Pathological Fracture Of Humerus Research Articles

Is delayed time to surgery associated with increased postoperative complications in patients with pathologic humerus fractures?

Delayed time to surgery, in the case of orthopedic trauma, is well known to be associated with higher morbidity and mortality, an extended duration of hospitalization, and an associated rise in overall cost. Delayed time to surgery of at least 3days following hospital admission is associated with elevated risk of complications following surgery for a standard, non-pathologic, humeral shaft fracture. To our knowledge, it is unknown whether the same association is present for pathologic humerus fractures. The primary objective of this study was to identify risk factors, including patient characteristics, comorbidities, and postoperative complications, that are associated with delayed time to surgery following pathologic humeral fracture. All patients undergoing surgical management of pathologic humerus fractures across a 6-year period from 2015 to 2021 were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Postoperative complications were reported within 30days of procedure. Delayed time to surgery was defined by ≥ 2days from hospital admission to surgery. We identified a total of 248 patients, and 39.9% (n = 99) of patients had delayed time to surgery. Multivariate logistic regression adjusted for all significantly associated variables was employed to identify predictors of delayed time to surgery for pathologic humerus fractures. The characteristics of patients significantly associated with delayed time to surgery were ASA classification ≥ 3 (p = 0.016), dependent functional status (p = 0.041), and congestive heart failure (p = 0.008). After adjusting for all significantly associated patient variables, the characteristics of patients independently associated with delayed time to surgery were non-home discharge (OR: 2.93, 95% CI 1.53-5.63; p = 0.001) and extended length of stay (OR: 2.00, 95% CI 1.06-3.77; p = 0.033). Delayed time to surgery of at least 2days was independently associated with non-home discharge and extended postoperative length of stay. After controlling for baseline patient characteristics and comorbidities, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic humeral fractures. This is in contrast to standard, non-pathologic humerus fractures in which delayed time to surgery is associated with an increased risk of postoperative complications. Retrospective Cohort Comparison; Prognosis Study.

Treating pathological metastatic fractures of the humerus by compound osteosynthesis: a retrospective cohort study

BackgroundThe number of malignant tumors is increasing as are bone metastases, such as those in the humerus. Arm function is important for an independent everyday life. In this study, compound osteosynthesis of metastatic fractures of the humerus is examined for its suitability in light of the competing risk of death. Materials and MethodsThis retrospective monocentric study includes a cohort of tumor patients who underwent primary compound osteosynthesis for pathological humeral fractures. The main endpoint was the continued existence of compound osteosynthesis using competing risk analysis (CRA) to contrast failure and death. Failure was defined as mechanical failure of the osteosynthesis construct like re-fracture or plate-and-screw dislocation or loosening, which provides an indication for re-intervention. Other complications are also described. ResultsWe included 36 consecutive patients (64% male, mean age 71.6 yrs.) from September 2007 to October 2020. In 58% of the cases, the left humerus was fractured. Lung carcinoma was the most common cause of bone metastases (27.8%). Compound osteosynthesis was performed with a median delay of five days after diagnosis of the pathologic fracture. Postoperative complications occurred in seven of the 36 patients (19.4%): radial nerve palsy (n = 3), postoperative hematoma (n = 2), re-fracture (n = 2) and screw loosening (n = 1). Few mechanical failures (8.3%) occurred within the first year; only one patient needed revision of the osteosynthesis (2.8%). Median patient survival after compound osteosynthesis was 26.6 weeks. CRA showed that for up to two years, the risk of death is clearly dominant over the risk of osteosynthesis failure from surgery. ConclusionOur study shows that compound osteosynthesis of the humerus is a suitable option for patients with pathologic humerus fractures. Compound osteosynthesis of the humerus usually survives the duration of malignant tumor disease.

Percutaneous calcium sulfate injection versus localized scrape bone grafting: clinical effect comparison in titanium elastic nail treatment of pathological fracture of proximal humerus caused by unicameral bone cysts in children.

