Prognostic Factors Influencing Survival and Oncological Outcome in Patients with Parosteal Osteosarcoma.

This study aimed to evaluate the significance of radiological (magnetic resonance imaging [MRI]) findings, surgical, and previous interventions on prognosis with oncological and functional outcome in patients with parosteal osteosarcoma (POS). Twenty-seven patients (8 male/19 female) who were operated with the diagnosis of primary POS in our institution were retrospectively reviewed. The epidemiological data, biopsy method, misdiagnosis/improper interventions, and delay in diagnosis were noted. The lesions' maximum circumferential extension, maximum longitudinal extension, intramedullary involvement, and neurovascular extensions in MRI sections were evaluated, and the resection type (segmental intraarticular/segmental intercalary/hemicortical), reconstruction type (biologic/non-biologic), and surgical margins were noted. Functional and oncological results at the last follow-up were assessed. The mean age was 31.6 (12-73) years, and mean follow-up was 80.8 (24-270) months. Intramedullary involvement percentage was related with maximum circumferential extension percentage and maximum longitudinal extension. (p = 0.006, p = 0.005) The intramedullary involvement ratio of ≤ 10% suggested no recurrence or metastasis. The neurovascular encasement was related to metastatic disease, deep infections, and complication related surgeries (p = 0.017, p = 0.002, p = 0.005). The most common resection type was segmental intraarticular resection (63%). The maximum circumferential extension percentage, the maximum longitudinal extension of the lesion, intramedullary involvement percentage, and neurovascular encasement had lower MSTS scores (p = 0.003, p = 0.028, p = 0.038, p = 0.022). The mean MSTS score was 81.1% (60-100%). The 5-year overall survival was 96.3%, local recurrence-free survival was 77.2%, and metastasis-free survival was 69.4%. The lesions' extent of intramedullary involvement, neurovascular bundle proximity, and maximum periosteal circumferential extension on MRI should be considered when planning the surgery.

What factors are associated with osteoarthritis after cementation for benign aggressive bone tumor of the knee joint: a systematic review and meta-analysis.

Background: The current systematic review aimed to answer the following questions: (i) Does extended curettage combined with the PMMA technique for the treatment of aggressive bone tumors around the knee led to the development of knee osteoarthritis? (ii) What factors are associated with osteoarthritis after bone cementation around the knee joint? Methods: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All electronic searches were performed on November 20, 2022, by a single researcher who evaluated the full texts of potentially eligible studies to determine inclusion. In these patients, the presence of osteoarthritis secondary to the surgical procedure was investigated. Data extracted included study type, characteristics of participants, sample size, gender, tumor site (femur or tibia), secondary osteoarthritis, tumor volume, distance from the joint cartilage, reoperation, follow-up time, Campanacci grade, and pathological fracture. Results: In total, 11 studies comprising 204 patients were evaluated, and it was found that 61 (30%) patients developed knee osteoarthritis due to extensive curettage and bone cement application for benign aggressive tumor treatment. According to the results obtained based the random effects model with the 11 studies included in the meta-analysis, the mean odds ratio of development knee OA with the 95% CI was calculated as -2.77 (-3.711, -1.83), which was statistically significant (z = -5.79; P < 0.000). Conclusion: The association of distance between the tumor and joint cartilage and development of osteoarthritis was not shown in this meta-analysis. Level of Evidence: Level IV prognostic study.

Is higher body mass index associated with secondary osteoarthritis in patients treated with bone cement for benign aggressive bone tumors? Long-term evaluation of 43 patients.

