Giant cell tumor of bone: a multicenter epidemiological study in brazil / Tumor de células gigantes ósseas: estudo epidemiológico multicêntrico no brasil

ABSTRACT Introduction: Giant cell tumor of bone (GCTB) mainly affects young adults' long bone epiphyses, threatening bone strength and joint function. Surgery is the primary treatment, although post-surgery recurrence is significant. This study analyzes patient profiles, treatments, and outcomes for GCTB in Brazil. Methods: We retrospectively assessed local recurrence, metastasis, and treatment approaches in 643 GCTB patients across 16 Brazilian centers (1989-2021), considering regional differences. Results: 5.1% (n=33) developed pulmonary metastases, 14.3% (n=92) had pathological fractures, and the local recurrence rate was 18.2% (n=114). Higher rates of pulmonary metastases (12.1%) and advanced tumors (Campanacci III, 88.9%) were noted in lower-income North and Northeast regions. The North also had more pathological fractures (33.3%), extensive resections (61.1%), and amputations (27.8%). These regions faced longer surgical delays (36-39 days) than the South and Southeast (27-33 days). Conclusions: Our findings corroborate international data, underscoring regional disparities in Brazil that may lead to worse outcomes in disadvantaged areas. This highlights the need for improved orthopedic oncology care in Brazil's economically and structurally challenged regions. Level of Evidence III; Retrospective Cohort.

RESUMO Introdução: O tumor de células gigantes do osso (TCG) atinge principalmente epífises de ossos longos em adultos jovens, impactando a resistência óssea e a funcionalidade articular. O tratamento principal é cirúrgico, mas há significativa recorrência pós-operatória. Este estudo analisa o perfil de pacientes e tumores de TCG no Brasil, abordagens de tratamento e resultados. Métodos: Avaliamos retrospectivamente taxas de recorrência, metástase e tratamentos em 643 pacientes tratados em 16 centros brasileiros de 1989 a 2021, considerando a distribuição geopolítica. Resultados: 5,1% desenvolveram metástases pulmonares e 14,3% tiveram fraturas patológicas. A recorrência local foi de 18,2%. Regiões economicamente menos favorecidas, como Norte e Nordeste, mostraram maiores incidências de metástases pulmonares (12,1%) e tumores avançados (Campanacci III, 88,9%). O Norte teve alta ocorrência de fraturas patológicas (33,3%), cirurgias extensas (61,1%) e amputações (27,8%). Nessas regiões, o tempo pré-cirúrgico foi mais longo (médias de 36 e 39 dias) comparado ao Sul e Sudeste (27 e 33 dias, respectivamente). Conclusões: Os resultados refletem disparidades regionais no Brasil, sugerindo que condições socioeconômicas influenciam os desfechos clínicos. Estes achados são importantes para melhorar o cuidado oncológico ortopédico em regiões desfavorecidas do país. Nível de Evidência III; Coorte Retrospectiva.

Immunohistochemical analysis by ki67 and idh1 in patients with chondrosarcoma / Análise imuno-histoquímica por meio de ki67 e idh1 em pacientes com condrossarcoma

ABSTRACT Objective: To perform an immunohistochemical evaluation using the IDH1 and Ki67 markers in patients who underwent treatment for chondrosarcoma in a reference service center in Brazil. Methods: Retrospective analytical observational study using medical records of patients diagnosed with chondrosarcoma. Besides the epidemiological and clinical profile, important variables for prognosis and correlation with immunohistochemical analysis results with Ki67 and IDH1 markers were evaluated. Results: Histopathological examinations by immunohistochemistry of 56 patients were analyzed, 52% of which were women, with the age group 20-60 years being more prevalent. Grade 1 and 2 histological subtypes corresponded to most chondrosarcomas. The femur, humerus, and tibia were the most frequent anatomical sites. Most tumors (59%) were larger than 8 cm. Ki67 expression was very low (< 10%) in 98% of patients. The analysis of IDH1 was positive in 43% of the cases. The correlation between IDH1 positivity and tumor size was statistically significant, but regarding survival, we observed no significance. Conclusion: Immunohistochemical analysis using IDH1 and Ki67 markers in patients with conventional chondrosarcoma is not useful for prognostic guidance. Level of Evidence II, Prognostic Assessment, Results of Immunohistochemical Tests and Correlation with Survival.

RESUMO Objetivo: Fazer uma avaliação imuno-histoquímica usando os marcadores IDH1 e Ki67 em pacientes que fizeram tratamento para condrossarcoma em um serviço de referência no Brasil. Métodos: Estudo retrospectivo, analítico e observacional de prontuários de pacientes com diagnóstico de condrossarcoma. Além do perfil epidemiológico e clínico, foram avaliadas variáveis importantes para o prognóstico e a correlação com os resultados da análise imuno-histoquímica utilizando os marcadores Ki67 e IDH1. Resultados: Foram analisados exames histopatológicos por imuno-histoquímica de 56 pacientes, dos quais 52% eram do sexo feminino. A faixa etária mais prevalente foi entre 20 e 60 anos. Os subtipos histológicos graus 1 e 2 corresponderam à maioria dos casos. Fêmur, úmero e tíbia foram os sítios anatômicos mais frequentes. A maioria dos tumores (59%) tinha tamanho superior a 8 cm. O Ki67 teve expressão muito baixa (< 10%) em 98% dos pacientes. Já a análise do IDH1 foi positiva em 43% dos casos. A correlação entre a positividade do IDH1 e o tamanho do tumor foi estatisticamente significativa; já em relação à sobrevida, não houve significância. Conclusão: A análise imuno-histoquímica por meio dos marcadores IDH1 e Ki67 em pacientes com condrossarcoma convencional não é útil para orientação prognóstica. Nível de Evidência II, Avaliação Prognóstica, Resultados de Exames Imuno-Histoquímicos e Correlação com Sobrevida.