A retrospective study was conducted to compare the mid-term clinical efficacy between percutaneous calcium sulfate injection (PCSI) and localized scrape bone grafting (LSBG) in using titanium elastic nails treat humerus pathologic fractures caused by unicameral bone cysts in children. Humerus pathologic fracture patients with unicameral bone cysts in our pediatric orthopedic department from January 2015 to January 2020 were retrospectively analyzed. Patients were divided into two groups, namely the PCSI group and the LSBG group, based on the type of bone grafting material they received. Preoperative assessments were made in both groups using the Cyst Index and Cyst activity. During the perioperative phase, assessments were made regarding operative time, bleeding, postoperative VAS scores, and the frequency of reoperation within 2 years. Clinical outcomes were evaluated using the Capanna scale at the last follow-up, and the occurrence of re-fractures during the follow-up period. A total of 22 patients were included, with a mean follow-up duration of 33.5 ± 5.8 months. No significant differences were found between the two groups in terms of Cyst Index and Cyst activity before the operation. The operative time, bleeding, and postoperative VAS scores in the PCSI group were found to be lower than those in the LSBG group (P < 0.05). The PCSI group also showed a higher frequency of reoperation within 2 years compared to the LSBG group (P < 0.05). However, no significant differences were observed between the two groups in terms of Capanna scale scores at the last follow-up and the incidence of re-fractures during follow-up. Both titanium elastic nails (TEN) combined with PCSI or LSBG were found to be safe and effective treatments for humerus pathologic fractures caused by unicameral bone cysts in children. PCSI is considered as a less invasive option with shorter operative times, less bleeding, and reduced postoperative pain, although it comes with the risk of multiple injections. On the other hand, LSBG is considered as a more invasive option for the treatment of active bone cysts but is associated with a lower recurrence rate.

Treatment of Pathologic Fracture of Humerus with Internal Fixation, Abrasion of the Lytic Lesion and Cement Infusion; A Case Report and Literature Review

Treatment of Pathologic Fracture of Humerus with Internal Fixation, Abrasion of the Lytic Lesion and Cement Infusion; A Case Report and Literature Review

Gorham Disease of Distal Humerus Successfully Treated by Slight Shortening and Pin and Plate Fixation

Background: Gorham's disease (GD) is one of the scarce and idiopathic skeletal diseases which causes osteolysis following the proliferation of blood vessels. Progressive osteolysis GD of distal humerus with articular involvement and pathologic fracture has not been reported and our case is the first report of this disease involving distal humerus and its joints’ surfaces.&#x0D; Case Report: A 9-year-old boy, case of nonunion of medial condyle of humerus and pathologic fracture of distal humerus after minor trauma, was referred to our clinic and treatment started by casting but due to displacement and nonunion, we decide to operate him. Intraoperative finding was in favour of aneurysmal bone cyst (ABC) near fracture site; therefore, wide resection and fixation by medial tension band wiring (TBW), lateral plating, and fibular allograft application was done (post-operation pathologic result did not show microscopical features of this tumor) and 6 weeks later, he developed stress riser fracture above lateral plate; thus, plate removal was done and severe bone resorption was revealed. Therefore, another specimen was sent for pathology that showed hamartomatous and hemangiomatous lesion of bone. All findings were in favour of GD. He was operated another time and fixed by Persian fixation with small pins and plate, and early plate removal was done for prevention of stress riser fracture.&#x0D; Conclusion: In cases of GD of distal humerus and pathologic fracture, Persian fixation is a good option for fixation and we suggest early device removal for prevention of stress riser fracture.

Intramedullary Nailing Versus Compound Plate Osteosynthesis in Pathologic Diaphyseal Humerus Fractures: A Retrospective Cohort Study.

Pathologic fractures of the extremities due to carcinoma metastases require individual and patient prognosis-related stabilization procedures. Considering the anatomic features of the humerus, implant material stability is less critical than femoral fractures because of less weight-bearing stress. Therefore, operation length, blood loss, and quick recovery of function are of greater interest. In this retrospective cohort study, we evaluated and compared the outcomes of compound plate osteosynthesis and intramedullary (IM) nailing while managing diaphyseal pathologic fractures of the humerus. We retrospectively reviewed patients treated at our institution for pathologic fractures of the diaphyseal humerus between 2010 and 2021 for group differences (plate osteosynthesis vs. IM nailing) in terms of blood loss, length of operation, implant survival, and upper extremity function. We reviewed 42 stabilization procedures due to pathologic diaphyseal humerus fractures, with a mean follow-up of 8.5±15.4 months. IM nailing (n=20) showed a significantly lower blood loss (266.7±23.7mL) than plate osteosynthesis (n=22, 571.1±92.6mL). We did not detect statistically significant differences in the complication rate, length of operation, or Musculoskeletal Tumor Society score. Our findings suggested that diaphyseal fractures of the humerus should be stabilized using an IM nail rather than plate osteosynthesis due to lower blood loss, while complication rate, implant survival, and length of operation remain indifferent.

