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1.
Bone Joint J ; 102-B(1): 72-81, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888363

RESUMO

AIMS: The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. METHODS: This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. RESULTS: There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. CONCLUSION: This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72-81.


Assuntos
Neoplasias Femorais/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/metabolismo , Estudos de Casos e Controles , Feminino , Neoplasias Femorais/secundário , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Escócia/epidemiologia , Índice de Gravidade de Doença , Análise de Sobrevida , Tempo para o Tratamento
2.
Br J Radiol ; 92(1104): 20190518, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31386558

RESUMO

OBJECTIVE: Confirming the surgical osseous margin of a resected malignant bone tumor macroscopically before reconstruction with a prosthesis is ideal. However, making the cut-surface of the femur specimen during surgery is difficult because of the hard bone tissue. In order to resolve this problem, the possibility of intraoperative MRI was considered. METHODS: MRI was performed at the surgical unit for five malignant femoral bone tumors that included two osteosarcomas and one undifferentiated high-grade sarcoma, and two metastatic tumors immediately after the tumor resection. The specimens were prepared in plastic containers with saline. RESULTS: The osseous surgical margins were confirmed to be those planned pre-operatively in all cases without metal-induced artifacts. The T1 weighted image (WI) was useful for evaluation of the osseous surgical margin, whereas the T2WI was useful for confirmation of extraosseous soft-tissue. CONCLUSION: The MRI was performed post-operatively as a preliminary evaluation of the technique. However, a limited sequence (i.e. coronal T1WI) with short examination time could be performed during surgery for the sole purpose of assessing the osseous margin. ADVANCES IN KNOWLEDGE: MRI examination of a resected malignant bone tumor specimen has not been reported, and can be an option for assessment of the osseous surgical margin.


Assuntos
Neoplasias Femorais/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Margens de Excisão , Osteossarcoma/diagnóstico por imagem , Implantação de Prótese , Sarcoma/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Feminino , Neoplasias Femorais/secundário , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Osteossarcoma/cirurgia , Sarcoma/cirurgia , Neoplasias da Bexiga Urinária/patologia
3.
Rev Esp Cir Ortop Traumatol ; 63(3): 173-180, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30922597

RESUMO

OBJECTIVE: To analyze a series of patients with bone tumours reconstructed with modular prostheses and to evaluate: 1) Survival of the implant. 2) Causes of failure. 3) Complication rates. 4) Limb salvage overall survival. 5) Functional results and full weight bearing. MATERIALS AND METHODS: A retrospective study from longitudinally maintained oncology databases was undertaken. All patients with bone tumours reconstructed with endoprosthesis were analysed. A toal of 106patients matched the inclusion criteria. They were divided into groups: group 1, primary bone tumours; group 2, bone metastasis; group 3, osteoarticular allograft reconstruction revisions. The type of failures were classified according to Henderson et al. (2014) and functional results assessed by the Musculoskeletal Tumor Society (MSTS). Demographic analysis, survival and the differences between groups were recorded. RESULT: The mean follow-up of the patients was 68 months. Mean age was 43 years. Overall implant survival was 86.4% at 2 years (95% CI: 79-94) and 73% at 5 years (95% CI: 60-80). Nineteen patients (18%) developed a prosthetic failure. The limb salvage overall survival was 96% at 5 years (95% CI: 91-99). The mean functional results according to the MSTS was 24 and mean time to full weight bearing was 2.3 weeks. CONCLUSIONS: Limb conservation surgery and endosprosthetic reconstruction is a valid option for patients with bone tumours with failure rates similar to other reconstruction methods.


Assuntos
Neoplasias Ósseas/cirurgia , Neoplasias Femorais/cirurgia , Falha de Prótese , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/secundário , Feminino , Neoplasias Femorais/mortalidade , Neoplasias Femorais/secundário , Seguimentos , Humanos , Úmero , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão , Procedimentos Cirúrgicos Reconstrutivos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Tíbia , Resultado do Tratamento , Suporte de Carga , Adulto Jovem
4.
Clin Orthop Relat Res ; 477(4): 707-714, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30811363

