Reconstruction of the pelvic ring in iliac or iliosacral resections: allograft or autograft?

BACKGROUND: The necessity to reconstruct the pelvic ring after an iliac or iliosacral resection is still debated. Different reconstructive techniques are available, including autologous and homologous graft and custom-made prosthesis. The aim of this study was to evaluate the functional outcome and complications of patients who underwent resection of iliac bone and part of the sacrum for primary bone tumour and reconstruction with an allograft or autograft. METHODS: We retrospectively evaluated 18 patients (10 males and 8 female) with a mean age of 28 years (range 9-56) who were operated between 1992 and 2015. Six patients were reconstructed with an autograft (Group A) and 12 patients with an allograft (Group B). All complications were recorded. At final follow-up, patients with the original reconstruction still in site were functionally evaluated with MSTS Score. RESULTS: Mean follow-up time was 107 months (range 4-221). Two patients (11.1%) had an external hemipelvectomy for local recurrence, and 3 patients died of the disease. Mean MSTS Score was comparable between the two groups 21.7 (range 20-25) in Group A and 19.9 (range 4-28) in Group B. Patients with partial sacral resection had an increased risk of local recurrence and lower MSTS Score [15.5 (range 7-20) vs. 22.2 (range 4-28)]. CONCLUSIONS: Biological reconstruction of pelvic ring with autologous or homologous bone graft gives acceptable functional results. However, the decision on how to reconstruct the pelvic ring after iliac resection should be taken on a patient-by-patient basis.

Vascularized fibular autograft as salvage technique in failure of allograft intercalary reconstructions after tumor resections.

Intercalary allografts after diaphyseal resections for bone tumors represent the most frequent option of reconstruction. Main complications are non-unions, fractures and infections. The purpose of the current study was to report our experience with the use of vascularized fibular autograft as rescue technique in failed previous reconstructions after intercalary bone tumor resection of the extremities. Twenty-eight patients were followed over time. Causes of failure were non-union, allograft fracture and infection. Vascularized fibular autograft was used with mechanical support of massive bone allograft in 13 cases. Functional results were excellent in 19 cases, good in 8 and fair in one patient. Among complications we reported 4 non-unions, 2 allograft fractures, 1 non-union with plate breakage, 1 plate breakage, 1 infection, 1 limb shortening and 1 knee varus deformity. The rationale of vascularized fibular autograft is to provide biologic support. The association with massive bone allograft provides mechanical strength and early stability.

Total elbow arthroplasty for primary and metastatic tumor.

BACKGROUND: Prostheses can be used in elbow reconstruction in both primary and metastatic lesions. Several authors have reported their experience with different types of implant, but not with modular prostheses. HYPOTHESIS: Limb salvage using an elbow prosthesis is effective in obtaining good functional results and reliable local tumor control. MATERIAL AND METHODS: Forty-seven patients treated at the Rizzoli Institute for elbow neoplasm from 1990 to 2012 were evaluated. There were 30 primary tumors (64%), 24 bone tumors and 6 soft tissue sarcomas, and 17 bone metastases. Elbow reconstruction used a modular prosthesis in 25 patients and a standard prosthesis in 22. Reconstruction was primary in 30 patients and secondary in 17. RESULTS: At last control, 15 (32%) were dead of disease (DOD) at a mean follow-up of 35 months, 12 (25%) were alive with disease (AWD) at a mean follow-up of 29 months, 19 (40%) showed no evidence of disease (NED) at a mean follow-up of 80 months. Early complications were related to unexpected neurological damage, observed in 12 patients (25%): in 5 cases the deficit resolved in a mean 6 months; in the others, no or only partial recovery was observed. Two implants (4%) developed infection: 1 was treated with antibiotic therapy, and the other required implant revision. One implant showing cement extrusion was revised. In 3 patients (6%) radiography showed a radiolucent halo around the stem (2 humeral, 1 ulnar); no measures were taken, as the patients were completely asymptomatic at every follow-up. In 3 patients (6%) partial resorption of the allograft was observed on X-ray, but remained unchanged at last follow-up, without pain or functional impairment. Seven local recurrences (15%) were observed, at a mean of 16 months after surgery; 5 were treated by resection and/or radiotherapy, and 2 by amputation. Mean functional scores on MEPS and MSTS were respectively 84% and 22/30 (73%). CONCLUSIONS: Elbow prostheses provided better function in primary than in metastatic tumor. Elbow prosthesis reconstruction after tumor resection is a viable option both for primary and secondary bone neoplasms. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: IV, retrospective study.