Role of incisional vacuum therapy in endoprosthetic bone reconstruction surgery / Papel da terapia a vácuo incisional em cirurgia de reconstrução óssea com endoprótese

ABSTRACT Reconstructive surgery with endoprostheses is the chosen method for treating bone malignancies. Postoperative infections are frequent complications, and their treatment involves prolonged hospital stays and antibiotic therapy. Among the advancements aimed at reducing the rate of postoperative infection, the use of incisional negative pressure therapy (iNPT) has shown promising results, with no reports in the literature regarding its use in patients with such conditions. Objective: To evaluate the effectiveness of iNPT in reducing postoperative complications in surgeries for resection of bone tumors associated with modular endoprosthesis reconstruction. Methods: Retrospective case series of 16 patients diagnosed with osteosarcoma, who underwent resection and reconstruction with endoprosthesis associated with iNPT during the postoperative period. Follow-up was performed for a period of six months, and the evaluated outcomes were the incidence of postoperative infection and complications of the surgical wound. Results: The use of iNPT for a postoperative period of seven days resulted in only three (18.7%) cases of postoperative infection. No cases of wound dehiscence, seroma formation, or hematoma at the surgical site were observed. Conclusion: The rate of surgical wound complications in our case series is lower than that reported in most of the literature, and iNPT appears to be an efficient way to reduce the rate of local complications in reconstructive surgeries with endoprosthesis after resection of bone malignancies. Level of Evidence III, Retrospective Study.

RESUMO A cirurgia reconstrutiva com endopróteses é o método escolhido no tratamento de malignidades ósseas. As infecções pós-operatórias são complicações frequentes, e seu tratamento envolve internações e antibioticoterapia prolongadas. Entre os avanços que visam reduzir a taxa de infecção pós-operatória, o uso da terapia com pressão negativa incisional (TPNi) vem mostrando resultados promissores, não havendo relatos na literatura de seu emprego em pacientes com tal quadro. Objetivo: Avaliar a eficácia da TPNi em reduzir complicações pós-operatórias em cirurgias de ressecção de tumores ósseos associadas à reconstrução com endopróteses modulares. Métodos: Série de casos retrospectiva de 16 pacientes diagnosticados com osteossarcoma, submetidos à ressecção e reconstrução com endoprótese associada à TPNi durante o pós-operatório. Foi realizado seguimento por um período de seis meses e os desfechos avaliados foram incidência de infecção pós-operatória e complicações da ferida operatória. Resultados: O uso da TPNi por um período pós-operatório de sete dias resultou em apenas três (18,7%) casos de infecção pós-operatória. Não foram observados casos em que ocorreu deiscência da ferida operatória, formação de seromas ou hematomas no sítio cirúrgico. Conclusão: A taxa de complicações de ferida operatória em nossa série de casos é menor que a da maior parte da literatura, e a TPNi parece ser uma forma eficiente de reduzir a taxa de complicações locais em cirurgias reconstrutivas com endoprótese após ressecção de malignidades ósseas. Nível de Evidência III, Estudo Retrospectivo.

Undifferentiated pleomorphic sarcoma: prognostic factors in 42 extremity cases / Sarcoma pleomórfico indiferenciado: fatores de prognóstico em 42 casos em extremidades

ABSTRACT Introduction: Soft tissue undifferentiated pleomorphic sarcoma (UPS) in extremities is considered a rare neoplasm, corresponding to 5% of soft tissue sarcomas (STS) today. The objective was to evaluate prognostic factors related to death, local recurrence (LR), and impact on survival rates. Methods: A retrospective study including 42 patients with UPS in extremities treated surgically in a single center. Comparisons were made between demographic data, characteristics of the neoplasia, and treatment. Between the variables with statistical significance, logistic regression analysis was used. Survival rates were evaluated using Kaplan-Meier plots. To compare the effect of variables on survival rates, the Log-Rank test was used. Results: Age group of patients was from 25 to 85 years (mean 58 years), with a mean follow-up of 29.6 months. The variables with the highest effect on survival rates were sizes larger than 15 cm (T4) with p = 0.01, presence of metastatic lesions, and prognostic stage IV according to the American Joint Committee of Cancer (AJCC) with p < 0.001. The mean survival was 25.9 months. Metastasis and stage IV of AJCC were associated with a reduction in patient survival (17.8 months) with Log-Rank test p < 0.001. Conclusion: The main factors of poor prognosis related to mortality and reduction of survival of UPS in extremities were metastatic lesions and stage IV of AJCC. Level of Evidence III, Retrospective Study.

RESUMO O sarcoma pleomórfico indiferenciado (SPI) de tecidos moles em extremidades, neoplasia rara, correspondente a 5% dos sarcomas de tecidos moles (STM). Objetivo: Avaliar fatores de prognóstico relacionados a óbito, recorrência local (RL) e impacto na sobrevida geral. Métodos: Estudo retrospectivo de 42 pacientes com SPI tratados cirurgicamente em centro único. Foram comparados dados demográficos, características da neoplasia e de tratamento; e para as variáveis com significância estatística, foi realizada análise de regressão logística. A sobrevida foi avaliada através de gráficos de Kaplan-Meier; e os efeito das variáveis sobre a sobrevida, por meio do teste de log-rank. Resultados: Os pacientes tinham idades entre 25 e 85 anos (média de 58 anos), com seguimento ambulatorial médio de 29,6 meses. As variáveis com maior relação com o desfecho óbito foram tamanho maior que 15 cm (T4), com p = 0,01, metástases e estágio IV de prognóstico da American Joint Committee on Cancer (AJCC), com p < 0,001. A sobrevida média dos pacientes foi de 25,9 meses. Presença de metástase e estágio IV da AJCC foram associados à redução na sobrevida dos pacientes (17,8 meses; p < 0,001). Conclusão: Os principais fatores de mau prognóstico relacionados ao óbito e à redução da sobrevida dos pacientes com SPI foram doença metastática e estágio IV da AJCC. Nível de Evidência III, Estudo Retrospectivo.