Management of Unicameral Bone Cyst with Pathological Fracture of Proximal Humerus with Curettage, Fibular Grafting and Plate Osteosynthesis: A Retrospective Study

Introduction: Unicameral Bone Cysts (UBC) are benign fluid filled lesions at metaphyseal regions of long bones of immature skeleton. Several treatment options exist but none have proven to be the best. Curettage helps to remove the cyst membrane responsible for lysis of bone and fibular grafting with plate osteosynthesis which gives adequate stability to the fracture and promotes healing of the UBC of proximal humerus with pathological fracture. Aim: To assess functional outcome, pain relief, healing of the cyst and recurrence of lesion with curettage and fibular bone grafting with proximal humerus plating in UBC of proximal humerus with pathological fracture. Materials and Methods: This was a retrospective study done using the medical records of 10 patients with UBC of proximal humerus with pathological fracture treated with curettage and fibular grafting and plate osteosynthesis at Nizams Institute of Medical Sciences, Hyderabad, Telangana, India, between January 2018 to December 2021. Patients were studied for functional outcome by Musculoskeletal Tumour Society (MSTS) score before surgery and one year after surgery. Healing of the cysts was evaluated by using a modified classification system by Chang et al., and pain relief was evaluated with pre and postoperative Visual Analogue Scale (VAS). Paired t-tests were used to compare the MSTS scores and VAS scores. Results: MSTS score increased significantly after surgery from 11.6±2.06 to 27.3±1.6, p&lt;0.0001. Cysts have healed completely in seven cases, partially in three cases and recurrence was seen in three cases at the end of one year. Mean VAS scores decreased significantly from 7.60±0.97 to 1.40±0.97 after the surgery. Among three cases with recurrence of UBC, two cases were diagnosed at eight months and one case at 12 months after surgery. Conclusion: Treatment of UBC of proximal humerus with pathological fracture by curettage, fibular grafting and plate osteosynthesis gives good functional outcome and cyst healing rate. It is a safe and effective procedure without any complications.

Early Experience in Pathologic Humerus Fracture Treated With the Photodynamic Bone Stabilization System Shows Limitations Related to Patient Selection.

Impending and complete pathologic fractures often necessitate surgical fixation. Traditional orthopedic implants are commonly used, achieving clinically acceptable outcomes, but their metallic composition can impair radiographic evaluation and affect radiation treatments. Recognition of these concerns led to the development of radiolucent implants such as the minimally invasive Photodynamic Bone Stabilization System (PBSS; IlluminOss Medical Inc), featuring a light cured polymer contained within an inflatable balloon catheter. Two participating hospitals in one health care system reviewed cases using the PBSS implant. Twenty-five patients with 29 impending or pathologic fractures in the proximal radius or humerus from metastatic carcinoma, myeloma, lymphoma, and melanoma were identified. Clinical charts and imaging were reviewed to determine the status of the implant at final follow-up as well as complications. For analysis, a chi-square test was used for nominal variables and a t test was used for continuous variables. Eleven of the 25 patients were alive with disease at the time of analysis. Eight of 29 (27.5%) implants failed. Five of 25 (20%) patients required repeat surgery due to complications, including 3 revision open reduction and internal fixations, 1 open reduction and internal fixation for a periprosthetic fracture, and 1 screw removal. Five of the 9 cases (56%) (P=.03) with lesions in the distal humeral shaft had breakage of the implant by final follow-up, compared with 3 of 20 cases (15%) (P=.03) elsewhere in the humerus; no failures were seen in the radius. One of 4 patients (25%) also had failure in the surgical neck, although this did not reach significance. Five patients were noted to have progression of disease on follow-up radiographs, with 4 failures in patients with progression. The PBSS implants potentially allow improved surveillance of fracture healing and tumor recurrence along with decreased scattering of radiation during treatment. Unfortunately, there may be a higher rate of mechanical failures, particularly for lesions involving the distal humerus. This may be due to decreased cross-sectional area of the implant in this region as compared with the metaphyseal and proximal regions. Caution should be exercised when treating distal humeral pathologic fractures with large lytic lesions where the underlying disease process is not well controlled. [Orthopedics. 2021;44(3):154-159.].