Multidisciplinary approach to osteosarcoma.

Osteosarcoma is a malignant bone tumor composed of mesenchymal cells producing osteoid and immature bone. Osteosarcoma is the most frequent primary malignant bone tumor, if we excluded myeloma, a haematologic disease. The incidence of osteosarcoma is 2-3/million/year, but is higher in adolescence, in which the annual incidence peaks at 8-11/million/year at 15-19 years of age. Local pain, followed by localized swelling and limitation of joint movement, are the typical signs and symptoms. Correct diagnosis can be achieved through a correct approach to the disease and the combination of clinical and radiographic aspects. The final step to confirm the diagnosis is the biopsy. Computer Tomography of the chest and Positron-Emission Tomography are mandatory to complete the staging, which is performed according the Musculoskeletal Tumor Society staging system. A multidisciplinary approach is needed both to get to a correct diagnosis (orthopaedic surgeon, radiologist and histopathologist) and to perform definitive treatment. Multidisciplinary approach should be performed in reference centers able to provide access to the full spectrum of care and where orthopaedic surgeon, oncologist, histopathologist, radiologist and radiotherapist can cooperate. The management of osteosarcoma is based primarily on neo-adjuvant and adjuvant chemotherapy and surgical resection; radiotherapy is not effective as osteosarcomas are relatively radioresistant. Prognostic factors include metastases at presentation, histologic response to induction chemotherapy, the site of the primary tumor (with axial lesions having an inferior outcome), serum lactate dehydrogenase and alkaline phosphatase levels.

Spontaneous-idiopathic left anterior descending artery dissection: is watchful waiting better than immediate stenting?

Spontaneous coronary artery dissection (SCAD) is a rare, complex disease, nowadays poorly understood yet. The lack of firm recommendations about this issue is a great limitation which makes any therapeutic decision controversial. The case described is that of a young, otherwise healthy woman, who presented with an ostial dissection of the left anterior descending (LAD) artery. Due to patient's stable clinical and hemodynamic parameters, we used a cautious approach based on watchful waiting and medical therapy, postponing stenting in order to achieve a partial vessel reopening with a more comfortable access to PCI.

Biodegradation of α-, ß-, and γ-hexachlorocyclohexane by Arthrobacter fluorescens and Arthrobacter giacomelloi.

The organochlorine pesticide γ-hexachlorocyclohexane (γ-HCH, lindane) and its non-insecticidal isomers α-, ß-, and δ- continue to pose serious environmental and health concerns, although their use has been restricted or completely banned for decades. The present study reports the first results on the ability of two Arthrobacter strains, not directly isolated from a HCH-polluted site, to grow in a mineral salt medium containing α-, ß-, or γ-HCH (100 mgl(-1)) as sole source of carbon. Growth of cultures and HCHs degradation by Arthrobacter fluorescens and Arthrobacter giacomelloi were investigated after 1, 2, 3, 4, and 7 days of incubation by enumerating colony forming units and GC with ECD detection, respectively. Both bacteria are able to metabolize the HCHs: A. giacomelloi is the most effective one, as after 72 h of incubation it produces 88 % degradation of α-, 60 % of ß-, and 56 % of γ-HCH. The formation of possible persistent compounds was studied by GC/MS and by HPLC analysis. Pentachlorocyclohexenes and tetrachlorocyclohexenes have been detected as metabolites, which are almost completely eliminated after 72 h of incubation, while no phenolic compounds were found.

Single-dose palonosetron for prevention of chemotherapy-induced nausea and vomiting in patients with aggressive non-Hodgkin's lymphoma receiving moderately emetogenic chemotherapy containing steroids: results of a phase II study from the Gruppo Italiano per lo Studio dei Linfomi (GISL).

