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.

Bone involvement in non-congenital syphilis / Compromiso óseo por sífilis no congénita

We documented two stages of bone involvement due to syphilis in two adult patients infected with human immunodeficiency virus. Bony lesions of secondary versus tertiary syphilis cannot be differentiated on clinical or radiologic grounds alone. Given the rarity of this clinical presentation, there is no consensus on treatment duration and related outcomes.

Se describen dos etapas de compromiso óseo por sífilis en dos pacientes adultos infectados por el virus de la inmunodeficiencia humana. Las lesiones óseas de la sífilis secundaria y de la sífilis terciaria no se pueden diferenciar únicamente por características clínicas o radiológicas. Dada la rareza de esta presentación clínica, no hay consenso sobre la duración del tratamiento y los resultados relacionados.

Sarcoma de Ewing multifocal: presentación de un caso pediátrico / Multifocal Ewing sarcoma: presentation of a pediatric case / Sarcoma de Ewing Multifocal: apresentação de um caso pediátrico

Introducción: el Sarcoma de Ewing es una neoplasia maligna de origen mesenquimático. Al momento del diagnóstico el 75% se presentan en forma localizada. Objetivo: comunicar un caso que por su presentación multifocal, generó dificultades diagnósticas. Caso clínico: niña de 6 años. Consulta por traumatismo de mano derecha tras caída de su altura 24 horas previas, constatándose en mano y puño derecho edema, calor y eritema, movilidad conservada. No fiebre. Radiografía: aumento del diámetro del tercer metacarpiano, imagen esmerilada, no trazos de fracturas. Ingresa con planteo de celulitis. Anemia leve microcítica, hipocrómica. Proteína C reactiva 82 mg/l. Recibe clindamicina intravenosa 72 horas, completa 14 días vía oral. Persistencia de alteraciones en puño y mano derecha, agrega tumoración de raíz nasal con desviación del eje, indolora. Fosfatasa alcalina, lactato deshidrogenasa, fosfatemia, calcemia normales. Resonancia magnética: alteración morfoestructural de radio, olecranon y tercer metacarpiano, fractura de olecranon y radio, reacción perióstica. Pet-Scan: lesión extensa ósea en macizo facial, tibias, cúbitos, humero derecho y clavícula. Biopsia 3er metacarpiano: tumor de células pequeñas, redondas azules, CD99 y vimentina positivo. Comienza poliquimioterapia y radioterapia sin complicaciones. Conclusiones: es frecuente que las manifestaciones clínicas iniciales sean confundidas con entidades más frecuentes, como post-traumáticas y/o inflamatorias, tal como ocurrió en este caso. Posteriormente, la aparición de nuevas lesiones y compromiso del estado general orientó el abordaje diagnóstico de la patología tumoral. La confirmación exige el estudio anatomopatológico con estudio inmunohistoquímico. La presencia de metástasis óseas constituye un factor de mal pronóstico y dificulta el abordaje terapéutico.

Introduction: Ewing's sarcoma is a malignant neoplasm of mesenchymal origin. At the time of diagnosis 75% of the cases are localized. Objective: to report a case that, due to its multifocal presentation, generated diagnostic difficulties. Clinical case: 6-year-old girl. She consulted for right hand trauma after a fall from her height 24 hours earlier, with edema, warmth and erythema in the right hand and fist, with preserved mobility. No fever. X-ray: increase in the diameter of the 3rd metacarpal, frosted image, no traces of fractures. Admitted with cellulitis. Mild microcytic anemia, hypochromic. C-reactive protein 82mg/l. Receives intravenous clindamycin 72 hours, completes 14 days orally. Persistence of alterations in fist and right hand, adds tumor of nasal root with deviation of the axis, painless. Alkaline phosphatase, lactate dehydrogenase, phosphatemia, normal calcemia. MRI: morphostructural alteration of radius, olecranon and 3rd metacarpal, fracture of olecranon and radius, periosteal reaction. Pet-Scan: extensive bone lesion in facial mass, tibiae, ulnae, right humerus and clavicle. Biopsy 3rd metacarpal: small cell tumor, blue round, CD 99 and vimentin positive. Polychemotherapy and radiotherapy were started without complications. Conclusions: it is frequent that the initial clinical manifestations are confused with more frequent entities, such as post-traumatic and/or inflammatory, as occurred in this case. Subsequently, the appearance of new lesions and compromise of the general condition guided the diagnostic approach of the tumor pathology. Confirmation requires anatomopathological study with immunohistochemical study. The presence of bone metastases constitutes a poor prognostic factor and hinders the therapeutic approach.