Pathological fracture of humerus with implant failure in multiple myeloma patient: A rare case report

Pathological fracture of humerus with implant failure in multiple myeloma patient: A rare case report

Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures.

Despite an increasing prevalence of patients sustaining pathologic fractures of neoplastic origin, few studies have investigated 30-day postoperative complication profiles after surgical treatment of pathologic humerus fractures. The purposes of this study were to use a large nationally representative database to determine short-term complication profiles after surgical treatment of pathologic humerus fractures and assess how these complications compared with more commonly studied native humerus fractures. Using the National Surgical Quality Improvement Program database, we identified 30,866 patients who underwent surgical treatment for either pathologic (n = 449) or native humerus fractures (n = 30,417) from 2007 to 2017. Thirty-day postoperative complication profiles were ascertained and compared between the 2 groups using χ2 analyses. Three logistic regression models were then performed to determine which complications were primarily attributable to the pathologic fracture itself vs. the increased comorbidity burden faced by these patients. Patients with pathologic humerus fractures experienced significantly higher rates of death (6.0% vs. 0.3%, P < .001), serious adverse events (12.2% vs. 3.7%, P < .001), minor complications (15.8% vs. 4.8%, P < .001), extended postoperative lengths of stay (42.3% vs. 21.3%, P < .001), discharge to facilities (22.3% vs. 13.5%, P < .001), and readmissions (14.8% vs. 3.4%, P < .001) compared with patients with native humerus fractures. With respect to specific complications, patients with pathologic fractures were at significantly higher risk of pulmonary complications (1.3% vs. 0.3%, P < .001), renal complications (0.7% vs. 0.2%, P = .007), thromboembolic complications (1.6% vs. 0.6%, P = .01), and transfusions (15.1% vs. 4.1%, P < .001). After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. These findings have significant implications for preoperative patient counseling and may be used to negotiate higher reimbursement rates for these patients given a significantly higher morbidity and mortality than was previously described in literature. Postoperatively, orthopedic surgeons should closely monitor patients with pathologic humerus fractures for deep vein thrombosis, renal complications, and pulmonary complications, use blood-sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogeneous profile of postsurgical complications.

Extending Dosing Intervals of Denosumab As a Maintenance Strategy in Multiple Myeloma: A Real-World Experience at a Large Academic Cancer Center

