Reconstructing diaphyseal tumors using radiated (50 Gy) autogenous tumor bone graft.

AIMS: Establish oncologic safety using 50 Gy to sterilize tumor bearing bone before reimplantation in primary diaphyseal high grade extremity tumors, determine extracorporeal radiotherapy (ECRT) graft survival, and analyze factors that affect union at osteotomy sites. MATERIALS AND METHODS: Seventy non metastatic patients underwent reconstruction with intercalary ECRT grafts sterilized with 50 Gy. Diagnosis included osteosarcoma (38) and Ewing's sarcoma (32). At last follow-up-49 patients were alive, 19 had died and 2 were lost to follow up. Survivors had minimum follow up of 3 years (range 39-127 months). RESULTS: Ninty one percent metaphyseal osteotomies united without additional intervention compared to 71% diaphyseal osteotomies. Additional small plate at diaphyseal osteotomy apparently reduced incidence of non-union (17% vs 31%) (P = 0.49). Addition of morsellised allograft did not help union. There were seven (10%) local recurrences, all in soft tissue. Seventeen of 69 patients (25%) needed removal of ECRT graft. Five year survival for ECRT graft (removal for all causes) was 79% and 84% (excluding removal for local recurrence). CONCLUSIONS: Reimplanting sterilized tumor bone using 50 Gy for tumor ablation is an easily applicable, oncologically safe, biological reconstruction option for primary diaphyseal extremity tumors.

A study of 853 high grade osteosarcomas from a single institution-Are outcomes in Indian patients different?

AIMS: To review outcomes of 853 patients of primary high grade osteosarcoma operated with curative intent between January 2006 to December 2013. METHODS: All patients underwent appropriate surgical resection after preoperative chemotherapy (non methotrexate based). Excised specimen was analyzed for margins and response to chemotherapy. We analysed various factors (sex, age, size, site, type of surgery, pathologic fractures, margin status, and chemotherapy induced necrosis) for their impact on outcomes. RESULTS: Five year overall survival (OS) for entire cohort was 49% and event free survival (EFS) was 42%. Seventy hundred thirty-eight non metastatic patients had OS of 53% and EFS of 47% at 5 years. The 3 year OS and EFS of the metastatic patients was 22% and 9%, respectively. Analysis of 738 non metastatic patients demonstrated that chemotherapy induced necrosis, size of tumor (< / >8 cms), type of surgery (limb salvage vs amputation) significantly affected overall survival. Local recurrence was 9%. Site of tumor (long bone vs pelvis), type of surgery and chemotherapy induced necrosis influenced local recurrence. CONCLUSIONS: Our patients appeared to have poorer survival compared to most Western data, possibly attributable to large tumors. In contrast to existing data, males (71%) were predominantly affected and only patients with 100% necrosis qualified as good responders regarding OS.

Topical vancomycin: Does it reduce surgical site infection in bone tumors?

INTRODUCTION: We retrospectively analyzed a consecutive group of patients operated for bone tumors of extremity and pelvis who received only perioperative antibiotics (Group A) against a similar group that had additional 1 g topical vancomycin sprinkled in the wound before closure (Group B). The aim was to determine if the addition of topical vancomycin decreases the incidence of deep surgical site infection (SSI). MATERIALS AND METHODS: A total of 221 patients operated between January 2011 and December 2011 were analyzed in Group A and 254 patients operated between April 2012 and March 2013 were analyzed in Group B. Any patient who required operative intervention for wound discharge was considered to be infected. All patients had a 1 year follow-up to determine the incidence of SSI. RESULTS: The overall rate of SSI was 7% (31 of 475 patients). Seventeen (8%) of Group A patients had SSI as against 14 (6 %) of Group B patients (P = 0.337). A subgroup analysis of endoprosthetic reconstructions, internal fixation implants (plates/intramedullary nails), extracorporeal radiation treated bones and strut allografts showed no difference between the two groups of patients. CONCLUSION: Our data suggest that the addition of topical vancomycin before wound closure in patients operated for bone tumors does not decrease the incidence of SSI. Further investigation of this technique using a case-controlled methodology with an increase in the dose of vancomycin may be warranted.

Aggressive Surgery in Palliative Setting of Lung Cancer: Is it Helpful?

With increase in survival and progression-free survival in the advanced metastatic cancers, the expectation of quality of life (QOL) has increased dramatically. Palliative care plays a vital role in the management of these advanced cancer patients. At present scenario, palliative care in advanced cancer has seen a completely different approach. Aggressive surgical procedures have been performed to improve the QOL in the advanced cancer patients. We report a case of advanced lung cancer with pathological femur fracture, treated with extensive total femur replacement surgery to provide better QOL.

Palliative Care in Musculoskeletal Oncology.

Patients in advanced stages of illness trajectories with local and widespread musculoskeletal incurable malignancies, either treatment naive or having recurrence are referred to the palliative care clinic to relieve various disease-related symptoms and to improve the quality of life. Palliative care is a specialized medicine that offers treatment to the disease-specific symptoms, places emphasis on the psychosocial and spiritual aspects of life and help the patients and their family to cope with advance stage cancer in a stronger and reasonable way. The overall outcome of musculoskeletal malignancies has improved with the advent of multidisciplinary management. Even then these tumors do relapse and leads to organ failures and disease-specific deaths in children and young adults in productive age group thus requiring an integrated approach to improve the supportive/palliative care needs in end-stage disease. In this article, we would like to discuss the spectrum of presentation of advanced musculoskeletal malignancies, skeletal metastasis, and their management.