RESUMO

BACKGROUND: Biologic agents may prolong survival of patients with certain kidney and lung adenocarcinomas that have metastasized to bone, and patient response to these agents should be considered when choosing between an endoprosthesis and internal fixation for surgical treatment of femoral metastases. QUESTIONS/PURPOSES: Among patients undergoing surgery for femoral metastases of lung or renal cell carcinoma, (1) Does survival differ between patients who receive only cytotoxic chemotherapy and those who either respond or do not respond to biologic therapy? (2) Does postsurgical incidence of local disease progression differ between groups stratified by systemic treatment and response? (3) Does implant survival differ among groups stratified by systemic treatment and response? METHODS: From our institutional longitudinally maintained orthopaedic database, patients were identified by a query initially identifying all patients who carried a diagnosis of renal cell carcinoma or lung carcinoma. Patients who underwent internal fixation or prosthetic reconstruction between 2000 and 2016 for pathologic fracture of the femur and who survived ≥ 1 year after surgery were studied. Patients who received either traditional cytotoxic chemotherapy or a biologic agent were included. Patients were classified as responders or nonresponders to biologic agents based on whether they had clinical and imaging evidence of a response recorded on two consecutive office visits over ≥ 6 months. Endpoints were overall survival from the time of diagnosis, survival after the femoral operation, evidence of disease progression in the femoral operative site, and symptomatic local disease progression for which revision surgery was necessary. Our analysis included 148 patients with renal (n = 26) and lung (n = 122) adenocarcinoma. Fifty-one patients received traditional chemotherapy only. Of 97 patients who received a biologic agent, 41 achieved a response (stabilization/regression of visceral metastases), whereas 56 developed disease progression. We analyzed overall patient survival with the Kaplan-Meier method and used the log-rank test to identify significant differences (p < 0.05) between groups. RESULTS: One-year survival after surgery among patients responsive to biologic therapy was 61% compared with 20% among patients nonresponsive to biologics (p < 0.001) and 10% among those who received chemotherapy only (p < 0.009). With the number of patients we had to study, we could not detect any difference in local progression of femoral disease associated with systemic treatment and response. Radiologic evidence of periimplant local disease progression developed in three (7%) of 41 patients who responded to biologic treatment, two (3%) of 56 patients nonresponsive to biologics, and one (2%) of 51 patients treated with traditional chemotherapy. With the numbers of patients we had, we could not detect a difference in patients who underwent revision. All three patients responsive to biologics who developed local recurrence underwent revision, whereas the two without a response to biologics did not. CONCLUSIONS: Biologic therapy improves the overall longevity of some patients with lung and renal metastases to the femur in whom a visceral disease response occurred. In our limited cohort, we could not demonstrate an implant survival difference between such patients and those with shorter survival who may have had more aggressive disease. However, an increased life expectancy beyond 1 year among patients responsive to biologics may increase risk of mechanical failure of fixation constructs. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Adenocarcinoma de Pulmão/terapia , Produtos Biológicos/uso terapêutico , Carcinoma de Células Renais/terapia , Fraturas do Fêmur/cirurgia , Neoplasias Femorais/cirurgia , Fixação Interna de Fraturas , Fraturas Espontâneas/cirurgia , Neoplasias Renais/tratamento farmacológico , Neoplasias Pulmonares/tratamento farmacológico , Implantação de Prótese , Adenocarcinoma de Pulmão/mortalidade , Adenocarcinoma de Pulmão/secundário , Adulto , Idoso , Idoso de 80 Anos ou mais , Produtos Biológicos/efeitos adversos , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/secundário , Tomada de Decisão Clínica , Bases de Dados Factuais , Progressão da Doença , Feminino , Fraturas do Fêmur/mortalidade , Fraturas do Fêmur/patologia , Neoplasias Femorais/mortalidade , Neoplasias Femorais/secundário , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/mortalidade , Fraturas Espontâneas/mortalidade , Fraturas Espontâneas/patologia , Humanos , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Expectativa de Vida , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Implantação de Prótese/efeitos adversos , Implantação de Prótese/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
5.
Strahlenther Onkol ; 195(4): 335-342, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30215093

RESUMO

PURPOSE: To reinvestigate the functional recovery after combined treatment with surgery and postoperative irradiation of complete or impending pathologic fractures of long bones. METHODS: We retrospectively evaluated the results of external beam radiation therapy (EBRT) carried out after 68 orthopedic stabilization procedures (femur, n = 55, 80.8%; humerus, n = 13, 19.2%) for actual or impending pathological fracture of long bone in 61 patients with skeletal metastases. The mean normalized total dose was 34.7 ± 7.8 Gy. Endpoints were patient's functional status (FS; 1 = normal pain free status; 2 = normal use with pain; 3 = significantly limited used; 4 = nonfunctional status), a need for a secondary procedure to the same site and overall survival following surgery. RESULTS: Overall, 75% of patients achieved normal functional status (FS 1-2) within 12 weeks after surgery. Functional recovery in surviving patients reached 93%. Median survival was 17 months (95% confidence interval 13.7-20.2). Secondary surgical intervention at the same location was necessary in 3 patients (4.4%). On multivariate analysis, only general status (p = 0.011) and growing potential of primary tumor (p = 0.049) were associated with achieving normal functional status within 12 weeks after surgery and radiotherapy. The applied radiation schemes demonstrated a comparable impact on functional recovery. CONCLUSIONS: Our results confirm the effectiveness of stabilizing surgery and fractionated postoperative radiotherapy in terms of functional recovery, supporting prior results assessing postsurgical radiotherapy versus follow-up. The patient's general status is a strong prognostic factor for functional recovery. Rapidly growing tumors may hinder achievement of a normal functional status.