Introduction: Osteolytic bone destruction is a defining characteristic of multiple myeloma (MM) and patients with MM have an increased risk of skeletal related events (SREs) - including pathologic fractures, spinal cord compression, and the need for radiation therapy or surgery to bone - which is a significant source of impaired quality of life and mortality. Bone modifying agents (BMAs), such as bisphosphonates or denosumab, have shown to substantially decrease or delay onset of new SREs. Optimal duration or frequency of a BMA, however, is less clear. Data supporting zoledronic acid administered at an extended dosing interval of every 3 months compared to the traditional 3-4 weeks interval in patients with MM have been previously reported in the Z-MARK study (Raje N, et al. Clin Cancer Res. 2016). Denosumab, an anti-RANKL monoclonal antibody, received approval for the prevention of SREs in patients with MM in early 2018, but there is a paucity of data for extending denosumab dosing intervals as maintenance. Herein, we report real-world observations by characterizing our use, safety and efficacy, and other practical considerations of denosumab administered at extended dosing intervals. Methods: In this retrospective study, patients with MM at Massachusetts General Hospital Cancer Center who received at least two doses of denosumab at extended intervals (&amp;gt;3 months) as a maintenance strategy between January 1, 2018 and September 30, 2019 were identified. The corresponding electronic medical records (EMRs) were reviewed for incidences of new SREs, hypocalcemia, and disease progression including those with bone-related progression requiring change in therapy. Incidences of new SREs were captured by reviewing radiologic reports/EMRs for pathologic and compression fractures and radiation/surgery to treat bone lesions while on treatment. Evaluation of hypocalcemia included the need for intravenous calcium repletion. Results: Over the 21-month period, a total of 194 patients received denosumab at various extended dosing intervals as maintenance. All patients had received monthly BMA preceding the maintenance therapy. Extended dosing intervals were: 3 months, between 3-6 months, and ≥6 months (58.8%, 26.8%, 14.4%, respectively). Majority of the patients (171, 88.1%) had received bisphosphonates prior to denosumab and evidence of bone disease at diagnosis was seen in 169 (87.1%) patients. Time from diagnosis of MM ranged from 0.3 - 17 years; 51.5% and 16.5% were ≥4 years and ≥8 years since diagnosis, respectively. New SREs while on denosumab maintenance occurred in 6 (3.1%) patients; these consisted of vertebral compression fractures and pathologic fractures of humerus and femur requiring surgical interventions or radiation. These SRE events were associated with disease progression and average time from MM diagnosis to these events was 7.9 years (range 6.2 - 9.5 years). Hypocalcemia (≥grade 1) was seen in 29 (14.9%) patients, and among these, only 6 required intravenous calcium repletion. Disease progression requiring change in therapy occurred in 46 (23.7%) patients and 34 (17.5%) patients had bone-related progression. Conclusions: Our data support the use of denosumab extended dosing during maintenance. However, our study has several limitations including retrospective nature of analysis, heterogeneity in the patient pool, and exclusion of patients with more frequent dosing of denosumab. Our experience therefore underscores the need to study denosumab extended dosing prospectively. Disclosures Branagan: Sanofi: Other: Advisory Board; Pharmacyclics: Other: Advisory Board. Yee:GSK: Consultancy; Celgene: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Amgen: Consultancy, Research Funding; Oncopeptide: Consultancy; Janssen: Consultancy; Karyopharm: Consultancy; Sanofi: Consultancy; Takeda: Consultancy, Research Funding. Raje:Celgene: Consultancy; Janssen: Consultancy; Bluebird Bio: Consultancy; BMS: Consultancy; Amgen: Consultancy. O'Donnell:Celgene: Consultancy.

Evaluating the reoperation rate and hardware durability of three stabilizing implants for 105 malignant pathologic humerus fractures

IntroductionMany patients sustaining a malignant pathologic humerus fracture (MPHF) elect for surgical stabilization. Complications prompting reoperation can occur, leading to additional quality of life and financial cost. One common event preceding reoperation is a broken implant (BI). The purpose of this study was to identify the rate of reoperation following surgical stabilization of MPHF with three techniques – photodynamic bone stabilization (PBS), intramedullary nail (IMN), and cemented plate fixation (CPF) – and estimate to what extent improved implant durability might prevent reoperation. Materials and methodsRetrospective data collection was performed, identifying 105 procedures (100 patients) who underwent non-articular MPHF surgery from 2010–2016: 19 PBS, 65 IMN, 21 CPF. All patients were followed for at least two years or until death. ResultsReoperation rates were similar at one year (10.5%,6.2%,4.8%, p = 737), two years (15.8%,6.2%,9.5%, p = 375), and final evaluation (15.8%,7.7%,14.3%, p = 248). The rate of BI for PBS, IMN, and CPF was 10.5%,0%, and 4.8% (p = 049 PBS/IMN) at one year, 15.8%,0%, and 9.5% (p = 010 PBS/IMN) at two years, and 15.8%,0%, and 14.3% (p = 010 IMN/PBS, p = 013 IMN/CPF) at final evaluation. ConclusionsReoperation rate was not significantly different at any time point. However, IMN surgery resulted in the lowest rate of broken implants (zero), statistically significant versus PBS at all time periods and versus CPF at final follow-up. PBS may eventually offer selected advantages for MPHF management, but current data suggests fragility must be thoughtfully considered.