PURPOSE: The control of nausea and vomiting induced by chemotherapy is paramount for overall treatment success in cancer patients. Antiemetic therapy during chemotherapy in lymphoma patients generally consists of anti-serotoninergic drugs and dexamethasone. The aim of this trial was to evaluate the efficacy of a single dose of palonosetron, a second-generation serotonin type 3 (5-HT(3)) receptor antagonist, in patients with aggressive non-Hodgkin's lymphoma receiving moderately emetogenic chemotherapy (MEC) containing steroids. METHODS: Patients received a single intravenous bolus of palonosetron (0.25 mg) before administration of chemotherapy. Complete response (CR) defined as no vomiting and no rescue therapy during overall phase (0-120 h) was the primary endpoint. Complete control (CC) defined as CR and only mild nausea was a secondary endpoint. RESULTS: Eighty-six evaluable patients entered in the study. A CR was observed in 74 patients (86.0%) during the overall phase; the CR during the acute (0-24 h) and delayed (24-120 h) phases was 90.7% and 88.4%, respectively. CC was 89.5% during the acute and 84.9% during the delayed phase; the overall CC was 82.6%. CONCLUSIONS: This was the first trial, which demonstrated the efficacy of a single dose of palonosetron in control CINV in patients with aggressive non-Hodgkin's lymphoma receiving MEC regimen containing steroids.

Vascular homografts for vessel substitution in skeletal and soft tissue sarcomas of the limbs.

Large vessel involvement by skeletal and soft tissue sarcomas of the extremities does not change the modern limb sparing surgery for those neoplasms. An arterial and, if the vein is open, a venous bypass should always be offered to any patient young or old, with high or low grade sarcoma, because preserving the limb permits quicker rehabilitation, which is particularly useful in the case of a short life expectancy. In 650 cases of skeletal sarcomas, 10 arterial (1.5%) and four venous bypasses were done, all with autologous veins but one in PTFE; we had no problems except a silent arterial occlusion. Of 1000 patients with soft tissue sarcomas, 32 (3%) had vessel involvement permitting limb sparing surgery. The arterial bypass, which is the limb-saving operation, was performed 16 times with a PTFE with one early occlusion and four cases of prosthesis infection, with two amputations despite redo operation with an autologous vein. The more recent 16 cases were, therefore, always done with biological vessel substitution--autologous vein or tissue bank vessel--with only one infection that healed without operation and one case of homograft rupture followed by amputation. Since 1999 in all 13 resected cases with an open vein, we did the arterial and the venous bypass (twice PTFE, six autologous vein, and five bank vessel) with the aim of avoiding postoperative venous hypertension, but only four of the venous bypasses remained open. Venous bypasses are a harmless, but still experimental, procedure.

Long-term outcome for patients with non-metastatic Ewing's sarcoma treated with adjuvant and neoadjuvant chemotherapies. 402 patients treated at Rizzoli between 1972 and 1992.

We evaluated the long-term results obtained in 402 patients with non-metastatic Ewing's sarcoma (ES) of the bone treated in a single institution with adjuvant and neoadjuvant chemotherapies between 1972 and 1992. Multivariate analyses showed male gender, age older than 14 years, high serum lactate dehydrogenase (LDH) level, axial location of the tumour, use of radiotherapy alone as a local treatment, and poor histological response to chemotherapy, to be independent, adverse prognostic factors for event-free survival (EFS). At a mean follow-up of about 18 years (10-30 years), 177 patients (44.0%) remained continuously free of disease, 2 died of doxorubicin-induced cardiotoxicity and 8 developed a second neoplasm (5 died, and 3 are alive and free of disease). 215 patients relapsed with metastases and/or local recurrence: 14 are alive and free of disease, 1 is alive with uncontrolled disease, and 200 died. The overall survival (OS) at real follow-ups of 5-, 10-, 15- and 20-years was 57.2, 49.3, 44.9 and 38.4%, respectively. We conclude that since local or systemic relapses, treatment-complications and second malignancies are more common after 5 years or more from the beginning of treatment; a long-term follow-up is mandatory for patients with ES.

Therapy and survival after recurrence of Ewing's tumors: the Rizzoli experience in 195 patients treated with adjuvant and neoadjuvant chemotherapy from 1979 to 1997.