Assuntos
Neoplasias Ósseas/secundário , Neoplasias Ósseas/terapia , Neoplasias Femorais/secundário , Neoplasias Femorais/terapia , Úmero/cirurgia , Radioterapia Adjuvante , Recuperação de Função Fisiológica , Idoso , Terapia Combinada , Feminino , Neoplasias Femorais/mortalidade , Seguimentos , Fraturas Espontâneas/mortalidade , Fraturas Espontâneas/radioterapia , Fraturas Espontâneas/cirurgia , Humanos , Masculino , Análise Multivariada , Medição da Dor , Estudos Retrospectivos , Taxa de Sobrevida
6.
J Surg Orthop Adv ; 27(3): 178-186, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30489242

RESUMO

Mirels scoring system for determining prophylactic stabilization need of skeletal metastases includes a limited number of variables and does not differentiate between procedure types. This study sought to identify additional variables associated with surgical failure, radiographic disease progression, and patient survival. A retrospective review was performed of patients from January 2004 to 2014 who underwent surgical treatment of skeletal metastases of the extremities, were >18 years of age, and had adequate radiographic surveillance. Eighty-nine metastatic bone lesions in 77 patients were included. Mirels score >8 (p = .015) and tumor origin (p = .008) were associated with surgical failure, which was 16.8%. Male gender (p < .001) and use of bone cement (p = .019) were associated with radiographic progression, 43.8% overall. Antiresorptive medications usage (p = .02) was associated with survival. The study concluded that tumor origin may be highly important when considering surgical treatment for metastatic bone disease and antiresorptive medications should be used postoperatively, given an association with survival. (Journal of Surgical Orthopaedic Advances 27(3):178-186, 2018).


Assuntos
Neoplasias Ósseas/cirurgia , Fraturas Espontâneas/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/secundário , Placas Ósseas , Neoplasias da Mama/patologia , Calcâneo/cirurgia , Feminino , Neoplasias Femorais/secundário , Neoplasias Femorais/cirurgia , Fixação Intramedular de Fraturas , Humanos , Úmero/cirurgia , Neoplasias Renais/patologia , Linfoma/cirurgia , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/secundário , Mieloma Múltiplo/cirurgia , Rádio (Anatomia)/cirurgia , Estudos Retrospectivos , Fatores de Risco , Tíbia/cirurgia , Falha de Tratamento , Ulna/cirurgia
7.
J Med Case Rep ; 12(1): 104, 2018 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-29681240

RESUMO

BACKGROUND: Pembrolizumab has significantly improved outcomes in patients with advanced non-small cell lung cancer. Combining programmed death-1 inhibitor with stereotactic body radiotherapy showed a slight toxicity and good benefits in recent clinical trials. However, patients infected with human immunodeficiency virus were excluded from most trials because it was assumed that their anti-tumor immunity was compromised compared with immunocompetent patients. CASE PRESENTATION: In June 2016, a 52-year-old Chinese man presented with human immunodeficiency virus and lung adenocarcinoma (T1bN3M1b). From November 2016 to December 2016, systemic chemotherapy and palliative radiotherapy for bone metastasis of femoral neck were carried out, but the tumor progressed. In January 2017, after immunochemistry detection of programmed death-1 and programmed death-ligand 1 expression (both > 50%), pembrolizumab was started. Three weeks after pembrolizumab, we combined stereotactic body radiotherapy for the primary lung tumor. He received no comfort and his CD4 lymphocyte count was stable. Human immunodeficiency virus-ribonucleic acid remained below the limits of detection. In March 2017, after three cycles of pembrolizumab and 5 weeks of stereotactic body radiotherapy therapy, he suddenly presented with palpitations. Emergency computed tomography scanning showed massive pericardial effusion and interstitial pneumonia. So we interrupted the pembrolizumab use and initiated treatment with prednisolone 1 mg/kg; however, the tumor progressed. Then, his CD4 lymphocyte count declined. Finally he died in June 2017 due to dyscrasia. CONCLUSIONS: Pembrolizumab combined with SBRT therapy for patients with human immunodeficiency virus infection and non-small cell lung cancer may lead to serious immune-related adverse events and more clinical trials are needed.