LIGHTNING STRIKES TWICE? ALVEOLAR HEMORRHAGE AND SINUS NODE DYSFUNCTION REQUIRING PACEMAKER AFTER INITIATING BORTEZOMIB FOR MULTIPLE MYELOMA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bortezomib is a proteasome inhibitor used in the treatment of multiple myeloma. Neuropathy, constipation, and edema are common side effects. Cardiotoxicity causing dysrhythmia and pacemaker placement have occurred, yet controversy exists regarding the risk of adverse cardiac events based on recent data. To date only 18 cases of alveolar hemorrhage (AH) associated with bortezomib have been described; symptoms occur after a median of four doses and respond to glucocorticoids. CASE PRESENTATION: DB is an 82 year old previously healthy male who presented with fatigue and arm pain admitted for a pathologic humerus fracture, acute renal failure and anemia. Bone marrow biopsy (48% k-restricted plasma cells via morphology, IgA K/L ratio of 345) confirmed the diagnosis of multiple myeloma. The patient received dexamethasone and 2.6mg of bortezomib on D1 and D4. Lenalidomide was held due to NSAID-induced nephropathy. The patient initially experienced distal neuropathy and extremity edema but was discharged and scheduled for outpatient therapy. At home, DB had a syncopal episode secondary to orthostasis and was admitted to the hospital where he received his third dose of bortezomib on D8 per protocol. A chest film ordered for worsening cough revealed right lower lobe infiltrates and bilateral pleural effusions. DB then developed sinus node dysfunction with multiple syncopal episodes requiring a pacemaker. On D26, he developed worsening hypoxia with increased effusions and ground glass opacities on CT imaging. He had preserved ejection fraction and normal IVC collapsibility on echocardiogram. Cefepime, vancomycin, sulfamethoxazole-trimethoprim, and prednisone yielded no improvements. Fat pad biopsy was negative for amyloid. Bronchial lavage was not done due to concern for inability to extubate post-procedure. Worsening renal function precluded CTA for pulmonary embolism. On D33 he was intubated due to respiratory failure. A BAL revealed three progressively bloody aliquots suggestive of AH and the patient was treated with 1g IV solumedrol for three days. Repeat BAL on D39 revealed markedly less bloody aliquots, suggestive of improvement and he was extubated on D48. DISCUSSION: Similar to previously cases, we demonstrate AH after three doses of bortezomib, bilateral infiltrates and effusions, lavage-proven hemorrhage and response to steroids. Unlike others, our case appears to be the first Caucasian male and the oldest known patient to experience this toxicity. Our case has an additional complexity of sinus node dysfunction after induction of bortezomib suggesting an even more rare potential toxicity of bortezomib. CONCLUSIONS: This may represent the first case of concomitant AH and sinus node dysfunction associated with bortezomib and highlights the importance of early recognition and rapid initiation of high dose glucocorticoid therapy. Reference #1: Sugita, Y., et al (2018). Early-Onset Severe Diffuse Alveolar Hemorrhage after Bortezomib Administration Suggestive of Pulmonary Involvement of Myeloma Cells. Reference #2: Diwadkar, Sachin, et al. “Bortezomib-Induced Complete Heart Block and Myocardial Scar: The Potential Role of Cardiac Biomarkers in Monitoring Cardiotoxicity.” Case Reports in Cardiology, vol. 2016, 2016, pp. 1–5., https://doi.org/10.1155/2016/3456287. Reference #3: Laubach, Jacob P., et al. “A retrospective analysis of 3954 patients in phase 2/3 trials of bortezomib for the treatment of multiple myeloma: towards providing a benchmark for the cardiac safety profile of proteasome inhibition in multiple myeloma.” British Journal of Haematology, vol. 178, no. 4, Mar. 2017, pp. 547–560., https://doi.org/10.1111/bjh.14708. DISCLOSURES: No relevant relationships by Patrick Bagley, source=Web Response No relevant relationships by Alexander Dew, source=Web Response

Mandibular Brown Tumor as Atypical Presentation of Primary Hyperparathyroidism: two Case Reports And Literature Review

