Management Of Bone Tumors Research Articles

Expanding the borders: Image-guided procedures for the treatment of musculoskeletal tumors.

Interventional radiology has revolutionized the local management of bone tumours, offering new minimal invasive alternatives to surgery and radiotherapy. Its role has continuously increased over the past years for the treatment of benign tumors and also of some malignant ones, especially in palliative situations. The development of protective techniques and new ablative technologies, such as cryoablation, contributes to expand the role of the interventional radiologist to new fields of applications in musculoskeletal oncology.

Ilizarov Fixator in the Management of Benign, Malignant and Complicated Cases of Bone Tumours

Objective: evaluate the Ilizarov fixator in the management of bone tumours regarding the duration and the ease of the procedure, the outcome and the complications. Methods: This study was done at the Department of Orthopedic surgery in Ain Shams University Hospitals. 15 patients with benign or malignant tumours were treated by resection followed by bone and soft tissue reconstruction and Ilizarov circular fixator in January 2012-April 2013 and followed up till July 2014. Results: Follow-up was done with a mean period of 21.7 (14-28) months. Adjustment of the frame was done as required. As regards malignant tumours, the disease free survival has a mean of 22.8 (12-30) months. 2 patients developed local recurrence. The overall survival was a mean of 25.8 (13-30) months. 1 patient died as a result of chemotherapy. The MSTS score was 50% to 100% with a mean value of 84.6%. ASAMI-bone score was excellent in 53% of the cases, good in 2 cases, fair in 1 case but poor in 4 cases. ASAMI-function score was excellent in 53% of cases, good in 33% of cases, fair in 1 case and poor in 1 case. The adverse effects were 7 problems, 5 obstacles and 6 complications according to Paley’s classification. Conclusion: Biological reconstruction using Ilizarov circular fixator should be considered safe and effective in the management of benign and low grade malignant tumours, and a salvage treatment in case of failure of other methods of limb salvage.

Protocolo para el estudio de muestras y estandarización del informe patológico de tumores óseos

Primary bone neoplasms represent a rare and heterogeneous group of mesenchymal tumours. The prevalence of benign and malignant tumours varies; the latter (sarcomas) account for less than 0.2% of all malignant tumours. Primary bone neoplasms are usually diagnosed and classified according to the criteria established and published by the World Health Organization (WHO 2013). These criteria are a result of advances in molecular pathology, which complements the histopathological diagnosis. Bone tumours should be diagnosed and treated in referral centers by a multidisciplinary team including pathologists, radiologists, orthopedic surgeons and oncologists.We analyzed different national and international protocols in order to provide a guide of recommendations for the improvement of pathological evaluation and management of bone tumours. We include specific recommendations for the pre-analytical, analytical, and post-analytical phases, as well as protocols for gross and microscopic pathology.

(ii) Principles of the surgical management of bone tumours

Abstract Bone tumours are rare and should be assessed and treated in specialized centres. Clinical staging uses various imaging techniques; pathological grading requires tumour biopsy following clinical staging. Surgery remains the mainstay of treatment for musculoskeletal tumours. The surgical margin describes the extent of the procedure, with marginal excision referring to a procedure that removes the tumour alone. Radical margins may require removal of the entire bone/compartment. Open incisional biopsy is the gold standard method for obtaining a representative specimen of tumour. Careful planning and good collaboration is crucial between surgeons, radiologists, and pathologists in order to prevent unnecessary morbidity. The aims of the bone tumour surgeon are to improve survival and maintain optimal function of the patient. This can potentially be achieved by amputation or limb salvage. Currently, limb salvage provides no greater risk to the survival of the patient compared to amputation. Reconstruction after excision of the tumour can be achieved by using endoprosthetic replacements, autografts, or massive allografts. Major complications of limb salvage include infection and difficulties associated with soft tissue re-attachment and coverage of the prosthesis.

"Advances in the surgical management of bone tumors".

Bone tumor surgery is extremely challenging, particularly when tumors are located in tightly confined anatomical areas and abutting critical organs and neurovascular structures. Tumor resection requires good cutting accuracy to ensure safety, to achieve negative margins, and to preserve critical structures when possible. The purpose of this paper was to review the literature on the surgical advances for bone tumor surgery published within the last year. The majority of literature identified focused on computer-assisted surgical approaches. There is increasing evidence that 3D navigation plays an important role in the resection of bone tumors. Reconstruction materials that encourage healing and prevent infections are also in development. Optimal care includes execution of a well-developed pre-operative plan using a multidisciplinary approach led by the orthopaedic oncologist.