BACKGROUND: This study was designed to investigate the secondary osteoarthritis rate in patients with benign aggressive bone tumors treated with curettage and cementing at long-term follow up. METHODS: Patients diagnosed with benign aggressive bone tumor (giant cell or aneurysmal bone cyst), treated with extended curettage and cementation with polymethylmethacrylate, who had a minimum of 60 months of follow up after surgery were included in this study. After definitive diagnoses were confirmed by a histopathologist, we decided to perform standard surgical management. Osteoarthritis was staged radiologically using the Kellgren-Lawrence scoring system, and the contralateral knees of the patients were used as the control group. Based on the Kellgren-Lawrence classification system, stages 3 and 4 were accepted as the existence of osteoarthritis. Body mass index, the distance to the subchondral joint line, tumor mass volume, the location of the tumor (i.e., femur, tibia, medial condyle, or lateral condyle), age, and sex were also investigated, all of which are factors that can affect the occurrence of osteoarthritis. RESULTS: Forty-three patients, 24 male (56%) and 19 female (44%), were included in the study. The mean age of the patients was 29.5 ± 10 years, and mean follow up duration was 128.7 months. Tumor localization was the distal femur in 20 patients (46.5%) and the proximal tibia in 23 patients (53.5%). The mean tumor mass volume was 77.84 cm3 and the distance to the knee joint subchondral line was 3.2 ± 2 mm. According to this scoring system, 14 patients were at stage 0, 10 patients were at stage 1, 10 patients were at stage 2, four patients were at stage 3, and five patients were at stage 4. When we compared osteoarthritis development, the affected knee had a significantly higher rate of osteoarthritis development than the contralateral knee. A univariate analysis demonstrated that age (P = 0.002) and body mass index (P = 0.045) were associated with secondary osteoarthritis. Moreover, multivariate analysis demonstrated that none of the variables were independently associated with secondary osteoarthritis. CONCLUSION: Patients with contralateral osteoarthritis had bilateral knee osteoarthritis, indicating that primary osteoarthritis progressed in both knees. Seven of the 43 patients (16.2%) showed secondary osteoarthritis. Although age and body mass index were associated with secondary osteoarthritis in univariate analysis, none of the variables were independently associated with secondary osteoarthritis in the multivariate analysis.

Is liquid nitrogen recycled bone and vascular fibula combination the biological reconstruction of choice in lower extremity long bone tumor-related defects?

INTRODUCTION: Combination techniques, which encompass the combined use of vascularized bone grafts with massive allografts or autografts (recycled bone grafts), are especially important in the biological reconstruction of tumor-related lower extremity long bone defects. Liquid nitrogen recycled bone (frozen autograft) and free vascular fibula graft (FVFG) combination, which was coined as the "frozen hotdog (FH)" method by the authors, has not been as widely used nor its outcomes reported for significantly sized patient groups. This study aims to provide an answer to whether FH is a safe and effective reconstructive tool for limb salvage in malignant tumors of the lower extremity regarding radiological, functional, and oncological outcomes. PATIENTS AND METHODS: Sixty-six (male/female: 33/33) patients, who underwent FH reconstruction for tumor-related massive defects of lower extremity long bones between 2006 and 2020, were retrospectively analyzed. The mean age was 15.8 (3.8-46.7) years. The most common tumor localizations were distal femur (42.4%) and proximal tibia (21.2%) while classic osteosarcoma and Ewing's sarcoma were the most common pathologies (60.6% and 22.7%, respectively). Mean resection and FVFG lengths were 160 (90-320) mm and 192 (125-350) mm, respectively. The mean follow-up was 73.9 (24-192) months. RESULTS: The mean MSTS score was 25.4 (15-30) and the mean ISOLS radiographic score was 22.6 (13-24). Mean time to full weight bearing without any assistive devices was 15.4 (6-40) months and the median time was 12 months. MSTS score negatively correlated with resected segment length and vascular fibula length (p < 0.001; p = 0.006). Although full contact apposition of the FH segment correlated with earlier full weight bearing compared to partial apposition (mean 13.7 vs. 17.9 months) (p = 0.042), the quality of reduction did not affect the ISOLS radiographic score at LFU. Overall limb survival rate was 96.3% at 5 and 10 years while FH survival rate was 91.0% and 88.1% at 5 and 10 years. Local recurrence-free survival rates were 88.8% and 85.9%, and overall survival was 89.9% and 86.1% at 5 and 10 years, respectively. Limb length discrepancy was the most common complication with 34 (51.5%) patients while shell nonunion was seen in 21 (31.8%) patients and graft fracture in 6 (9.1%). CONCLUSION: The "FH" method is a safe, effective, and extremely cost-efficient reconstructive tool for tumor-related lower extremity long bone defects. Patient compliance to protracted weight-bearing, ensuring the vitality of the FVFG, and achieving an oncologically safe resection are key factors for a successful outcome.