Extremities Soft Tissue Sarcomas, more Common and as Dangerous as Bone Sarcomas / Sarcomas de partes moles nos membros, mais comuns e tão graves quanto os sarcomas ósseos

Abstract Musculoskeletal sarcomas are rare diseases that require attention. They often present high degree of malignancy at diagnosis and, if underestimated, they can evolve aggressively locally and systemically. They present as soft tissues arcoma and bone sarcomas, with soft tissue being four to five times more common. Most soft tissue sarcomas occur in the extremities. The most common subtypes in children and adolescents are rhabdomyosarcoma and synovial sarcoma; in adults, undifferentiated pleomorphic sarcoma, liposarcoma, leiomyosarcoma, myxofibrosarcoma and synovial sarcoma; all with a high degree of histological malignancy. Many soft tissue sarcomas are confused with benign soft tissue tumors, 100 times more common, so they are resected without the necessary planning, resulting in amputation of a limb that could have been preserved. As in all cancers, the most important prognostic factor is metastatic disease. When it is present, the overall survival rate falls around 20 to 30%. Survival rates are generally similar between bone and soft tissue sarcomas. So soft tissue sarcomas, in addition to being more prevalent, are as aggressive as bones arcomas, deserving a lot of attention from orthopedic surgeons, who are often the first line of care of carriers of these tumors.

Resumo Os sarcomas musculoesqueléticos são doenças raras que exigem atenção. Frequentemente, apresentam alto grau de malignidade ao diagnóstico e se subestimados podem evoluir de forma agressiva local e sistemicamente. Apresentam-se como sarcoma de partes moles e sarcomas ósseos, sendo os de partes moles quatro a cinco vezes mais comuns. A maioria dos sarcomas de partes moles ocorre nos membros. Os subtipos mais comuns nas crianças e adolescentes são o rabdomiossarcoma e o sarcoma sinovial, nos adultos o sarcoma pleomórfico indiferenciado, lipossarcoma, leiomiossarcoma, mixofibrossarcoma e sarcoma sinovial; todos de alto grau de malignidade histológica. Muitos sarcomas de partes moles são confundidos com tumores benignos de partes moles, 100 vezes mais comuns, por isso são ressecados sem o planejamento necessário, acarretando em amputação de um membro que poderia ter sido preservado. Como em todos os cânceres, o fator prognóstico mais importante é a doença metastática. Na sua vigência, a taxa de sobrevida global cai em torno de 20 a 30%. As taxas de sobrevida no geral são parecidas entre os sarcomas ósseos e de partes moles, portanto o sarcoma de partes moles, além de mais prevalente, mostra-se tão agressivo quanto os sarcomas ósseos, por isso merece muita atenção dos ortopedistas que frequentemente são a primeira linha de atendimento dos portadores destes tumores.

Three-dimensional printing in orthopedics: where we stand and where we are heading / Impressão 3d na ortopedia: onde estamos e aonde podemos chegar

ABSTRACT Three-dimensional printing is a technology in expansion in the medical field. It also presents many applications in orthopedics. Our review article aims to describe 3D printing, types of 3D printers, and its use in the orthopedic field. 3D models can be created using tomography scans. Those models can then be manipulated, even simulating surgeries. It is possible to print biomodels, which will help us understand deformities and plan surgeries. Orthopedic surgeons must be updated in these disruptive technologies that may help their daily practice. Level of Evidence V, Expert opinion.

RESUMO A impressão 3D é uma tecnologia em expansão na medicina, possuindo diversas utilidades na ortopedia. O objetivo deste artigo de revisão é descrever o que é a impressão 3D, seus tipos e suas aplicações na ortopedia. Modelos em 3 dimensões podem ser criados a partir da tomografia computadorizada. Estes modelos podem ser manipulados em softwares específicos, onde inclusive cirurgias podem ser simuladas. Utilizando impressoras 3D podemos criar biomodelos que nos ajudam a compreender deformidades e planejar cirurgias. É importante que o ortopedista se mantenha atualizado nestas novas tecnologias disruptivas que podem auxiliar muito no seu dia a dia. Nível de Evidência V, Opinião do especialista.

Prognostic factors in patients with appendicular myxofibrosarcoma / Fatores de prognóstico em pacientes com mixofibrossarcoma apendicular

ABSTRACT Objective: Myxofibrosarcoma (MFS) is a common soft tissue sarcoma (STS) that affects the extremities in elderly patients. The objective was to analyze the prognostic factors and outcomes of patients with MFS treated at a single institution. Methods: We retrospectively reviewed the records of 75 patients with MFS. We compared age, sex, tumor size and location, grade and stage of the disease. Median age was 49.7 years (range, 1 to 88 y). Location: upper extremity (25.4%), lower extremity (66.6%) and pelvis (8%). Patients had high-grade tumors in 46.7% of the reports. Margins were negative in 76% of the cases. Bivariate Cox regression analysis was used to determine associations between clinical and treatment factors with local recurrence (LR). Results: Median follow-up time was 30.7 months (range, 1.8 to 383.8 m). We found 26.7% of LR. Distant metastasis (DM) was reported in 27 (36%) patients. Lung was the most common site of DM, reported in 92.6% of patients. Overall survival (OS) with metastasis was 21.2 months (range, 4.8 to 114.8 m). Predictors of OS were grade, LR (hazard ratio [HR] 5.13, 95% confidence interval, 2.15-12.24, P <0.001), and DM (HR 540.97, 95% confidence interval, 5.04-58112.03, P< 0.001). Conclusions: Tumor grade, LR, positive margins and DM were significant predictors of poor OS prognosis. Level of Evidence IV, Case Series.