Computer-aided resection and endoprosthesis design for the management of malignant bone tumors around the knee: outcomes of 12 cases

BackgroundTo report the outcomes of computer-aided resection and endoprosthesis design for the management of malignant bone tumors around the knee.MethodsComputed tomography (CT) and magnetic resonance imaging (MRI) data were input into computer software to produce three-dimensional (3D) models of the tumor extent. Imaging data was then used to create a template for surgical resection, and development of an individualized combined allogeneic bone/endoprosthesis. Surgical simulations were performed prior to the actual surgery.ResultsThis study included 9 males and 3 females with a mean age of 25.3 years (range, 13 to 40 years). There were 9 tumors in the distal femur and 3 in the proximal tibia. There were no surgical complications. In all cases pathologically confirmed clear surgical margins were obtained. Postoperative radiographs showed the range of tumor resection was in accordance with the preoperative design, and the morphological reconstruction of the bone defect was satisfactory with complete bilateral symmetry. The mean follow-up time was 26.5 months. Two patients died of their disease and the remaining are alive and well without evidence of recurrence. All patients are able to ambulate freely without restrictions. At the last follow-up, the average International Society of Limb Salvage score was 25.8 (range, 18 to 27), and was excellent in 8 cases and good in 4 cases.ConclusionsComputer-aided design and modeling for the surgical management of bone tumors and subsequent limb reconstruction provides accurate tumor removal with the salvage of a maximal amount of unaffected bone and precise endoprosthesis reconstruction.

Recent Developments in the Surgical Treatment of Bone Tumors and Their Impact on Quality of Life

The management of bone tumors has rapidly evolved over the last decades. Before the 1970s, amputation and arthrodesis were almost exclusively performed at the surgical theaters of tertiary tumor centers. Currently, with the evolutions in diagnostic imaging, surgical techniques, metallurgy, and adjuvant therapies, more than 90% of bone sarcomas patients are treated with limb salvage surgery. It is well documented in the related literature that limb salvage surgery does not compromise the survival of the patients. The main indication for limb salvage is the ability to obtain wide-margin (microscopically negative) surgical resection. A relative contraindication is local recurrence in a patient that previously had limb salvage surgery, except if the recurrence can be excised with wide margins. Various reconstruction options have been described following bone tumors resection with limb salvage, including megaprosthetic and biological reconstructions with allografts and vascularized bone autografts. However, what is the impact of bone tumors surgical resections and their reconstructions on the quality of life of tumor patients? This special issue tries to address the recent developments in the surgical treatment of bone tumors and their impact on quality of life. Expert authors in tumor surgery present their experience and knowledge on this subject.

Management of Bone Tumours in Paediatric Oncology

The management of bone tumours in paediatric oncology requires careful multidisciplinary planning due to the need for multimodal therapy approaches. The non-specific symptoms often lead to a delayed definitive diagnosis of a bone tumour. Imaging procedures are of major importance for an individualised and optimised treatment planning. They have to be carried out before any surgery, including biopsies. The introduction of multi-agent chemotherapy has led to a significant improvement in survival rates in patients suffering from Ewing's sarcomas and osteosarcomas. However, local therapy still remains indispensable in order to achieve long-term survival. For osteosarcoma, surgery remains the only adequate local therapy modality. Radiotherapy may be considered if surgery is not feasible. In these cases, high radiation doses need to be applied. The choice for local therapy modality is not as clear in patients with Ewing's sarcoma. Today, surgery is often preferred if a wide or at least marginal resection can be carried out. Additional radiotherapy is advised in patients with marginal/intralesional resection or poor histological response to induction chemotherapy. Definitive radiotherapy is recommended for inoperable lesions. In the future, new radiotherapy approaches, such as intensity-modulated radiotherapy or proton therapy, may yield better results with minor risks of late effects.