Introdução: O sarcoma de Ewing é um neoplasma maligno de origem mesenquimatosa. No momento do diagnóstico, 75% dos casos são localizados. Objetivo: Relatar um caso que, devido a sua apresentação multifocal, causou dificuldades diagnósticas. Caso clínico: Menina de 6 anos. Ela consultou por traumatismo à mão direita após cair de sua altura 24 horas antes, com edema, calor e eritema na mão direita e punho, com mobilidade preservada. Sem febre. Raio-X: aumento do diâmetro do 3º metacarpo, imagem fosca, sem vestígios de fraturas. Admitido com a sugestão de celulite. Anemia microcítica leve, hipocrómica. Proteína C reativa 82mg/l. Recebe clindamicina intravenosa por 72 horas, completa 14 dias por via oral. Persistência de alterações no punho e mão direita, tumor indolor da raiz nasal com desvio do eixo. Fosfatase alcalina, desidrogenase láctica, fosfataemia, calcemia normal. IRM: alteração morfo-estrutural do rádio, olecrânio e 3º metacarpo, fratura do olecrânio e do rádio, reação periosteal. Pet-Scan: extensa lesão óssea na massa facial, tíbia, ulnae, úmero direito e clavícula. Biópsia do 3º metacarpo: tumor de pequenas células, redondo azul, CD 99 e vimentina positiva. Ela iniciou a poli-quimioterapia e radioterapia sem complicações. Conclusões: É comum que as manifestações clínicas iniciais sejam confundidas com entidades mais freqüentes, tais como pós-traumáticas e/ou inflamatórias, como ocorreu neste caso. Posteriormente, o aparecimento de novas lesões e o envolvimento do quadro geral levaram a uma abordagem diagnóstica da patologia tumoral. A confirmação requer um estudo anatomopatológico com estudo imuno-histoquímico. A presença de metástases ósseas é um fator de mau prognóstico e dificulta a abordagem terapêutica.

Argon Beam Coagulation as an Adjuvant for Extended Curettage for Giant Cell Tumors of the Bone: A Study of 50 Cases / Coagulação por plasma de argônio como adjuvante à curetagem estendida em tumores de células gigantes do osso: Um estudo de 50 casos

Abstract Objective Extended curettage with adjuvants of giant cell tumors of bone is associated with a lower rate of recurrence of the tumor while preserving the adjacent joint. The present study was conducted to estimate the recurrence rate and functional outcome after using argon beam as an adjuvant for extended curettage. Methods We selected 50 patients with giant cell tumors, meeting all the inclusion criteria, who underwent extended curettage using high speed burr and argon beam photocoagulation between July 2016 to January 2019. On their follow-up visit, they were assessed for any complaints of pain and signs like tenderness, locally raised temperature, and decreased range of motion of the adjacent joint. Radiologically, the patients were assessed for any increased lucency around the cement mantle and uptake of the subarticular graft. Musculoskeletal Tumor Society Score (MSTS) was administered to the patients, and range of motion of the adjacent joint was compared with the contralateral joint. Results Recurrence was found in 4 patients, that is, an 8% recurrence rate. Twenty-six out of 28 patients with a tumor in the lower limb had a grade-5 weight bearing status 6 months from the surgery, and their range of motion was comparable to contralateral healthy joint with an average MSTS score of 27 (18-30). Conclusion Extended curettage of giant cell tumors using argon beam coagulation is associated with low recurrence rates of the tumor and is an effective modality in the treatment of these tumors besides having a functional outcome comparable to the healthy limb.