BACKGROUND: Many papers have reported the results achieved with combined therapy for Ewing's tumors, but little is known about the treatment and outcome of those 30-40% of patients who relapse. PATIENTS AND METHODS: In a retrospective study, we evaluated 195 patients with Ewing's tumors treated at our institution from 1979 to 1997 with chemotherapy, radiotherapy, surgery or combined therapies after recurrence. RESULTS: A second complete remission was achieved in only 26 patients (13.3%); 12 relapsed again and died of the tumor. The 5-year post-relapse event-free survival and overall survival were 9.7% and 13.8%, respectively; both of which were significantly better for patients who had relapsed >/=2 years after the beginning of the first treatment (14.3% versus 2.5%; P <0.001) and for patients who relapsed with only lung metastases (14.5% versus 0.9%; P <0.0005). In terms of treatment, patients treated with surgery or radiotherapy, alone or in combination with chemotherapy, had better survival rates than patients treated with chemotherapy alone (15.4% versus 0.9%; P <0.0001). CONCLUSIONS: The outcome of Ewing's tumor patients who relapse after combined treatment is very poor. However, these patients may be divided into two groups: those that can be cured with traditional treatments (late relapse and/or only lung metastases), and a second group of patients (early relapses with metastases in lungs and/or other sites) who gain no benefit from traditional therapies. For the latter group, multicenter studies are needed to evaluate new strategies of treatment.

Radiological features of 24 periosteal chondrosarcomas.

OBJECTIVE: To report the imaging findings of 24 periosteal chondrosarcomas diagnosed, staged, treated and followed in a single institution, to analyze and define their pattern, and discuss their practical consequences. DESIGN AND PATIENTS: Plain films, 16 CT examinations and four MRI examinations were reviewed, and compared with the histological evaluation. RESULTS: There were 20 men and four women, aged from 17 to 65 years. Twelve lesions involved the distal femoral metaphyses (8 posteriorly), five the proximal humerus, two the proximal metaphyses of the femur and two of the tibia, two the humeral shafts and one the iliac wing. Size varied from 4 to 11 cm. The cortex was always involved (thick, 15; thin, 13). Typical cartilaginous calcifications and cartilaginous lobules were very frequent. Radial thick periosteal bone formations (n = 6) indicated calcifications between the lobules of cartilage. Medullary involvement was rare (n = 2). All patients are alive and free of disease. CONCLUSIONS: Recognizing periosteal chondrosarcoma is of paramount importance because the prognosis is excellent after adequate local surgery alone. The patterns of other surface tumors of bone are usually different.

Radiological study of 12 high-grade surface osteosarcomas.

OBJECTIVE: The purpose of our study was to report the imaging characteristics of 12 high-grade surface osteosarcomas, diagnosed, staged, treated and followed up in a single institution. DESIGN AND PATIENTS: There were 3 females and 9 males ranging in age from 15 to 34 years (mean 20 years). The radiological documents (plain films in all patients, CT scans in 8 and MR images in 6) were reviewed and compared with the histological findings. RESULTS: Disease sites were the femur (7), tibia (4) and fibula (1). Tumor size varied from 6 to 17 cm. The cortex appeared normal in two patients, thick in seven and/or thin in five. The tumor showed dense ossification in all except in one case where ossification was slight. Minimal marrow involvement was visible in two cases on CT/MRI. Only one case exhibited a satellite nodule in a previous biopsy tract. Two cases radiologically mimicked periosteal osteosarcoma. CONCLUSION: High-grade surface osteosarcomas are often characterized by the presence of an ossified mass contiguous with and originating from the cortical bone with no or minimal marrow involvement.

[Role of magnetic resonance in the evaluation of the normal and osteochondrosis hip in early and late childhood]. / Ruolo della Risonanza Magnetica nella valutazione dell'anca normale e osteocondrosica nella prima e seconda infanzia.

