Aloinjerto osteoarticular para reconstrucción de defecto óseo tras resección tumoral en húmero proximal: complicaciones y alternativas. Serie de casos y revisión de la literatura / Osteoarticular allografts for reconstruction of bone defects after proximal humerus tumour resection. Complications and options for reconstruction. Case series and review of the literature

Objetivo: Exponer nuestra experiencia en la reconstrucción de defecto óseo masivo de húmero proximal tras resección tumoral mediante aloinjerto estructural, analizar las complicaciones asociadas a la técnica, comparándolas con otras series publicadas, y revisar otras alternativas para la reconstrucción. Materiales y métodos: Presentamos una serie de cinco casos tratados mediante el mismo protocolo quirúrgico y por el mismo cirujano con diagnóstico de tumor maligno en húmero proximal o medio mediante reconstrucción con aloinjerto osteoarticular masivo. Analizamos las indicaciones y exponemos las complicaciones que aparecieron. Resultados: Se realizó la reconstrucción con aloinjerto osteoarticular a pacientes con diagnóstico de osteosarcoma (2 casos), sarcoma de Ewing, tumor de células gigantes y lesión metastásica de un cáncer de mama (1 caso). Se obtuvo, con un seguimiento medio de 3,8 años, una consolidación completa en todos los casos, en un tiempo medio de 12,6 meses. Dos pacientes tuvieron complicaciones en relación a fractura del aloinjerto o reabsorción de las tuberosidades. No hubo ningún caso de infección periimplante. Solo en un caso hubo recurrencia local de la enfermedad.Se realizó además una revisión bibliográfica sobre las complicaciones e indicaciones de las distintas técnicas de reconstrucción del húmero proximal. Conclusiones: Aunque con una tasa de complicaciones importante, la reconstrucción con aloinjerto osteoarticular es una opción válida especialmente en paciente activo, joven o pediátrico

Objetives: Massive structural allografts are a suitable option for the reconstruction of extensive tissue loss due to tumour resection. In this paper we report our experience and review indications and complications of this technique. Methods: This paper reports a five-case series of patients who were treated with the same surgical technique with malignant tumour located in proximal humerus. The reconstruction was made using osteoarticular allografts. The paper analyses the indications for the technique and reports the complications encountered. Results: The reconstructions with the massive allografts were performed in patients with diagnosis of osteosarcoma (2 cases), Ewing sarcoma, Giant cells tumour and breast metastase (1 case). After an average follow-up of 3.8 years, a complete bone fusión was achieved in all cases, in 12.6 months on average. Two patients had complications in relation to fracture. Infection did not occur in any of the cases. Only one case had a local recurrence of the tumour. In addition, literature about complications and indications for the different techniques for reconstruction of proximal humerus was reviewed. Conclusions: Reconstruction of the proximal humerus with osteoarticular allografts is a valid option especially in the functionally active patient, young or pediatric, in spite of a significant complication rate

Tumor benigno de células notocordales / Benign notochordal cell tumors

Los tumores benignos de células notocordales (TBCN) son lesiones con diferenciación notocordal que afectan al esqueleto axial. Se caracterizan por cursar asintomáticos o con sintomatología inespecífica, y por pasar desapercibidos radiológicamente por su pequeño tamaño, o bien por ser confundidos con otras lesiones óseas benignas, como hemangiomas vertebrales. Cuando son grandes o sintomáticos pueden plantear el diagnóstico diferencial con metástasis, tumores óseos primarios y cordomas. Presentamos el caso de un TBCN de difícil diagnóstico, en una mujer de 50 años de edad, con una lesión sacra vista en la resonancia magnética (RM). Se programó una biopsia guiada por tomografía computarizada (TC) para filiar la lesión, pero la tumoración no era claramente identificable en la TC, por lo que se utilizaron las referencias anatómicas de la RM para seleccionar el plano adecuado. Tanto la planificación del abordaje como la correlación radiopatológica fueron determinantes para llegar al diagnóstico definitivo

Benign notochordal cell tumors (TBCN) are lesions with notochordal differentiation which affect the axial skeleton. They are characterized by asymptomatic or non-specific symptomatology and are radiologically unnoticed because of their small size, or because they are mistaken with other benign bone lesions, such as vertebral hemangiomas. When they are large, or symptomatic, can be differential diagnosis with metastases, primary bone tumors and chordomas. We present a case of a TBCN in a 50-year-old woman, with a sacral lesion seen in MRI. A CT-guided biopsy was scheduled to analyze the lesion, finding that the tumor was not clearly recognizable on CT, so the anatomical references of MRI were used to select the appropriate plane. The planning of the approach and the radio-pathological correlation were determinant to reach the definitive diagnosis

Occult phosphaturic mesenchymal tumour of femur cortex causing oncogenic osteomalacia - diagnostic challenges and clinical outcomes.