RESUMO Objetivos: O mixofibrossarcoma (MFS) é um sarcoma de partes moles (SPM) frequente em idosos, que afeta os membros. O objetivo foi analisar os fatores prognósticos e os desfechos dos pacientes diagnosticados com MFS em uma única instituição. Métodos: Foram analisados retrospectivamente prontuários de 75 pacientes com MFS. Comparamos idade, sexo, tamanho e localização do tumor, grau histológico e o estádio da doença. A media da idade foi 49,7 anos (faixa de 1 a 88 anos). A localização foi: membro superior (25,4%), membro inferior (66,6%) e pelve (8%). Dos tumores, 46,7% foram de alto grau. As margens foram negativas em 76%. A análise de regressão de Cox bivariada foi usada para determinar as associações entre os fatores clínicos e de tratamento com a recorrência local (RL). Resultados: A media do acompanhamento foi 30,7 meses (faixa de 1,8 a 383,8 meses) e 26,7% dos pacientes tiveram RL. Metástases a distância (MD) foram relatadas em 27 (36%) pacientes. O local mais comum de MD foi o pulmão (92,6%). A sobrevida geral (SG) com metástase foi 21,2 meses (faixa de 4,8 a 114,8 meses). Os fatores preditivos de SG foram grau, RL (razão de probabilidades [HR] 5,13, intervalo de confiança de 95%, 2,15-12,24, P < 0,001) e MD (HR 540,97, intervalo de confiança de 95%, 5,04-58.112,03, P < 0.001). Conclusões: Grau histológico do tumor, margens comprometidas, RL e MD foram fatores preditivos de pior prognóstico da SG. Nível de Evidencia IV, Série de Casos.

Tibial adamantinoma: analysis of seven consecutive cases in a single institution / Adamantinoma da tíbia: análise de sete casos consecutivos em uma única instituição

ABSTRACT Objective: Adamantinoma accounts for less than 1% of the primary bone neoplasms. The tibia is the most affected bone and it is predominant in male patients between the second and third decades of life. The objective of this study is to obtain epidemiological and clinical information on patients with adamantinoma of the tibia treated surgically between 1989 and 2016. Methods: Retrospective series of seven patients diagnosed with adamantinoma of the tibia that underwent surgery at the orthopedic oncology service of our hospital. The information was obtained from the medical records and histopathological reports of our institution. Results: A total of 2870 medical records with histological reports were evaluated. Seven cases of adamantinoma of the tibia were included. The mean age was 28.5 (17-49) years. We found a predominance of females (71.4%) and the most affected side was the left one, with four cases (57.1%). The biopsy revealed bone adamantinoma in four (57.1%) patients, while the diagnosis of the other patients was confirmed after the histological examination of the surgical specimen. All the patients underwent surgery as definitive treatment. No positive margins were reported. No local recurrence (LR) was reported and two patients had distant metastasis (DM). Conclusion: The prognosis of survival in cases of adamantinoma of the tibia is high. The rates of LR and DM were low. Surgical treatment with extensive tumor resection is the treatment of choice. Level of Evidence IV, Case Series.

RESUMO Objetivo: O adamantinoma representa menos de 1% das neoplasias ósseas primárias. Afeta predominantemente a tíbia, em pacientes do sexo masculino entre a segunda e terceira décadas da vida. O objetivo deste trabalho é obter informação epidemiológica e clínica dos pacientes com adamantinoma da tíbia, tratados mediante cirurgia entre 1989 e 2016. Métodos: Série retrospectiva de sete pacientes com diagnóstico de adamantinoma da tíbia, tratados cirurgicamente no serviço de oncologia ortopédica do nosso hospital. A informação foi obtida dos relatos clínicos e patológicos do instituto. Resultados: Um total de 2870 prontuários com relatos anatomopatológicos foram revisados. Sete casos de pacientes com adamantinoma na tíbia foram encontrados. A média de idade foi de 28,5 anos (17-49). Encontramos predominância do sexo feminino (71,4%). O lado mais afetado foi o esquerdo, com quatro (57,1%) casos. A biópsia diagnosticou adamantinoma em 57,1% dos casos e o diagnóstico dos outros casos foi definido após exame da peça cirúrgica. Todos os pacientes receberam tratamento cirúrgico como terapia definitiva. Não foram reportadas margens comprometidas. Nenhum paciente apresentou recorrência local (RL). Dois pacientes apresentaram metástase à distância (MD). Conclusão: O prognóstico de sobrevida do adamantinoma da tíbia é alto. Apresenta taxas baixas de RL e MD. A cirurgia com ampla ressecção do tumor é o tratamento de escolha. Nível de Evidência IV, Série de Casos.