Resumo Objetivo A curetagem estendida com adjuvantes de tumores de células gigantes do osso está associada a uma menor taxa de recidiva da neoplasia e à preservação da articulação adjacente. Este estudo foi feito para estimar a taxa de recidiva e o resultado funcional após o uso de plasma de argônio como adjuvante à curetagem estendida. Métodos Cinquenta pacientes com tumores de células gigantes que atendiam a todos os critérios de inclusão foram selecionados para o estudo e submetidos à curetagem estendida com broca de alta velocidade e fotocoagulação com plasma de argônio entre julho de 2016 e janeiro de 2019. À consulta de acompanhamento, os pacientes foram avaliados quanto a quaisquer queixas de dor e sinais como sensibilidade, aumento local da temperatura e diminuição da amplitude de movimento da articulação adjacente. Radiologicamente, os pacientes foram avaliados quanto à presença de qualquer aumento de radiotransparência ao redor do manto de cimento e incorporação do enxerto subarticular. O questionário Musculoskeletal Tumor Society Score (MSTS) foi administrado aos pacientes e a amplitude de movimentação da articulação adjacente foi comparada à articulação contralateral. Resultados Quatro pacientes apresentaram recidiva, o que corresponde a uma taxa de 8%. Seis meses após a cirurgia, 26 de 28 pacientes com tumor no membro inferior tinham capacidade de sustentação de peso de grau 5 e amplitude de movimento comparável à articulação saudável contralateral, com pontuação MSTS média de 27 (intervalo de 18 a 30). Conclusão A curetagem estendida de tumores de células gigantes com coagulação por plasma de argônio está associada a baixas taxas de recidiva da neoplasia; é uma modalidade eficaz no tratamento desses tumores e o resultado funcional é comparável ao do membro saudável.

Technique for Foot Reconstruction with Custom-made Calcaneal Prosthesis in Primary Malignancy - A Case Report / Técnica de reconstrução do pé com prótese de calcâneo feita sob medida em câncer primário - Relato de caso

Abstract The foot is an uncommon location for osseous tumors, comprising ~ 3% of all skeletal tumors, which occur particularly around the calcaneum. Radical surgery creates a void in the foot which adversely affects the ability to salvage it. Calcaneal replacement surgeries are not commonly performed due to factors involving instability of the prosthesis, soft-tissue defects, and resultant failure, which can occur in the postoperative period. Thus, we herein report a rare case of synovial sarcoma arising from the sheath of the tibialis posterior tendon, with secondary involvement of the calcaneus bone. Considering the previous experiences of different surgeons, a custom-made prosthesis was designed with relevant modifications.

Resumo O pé é um local incomum para tumores ósseos, e compreende cerca de 3% de todos os tumores esqueléticos, em especial ao redor do calcâneo. A cirurgia radical cria um vazio no pé, o que afeta de forma negativa a capacidade de resgate do membro. As cirurgias de reconstrução do calcâneo não são comumente realizadas por causa da instabilidade da prótese, defeito de partes moles, e consequente possibilidade de insucesso pósoperatório. Assim, apresentamos aqui um caso raro de sarcoma sinovial originário da bainha do tendão tibial posterior com acometimento secundário do osso calcâneo. Considerando as experiências prévias de diferentes cirurgiões, projetamos uma prótese sob medida com modificações relevantes.

Axial Axis Metastasis / Metástase do eixo axial

Abstract Axial axis metastasis remains a challenge for surgical as well as other treatment modalities, like chemotherapy, immunotherapy, and radiotherapy. It is unequivocal that surgery provides pain improvements and preservation of neurological status, but this condition remains when associated with radiotherapy and other treatment modalities. In this review, we emphasize the current forms of surgical treatment in the different regions of the spine and pelvis. The evident possibility of percutaneous treatments is related to early or late cases, and in cases in which there are greater risks and instability to conventional surgeries associated with radiotherapy and have been shown to be the appropriate option for local control of metastatic disease.

Resumo As metástases no eixo axial permanecem um desafio para o tratamento cirúrgico bem como para outras modalidades, como quimioterapia, imunoterapia e radioterapia. É inequívoco que a cirurgia proporciona melhorias na dor e na preservação do status neurológico; porém, há permanência desta condição quando associada à radioterapia e a outras modalidades de tratamento. Nesta revisão damos ênfase às formas de tratamento cirúrgico atuais nas diferentes regiões da coluna vertebral e pelve. A evidente possibilidade de tratamentos percutâneos está relacionada a casos iniciais ou tardios, bem como a casos em que há maiores riscos e instabilidade às cirurgias convencionais associadas à radioterapia, e tem se mostrado a opção adequada para o controle local da doença metastática.

