Update in Imaging Evaluation of Bone and Soft Tissue Sarcomas.

The evolution in imaging evaluation of musculoskeletal sarcomas contributed to a significant improvement in the prognosis and survival of patients with these neoplasms. The precise characterization of these lesions, using the most appropriate imaging modalities to each clinical condition presented, is of paramount importance in the design of the therapeutic approach to be instituted, with a direct impact on clinical outcomes. The present article seeks to update the reader regarding imaging methodologies in the context of local and systemic evaluation of bone sarcomas and soft tissues.

Update in Imaging Evaluation of Bone and Soft Tissue Sarcomas / Atualização na avaliação por imagens dos sarcomas ósseos e das partes moles

Abstract The evolution in imaging evaluation of musculoskeletal sarcomas contributed to a significant improvement in the prognosis and survival of patients with these neoplasms. The precise characterization of these lesions, using the most appropriate imaging modalities to each clinical condition presented, is of paramount importance in the design of the therapeutic approach to be instituted, with a direct impact on clinical outcomes. The present article seeks to update the reader regarding imaging methodologies in the context of local and systemic evaluation of bone sarcomas and soft tissues.

Resumo A evolução na avaliação por imagens dos sarcomas musculoesqueléticos contribuiu para melhora significativa no prognóstico e na sobrevida dos portadores destas neoplasias. A caracterização precisa destas lesões, mediante utilização das modalidades de imagem mais adequadas a cada condição clínica apresentada, é de suma importância no delineamento da abordagem terapêutica a ser instituída, com impacto direto sobre os desfechos clínicos. O presente artigo busca atualizar o leitor a propósito das metodologias de imagem no contexto da avaliação local e sistêmica dos sarcomas ósseos e das partes moles.

Updating on Bone and Soft Tissue Sarcomas Staging.

Bone and soft tissue sarcomas consist of a heterogeneous group of malignant tumors of mesenchymal origin that can affect patients from any age. The precise staging of these lesions determines the best therapeutic strategies and prognosis estimates. Two staging systems are the most frequently used: the system proposed by the University of Florida group, led by Dr. William F. Enneking (1980) and adopted by the Musculoskeletal Tumor Society (MSTS), and the system developed by the American Joint Committee on Cancer (AJCC) (1977), currently in its 8 th edition (2017). This paper updates the reader on the staging of bone and soft tissue sarcomas affecting the musculoskeletal system.

Updating on Bone and Soft Tissue Sarcomas Staging / Atualização no estadiamento dos sarcomas ósseos e das partes moles

Abstract Bone and soft tissue sarcomas consist of a heterogeneous group of malignant tumors of mesenchymal origin that can affect patients from any age. The precise staging of these lesions determines the best therapeutic strategies and prognosis estimates. Two staging systems are the most frequently used: the system proposed by the University of Florida group, led by Dr. William F. Enneking (1980) and adopted by the Musculoskeletal Tumor Society (MSTS), and the system developed by the American Joint Committee on Cancer (AJCC) (1977), currently in its 8th edition (2017). This paper updates the reader on the staging of bone and soft tissue sarcomas affecting the musculoskeletal system.

Resumo Os sarcomas ósseos e das partes moles consistem em grupo heterogêneo de neoplasias malignas de origem mesenquimal que podem ocorrer em qualquer faixa etária. O estadiamento preciso destas lesões determina as melhores estratégias terapêuticas e estimativas de prognóstico. Dois sistemas de estadiamento são os mais frequentemente empregados no manejo destas neoplasias: o sistema proposto pelo grupo da Universidade da Flórida, liderado pelo Dr. William F. Enneking (1980), adotado pela Musculoskeletal Tumor Society (MSTS) e o sistema desenvolvido pela American Joint Committee on Cancer (AJCC) (1977) que se encontra em sua 8a edição (2017). O presente artigo busca atualizar o leitor a respeito do estadiamento dos sarcomas ósseos e das partes moles que acometem o sistema musculoesquelético.

