy of musculoskeletal tumours is hazardous and, when poorly performed, can compromise limb salvage surgery and patient survival. The aim of the present paper is to examine the early management of such patients referred to the Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, Australia with particular reference to biopsy.

METHODS

We conducted a prospective audit of all patients referred to our musculoskeletal tumour service during 2002. Inclusion criteria were: all patients with primary tumours of the musculoskeletal system. We compared the outcome of patients biopsied prior to referral with that of patients biopsied in a recognized treatment centre.

RESULTS

One hundred and forty-two patients were included. The referring surgeon performed biopsies in 29 cases, of which 20 were malignant lesions. The senior author biopsied the remaining 113 cases, of which 57 were malignant. Definitive treatment was hindered by a badly performed biopsy in 38% of patients biopsied by the referring surgeon. In 25% the definitive treatment had to be changed either to a more radical procedure than would have originally been necessary or to palliative rather than curative intent. Patients biopsied elsewhere were more likely to have an incomplete excision requiring re-excision, more likely to require amputation, and more likely to require adjuvant radiotherapy.

CONCLUSIONS

There is a high complication rate when patients with musculoskeletal tumours are biopsied by surgeons inexperienced in their management. These patients are better served by early referral to a specialist centre where staging investigations including biopsy can be performed with minimal morbidity.

Parachordoma is not distinguishable from axial chordoma using immunohistochemistry

Parachordoma is a rare soft tissue tumor that morphologically resembles chordoma of the axial skeleton but occurs in a peripheral site. A recent study reported immunohistochemical differences between chordoma and parachordoma. While both tumors were positive for cytokeratin (CK) 8/18 (as recognized by the antibody Cam5.2), S100 and epithelial membrane antigen (EMA), only the chordoma was positive for CK7, CK20, CK 1/5/10/14 (as recognized by the antibody 34betaE12) and carcinoembryonic antigen (CEA). It has since been suggested that tumors indistinguishable from chordoma that involve the periphery should be termed chordoma periphericum and that these tumors are distinct from parachordoma. In the current study, the clinical, radiological, pathological, immunohistochemical and ultrastructural features of a chordoma-like tumor involving the deep soft tissues of the lower leg of a 69-year-old woman are presented. Microscopically, the tumor had a pseudolobulated growth pattern and consisted of sheets, nests and cords of epithelioid cells, some with a physaliferous appearance, separated by abundant myxoid stroma. The tumor cells were positive for CK 8/18, EMA and S100, showed focal staining for CK7, and were negative for CK20, CK 1/5/10/14 and CEA. On the basis of these results a diagnosis of parachordoma was favored. For comparison, an immunohistochemical analysis of five axial chordomas was also performed. The chordomas showed positivity for CK 8/18 (5 of 5 cases), EMA (5 of 5 cases), S100 (5 of 5 cases), CK 1/5/10/14 (1 of 5 cases) and CK7 (1 of 5 cases). Stains for CK20 and CEA were negative in all five chordomas. The results of the present study suggest that the expression of antigens for CK 1/5/10/14, CK7, CK20 and CEA in chordoma might not be as common as what has been previously reported. The results also suggest that parachordoma might not be easily distinguished immunohistochemically from axial chordoma (and therefore also from so-called chordoma periphericum).

Patterns of care for patients with advanced soft tissue sarcoma: experience from Australian sarcoma services

Background

There is a paucity of data on the current management of patients with advanced soft tissue sarcoma (STS) in the Australian health care setting. This study utilised the Australian sarcoma database to evaluate the patterns of care delivered to patients with advanced STS at Australian sarcoma services.

Methods

Prospectively collected data from six sarcoma centres in Australia were sourced to identify patients diagnosed with advanced STS between 1 January 2010 and 31 December 2012. Descriptive statistics were analysed for patient demographics, clinicopathological characteristics and treatment patterns. Overall survival was estimated using the Kaplan–Meier product limit method.

Results

Of 253 patients with advanced STS, four major STS subtypes were identified: undifferentiated pleomorphic sarcoma (23 %), leiomyosarcoma (17 %), liposarcoma (14 %), and synovial sarcoma (8 %); with the rest grouped as “other STS” (38 %). Approximately one-third of patients received palliative systemic therapy with the most common first-line therapy being doxorubicin alone (50 %). A small percentage of patients participated in clinical trials (20 %). Palliative radiotherapy was utilised mostly for treatment of symptomatic distant metastases and one-third of patients underwent metastasectomy, most commonly for pulmonary metastases. The median overall survival (OS) in this series was 18 months and no significant difference in OS was observed across different STS histological subtypes.

Conclusions

This is the first detailed study outlining patterns of care for Australian patients with advanced STS managed at sarcoma services. These data highlight a particular area of weakness in the lack of clinical trials for sarcoma patients and also serve as an important reference point for understanding how practice may change over time as treatment options evolve.

