Management Of Primary Bone Tumors Research Articles

Does an excision of needle bone biopsy tract affect the prognosis in patients with primary bone tumor?

BackgroundOpinion remains divided as to whether excision of needle biopsy tract is beneficial and affect the prognosis. The aim of the study was to compare the outcomes in patients of primary malignant bone tumor who had undergone surgery with or without biopsy tract excision. MethodsFrom January 2017 to June 2020, 240 patients with primary malignant bone tumors who underwent percutaneous needle biopsy followed by surgery were included. We categorized patients into Biopsy tract excision (Group1:185 patients) and Non Biopsy tract excision (Group 2:55 patients). Median follow-up of patients was 58.6 months (range; 12–61.8months). ResultsDemographics, histopathological type, tumor location, type of surgery were similar in biopsy tract excision and non excision group. We found biopsy tract seeding in two cases out of 185 (1.1 %). Local recurrence in biopsy tract excision and non excision group was observed in 3.2 % and 1.8 % respectively with p value 0.58. The mean local recurrence free survival rate in group 1 and 2 was 60 and 44 months respectively. Limb salvage was performed in 71.6 % and in amputation in 28.3 % cases. The local recurrence in limb-salvage and amputation group was observed in 3.4 % (6/172) and 1.4 % (1/68) respectively. ConclusionThere was no significant difference in the rate of local recurrence between patients who were treated by biopsy tract excision or non tract excision. Percutenous needle bone biopsy tract leads to minimal risk of tumor seeding during surgical resection of primary bone tumors.We recommend the further multi centre studies with more number of patients to reach a consensus on resection of needle biopsy tract during surgical management of primary bone tumors.

World health organization classification of bone tumors (fifth edition): What a radiologist needs to know?

Since 1967, the World Health Organization (WHO) classification of tumors is regarded as a reference standard and practical guide and provides a precious resource not only for the histopathologists and oncosurgeons but also for the radiologists involved in cancer care. Primary bone tumors are a rare and heterogeneous group of neoplasms that have a broad spectrum of morphological, biological, genetic, and radiological features. Appropriate imaging workup and accurate histopathological diagnosis are crucial for appropriate management and prognostication. The fourth edition of the WHO classification of tumors of soft tissue and bone was introduced in 2013. In the past 7 years, there have been considerable advances in the understanding of this large and diverse group of tumors. With technological advances and the introduction of new molecular and genetic data about some bone tumors, there has been reorganization in the classification and introduction of a few new entities. The new WHO classification of soft tissue and bone tumors introduced in 2020 (fifth edition) has made essential refinements in the classification and has also introduced many new entities. Newly identified genetic alterations and corresponding immunohistochemical markers are included in the new classification, and this has helped in the reclassification of the existing tumor entities. These novel genetic alterations not only help in prognostication but are a target for potential therapeutic options which can bring a paradigm shift in the chemotherapeutic regimen for these entities in the future. The sole basis for the classification of bone tumors is histopathological. Although radiologists are not expected to know about the exquisite pathological details of bone tumors, a broad knowledge of the recent updates, including the reclassification of a few entities or the introduction of some, is vital for narrowing the differentials in imaging. A multidisciplinary approach including an orthopedic oncologist, radiologist, pathologist, surgical, and medical oncologist is required for accurate diagnosis and management of primary bone tumors. We hereby present a simplified review for the radiologists comprising the relevant details of the updates in bone tumors along with a simplified diagnostic algorithm to characterize these lesions.

Resection arthrodesis and osteoarticular allografts reconstruction after resection of primary bone tumors around the knee: Long-term clinical outcomes and prognostic factors for failure of biological reconstruction.

The biological reconstruction of the knee with osteoarticular allografts and resection arthrodesis have been reported but there has not yet been a direct comparison between both these procedures. This study aimed to identify the prognostic factors that influence failure of biological reconstruction and compared the results between both procedures. Between 1994 and 2017, we performed 92 limb-sparing procedures using resection arthrodesis (n=53) and osteoarticular allograft reconstruction (n=39) for the management of primary bone tumors around the knee. The minimum follow-up time was 2 years in both groups. The failure rate of reconstruction in the osteoarticular allograft and resection arthrodesis group was 48.7% and 39.6%, respectively (p=0.75). The mean MSTS score in the osteoarticular allograft and resection arthrodesis group was 23.7 and 21.8, respectively (p=0.01). The significant risk factor for failure after biological reconstruction was the administration of chemotherapy (p=0.001; HR=3.39; 95% CI,1.60-7.17). Patients who underwent osteoarticular allograft had a better functional outcome than those who underwent resection arthrodesis reconstruction, but clinical outcomes between the groups were comparable. Chemotherapy is a significant adverse prognostic factor for failure of biological reconstruction.