Objective. We report two cases of patients who developed solitary expansive mandibular tumor of aggressive behavior who were surgically removed in suspicion of malignancy with histopathological diagnosis of Central Giant Cell Granuloma and Giant Cell Bone Tumor in patients undiagnosed of primary hyperparathyroidism (PHTP). Methods: Two cases report and review of the literature. Results: We present two cases of single mandibular tumor with aggressive, expansive, rapidly evolving behavior. In both cases, a malignant tumor process was suspected and the lesion was surgically resected. The histopathological diagnosis was Giant Cell Bone Tumor (GCTB) in one and Central Giant Cell Granuloma (CGCG) in the other. We are unaware of their biochemical studies of both patients at the time of the intervention. Several months later, they were sent to the Endocrinology Service for hypercalcemia. One of them presented hypercalcemic crisis and pancreatitis and the other a pathological fracture of humerus. The diagnosis of ...

Lung and Liver Plasmacytoma With Multiple Myeloma

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Multiple Myeloma is a neoplasm characterized by clonal expansion of plasma cells.This case shows an atypical and aggressive presentation of multiple myeloma with metastasis to bone, lungs and liver. CASE PRESENTATION: 46 y/o AAM presented with diffuse body pain, pathologic fracture of humerus and lytic bone lesions. CT chest and abdomen revealed multiple nodules in liver and lungs. SPEP, UPEP and Immunofixation were done with results positive for light chains consistent with multiple myeloma. Bone marrow biopsy showed necrosis and highly anaplastic plasma cell dyscrasia. CT guided liver biopsy of the nodule revealed plasma cells, consistent with plasmacytoma confirming metastasis to liver and lungs. Patient rapidly deteriorated, developing cord compression and respiratory failure secondary requiring mechanical ventilation. Due to the poor prognosis and rapid deterioration, the patient did not qualify for chemotherapy or surgical interventions. DISCUSSION: Multiple Myeloma accounts for 10% of hematologic cancers. Presentation is usually seen at age of 65 with only 2% of patients presenting between 40 and 49. 30% of patients are diagnosed incidentally and another 30% are diagnosed after pathologic fractures or history of bone pain.Besides the bone pain (58%) and pathologic fractures, other modes of presentation are infection, weight loss (24%), anemia (73%), hypercalcemia (28%), spinal cord compression or renal failure (48%).Extramedullary presentation is seen in less than 7% of patients, usually as solitary extramedullary plasmacytomas in the head and neck.A few cases of multiple myeloma presenting as nodular hepatic lesions have been reported, however they usually present as a solitary lesions.Rarity of our case is highlighted by the multiple plasmacytomas in the liver and lung. Commonly used, first line treatment regimens for multiple myeloma include a steroid backbone, proteasome inhibitor and Lenalidomide. Eligibility for bone marrow transplant should be individualized and depends on several factors. CONCLUSIONS: Even though literature emphasizes the classic presentation of Multiple Myeloma as bone pain, hypercalcemia, anemia and renal disease, this clonal oncotic disease can also present with multiple plasmacytomas. With such a presentation multiple myeloma tends to behave aggressively and appropriate palliative intervention should be considered. Reference #1: Multiple myeloma with lung plasmacytoma Rajendra Prasad;Sanjay Kumar Verma;Rakhi Sodhi Lung India2011 Reference #2: Multiple myeloma in young patients:clinical presentation and treatment Bladé J,Kyle RA;Leuk Lymphoma1998 Reference #3: Guidelines on the diagnosis and management of solitary plasmacytoma of bone and solitary extramedullary plasmacytoma. Soutar R,Lucraft H,Jackson G,Reece A, Bird J,Low E,Samson D;Br J Haema2004 DISCLOSURE: The following authors have nothing to disclose: Theo Trandafirescu, Vansha Singh, Ana Ventura No Product/Research Disclosure Information

Management of pathological fracture of the humerus secondary to osteofibrous dysplasia after curettage with elastic intramedullary nail: A case report

Introduction: Fibrous dysplasia is a rare non neoplastic bone disease of unknown aetiology which has a wide spectrum of symptoms such as pain, deformity, fracture depending on the area of involvement. Cases are diagnosed within the first three decades of life, though most commonly diagnosed in children and adolescents. Fibrous dysplasia presents in two forms monostotic or polyostotic. We present a case of pathological fracture of humerus secondary to fibrous dysplasia admitted in department with a background of posttraumatic pain in the right arm. Conclusion: Pathological fracture of humerus in a child secondary to Fibrous dysplasia can be managed with curettage and bone grafting along with elastic intramedullary nail.