Tumors of the coracoid process: clinical evaluation of twenty-one patients

We present the incidence and management of bone tumors of the coracoid process and discuss the related clinical and imaging findings and treatment. We present 21 patients (7 males and 14 females; mean age, 39 years) treated for bone tumors of the coracoid process from 1900 to 2010. Mean follow-up was 44 months (range, 12-132 months). Clinical presentation, imaging, surgical treatment, complications, range of shoulder motion, and Musculoskeletal Tumor Society (MSTS) function were evaluated. Bone tumors were benign in 7 (33%) and malignant in 14 (67%). The most common were chondrosarcomas, osteoblastomas, and chondroblastomas. The most common presentation was pain and palpable mass for a mean duration of 11 months. Limb salvage, with or without megaprosthetic reconstruction, was achieved in 20 patients. One patient required forequarter amputation. One patient with chondroblastoma and 2 with chondrosarcoma had local recurrence. The range of shoulder motion varied according to the type of resection: patients with curettage and limited resections without involvement of the abductor mechanism had better shoulder motion, and patients with scapulectomy and proximal humeral resections had significant limitations of motion. The mean MSTS score was 80% (range, 50%-100%). Chondrosarcomas, osteoblastomas, and chondroblastomas are the most common bone tumors of the coracoid process. Limited resections are associated with nearly normal range of motion and excellent function; however, limited resections are acceptable in only in a small number of patients. In patients with malignant and recurrent lesions, wide resection is required, which is associated with significant limitations of shoulder function.

The importance of radiographic imaging in the microscopic assessment of bone tumors

IntroductionPrimary bone tumors are rare and require a multidisciplinary approach. Diagnosis involves primarily the radiologist and the pathologist. Bone lesions are often heterogeneous and the microscopic diagnostic component(s) may be in the minority, especially on core needle biopsies. Reactive processes, benign, and malignant tumors may have similar microscopic aspects. For these challenging cases, the correlation of microscopic and radiologic information is critical, or diagnostic mistakes may be made with severe clinical consequences for the patient. The purpose of this article is to explain how pathologists can best use imaging studies to improve the diagnostic accuracy of bone lesions. DiagnosisMany bone lesions are microscopically and/or radiographically heterogeneous, especially those with both lytic and matrix components. Final diagnosis may require specific microscopic diagnostic features that may be present in the lesion, but not the biopsy specimen. A review of the imaging helps assess if sampling was adequate. The existence of a pre-existing bone lesion, syndrome (such as Ollier disease or multiple hereditary exostosis), or oncologic history may be of crucial importance. Finally, imaging information is very useful for the pathologist to perform accurate local and regional staging during gross examination. ConclusionClose teamwork between pathologists, radiologists, and clinicians is of utmost importance in the evaluation and management of bone tumors. These lesions can be very difficult to interpret microscopically; imaging studies therefore play a crucial role in their accurate diagnosis.

Percutaneous Magnetic Resonance Imaging–Guided Bone Tumor Management and Magnetic Resonance Imaging–Guided Bone Therapy

Magnetic resonance imaging (MRI) is promising tool for image-guided therapy. In musculoskeletal setting, image-guided therapy is used to direct diagnostic and therapeutic procedures and to steer patient management. Studies have demonstrated that MRI-guided interventions involving bone, soft tissue, joints, and intervertebral disks are safe and in selected indications can be the preferred action to manage clinical situation. Often, these procedures are technically similar to those performed in other modalities (computed tomography, fluoroscopy) for bone and soft tissue lesions. However, the procedural perception to the operator can be very different to other modalities because of the vastly increased data.Magnetic resonance imaging guidance is particularly advantageous should the lesion not be visible by other modalities, for selective lesion targeting, intra-articular locations, cyst aspiration, and locations adjacent to surgical hardware. Palliative tumor-related pain management such as ablation therapy forms a subset of procedures that are frequently performed under MRI. Another suitable entity for MRI guidance are the therapeutic percutaneous osseous or joint-related benign or reactive conditions such as osteoid osteoma, epiphyseal bone bridging, osteochondritis dissecans, bone cysts, localized bone necrosis, and posttraumatic lesions. In this article, we will describe in detail the technical aspects of performing MRI-guided therapeutic musculoskeletal procedures as well as the clinical indications.

