Functional recovery after surgical stabilization and postoperative radiotherapy due to metastases of long bones

PURPOSE

To reinvestigate the functional recovery after combined treatment with surgery and postoperative irradiation of complete or impending pathologic fractures of long bones.

METHODS

We retrospectively evaluated the results of external beam radiation therapy (EBRT) carried out after 68 orthopedic stabilization procedures (femur, n = 55, 80.8%; humerus, n = 13, 19.2%) for actual or impending pathological fracture of long bone in 61 patients with skeletal metastases. The mean normalized total dose was 34.7 ± 7.8 Gy. Endpoints were patient's functional status (FS; 1 = normal pain free status; 2 = normal use with pain; 3 = significantly limited used; 4 = nonfunctional status), a need for a secondary procedure to the same site and overall survival following surgery.

RESULTS

Overall, 75% of patients achieved normal functional status (FS 1-2) within 12 weeks after surgery. Functional recovery in surviving patients reached 93%. Median survival was 17 months (95% confidence interval 13.7-20.2). Secondary surgical intervention at the same location was necessary in 3 patients (4.4%). On multivariate analysis, only general status (p = 0.011) and growing potential of primary tumor (p = 0.049) were associated with achieving normal functional status within 12 weeks after surgery and radiotherapy. The applied radiation schemes demonstrated a comparable impact on functional recovery.

CONCLUSIONS

Our results confirm the effectiveness of stabilizing surgery and fractionated postoperative radiotherapy in terms of functional recovery, supporting prior results assessing postsurgical radiotherapy versus follow-up. The patient's general status is a strong prognostic factor for functional recovery. Rapidly growing tumors may hinder achievement of a normal functional status.

Is Total Femur Replacement a Reliable Treatment Option for Patients With Metastatic Carcinoma of the Femur?

BACKGROUND

The majority of metastatic bone lesions to the femoral bone can be treated without surgery or with minimally invasive intramedullary nailing. In rare patients with extensive metastatic disease to the femur, total femur replacement may be the only surgical alternative to amputation; however, little is known about this approach.

QUESTIONS/PURPOSES

In a highly selected small group of patients with metastatic carcinoma of the femur, we asked: (1) What was the patient survivorship after this treatment? (2) What was the implant survivorship free from all-cause revision and amputation, and what complications were associated with this treatment? (3) What functional outcomes were achieved by patients after total femur replacement for this indication?

METHODS

Eleven patients (three men, eight women) with a mean age of 64 years (range, 41-78 years) received total femur replacements between 1986 and 2016; none were lost to followup. The most common primary disease was breast cancer. In general, during this period, our indications for this procedure were extensive metastatic disease precluding internal fixation or isolated proximal or distal femur replacement, and an anticipated lifespan exceeding 6 months. Our contraindication for this procedure during this time was expected lifespan less than 6 months. Patient survival was assessed by Kaplan-Meier analysis; implant survival free from revision surgery and amputation were assessed by competing risk analysis. Function was determined preoperatively and 6 to 12 weeks postoperatively with the Musculoskeletal Tumor Society (MSTS) score normalized to a 100-point scale, with higher scores representing better function from a longitudinally maintained institutional database.

RESULTS

Eleven patients died at a median of 5 months (range, 1-31 months) after surgery. One-year revision-free and limb survival were 82% (95% CI, 51%-98%) and 91% (95% CI, 61%-99%), respectively. Reasons for reoperation were hip dislocation, infection and local recurrence in one patient each. The latter two complications resulted in amputation in two patients. The median MSTS score was 32 (range, 13-57).

CONCLUSIONS

Despite attempts to select patients who might have anticipated greater life expectancy, eight of 11 patients died by 6 months after surgery, and an additional two patients had undergone an amputation at 8 and at 17 months postoperatively. Most patients undergoing total femur replacement in this series did not recover from the procedure by the time they died, despite our best attempts to perform the procedure in patients whom we thought would live at least 6 months. Based on this, we believe that most patients with extensive metastatic disease to the femur should be offered palliative care, rather than major reconstruction.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Primary Chemotherapy and Delayed Surgery for Malignant Fibrous Histiocytoma of Bone in the Extremity

Between March 1983 and September 1988, 22 patients with non-metastatic malignant fibrous histiocytoma MFH of bone of the extremities were treated with two regimens of neoadjuvant chemotherapy successively activated. Preoperatively, the patients received moderate doses of methotrexate and cisplatinum-Regimen 1- or high dose methotrexate, cisplatinum and adriamycin-Regimen 2. Cisplatinum was delivered intra-arteriously, the other drugs intravenously. Limb salvage surgery was performed in 20 patients, and 2 patients were amputated. The surgical margins were adequate (radical or wide) in 18 cases and inadequate (marginal) in 4. The histologic response to chemotherapy was good (90% or more tumor necrosis) in 8 patients. In both regimens postoperative chemotherapy was tailored according to the grade of necrosis determined by preoperative treatment on the primary tumor. At an average follow-up of 40 months (15-70), 15 patients (68%) remained continuously disease-free and 7 relapsed with metastases. No local recurrences were observed. Regimen 2 was slightly more effective than Regimen 1 in terms of good histologic response (5/10 vs 1/12) and continuous disease-free survival (8/10 vs 7/127). The results demonstrate that, as in osteosarcoma, in non-metastatic malignant fibrous histiocytoma of bone in the extremities a high percentage of patients can be cured with neoadjuvant chemotherapy and that in most of them limb sparing surgery is possible and safe.

Proximal femoral osteosarcoma: Diagnostic challenges translate into delayed and inappropriate management

BACKGROUND

The proximal femuris is an uncommon site of osteosarcoma. The unusual manifestations at this site may lead to diagnostic and therapeutic mistakes. We therefore performed a retrospective study to estimate the proportions of patients with imaging study findings and/or clinical manifestations typical for osteosarcoma and/or inappropriate treatment decisions.

HYPOTHESIS

Proximal femoral osteosarcoma often produces atypical clinical and radiological presentations.

MATERIAL AND METHODS

Consecutive patients who underwent surgery at our center to treat proximal femoral osteosarcoma were included. For each patient, we collected the epidemiological characteristics, clinical symptoms, imaging study findings, treatment, and tumor outcome. Proportions were computed with their confidence intervals.

RESULTS

Twelve patients had surgery for proximal femoral osteosarcoma between 1986 and 2015. Imaging findings were typical in 1 (8%) patient; they consisted of ill-defined osteolysis in 11/12 (92%) patients, a periosteal reaction in 1/12 (8%) patient, soft tissue involvement in 7/12 (58%) patients, and immature osteoid matrix in 11/12 (92%) patients. No patient had the typical combination of pain with a soft tissue swelling. Management was inappropriate in 2/12 (17%) patients, who did not undergo all the recommended imaging studies before surgery and were treated in another center before the correct diagnosis was established. At last follow-up, 4 patients had died (after a mean of 7 years) and 8 were alive (after a mean of 4 years).

CONCLUSION

Proximal femoral osteosarcoma is uncommon and rarely produces the typical clinical and imaging study findings. The atypical presentation often results in diagnostic errors and inappropriate treatments. Ill-defined osteolysis on standard radiographs should prompt computed tomography or magnetic resonance imaging of the proximal femur. Treatment in a specialized center is imperative.

LEVEL OF EVIDENCE

IV, retrospective study.

Prognostic significance of chemotherapy-induced necrosis in osteosarcoma patients receiving pasteurized autografts

Background

Among various reconstruction methods after wide excision for osteosarcoma, pasteurized autograft is often preferred. While the whole area of the tumor can be assessed for chemotherapy-induced necrosis, one of the important prognostic factors, in other reconstructive techniques, only a portion removed from a wide-resection specimen is available when using pasteurized autograft method. The assessment, therefore, may be unreliable. We analyzed the prognostic significance of the chemotherapy-induced necrosis in osteosarcoma patients who underwent reconstruction with pasteurized autografts.