Treatment of neuropathic unstable knee osteoarthritis by a condylar, rotating-hinge prosthesis with cementless pentagonal stem: a case series.

INTRODUCTION AND IMPORTANCE: Total knee arthroplasty (TKA) in the neuropathic unstable knee (NUK) setting is classically a challenging orthopedic problem due to intraoperative technical difficulties and a higher frequency of periprosthetic complications. More recently, satisfactory results have been reported using improved constraints, stems and revision-type TKA components. The study aims to present long-term results of a small case series with NUK osteoarthritis reconstructed by a condylar, semi-constrained prosthesis with a polygonal, hydroxyapatite-coated (HA-coated) press-fit stem. CASE PRESENTATION: From 2009 through 2010, three knees in three patients with advanced NUK arthropathy underwent TKAs in our institution using the PENTA® prosthesis. The average age at surgery was 44 years (32-58). The patients were followed up for a mean period of 124 months (120-128). The etiology of NUK was determined to be poliomyelitis sequela in 2 cases and spinal cord injury in one case. Functional outcomes were assessed with Knee Society (KS) Knee and Function Scores, and radiological outcomes were evaluated with ISOLS radiographic implant scores. Patients were monitored for complications clinically and radiologically. CLINICAL DISCUSSION: KS knee scores improved from a mean of 12,3 (0-37) preoperatively to 71,3 (65-77) and KS function scores improved from a mean of 1,7 (0-5) preoperatively to 68,3 (55-80) at the latest follow-up. Radiological outcomes were excellent according to ISOLS scores, and no complications were observed. CONCLUSION: Although this is a small case series, the significant improvement in functional scores, excellent radiological outcome, and implant survival at the end of a long follow-up period warrants TKA with a semi-constrained hinged implant in the setting of NUK. PENTA® prosthesis offers a good choice of implant with its hydroxyapatite-coated, press-fit, pentagonal stem and precisely designed rotating hinge.

External validation of the PATHFx decision-support tool on Turkish patients with skeletal metastasis.

Objective: Accurate determination of life expectancy becomes very important when determining the treatment of patients with pathologic fractures. We aimed to investigate the predictive role of the PATHFx model in Turkish patients by estimating the area under curve (AUC) of the receiver operator characteristic (ROC) and externally validating the results of PATHFx on the Turkish population. Methods: The data of 122 patients who presented to one of four orthopaedic oncology referral centres in Istanbul (2010-2017) and underwent surgical management of pathologic fractures were retrospectively collected. Patients were evaluated according to age, sex, type of pathologic fracture, presence of organ metastasis, presence of lymph node metastasis, haemoglobin concentration at presentation, primary oncologic diagnosis, number of bone metastases, and Eastern Cooperative Oncology Group (ECOG) status. Estimations of the PATHFx program by months were statistically evaluated using ROC analysis. Results: In our study population (122 patients), all survived the first month, 102 survived the third month, 89 were alive at 6 months, and 58 patients survived at 12 months. At 18 and 24 months, 39 and 27 patients were alive, respectively. The AUC value was 0.677 at 3 months, 0.695 at 6 months, 0.69 at 12 months, 0.674 at 18 months, and 0.693 at 24 months. The 3-, 6-, 12-, 18-, and 24-month survival rates were statistically significant (P < 0.01 and P < 0.05). ECOG performance status was 0-2 points in 33 patients (Memorial Sloan-Kettering Cancer Center (MSKCC) data set: 93 cases, our data set: 33 cases). ECOG performance status was 3-4 points in 89 patients (MSKCC data set: 96 cases, our data set: 89 cases). Conclusions: The objective data used by PATHFx for prediction provided statistically accurate estimates on Turkish patients, who are presumed to have mixed genomes through history from both Europe and Asia, and demonstrates its applicability to the Turkish population.

