Total femoral prosthesis replacement in management of femoral malignant bone tumor / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the indications of reconstruction with total femoral prosthesis for the patients with a majority of femur infiltrated by malignant bone tumor, and to evaluate the functional outcome and complication.</p><p><b>METHODS</b>Between October 1996 and October 2002, 17 patients with malignant bone tumor were treated with total femoral prosthesis replacement. The patients included 8 males and 9 females, whose age was from 12 to 34 years, with the average of 16 years. The lesions were located in the proximal femur metaphysis in 1, the distal femur metaphysis in 6, the femur shaft in 10, pathologic fracture in 2, skip lesions in 3. The extent of lesions was 23-28 cm (a majority of femur infiltrated by malignant bone tumor). Preoperative pathologic diagnosis were established by open biopsy (2 cases) or needle biopsy (15 cases). All patients were osteosarcoma. According to Enneking surgical staging system, the cases were 12 IIB and 5 IIIB. Seventeen cases received preoperative chemotherapy and 15 cases received postoperative chemotherapy.</p><p><b>RESULTS</b>Seventeen cases were followed up with a mean time of 45 months (range 9-120 months). Local recurrence was observed in 3 (17.6%) after operation 6-14 months. In 12 IIB cases, 4 cases (33%) developed pulmonary metastasis and died. Eight cases remained continuously disease-free for average 75 months (range 50-120 months). In 5 IIIB cases, all with a mean survived term of 13 months (range 9-20 months) died. Fifteen patients (88%) could walk. The patients had maintained average 74% (range 40% - 93%) limb function scores evaluated by ISOLS criteria. Four cases had complications of paralysis of common peroneal nerve (3 cases) and dislocation of hip joint (2 case). No infection took place.</p><p><b>CONCLUSIONS</b>Total femoral prosthesis replacement could be used in the treatment of the patients with a majority of femur infiltrated by malignant bone tumor and could effectively recover their limb function to a great extent. The procedure can effectively improve the quality of life for the patients with malignant bone tumor staging IIIB.</p>

Prognostic factors for the local recurrence of osteosarcoma in extremities treated with combined therapy / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the prognostic factors for the local recurrence of osteosarcoma in extremities treated with combined therapy.</p><p><b>METHODS</b>Between 1992 and 2001, 189 patients with non-metastatic osteosarcoma were treated. The average age at diagnosis was 18 years old. Tumors were located in the distal femur in 86 patients, proximal tibia in 52, and other locations in 51. Pathologic fracture occurred in 22 cases. One hundred and sixteen patients received combined therapy, 73 patients underwent non-combined therapy (tumor resection only or unfinished chemotherapy). In the combined therapy group, 90 patients underwent limb salvage surgery and 26 patients received amputations. In the non-combined therapy group, 42 patients underwent limb salvage surgery and 31 patients received amputations. With Chi-Square test, local recurrence rates were retrospectively evaluated in relation to gender, age, tumor site, pathologic fracture, serum level of alkaline phosphatase, protocol of chemotherapy, type of surgery, surgical margin, size of tumor, and postoperative chemotherapy. Multiple factors were analyzed by Logistic regression analysis.</p><p><b>RESULTS</b>The 5-year-survival rate was 78.5% in the combined therapy group and 35.1% in the non-combined therapy group. Local recurrence rate was 16.6% (15 cases) in limb salvage surgery with combined therapy group (90 cases) and 38.1% (16 cases) in limb salvage surgery with non-combined therapy group (42 cases) (P<0.001). Metastasis rate was 28.4% (33 cases) in the combined therapy group (116 cases) and 65.7% (48 cases) in the non-combined therapy group (73 cases) (P<0.000). The local recurrence rate was significantly related to serum level of alkaline phosphatase after preoperative chemotherapy, type of surgery, surgical margin and chemotherapy protocol. Moreover, Logistic regression revealed that surgical margin and serum level of alkaline phosphatase after preoperative chemotherapy were the key factors affecting the local recurrence.</p><p><b>CONCLUSIONS</b>The local recurrence is related to the surgical margin. The adequate surgical margin is very important for the limb salvage. The local recurrence is highly related to metastasis. The inadequate surgical treatment would damage the survival of patients with osteosarcoma.</p>