Distal Tibial Reconstruction in the Management of Primary Bone Tumors in Children and Adolescents.

Distal tibial primary bone tumors are rare, and options for limb salvage surgery are limited and challenging. Importantly, local control has shown to be crucial and necessary for cure, and radical surgery is one of the most important components of therapy for some bone sarcomas. We investigated the feasibility and functional and oncological outcomes of distal tibial reconstruction using endoprosthesis in children with malignant bone tumors. Fourteen patients (median age 13.6 years) with primary bone tumors (4 Ewing sarcoma [ES], 10 osteosarcoma) of the distal tibiae were treated during 2013-2019. All patients had reconstruction using a modular (13 patients) or expandable custom-made titanium bone replacement system (1 patient). All patients received chemotherapy before and after surgery. Twelve patients (85.7%) are alive with a median follow-up 20 months from diagnosis. Five-year estimates of event-free survival and overall survival were 60.6% and 76.4%, respectively. Three patients had postoperative complications requiring second surgery. Maximum dorsiflexion and plantar flexion of the foot were 20 degrees (range 0-20 degrees) and 20 degrees (range 5-20 degrees), respectively. For select distal tibial sarcomas, after neoadjuvant chemotherapy pretreatment and radical resection, reconstruction using an endoprosthesis as a radical surgery provides an option was associated with a low rate of short-term local complications and relatively good early function. Level IV, therapeutic study.

Long-term Follow-up of the Use of a Synthetic Bone Graft Composite in the Surgical Management of Primary Bone Tumors

The surgical management of benign and benign aggressive bone tumors typically involves intralesional curettage and reconstruction of the resulting defect with cement or bone graft material. At the authors' institution, an injectable synthetic calcium sulfate-calcium phosphate composite is now the standard graft material for these cases. This study reports the long-term follow-up, specifically the stability of bone regeneration, for the use of the synthetic graft material for oncologic reconstruction. Fourteen patients who underwent intralesional curettage of a primary bone tumor followed by cavitary reconstruction with synthetic graft material who had at least 4-year follow-up were identified from an institutional orthopedic oncology database. Clinical outcome data, focusing on long-term clinical and radiographic features of the reconstruction, were extracted from electronic and paper medical records. Seven females and 7 males were included (mean age at surgery, 28.1 years; range, 13-64 years). Follow-up ranged from 50 to 105 months (mean, 68 months). Most surgical reconstructions were done for the lower limb (n=11), and giant cell tumor of bone was the most common tumor treated. The mean amount of synthetic graft material used was 18.6 cm3. Complete radiographic resorption and new bone incorporation was observed within the first year, and bone remodeling was complete in all patients. Bone remodeling remained stable throughout the longer-term follow-up (ie, up to 9 years). The use of an injectable synthetic calcium sulfate-calcium phosphate composite is a viable option in the reconstruction of cavitary bone defects following intralesional curettage of primary benign bone tumors. This reconstruction technique was safe, with no long-term complications, and led to complete radiographic resorption and new bone incorporation with long-lasting stability. [Orthopedics. 2018; 41(6):e868-e875.].

The use of a non-invasive extendable prosthesis at the time of revision arthroplasty.

The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370-7.

Preoperative embolization of primary bone tumors: A case control study.

To study the safety and effectiveness of preoperative embolization of primary bone tumors in relation to intraoperative blood loss, intraoperative blood transfusion volume and surgical time. Thirty-three patients underwent preoperative embolization of primary tumors of extremities, hip or vertebrae before resection and stabilization. The primary osseous tumors included giant cell tumors, aneurysmal bone cyst, osteoblastoma, chondroblastoma and chondrosarcoma. Twenty-six patients were included for the statistical analysis (embolization group) as they were operated within 0-48 h within preoperative embolization. A control group (non-embolization group, n = 28) with bone tumor having similar histological diagnosis and operated without embolization was retrieved from hospital record for statistical comparison. The mean intraoperative blood loss was 1300 mL (250-2900 mL), the mean intraoperative blood transfusion was 700 mL (0-1400 mL) and the mean surgical time was 221 ± 76.7 min for embolization group (group I, n = 26). Non-embolization group (group II, n = 28), the mean intraoperative blood loss was 1800 mL (800-6000 mL), the mean intraoperative blood transfusion was 1400 mL (700-8400 mL) and the mean surgical time was 250 ± 69.7 min. On comparison, statistically significant (P < 0.001) difference was found between embolisation group and non-embolisation group for the amount of blood loss and requirement of blood transfusion. There was no statistical difference between the two groups for the surgical time. No patients developed any angiography or embolization related complications. Preoperative embolization of bone tumors is a safe and effective adjunct to the surgical management of primary bone tumors that leads to reduction in intraoperative blood loss and blood transfusion volume.