Patients and methods

We reviewed the records of osteosarcoma patients who underwent treatment in our institution from 1998 to 2013. Cases of reconstruction with pasteurized autografts were defined as the patient group, and the same number of patients who underwent other reconstruction methods served as controls. Chemotherapy-induced necrosis was evaluated for removed extra-osseous and curetted intramedullary tumor tissues.

Results

A total of 22 patients were identified; the median age was 15.5 years, and there were 12 males. The most common tumor location was the distal femur. The most common histological subtype was osteoblastic. Median size was 8.1 cm. Disease status was stage IIB in 13 patients and IIA in 9. Median follow-up was 76 months. No differences between the patient and control groups were observed in potential prognostic factors, overall survival, metastasis-free survival, or recurrence-free survival. Univariate analyses demonstrated that histological response was a significant prognostic factor for metastasis-free survival and also significant for recurrence-free survival.

Conclusion

Chemotherapy-induced necrosis grading, using only available tumor tissues, could be a prognostic factor for osteosarcoma patients receiving pasteurized autografts for reconstructive surgery.

Serum CEACAM1 Level Is Associated with Diagnosis and Prognosis in Patients with Osteosarcoma

Carcinoembryonic antigen related cell adhesion molecule 1 (CEACAM1) is a trans-membrane multifunctional cell adhesion molecule associated with tumor cell proliferation, apoptosis, angiogenesis, invasion, and migration during tumor development. In the present study, we evaluated serum CEACAM1 level in osteosarcoma patients to explore its diagnostic and prognostic value for this particular malignancy. Sera from 113 patients with primary osteosarcoma, 98 patients with benign bone tumors and 126 healthy controls were obtained. Serum CEACAM1 level was measured with ELISA and correlation with clinicopathological characteristics was further analyzed. Receiver operating curves (ROC), Kaplan-Meier curves, and log-rank analyses as well as Cox proportional hazard models were used to evaluate diagnostic and prognostic significance. The results revealed that serum CEACAM1 level was significantly higher in osteosarcoma patients compared to benign bone tumors and healthy controls (455.2 ± 179.9 vs 287.4 ± 103.2, 260.8 ± 109.7 pg/ml, respectively). Osteosarcoma patients with larger tumors, later-tumor stages, low tumor grades, and distant metastases had much higher CEACAM1 compared to those with smaller tumors, earlier tumor stages, high tumor grades and non-distant metastases (P < 0.05 for all). Multivariate logistic regression analysis confirmed that high serum CEACAM1 level was an independent risk factor for distant metastases (OR = 3.02, 95%CI 1.65–4.17). To distinguish osteosarcoma patients from those with benign bone tumor and healthy controls, ROC/AUC analysis indicated an AUC of 0.81 (sensitivity 0.61; specificity 0.89) and an AUC of 0.77 (sensitivity 0.57; specificity 0.92), respectively. Osteosarcoma patients with higher CEACAM1 had relatively lower survival compared to those with low CEACAM1 (P < 0.01), and multivariate analyses for overall survival revealed that high serum CEACAM1 level was an independent prognostic factor for osteosarcoma (HR = 1.56, 95%CI 1.23–3.28). The present study suggested that elevated serum CEACAM1 level might be a novel diagnostic and prognostic biomarker for osteosarcoma patients.

[Bipolar prosthetic replacement for proximal femoral tumors]

OBJECTIVE

To evaluate the effectiveness of bipolar prosthetic replacement for proximal femoral tumors from the perspectives of patient survival, prosthesis survival, functional outcomes, and complication rates.

METHODS

Between July 2001 and July 2010, 96 patients with proximal femoral tumors underwent wide resection and bipolar prosthetic replacement, including 83 cases of primary femoral tumors and 13 cases of soft tissue sarcomas involving the proximal femur. There were 50 male and 46 female patients with a mean age of 43.2 years (range, 15-69 years). Prosthetic replacement for proximal femoral tumors was used in 85 patients and deactivated bone-prosthetic complex was used in 11 patients. According to Enneking staging, the patients were divided into 3 groups: group A, 24 patients at stages IA, IB, and benign lesion; group B, 56 patients at stages IIA and IIB; and group C, 16 patients at stage III, myeloma, and lymphoma. The American Musculoskeletal Tumor Society 1993 version (MSTS93) functional score was used to evaluate the lower limb function.

RESULTS

Primary healing of incision was obtained in 93 patients; 3 patients had poor healing, which was cured after debridement. Of the patients, 89 were followed up 6.5 years on average (range, 1-10 years). During follow-up, 28 patients died of tumor. The 5- and 10-year survival rates of patients were 100% in group A, and were 56.5% and 41.5% in group B respectively, and the 5-year survival rate was 18.4% in group C; there was significant difference among 3 groups (P < 0.01). The 5- and 10-year survival rates of prosthesis were 74.4% and 62.5%, which were significantly higher than those of patients in groups B and C (P < 0.01). Sixty-one patients were followed up 1-10 years (mean, 4.7 years) for functional evaluation. The mean MSTS93 score of the survival patients was 79% (range, 63%-95%) at last follow-up. Complications were observed in 15 patients (16.9%): hip dislocation in 2, delayed infection in 2, aseptic loosening in 8, severe acetabulum wear in 1, and hip pain in 2.

CONCLUSION

Bipolar proximal femoral prosthetic replacement for proximal femoral tumors can provide a satisfactory functional outcome, especially for tumors at stage II or III and myeloma and lymphorma patients. Revision is needed because of main late complications of aseptic loosening, hip pain, and acetabulum wear.

[Analysis of clinical prognostic factor for 99 patients with metastases of proximal femur]

OBJECTIVE

To identify the clinical features and independent predictors of survival in patients with metastases of proximal femur.

METHODS

In the study, 99 patients with proximal femoral metastatic lesions from 2003 to 2011 were analyzed retrospectively. The median age of patients was 56 years old (15-87 years old), and the most common diagnosis was lung cancer, followed by breast cancer. The overall survival rate after bone metastases was calculated using the Kaplan-Meier method. The prognostic factors were identified by univariate analysis using a Log-rank test and by multivariate analysis using Cox proportional hazards regression models.

RESULTS

The 0.5-, 1- and 2-year survival rates were 55.7%, 24.3% and 7.7%, respectively, with an average survival time of 10.34 months for patients with metastases of proximal femur. In univariate analysis, the number of bone lesions, viscera metastases, and sensitivity to hormone therapy of primary tumor were correlated with prognosis. By multivariate analysis using Cox regression, the dependence to hormone therapy of primary tumor was the only independent prognostic factor.

CONCLUSION

Patients with femoral metastatic lesions can be operated safely and with acceptable complication rates. The prognostic factor analysis will help us to determine the appropriate surgical treatment for proximal femoral metastases.

Survival and ambulatory function after endoprosthetic replacement for metastatic bone tumor of the proximal femur

The purpose of this study was to clarify the ambulatory functional and oncological outcomes of tumor excision and endoprosthetic reconstruction for a metastatic lesion of the proximal femur. Subjects comprised 40 patients (18 women, 22 men; average age 63.4 years). The mean follow-up periods were 15.2 months for patients dying of the disease, and 38.7 months for survivors. Seven patients were lost to follow-up for 1.9 to 13.1 months. Endoprosthesis was performed after intralesional aggressive curettage in 20 patients and following excision of the lesion with a clear margin, in another 20. Postoperative radiation therapy was carried out on 27 limbs (intralesional 13, marginal 6, wide 8). Chemotherapy was administered to 19 patients after discussion with the medical oncologist. The cumulative survival rates at 6 and 12 months were 60% and 35%, respectively, while the rates with ambulant status were 48% at 6 months and 34% at 12 months. An analgesic effect was achieved for all patients. Ambulatory function was restored in 34 patients with a mean ambulant period of 17.8 months; however, the other 6 patients remained non-ambulatory. The ambulant period expressed as a percentage of survival time averaged 75.9%. Though there was local recurrence in 4 of 40 patients, ambulant function was not affected. Postoperative ambulatory function was inferior in patients with a short life expectancy; those with moderate or long life expectancy are good candidates for endoprosthetic replacement after tumor excision and can regain ambulant function for as long as nearly 80% of the survival period.