Extra-abdominal desmoid tumor: analysis of 23 consecutive cases in a single institution / Tumor desmoide extra-abdominal: análise de 23 casos consecutivos em uma única instituição

ABSTRACT Objective: Extra-abdominal desmoid tumor (EDT) is a rare condition, caused by proliferation of fibroblasts. Despite being a benign tumor, it is locally aggressive and has unpredictable clinical behavior. The objective of this study is to present the clinical outcomes of patients with EDT treated surgically between 1995 and 2016. Methods: This is a retrospective series of 23 patients with histopathological diagnosis of EDT that underwent surgery at the orthopedic oncology service of our hospital. The information was obtained from the institute's clinical and pathology reports. Results: A total of 223 medical records with histopathological reports were evaluated. Only 23 cases of EDT were included in the present study. The mean age was 22.5 years. Twelve (52.2%) patients had the tumor on the lower limbs, seven (30.4%) on the upper limbs and four (17.4%) cases were reported on the back. Five (21.7%) patients had tumors measuring less than 5 cm, while eighteen (78.3%) patients had tumors measuring more than 5 cm. All patients underwent surgery as the definitive treatment in our institute. Twelve (52.2%) cases presented negative margins (NM) and eleven (47.8%) cases had positive margins (PM). Local recurrence (LR) occurred in eleven (47.8%) patients. Conclusion: Impairment of the surgical margin was the only prognostic factor found for LR of EDT. Level of Evidence IV, Case Series.

RESUMO Objetivo: O tumor desmoide extra-abdominal (TDE) é raro, formado por proliferação de fibroblastos. Apesar de ser um tumor benigno, é localmente agressivo e tem comportamento clínico imprevisível. O objetivo desta pesquisa é apresentar os resultados clínicos obtidos nos pacientes com TDE, tratados cirurgicamente entre 1995 e 2016. Métodos: Trata-se de uma série retrospectiva de 23 pacientes com diagnóstico anatomopatológico de TDE, tratados cirurgicamente no serviço de oncologia ortopédica de nosso hospital. A informação foi obtida dos relatos clínicos e patológicos do instituto. Resultados: Um total de 223 prontuários com relato anatomopatológico foi revisado. Apenas 23 casos de TDE foram incluídos no presente estudo. A média de idade foi de 22,5 anos. Doze (52,2%) casos se localizaram nos membros inferiores, sete (30,4%) casos nos membros superiores e quatro (17,4%) casos se localizaram no dorso. Cinco (21,7%) casos tinham tamanho < 5 cm e 18 (78,3%) casos tinham tamanho > 5 cm. Todos os pacientes receberam tratamento cirúrgico como terapia definitiva no instituto. Doze (52,2%) casos apresentaram margens livres (ML) e onze (47,8%) casos tinham margens comprometidas (MC). A recorrência local (RL) ocorreu em onze (47,8%) pacientes. Conclusão: O comprometimento da margem cirúrgica foi o único fator de prognóstico encontrado para a RL do TDE. Nível de Evidência IV, Série de Casos.

Peripherally inserted central catheters in orthopedic patients: experience from 1023 procedures / Cateter central de inserção periférica em pacientes ortopédicos. experiência em 1023 procedimentos

ABSTRACT Objectives The advantages of using a peripherally inserted central catheter (PICC) in hospitalized patients make this device very important for intravenous therapy. This study describes the use of PICCs at the Institute of Orthopedics and Traumatology at the Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo over the last 10 years. Methods This retrospective study analyzed 1,057 medical records and included 1,023 medical files with complete information on the punctured vein, diagnosis, duration of catheterization, complications, and catheter tip positioning. Results Seven hundred and twenty PICCs (70.4%) were considered successfully positioned, and mean duration of catheterization was 34.3 days. The basilic vein was used in 528 (51.6%) patients, while 157 (15.4%) catheters were removed due to complications. No cases of catheter-related thrombosis or infection were found. Eight hundred and sixty-six (84.6%) patients completed their treatment with PICC in place. Conclusion PICC is a safe intravenous device that can be successfully utilized for medium- and long-course intravenous therapy in hospitalized and discharged orthopedic patients. Level of Evidence IV; Case series.

RESUMO Objetivos As vantagens da utilização do Cateter Central de Inserção Periférica (CCIP) no ambiente hospitalar faz com que esse cateter ocupe uma posição de destaque na terapia intravenosa. Este trabalho relata o uso do CCIP nos pacientes do Instituto de Ortopedia e Traumatologia do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (IOT-HC-FMUSP) nos últimos 10 anos. Métodos Trata-se de um estudo retrospectivo, no qual foram analisados 1057 prontuários. Foram incluídos 1023 prontuários de pacientes submetidos à inserção do CCIP, em que foram analisados a veia puncionada, diagnóstico do paciente, tempo em que o paciente permaneceu com o cateter, complicações e posicionamento da ponta do CCIP. Resultados Setecentos e vinte CCIPs (70,4%) foram considerados adequadamente posicionados. O tempo médio de utilização do cateter foi de 34,3 dias. A veia basílica foi a mais utilizada em 528 (51,6%) pacientes. Cento e cinquenta e sete (15,4%) cateteres foram removidos devido a complicações. Nenhum caso de trombose ou infecção relacionada ao cateter foi observada. Oitocentos e sessenta e seis (84,6%) permaneceram com o CCIP até o final do tratamento. Conclusão O CCIP é um dispositivo intravenoso seguro e pode ser utilizado para terapia intravenosa de média e longa duração em pacientes ortopédicos hospitalizados ou desospitalizados. Nível de Evidencia IV; Série de casos.