INTRODUCTION: Despite MR potentials, few studies investigate the features of normal hips and of hip osteochondrosis in early and late childhood. We report our personal experience with MRI of hip osteochondrosis in pediatric patients. MATERIAL AND METHODS: MR images were obtained with total body MR equipment at medium and high fields. The normal hips were studied in children aged 34 months to 6 years with abdominal-urinary tract disorders and in 9 patients of the same age with unilateral Perthes disease. Hip osteochondrosis was studied in 6 children with Catteral's type III and IV and in 3 with type I and II disease. General anesthesia was never necessary to perform MRI. RESULTS: MRI exactly defined the cephalic anatomic profiles of normal hips which are not depicted with conventional radiography before the femoral head cartilage ossifies completely. MR contrast resolution was very high in depicting the maturation of the epiphyseal nucleus and its exact site in the cartilagineous epiphyseal hemisphere proximal to the femur. The analysis of MR morphological and structural changes permitted to correlate MR findings with the histopathologic features described in the literature. In addition, MRI of childhood hip osteochondrosis showed maked structural changes of the epiphyseal nucleus which are usually missed with conventional radiography. MRI permits early location of the abnormal area and the recognition of growing disk abnormalities; it also shows the whole cephalic cartilage and the changes of the epiphyseal nucleus evolution, which permits to differentiate osteochondrosis evolution from recessive patterns. Finally, MRI clearly showed the increased equatorial diameters of the involved femoral heads and the associated decrease in polar diameters, which is essential to study the biomechanics of hip osteochondrosis and therefore to plan treatment. CONCLUSIONS: MRI, even with coronal sequences and T1-weighting only, permits: 1) to image normal hips and hip osteochondrosis, especially in early and late childhood; 2) to clearly define cephalocotyloid relationships; 3) to depict the actual anatomic margins of the head and its structure; 4) to investigate the head cartilage extent and to locate the ossification nucleus. These morphologic and structural data are very useful to diagnose and manage hip osteochondrosis in the evolutive age. MRI shows abnormal changes in anatomic structures which are not seen with conventional radiography and demonstrates the evolution of the osteochondrosis process over time. In children over six, at the end of the ossification process of the head cartilage, conventional radiography alone is often sufficient to depict cephalocotyloid relationships and the MR diagnostic criteria of bone-cephalic diseases are similar to those used in adult hip studies.

Communication and family planning in Sub-Saharan Africa.

PIP: An analysis of 46 posters from 27 countries of Sub-Saharan Africa allowed the values conveyed by this medium to be defined, the status of the announcer and the recipient to be clarified, and their relationship and the attendant social consequences to be brought out. One of the primary characteristics of this sample was that the vast majority of the posters contained drawings and only a limited number used photos. The family was the theme most commonly represented by the image and the text: information on family planning necessarily involved the family, the synonym of fertility. The majority of posters represented the traditional, nuclear family of the Western world, comprising the father, mother, and children. It was interesting to observe that this image did not necessarily reflect reality in Africa, where traditionally the extended family, including the grandparents, uncles and aunts, is more widespread. The message most commonly conveyed the image of the nuclear family. The number of children shown varied from 1 to 4, with an average of 2. The most widely used message strategies in this sample of posters involved three types of announcer: authoritarian, nonauthoritarian, and character announcer. The authoritarian type announcer was not visually depicted but consisted of messages that were written orders or threats. The nonauthoritarian announcer, also not depicted, gave messages that contained no orders or threats. The character announcer was one the characters portrayed in the picture.^ieng

The sonographic appearances of gastric lymphoma.

The sonographic images obtained from 17 patients with gastric lymphoma were reviewed. In 15/17 cases the tumor presented as an abdominal mass, either with a "target-like" pattern or with a solid, homogeneous structure; in the remaining two cases only thickening of portions of the gastric wall was seen. Two features that may help to differentiate lymphoma from other gastric diseases were observed in patients of this series. In eight cases thickened mucosal folds could be identified within the gastric mass, outlined by strong luminal echoes arranged like the spokes of a wheel. A hypoechoic appearance of hte infiltrated gastric wall was seen in 13/17 cases; it was less echogenic than the adjacent liver parenchyma and, often, it was almost echo-free. Sonography is often used as the first imaging method in cases of patients with abdominal complaints and clinically unsuspected tumors of the stomach may be visualized first by it. In such cases, identification of these features within a gastric mass may allow sonography to suggest the lymphomatous nature of the disease.