The Role of Whole-Body Magnetic Resonance Imaging in Assessing Extrapulmonary Metastases in Osteosarcoma Staging and Restaging: A Pilot Study.

OBJECTIVE: The aim of the study is to investigate the role of whole-body magnetic resonance imaging (MRI) in assessing extrapulmonary metastases in primary osteosarcoma staging. METHODS: We retrospectively reviewed medical data to identify primary osteosarcoma patients with available preoperative whole-body MRI obtained in the staging or restaging. Histopathology was the reference test for assessing the diagnostic performance, if available. Otherwise, oncology board decisions were used as the reference. In addition, the benefits of whole-body MRI to F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) and bone scintigraphy were investigated. RESULTS: In all, 36 patients with osteosarcoma (24 staging, 12 restaging) with a mean age of 16.36 ± 5.63 years (range, 9-29 years) were included in the study. The median follow-up duration was 26.61 months (interquartile range, 33.3 months). Of 36 patients, 8 had skeletal, 1 had a lymph node, and 1 had a subcutaneous metastasis. Whole-body MRI correctly identified all patients with metastatic disease but incorrectly classified a bone infarct in one patient as a skeletal metastasis, equating a scan-level sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 100%, 96.3%, 97.3%, 100%, and 90.91%. Whole-body MRI contributed to bone scintigraphy by identifying a skeletal metastasis in one patient and positron emission tomography-computed tomography by ruling out a skeletal metastasis in another. CONCLUSIONS: Whole-body MRI could accurately identify extrapulmonary metastases in primary osteosarcoma patients for staging or restaging. In addition, it might contribute to the standard whole-body imaging methods.

Femoral Discrepancy After Childhood Bone Sarcoma Surgery Can Be Treated With Magnetic Intramedullary Nails.

This study aims to determine whether femoral lengthening with a magnetic motorized intramedullary nail (PRECICE; NuVasive) is safe and effective in patients with discrepancy due to limb salvage performed for bone sarcomas before skeletal maturity. Six patients (male, 4; female, 2) with a mean age of 9.3 years (range, 4.8-12.8 years) at the time of index limb salvage surgery were retrospectively analyzed. Four patients had undergone biological reconstruction with liquid-nitrogen recycled frozen autograft shell and inlaid vascular fibula combination and 2 had undergone nonbiological reconstruction with distal femur modular tumor endoprosthesis. The mean age at PRECICE operation was 16.1 years (range, 13.4-20.1 years). The mean prelengthening femoral discrepancy was measured as 60 mm (range, 39-80 mm). Lengthening was achieved in 5 of these 6 patients. Although the PRECICE nail was successfully implanted in the sixth patient, lengthening could never be performed owing to failure to overcome the chronic diaphyseal nonunion first, as intended with compressive use of the nail. For the other 5 patients, in whom lengthening was performed, the mean lengthening was 45 mm (range, 35-52 mm), the mean ratio of achieved to planned lengthening was 93% (range, 74%-100%), and the mean bone-healing index was 41 days per cm (range, 24-69 days per cm). Mean Musculoskeletal Tumor Society score improved from 25.6 to 27.2 after lengthening. No major complications occurred. The outcomes of this study demonstrate that the PRECICE implant can safely and effectively correct femoral length discrepancy caused by limb salvage performed for osteosarcoma before skeletal maturity. [Orthopedics. 2023;46(1):27-34.].

Long-term results of different surgical options in the management of solitary enchondroma.

BACKGROUNDS: We aimed to compare the average 10-year results of patients treated with three different surgical methods, that is, extended curettage, extended curettage with grafting and extended curettage with cementation for the management of solitary enchondromas. METHODS: Two hundreds and three patients with a solitary enchondroma who underwent surgery at our department between 1990 and 2015 were evaluated retrospectively. Only extended curettage was performed in Group A (n: 75), extended curettage with grafting with autologous bone graft from the iliac crest in Group B (n: 58), and extended curettage with bone cement in Group C (n: 70). Surgical complications and recurrence were analysed and compared between these groups. RESULTS: No significant differences were noted among the groups in terms of gender (P = 0.654), age (P = 0.264) and follow-up duration (P = 0.919). The mean follow-up period in all groups was 122.9 ± 39 (range: 60-271) months. In addition to curettage and cementation, three patients received mechanical support with plate screws because of fracture risk. One patient in the extended curettage with grafting group had surgical site infection that was treated with simple debridement and antibiotherapy. One patient in the extended curettage group had lost motions of the proximal interphalangeal joint, which was treated with aggressive physiotherapy. CONCLUSION: We compared the average 10-year results of patients treated with three surgical options, namely, extended curettage, extended curettage with grafting, and extended curettage with cementation and no difference was found among the groups in local control of solitary enchondromas.