Assuntos
Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/terapia , Anticorpos Monoclonais Humanizados/efeitos adversos , Antineoplásicos Imunológicos/efeitos adversos , Carcinoma Pulmonar de Células não Pequenas/terapia , Radiocirurgia/efeitos adversos , Adenocarcinoma/complicações , Adenocarcinoma/diagnóstico por imagem , Contagem de Linfócito CD4 , Carcinoma Pulmonar de Células não Pequenas/complicações , Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Carcinoma Pulmonar de Células não Pequenas/secundário , Evolução Fatal , Neoplasias Femorais/secundário , Infecções por HIV/complicações , Humanos , Doenças Pulmonares Intersticiais/etiologia , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/etiologia , Tomografia Computadorizada por Raios X
8.
Rev Med Interne ; 39(6): 431-434, 2018 Jun.
Artigo em Francês | MEDLINE | ID: mdl-29502928

RESUMO

BACKGROUND: Benign metastasizing leiomyoma (BML) is a rare condition characterized by histologically benign "metastatic" smooth muscle tumors, which can affect women with history of uterine surgery. We report the case of a patient with bone metastases of BML. CASE REPORT: A 78-year-old woman who had undergone uterine surgery six years before hospital admission, was diagnosed with large pulmonary and pleural metastases that necessitated surgical removal. Pathological examination allowed the diagnosis of BML with positive staining for estrogen and progesterone receptors. Three years later, a BML metastasis in the right femoral diaphysis was unexpectedly discovered and treated by osteosynthesis because of a high risk of fracture. Despite an aromatase-inhibitor treatment, new lungs lesions appeared in the next few months. CONCLUSION: BML is a potential cause of aggressive, although histologically benign, bone tumor in women with a history of uterine surgery.


Assuntos
Neoplasias Femorais/secundário , Leiomioma/patologia , Neoplasias Uterinas/patologia , Idoso , Neoplasias Ósseas/secundário , Feminino , Humanos , Invasividade Neoplásica
9.
Clin Orthop Relat Res ; 476(3): 529-534, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29529636

RESUMO

BACKGROUND: Preoperative transarterial embolization has been utilized in the surgical treatment of metastatic renal cell carcinoma of the femur to decrease perioperative blood loss. However, few studies have documented its efficacy in decreasing the proportion of patients receiving transfusions in the setting of prophylactic treatment of impending pathologic femur fractures. QUESTIONS/PURPOSES: In a population of patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation, the purpose of this study was to quantify and compare the proportion of patients who received at least one transfused unit of blood between a group treated with preoperative embolization and a group without preoperative embolization. METHODS: A retrospective study was performed using a Medicare claims-based database. International Classification of Diseases, 9 Revision and Current Procedural Terminology codes were used to identify 1285 patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation. The proportion of patients who received one or more blood transfusions was compared between 135 patients who underwent preoperative embolization and a group of 1150 concurrent control patients who did not undergo preoperative embolization. The control group was older than the embolization group, with 44% of these patients > 75 years old and 33% of the embolization group > 75 years. There was no difference in the female:male ratio between groups. Statistical comparisons of outcomes related to transfusion percentages were performed using Pearson chi square analysis with p < 0.05 considered significant. With the numbers available, we had 80% power to detect a difference in the percentage of patients transfused of 11% between the study groups at α = 0.05. RESULTS: No difference in transfusion percentage was observed between preoperative transarterial embolization (41 of 135 [30%]) and the control group (359 of 1150 [31%]; relative risk, 0.973; 95% confidence interval, 0.743-1.274; p = 0.84). The percentage of all patients who received a transfusion was 31% (400 of 1285). CONCLUSIONS: Preoperative embolization may not be mandatory in the prophylactic treatment of metastatic renal cell carcinoma of the femur, as demonstrated by the 69% of patients who received zero units of blood despite not receiving embolization. However, assessment of the efficacy of embolization in decreasing blood loss in the current study is limited as a result of biases associated with the database design of the study; the decision of whether to send a patient for embolization should be made on a case-by-case basis. The current study does not identify specific risk factors that should factor into this decision and underscores the need for further research in this regard. A plausible future research design to account for the low numbers and selection bias that limited the current study as well as the existing studies might be a multicenter, retrospective case-control study. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Carcinoma de Células Renais/terapia , Embolização Terapêutica/métodos , Fraturas do Fêmur/prevenção & controle , Neoplasias Femorais/terapia , Fixação de Fratura/métodos , Fraturas Espontâneas/prevenção & controle , Neoplasias Renais/patologia , Cuidados Pré-Operatórios/métodos , Idoso , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue , Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Bases de Dados Factuais , Embolização Terapêutica/efeitos adversos , Feminino , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/patologia , Neoplasias Femorais/secundário , Neoplasias Femorais/cirurgia , Fixação de Fratura/efeitos adversos , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/patologia , Humanos , Masculino , Hemorragia Pós-Operatória/prevenção & controle , Cuidados Pré-Operatórios/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
10.
Clin Orthop Relat Res ; 476(5): 977-983, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29480890