Primary bone lymphoma in children: report of 11 cases and review of literature / 白血病·淋巴瘤

Objective:To investigate the clinical manifestations, pathological features, treatment and prognosis of primary bone lymphoma in children.Methods:The clinical data of children who were initially diagnosed as primary bone lymphoma and treated in Beijing Children's Hospital Affiliated to Capital Medical University from January 2016 to January 2020 were retrospectively analyzed, including gender, onset age, primary involvement site, clinical stage, pathological type, fracture, and clinical outcome. The related literature was reviewed.Results:All 11 children were initially diagnosed as primary bone lymphoma, with a median age of onset of 8.6 years old (2.7-12.3 years old), including 7 males and 4 females. There were 7 cases of diffuse large B-cell lymphoma (DLBCL), 3 cases of B lymphoblastic lymphoma (BLL), and 1 case of anaplastic large cell lymphoma (ALCL). The initial symptoms were bone pain in 8 cases, local swelling in 1 case, limp in 1 case, and fever in 1 case. One case was in stage Ⅰ, 7 cases were in stageⅡ, and 3 cases were in stage Ⅳ, and the most common sites of involvement were femur and tibia. All 11 cases were treated with chemotherapy according to different pathological types, with a median follow-up time of 45 months (7-80 months). Ten cases got complete remission, 1 case of BLL died of bone marrow recurrence after chemotherapy remission.Conclusions:The clinical manifestations of primary bone lymphoma in children are insidious, DLBCL is the most common pathological type, and the prognosis is good after standardized treatment.

Resection of ankle tumor lesion and reconstruction with the use of allograft / Ressecção de lesão tumoral do tornozelo e reconstrução com uso de aloenxerto

RESUMO A reconstrução do terço distal da tíbia devido à ressecção de tumor maligno apresenta alguns fatores que dificultam sua realização, como camada subcutânea delgada, feixes neurovasculares que transpassam os compartimentos, tempo cirúrgico prolongado, material ortopédico específico e equipe multidisciplinar treinada. O aloenxerto de banco de tecido faz parte deste arsenal ortopédico. Objetivo: Descrever o protocolo realizado no Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad. Métodos: Série de seis casos submetidos à ressecção com margens oncológicas, reconstrução com aloenxerto e uso de haste retrógrada de tornozelo como cirurgia preservadora do membro. Três dos seis pacientes eram do sexo feminino, as lesões tinham em média 9,3 cm de comprimento e o tempo cirúrgico médio foi de 3,25 horas. Resultados: A principal complicação de curto prazo (≤ 30 dias) foi a paralisia do nervo fibular, enquanto a principal complicação de longo prazo (> 30 dias) foi a infecção do sítio cirúrgico (dois casos). A consolidação dos dois focos ocorreu em três pacientes, e dois pacientes evoluíram para pseudoartrose assintomática do foco proximal com consolidação do foco distal. Conclusão: Apesar das complicações, a cirurgia proposta permite ao paciente a chance de preservar seu membro diante de uma cirurgia radical imediata. Nível de Evidência IV, Série de Casos.

ABSTRACT Reconstruction of the distal third of the tibia due to resection of a malignant tumor has some hindering factors, such as a thin subcutaneous layer, neurovascular bundles that cross compartments, prolonged operative duration, specific orthopedic material, and a trained multidisciplinary team. Allografting with material from tissue banks is part of this orthopaedic arsenal. Objective: To describe the protocol used at Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad. Methods: Series of six cases subjected to resection with oncologic margins, allograft reconstruction, and use of a retrograde ankle nail as limb-salvage surgery. Three of the six patients were women, the lesions were on average 9.3 cm long, and the average operative duration was 3.25 hours. Results: The main short-term complication (≤ 30 days) was peroneal nerve palsy, while the main long-term complication (> 30 days) was surgical site infection (two cases). Consolidation of the two foci occurred in three patients, and two patients developed asymptomatic pseudoarthrosis of the proximal focus with consolidation of the distal focus. Conclusion: Despite the complications, the proposed surgery gives patients the chance to preserve their limb in the face of immediate radical surgery. Level of Evidence IV, Case Series.

Tumor de células gigantes malignizado: a propósito de un caso

Introducción: La rodilla es la región anatómica donde asientan la mayor cantidad de tumores benignos y malignos que afectan el esqueleto humano, entre ellos se encuentra el tumor de células gigantes. Objetivo: Conocer un paciente con un tumor de células gigantes que sufrió transformación maligna. Caso clínico: Paciente, masculino de 28 años de edad, blanco sin antecedentes mórbidos de salud, que acudió a la consulta externa de la especialidad de Ortopedia y Traumatología por presentar desde hace dos años una tumoración dolorosa a nivel de la rodilla que en los últimos dos meses ha aumentado de tamaño. Se realizaron exámenes imagenológicos mediante radiografía simple, tomografía axial computarizada e imagen de resonancia magnética, además de toma de biopsia incisional para confirmar el diagnóstico. Al analizar los resultados de los exámenes anteriores el equipo multidisciplinario decidió la amputación de la extremidad. Conclusiones: El tumor de células gigantes es una enfermedad que se presenta con mayor frecuencia desde la tercera a quinta décadas de la vida, sus complicaciones principales son la recidiva, las metástasis pulmonares y la transformación maligna. Por lo general, los enfermos con esta última complicación necesitan de procedimientos como la amputación de la extremidad.