Primary bone lymphomas: retrospective analysis of 42 consecutive cases / Linfoma ósseo primário: análise retrospectiva de 42 casos consecutivos

ABSTRACT Objective: It is difficult to define parameters for management and factors associated with primary bone lymphoma (PBL). This article presents the experience in a single institution with 42 patients with PBL over a 16-year period (2000-2016). Methods: Fifty-five patients were retrospectively evaluated, and forty-two were included (76.3%). Results: Median age at diagnosis was 51.5 years, and median follow-up was 102.7 months. One patient had HIV. Pain in the affected site was the most prevalent symptom. The average time between symptom onset and diagnosis was 5.4 months. The vertebrae were most affected (n=16, 33.3%). According to the International Prognostic Index Score (IPI), 64.3% of the patients were classified as having low-grade lymphoma and 25.7% as low-intermediate. The most common histology was diffuse large B cell lymphoma (DLBCL) (85.7%). Immunophenotyping was CD20 positive in 93.5% of patients, and 11 patients had pathological fracture. All patients received chemotherapy and 30% of the regimens included rituximab. Thirty-eight percent of patients received radiation therapy. Overall survival was 50%, and survival median time was 80 months. Age and chemotherapy regimen influenced patient survival. Younger patients and patients who received RCHOP had better prognoses. Conclusions: The choice of chemotherapy regimen associated with age influenced survival for patients with PBL. Level of Evidence IV; Case series.

RESUMO Objetivo: É difícil definir parâmetros para o tratamento e os fatores associados ao prognóstico de linfoma ósseo primário (LOP). Apresentamos a experiência de uma única instituição, com 42 casos de LOP durante 16 anos (2000-2016). Métodos: Cinquenta e cinco pacientes avaliados retrospectivamente e quarenta e dois incluídos (76,3%). Resultados: A mediana da idade foi 51,5 anos e a mediana do seguimento foi 102,7 meses. Um paciente era portador do vírus da imunodeficiência humana. Dor no membro foi o sintoma mais prevalente. O tempo médio entre os sintomas e o diagnóstico foi de 5,4 meses. O sítio anatômico mais afetado foram as vértebras (n = 16, 33,3%). Em relação à International Prognostic Index Score (IPI), 64,3% dos pacientes tinham baixo grau e 25,7% tinham baixo-intermediário. O diagnóstico histológico mais comum foi linfoma difuso de grandes células B (LDGCB), com 85,7% dos casos. A imunofenotipagem foi positiva para CD20 em 95,3%. Onze pacientes tinham fratura patológica. Todos receberam quimioterapia, sendo que 30% dos regimes incluíam rituximabe. A radioterapia foi utilizada em 38% dos pacientes. A porcentagem total de sobrevida foi de 50% e o tempo médio de sobrevida foi de 80 meses. A idade e o regime de quimioterapia juntos influenciaram diretamente a sobrevida dos pacientes. Os pacientes jovens, assim como os que receberam RCHOP, tiveram prognóstico de sobrevida melhor. Conclusão: A escolha do regime de quimioterapia associada à idade do paciente influenciou a sobrevida dos pacientes com LOP. Nível de Evidência IV; Série de casos.

SERUM VALUES OF ALKALINE PHOSPHATASE AND LACTATE DEHYDROGENASE IN EWING'S SARCOMA

ABSTRACT Objective: To study the relationship between the serum levels of alkaline phosphatase (AP) and lactate dehydrogenase (LDH), and the percentage of tumor necrosis (TN) in patients with Ewing´s Sarcoma (ES) . Methods: This is a case series with retrospective evaluation of patients with diagnosis of ES divided into 2 groups: Group 1, patients whose serum levels of alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) were obtained in the staging phase before preoperative chemotherapy (CT), and Group 2, patients whose values were measured after completion of the preoperative CT. The percentage of tumor necrosis (TN) of surgical specimens extracted in surgery was also evaluated . Results: Eighty four medical records from 1995 to 2015 were included. Both AP as LDH decreased in the patients studied, the pre CT value being higher than the post CT value. The average decrease of LHD was 272.95 U/L and AP was 10.17 U/L. The average tumor necrosis was 65.12 %. There was no statistical correlation between serums levels and the tumor necrosis percentage . Conclusion: The serum levels values of AP and LDH are not predictors for chemotherapy-induced necrosis in patients with ES. Level of Evidence IV, Case Series.

UNCEMENTED ARTHROPLASTY AFTER HIP METASTATIC DISEASE AND MULTIPLE MYELOMA

ABSTRACT Objective: To describe a case series using a combination of narrative, graphical exploratory analysis and Bayesian Network modeling. Methods: Case series with 34 patients undergoing uncemented and hybrid arthroplasty procedures secondary to hip pain or fracture secondary to metastatic disease or multiple myeloma. Results: The most common tumors included gastrointestinal, multiple myeloma and breast cancer. Most devices were total arthroplasty (n = 16, 84.2%) rather than partial and uncemented arthroplasty (n = 12, 63.2%) rather than hybrid. The average time between surgery and deambulation was 20 days, the average length of hospital stay was 13 days, and the average patient survival was 589 days. Only one infection was reported. Uncemented and hybrid arthroplasty devices did not differ regarding time to walk, as well as the length of hospital stay in this sample. Conclusion: Our model may be used as a prior for the addition of subsequent patient samples, personalizing, thus, its recommendations to other patient populations. Level of Evidence IV, Case series.