RESUMO

BACKGROUND: The majority of metastatic bone lesions to the femoral bone can be treated without surgery or with minimally invasive intramedullary nailing. In rare patients with extensive metastatic disease to the femur, total femur replacement may be the only surgical alternative to amputation; however, little is known about this approach. QUESTIONS/PURPOSES: In a highly selected small group of patients with metastatic carcinoma of the femur, we asked: (1) What was the patient survivorship after this treatment? (2) What was the implant survivorship free from all-cause revision and amputation, and what complications were associated with this treatment? (3) What functional outcomes were achieved by patients after total femur replacement for this indication? METHODS: Eleven patients (three men, eight women) with a mean age of 64 years (range, 41-78 years) received total femur replacements between 1986 and 2016; none were lost to followup. The most common primary disease was breast cancer. In general, during this period, our indications for this procedure were extensive metastatic disease precluding internal fixation or isolated proximal or distal femur replacement, and an anticipated lifespan exceeding 6 months. Our contraindication for this procedure during this time was expected lifespan less than 6 months. Patient survival was assessed by Kaplan-Meier analysis; implant survival free from revision surgery and amputation were assessed by competing risk analysis. Function was determined preoperatively and 6 to 12 weeks postoperatively with the Musculoskeletal Tumor Society (MSTS) score normalized to a 100-point scale, with higher scores representing better function from a longitudinally maintained institutional database. RESULTS: Eleven patients died at a median of 5 months (range, 1-31 months) after surgery. One-year revision-free and limb survival were 82% (95% CI, 51%-98%) and 91% (95% CI, 61%-99%), respectively. Reasons for reoperation were hip dislocation, infection and local recurrence in one patient each. The latter two complications resulted in amputation in two patients. The median MSTS score was 32 (range, 13-57). CONCLUSIONS: Despite attempts to select patients who might have anticipated greater life expectancy, eight of 11 patients died by 6 months after surgery, and an additional two patients had undergone an amputation at 8 and at 17 months postoperatively. Most patients undergoing total femur replacement in this series did not recover from the procedure by the time they died, despite our best attempts to perform the procedure in patients whom we thought would live at least 6 months. Based on this, we believe that most patients with extensive metastatic disease to the femur should be offered palliative care, rather than major reconstruction. LEVEL OF EVIDENCE: Level IV, therapeutic study.


Assuntos
Carcinoma/cirurgia , Neoplasias Femorais/cirurgia , Osteotomia , Implantação de Prótese , Adulto , Idoso , Amputação , Carcinoma/mortalidade , Carcinoma/secundário , Tomada de Decisão Clínica , Bases de Dados Factuais , Progressão da Doença , Feminino , Neoplasias Femorais/mortalidade , Neoplasias Femorais/secundário , Humanos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Osteotomia/mortalidade , Seleção de Pacientes , Intervalo Livre de Progressão , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/mortalidade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
11.
Bone Joint J ; 100-B(1): 101-108, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29305458

RESUMO

AIMS: Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction. PATIENTS AND METHODS: We reviewed 100 consecutive PFRs performed between January 2003 and January 2013 without acetabular resurfacing. The procedure was undertaken in 74 patients with metastases, for a primary bone tumour in 20 and for myeloma in six. There were 48 male and 52 female patients, with a mean age of 61.4 years (19 to 85) and median follow-up of two years (interquartile range (IQR) 0.5 to 3.7 years). In total, 52 patients presented with a pathological fracture and six presented with failed fixation of a previously instrumented pathological fracture. RESULTS: All patients underwent reconstruction with either a unipolar (n = 64) or bipolar (n = 36) articulation. There were no dislocations and no acetabular resurfacings. Articular wear was graded using the criteria of Baker et al from 0 to 3, where by 0 is normal; grade 1 represents a narrowing of articular cartilage and no bone erosion; grade 2 represents acetabular bone erosion and early migration; and grade 3 represents protrusio acetabuli. Of the 49 patients with radiological follow-up greater than one year, six demonstrated grade 1 acetabular wear and two demonstrated grade 2 acetabular wear. The remainder demonstrated no radiographic evidence of wear. Median medial migration was 0.3 mm (IQR -0.2 to 0.7) and superior migration was 0.3 mm (IQR -0.2 to 0.6). No relationship between unipolar versus bipolar articulations and wear was evident. CONCLUSION: Hemiarthroplasty PFRs for tumour reconstruction eliminate joint instability and, in the short to medium term, do not lead to native acetabular wear necessitating later acetabular resurfacing. Cite this article: Bone Joint J 2018;100B:101-8.