Introduction: The knee is the anatomical region where the largest number of benign and malignant tumors that affect the human skeleton settle, among them is the giant cell tumor. Objective: To present a patient with a giant cell tumor that underwent malignant transformation. Clinical case: A 28-year-old white male with no morbid health history, who attended the Orthopedics and Traumatology outpatient clinic for presenting a tumor accompanied by pain at the level of the right knee. It appeared two years ago, but has increased in size rapidly in the last two months. Imaging tests were performed using plain radiography, computed tomography, and magnetic resonance imaging, as well as incisional biopsy to confirm the diagnosis. After analyzing the results of the previous examinations, the multidisciplinary team decided to amputate the limb. Conclusions: The giant cell tumor is an entity that occurs most frequently from the third to fifth decades of life; its main complications are recurrence, lung metastases and malignant transformation. In general, patients with this last complication need procedures such as amputation of the limb.

Emphasis on precision intelligent medical research, positive response to the development trend of bone tumor diagnosis and treatment / 中华骨科杂志

Since the implementation of surgery-based comprehensive treatment, there have been great advances and breakthroughs in the diagnosis and treatment of bone tumors. The survival rate of primary malignant bone tumors has significantly improved, for example, the 5-year survival rate of osteosarcoma has increased from 5%-20% to 60%-70%. Characteristics of bone tumors are as follows: (1) have a wide range of lesion sites; (2) various types; (3) high heterogeneity; (4) structural reconstruction is as important as functional reconstruction; (5) metastatic tumors are more common than primary tumors. Based on the characteristics above, the combination of clinical, imaging and pathology is the basic principle in the diagnosis of bone tumors; Following the principle of tumor resection to achieve local control, it is necessary not only to carry out effective reconstruction of bone and soft tissue structural defects, but also to obtain as perfect motor function as possible. Due to the development of genetic research, bioinformatics technology, digital medicine and computer technology, the diagnosis and treatment of bone tumors have entered the stage of precision medicine with four characteristics: accuracy, punctuality, sharing and individualization. Using the multi-omics technology of genomics, transcriptomics, proteomics and metabolomics to explore the mechanism of the occurrence and development of bone tumors and find new target genes provides a direction for the application of precision medicine in bone tumors in the future. The application of Wise Information Technology of med based on artificial intelligence is of great significance for the auxiliary diagnosis and precise treatment.

Research progress of artificial intelligence in the diagnosis and treatment of bone tumors / 中华骨科杂志

Artificial intelligence (AI) has a broad application prospect in the field of bone tumor. By utilizing deep learning models and AI technology, it can provide effective assistance in pathological diagnosis of bone tumors, molecular biology diagnosis, imaging diagnosis and clinical data processing, providing patients with more accurate and personalized medical services. In terms of pathological diagnosis, AI can assist doctors to accurately identify and classify tumor types by automatically analyzing and reading a large number of pathological tissue section images. In terms of molecular biology diagnosis, AI discovers key genes and signaling pathways associated with bone tumors by analyzing large-scale genomics and transcriptomics data, which provides the basis for prognostic assessment and individualized treatment development. In terms of imaging diagnosis, AI can assist doctors to quickly and accurately analyze the image characteristics of bone tumors, automatically mark the location, size and morphology of tumors, guide treatment and predict prognosis. AI can also process large-scale clinical data to identify potential clinical features and patterns to assist in risk assessment, treatment decisions, and predicting prognosis. This paper reviews recent studies on the application of AI in the field of bone tumor diagnosis and treatment, with a view to improving the accuracy of bone tumor diagnosis, improving clinical prognosis, and providing a theoretical basis for the integrated development and innovation in the cross-field of medicine and industry.