Mid-term implant survival, functional and radiological results and mechanical complications of mega-prosthetic reconstruction around the knee with the PENTA® system.

AIM: Mega-prosthetic reconstruction is the most common treatment method for massive osteoarticular defects caused by tumor resection around the knee. The new implant is a highly modular rotational-hinged megaprosthesis system with a distinct pentagonal stem geometry and variable implantation options. The aim of this study is to present the mid-term implant survival characteristics, functional and radiological results and mechanical complication profile of the new megaprosthesis. METHODS: One hundred and one mega-prosthetic knee reconstruction procedures in 90 patients (M/F: 51/39) utilizing the new implant system were retrospectively analyzed. In 68 patients, the megaprosthesis was used for primary reconstruction following tumor resection while it was used for revision of other implants in 22. The mean age was 28.5 (7-66) years and the mean follow-up was 59.2 (24-124) months. The most common primary pathology was osteosarcoma with 63-70% patients, the most common anatomical site of involvement was the distal femur with 56-62% patients. RESULTS: Henderson Type 2 failure (aseptic loosening) was seen in only 2-2.2% patients while Type 3 (structural failure) was seen in 29-32.2% Although the 5-year anchorage survival rate was 94.3%, overall mechanical implant survival was 76.1% at 5 years due to a relatively high failure rate in the first-generation hinge mechanism of the implant. The 5-year hinge survival rate demonstrated a significant improvement rate from 61.7% to 87.2% between the first and second generations of the implant (p = 0.027). The mean MSTS score was 24 out of 30 (14-29). The mean cumulative ISOLS radiographic score for index megaprosthesis operations was 19.7 (12-24), which corresponded to excellent outcome. CONCLUSION: The new megaprosthesis system is a reliable choice for the reconstruction of tumor-related massive osteoarticular defects around the knee. Although long-term follow-up is necessary for a definitive evaluation of the implant's survival characteristics, midterm follow-up yields exceptional anchorage properties related to pentagonal stem geometry with very good functional outcomes.

Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors.

OBJECTIVES: This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. METHODS: Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. RESULTS: The mean follow-up was of 39 months (range 3-120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. CONCLUSION: Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Management of primary malignant bone and soft tissue tumors of foot and ankle: Is it worth salvaging?

BACKGROUND AND OBJECTIVE: Performing limb salvage with safe margins and preserving meaningful function is very difficult in the setting of primary malignant bone and soft tissue tumors due to the complex and constrained anatomy of the foot and ankle. The study aims to evaluate the efficacy of limb salvage procedures in terms of functional and oncological outcomes. METHODS: Clinical data of 48 patients, who underwent surgical treatment between 1992 and 2015 in our institution, were retrospectively analyzed. Twenty-one (43.7%) patients had unplanned resections elsewhere previously. Limb salvage surgery (LSS) was the index surgery in 43 (89.6%) patients. In the LSS group, 28 (65.1%) received preoperative radiotherapy and 13 (30.2%) underwent complex reconstruction. The functional outcomes were assessed with Musculoskeletal Tumor Society (MSTS) scores. Limb survival and oncological outcomes were evaluated according to Kaplan-Meier curves. RESULTS: The mean follow-up time was 32.7 (3-115) months. Mild deformities and wound healing problems were the most common problems. While the functional scores were significantly higher in the LSS group, no significant difference was detected between amputation and LSS patients in terms of survival rates. CONCLUSION: LSS performed in specialized centers is an effective treatment method for malignant tumors of the foot and ankle.