BACKGROUND: Tumor induced osteomalacia (TIO) are extremely rare paraneoplastic syndrome with less than 300 reported cases. This report highlights the pitfalls and challenges in diagnosing and localizing TIO in patients with refractory and resistant osteomalacia. PATIENT AND METHODS: 41- year gentleman with 4-year history of musculoskeletal weakness and pathologic fractures presented in wheelchair bound incapacitated state of 1-year duration. Investigations were significant for severe hypophosphatemia, severe phosphaturia, normal serum calcium, reduced 1,25-dihydroxy vitamin-D, elevated ALP, elevated intact parathyroid hormone (iPTH), and pseudo-fractures involving pelvis and bilateral femur. Whole body MRI and 99mTc methylene diphosphonate bone-scan were also normal. Whole body FDG-PET scan involving all 4 limbs revealed a small FDG avid lesion at lateral border of lower end of left femur (SUV max 3.9), which was well characterized on 3-dimensional CT reconstruction. Plasma C-terminal fibroblast growth factor (FGF)-23 was 698 RU/ mL (normal < 150 RU/ml). Wide surgical excision of the tumor was done. Histopathology confirmed mesenchymal tumor of mixed connective tissue variant. Serum phosphorous normalized post-surgery day-1. High dose oral calcium and vitamin-D was continued. FGF-23 normalized post surgery (73RU/ml). Physical strength improved significantly and now he is able to walk independently. CONCLUSION: TIO is frequently confused with normocalcemic hyperparathyroidism and vitamin-D resistant rickets/osteomalacia, which increases patient morbidity. Imaging for tumor localization should involve whole body from head to tip of digits, cause these tumors are notoriously small and frequently involve digits of hands and legs. Complete surgical removal of the localized tumor is key to good clinical outcomes.

Clinical long-term outcome, technical success, and cost analysis of radiofrequency ablation for the treatment of osteoblastomas and spinal osteoid osteomas in comparison to open surgical resection.

OBJECTIVE: To assess the clinical success and costs of computed tomography (CT)-guided radiofrequency ablation (RFA) of osteoblastoma (OB) and spinal osteoid osteoma (OO). MATERIALS AND METHODS: Nineteen patients with OB and eight patients with spinal OO were treated with CT-guided RFA. The OBs were localized in the extremities (n = 10), the vertebral column (n = 2), and (juxta-)articular (n = 7). Dedicated procedural techniques included three-dimensional CT-guided access planning in all cases, overlapping RFA needle positions (median, two positions; range, 1-6 RF-electrode positions) within the OB nidus (multiple ablation technique, n = 15), and thermal protection in case of adjacent neural structure in four spinal OO. The data of eight operated OB and ten operated spinal OO patients were used for comparison. Long-term success was assessed by clinical examination and using a questionnaire sent to all operated and RFA-treated patients including visual analogue scales (VAS) regarding the effect of RFA on severity of pain and limitations of daily activities (0-10, with 0 = no pain/limitation up to 10 = maximum or most imaginable pain/limitation). RESULTS: All patients had a clear and persistent pain reduction until the end of follow-up. The mean VAS score for all spinal OO patients and all OB patients treated either with RFA or with surgical excision significantly decreased for severity of pain at night, severity of pain during the day, and both for limitations of daily and of sports activities. CONCLUSIONS: RFA is an efficient method for treating OB and spinal OO and should be regarded as the first-line therapy after interdisciplinary individual case discussion.

Benign bone tumors.

A solid knowledge of underlying histopathology of benign bone tumors aids in differential diagnoses of these tumors. Important factors in diagnosis of a bone tumor include patient age and gender; the bone involved; the location of the tumor along, within, or on the bone; lesion margin; matrix proliferation; and periosteal reaction. This article provides a review of the origin of the tumor matrix and its influence on the imaging properties of these tumors.

[Clinical and radiological evaluation of malignant metaplasia of benign primary bone tumors on the material of University Orthopaedic Department of Szczecin between 2002-2007]. / Ocena kliniczna i radiologiczna metaplazji zlosliwej pierwotnych lagodnych nowotworów kosci oraz zmian pseudonowotworowych w materiale Kliniki Ortopedii PAM w Szczecinie w latach 2002-2007.

The study presents clinical and diagnostic problems in patients with malignant bone metaplasia. Material is composed of 13 patients treated surgically between april 2002 and august 2007. In three cases tumors were localised in tibia, in 5 patients around distal femur, in 2 in pelvis, in 2 in humerus and in 1 in lumbar spine. None of the patients has had recurrence by february 2006 r, 12 patients have been free of the disease so far. However, one individual diagnosed with giant cell tumor metaplasia to osteosarcoma did not accept proposed therapy. The authors have particularly emphasized thorough clinical and radiological evaluation and the need of team work before surgical procedure.

Calvarial lesions: a radiological approach to diagnosis.

Calvarial lesions are frequently identified in radiological studies. A wide variety of neoplasms and non-neoplastic lesions can involve the calvarium, and their imaging appearances vary according to their pathologic features. These lesions are usually asymptomatic but may manifest as a lump with or without associated pain. Clinical information, including the age of patient, is an important factor in the diagnostic process. In this paper, we illustrate the value of cross-sectional imaging techniques by computed tomography (CT) and magnetic resonance imaging (MRI) in evaluating these lesions. We also review the literature and discuss the specific imaging characteristics of the most common calvarial lesions in order to provide information that can guide radiological diagnosis or limit differential diagnosis.

