Osteosarcoma parostal desdiferenciado en diáfisis de cúbito metastásico a pulmón / Dedifferentiated diaphyseal juxtacortical osteosarcoma of ulna with metastasis to the lung

Resumen: El osteosarcoma parostal desdiferenciado es una variante en la cual un osteosarcoma de alto grado coexiste con un osteosarcoma parostal. Se presenta el caso de un paciente femenino de 20 años; acudió con seis meses de evolución de dolor y limitación funcional en el antebrazo derecho sin causa aparente; se le realizaron radiografías, donde se observó una lesión tumoral en la diáfisis del cúbito derecho. A la exploración física, presentó dolor a la palpación en la diáfisis del cúbito y limitación a la pronosupinación. La tomografía axial computada de tórax reveló enfermedad metastásica en el lóbulo superior del pulmón izquierdo. Se le efectuó una biopsia incisional de la tumoración en el cúbito derecho, con reporte de osteosarcoma parostal desdiferenciado. Por ello, inició manejo con quimioterapia neoadyuvante con cisplatino y doxorrubicina hasta completar tres ciclos. El tratamiento quirúrgico consistió en resección intercalar de la diáfisis del cúbito derecho más reconstrucción de injerto autólogo microvascularizado de la diáfisis del peroné derecho y estabilización del injerto con placa de compresión dinámica (DCP) 3.5 mm y placa tercio de caña. En el mismo procedimiento se le efectuó metastasectomía pulmonar por toracoscopía. El reporte histopatológico postquirúrgico, con necrosis de 100%. Actualmente, la paciente se encuentra asintomática, sin datos de actividad tumoral. El osteosarcoma parostal desdiferenciado es una patología rara, pero que se debe sospechar como diagnóstico diferencial ante un osteosarcoma parostal; se debe tener en cuenta que esta enfermedad puede generar metástasis por su patrón desdiferenciado. Es importante planificar un tratamiento quirúrgico que permita una adecuada reconstrucción funcional, siempre teniendo en cuenta el principio oncológico.

Abstract: Dedifferentiated parosteal osteosarcoma is a variant in which a high grade osteosarcoma coexists with a parosteal osteosarcoma. We report the case of a 20-year-old female patient who presented with six months of evolution of pain and functional limitation of the right forearm, with no apparent cause; radiographs were performed, observing a tumoral lesion in the diaphysis of the right ulna. Physical examination showed pain upon palpation in the diaphysis of the ulna and limitation of prone-supination. Axial computed tomography of the thorax revealed metastatic disease in the upper lobe of the left lung. An incisional biopsy was performed on the right ulna, with a report of dedifferentiated parosteal osteosarcoma. Therefore, the patient was managed with neoadjuvant chemotherapy with cisplatin and doxorubicin until completing three cycles. Surgical treatment consisted of intercalary resection of the diaphysis of the right ulna, plus reconstruction of the microvascularized autologous graft of the right fibular diaphysis and graft stabilization with 3.5 mm dynamic compression plate (DCP) and one-third tubular plate. In the same procedure, pulmonary metastasectomy was performed by thoracoscopy. Post-surgical histopathological report with 100% necrosis. Currently, the patient is asymptomatic, with no evidence of tumor activity. Dedifferentiated parosteal osteosarcoma is a rare pathology, but should be suspected as a differential diagnosis in the presence of a parosteal osteosarcoma; it should be taken into account that this disease can metastasize due to its dedifferentiated pattern. It is important to plan a surgical treatment that allows an adequate functional reconstruction, always taking into account the oncological principle.

Adamantinoma de tibia: manejo quirúrgico con aloinjerto intercalar. A propósito de un caso / Adamantinoma of tibia: Surgical management with intercalary allograft. Report of a case

El adamantinoma es un tumor maligno bifásico que comprende el 0,4% de todos los tumores óseos primarios y el 23% comienza con fracturas patológicas asociadas a traumatismos ocurridos meses o años antes. Presentamos el caso de una paciente de veinte años de edad quien comienza con fractura patológica de la tibia derecha por un trauma de baja energía, con estudios radiológicos e histopatológicos que confirmaron la presencia de un adamantinoma. Fue manejado quirúrgicamente mediante resección amplia del segmento tumoral y reconstrucción con aloinjerto intercalar de tibia fijado con un clavo endomedular de estabilidad multidireccional sustentado con una placa antirrotatoria proximal. Los resultados radiológicos y clínicos fueron satisfactorios.

The adamantinoma is a biphasic malignant tumor comprising 0.4% of all primary bone tumors and 23% debuts with pathological fractures associated with trauma that occurred months or years earlier. We report the case is presented of a twenty-year-old woman that debuted with a pathological fracture of the right tibia with a low-energy trauma. The radiological and histopathological studies confirmed the presence of an adamantinoma. This was treated surgically by wide resection of the tumor and reconstructed with an intercalary allograft bone segment that was fixed with a tibial intramedullary multidirectional antirotatory stability nail sustained further by a proximal plate. The radiological and clinical results were satisfactory.