Excision-alcoholization-replantation method in management of bone tumors

Objective To evaluate the functional outcomes and complications of patients with bone tumors who were treated with the excision-alcoholization-replantation (EAR) method. Methods From August 1965 to August 2003, 191 patients treated with the EAR method who had suitable follow-up were evaluated in our department, including 102 males and 89 females with an average age of 20 years (range, 10-62). On the basis of Enneking tumor staging, 136 patients were identified II B stage, 25 I B stage, and 30 invasive benign tumors and tumor-like lesion. The length of the resected part ranged from 5 cm to 26 cm, with marginal resection in 30 cases, wide resection in 116. The oncological parameters that were evaluated included survival of the patients, local recurrence, and metastasis. Complications included non-union, infection, and fracture of the grafts. Mankin evaluation system was used to assess functional outcomes. Results The mean follow-up time was 32 months (range, 1-372), 52 patients died with disease at the final follow-up. Five-year survival rates of high grade sarcoma and low grade sarcoma were 59% and 90%, respectively, with statistical significance (P=0.02). Lung metastasis were demonstrated in 52 patients (27.2%, 52/191), 51 (26.7%, 51/191) had local recurrence. Except the tumor factor, the total complication rate was 50.3%(96/191). Local complications included 33 nonunion (17.3%, 33/191), 39 fracture of the grafts (20.4%, 39/191), 39 infections of the graft (20.4%, 39/191), 15 fracture of internal fixation (7.9%, 15/191), 5 instability or semiluxation of the joint (2.6%, 5/191). The 5-year survival rate of inactivated bone was 55%. On the basis of Mankin functional evaluation, the satisfied rate was 50.3%. At last there were 141 patients (73.8%, 141/191) preserved their extremities. Conclusion Compared to other methods in the same period, EAR method is considered on the same level of safety in oncology, which superiorities are economic-applicable to patients and the well fitness of bone graft with the defects. Key words: Bone neoplasms; Ethanol; Replantation; Postoperative complications

Surgical technique of combined anterior-lateral and lateral approach in the management of bone tumor of femoral neck

Objective To explore surgical procedure of combined anterior-lateral and lateral approach for the treatment of bone tumors of femoral neck. Methods Forty patients with bone tumors of femoral neck treated in Tianjin Hospital were included from July 2005 to August 2009. Of the patients, 12 who were treated with curettage and bone graft through combined anterior-lateral and lateral incision were analyzed in this study. There were 7 males and 5 females with an average age of 34 years ranging from 17 to 68 years. 4 patients were diagnosed as chondroblastoma, 2 giant cell tumor, 3 fibrous dysplasia, and 3 single bone cysts. 7 patients suffered from pathologic fractures, and 5 had presented thin cortical bone because of tumor involvement. There were 1 tumor located in H1 zone, 4 in H2 zone and 7 in H1,2 zone according to ISOLS femoral neck classification. All patients were treated by curettage and bone graft via anterior-lateral approach, 10 cases underwent internal fixation with anatomical plate, and 2 cases with canulated screws with lateral approach. Results The follow-up time ranged from 10 to 68 months with an average of 35 months.Pain disappeared in all patients, and there were not recurrence of tumor, pathologic fractures and avascular necrosis. One case had complained of lateral femoral skin numbness which may be caused by injures of femoral lateral nerves. One case had difficulties in the valgus of hip joint. The mean MSTS score was 29.2 points ranging from 27 to 30 points. Conclusion Anterior approaches of ＂SP＂ incision is helpful to thorough curettage which decrease the risk of recurrence due to good visualization and intemal fixation is easy to perform via lateral approaches. The result suggested that combined anterior-lateral ＂SP＂ and lateral incision is liable option in treatment of bone tumors of femoral neck. Key words: Neoplasms; Femur neck; Fractures, spontaneous

(iii) The principles of surgical resection and reconstruction of bone tumours

Abstract The management of bone tumours has made vast strides in the last few decades. The advent of better imaging modalities, more effective chemotherapy, improved radiotherapy techniques, a better understanding of anatomy with continuous refinement in surgical techniques and advances in prosthesis design and materials have all played a part in increasing the incidence of limb salvage surgery. From an era where amputation was the only option, the current day function preserving resections and complex reconstructions have been a major advance. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in malignant bone tumours and describes the various reconstruction options available in order to restore structural and skeletal stability after resection of large bone segments. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.