Neoadjuvant radiotherapy for myxoid liposarcomas: Oncologic outcomes and histopathologic correlations.

OBJECTIVE: The aim of this study was to evaluate the histopathological features of primary extremity myxoid liposarcoma before and after neoadjuvant radiation therapy, and to evaluate the oncological outcomes of the patients. METHODS: The study included 23 patients (16 men and 7 women with a mean age of 43 (24-69) years) with primary myxoid liposarcoma of the extremities, who were treated between January 1998 and December 2015. Inclusion criteria were histopathological confirmation of the diagnosis with both the initial biopsy and the resection specimen, and having undergone neoadjuvant radiotherapy. Demographic, clinical and histopathological data were evaluated. RESULTS: Over a mean follow-up time of 55.2 (8-139) months, 5 patients (21.7%) died secondary to disease progression, leaving 18 patients (78.3%) still alive at the time of last follow-up. Only one patient (4%) experienced local recurrence and six (26%) patients developed distant metastases. Disease-free survival at 5 and 10 years were 66%; whereas, overall patient survival at 5 and 10 years were 78.1% and 71.0%, respectively. Tumor size (>15 cm) and presence of metastasis were significantly associated with increased overall mortality. On histopathology, necrosis was present in 12/23 resection specimens. Hyalinization/fibrosis and residual viable tumor was present in all specimens. Adipocytic maturation/cytodifferentiation was seen in 8/23 patients. CONCLUSION: Neoadjuvant radiotherapy was effective for myxoid liposarcomas histopathologically, although these histopathological features did not affect the patients' oncological outcomes. Favorable oncological outcomes were obtained with neoadjuvant radiotherapy, surgical resection and chemotherapy. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Malignant transformation of aggressive osteoblastoma to ostesarcoma.

Osteoblastoma is a rare, bone-forming tumor, characterized by osteoid and woven bone production. A 13-year-old boy patient presented to our clinic with complaint of pain in his left proximal tibia. We performed curettage and bone grafting for the lesion diagnosed as osteoblastoma. Two years later, the patient admitted to the hospital with a mass in the same region which was diagnosed by biopsy to be osteosarcoma. Patient was performed reconstruction operation with local resection and mega prosthesis. Fourteen months after termination of chemotherapy, lung metastasis developed and the patient died consequently. In this article, we reported a patient with aggressive osteoblastoma of the left proximal tibia which recurred as an osteosarcoma and discussed the difficulties in the histopathological diagnosis and management of these patients. As some other cases in the literature, our case indicates that osteoblastomas may undergo malignant transformation.

Clinical management of a challenging malignancy, osteoblastoma-like osteosarcoma: a report of four cases and a review of the literature.

Osteoblastoma-like osteosarcoma, a rare form of osteosarcoma, is a malignant lesion associated with risks of both local recurrence and distant metastasis. The differential diagnosis of osteoblastoma-like osteosarcoma from osteoblastoma and aggressive osteoblastoma remains controversial and challenging. Previous studies suggest that these three types of tumor are distinct entities. However, working out a precise diagnosis may not always be possible immediately on the basis of initial clinical, radiological, and histopathological features. On the other hand, the importance of a correct diagnosis cannot be overemphasized since the treatment strategies change dramatically according to the nature of the lesion. In all of our cases, initial Tru-Cut biopsies revealed osteoblastic features with minimal atypia, but further biopsies confirmed malignancy. A high index of suspicion and considerable experience are prerequisites for accurate diagnosis in case of clinicopathological and radiological discordance.

Osteosarcoma After Hematopoietic Stem Cell Transplantation in Children and Adolescents: Case Report and Review of the Literature.

Osteosarcoma as a secondary malignancy after hematopoietic stem cell transplantation (HSCT) is very rare. We present a case and review of 18 other cases reported to date. Our patient underwent HSCT for myelodysplastic syndrome at the age of 4 years. She developed osteosarcoma 13 years later. She underwent surgery after three courses of neoadjuvant chemotherapy followed by chemotherapy and mifamurtide. She has no evidence of disease 28 months after termination of chemotherapy. In 18 other cases of secondary osteosarcoma in the literature, 15 had received total body irradiation, eight had received alkylating agents, and six had received etoposide. The median interval from HSCT to the onset of osteosarcoma was 6.5 years (range 2.5-15.3), which confirms that children undergoing HSCT should be followed up for many years. In conclusion, osteosarcoma must be included in the differential diagnosis among solid tumors that may develop following HSCT.