The Impact of Lung Carcinoma Histology on the Frequency of Bone Metastases.

Objective Lung cancer is the leading cause of death by cancer, and the bones are one of the most common sites of metastasis from this condition. This study aimed to evaluate the influence of lung carcinoma histology on the frequency of bone metastases. Methods This retrospective study evaluated the medical records of 407 patients diagnosed with lung cancer between 2003 and 2012. The prevalence of bone metastases and their association with histological subtypes were evaluated using chi-squared tests, odds ratios (ORs) and 95% confidence intervals (CIs). The overall survival was evaluated using the Kaplan-Meier method. Results The prevalence of bone metastases was 28.2% ( n = 115), and the spine was the most frequently affected site (98 metastases; 32.1%). Adenocarcinoma was the most common histological subtype of lung carcinoma (46.7%), and it was significantly more frequent among patients with bone metastases (58.3% versus 42.1%; p = 0.003; OR = 1.92; 95% CI: 1.29-2.97). Squamous cell carcinoma was significantly less frequent among patients with bone metastases (13.0% versus 29.8%; p = 0.0004; OR = 0.35; 95% CI: 0.19-0.64). The median survival time after the first bone metastasis diagnosis was 4 months. Conclusion Adenocarcinoma was the most common histological subtype of lung carcinoma, and it was significantly associated with a higher risk of developing bone metastases.

The Impact of Lung Carcinoma Histology on the Frequency of Bone Metastases / O impacto da histologia do carcinoma pulmonar na frequência das metástases ósseas

Abstract Objective Lung cancer is the leading cause of death by cancer, and the bones are one of the most common sites of metastasis from this condition. This study aimed to evaluate the influence of lung carcinoma histology on the frequency of bone metastases. Methods This retrospective study evaluated the medical records of 407 patients diagnosed with lung cancer between 2003 and 2012. The prevalence of bone metastases and their association with histological subtypes were evaluated using chi-squared tests, odds ratios (ORs) and 95% confidence intervals (CIs). The overall survival was evaluated using the Kaplan-Meier method. Results The prevalence of bone metastases was 28.2% (n = 115), and the spine was the most frequently affected site (98 metastases; 32.1%). Adenocarcinoma was the most common histological subtype of lung carcinoma (46.7%), and it was significantly more frequent among patients with bone metastases (58.3% versus 42.1%; p = 0.003; OR = 1.92; 95% CI: 1.29-2.97). Squamous cell carcinoma was significantly less frequent among patients with bone metastases (13.0% versus 29.8%; p = 0.0004; OR = 0.35; 95% CI: 0.19-0.64). The median survival time after the first bone metastasis diagnosis was 4 months. Conclusion Adenocarcinoma was the most common histological subtype of lung carcinoma, and it was significantly associated with a higher risk of developing bone metastases.

Resumo Objetivo O câncer de pulmão é a principal causa de morte por neoplasia, e os ossos são os principais locais de metástases desse tipo de câncer. O objetivo deste estudo foi avaliar a influência do tipo histológico do carcinoma de pulmão na frequência das metástases ósseas. Métodos Foram avaliados retrospectivamente os registros médicos de 407 pacientes diagnosticados com câncer de pulmão entre 2003 e 2012. A prevalência de metástases ósseas e suas associações com os subtipos histológicos foram avaliadas com o teste qui-quadrado, razão de probabilidade (RP), e intervalos de confiança (IC) de 95%. A sobrevida global foi avaliada com o método de Kaplan-Meier. Resultados A prevalência das metástases ósseas foi de 28,2% (n = 115), e a coluna vertebral foi o local mais frequente (98 metástases: 32,1%). O adenocarcinoma foi o subtipo histológico mais comum de carcinoma pulmonar (46,7%) e foi significativamente mais frequente entre os pacientes com metástases ósseas (13,0% versus 29,8%; p = 0,0004; OR = 0,35; 95% IC: 0,19-0,64). O tempo médio de sobrevida após o diagnóstico da primeira metástase óssea foi de 4 meses. Conclusão O adenocarcinoma foi o subtipo histológico mais comum de carcinoma pulmonar e foi significativamente associado a um maior risco de desenvolvimento de metástases ósseas.