Assuntos
Acetábulo/cirurgia , Artroplastia de Quadril/métodos , Neoplasias Femorais/cirurgia , Hemiartroplastia/métodos , Prótese de Quadril , Acetábulo/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Feminino , Neoplasias Femorais/secundário , Seguimentos , Hemiartroplastia/efeitos adversos , Luxação do Quadril/etiologia , Humanos , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Falha de Prótese , Radiografia , Reoperação/métodos , Reoperação/estatística & dados numéricos , Adulto Jovem
12.
J Orthop Sci ; 23(2): 394-402, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29128112

RESUMO

BACKGROUND: We assessed whether there was a difference in attenuation measurements (in Hounsfield units - HU) and geometric distribution of HU between femora with metastatic lesions that fracture, and metastatic lesions that did not fracture nor underwent prophylactic fixation. METHODS: Nine patients with femoral metastases who underwent CT and developed a pathological fracture were matched to controls. All femora were delineated in axial CT slices using a region of interest (ROI) tool; the HU within these ROIs were used to calculate: (1) the cumulative HU of the affected over the nonaffected side per slice and presented as a percentage, and (2) the cumulative HU accounting for geometric distribution (polar moment of HU). We repeated the analyses including cortical bone only (HU of 600 and above). RESULTS: CT-based calculations did not differ between patients with a lesion that fractured and those that did not fracture nor underwent prophylactic fixation when analyzing all tissue. However, when including cortical bone only, the pathological fracture group had a lower cumulative HU value compared to the no fracture and no fixation group for the weakest cross-sectional CT image (pathological fracture group, mean: 71, SD: 23 and no fracture and no prophylactic fixation group, mean: 85, SD: 18, p = 0.042) and the complete lesion analysis (pathological fracture group, mean: 78, SD: 21 and no fracture and no prophylactic fixation group, mean: 92, SD: 15, p = 0.032). CONCLUSION: The demonstrated CT-based algorithms can be useful for predicting pathological fractures in metastatic lesions.


Assuntos
Algoritmos , Neoplasias Femorais/complicações , Neoplasias Femorais/diagnóstico por imagem , Fraturas Espontâneas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Área Sob a Curva , Estudos de Casos e Controles , Feminino , Neoplasias Femorais/secundário , Fixação de Fratura/métodos , Consolidação da Fratura/fisiologia , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Valores de Referência , Estudos Retrospectivos , Medição de Risco
14.
J Radiat Res ; 58(5): 661-668, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28992299

RESUMO

We analyzed 428 femoral metastases initially treated with radiotherapy between 2002 and 2011 to clarify the clinical details of post-irradiation fractures of femoral metastasis. Patients included 161 men and 167 women, with a mean age of 62 years. Fracture incidence, fracture site, fracture risk based on X-ray images before radiotherapy, and interval from completion of radiotherapy to fracture occurrence were assessed. In addition, 24 pathological specimens obtained during 27 surgeries for these fractures were examined. Fractures occurred in 7.7% of 428 femoral metastases (total 33: 28 actual fractures and five virtual fractures with progressive pain and bone destruction). The fracture rate was 7.8% in the proximal femur and 1.5% in the shaft (P = 0.001). Fractures occurred a median of 4.4 months after radiotherapy, with 39.4% occurring within 3 months and 63.6% within 6 months. Among femurs with high fracture risk according to Harrington's criteria or Mirels' score, the fracture rate was 13.9% and 11.8%, respectively. Viable tumor cells were detected in all five patients with painful virtual fracture, in 85.7% of femurs with actual fractures that occurred within 3 months, and in only 25.0% of actual fractures occurring after 3 months. Post-irradiation fractures of femoral metastasis most frequently occurred within 3 months after radiotherapy, and were more common in the peritrochanteric area than in the shaft. Radiological evidence of impending fracture did not correlate with a high fracture rate. Actual fractures occurring after more than 3 months were likely caused by post-irradiation fragility of the femur, without viable tumor cells.