Long-Term Clinical and Functional Outcomes After Treatment for Localized Ewing's Tumor of the Lower Extremity

PURPOSE

Retrospective review describing the 35-year University of Florida experience with Ewing's tumors of the lower extremity.

PATIENTS AND METHODS

Fifty-three patients were treated between 1971 and 2006. Thirty patients were treated with radiotherapy (RT) alone and 23 patients were treated with surgery +/- RT. Larger tumors and tumors of the femur were treated more often with definitive RT. Median potential follow-up was 19.2 years. Functional outcome was assessed using the Toronto Extremity Salvage Score (TESS).

RESULTS

Before 1985, 24% of patients were treated with surgery; since then, the rate has increased to 61%. The 15-year actuarial overall survival (OS), cause-specific survival (CSS), freedom from relapse, and limb preservation rates were 68% vs. 47% (p = 0.21), 73% vs. 47% (p = 0.13), 73% vs. 40% (p = 0.03), and 43% vs. 40% (p = 0.52), respectively, for patients treated with surgery +/- RT vs. RT alone. Excluding 8 patients who underwent amputation or rotationplasty, the 15-year actuarial local control rate was 100% for the surgery +/- RT group and 68% for the definitive RT group (p = 0.03). The ranges of the TESS for surgery +/- RT vs. RT alone were 70-100 (mean, 94) and 97-100 (mean, 99), respectively. Twenty-six percent (6/23) of patients had complications related to surgery requiring amputation or reoperation.

CONCLUSIONS

Overall survival and CSS were not statistically compromised, but we observed an increased risk of relapse and local failure in patients treated with RT alone, thereby justifying a transition toward primary surgical management in suitable patients. However, despite an adverse risk profile, patients treated with RT alone had similar long-term amputation-free survival and demonstrated comparable functional outcomes. Poor results observed in Ewing's of the femur mandate innovative surgical and RT strategies.

Total hip replacement for proximal femoral tumours: our midterm results

Data from 44 patients (23 males, 21 females) with a median age of 39 (range 13-80) years who underwent total hip arthroplasty for proximal femoral tumours (1994-2004) were analysed. The histological diagnoses included 14 metastases, six osteosarcomas, six chondrosarcomas, four Ewing's sarcomas, four giant cell tumours, three malignant fibrous histiocytomas, two parosteal and two periosteal osteosarcomas, and one each primary neuroectodermal tumour, myeloid disease, and aneurysmal bone cyst. Twenty-one patients (48%) had pathological fractures. The cause of the pathological fracture was metastasis in 12 patients (57%). Twenty-eight patients (64%) had soft tissue invasion. Complications observed in 17 patients (37%) were local recurrence in two, postoperative haematoma in two, dislocation of prosthesis in five, deep infection in six, and one patient died of myocardial infarction in the early postoperative period. During our midterm survival analysis, functional results were excellent in 25% of patients, good in 57%, fair in 12%, and poor in 6%.

Long-term follow-up after limb salvage in skeletally immature children with a primary malignant tumor of the distal end of the femur

BACKGROUND

Skeletally immature children with a primary malignant tumor in the distal end of the femur are candidates for limb-salvage surgery; however, functional impairment due to subsequent limb-length discrepancy must be considered. Our aim was to evaluate the long-term clinical outcome of limb salvage in patients with a sarcoma of the distal end of the femur who were eleven years old or less, focusing on limb-length discrepancy and complications.

METHODS

The cases of forty children were retrospectively reviewed in a multicenter study based on the responses to a questionnaire. Twenty-eight patients had had endoprosthetic reconstruction, and twelve had had biological reconstruction. Functional evaluation was based on the Musculoskeletal Tumor Society scoring system, with numerical values from 0 to 5 points assigned for each of the following six categories: pain, function, emotional acceptance, use of supports, walking ability, and gait. These values were added, and the functional score was presented as a percentage of the maximum possible score. Limb-length discrepancy was measured with orthoroentgenograms. Complications and their treatment were analyzed. Patient survival and the survival of the reconstructions were analyzed with use of the Kaplan-Meier method.

RESULTS

Seven patients died and thirty-three remained alive, for a survival rate of 82% at ten years postoperatively. For the surviving patients, the mean follow-up periods (and standard deviations) were similar for the twenty-two who had endoprosthetic reconstruction (13.2 +/- 3.9 years) and the eleven who had biological reconstruction (10.4 +/- 4.4 years). All patients had reached skeletal maturity. The mean final functional score was 74% +/- 18% in the endoprosthetic reconstruction group and 68% +/- 17% in the biological reconstruction group (p = 0.37). For the nineteen patients who underwent limb-lengthening, the mean functional score increased significantly from 65% +/- 21% before the procedure to 81% +/- 11% after the lengthening (p = 0.0016). There were five early and twenty-eight late complications. In the endoprosthetic reconstruction group, the most frequent complications were deep infection and aseptic loosening. In the biological reconstruction group, the most frequent complications were implant breakage and nonunion. Revision surgeries were required in seventeen patients, including five who had an amputation. The rate of survival of the endoprosthetic reconstructions was 77% at five years and 51% at ten years postoperatively, whereas the rate of survival of the biological reconstructions was 46% at both five and ten years postoperatively.

CONCLUSIONS

Endoprosthetic or biological reconstructions as limb salvage provided good functional outcome in skeletally immature children with a malignant bone tumor of the distal aspect of the femur despite a high rate of revisions and limb-lengthening procedures.

Outcome in two groups of patients with allograft-prosthetic reconstruction of pelvic tumor defects

To predict the outcomes obtained with allograft-implant composite reconstruction of pelvic defects after bone tumor resection better, a retrospective review of a prospectively collected database was done and two groups of patients were identified. These groups were compared with respect to oncologic and functional outcomes in this investigation. Group 1 included 21 patients with allograft total hip replacement reconstruction for pelvic bone tumors that required Type I and II or Type I, II, and III pelvic resections. Group 2 included five patients who required an acetabular allograft in combination with proximal femoral replacement for reconstruction of Type II pelvic resections done to treat proximal femoral bone sarcomas that invaded or surrounded the hip joint. Functional assessment was measured with three instruments (Toronto Extremity Salvage Score, Musculoskeletal Tumor Society 1987, and the Musculoskeletal Tumor Society 1993 scores). In Group 1, nine of 19 evaluable patients (two patients died in the immediate postoperative period) either retained the allograft until their death or were still alive at last followup with their allograft in place. An additional patient had revision surgery to an allograft-saddle composite that remains intact. The functional results in Group 1 were influenced heavily by the occurrence of deep infection. Nine of 19 evaluable patients developed infection, with seven patients requiring either removal of the graft (three patients) or hindquarter amputation (four patients). Two patients retained their infected allografts with long-term antibiotic suppression. In 10 Group 1 patients who did not develop infection, reasonable functional results were obtained. Group 2 patients had no infections and better functional results.

LEVEL OF EVIDENCE

Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Dislocation rate after hip hemiarthroplasty in patients with tumor-related conditions

BACKGROUND

Hemiarthroplasty is frequently used to treat femoral neck insufficiency resulting from neoplastic disease in the proximal part of the femur. The authors of a recent study analyzed the dislocation rates following hemiarthroplasty but excluded patients with tumor involvement of the site of the surgery as they hypothesized that the dislocation rates would be markedly higher in such patients. The current study was performed to compare the dislocation rate following hemiarthroplasties performed in patients without tumor involvement with the rate following hemiarthroplasties in patients with tumor involvement of the surgical site.

METHODS

Patients who had undergone hemiarthroplasty following resection of a tumor involving the proximal part of the femur were identified in a total joint registry, and the patients' charts were reviewed retrospectively to determine dislocation rates, preoperative conditions, and postoperative outcomes and treatments. Between 1974 and 2001, 1812 patients were treated with hemiarthroplasty for reasons other than tumor involvement and 320 hemiarthroplasties were performed because of tumor-related conditions. The patients who were treated for a tumor-related condition were younger, and a higher proportion of them were men.