Pathological fractures due to bone metastases from lung cancer: risk factors and survival / Fratura patológica devido à metástase óssea do câncer de pulmão: fatores de risco e sobrevida

ABSTRACT Introduction: Pathological fractures are frequent skeletal-related events among lung cancer patients, which result in high morbidity and decreased overall survival and make operative treatment decisions challenging. Objectives: To identify risk factors associated with the occurrence of pathological fractures in patients with lung cancer and to determine survival. Methods: We conducted a retrospective cohort study with 407 lung carcinoma patients diagnosed between 2006 and 2015. The prevalence of bone metastases and pathological fractures was calculated. Statistical analysis was conducted using a chi-squared test, and the odds ratio and 95% confidence interval were calculated. Overall survival was determined using the Kaplan-Meier method and differences were compared using the log-rank test. Results: The prevalence of bone metastases and pathological fractures was 28.2% (n = 115) and 19.1% (n = 22), respectively. Pathological fractures were more frequent among patients with bone metastases at the time of diagnosis of lung cancer (24.7% [n = 20] vs. 5.9% [n = 2]; p < 0.05). The median overall survival following the diagnosis of lung cancer, bone metastases, and pathological fracture was 6, 4, and 2 months, respectively. Conclusions: Pathological fracture was associated with synchronous bone metastases and overall survival times were considerably reduced. Level of Evidence IV, Case Series.

RESUMO Introdução: Fratura patológica é um evento esquelético frequente em pacientes com câncer de pulmão, resultando em alta morbidade e sobrevida global reduzida que torna a decisão de tratamento cirúrgico desafiadora. Objetivos: Identificar fatores de risco associados à ocorrência de fraturas patológicas em pacientes com câncer de pulmão e determinar a sobrevida. Métodos: Conduzimos um estudo retrospectivo de coorte com 407 pacientes diagnosticados com carcinoma pulmonar entre 2006 e 2015. A prevalência de metástase óssea e fratura patológica foi calculada. Análise estatística foi conduzida usando o teste X2, e razão de chances e o intervalo de confiança de 95% foi calculado. A sobrevida global foi determinada usando o método de Kaplan-Meier e as diferenças foram comparadas usando o teste do log-rank. Resultados: A prevalência de metástases ósseas e fraturas patológicas foi de 28,2% (n = 115) e 19,1% (n = 22), respectivamente. Fraturas patológicas foram mais frequentes em pacientes com metástases ósseas ao diagnóstico do câncer de pulmão (24,7 % [n = 20] vs. 5,9% [n = 2]; p < 0.05). A sobrevida global média após o diagnóstico do câncer de pulmão, da metástase óssea e da fratura patológica foram 6, 4 e 2 meses, respectivamente. Conclusão: Fratura patológica foi associada à metástase óssea sincrônica e a sobrevida global consideravelmente reduzida. Nível de Evidência IV. Série de Casos.

PERCUTANEOUS TREATMENT OF ANEURYSMAL BONE CYST WITH CALCITONIN AND METHYLPREDNISOLONE.

OBJECTIVE: To introduce the intralesional calcitonin and methylprednisolone percutaneous injection method, which results in the promotion of primary aneurysmal bone cyst (ABC) healing. METHODS: A retrospective cohort study involving 76 patients diagnosed with ABC was performed between 2005 and 2014. Patients treated with calcitonin and methylprednisolone injection and who underwent more than 2 years of follow-up were considered eligible for the study (n=47). The Enneking staging and Capanna classification systems were used during the initial evaluation. Treatment response was assessed by Rastogi radiographic grading based on the degree of healing. X2 and Wilcoxon signed-rank tests and odds ratio calculations were used in the statistical analysis with a 5% significance level. RESULTS: The proximal tibia extremity was the most commonly affected site (17.0%). Thirty-three (70.3%) ABC cases were staged as B3 and 28 (59.7%) were classified as type II. The average number of injections performed was 2.8 per patient, with an average reduction of the initial lytic area of 83.7% (p-value=0.00001). Satisfactory results for 91.4% (n=43; p-value=0.00001) were obtained and 5 recurrences occurred. No side effects were observed. CONCLUSION: Intralesional calcitonin and methylprednisolone percutaneous injection is a minimally invasive, effective, and safe method for promoting primary ABC healing. Level of evidence IV, Type of study: case series.