Assuntos
Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Neoplasias Femorais/radioterapia , Neoplasias Femorais/secundário , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/patologia , Neoplasias Femorais/diagnóstico por imagem , Neoplasias Femorais/patologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Fatores de Tempo
15.
Injury ; 48 Suppl 3: S48-S54, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29025610

RESUMO

INTRODUCTION: Metastases to the proximal femur are usually managed surgically by tumor resection and reconstruction with an endoprosthesis, or by fixation with osteosynthesis. Still controversy remains regarding the most appropriate surgical treatment. We posed the following questions: (1) Is the frequency of surgical revision greater in patients treated with internal fixation than endoprosthetic reconstruction, and (2) Do complications that do not require surgery occur more frequently in patients treated with internal fixation rather than in those with endoprosthetic reconstruction? MATERIALS AND METHODS: A systematic review was performed of those studies reporting on surgical revision and complication rates comparing the two surgical methods. Ten studies including 1107 patients met the inclusion criteria, three with high methodological quality, three intermediate, and four with lowquality, according to the STROBE guidelines. RESULTS: At present, prosthetic dislocation is the most common complication observed in patients managed by prosthesis replacement of the proximal femur, while loosening was the main cause of reoperation in the fixation group. Time to reintervention ranged from 3 to 11.6 months for the prosthetic replacement and from 7.8 to 22.3 months for the fixation group. Non surgical complications, (mainly dislocations and infections) were more commonly observed in patients operated on by prosthetic replacement. CONCLUSIONS: Implant related complications and surgery-related morbidity should be taken into account in the decision-making process for the surgical management of these patients. These data can improve the surgeon-patient communication and guide further studies on patients' survival and complications with respect to surgery.


Assuntos
Neoplasias Femorais/cirurgia , Fixação Interna de Fraturas , Implantação de Prótese , Fenômenos Biomecânicos , Cimentos para Ossos , Neoplasias Femorais/secundário , Humanos , Educação de Pacientes como Assunto , Relações Médico-Paciente , Desenho de Prótese , Medição de Risco , Resultado do Tratamento
16.
J Arthroplasty ; 32(12): 3607-3610, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28735800

RESUMO

BACKGROUND: The hip is a common location for metastatic tumors. Due to the high loads placed through the proximal femur, surgery is often indicated to provide pain relief and restore function. Historically, these lesions are reconstructed with a hemiarthroplasty; however, there are few reports on the outcome of these reconstructions. The purpose of this study is to evaluate the outcome of hemiarthroplasty for the treatment of proximal femur metastatic disease, with a specific focus on the rates of conversion to total hip arthroplasty (THA). METHODS: One hundred ninety-nine patients (102 women, 97 men) were treated using a hemiarthroplasty to reconstruct the proximal femur for metastatic disease between 1992 and 2014. Mean age and body mass index were 62 years and 27.4 kg/m2, respectively. The most common site of primary disease was the breast (n = 63). The most common location for the metastatic disease was the femoral neck (n = 148). Mean follow-up for surviving patients was 4 years. RESULTS: Over the course of the study, 2 (1%) patients underwent conversion to a THA due to groin pain and degenerative changes. In addition, complications occurred in 12% of patients, most commonly a deep venous thrombosis (n = 5). Following the procedure, mean Harris Hip Score and Musculoskeletal Tumor Society 1993 scores were 73 and 63%, respectively. CONCLUSION: Reconstruction of the proximal femur with a hemiarthroplasty endoprosthesis provides a majority of patients with a durable means of reconstruction, with a low rate of conversion to THA.


Assuntos
Neoplasias Femorais/complicações , Hemiartroplastia/estatística & dados numéricos , Fraturas do Quadril/etiologia , Fraturas do Quadril/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Criança , Feminino , Neoplasias Femorais/mortalidade , Neoplasias Femorais/secundário , Fêmur/cirurgia , Colo do Fêmur/cirurgia , Hemiartroplastia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
17.
Hautarzt ; 68(10): 831-834, 2017 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-28567510

RESUMO

We report on an atypical clinical course of a patient with the very rare diagnosis of an apocrine sweat gland carcinoma with lymphatic metastasis, a single metachronous distant metastasis and a now reached survival time of more than 4 years and give a review about the current literature. Only a very small number of cases have been described. The recommendations for diagnostics and treatment of this tumor, therefore, are not based on prospective randomized studies but upon case reports and on new immunohistochemical and genetic markers.