Long-term results of combined therapy for primary osteosarcoma in extremities of 189 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the survival rates and complications of combined therapy for primary osteosarcoma of the extremities between 1992 and 2001.</p><p><b>METHODS</b>From 1992 to 2002, 189 patients with non-metastatic osteosarcoma were treated. Their average age at diagnosis was 18 years old (ranging from 4 to 39). Tumors were located at distal femurs in 86 patients, proximal femurs in 4, proximal tibia in 52, proximal humors in 19 and other locations in 28. Combined therapy (resection of tumor with chemotherapy) was given 116 patients and non-combined therapy (tumor resection only and unfinished chemotherapy) to 73. In combined therapy group, 90 patients underwent limb salvage surgery, and 26 patients received amputations. In non-combined therapy group, 42 patients underwent limb salvage surgery and 31 patients received amputations.</p><p><b>RESULTS</b>The 5-year-survival rates were 78.5% in the combined therapy group and 35.1% in the non-combined therapy group. Local recurrence rate was 16.6% (15 cases) in limb salvage surgery with combined therapy group (90 cases) and 38.1% (16 cases) in limb salvage surgery with non-combined therapy group (42 cases) (P < 0.007). Metastasis rate was 28.4% (33 cases) in the combined therapy group (116 cases) and 65.7% (48 cases) in the non-combined therapy group (73 cases) (P < 0.000). Functional evaluation showed that the patients who underwent salvage surgery had higher functional scores than those who had an amputation. According to MSTS scoring system (1993), 56 patients (excision alcohol replacement 36 cases, allograft 10 cases and prosthesis 10 cases) were evaluated functional scores. The average scores reached same level (P > 0.5).</p><p><b>CONCLUSIONS</b>(1) In this study, the 5-year-survival rate in the combined therapy is improved. The treatment for the patients with metastasis in lung is very difficult for improvement of the 5-year-survival rate. (2) The local recurrence is related the surgical margin. The adequate surgical margin is very important for the limb salvage. (3) The combined therapy is very essential for improving survival rate.</p>

Allograft replacement in management of giant cell tumor of bone: a report of 77 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the functional outcome and the complications of allograft replacement in management of giant cell tumors of bone.</p><p><b>METHODS</b>Seventy-seven patients who underwent bone tumor resection and massive allograft reconstruction of bone defects between 1992 and 2002 were evaluated. The length of the resected part ranged from 5 to 11 centimeters. Fresh-frozen allografts were employed as osteoarticular grafts (n = 47), hemi-condylar (n = 12), massive (n = 14) or allograft-prosthesis composite (n = 4). Most of the lesions located in proximal and distal femur, proximal tibia and humerus. The oncological parameters that were evaluated including survival of the patient, local recurrence, and metastasis. The radiographic parameters included time to union, stability of the joint, fracture of the allograft. Mankin evaluation system was used to assess functional outcome.</p><p><b>RESULTS</b>At a median of 35 months (range from 12 to 135 months) after the operation, 76 of the patients in the study group were free of disease, and one had died of disease. Eleven (14.1%) patients had local recurrence and 12 (15.4%) nonunion. Late complications included 5 (6.4%) fractures of the allograft and 5 (6.4%) infections of the graft. Instability of the joint in the form of subluxation was noted in 5 (6.4%) patients. One extremity were amputated due to local recurrence. On the basis of Mankin functional evaluation, the total satisfied rate was 83.2 percent. Osteoarticular graft got the highest score (91.5%) and hemi-condylar got the lowest (66.6%). Massive grafts and composite were at the middle (ranges from 71.4% to 75%).</p><p><b>CONCLUSION</b>Allografts offer many types of reconstruction for bony defects after tumor resection. The functional results are comparable to other methods of reconstruction, and once incorporated by the host, offer the advantage of longevity. It is also a method with high complication, and decreasing the complications could improve the functional score. Less resection could get better reconstruction and better function, less margin resulted at the same time. The risk of recurrence increases when less surgical margin achieves. The main end-result-influencing factor is local recurrence.</p>

Comparison of evaluating system for patients with spinal metastases / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the differences in selecting patients who will undergo operation by comparing the evaluating systems and to discuss the indication of surgery performed on patients with spinal metastases.</p><p><b>METHODS</b>Of the 113 patients presented at Jishuitan Hospital, Beijing, PRC. from February 1994 to February 2002, who were diagnosed as spinal metastases, the clinical, pathological and imaging records of 82 patients were reviewed. Harrington's classification system, Tokuhashi's scoring system, Tomita's scoring system, and Grubb's scoring system were used to evaluate each of these patients at the same time. The classification or score concerning each patient was recorded and compared. SPSS software was used for statistical analysis. McNemar Test was used to compare the proportion of surgery indicated by different evaluating systems.</p><p><b>RESULTS</b>(1) Surgical treatment was indicated for 92.7% of patients by Tomita's scoring system and 69.5% by Harrington's classification system respectively. The difference was statistically significant at the level of P < 0.001. (2) Seventy-five cases with spinal cord palsy and progressive pain could be assessed by Tokuhashi's system. These patients were evaluated by Tomita's system at the same time. The type of surgery determined by Tokuhashi's score was excisional operation for 20% of the patients, palliative operation for 20%. As for the remaining 60%, either excisional or palliative operation might be chosen. The type of surgery determined by Tomita's score was excisional operation for 49.3% of the patients, palliative for 42.7%, and nonsurgical modality for the remaining 8.0%. (3) Twenty-five patients were classified as I, II or III, by Harrington's classification system. These patients were evaluated by the Grubb scoring system to predict the possibility of pathologic fracture and by Tomita's system at the same time to determine if an operation was necessary. By Grubb's system, prophylactic stabilization was necessary for twenty-two patients. By Tomita's system, surgery was chosen for 23 patients. But the treatment options were different in 5 patients assessed by the two systems.</p><p><b>CONCLUSIONS</b>There was a great difference in the selection of treatment modality for patients with spinal metastases by different evaluating systems. That no systems have incorporated the evaluation of life expectancy and the local lesion causes differences. The patients should be evaluated individually by more factors than those proposed by the established systems.</p>