Tumors of the patella: the experience of Institute of Orthopedics and Traumatology at University of São Paulo, Brazil

OBJECTIVE: To obtain epidemiological data from the tumors of the patella diagnosed and treated at the Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo (IOT-HC-FMUSP) between 1998 and 2015. METHODS: Series of cases with retrospective evaluation of patients diagnosed with tumors located in the patella. The data was obtained from the records and patients' charts at the Department of Pathology of IOT-HC-FMUSP. RESULTS: A total of 2220 medical records from patients with anatomopathological reports were included in the study. Only eight (0.3%) patients had patellar tumors. We found that six (75%) of these were benign, one (12.5%) was a pseudotumoral lesions and one (12.5%) was reported as malignant. Among benign tumors, the giant cell tumor (GCT) was the most frequently reported corresponding to 50% of the cases. Hemagioendothelioma was the only case of malignant tumor in this series. As for the pseudotumoral lesions, we found a brown tumor. CONCLUSION: From the data obtained retrospectively in a 17 year time frame, in a service that treats benign, malignant and pseudotumoral bone lesions, we conclude that our casuistry in patellar tumors is similar to that reported in scientific literature, where benign tumors are predominant in a 7:1 ratio over malignant tumors, being a rare location of appearance, with the GCT as the most common diagnosis . Level of Evidence IV, Case Series

Serum values of alkaline phosphatase and lactate dehydrogenase in osteosarcoma

OBJECTIVE: To study the relationship between the pre and post chemotherapy (CT) serum levels of alkaline phosphatase (AP) and lactate dehydrogenase (LDH), and the percentage of tumor necrosis (TN) found in specimens after the pre surgical CT in patients with osteosarcoma. METHODS: Series of cases with retrospective evaluation of patients diagnosed with osteosarcoma. Participants were divided into two groups according to serum values of both enzymes. The values of AP and LDH were obtained before and after preoperative CT. The percentage of tumor necrosis (TN) of surgical specimens of each patient was also included. RESULTS: One hundred and thirty seven medical records were included from 1990 to 2013. Both the AP as LDH decreased in the patients studied, being the higher in pre CT than post CT. The average LHD decrease was 795.12U/L and AP decrease was 437.40 U/L. The average TN was 34.10 %. There was no statistically significant correlation between the serums values and the percentage of tumoral necrosis. CONCLUSION: The serum levels values of AP and LDH are not good predictors for the chemotherapy-induced necrosis in patients with osteosarcoma. Level of Evidence IV, Case Series

Bioactive glass in cavitary bone defects: a comparative experimental study in rabbits

OBJECTIVES: To compare bioactive glass and autograft regarding their histomorphometric characteristics. METHODS: The authors conducted a prospective case-control experimental study on animals in order to compare the histomorphometric characteristics of bioactive glass versus autograft. Eight rabbits underwent surgery in which a cavitary defect was created in both proximal femurs. One side was filled with bioactive glass granules and the other, with autograft grafted from the contralateral side. The sides were randomized. Fourteen days after surgery, the animals were euthanized. RESULTS: Histologic analysis revealed that bone neoformation was equivalent among the two groups and the osteoblasts cell-count was higher in the femurs treated with bioactive glass. The osteocytes cell-count, however, was lower. The similarity in bone formation between both groups was consistent to literature findings. CONCLUSION: Bioactive glass is similar to autograft regarding bone neoformation in this animal model of cavitary bone defects. Level of Evidence III, Case-Control Study.

Gct: what happened after 10 years of curettage and cement? Retrospective study of 46 cases

Comparar o resultado funcional de pacientes tratados portumor de células gigantes (TCG) que evoluíram com e sem artrose, edeterminar se o desenvolvimento da artrose está relacionado à distânciaentre o tumor e o osso subcondral. Métodos: 46 pacientes tratadospor TCG entre 1975 e 1999 preencheram os critérios de inclusão. OTCG foi diagnosticado por biópsia percutânea e confirmado após aressecção em todos os casos. As classificações de Campanacci eKellgren, a distância do cimento para o osso subcondral e o escorede MSTS foram obtidos para todos os casos. Resultados: A distânciado cimento para o osso subcondral está associada ao maior risco dedesenvolver artrose, mas não houve diferença nos escores funcionaisde MSTS entre os pacientes com e sem artrose. Conclusão: A distânciaentre o cimento e o osso subcondral tem valor prognóstico comrelação ao aparecimento de artrose, mas isso não acarreta impactono resultado funcional. Nível de Evidência IV, Estudo Terapêutico...

To compare the functional outcome of patients with andwithout arthrosis, and to determine whether the development of arthrosisis related to the distance of the tumor from the subchondralbone. Methods: Forty six patients treated for Giant-cell tumor (GCT)between 1975 and 1999 met inclusion criteria. GCT was diagnosedby percutaneous biopsy and confirmed after resection, in allcases. Campanacci’s and Kellgren’s classification, the distance ofthe cement to the articular surface and MSTS score were obtainedthroughout the sample. Results: The distance of the cement to thesubchondral bone was associated with greater risk of developingarthrosis, but there was no difference in MSTS scores betweenpatients with or without arthrosis. Conclusion: We found that thedistance from the cement to the subchondral bone has a prognosticvalue regarding future arthrosis, but it does not impact on thefunctional outcome. Level of Evidence IV, Therapeutic Study...

Correlation between the expression of VEGF and survival in osteosarcoma

Apresentar uma série de 50 casos consecutivos de pacientescom osteossarcoma de extremidade não metastático, e tentarcorrelacionar a expressão da proteína VEGF na biópsia com o prognóstico– sobrevida global, sobrevida livre da doença e recorrêncialocal. Métodos: Cinquenta casos de osteossarcoma de extremidadenão metastático tratados entre 1986 e 2006 no Instituto de Ortopediae Traumatologia da Universidade de São Paulo São Paulo, Brasil,foram avaliados quanto à expressão de VEGF. Havia 19 pacientesfemininos e 31 masculinos. A média de idade foi 16 anos (intervalo,5-28 anos) e o seguimento médio foi de 60,6 meses (intervalo, 25-167 meses). As variáveis estudadas foram idade, gênero, localizaçãoanatômica, tipo de cirurgia, margens cirúrgicas, tamanho do tumor,necrose pós-quimioterapia, recorrência local, metástases pulmonarese morte. Resultados: Trinta e seis pacientes mostraram expressãode VEGF igual ou menor a 30% das células (baixo), e os 14 restantesmostraram expressão de VEGF acima de 30% (alto). Entre os 36pacientes com baixa expressão, nove desenvolveram metástasespulmonares e quatro morreram (11,1%). Entre os 14 pacientes comalta expressão de VEGF, seis desenvolveram metástases pulmonarese três morreram (21,4%). Conclusão: Não houve correlaçãosignificativa entre a expressão de VEGF com nenhuma das variáveisestudadas. Nível de Evidência IV, Estudo Terapêutico...