OBJETIVO: Apresentar o método de injeção intralesional percutânea de calcitonina e metilprednisolona para promover a ossificação do cisto ósseo aneurismático (COA). MÉTODOS: Foi realizado um estudo retrospectivo de coorte envolvendo 76 pacientes com diagnóstico de COA entre 2005 e 2014. Os pacientes tratados com injeção de calcitonina e metilprednisolona e acompanhados durante mais de dois anos foram considerados elegíveis para o estudo (n = 47). Foram utilizados o sistema de estadiamento de Enneking e a classificação de Capanna durante a avaliação inicial. A resposta ao tratamento foi avaliada pela classificação radiográfica Rastogi, com base no grau de cicatrização. Os testes X2, Wilcoxon e o cálculo da razão de chances foram utilizados na análise estatística com nível de significância de 5%. RESULTADOS: A extremidade proximal da tíbia foi o local mais frequente (17,0%). Trinta e três (70,3%) COA eram B3 e 28 (59,7%) do tipo II. O número médio de injeções aplicadas foi de 2,8 por paciente, com redução média da área lítica inicial de 83,7% (p = 0,00001). Resultados satisfatórios para 91,4% (n = 43; p = 0,00001) dos pacientes e houve cinco recidivas. Nenhum efeito colateral foi observado. CONCLUSÃO: A injeção intralesional percutânea de calcitonina e metilprednisolona é um método minimamente invasivo, eficaz e seguro para promover a ossificação do COA. Nível de evidência IV, Tipo de estudo: série de casos.

Percutaneous treatment of aneurysmal bone cyst with calcitonin and methylprednisolone / Tratamento percutâneo de cisto ósseo aneurismático com calcitonina e metilprednisolona

ABSTRACT Objective: To introduce the intralesional calcitonin and methylprednisolone percutaneous injection method, which results in the promotion of primary aneurysmal bone cyst (ABC) healing. Methods: A retrospective cohort study involving 76 patients diagnosed with ABC was performed between 2005 and 2014. Patients treated with calcitonin and methylprednisolone injection and who underwent more than 2 years of follow-up were considered eligible for the study (n=47). The Enneking staging and Capanna classification systems were used during the initial evaluation. Treatment response was assessed by Rastogi radiographic grading based on the degree of healing. X2 and Wilcoxon signed-rank tests and odds ratio calculations were used in the statistical analysis with a 5% significance level. Results: The proximal tibia extremity was the most commonly affected site (17.0%). Thirty-three (70.3%) ABC cases were staged as B3 and 28 (59.7%) were classified as type II. The average number of injections performed was 2.8 per patient, with an average reduction of the initial lytic area of 83.7% (p-value=0.00001). Satisfactory results for 91.4% (n=43; p-value=0.00001) were obtained and 5 recurrences occurred. No side effects were observed. Conclusion: Intralesional calcitonin and methylprednisolone percutaneous injection is a minimally invasive, effective, and safe method for promoting primary ABC healing. Level of evidence IV, Type of study: case series.