Updates in the Treatment of Bone Cancer

Although extremely rare, primary bone cancers are often curable with proper treatment. Effective management of primary bone tumors hinges on the involvement of a multidisciplinary team of physicians with expertise in this area, both in the realms of diagnosis and treatment. In her presentation at the NCCN 18th Annual Conference, Dr. J. Sybil Biermann reviewed the changes to the 2013 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for bone cancer, featuring the introduction of new sections on giant cell tumor of bone (GCTB) and chordoma. The benefits of denosumab for the benign GCTB and the unique challenges associated with the malignant chordoma are also explored.

Use of a Calcium Sulfate–Calcium Phosphate Synthetic Bone Graft Composite in the Surgical Management of Primary Bone Tumors

Benign primary bone tumors are commonly treated with intralesional curettage with or without the use of surgical adjuvants. The reconstructive approach to the resulting contained bone defects is controversial, and clinical practice is varied. Synthetic bone substitutes may provide early mechanical support while minimizing the risks of disease transmission, nonunion, infection, and donor-site morbidity. Limited data exists regarding the use of calcium sulfate-calcium phosphate composite bone substitute for this purpose. The authors retrospectively reviewed the clinical outcomes of 24 patients with benign primary bone tumors who underwent intralesional curettage followed by reconstruction with a calcium sulfate-calcium phosphate composite bone substitute. Mean follow-up was 23 months. The most common diagnosis was giant cell tumor of bone. Six patients had upper-extremity tumors and 18 had lower-extremity tumors. Mean preoperative radiographic tumor volume was 41.0 cm(3). Mean volume of PRO-DENSE (Wright Medical Technology, Arlington, Tennessee) used in each patient was 15.6 cm(3). Mean time to full weight bearing for all patients was 7.3 weeks. Two patients sustained local tumor recurrences. No postoperative fractures occurred, and no complications occurred related to the use of the calcium sulfate-calcium phosphate composite. One case of deep infection occurred secondary to wound breakdown. The use of a calcium sulfate-calcium phosphate composite was associated with rapid biological integration and an early return to activities of daily living, with no composite-related complications. This technique is a viable option in the reconstruction of cavitary bone defects following intralesional curettage of primary benign bone tumors.

Surgical Management of Primary Bone Tumors of the Spine

Multicenter ambispective cohort analysis. The purpose of this study is to determine whether applying Enneking's principles to surgical management of primary bone tumors of the spine significant decreases local recurrence and/or mortality. Oncologic management of primary tumors of spine has historically been inconsistent, controversial, and open to individual interpretation. A multicenter ambispective cohort analysis from 4 tertiary care spine referral centers was done. Patients were analyzed in 2 cohorts, "Enneking Appropriate" (EA), surgical margin as recommended by Enneking, and "Enneking Inappropriate" (EI), surgical margin not recommended by Enneking. Benign tumors were not included in mortality analysis. Two cohorts represented an analytic dataset with 147 patients, 86 male, average age 46 years (range: 10-83). Median follow-up was 4 (2-7) years in the EA and 6 (5.5-15.5) years in the EI. Seventy-one patients suffered at least 1 local recurrence during the study, 57 of 77 in the EI group and 14 of 70 in the EA group. EI surgical approach caused higher risk of first local recurrence (P < 0.0001). There were 48 deaths in total; 29 in the EI group and 19 in the EA. There was a strong correlation between the first local recurrence and mortality with an odds ratio of 4.69, (P < 0.0001). EI surgical approach resulted in a higher risk of mortality with a hazard ratio of 3.10, (P = 0.0485) compared to EA approach. Surgery results in a significant reduction in local recurrence when primary bone tumors of the spine are resected with EA margins. Local recurrence has a high concordance with mortality in resection of these tumors. A significant decrease in mortality occurs when EA surgery is used.