RESULTS

The ten-year dislocation rate after the hemiarthroplasties performed for tumor-related conditions (10.9%) was higher than that following the hemiarthroplasties performed for non-tumor-related conditions (2.1%) (p = 0.002). The median time to dislocation in the patients with a tumor-related condition (twenty-four days) was shorter than that for the patients without tumor involvement (thirty-seven days). Preservation of the greater trochanter in patients with tumor involvement did not have a significant influence on the dislocation rate, but it showed a favorable trend toward decreasing that rate (hazard ratio = 3.5, p = 0.06).

CONCLUSIONS

The short-term and long-term dislocation rates associated with hemiarthroplasties performed for a tumor-related condition at the site of the surgery were significantly higher than those associated with hemiarthroplasties performed for reasons other than tumor involvement. Preservation of the greater trochanter showed a trend toward decreasing the likelihood of dislocation following the hemiarthroplasty, and it was more influential than the level of resection and the extent of soft-tissue compromise. We think that preservation of the greater trochanter should be attempted when it is justifiable according to the principles of oncologic surgery.

Unreamed femoral nail with spiral blade in subtrochanteric fractures: experience of 55 cases

OBJECTIVE

To evaluate the use of the unreamed femoral nail with spiral blade (UFN-SB) in the treatment of subtrochanteric femoral fractures.

DESIGN

A retrospective review of a consecutive series of 55 fractures. Fourteen patients had metastatic disease (four had prophylactic nailing).

RESULTS

In five fractures, the UFN-SB failed: there was migration in three cases and breakage of the spiral blade in two cases, with breakage of the nail in two cases. Revision surgery was necessary in four cases. Five out of seven complications related to the spiral blade were seen in patients with a Seinsheimer fracture Type IIC or V. All other fractures healed within 1 year including those that needed revision surgery. In two cases the end result was THR.

CONCLUSIONS

No complication was observed in pathological fractures, which may be because of a high mortality in the first 4 months after surgery due to co morbidity. The main advantage of the nail seems to be its ease of use. It can be inserted through a small incision. The options in spiral blade angle insertion make it a very versatile implant. The implant should probably not be used in Type IIC or V (Seinsheimer) fractures.

Stage-IIB osteosarcomas around the knee. A study of MMP-9 in surviving tumour cells

We studied 55 patients with stage-IIB osteosarcoma around the knee with respect to the expression of matrix metalloproteinase (MMP)-9 in the surviving tumour cells in surgical resection specimens. They were followed up for a minimum of 2.5 years. Factors significantly associated with poor overall survival were a high serum level of alkaline phosphatase at diagnosis and tumour cells expressing MMP-9 in the resection specimens. The only factor strongly associated with disease-free survival was the immunohistochemical status of tumour cells for MMP-9 in the resection specimens. The percentage of necrosis after chemotherapy failed marginally to reach statistical significance. On Cox regression analysis only MMP-9 remained significant for overall and disease-free survival.

[Treatment outcome after surgical management of osseous breast carcinoma metastases. Preventive stabilization vs. management after pathological fracture]

AIM OF THE STUDY, METHOD: The advantages of a prophylactic care of fracture-endangered, osseous metastasis of the mammary cancer stand opposite to the perioperative risk and to conservative alternatives. As a pathologic fracture cannot surely be excluded while performing a conservative proceeding, a retrospective trial was set up to compare the results of treatment after a pathologic fracture (n = 35) with those undergoing a prophylactic attendance (n = 44).

RESULTS

The intraoperative, cardio-pulmonary complications were distributed in balance totally amounting to 20.3% (n = 16). Intraoperative complications concerning surgical procedure (n = 3) exclusively occurred within the fracture group. Generally, postoperative complications arose in 20.3% (n = 16) of all cases, in which the patients belonging to the fracture group were increasingly afflicted [28.6% (n = 11/35) vs. 11.4% (n = 5/44); p < 0.02]. While there were no differences between both groups concerning the postoperative, surgery-technical complications, significantly more patients (91.8% [n = 40/44]) of the prophylactic-care group achieved a complete postoperative usability of the operated area than in the fracture-group [74.3% (n = 26/35)] (p < 0.05). The average survival time tended to be longer within the prophylactic-care group [19.3 +/- 15.6 month (prophylactic-care group) vs. 15.0 +/- 16.9 month (fracture group)].

CONCLUSIONS

The prophylactic treatment of fracture endangered, osseous metastasis of the mammary cancer leads to reduction of the general, postoperative complications compared to the patients with a pathologic fracture. Further, those patients have a better chance to recover full mobility after surgery. Considering the long survival time after the incidence of osseous metastasis at the mammary cancer a prophylactic treatment represents the method of first choice compared with the conservative treatment which persistently contains the risk of fracturing.

Definitive intraoperative very high-dose radiotherapy for localized osteosarcoma in the extremities

PURPOSE

To evaluate the outcome and adverse effects in patients with osteosarcoma treated with very high-dose definitive intraoperative radiotherapy (IORT), with the intention of saving the affected limb.

METHODS AND MATERIALS

Thirty-nine patients with osteosarcoma in their extremities were treated with definitive IORT. The irradiation field included the tumor plus an adequate wide margin and excluded the major vessels and nerves. Forty-five to 80 Gy of electrons or X-rays were delivered. The median follow-up of the surviving patients was 124 months.

RESULTS

The cause-specific and relapse-free 5-year survival rate was 50% and 43%, respectively. Distant metastasis developed in 23 patients; 19 died and 4 were alive for >10 years. Nine local recurrences were found 4-29 months after IORT in the affected limb. No radiation-induced skin reaction or nerve palsy was observed in the patients treated with X-rays. Experiments using phantoms also confirmed that the scatter dose was below the toxic level in the IORT setting with X-rays.

CONCLUSIONS

Very high-dose definitive IORT combined with preventive nailing and chemotherapy appeared to be a promising quality-of-life-oriented alternative to treating patients with osteosarcomas in the extremities, although the problem of recurrences from the surrounding unirradiated soft tissue remains to be solved.

Bone reaction induced by femoral stem of titanium alloy endoprosthesis for malignant bone tumors at the distal femur

We demonstrated radiological evaluations after limb salvage surgery with an uncemented titanium endoprosthesis possessing a rotating hinge-type knee joint for 7 patients with malignant bone tumors at the distal femur. Although radiographically, cortical hypertrophy and new bone formation at the junction between implant and cortex appeared in all cases, there was a small quantity of subsidence of the implant in all cases. Loosening of the stem was found in 2 patients at 4 and 9 years after surgery. However, after revision surgery, the function restored as before. The latest average functional score according to the system of the International Society of Limb Salvage was good, being 73%.

Relationship between dose-intensity of treatment and outcome for patients with osteosarcoma of the extremity treated with neoadjuvant chemotherapy

One hundred and forty-four patients with osteosarcoma of the extremity treated with neoadjuvant chemotherapy at the authors' institution between 1986 and 1989 were retrospectively analyzed to evaluate the relationship between the dose-intensity of chemotherapy actually received (RDI) and the prognosis. Preoperative chemotherapy consisted of high-dose methotrexate i.v., cisplatin i.a., and doxorubicin i.v. After surgery "good responder" patients (90% or more tumor necrosis) had a 31-weeks of chemotherapy with the same drugs, while "poor responder" patients (less than 90% tumor necrosis) received a 40 weeks treatment with ifosfamide and etoposide added to the three drugs used preoperatively. Due to delays and dose-reductions, only 17 patients (12%) received the treatment exactly as scheduled by the protocol, 66 (46%) received a dose-intensity between 90 and 99%, and 61 (42%) a dose-intensity between 63 and 89%. At a follow-up ranging between 10 and 13 years, 97 patients (67%) remained continuously free of disease, 45 relapsed, and two died of doxorubicin-induced cardiopathy. The continuous disease-free survival (CDFS) was not related to patients' gender and age, tumor histology, site and size, serum value of alkaline phosphatase, type of surgery and histologic response to chemotherapy. According to the RDI, CDFS resulted significantly higher for those 81 patients who received 90% or more of the scheduled dose-intensity than for those 61 who had less than 90% of the scheduled dose-intensity (76.5% v.s. 57.3%; p<0.02). These results seem to suggest that in neoadjuvant treatment of osteosarcoma the dose-intensity of chemotherapy is crucial for outcome, therefore every effort should be made to avoid reductions of doses and/or delays in performing the cycles of chemotherapy.