Cortico-medullary continuity in bizarre parosteal osteochondromatous proliferation mimicking osteochondroma on imaging.

Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is an unusual surface-based lesion of bone found most commonly in the hands and feet. In the original description of the lesion and in all publications that followed, one of the key imaging characteristics used to define this entity was the lack of cortico-medullary continuity with the underlying bone. The authors present 4 unique cases of pathologically proven BPOP in which cortico-medullary continuity with the underlying bone was demonstrated on imaging. It is believed that florid reactive periostitis, BPOP and turret osteochondroma may reflect points along the same continuum with trauma the likely inciting event. The authors suggest that, given this continuum, it may be possible to have BPOP lesions demonstrating overlapping imaging features with osteochondroma. If this is the case, strict adherence to the standard imaging criterion of lack of continuity between the lesion and the underlying bone may lead to misdiagnosis of these unusual cases of BPOP as osteochondromas.

Radiologic appearance of primary jaw lesions in children.

BACKGROUND: The jaw (an unusual site of primary tumors in children and adolescents) has lesions often found incidentally by dentists on routine panoramic radiographs or during examination of a child who has swelling or tooth pain. OBJECTIVE: This pictorial seeks to familiarize pediatric radiologists with the radiographic appearance of a variety of primary jaw lesions. MATERIALS AND METHODS: We retrospectively searched institutional records for cases of primary jaw lesions in children and adolescents. Jaw lesions were characterized as: I, well-circumscribed radiolucent lesions; II, lesions with mixed or variable appearance; III, poorly circumscribed radiolucent lesions; and IV, radiopaque lesions. RESULTS: Although most oral and maxillofacial lesions in children are benign, a broad spectrum of tumors was identified; lesions may occur in patients with unrelated prior malignancy. CONCLUSION: Because radiologic studies may identify jaw lesions and direct further care, familiarity with the appearance of these entities is prudent.

Fibro-osseous, osseous, and cartilaginous lesions of the orbit and paraorbital region. Correlative clinicopathologic and radiographic features, including the diagnostic role of CT and MR imaging.

Fibro-osseous and cartilaginous lesions of the orbit and facial region share overlapping clinical, radiologic, and pathologic features that may lead to diagnostic confusion and possible misdiagnosis. The value of imaging studies in the histopathologic diagnosis of these lesions cannot be overemphasized. The histopathologic diagnosis of such lesions should not be rendered in the absence of radiographic correlation.

Punción biopsia ósea percutánea guiada bajo TC / TC guided percutaneous biopsy of the bone lesions

Se evaluaron los beneficios de la biopsia percutánea por TC en distintas lesiones óseas. Las indicaciones se establecieron por protocolos de acuerdo a si la lesión era inflamatoria, benigna o maligna, respetando las contraindicaciones del método. Del total de biopsias realizadas entre enero de 1995 y septiembre de 1996, se extrajeron 76 por disponerse del estudio por TC y del resultado anatomopatológico. Las muestras extraídas correspondieron a: vértebra, 33; fémur, 17; tibia, 6; costillas, 6; ilíaco, 4; esternón, 4; sacro, 2; rama isquiopubiana, 2; cuboides, 1 y escafoides, 1. Se concluye que la biopsia percutánea guiada bajo TC es la técnica de elección para determinar la etiología de las lesiones del sistema musculoesquelético, cuando está indicada una biopsia guiada por imágenes. El método tiene muy baja morbilidad y es bien tolerado por el paciente (AU)

Tumores musculoesqueléticos de la pelvis y la cadera / Soft tissue and bone tumores of the hip and pelvis

El tratamiento actual de los tumores musculoesqueléticos cuya filosofía es la reducción de la magnitud de la cirugía con reservación de los miembros y de ser posible de la función, ha provocado una gran demanda de los métodos del diagnóstico por imágenes. Cuando las lesiones asientan en la pelvis al tema etiológico se suma la dificultad en su detección debido a la particular anatomía del área. Con el objeto de analizar la incidencia de los tumores musculoesqueléticos y el aporte de divesos métodos diagnósticos se estudió una población constituída por 214 pacientes con tumores o lesiones seudotumorales pelvianas comprobados histológicamente. Se detectaron 19 lesiones seudotumorales, 27 tumores benignos, 6 tumores o células gigantes y 162 tumores malignos. Dos tercios de las lesiones seudotumorales y de los tumores benignos ocurrieron por debajo de los 30 años de edad. Los tumores malignos fueron mayoría (75 por ciento) destacándose las metástasis (70 por ciento de todos los tumores malignos). El tumor primario más frecuente fue el condrosarcoma. El diagnóstico por imágenes juega en la actualidad un rol significativo en el diagnóstico y estadificación de los tumores muescoesqueléticos. Junto con la clínica y la anatomía patológica constituyen el trípode indispensable para arribar al diagnóstico definitivo e instituir la terapéutica adecuada (AU)