Intercalary Allograft Reconstruction after Malignant Tumor Resection around the Knee / 대한정형외과학회잡지

PURPOSE: We aimed to assess the treatment outcomes and factors affecting bone union of intercalary allograft reconstruction after primary malignant bone tumor resection around the knee. MATERIALS AND METHODS: Twenty-one patients who underwent intercalary allograft reconstruction after resection of a malignant tumor of femur or tibia were retrospectively reviewed. The average follow-up period was 46.4 months. Location of the tumor was as follows: femur in 12 cases and tibia in 9. Osteosarcoma was the most common tumor (12 cases). Intercalary allograft was internally fixed with an intramedullary (IM) nail in 3 cases, with a plate in 12 cases and with an IM nail combined with a plate in 6 cases. The survival of the grafts and functional outcomes were evaluated. Factors affecting bone union and complications were assessed. RESULTS: All allografts survived without removal. The average Musculoskeletal Tumor Society functional score was 27. The mean length of the allograft was 16.7 cm and bony union took 10.9 months, in average. Nonunion occurred in 6 cases: at the diaphyseal side in 3, and the remaining 3 at the metaphyseal side. The graft length was shorter than average in all the diaphyseal side nonunion cases and longer than average in all the metaphyseal side nonunion cases. All cases of nonunion obtained bone union after additional operations (autologous bone graft alone: 1, bone graft with hardware change: 5). CONCLUSION: Survival and functional outcomes of intercalary allograft were satisfactory. Long allograft showed a tendency of fracture or nonunion at the metaphyseal side. Nonunion could be managed with additional operation without allograft removal.

Low-heat Treated Intercalary Autograft Reconstruction in Limb Salvage of Primary Malignant Bone Tumor / 대한정형외과학회잡지

PURPOSE: This study evaluated the effectiveness of a low-heat treated intercalary autograft reconstruction in primary malignant bone tumors mainly involving the diaphysis. MATERIALS AND METHODS: Twenty patients who had primary malignant bone tumors underwent a low-heat treated intercalary autograft reconstruction between May 1987 and May 2004. The mean age was 24 years, and the mean follow up was 59.8 months. Osteosynthesis between host bone and low-heat treated autograft was carried out using plates and screws (n=7), rigid IM nails (n=6), plates and flexible IM nails or K-wires (n=4), and rigid IM nail and plate (n=3). Intramedullary cement augmentation was performed in 10 patients but the primary bone graft on the host-graft junction was not performed. RESULTS: The mean segmental excised bone length was 152 mm. One patient died from acute cardiac arrest unrelated to the tumor but there was no local recurrence and metastasis. Host graft union was achieved in 18 patients after a mean of 8.5 months after surgery. Complications were observed in 7 patients (35%), including 3 fractures, 2 nonunions, and 2 infections. The mean functional outcome was 82% (24.6). CONCLUSION: A low-heat treated intercalary autograft is a simple, economic and best fitting reconstruction system with a low rate of ultimate failure in carefully selected patients. However, a long term study will be needed to evaluate the graft incorporation and possibility of bone resorption.

Pseudoartrosis de acromión tras politraumatismo tratamiento con autoinjerto intercalar y de cresta iliaca / Pseudoarthrosis of acromion due to politrumatism: treatment with autologus graffting intercalar of iliac crest

Las fracturas de la escápula son poco frecuentes una incidencia en torno al 0,4 Y el 1 % de las fracturas que afectan al miembro superior. La fractura de acromion comprende el 7% de las fracturas que afectan a la escápula'. Suelen aparecer en pacientes politraumatizados con lesiones más graves que pueden enmascararlas y post-poner de este modo su diagnóstico y tratamiento. Presentamos un caso clínico de una paciente de 56 años de edad con antecedente de politraumatismo. Que presentaba unas pseudo-artrosis francas del proceso acromial de su hombro derecho con clínica dolorosa y limitación de movimiento.Se trató de manera quirúrgica mediante el aporte de injerto óseo intercalar y fijación mediante placa de osteo-síntesis obteniendo buenos resultados clínico radiológicos a día de hoy. La clínica dolorosa ha desaparecido por completo a día de hoy.

The fractures of the scapula are not very frequent, an incidence around the 0,4 and 1 % of the fractures that affect the upper limb

Intercalary Resection and Reconstruction for Malignant Bone and Soft Tissue Tumor of Lower Extremity / 대한정형외과학회잡지

PURPOSE: This study was undertaken to evaluate methods of reconstruction and their functional outcomes for segmental resections of the long bones of the lower extremity . MATERIALS AND METHODS: Eighteen cases were eligible for this study. There were 11 femoral lesions and there were 7 tibial. Lesions that had a good bone stock were reconstructed by means of a combination of rigid fixation and heat treated autogenous bone (Group1: in which there were 11 cases). Osteolytic lesions and those that necessitate a pathologic analysis underwent a temporary fixation procedure using intramedullary nail and bone cement (Group 2:7 cases). The average follow-up period was 49 (12-160) months. RESULTS: At the final follow-up examination, 15 patients were disease free, 2 had died of disease and remaining one was alive with disease. There were a total of 10 complications, 7 occurred in Group 1 and 3 in Group 2. Four cases of nonunion in Group 1 had a solid union after augumentation bone graft and a change of fixation device. Average union time for the recycled bone was 15 (9-35) months and their average functional score was 25.8. CONCLUSION: Although reconstruction by heat treated bone is a feasible, inexpensive method that has a low infection rate, the union process is not always successful. A rigid initial fixation is essential for a primary union. Temporal fixation using an IM nail and cement is a relatively sound method both functionally and technically and it might be useful in cases where the prognosis is unpredictable.