Surgical options in cases of tumorous destruction of the proximal humerus: twenty-one patients followed from 4-9 years.

PURPOSE: To compare the postoperative outcomes of several techniques of reconstructive surgery for malignant and aggressive benign tumors of the proximal humerus. PATIENTS AND METHODS: Twenty-one shoulder reconstructions following tumor resection were studied. Nine cases with an intracompartmental tumor were treated with endoprosthetic reconstruction. Three cases with the tumor involving the glenoid were treated with a typical Malawer VB shoulder girdle resection. In 5 patients with extracompartmental resections including the rotator cuff or the deltoid muscle a modified Tikhoff-Linberg procedure using polypropylene mesh was performed. In 4 patients with extracompartmental excision the authors proceeded to skeletal reconstruction using a modular endoprosthesis, while soft tissue reconstruction was undertaken using monofilament polypropylene mesh in order to enforce joint stability. RESULTS: All patients achieved stable shoulders. In cases where the technique was modified with mesh the functional outcome was fairly improved and the cosmetic result was excellent. CONCLUSION: For extracompartmental excisions including the deltoid or the rotator cuff the authors recommend a modified Tikhoff-Linberg procedure. Using polypropylene mesh they aim to achieve a static suspension in order to avoid the excessive traction of the neurovascular bundle, which is the most common complication of this procedure. Substitutionally such cases may be treated by reconstruction with a modular endoprosthesis. They recommend stabilization of the prosthesis with the use of mesh implant, avoiding in this way instability.

Chemoembolization facilitates limb salvage surgery in stage III soft tissue sarcoma.

A 26 year-old male was referred to our unit because of a stage III soft tissue sarcoma in the shoulder girdle-axillary area and reduced forearm-distal arm strength. Imaging studies revealed that the tumor encompassed the axillary artery and brachial plexus. We chemoembolized it using vincristine, adriamycin and cyclophosphamide (VAC) plus gel foam and performed limb salvage surgery (LSS) afterwards. The patient received adjuvant chemotherapy (ifosfamide/mesna, adriamycin, and dacarbazine/MAID) and finally radiation therapy (RT; 6500 cGy total dose). Thirty-six months after the operation the patient remains free of disease, without local recurrence and excellent neurological recovery and functional rehabilitation. In stage III soft tissue sarcomas, especially in proximity with major nerve/arterial bundles, a multimodality approach is mandatory; chemoembolization is very effective in shrinking the tumor and defining its margins so as to make feasible a LSS.

Evaluation of cytotoxic treatment of patients with osteosarcoma by an in vitro chemoresistance assay.

During the previous two decades several assays have been developed aiming to select the most effective chemotherapy regimen for each individual, avoiding the possible toxicity of ineffective drugs. In order to evaluate cytotoxic treatment for patients with osteosarcoma, we applied an in vitro chemoresistance assay by culturing tumour cells and determining their in vitro survival rates after exposure to various chemotherapeutic drugs. The conditions of the assay were optimised in two established osteosarcoma cell lines (KHOS and U2-OS), as compared with data derived after treatment of primary normal adult osteoblasts. Chemotherapeutic drugs (cisplatin, adriamycin or methotrexate or combinations) concentrations were chosen in a range that has been reported to induce tumour cell death in the plasma patients' The method applied successfully in 6 cell cultures originated from biopsies of 7 patients with osteosarcoma and the in vitro response to chemotherapeutic drugs was correlated with the clinical outcome. Such analysis revealed both positive and negative correlation of the in vitro data to the patients clinical responses. Therefore, this study indicated that, although in vitro chemoresistance is a valuable assay, additional analysis and implications of other factors are required for a general evaluation of cytotoxic treatment for patients with osteosarcoma.

Effects of polyphenolic grape extract on the oxidative status of muscle and endothelial cells.

A grape pomace extract enhanced antioxidant mechanisms in muscle and endothelial cells both in the absence and in the presence of oxidative stress-induced agent tert-butyl hydroperoxide (tBHP). In particular, muscle (C2C12) and endothelial (EA.hy926) cells were treated with the extract at noncytotoxic concentrations for 24 h, and the oxidative stress markers, total reactive oxygen species (ROS), glutathione (GSH), thiobarbituric reactive substances (TBARS), and protein carbonyl levels were assessed. The results showed that the grape extract treatment reduced significantly ROS, TBARS, and protein carbonyl levels and increased GSH in C2C12 cells, while it increased GSH and decreased protein carbonyl levels in EA.hy926 cells. In the presence of tBHP, the grape extract treatment in C2C12 cells reduced significantly ROS, TBARS, and protein carbonyls and increased GSH compared with tBHP alone treatment, while, in EA.hy926 cells, the extract decreased significantly TBARS and protein carbonyls but increased GSH. The antioxidant potency of the extract was different between muscle and endothelial cells suggesting that the antioxidant activity depends on cell type. Moreover, the antioxidant activity of the grape extract, in both cell lines, exerted, at least in part, through increase in GSH levels. The present work is the first to report the effects of grape extract shown for skeletal muscle cells.

Reconstruction of tibia defects by ipsilateral vascularized fibula transposition.

INTRODUCTION: Segmental defects of the tibia after open fractures, sepsis and tumor surgery present a challenging problem. Similarly, tumor surgery often involves radical resections and multiple procedures and is frequently accompanied by irradiation or chemotherapy creating an avascular bed. The aim of this study is to report the results and discuss the role of the ipsilateral pedicle vascularized fibula (IPVF) a technique used for reconstruction of tibia defects. MATERIALS AND METHODS: Reconstruction of large tibia defects 6-22 cm due to tumor resection were performed in 5 patients by ipsilateral vascularized fibula transposition. The mean age of the patients was 35.4 years (19-42) SD 9.31. The mean follow-up was 59.6 months (24-96) SD 29.2. The mean length of the bone defect was 14.6 cm (6-22) SD 6.066 and the mean time for union was 8 months (6-12) SD 2.82. Arteriography was used preoperatively in all patients to evaluate the lower limb vasculature and to select the optimal surgical approach. The osteosynthesis was stabilized by a plate. RESULTS: There was sound union in all cases. There were only two minor complications one partial paresis of peroneal nerve and one superficial infection. The mean follow-up was 59.6 months (24-96) SD 29.2. No patient presented with any complaints with the procedure and all had good functional results. CONCLUSIONS: The procedure was technically simple compared to free vascularized fibula and could be performed in hospital with low resources. There are several advantages: (a) achievement of bone defect reconstruction retaining periosteal and endosteal circulation, (b) preservation of a major vessel of the lower leg, (c) avoidance of difficulty and risk of microvascular technique and (d) no donor-morbidity. We routinely recommend preoperative angiography and intraoperatively meticulous dissection to prevent damage to the vascular pedicle.

Adamantinoma of tibia: a case of late local recurrence along with lung metastases.

Adamantinomas of long bones are rare primary low-grade malignant tumours composed of cells with epithelial and fibrous characteristics. Local recurrence, though scarce, occurs 5-15 years after the onset of diagnosis. We report a case of local recurrence of an adamantinoma localised in tibia, along with the presence of two lung metastases, 24 years after diagnosis and surgical therapy of the primary tumour. The local recurrence and the lung metastases were removed surgically. The patient remains free of the disease for 3 years.