Assuntos
Adenocarcinoma/cirurgia , Glândulas Apócrinas , Axila , Doenças Raras , Neoplasias das Glândulas Sudoríparas/cirurgia , Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Adenocarcinoma/secundário , Idoso , Glândulas Apócrinas/patologia , Glândulas Apócrinas/cirurgia , Artroplastia de Quadril , Axila/patologia , Axila/cirurgia , Terapia Combinada , Progressão da Doença , Neoplasias Femorais/patologia , Neoplasias Femorais/secundário , Neoplasias Femorais/cirurgia , Colo do Fêmur/patologia , Seguimentos , Humanos , Comunicação Interdisciplinar , Colaboração Intersetorial , Excisão de Linfonodo , Metástase Linfática/patologia , Masculino , Radioterapia Adjuvante , Neoplasias das Glândulas Sudoríparas/diagnóstico , Neoplasias das Glândulas Sudoríparas/patologia
19.
Orthop Surg ; 9(2): 221-228, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28598582

RESUMO

OBJECTIVE: To evaluate the clinical outcomes and complications of segmental prosthetic reconstruction for pathological diaphyseal femoral fractures secondary to metastatic tumors. METHODS: Between 2011 and 2015, we retrospectively evaluated 16 patients (6 men and 10 women; 64.5 ± 11.4 years old at diagnosis) who underwent prosthetic reconstruction after segmental resection of diaphyseal femoral fractures due to metastatic lesions. Visual analog scale (VAS), functional outcomes, implant-related complications, and Mean postoperative Musculoskeletal Tumor Society (MSTS) score for each patient were collected. RESULTS: The mean length of bone defect was 10.2 ± 2.6 cm (range, 8-16 cm); follow-up was 9 ± 6.8 months (range, 2-25 months) for all patients, and 24 months (23 and 25 months) for the 2 patients still alive. At final follow-up, 14 patients were dead, indicating a mean survival of 6.9 ± 3.6 months (range, 2-14 months). Mean preoperative VAS score was 8.5 ± 1.0, which decreased to 2.5 ± 1.3 at day 2 postoperatively, indicating significant pain relief (P < 0.05). The MSTS score for lower extremities was 84.6% (range, 73%-90%). The range of motion and function of adjacent joints was within the normal limits in all cases. Three patients (33%) developed complications, including aseptic loosening because of disease progression (1), infection (1), and peri-prosthesis fracture (1). CONCLUSION: These findings demonstrated that this approach greatly relieves pain, and yields satisfactory functional outcomes with fewer complications in patients with pathological femoral fractures secondary to metastatic tumors; however, survival was not significantly improved.


Assuntos
Fraturas do Fêmur/cirurgia , Neoplasias Femorais/secundário , Fraturas Espontâneas/cirurgia , Feminino , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/mortalidade , Neoplasias Femorais/mortalidade , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Estudos Retrospectivos , Resultado do Tratamento
20.
J Orthop Sci ; 22(5): 938-945, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28629828

RESUMO

BACKGROUND: Pathological fracture of the proximal femur is a main cause of cancer patients losing their ability to walk. Although both osteosynthetic devices (predominantly intramedullary nails) and prosthetic replacement have been widely performed for treatment, controversies exist regarding which procedure should be used for the various conditions. In order to decide the eligibility criteria of a planned randomized prospective study about the treatment of pathological fractures of the proximal femur, we assessed the factors affecting the selection of operative procedures using questionnaires sent to the members of the Bone and Soft Tissue Tumor Study Group (BSTTSG) of the Japan Clinical Oncology Group (JCOG). METHODS: Questionnaire surveys to evaluate (1) the priority levels of the factors, (2) the equipoise range of each factor in situations where either procedure could be applied, (3) risk and benefit of each procedure, and (4) the degree of bone destruction affecting the selection of operative procedures, were sent to 26 institutions. RESULTS: Over 80% of the institutions answered. Orthopaedic surgeons of BSTTSG decided on the procedure according to the following factors in descending order: life expectancy, performance status before fracture, the degree of bone destruction, walking ability before fracture, general complications, the number of bone metastases in other sites, and the visceral metastasis status. With regard to bone destruction, (1) the involvement of the head, neck, calcar, and intertrochanteric region, (2) transverse destruction >1/2, and (3) soft-tissue tumor extension, were the factors that led to the choice of prosthesis treatment. CONCLUSIONS: Using these identified factors, the inclusion criteria for the prospective randomized study of the surgical treatment of metastatic bone tumors of the proximal femur were optimized. The evaluation system about the bone destruction of metastases needs to be refined through the following prospective randomized study.


Assuntos
Tomada de Decisão Clínica , Neoplasias Femorais/secundário , Neoplasias Femorais/cirurgia , Fraturas Espontâneas/cirurgia , Neoplasias Femorais/complicações , Fraturas Espontâneas/etiologia , Pesquisas sobre Serviços de Saúde , Humanos , Procedimentos Ortopédicos , Estudos Prospectivos
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