RESUMO Objetivo: Apresentar o método de injeção intralesional percutânea de calcitonina e metilprednisolona para promover a ossificação do cisto ósseo aneurismático (COA). Métodos: Foi realizado um estudo retrospectivo de coorte envolvendo 76 pacientes com diagnóstico de COA entre 2005 e 2014. Os pacientes tratados com injeção de calcitonina e metilprednisolona e acompanhados durante mais de dois anos foram considerados elegíveis para o estudo (n = 47). Foram utilizados o sistema de estadiamento de Enneking e a classificação de Capanna durante a avaliação inicial. A resposta ao tratamento foi avaliada pela classificação radiográfica Rastogi, com base no grau de cicatrização. Os testes X2, Wilcoxon e o cálculo da razão de chances foram utilizados na análise estatística com nível de significância de 5%. Resultados: A extremidade proximal da tíbia foi o local mais frequente (17,0%). Trinta e três (70,3%) COA eram B3 e 28 (59,7%) do tipo II. O número médio de injeções aplicadas foi de 2,8 por paciente, com redução média da área lítica inicial de 83,7% (p = 0,00001). Resultados satisfatórios para 91,4% (n = 43; p = 0,00001) dos pacientes e houve cinco recidivas. Nenhum efeito colateral foi observado. Conclusão: A injeção intralesional percutânea de calcitonina e metilprednisolona é um método minimamente invasivo, eficaz e seguro para promover a ossificação do COA. Nível de evidência IV, Tipo de estudo: série de casos.

PATHOLOGICAL FRACTURES DUE TO BONE METASTASES FROM LUNG CANCER: RISK FACTORS AND SURVIVAL.

INTRODUCTION: Pathological fractures are frequent skeletal-related events among lung cancer patients, which result in high morbidity and decreased overall survival and make operative treatment decisions challenging. OBJECTIVES: To identify risk factors associated with the occurrence of pathological fractures in patients with lung cancer and to determine survival. METHODS: We conducted a retrospective cohort study with 407 lung carcinoma patients diagnosed between 2006 and 2015. The prevalence of bone metastases and pathological fractures was calculated. Statistical analysis was conducted using a chi-squared test, and the odds ratio and 95% confidence interval were calculated. Overall survival was determined using the Kaplan-Meier method and differences were compared using the log-rank test. RESULTS: The prevalence of bone metastases and pathological fractures was 28.2% (n = 115) and 19.1% (n = 22), respectively. Pathological fractures were more frequent among patients with bone metastases at the time of diagnosis of lung cancer (24.7% [n = 20] vs. 5.9% [n = 2]; p < 0.05). The median overall survival following the diagnosis of lung cancer, bone metastases, and pathological fracture was 6, 4, and 2 months, respectively. CONCLUSIONS: Pathological fracture was associated with synchronous bone metastases and overall survival times were considerably reduced. Level of Evidence IV, Case Series.

INTRODUÇÃO: Fratura patológica é um evento esquelético frequente em pacientes com câncer de pulmão, resultando em alta morbidade e sobrevida global reduzida que torna a decisão de tratamento cirúrgico desafiadora. OBJETIVOS: Identificar fatores de risco associados à ocorrência de fraturas patológicas em pacientes com câncer de pulmão e determinar a sobrevida. MÉTODOS: Conduzimos um estudo retrospectivo de coorte com 407 pacientes diagnosticados com carcinoma pulmonar entre 2006 e 2015. A prevalência de metástase óssea e fratura patológica foi calculada. Análise estatística foi conduzida usando o teste X2, e razão de chances e o intervalo de confiança de 95% foi calculado. A sobrevida global foi determinada usando o método de Kaplan-Meier e as diferenças foram comparadas usando o teste do log-rank. RESULTADOS: A prevalência de metástases ósseas e fraturas patológicas foi de 28,2% (n = 115) e 19,1% (n = 22), respectivamente. Fraturas patológicas foram mais frequentes em pacientes com metástases ósseas ao diagnóstico do câncer de pulmão (24,7 % [n = 20] vs. 5,9% [n = 2]; p < 0.05). A sobrevida global média após o diagnóstico do câncer de pulmão, da metástase óssea e da fratura patológica foram 6, 4 e 2 meses, respectivamente. CONCLUSÃO: Fratura patológica foi associada à metástase óssea sincrônica e a sobrevida global consideravelmente reduzida. Nível de Evidência IV. Série de Casos.

The relationship between lung cancer histology and the clinicopathological characteristics of bone metastases.