Long-term followup of uncemented tumor endoprostheses for the lower extremity

Between 1982 and 1989, 100 primary lower limb reconstructions were done using the Kotz Modular Femur Tibia Reconstruction System after resection of a malignant tumor. In 32 patients a proximal femur prosthesis was implanted, in 40 patients a distal femur prosthesis was implanted, in 19 patients a proximal tibia component was implanted, in four patients a total femur prosthesis was implanted, and in five patients a total knee prosthesis was implanted. The Kaplan-Meier estimate of the overall survival rate of the prostheses was 85% after 3 years, 79% after 5 years, and 71% after 10 years. The most common reason for implant failure was aseptic loosening in 27% of patients (11 patients; range, 10-121 months) after the initial operation. The other reasons for revision surgery were implant fracture (n 5 4) and infection (n 5 4). Early repair of prostheses-related minor complications, such as worn polyethylene bushings, resulted in a statistically significant reduction of implant failure. After a median followup of 127.5 months after the initial surgery, 51 patients had died and eight patients were lost to followup. Forty-one patients were evaluated clinically and radiologically using the Musculoskeletal Tumor Society score and the radiologic implant evaluation system of the International Symposium on Limb Salvage; these 41 patients had a mean of 80% (range, 40%-100%) of the normal functional capability.

Functional outcome following surgical treatment of metastatic tumors involving the femur

Thirty-eight patients treated surgically for metastatic tumors of the femur were reviewed to evaluate the effects of surgical treatment on quality of life. Average age at surgery was 59 years. The most common origin site of metastatic tumors was the lung. The intertrochanteric area was involved in 14 patients, followed by the subtrochanteric area in 11, femoral neck in 7, and shaft in 6 patients. Surgery was based on the principles that tumor excision should be maximal, and to permit early postoperative ambulation, internal fixation should be rigid with cement augmentation. Types of internal fixation were applied according to lesion site to allow early ambulation and included intramedullary nailing (11), compression hip screw (9), and Rowe plates (7). Prosthetic replacement was performed in 9 patients. Average performance scores improved from 3.8 preoperatively to 2 postoperatively, based on the Functional Classification of the New York Heart Association. In 31 patients (82%), the degree of pain relief was more than a lot according to the criteria of Kaiko. Thirty-five patients survived >5 months postoperatively. In patients with a single metastatic lesion, survival was 21 months, and in patients with multiple lesions, survival was 10 months. Surgical stabilization of a pathologic lesion involving the femur resulted in improvement in the quality of life, including pain relief and early ambulation. In selected patients with a single metastatic lesion and a low-grade primary tumor, prolonged postoperative survival may be expected.

[Proximal femoral reconstruction with megaprosthesis versus allograft prosthesis composite. A comparative study of functional results, complications and longevity in 41 cases]

PURPOSE OF THE STUDY

To compare femoral reconstruction using megaprosthesis versus allograft prosthesis composite.

MATERIAL AND METHODS

Forty-one consecutive proximal femoral reconstructions with an allograft-prosthesis composite (21 cases) or a megaprosthesis (20 cases) after tumor resection were reviewed in a retrospective study. The following criteria were considered: functional outcome; long term survival; complications. Chi-square test and Wilcox tests were used to compare groups. The medium and long-term survival curves for these reconstructions were made using the Kaplan-Meier standard methods. The failure of prosthesis was defined as revision for mechanical failure (either aseptic loosening or dislocation), for infection or local recurrence. The comparison of the curves was performed using the Log-Rank test.

RESULTS

Infection (10 p. 100) and instability, in both groups, and loosening, in the megaprosthesis group, were the common causes of failure. There was difference between functional results in the two groups (limping and crutches using was more lower in allograft-prosthesis composite group). Survival analysis showed a 5 and 10-year survival of 77 +/- 12 p. 100 for the patients with composites. Five and ten - year survival were 73 +/- 11 p. 100 and 0 p 100 respectevely for those with megaprostheses. No significant difference was noted between survival of these two groups but a tendancy (p =0.09). Radiological allograft resorption was noted for more than 50 p. 100 of allograft composite prosthesis without modification of functional result or symptomatic loosening.

DISCUSSION

The functional results seem better in the composite group when compared to the megaprosthesis group. Reconstruction of the abductor mechanism is essential to stabilize the prosthesis and to decrease the limp. When the great trochanter cannot be preserved, we used suture of gluteus medius tendon to tensor of fascia lata, which is re-enforced using a piece of biceps femoris. The dislocation rate was approximately the same in our two groups. Several authors reported a lower dislocation rate with composite reconstructions than massive prosthesis. The rate of infection is similar to other reported series. In our study it has been possible to show a tendancy for superior survival of the composite reconstruction. When the review was later than 5 years the radiological appearance of the graft in our series was often concerning with resorption or fragmentation present in six of the eight cases. This radiological appearance is not as yet responsible for any revision or any change in the functional result however it does remain a worry.

CONCLUSION

Composite reconstructions probably allow a better functional result when considering proximal reconstruction of the femur. The radiological appearance of these allografts in the long term is however worry some without any evidence so far of worsening functional level or any evidence of prosthetic loosening. It would seem to us that the current level of knowledge would advocate the use of massive allografts together with prosthesis. This does seem still to remain the best choice for proximal femoral reconstruction.

Doxorubicin-cisplatin chemotherapy for high-grade nonosteogenic sarcoma of bone. Comparison of treatment and control groups

OBJECTIVE

To evaluate the role of chemotherapy with a combination of doxorubicin (adriamycin) and cisplatin in high-grade, nonosteogenic, non-Ewing's sarcoma (non-OSA) of bone.

DESIGN

A case series comparison with a literature-derived control group.

SETTING

A university-affiliated tertiary care centre.

PATIENTS

Thirty patients with a diagnosis of non-OSA. Of these, 8 had low-grade disease (grade 1 or 2) and 22 had high-grade disease (grade 3). Eleven of the 22 with high-grade disease had malignant fibrous histiocytoma. Seventeen patients with nonmetastatic high-grade non-OSA were compared with a literature cohort of 37 patients who met the eligibility criteria of nonmetastatic, high-grade non-OSA treated with surgery, with or without radiotherapy. The mean follow-up was 25.2 months.

INTERVENTIONS

Eight patients with low-grade tumour underwent surgery alone; 22 patients with high-grade tumour underwent surgery and 6 courses of adriamycin (75 mg/m2 every 3 weeks) and cisplatin (100 mg/m2 every 3 weeks).

MAIN OUTCOME MEASURES

Disease-free survival and overall survival in those with high-grade tumours treated with or without chemotherapy.

RESULTS

Of 8 patients who had low-grade tumours and underwent surgery alone, 3 had systemic relapse. Of the 22 having high-grade tumours, 4 did not receive chemotherapy because of age and comorbid conditions. Of the other 18, 13 received 3 courses of chemotherapy preoperatively and 3 courses postoperatively, 4 received all 6 courses postoperatively and 1 received all chemotherapy preoperatively to treat metastatic disease. In the 17-patient cohort used for comparison with the literature control group, disease-free survival was 57% at a mean follow-up of 25.6 months and overall survival was 57% at a mean follow-up of 30.1 months. In the control group, disease-free survival was 16% at a mean follow-up of 20.9 months and overall survival was 26% at a mean follow-up of 29.9 months. These differences are significant: p = 0.0000, chi 2 = 41.61 for disease-free survival and p = 0.0000, chi 2 = 46.49 for overall survival.

CONCLUSIONS

The findings of this study support the use of adjuvant chemotherapy in patients with high-grade non-OSA, in whom malignant fibrous histiocytoma was the predominant histologic subtype.

Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors

BACKGROUND AND OBJECTIVES

Limb-sparing surgery has become the preferred surgical treatment of malignant bone tumors. The objective of this study was to evaluate factors that influence the morbidity and outcome of prosthetic knee replacement after resection of malignant tumors of the distal femur.

METHODS

Eighty-two patients who had a resection of malignant tumor of the distal femur and implantation of a segmental knee prosthesis (minimum follow-up, 2 years) were retrospectively reviewed.

RESULTS

Twenty-nine patients (35%) underwent 32 prosthetic revisions, 6 from perioperative wound complications, 13 from aseptic loosening, and 13 from other complications. The 3-, 5-, and 10-year Kaplan-Meier prosthetic survival rates were 82%, 71%, and 50%, respectively. On univariate analysis, patients who had more than 40% resection of the distal femur (P = 0.010) and those who had all their vasti muscles resected (P = 0.011) had significantly worse prosthetic survivals than the others. On multivariate analysis, resection of more than 40% of the distal femur was a significant negative prognostic factor for prosthetic survival (P = 0.017). Aseptic loosening was the primary cause of late prosthetic failure. Differences in the magnitude of resection influenced prosthetic survivorship more than prosthetic design.

CONCLUSIONS

In the distal femoral endoprosthetic replacement, higher short- and long-term complications were found after extensive resections. Aseptic loosening was the primary cause of prosthetic failure.

Ewing's sarcoma of the femur. Prognosis in 69 patients treated by the CESS group

We reviewed the treatment outcome of 69 patients with Ewing's sarcoma of the femur. The patients received chemotherapy according to the CESS 81 (n 14), CESS 86 (n 43), and CESS 91P (n 12) protocols. The 10-year relapse-free survival rates were 36%, 65%, and 65% (p = 0.01). 68 patients received local treatment. The primary tumor was treated by surgery without radiotherapy in 28 patients; 1 developed a local recurrence and 7 metastases. 10 patients received radiotherapy alone; 4 developed metastases and 4 local recurrences and metastases. 30 cases had a combination of surgery and radiotherapy; 7 developed metastases and 1 a local recurrence and metastasis. The survival of patients after radiotherapy alone was worse than that of patients after surgery with/without radiotherapy (p = 0.005). Pathological fractures (n 16) did not influence the prognosis.

Thallium-201 scintigraphy to assess effect of chemotherapy in osteosarcoma

Imaging results in patients with high-grade osteosarcoma of the extremities were reviewed to determine whether scintigraphic appearance correlated with histologic response to preoperative chemotherapy.

METHODS

Histologically, the percent tumor necrosis in specimens from 30 patients were classified into three grades: grade 1 = necrosis less than 60%, grade 2 = 60%-89% necrosis and grade 3 = diffuse necrosis greater than 90% based upon whole transverse sections. Scintigraphically, we analyzed 201TI uptake before and after preoperative chemotherapy. The changes in the tumor-to-background ratio were defined by an alteration ratio.

RESULTS

Of the 11 patients with a grade 1 response, the ratio showed -67.1% +/- 45.4% (mean +/- s.d.). Of the 9 patients with a grade 2 response, the ratio showed 37.9% +/- 29.9% of the 10 patients with a grade 3 response the ratio showed 105.5% +/- 12.4%. The ratios correlated well with the histologic grades (p < 0.0001; analysis of variance).

CONCLUSION

Thallium-201 scintigraphy accurately assesses the effect of chemotherapy on osteosarcoma.

Low grade central osteogenic sarcoma. A long-term followup of 20 patients

Osteogenic sarcoma is a heterogeneous family of tumors that has a variable biologic behavior. Low grade central osteogenic sarcoma is an uncommon form that is characterized by a long premorbid history and is compatible with prolonged survival after treatment. Twenty cases of low grade central osteosarcoma with long-term followup (16 [2.5-48] years) were studied retrospectively. The age distribution was broad (range, 15-83 years). All tumors arose in the lower limb. The primary symptom was pain; mean duration was 44 months (range, 1-180 months). A diagnosis of low grade central osteosarcoma was made primarily for 11 patients. For 9 others, fibrous dysplasia (3), nonossifying fibroma (2), fibroma (1), chondromyxoid fibroma (1), chondrosarcoma (1), and simple bone cyst (1) were diagnosed initially. Intralesional surgery was associated with recurrence in every case. Radical margins were not associated with local recurrence. Four recurrences were higher grade and 1 was dedifferentiated. Three of 4 patients with metastases died of their disease. Five- and 10-year survival was 90% and 85%, respectively. Histology and radiology are complementary for confirming the diagnosis. Low grade central osteosarcoma seems to be controllable by surgery alone if at least wide margins are used.

Ewing's sarcoma of the proximal femur

The cases of 16 patients with Ewing's sarcoma of the proximal femur treated in the era of multiagent chemotherapy were reviewed, with emphasis on the mechanical problem of tumor involvement in this structurally demanding site. Fourteen patients received chemotherapy and local radiotherapy as the initial primary treatment. One patient had chemotherapy and radiotherapy, followed by wide local resection. One patient had amputation, followed by chemotherapy, for pathologic fracture and extensive soft tissue involvement at presentation. Two local recurrences occurred. Excluding the 2 patients whose femurs were fixed prophylactically, the pathologic fracture rate was 79%. In addition, by excluding the 2 patients who died before fracture, the pathologic fracture rate was 92%. Nonunion occurred in 5 (71%) of the 7 pathologic fractures not treated by resection and required as many as 5 additional surgical procedures to obtain union. At latest followup evaluation (average, 6.3 years), 10 patients had no evidence of disease, 1 was alive with disease, and 5 had died of their disease. Options for management should include primary resection and reconstruction or prophylactic internal fixation after completion of chemotherapy plus or minus radiotherapy.

[Limb-salvage surgery in 60 patients with osteosarcoma]

Limb-salvage surgery plays an important role in the treatment of osteosarcoma. From 1974 to 1993, 104 patients with osteosarcoma were treated in our department. Sixty of them were treated with limb-salvage procedures. In fourty-four patients of stage II B receiving adjuvant chemotherapy, the five-year survival rate was 46.69%. The overall local recurrence rate was 15%. The infection rate was 12.9%, and mechanical complication occurred in 14.8% of the patients. The functional result was generally good. Improved concepts of en bloc resection and better reconstructive techniques suggest that limb-salvage procedures are not only possible but can provide excellent functional result in patients with osteosarcoma. Further work must be directed to reducing local recurrence and improving reconstructive techniques.

Neoadjuvant chemotherapy for the treatment of osteosarcoma of the extremities: excellent response of the primary tumor to preoperative treatment with methotrexate, cisplatin, adriamycin, and ifosfamide. Preliminary results

A total of 48 patients with non-metastatic osteosarcoma of the extremities were treated with a new neoadjuvant chemotherapy protocol which, prior to surgery, included the use of high dose methotrexate, cisplatin, adriamycin and ifosfamide. Cisplatin was administered intra-arterially, whereas the other drugs were given intravenously. In all of the cases response to this chemotherapy protocol was very good, allowing for conservative treatment in 46 out of 48 patients. Histological evaluation of chemotherapy response showed good (> 90%) and total necrosis in 87 and 54% of the cases, respectively. Drug toxicity was acceptable. Results were significantly better than those previously obtained in our and in other institutes when only three drugs were used (methotrexate, cisplatin, and adriamycin) in the preoperative treatment scheme. Since it has been demonstrated that grade of histological response to preoperative chemotherapy, and prognosis are closely related in osteosarcoma of the extremities treated with neoadjuvant chemotherapy, in addition to allowing for the use of conservative surgery in the majority of cases, this new protocol may also lead to a significant increase in the patient cure rate.

Impending and actual pathological fractures in patients with bone metastases of the long bones. A retrospective study of 233 surgically treated fractures

OBJECTIVE

Analysis of short-term and long-term complications after cemented osteosynthesis for pathological fractures.

DESIGN

Retrospective study.

SETTING

South Municipal Hospital and the Daniël den Hoed Cancer Centre, Rotterdam, The Netherlands.

SUBJECTS

199 patients consecutive surgically treated between 1978 to 1990 for 233 fractures (161 actual and 72 impending) caused by metastatic lesions of the femur, humerus and tibia.

