Bone metastases in the hip region: surgical treatment.

Subjective factors of the patient such as age, weight, occupation, expectations, etc. must be carefully evaluated in terms of surgery. It is always important to remember life expectancy, and the choice of a surgical procedure must be based on it. Limited survival and possible radiation therapy must eliminate methods that require long healing times: we no longer use bone grafts because the risk of healing time taking up too much of the time left for the patient is too high. Reconstructions must have an immediate solidity allowing early use of the limb. Thus, in the proximal femur, we above all use protheses (traditional or modular RPS); in acetabular lesions that do not involve the joint surface, our treatment of choice is curettage with liquid nitrogen and cement, armed with screws and nails. Prostheses, which are always cemented, are assembled using bipolar cups; cases where lysis is so wide on the cotyloid side as to require THR are rare. The cotyles, in cases such as these, are those that allow for anchoring with several sites (Octopus type), the McMinn or, at times, common cotyles in PE.

Resection of the proximal humerus for metastases and replacement with RPS prosthesis.

In the surgical treatment of metastatic lesions of the proximal humerus it is important to find solutions that eliminate pain and solve the mechanical problem in a short time and with reduced costs. In 90% of cases, intralesional curettage, freezing with liquid nitrogen and cement enhanced intramedullary instrumentation is capable of brilliantly solving the problems of these patients. When, instead, osteolysis involves the greater tuberosity and/or the joint region, resection of the proximal humerus followed by reconstruction with a modular prosthesis is indicated. Of those available on the market, the RPS system (LIMA) has features that make it equivalent to others, but at costs considerably lower. However, in reconstructions with prostheses, active abduction is significantly limited. A personal series of 20 patients is presented.

Limb salvage in lower-extremity sarcomas and technical details about vascular reconstruction.

Vascular surgery may allow limb salvage when a sarcoma of the lower limb involves the main vascular bundle. We present our experience and describe the techniques which have been employed for such surgery. From October 1995 to April 1999, vascular surgery procedures were employed in seven patients with sarcomas of the thigh: two complete subadventitia dissections of the main vascular trunks, four artery replacements (two polytetrafluoroethylene [PTFE] grafts and two autologous saphenous grafts), and five venous reconstructions (all with autogenous saphenous graft: three substitutions; two distal transpositions with one external rigid support at the anastomosis). Clinical and instrumental (sonogram, computed tomography [CT] scan, echodoppler) follow-up was carried out at 3, 6, and then every 12 months after surgery (mean, 25 months; range, 6-53 months). Operative mortality and morbidity were nil. All the grafts were patent (one arterial thrombosis was successfully treated on the first postoperative day). The functional result was good in six patients and fair in one. Two patients died, 24 and 13 months after surgery, with disseminated disease, but had no local recurrence. Five patients are alive and disease-free. Vascular techniques allow limb salvage with en-bloc resection of sarcomas of the thigh involving the main vessels. Venous reconstructions are indicated after removal of both the superficial and deep femoral veins. We suggest limiting the number of anastomoses (two transpositions in our series) and using external rigid support in those patients with a small saphenous vein graft (one patient in our series).

CT-guided percutaneous trochar-biopsy of the spine.

As is the case for tumor lesions of the limbs, for the spine, too, no treatment should be started without a pathological diagnosis. Open biopsy of the spine is always a major surgical procedure with all of the related risks, and the surgeon is frequently tempted to perform, during the same operation, biopsy and definitive treatment. This approach leads many patients to unnecessary major operations, when the final histology shows a disease which does not carry an indication for surgical resection. CT-guided percutaneous Trochar-Biopsy is a safe procedure used to obtain an adequate sample for full histological evaluation. Eliminating the need for biopsy, several major vertebral resections could be avoided. This technique deserves to become the standard first-choice procedure whenever a biopsy of the spine is required.

Radiotherapy and spinal brace: still first-choice treatment for vertebral metastases from breast cancer.

In metastatic breast cancer the goal to reach must be the best possible palliation with minimum discomfort for the patient. We reviewed our experience with radiotherapy (20 or 30 Gy), systemic therapy and brace. Among 2200 breast cancer patients, we extracted 28 potential candidates for resection. All of them developed new metastases outside the treated field within one year. Local control was achieved in 68%, and 80% of them had stable or better performance status at 3 months. From our analysis, even patients with a so called "solitary lesion" do not seem to have a better prognosis than others. We conclude that radiotherapy (with systemic therapy and a brace) is still first-choice treatment for vertebral metastases; CT-guided percutaneous biopsy can avoid worthless major operations. The role of surgery should be limited to neurological compression, severe mechanical instability and to salvage the failures of conservative treatment.

[Is radiotherapy still the first choice treatment in spinal metastases from breast cancer?]. / La radioterapia è ancora il trattamento di prima scelta delle metastasi vertebrali da cancro della mammella?

The skeletal system is a frequent site of metastatic involvement from breast cancer, whose pattern of spread is such that cure becomes practically impossible. The best palliation with the minimum discomfort for the patient must therefore be the major objective. With an increasing number of reports about major surgical procedures for spinal metastases, we reviewed our series of patients submitted to radiotherapy. Of 2,189 breast cancer patients, we selected 28 who might have been potential candidates for surgical resection (with lesions only in the spine, only one or no more than three contiguous bodies involved and no other metastases). All these patients had been treated with 20 or 30 Gy plus systemic (chemo, hormone, or both) therapy. Follow-up revealed that all of them had developed new metastases outside the treated field within one year. Local control was achieved in 68% of patients and 75% of them had stable or better performance status at 3 months. Median survival was 36 months. From our analysis, even patients with a so called "solitary lesion" seem not to have a better prognosis than others. We conclude that radiotherapy is still the method of choice to treat vertebral metastases from breast cancer. The role of surgery should be limited to patients with neurologic compression or severe mechanical instability.