MMP-3 gene polymorphisms and Osteosarcoma.

Osteosarcoma (OSA) is the most common adolescence cancer among all primary bone tumors next only to multiplemyeloma. It has a substantially worse prognosis and ability to metastasize to lung. MMPs (matrix metalloproteinases) are among the major proteases that take part in regulation of ECM (extracellular matrix). MMPs play an active role in the formation of the osteoid tissue, rich in collagens and other ECM proteoglycans. They also take part in pro-osteoclast, osteoclast, osteoblast, and osteoid formation. Many members of the MMP gene family have been linked to human cancers. It has been shown that MMPs particularly play a role in the tumor's acquisition of an invasive and metastatic character. In our study, the E45K and T102T polymorphisms of MMP-3 were studied using the PCR-RFLP method in 135 Turkish subjects (54 subjects with osteosarcoma and 81 healthy controls). We found that frequencies of E45K G allele (p:0,010, χ²:6,710, OR:1,429, 95% Cl: 1,019-1,858) and AG genotype (p:0,001, χ²:14,753, OR:2,32, 95% Cl: 1,491-3,626) were elevated in patients compared to controls. Besides, there was a significant difference in.E45K AA genotype between study groups (p:0,004, χ²:8,182, OR: 2,929, 95% Cl: 1,38-6,19). There were no significant differences between any genotypes or allele in the control and patient groups for MMP-3 T102T polymorphism. Our findings indicate that the G allele and AG genotype of MMP-3 E45K polymorphism is associated with increased risk of osteosarcoma in adolescent population of Turkey.

Lung Metastasis Mimicking Fingertip Infection.

Metastasis fingers (acral metastasis) are finding a poor prognosis. Past medical history should be questioned and metastasis from primary tumor should be kept in mind in patients with pain, swelling, and hyperemia in fingers. Successful surgical treatment on acral metastasis does not extend the life expectancy; however, it reduces the patient's pain during his terminal period, saves the functions of the limb, and increases life comfort.

Survival and prognostic factors in adult patients with recurrent or refractory ewing sarcoma family tumours: a 13-years retrospective study in Turkey.

AIM: The aim of the present study was to evaluate the results of treatment and prognostic factors in adult patients with recurrent or refractory Ewing's sarcoma family tumors (ESFT). PATIENTS AND METHODS: We retrospectively evaluated treatment outcomes of 54 consecutive patients with ESFT (aged 15 years or more) with complete medical records, who were treated with multimodal therapies after recurrence at the Istanbul University, Institute of Oncology. RESULTS: The commonly used chemotherapy regimens at relapse were ifosfamide and etoposide (IE), ifosfamide and etoposide plus carboplatin (ICE), and oral etoposide. The median progression-free survival and overall survival for the entire group were 6.3 (95% confidence interval, 3.08-9.60) and 8.6 (95% confidence interval CI, 4.7-12.4) months, respectively. Multivariate analysis using a Cox proportional hazards model showed that non-IE/ICE chemotherapy regimens (p=0.003, hazard ratio=2.38) and the presence extrapulmonary metastases (p=0.045, hazard ratio=2.15) were associated with worse overall survival. CONCLUSION: In primary refractory or relapsed ESFT, the presence of extrapulmonary metastases and treatment with salvage regimens other than ifosfamide and etoposide and/or carboplatin correlate with a poor prognosis.

Avulsion fractures involving the straight and reflected heads of the rectus femoris.

Tumours and sport injuries can both affect active, young patients, and the symptoms of the two often overlap. Neglected avulsion injuries sometimes cause a mass to develop which can mimic a tumour. We discuss the diagnosis, treatment, and results following nine anterior inferior iliac spine (AISS) avulsion fractures.