INTERVENTIONS

Local resection of the tumour was followed by endoprostheses (n = 52) and by internal plate osteosynthesis (n = 167); 14 fractures were treated with intramedullary nails. Bone cement was added in 211 cases (91%).

MAIN OUTCOME MEASURES

Pain relief, mobilisation, complications.

RESULTS

Pain relief was achieved in about 90%. 145 (76%) who were treated for fractures of the lower extremity were able to walk again. There were 13 local complications: 26 (11%) implanted devices failed (cumulative probability 40%, after 60 months). In 11 cases the fixation failed after 7 weeks. The failure rate was 16% in the subtrochanteric region treated with an angled blade (probability 70% after four years). The patients' survival rate was 55% after six months and 20% at two years.

CONCLUSION

Despite the poor life expectancy, our results indicate that hemiarthroplasty or osteosynthesis with bone cement for treatment of pathological (impending) fractures is a safe way to restore limb function and to improve quality of life.

Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study

The outcome of treatment of nonmetastatic high-grade osteosarcoma in the distal part of the femur was studied in 227 patients from twenty-six institutions. Eight of the seventy-three patients who had had a limb-salvage procedure and nine of the 115 patients who had had an above-the-knee amputation had a local recurrence, but there was no local recurrence in the thirty-nine patients who had had a disarticulation at the hip. There were no significant differences in the rate of survival or in the duration of the postoperative disease-free period between the three groups. One hundred and nine patients (48 per cent) were alive at an average of eleven years after the operation, and ninety patients (40 per cent) remained continuously disease-free. An additional operation on the limb was necessary more often for patients who had had a limb-salvage procedure than for those who had had an amputation. Function in seventy-eight living patients was assessed with the system of the Musculoskeletal Tumor Society for evaluation of function and by the functional assessment portion of the 1989 scoring system of the Knee Society; the scores were higher for the patients who had had a limb-salvage procedure than for the two groups of patients who had had an amputation. No difference was identified between the groups with regard to the patient's acceptance of the postoperative state, the ability to walk, or the amount of pain. The quality of life was evaluated for twenty-nine patients with a series of complex questionnaires.(ABSTRACT TRUNCATED AT 250 WORDS)

[Special endoprostheses of the knee joint in bone tumors]

Since the introduction of more effective adjuvant therapies in the area of primary and secondary bone tumors, limb salvage procedures have become more and more important. At the Orthopedic Department of the Technical University, Munich, 52 special knee prostheses have been implanted in patients with malignant tumors of the distal femur and proximal tibia. On the basis of the ISOLS criteria, the functional results achieved were excellent in 14%, good in 47%, satisfactory in 35%, and poor in only 5% of patients after an average follow-up period of 43 months (range: 3-156 months). The perioperative complication rate was 27%, and late complications were material fatigue and wear. In the case of primary tumors, a customized prostheses, and in the case of secondary tumors a modular system is recommended. Individual treatment planning is essential.

Long-term survival after central nervous system relapse in a patient with osteosarcoma

BACKGROUND

Since the advent of multiagent adjuvant chemotherapy, survival among patients with localized osteosarcoma has improved to 60% or more. Pulmonary relapse, the most common cause of treatment failure, is associated with less than 25% long-term survival; central nervous system (CNS) metastasis, when it occurs, often presents as a catastrophic clinical event in preterminal patients.

METHODS

The authors report a patient with osteosarcoma who had an isolated pulmonary relapse and a subsequent isolated CNS relapse. Complete surgical resection was accomplished on both occasions and followed in the initial instance by adjuvant chemotherapy and in the latter instance by adjuvant whole-brain irradiation.

RESULTS

An isolated CNS metastasis was resected and adjuvant whole brain irradiation was administered; the patient is alive and relapse free more than 5 years later.

CONCLUSIONS

Patients with osteosarcoma in whom isolated, resectable metastases develop can derive benefit from gross total resection followed by adjuvant chemotherapy or radiation therapy for microscopic residual disease.

Prosthetic and extremity survivorship after limb salvage for sarcoma. How long do the reconstructions last?

Ninety-three consecutive prosthetic reconstructions performed for limb salvage after the resection of sarcomas of the lower extremity were reviewed to determine how long the reconstructions lasted, how successful they were in avoiding amputation in the long term, how significant a problem was aseptic loosening, and what was the associated patient survival. Reconstruction was of the proximal femur in 16, distal femur in 61 and proximal tibia in 16 patients. Minimum follow-up time was 24 months, with a median of 66 months and mean of 80 months. If any event leading to the removal of the prosthesis is considered a reason for failure, the event-free prosthetic survival at five years for the proximal femur was 88%, distal femur 59%, and proximal tibia 54%. Limb survival at five years was significantly better, with the proximal femur at 88%, distal femur at 88%, and proximal tibia at 78% intact. Aseptic loosening survival was better than the event free prosthetic survival, which demonstrates the influence of factors such as sepsis (hematogenous) or wound necrosis that lead to prosthetic removal. Aseptic loosening survivorship of the proximal femur at five years was 100%; distal femur, 78%; and the proximal tibia, 73%. At five years, patient survival was low for the proximal femur (62%) and distal femur (75%) but notably better for the proximal tibia (93%). Prosthetic, extremity, and patient survival differed depending on the site. Wound necrosis was a significant cause of prosthetic removal and loss of limb early in this series, but the more aggressive use of soft tissue procedures has improved this.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term follow-up results after heavy dose chemotherapy of primary malignant bone tumors of the limbs]

Ninety-three cases of primary malignant bone tumors of the limbs were treated for 651 times with preoperative and postoperative HD-MTX-CFR regimen. A number of toxic side reactions appeared, most of which were those of the digestive tract. The side reactions treated symptomatically subsided uneventfully All cases were followed up for 5-7 years, 36 patients died and 57 survived with a 5-year survival rate of 61.3%. A new method to limb salvage was used in 44 cases: the bone segment with tumor was amputated, and replanted back after inactivation with alcohol excision. The five-year survival rate was 63.6%. The excellent results of treatment gave the patients new hope dispelling the misgivings of becoming disabled.

Limb salvage surgery for locally aggressive and malignant bone tumors

Since 1983, 77 patients have had limb salvage surgery for locally aggressive or malignant bone tumor of the limbs or pelvis. Twenty-nine patients had locally aggressive lesions with giant cell tumors the most prevalent, and 48 patients had malignant lesions, of which osteosarcomas predominated. Resection with a wide margin could be achieved in most of the patients. A mobile joint reconstruction was performed in 57 patients and an arthrodesis in 14 patients. At follow-up, 14 patients have died of disease, 7 patients have survived with disease, and 56 patients (73%) have survived without disease. Local recurrences were encountered in 4 patients (5%). The overall functional results were classified as excellent in 11 patients, good in 45 patients, and fair in 9 patients. Twelve patients had poor results because of failure of the reconstruction or amputation due to complications. Twenty-seven complications were encountered, among which infection was the most serious. Careful selection of patients and consideration of procedure chosen to reconstruct the defect are important for a successful outcome. This decision is based on a number of factors related to the tumor and the patient. Presently, major neurovascular involvement, displaced pathological fracture, inappropriate biopsy incision, extreme youth of the patient, and infection were considered to be contraindications to resection in our institution. Although various procedures promise functional restoration, the reconstructive procedure should be individualized and designed to meet the needs of the patient.

Brain metastases in osteosarcoma. Report of a long-term survivor and review of the St. Jude Children's Research Hospital experience

BACKGROUND

Brain metastasis has been considered a rare event in osteosarcoma, although with prolonged survival an increasing incidence has been suggested. There have been no prior reports of long-term survivors among patients with this complication.

METHODS

The authors describe a child treated for osteosarcoma who is alive and free of disease 8 years after the detection of brain metastases. Of 254 patients with primary osteosarcoma referred to St. Jude Children's Hospital between 1962 and 1989, 13 developed brain metastases, all after relapse or recurrence in another site. Concomitant active lung metastases were present in all of the patients except the one long-term survivor, whose pulmonary disease had responded to treatment with cisplatin and doxorubicin. Log-rank analyses were used to compare survival duration and the frequency of brain metastases among patients treated before and after 1982, when effective multiagent therapy was initiated.