Percutaneous Bone Tumor Management

Interventional radiology plays a major role in the management of bone tumors. Many different percutaneous techniques are available. Some aim to treat pain and consolidate a pathological bone (cementoplasty); others aim to ablate tumor or reduce its volume (sclerotherapy, thermal ablation). In this article, image-guided techniques of primary and secondary bone tumors with vertebroplasty, ethanol injection, radiofrequency ablation, laser photocoagulation, cryoablation, and radiofrequency ionization (coblation) will be reviewed. For each modality, the principles, the indications, and the results will be presented. The technical choice depends on the therapeutic intent-curative or palliative-and the need for consolidation, but also on the general status of the patient and the other therapeutic options. For the most complex cases, combined treatments can be required. However, the less disabling technique should always be considered first.

Bone tumors in children

Bone tumors in general, and specifically in children, are relatively rare. In children the large majority of them are malignant. During the last decades a significant improvement in diagnosis and management of these tumors has been achieved, mainly through introduction of neoadjuvant chemotherapy, refinement of surgical techniques and improvement of imaging methods allowing accurate staging. Pathological diagnostics have also significantly evolved in some areas of the field. The role of the pathologist in patient with bone tumor management is more complex than in most other fields. In this paper we present the most prominent features of the approach to morphological diagnosis of bone lesions with special emphasis on childhood bone tumors.

Massive allograft replacement in management of bone tumors

Objective To evaluate the functional outcome and complications of allograft replacement in management of bone tumors.

Calcaneus replacement after total calcanectomy via vascularized pelvis bone

Because of loss of function and chronic pain total calcanectomy is a serious impairment for the patient. There are few reports concerning replacement procedures using ribs [Brenner P, Zwipp H, Rammelt S. Vascularized double barrel ribs combined with free serratus anterior muscle transfer for homologous restoration of the hindfoot after calcanectomy. J Trauma-Injury Infect Crit Care 2000;49(2):331-5; Lin CH, Wei FC, Levin LS, Su JI. Free composite serratus anterior and rib flaps for tibial composite bone and soft-tissue defect. Past Reconstr Surg 1997;99:1656-65; Moscona RA, Ullmann Y, Hirshowitz B. Free composite serratus anterior muscle-rib flap for reconstruction of severely damaged foot. Ann Plast Surg 1988;20:167-72] or homologeous bone graft [Mankin HJ, Gebhardt MC, Jennings LC, Springfield DS, Tomford WW. Long-term results of allograft replacement in the management of bone tumors. Clin Orthop 1996;324:86-97; Muscolo DL, Miguel AA, Aponte-Tinao A. Long-term results of allograft replacement after total calcanectomy. J Bone Joint Surg Am 2000;82(1):109-12; Ottolenghi CE, Petracchi LJ. Chondromyxosarcoma of the calcaneus; report of a case of total replacement of involved bone with a homogenous refrigerated calcaneus. J Bone Joint Surg 1953;35A(1):211-4]. We report a case of calcaneus replacement by vascularized iliac crest bone.

The Role of Radiation Treatment in the Contemporary Management of Bone Tumors

Radiotherapy is integral in the multidisciplinary approach to patients with musculoskeletal neoplasms. Multiple studies have established a role for radiotherapy as a definitive local treatment of unresectable lesions or when surgery might yield unacceptable functional outcomes, such as in Ewing's tumor or base of skull chondrosarcoma. Radiotherapy is also used as an adjuvant treatment after surgery with close or positive margins. In the metastatic setting, external beam radiotherapy and bone-seeking intravenous radioisotopes are used on a case-by-case basis for palliation. As radiotherapy and its delivery techniques have evolved, so has its role in treating tumors such as Ewing's sarcoma, chordoma and chondrosarcoma, osteosarcoma, primary lymphoma of bone, malignant fibrous histiocytoma of bone, and vascular tumors. Radiation can also be successfully used to treat unresectable or recurrent benign tumors, such as giant cell tumor and aneurysmal bone cyst. This article reviews the indications for radiotherapy for various bone tumors and summarizes some of the important data supporting its use.

Staging of Bone Tumors: A Review with Illustrative Examples

The radiologist plays an important role in the workup and staging of bone tumors. The purpose of this article is to review that role and to discuss recent changes to the primary malignant bone tumor staging system developed by the American Joint Committee on Cancer. Knowledge of staging parameters for the diagnosis and management of bone tumors will help the radiologist to generate meaningful reports for the referring physician.