OBJECTIVES: Lung cancer is the leading cause of death due to cancer, and bone is one of the most frequent sites of metastasis. However, there is no published evidence regarding an association between lung cancer histology and skeletal complications. Therefore, we evaluated the influence of lung cancer histology on the frequency of bone metastases (BMs), skeletal-related events (SREs), and survival after BM. MATERIAL AND METHODS: This retrospective study evaluated medical records from 413 patients who were diagnosed with lung cancer between 2003 and 2012. The prevalences of BMs and SREs were calculated, and their associations with the histological subtypes were evaluated using the chi-square test, odds ratios (OR), and 95% confidence intervals (CI). Overall survivals and associations with the histological subtypes were evaluated using the Kaplan-Meier method and the log-rank test. RESULTS: The prevalences of BM, synchronous BM, and SREs were 28.2%, 70.4%, and 68.7%, respectively. Adenocarcinoma was the most common histological subtype (46.7%), and was significantly more frequent among patients with BM (58.3% vs. 42.1%; p=0.003; OR: 1.92; 95% CI: 1.29-2.97). Squamous cell was significantly less frequent among patients with BM (13.0% vs. 29.8%; p=0.0004; OR: 0.35; 95% CI: 0.19-0.64). The median survival time after the first BM diagnosis was 4 months, and there was no significant difference in the survival periods for the various histological subtypes. CONCLUSION: Adenocarcinoma and squamous cell were significantly associated with higher and lower risks of developing BM, respectively.

Parosteal aneurysmal bone cyst.

The incidence of aneurysmal bone cysts is 0.14 cases per 100,000 individuals. Parosteal aneurysmal bone cysts are the least prevalent subtype and represent 7% of all aneurysmal bone cysts. We present the case of a 38-year-old male patient with pain and bulging in his right arm for eight months. He had previously been diagnosed as presenting giant-cell tumor, but his slides were reviewed and his condition was then diagnosed as parosteal aneurysmal bone cyst. The patient was treated with corticosteroid and calcitonin infiltration into the lesion and evolved with clinical and radiological improvement within the first five weeks after the operation.

O cisto ósseo aneurismático tem uma incidência de 0,14 a cada 100 mil indivíduos. O subtipo parosteal é o menos prevalente, representa 7% de todos. Apresentamos um paciente masculino, 38 anos, com dor e abaulamento em braço direito havia oito meses. Diagnosticado previamente como tumor de células gigantes, teve sua lâmina revisada e então foi feito o diagnóstico de cisto ósseo aneurismático parosteal. O paciente foi tratado com infiltração intralesional de corticosteroide e calcitonina e evoluiu com melhoria clínica e radiológica já nas primeiras cinco semanas pós-operatórias.

Cisto ósseo aneurismático parosteal / Parosteal aneurysmal bone cyst

O cisto ósseo aneurismático tem uma incidência de 0,14 a cada 100 mil indivíduos. O subtipo parosteal é o menos prevalente, representa 7% de todos. Apresentamos um paciente mas culino, 38 anos, com dor e abaulamento em braço direito havia oito meses. Diagnosticado previamente como tumor de células gigantes, teve sua lâmina revisada e então foi feito o diagnóstico de cisto ósseo aneurismático parosteal. O paciente foi tratado com infiltração intralesional de corticosteroide e calcitonina e evoluiu com melhoria clínica e radiológica já nas primeiras cinco semanas pós-operatórias.

The incidence of aneurysmal bone cysts is 0.14 cases per 100,000 individuals. Parosteal aneurysmal bone cysts are the least prevalent subtype and represent 7% of all aneurysmal bone cysts. We present the case of a 38-year-old male patient with pain and bulging in his right arm for eight months. He had previously been diagnosed as presenting giant-cell tumor, but his slides were reviewed and his condition was then diagnosed as parosteal aneurysmal bone cyst. The patient was treated with corticosteroid and calcitonin infiltration into the lesion and evolved with clinical and radiological improvement within the first five weeks after the operation.