Telangiectatic dedifferentiation of a parosteal osteosarcoma

A unique case of parosteal osteosarcoma (POS) of the proximal femur, with areas of telangiectatic dedifferentiation, in a 28-year-old woman is reported. The patient had a 7-week history of pain and swelling in her right thigh. A biopsy diagnosis of POS was established. The patient was treated with two cycles of intraarterial chemotherapy, followed by limb salvage surgery. Histological examination of the resected specimen showed POS with areas of dedifferentiation composed of highgrade telangiectatic osteosarcoma with associated secondary aneurysmal bone cyst change.

Custom designed and 3D-printed titanium pelvic implants for acetabular reconstruction after tumour resection

BACKGROUND

Reconstructive procedure following resection of large pelvic tumours around the hip joint remains a complex challenge.

METHODS

This study presents a retrospective case series of patients presenting with benign or malignant pelvic tumour for which an internal hemipelvectomy including the hip joint and subsequent reconstruction with a custom designed 3-dimensional printed titanium pelvic implant (3DPPI) has been performed between August 2013 and January 2018.

RESULTS

15 consecutive patients with a median age of 33.9 years (IQR 26.4-72.2) and a median BMI of 20.7 kg/m2 (IQR 19.0-33.3) were reviewed after median follow-up of 33.8 months (IQR 24.0-78.1). The majority of patients presented with a malignant tumour as their principal diagnosis (n = 13, 86.7%). The median surgical time was 5.5 hours (IQR 4.5-8.5) and median peri-operative blood loss was 5000 ml (IQR 2000-10000). The median MSTS score at follow-up was 63.3% (IQR 51.7-86.7%). The median NRS in rest was 0.0 (IQR 0.0-5.0), the median NRS during activity was 2.0 (IQR 0.5-7.0) and the median HOOS-PS was 76.6% (IQR 67.9-91.0). 4 patients had implant-specific complications (n = 4, 26.6%); 1 hip dislocation (Henderson type 1a), 3 structural complications (type 3a), 1 deep infection (type 4a) and 1 local tumour recurrence (type 5b). At follow-up, 4 out of 15 implants were classified as a failure, resulting in an implant survival rate of 73.3%.

CONCLUSIONS

Acceptable peri-operative outcomes, functional results, complication rates and short-term implant survival can be achieved in a cohort of complex patients undergoing 3DPPI reconstruction after hemipelvectomy including the acetabulum.

Radiation Therapy as an Alternative Treatment for Desmoid Fibromatosis

AIM

To determine the outcome after radiation therapy for desmoid fibromatosis.

MATERIALS AND METHODS

A retrospective review of 50 patients treated between 1988 and 2016 in a specialised bone and soft tissue tumour clinic.

RESULTS

The median age at the time of radiation therapy was 36.8 years (range 15.1-69.0) and the median follow-up time was 51 months. Forty-three patients underwent radiation therapy as the definitive treatment with a median dose of 56 Gy (range 30-58.8 Gy). The median dose for the seven patients treated with postoperative radiation therapy was 50.4 Gy (range 48-56 Gy). Eleven patients (22%) developed progressive disease after radiation therapy at a median time of 41 months (range 12-113 months). The recurrences were within the radiation therapy field in four patients and outside the field in seven patients. One patient developed a radiation-induced malignancy 20 years after treatment.

CONCLUSIONS

Radiation therapy is an alternative treatment in the management of desmoid fibromatosis. It should be considered in patients for whom surgical resection is not feasible, or as adjuvant therapy after surgery with involved margins where any further recurrences would cause significant morbidity.

Epiphyseal osteoblastoma-like osteosarcoma

Osteoblastoma-like osteosarcoma is a rare variant of osteosarcoma occurring in this instance in a highly unusual location: the lateral femoral condyle of a 13-year-old girl. The radiological features were non-aggressive and, although slightly unusual, were most suggestive of chondroblastoma.

Bilateral total hip arthroplasty in Severe Hereditary Multiple Exostosis: a report of two cases

Staged bilateral hip arthroplasties were carried out in two patients with osteoarthritis of the hip secondary to the development of hip dysplasia in Hereditary Multiple Exostosis (HME).Both patients had near ankylosis of their hips with pain and difficulty in performing activities of daily living. A proximal femur replacing prosthesis was implanted through an extended trochanteric osteotomy, with preservation of as much proximal bone stock as possible. At latest followup (two to five years), there was a sustained improvement in range of motion and symptoms. The Harris Hip Scores improved from 25 and 31 to 83 and 78. The Toronto Extremity Salvage Scores improved from 49% and 55% to 88% and 75%. Radiographs show bony ingrowth and healing of the trochanteric fragments. In severe HME, hip arthroplasty with replacement of the proximal femur provides good symptomatic relief and return of hip joint movement.