186. Surgical Management of Primary Bone Tumors of the Spine: Validation of the Enneking Classification: A Multicenter Cohort Study

186. Surgical Management of Primary Bone Tumors of the Spine: Validation of the Enneking Classification: A Multicenter Cohort Study

Functional Outcome Study of Mega-Endoprosthetic Reconstruction in Limbs With Bone Tumour Surgery

Amputation is no longer the sole contribution of the orthopaedic surgeon to the management of primary bone tumours. Improvements in the design of endoprostheses and surgical reconstructive techniques have combined with advances in chemotherapeutic regimens to result in surgical procedures for salvaging limbs with aggressive sarcomas and in limb reconstruction. This has made limb salvage a viable alternative to amputation in many cases. The aim of this study was to evaluate functional outcome and complications of patients with primary bone tumours who were treated with re-section and mega-endoprosthetic replacement. Nineteen patients with bone tumours were retrospectively reviewed. These patients had wide local re-section and mega-endoprosthetic reconstruction performed between 1999 and 2006 in a tertiary hospital. Functional evaluation was performed based on the Musculoskeletal Tumour Society (MSTS) scoring system, with numerical values from 0 to 5 points assigned for each of the following 6 categories: pain, function, emotional acceptance, use of supports, walking ability and gait. These values were added, and the functional score was presented as a percentage of the maximum possible score. Complications were also analysed. The final mean functional score was 78.3% +/- 16.6%. Eight patients had complications related to surgery, including infection and subluxation of hip implant. Six patients had infection, while 2 had subluxation of hip implants. Infection was a common complication in our study. None had implant breakage, loosening or fracture. We found no statistical difference in the functional outcome between upper limb and lower limb procedures, and between hip and knee procedures. T-test also showed no evidence of gender differences in functional outcome. Kaplan-Meier survival analysis revealed the mean survival duration of megaprosthesis to be 75.6 months. Mega-endoprosthetic reconstruction in limb salvage provides good functional outcome in patients with bone tumours. The early results from patients treated with mega-endoprosthesis have been encouraging.

Nuclear medicine in primary bone tumors

Introduction: Conventional radiography is the method of choice to diagnose a primary bone tumor but in many cases it is necessary to integrate it with nuclear medicine scintigraphy using several radionuclides, including 67Ga, 201Tl, 99mTc-MIBI and especially 99mTc-diphosphonates. Recently a new technique has been recently introduced, that is positron emission tomography with 2( 18F) fluoro-2 deoxy- d-glucose as radiopharmaceutical. Objective: The specific purpose of this work is to show that nuclear medicine bone scanning is a very important method in the detection and diagnostic management of primary bone tumors. Diagnosis, staging and follow-up: Three-phase bone scintigraphy, integrated with SPECT, is clinically useful to confirm the radiologic diagnosis of bone tumor. These techniques conveniently related to each other and to radiographic findings, can evaluate the tumor's local aggressiveness, often differentiating benign from malignant lesions, to monitor treatment efficacy, to permit total body scanning for the detection of recurrences. Nuclear medicine diagnostic techniques are not in competition with radiographic tools as CT and MRI which are highly sensitive in detecting even small lesions thanks to their excellent anatomical resolution. In questionable cases, we can integrate radiologic imaging with dynamic studies, in particular with FDG-PET, increasing the specificity of diagnosis and permitting more accurate follow-up. Conclusions: Patient management optimization needs the integration between dynamic nuclear medicine findings and the anatomical patterns provided by conventional radiology to increase imaging sensitivity and specificity. Equipe work is determinant to customize the diagnostic work-up to the individual patient's needs to reduce the cost of patient management avoiding useless examinations.

Controversies in the management of primary bone tumours: an Australian perspective

Controversies in the management of primary bone tumours: an Australian perspective

The total femoral prosthesis. A preliminary report.

The use of a total femoral prosthesis can offer a realistic alternative to amputation or disarticulation. The limited indications for such a prosthesis in the surgical management of primary bone tumours and pathological fractures still exist. In this specialised clinic there is an increased need to replace the entire femur where repeated procedures have failed, from loss of bone stock with infection or because of non-union in the presence of a prosthesis. Over the past eight years, four basic models have been developed. The most recent designs allow for the preservation of non-involved bone or for stable support where there is complete acetabular destruction.

The value of percutaneous needle biopsy in the management of primary bone tumors

Thirty-four suspected primary bone neoplasms were evaluated by needle biopsy at M. D. Anderson Hospital and Tumor Institute between September 1976 and February 1978. Adequate material for evaluation was obtained in 31 cases. The accuracy rate of the procedure was 93%. Needle biopsy is a rapid, effective and safe method of evaluating unsuspected primary lesions of bone. The indications, contraindications, and technique are emphasized. The benefits over open biopsy are indicated.