Pseudoaneurysms Masquerading as Malignant Bone Tumours.

Swelling around the knees can be due to both neoplastic as well as non neoplastic aetiology. One of the rare cause for the same is pseudoaneurysm. Pseudoaneurysms can mimic a bone tumor or a soft tissue sarcoma. Pseudoanuerysms result because of the gradual growth occurring due to constant arterial pressure and development of a reactive fibrous capsule. Inappropriate diagnosis and management of these lesions may result in major morbidity and rarely mortality. We present two cases of pseudoaneurysms around the knees which were misdiagnosed as osteogenic sarcomas. These cases also stress on the importance of multidisciplinary care, in preventing avoidable morbidity, mortality and providing safe and optimal care to the patients.

Reconstruction of the elbow and forearm for Ewing sarcoma of ulna: A new biological technique.

Primary bone tumors around the elbow represent <1% of all the skeletal tumors. Surgery with or without adjuvant therapy (radiotherapy, chemotherapy) is the treatment of choice for malignant tumors. Reconstruction of the elbow and forearm in malignant tumors is challenging as it involves a complex interplay between multiple joints which need to be stabilized for the optimal functional outcome. We describe a new technique for the reconstruction of the elbow after resection of a proximal ulna tumor with articular radio-ulnar synostosis with the creation of a single bone forearm. We attempted to achieve a mobile elbow and stable wrist joint with the radio-ulnar union at the proximal articular surface of the ulna resulting in a single bone forearm. The procedure involves an oblique osteotomy preserving the olecranon process (after taking adequate margins based on oncological principles) and its articular cartilage along with the attachment of the triceps tendon. Then the radial head was partially denuded of its cartilage using a burr, leaving cartilage only on the volar side, and then fused to the remnant olecranon. Osteosynthesis was done using compression screw and tension band wiring. The advantages of this procedure are that the mobility at wrist and elbow are retained, it requires minimal hardware and allows for primary closure of the wound.

Clinicopathological features of five unusual cases of intraosseous myoepithelial carcinomas, mimicking conventional primary bone tumours, including EWSR1 rearrangement in one case.

Primary intraosseous myoepithelial tumours, including carcinomas are rare tumours. The concept of histopathological spectrum of these tumours is evolving. We describe clinicopathological and immunohistochemical features of five myoepithelial carcinomas, including molecular cytogenetic results in one case. There were five male patients within age-range of 8-40 years (median = 26). Four tumours occurred in the long bones, including two tumours, each, in the femur and fibula, respectively, while a single tumour occurred in the proximal phalanges. Tumour size (n = 3 cases) varied from 5.6 to 8.6 cm. On radiological imaging, most tumours appeared as expansile, lytic and destructive lesions. Two tumours appeared as sclerotic lesions. Two cases were referred with diagnoses of chondrosarcomas and a single case was referred with two different diagnoses, including an adamantinoma and an osteosarcoma. Histopathological examination in all these cases showed multinodular tumours comprising mostly polygonal cells, exhibiting moderate nuclear atypia and interspersed mitotic figures within a stroma containing variable amount of myxoid, chondroid, hyalinised and osteoid-like material. Three tumours revealed prominent squamous differentiation. By immunohistochemistry, tumour cells were positive for EMA (5/5), pan CK (AE1/AE3) (3/3), CK5/6 (4/4), CK MNF116 (1/1), S100 protein (5/5) and GFAP (3/5). The first tumour revealed EWSR1 rearrangement. The first patient, 10 months after tumour resection and a simultaneous lung metastatectomy, is free-of-disease (FOD). The second patient, 11 months after tumour resection is FOD. The third and fourth patients underwent wide resections and are on follow-up. The fifth patient underwent resections, including a lung metastatectomy. Primary intraosseous myoepithelial carcinomas are rare and mimic conventional primary bone tumours. Some primary intraosseous myoepithelial carcinomas display EWSR1 rearrangement. Squamous differentiation may be considered as an addition to their evolving histopathological spectrum. Immunohistochemical stains constitute as a necessary tool for arriving at the correct diagnosis in such cases, which has treatment implications. Surgical resection remains the treatment mainstay.

Inferior Vena Caval Tumor Thrombus in Giant Cell Tumor of Sacrum - An Unusual Complication Treated with Multimodality Management.

INTRODUCTION: Giant cell tumor is the most common benign lesion encountered. It accounts for 5 % of all skeletal tumors. It mainly affects the epiphysis of long bones and rarely axial bones. In axial bones, sacrum is the most common site to be affected. CASE REPORT: A 23 year old female with giant cell tumor of sacrum was treated initially with conservative treatment (serial angioembolisation and bisphosphonates). Later intralesional curettage was done as the patient started developing bladder and bowel disturbances after two sessions of angioembolisation. Six months later patient again presented with pain at the primary lesion site and bilateral limb swelling. Imaging revealed recurrence of the disease and tumor thrombus extending into the inferior vena cava up to the subhepatic region. CONCLUSION: Treatment of sacral GCT (Giant Cell Tumor) poses a unique challenge to the treating surgeon because of the close proximity of vital neurovascular structures, viscera and associated complications related to the disease. Tumor thrombi are a very rare phenomenon associated with giant cell tumors of the bone. High index of suspicion and multimodality approach is the key in treating such challenging tumors and their complications.