RESULTS

Log-rank analyses comparing patients treated before and after 1982 showed that the introduction of effective modern therapy improved survival among patients at risk for brain metastases (i.e., those with recurrent and progressive disease, P = 0.007) but was not associated with a statistically significant increase in the frequency of brain metastases (15.5% versus 4.5%, P = 0.125).

CONCLUSIONS

Although the outlook for patients with this complication remains bleak, the resolution of brain metastases after eight courses of ifosfamide in the patient described in this article suggests that enrollment of selected patients in Phase II trials is merited.

[Diagnosis and treatment of primary malignant fibrous histiocytoma of bone]

Eleven cases of primary malignant fibrous histiocytoma of bone treated surgically were reported. There were 7 males and 4 females, with age ranged from 29 to 50 years (mean age 35.3 Yrs). The sites of involvement were femur (3 cases), tibia (3), humerus (2), radius (1) temporal bone, (1) and maxilla (1). The prominent findings in these cases were pain and swelling associated with regional mass. Differential diagnosis should be made from giant cell tumor, fibrosarcoma, osteosarcoma reticulum cell sarcoma and osteomyelitis. We in order to improve survival rate, think the ablative surgery should be the therapy of choice with post operational adjuvant chemotherapy. The five-year survival was 44% in these cases.

Improved results in osteogenic sarcoma 1973-79 vs. 1980-86: analysis of results from a single center

Analysis of treatment results in osteogenic sarcoma patients with classical limb primary tumors and without metastasis at diagnosis or major protocol violations showed improved prognosis with a minimum follow-up of over 5.5 years when divided by years of treatment for all event-free survivors. Twelve patients treated in 1980-86 had a 5-year disease-free survival of 67% and 9 treated in 1973-79 had a 5-year disease-free survival of 33% (P = 0.0368). The improvement appeared to reflect the increase in the intensity of the chemotherapy utilized. Definitive surgery, amputation or limb salvage did not affect the outcome. With these surgical approaches the disease-free survival was 67% and 60% respectively.

[A surgical method in the complex treatment of metastatic bone tumors]

The article deals with the results of operations applied in the system of complex treatment of 83 patients (86 operations) with metastases of malignant tumours in the skeletal bones. Fourteen patient had carcinoma of the lung, 23--carcinoma of the breast, 28--carcinoma of the kidney, 8--carcinoma of the thyroid gland, and 10 patients had other malignant tumors. Operative interventions in the form of resection of the articular end or total removal of a tubular bone with endoprosthesis in affection of a long tubular bone and its pathological fracture or the threat of such fracture were substantiated. In the presence of special indications, osteosynthesis of the pathological fracture or amputation (exarticulation) of the limb may be undertaken. Laminectomy is indicated in metastatic lesion of the spine with the development of neurological disorders. Four (5%) patients died in the postoperative period. Average survival in the group of patients was 35 months, in the separate groups it was as follows: lung carcinoma metastases--9 months, kidney carcinoma metastases--31 months, thyroid carcinoma metastases--37 months, breast carcinoma metastases--40 months, metastases of other forms of malignant tumors--30 months. Longest survival--7.5 years. Average value of life quality according to Karnovsky was 30% before operation and 67% after it.

Rotationplasty in segmental resections of the femur

The authors report 26 cases of high-grade malignant tumors of the distal femur (23 osteosarcomas, 3 Ewing's tumors) submitted to rotation-plasty. The five-years actuarial survival rate (in the 23 cases of osteosarcoma) was 69% and there was no incidence of local recurrence. The following complications were observed: wound dehiscence (6 cases), arterial thrombosis (in 2 patients submitted to resection and vascular termino-terminal suturing), paralysis of the sciatic nerve (2 cases), delay in consolidation (2 cases), traumatic fracture of the neo-femur (3 cases). All of the complications were resolved favorably, 5 of these requiring surgical treatment (33%). Satisfactory functional results were obtained in all of the cases, except in one patient who had limitation of the ankle joint subsequent to vascular compartmental syndrome. On the basis of the oncological, functional and biomechanical results reported in this study and in the literature, the authors discuss current indications for rotation-plasty.

Local growth and the prognosis of osteosarcoma

We have analysed 63 patients who had stage II osteosarcoma of the distal femur (32) or proximal tibia (31) to determine the patterns of disease-free and overall survival in relation to local growth. All had neoadjuvant chemotherapy. The extent of local growth predicts both types of survival in these tumours.

Pathological fractures of the femur: improvement of quality of life after surgical treatment

Radiotherapy and chemotherapy will result in an increase in the number of pathological fractures that occur, principally as a consequence of metastatic disease. These lesions are painful, especially at the level of the femur, and are apt to make invalids of the patient. If surgical intervention is applied as quickly as possible, (compound double-plate osteosynthesis or endoprosthesis), preferably before the lesion becomes a real fracture, the patient still has a chance of keeping a good, painless and well-functioning limb. This report concerns 40 patients with 48 pathological femoral fractures. Seventy-five percent of the lesions were localised at the level of the proximal extremity (femoral head or neck, trochanteric region, subtrochanteric region). Twenty cases were treated with an endoprosthesis, 28 by osteosynthesis; 4 patients died within the 1st month after surgery. In two of them, the data when considered post-facto were judged to show that any surgery would be too risky. Forty-five percent of patients survived for more than 1 year after operation. The average survival time of the whole group was slightly over 10 months. One patient is still going strong more than 35 months after surgery. Survival time was essentially dependent on the primary underlying malignant process. The results obtained have been more than reasonable: in 67% recovery of walking capacity, in 75% an effective fight against the pain.

The Van Nes tibial rotationplasty. A functionally viable reconstructive procedure in children who have a tumor of the distal end of the femur

Twelve patients who had a malignant tumor of the distal end of the femur were treated with a Van Nes tibial rotationplasty. The survival rates were comparable with those for above-the-knee amputees and patients who had an endoprosthetic replacement. The results of functional testing showed that these patients performed as well as those who had endoprosthetic replacement and better than those who had above-the-knee amputation. Rotationplasty is therefore a favorable alternative to amputation or endoprosthetic replacement, either as a primary or as a salvage procedure.

Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures

A retrospective study of the surgical treatment of 166 metastatic lesions of the humerus and femur in 147 patients was performed. There were 106 women and 41 men whose average age was 62 years. Two-thirds of the patients were treated for complete fractures, while one-third were treated for impending fractures. Breast, lung, and kidney carcinoma accounted for the majority of the primary lesions. One-half of the patients died within nine months of surgery, while one-quarter were alive 19.1 months after surgery. The patients with breast cancer had the best prognosis, while the patients with lung cancer had the worst. The probability of implant failure increased linearly with time to 33% at 60 months. The probability of failure for the femoral lesions was greater, with 44% at 60 months. The average survival in the patients with failed fixation in the femoral lesions was 34.5 months with a mean interval to failure at 17.7 months. The failure rate was high (23%) in proximal femoral lesions treated with a compression screw or nail plate. Common reasons for failure included poor initial fixation, improper implant selection, and progression of disease within the operative field. Bone cement augmentation should be used with the fixation device when possible. Complications due to hip-screw cut-out from the head may also be reduced by applying bone cement around the screw threads.

[Ewing's sarcoma--report of 18 cases]

Eighteen cases of Ewing's sarcoma are presented. The mean age was 13 years. The male to female ratio was 2:1. Tumor occurred frequently in the long bones, especially the femur. The average course was 7 months. The main symptoms were pain, moderate fever, tumor mass with tenderness and leucocytosis. Diagnosis was established according to the clinical, radiological and pathological findings. In this series, the major treatment was radiotherapy alone or radiotherapy combined with chemotherapy. The mean survival time was 16 months with 2- and 5-year survival rate of 31% and 20%, respectively. Misdiagnosis and failure or interruption of the combined treatment were the main factors for poor prognosis.