P1.09 - Phase I clinical study of intratumoral injection of Clostridium novyi-NT spores in patients with advanced cancer

ABSTRACT Background: Intratumoral injection of Clostridium novyi-NT (attenuated strain of Clostridium) induced a microscopically precise, tumor-localized response in a rat orthotopic brain tumor model and in companion dogs bearing spontaneous solid tumors. Furthermore, intratumoral injection can plausibly induce an immune mediated abscopal effect in non-injected tumor sites. Methods: A standard 3 + 3 dose escalation Phase 1 study of a single intratumoral injection of C.novyi-NT was designed to determine the DLTs, MTD and preliminary activity in adult patients with advanced cancers and superficially located tumors (1-12 cm in size). The SOFA score and temperature are used to guide antibiotic usage. Results: To date, a total of 5 patients (women, n = 3; men, n = 2) with advanced sarcomas (leiomyosarcoma, n = 2; chondrosarcoma, n = 1; carcinosarcoma, n = 1; angiosarcoma, n = 1), median age 54 years, have received an intratumoral injection of 1 x104 (n = 3) and 3 x104 spores (n = 2). Evidence of germination has been noted in 3 patients and has consisted of pain in the injected tumor, fever, elevated WBC with a left shift, an elevated C-reactive protein, and necrosis and gas pockets in the injected tumor on radiographic imaging. Treatment-related grade 3 adverse events include leukocytosis, pathologic fracture, pain and respiratory insufficiency. The most significant morbidity was observed in a patient with a large volume of tumor destruction leading to a pathologic fracture of the necrotic right proximal humerus, which required an aggressive orthopedic surgical procedure. Of note histopathology demonstrated extensive tumor necrosis with small foci of residual tumor cells during surgery. Two patients had between 22-24% shrinkage in the injected tumor and an overall response of stable disease at 2 months. Because exploratory cytokine analysis suggests the potential for a systemic response and because abscopal responses were seen in the companion dog studies, the clinical protocol has been amended to include biopsies of both injected and non-injected tumors pre and post C.novyi-NT injection. Conclusions: Intratumoral injection of Clostridium novyi-NT is feasible and has lead to significant destruction of injected tumor masses in the first two doses studied.

Simple bone cyst with pathological fracture of humerus treated with extensive curettage followed by incorporation of fibular strut-graft

A simple bone cyst is an intramedullary cyst usually filled with serous and serosanguinous fluid. We hereby present a case of a 16-year-old male patient with simple bone cyst with pathological fracture of left humerus, who underwent extensive curettage of the lesion followed by incorporation of autogenous nonvascularized fibular strut-graft taken from ipsilateral limb. Simple bone cyst complicated with pathological fracture may be treated with cortical bone grafting with fibular strut-graft and synthetic fillers. Additional internal fixation with suitable implant is required to fix the pathological fracture. Therefore, by this methodology, we can take care of the disease and its complications as well in a same sitting reducing patient's morbidity.

Atypical presentation of bronchogenic carcinoma with humeral metastasis

Bronchogenic carcinoma often manifests with some atypical symptoms which delay the diagnosis of malignancy. The primary manifestation of lung cancer with pathological fracture of humerus due to skeletal metastasis is very rare. We hereby report such a case in an elderly nonsmoker male who initially presented with nontraumatic painful swelling of right arm which was found to be due to humeral fracture. However, initial management by the orthopedic surgeon over 3 months did not provide adequate relief. On subsequent evaluation, chest X-ray showed a right hilar mass. Further radiologic imaging and a guided biopsy from lung mass confirmed an adenocarcinoma. Fine needle aspiration from humeral osteolytic lesion also confirmed metastatic deposit. This case highlights the importance of suspecting pathological fracture while dealing with nontraumatic fracture, especially in elderly patients, which avoids the diagnostic delay.

Surgical treatment of pathologic fractures of humerus

Surgical treatment of pathologic fractures of humerus