To present a series of 50 consecutive patients withnon-metastatic extremity osteosarcoma, and attempt to correlateexpression of the VEGF protein in biopsy tissue to their prognosisregarding overall survival, disease-free survival and local recurrence.Methods: Fifty cases of non-metastatic osteosarcoma ofthe extremities treated between 1986 and 2006 at Instituto deOrtopedia e Traumatologia da Universidade de São Paulo, SãoPaulo, Brasil, were evaluated regarding expression of the VEGFprotein. There were 19 females and 31 males. The mean age was16 years old (range 5-28 years old) and the mean follow-up was60.6 months (range 25-167 months). The variables studied wereage, gender, anatomic location, type of surgery, surgical margins,tumor size, post chemotherapy necrosis, local recurrence, pulmonarymetastasis and death. Results: Thirty-six patients showedVEGF expression on 30% or less cells (low), and the remaining14 cases had VEGF expression above 30% (high). Among the 36patients with low VEGF expression, nine developed pulmonarymetastasis and four died (11.1%). Among the 14 patients withhigh VEGF expression, six developed pulmonary metastasis andthree died (21.4%). Conclusion: There was no statistically significantcorrelation between the expression of VEGF and any of thevariables studied. Level of Evidence IV, Therapeutic Study...

Correlação entre a expressão de VEGF e a sobrevida no osteossarcoma / Correlation between the expression of VEGF and survival in osteosarcoma

Foram analisados 50 casos de osteossarcoma não metastáticos das extremidades tratados no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 1986 e 2006 no que se refere à expressão de VEGF. Dezenove pacientes do sexo feminino e 31 do sexo masculino foram a casuística do trabalho. A idade variou de 5 a 28 anos (média de 16 anos) e o seguimento dos pacientes variou de 25 a 167 meses (média de 60,6 meses). As variáveis estudadas foram idade, sexo, localização anatômica, tipo de cirurgia, margens cirúrgicas, tamanho do tumor, necrose pós QT, recidiva local, metástase pulmonar e óbito. Trinta e seis pacientes apresentaram expressão de VEGF menor ou igual a 30% das células tumorais (baixa expressão), ao passo que os 14 restantes apresentaram expressão acima de 30% das células (alta expressão). Dos 36 pacientes com baixa expressão de VEGF, nove evoluíram com metástases pulmonares, dos quais quatro foram a óbito (11,1%). Dentre os 14 casos com alta expressão de VEGF, seis evoluíram com metástases pulmonares e três foram a óbito (21,4%). Porém, não houve correlação estatisticamente significante entre a expressão de VEGF e qualquer das variáveis estudadas.

Fifty cases of nonmetastatic osteosarcoma of the extremities treated between 1986 and 2006 at the Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were evaluated regarding the expression of VEGF. There were 19 females and 31 males. The mean age was 16 years (528) and the mean followup was 60,6 months (25 167). The variables studied were age, gender, anatomic location, type of surgery, surgical margins, tumor size, post chemotherapy necrosis, local recurrence, pulmonary metastasis and death. Thirtysix patients showed VEGF expression equal or under 30% of the cells (low expression), as the remaining 14 cases had VEGF expression above 30% (high expression). Among the 36 patients with low VEGF expression, nine developed pulmonary metastasis and four died (11,1%). Among the 14 patients with high VEGF expression, six developed pulmonary metastasis and three died (21,4%). There was no statistical significant correlation between the VEGF expression and any of the variables studied.

Primary malignancy in giant cell tumor: a case report / Malignização primária no tumor de células gigantes: um estudo de caso

Context: Primary malignancy in giant cell tumor (PMGCT) is rare. It is defined as a high-grade sarcoma originating in a giant cell tumor (GCT) and seems to behave less aggressively than its secondary counterpart does. Case report: This report presents the case of a 39-year-old female with pain in her left shoulder for one month. Radiography showed a pathological fracture of the proximal humerus associated with an osteolytic lesion. Histopathological analysis showed typical areas of GCT juxtaposed with a sarcomatous component. Conclusions: PMGCT seems to behave less aggressively than secondary malignancy in GCT, and it may simulate its more common benign counterpart clinically and radiographically. However, it requires a more aggressive type of treatment.

Contexto: Malignização primária no tumor de células gigantes (MPTCG) é rara. Ela é definida como um sarcoma de alto grau originário de um tumor de células gigantes que parece ser menos agressivo que o tipo secundário. Relato de Caso: Relatamos um caso de uma paciente de 39 anos de idade, com dor no ombro esquerdo há um mês. A radiografia mostrou uma fratura patológica do úmero proximal associada a uma lesão osteolítica. O exame histopatológico revelou típicas áreas de tumor de células gigantes justapostas por um componente sarcomatoso. Conclusão: MPTCG parece se comportar menos agressivamente que a neoplasia secundária do tumor de células gigantes (TCG), e pode simular o TCG, que é mais comum, tanto clínica como radiograficamente. Entretanto, exige tratamento mais agressivo.