Parosteal osteosarcoma: a clinical study of 48 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the way of diagnosis and therapy of parosteal osteosarcoma.</p><p><b>METHODS</b>A retrospective review was conducted of 48 patients treated at our department between June 1964 and December 2001. The average age of patients in this study was 29.2 years (13 - 47 years). Thirty-two of the patients were female; sixteen were male. The single most common site is the posterior aspect of the distal femur (in 36 patients), followed by the femur shaft (in 6 patients), the proximal tibia (in 2 patients), etc. Nine patients had been operated on before referral to our department.</p><p><b>RESULTS</b>The average follow-up period from the first operation was 5.2 (0.25 - 24) years. In 36 of the 39 patients in whom a limb-salvage procedure was performed, a segment of the tumor-bearing bone was excised along with the tumor, whereas in 3 patients only the subadjacent cortex was excised with the tumor. In the limb-sparing group, the reconstruction was achieved by means of attenuated tumor bone or allograft in 23 cases, by endoprosthetic replacement in 9 cases, and by allograft replacement in 4 cases. The local resections were wide in 35 cases, and marginal in 13 cases. After marginal surgery, local recurrence occurred in 5/13 patients, whereas it occurred in 3/35 patients treated with wide resection. Pulmonary metastases developed in 6 patients, four patients died, and 2 patients are alive with disease. There were 4 cases of fractures of bone grafts. Four patients developed an infection. Long-term survival rate is 85.8%. For tumors that invaded the medullary canal there was no statistical association with local recurrence or metastasis. There is statistical significance between surgical margin and local recurrence.</p><p><b>CONCLUSIONS</b>Wide surgical excision alone is adequate treatment for patients with conventional parosteal osteosarcoma. A tumor-free margin remains the critical factor determining overall prognosis. When a marginal excision was knowingly done to preserve a major neurovascular bundle, the risk of recurrence was less than when it was done to shell-out a presumptively benign lesion. Repeated recurrence probably increases the risk of dedifferentiation and thereby worsens the prognosis. Recurrent lesions with multiple soft-tissue satellite nodules or involvement of the neurovascular structures may however require amputation to provide sufficient local control when a wide margin cannot be achieved. An individualized resection will be performed in the future probably under the help of the advanced technique of image to distinguish the reactive zone from the normal tissue precisely.</p>

Surgical management of metastatic disease of long bone / 中华外科杂志

<p><b>OBJECTIVE</b>To improve the life quality of cancer patients with metastasis to long bone and to select suitable surgical treatment.</p><p><b>METHODS</b>Fifty two patients with metastasis 27 men and 25 women, were treated from 1990 to 1999. Their average age was 56.8 years (33 - 74). In 16 patients with multiple lesions, underwent surgery at bone shaft (29 patients) and bone epiphysis (26). Thirty patients were treated for pathologic fracture and the rest for impending fracture. Operations included limb-salvage (51 patients) and amputation (4) Limb salvage consisted of intralesional curettage (3 patients), intramedullary nailing reconstruction (29), endoprosthesis (18), and temporary spacer (1). 21 patients accepted postoperative chemotherapy or radiotherapy.</p><p><b>RESULTS</b>Follow-up of 52 patients for a mean of 28.2 months (2 - 122 months) showed pain relief (41 patients), (75%) and full or part weight-bearing stability (36) 69%. Local tumor recurrence occurred in 11 patients.</p><p><b>CONCLUSIONS</b>Surgical treatment can effectively improve the life quality of patients with metastasis to long bone. The metastatic lesions should be resected with wide or radical margin for the patients with kidney, breast, prostate and thyroid cancer.</p>