Application of three-dimensional printed endoprosthesis for reconstruction after metaphysis-involved intercalary tumor resection / 中华骨科杂志

Objective:To describe the design, manufacture and use of three-dimensional (3D)-printed endoprosthesis for reconstruction after metaphysis-involved intercalary tumor resection and to evaluate its outcome.Methods:Forty-three patients who received metaphysis-involved intercalary tumor resection followed by 3D-printed endoprosthetic reconstruction in Musculoskeletal Tumor Center, Peking University People's Hospital between January 2018 and December 2021 were retrospectively reviewed. There were 25 males and 18 males with an average age of 20.1±15.2 years (range, 4-58 years). The pathological diagnosis included 24 cases of osteosarcomas, 6 cases of Ewing sarcomas, 5 cases of chondrosarcomas, 2 cases of pleomorphic undifferentiated sarcomas, 3 cases of soft-tissue sarcomas (liposarcoma, synovial sarcoma, malignant peripheral nerve sheath tumor for each) and 3 others (adamantinoma, recurrent aneurysmal bone cyst and recurrent osteofibrous dysplasia for each). The tumors located at femur in 25 patients (58%), including 14 lesions involving distal femoral metaphysis and 11 lesions involving both proximal and distal metaphysis; the tumors located at tibia in 11 patients (26%), including 4 lesions involving distal tibial metaphysis, 5 lesions involving proximal tibial metaphysis and 2 lesions involving both proximal and distal tibial metaphysis; the tumors located at humerus in 7 patients (16%), including 1 lesion involving distal humeral metaphysis, 3 lesions involving proximal humeral metaphysis and 3 lesions involving both proximal and distal humeral metaphysis. The endoprosthesis was designed in a semi-modular fashion and consisted of three parts: a diaphysis-fixing component, a semi-modular lap joint component, and a custom-made 3D-printed metaphysis-fixing component which was designed as two types with 3D-printed porous bone-contacting surfaces according to the osteotomy plane (Type I on meta-diaphyseal region, Type II on meta-epiphyseal region). The functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) 93 system.Results:All surgeries were accomplished sucessfully. The median resection length and the distance from osteotomy plane to adjacent joint was 16.0 (13.0, 22.0) cm and 4.5 (3.5, 6.0) cm, respectively. 59 metaphysis-fixing components were installed in 43 patients. Type I components were used in single and dual ends of endoprosthesis in 12 and 6 cases respectively. Type II components were used in single and dual ends in 15 and 5 cases respectively. Hybrid endoprosthesis with Type I and II components were used in 5 cases. The mean follow-up time was 26.0 (17, 37) months (range, 12-54 months). The mean MSTS 93 score was 29.0 (28.0, 30.0) points (range, 21-30 points). Implant failures were found in 5 patients, including 2 cases of aseptic loosening (loosening was observed in the cementing diaphysis-fixing stems while no evidence of loosening in metaphysis-fixing components) and 3 cases of local tumor progression. The 2-year implant survival rate was 90.3% (95% CI: 0.81, 0.99). Conclusion:Using 3D-printed intercalary endoprosthesis for reconstruction after intercalary resection of metaphysis-involved bone tumor shows satisfactory functional outcome and implant survival. Moreover, by assembling endoprosthetic components according to the different osteotomy plane, the semi-modularized endoprosthesis also provids a comprehensive and individualized reconstruction for patients with metaphysis-involved intercalary tumor.

The treatment of 3D-printed metal prostheses on bone defect of malignant bone tumors in lower limbs / 中华骨科杂志

Objective:To investigate the early and middle term clinical efficacies of 3D-printed metal prostheses in the reconstruction of bone defects after osteotomy in malignant bone tumors.Methods:A total of 34 patients with malignant bone tumors of lower extremity femur and tibia who underwent 3D printing individualized metal prosthesis replacement surgery in the Department of Bone and Soft Tissue of Affiliated Cancer Hospital of Zhengzhou University from March 2019 to March 2022 were retrospectively analyzed. There were 23 males and 11 females, with an average age of 19.1±15.2 years (range, 7-80 years). There were 22 children and adolescents younger than 18 years old. There were 3 cases in the proximal femur, 15 cases in the middle and distal femur, 10 cases in the proximal tibia and 6 cases in the distal tibia. According to the final pathological diagnosis, 24 cases of osteosarcoma, 6 cases of Ewing's sarcoma, 2 cases of undifferentiated sarcoma, 1 case of osteosarcoma, and 1 case of malignant giant cell tumor of bone were enrolled in this study. Postoperative complications, wound healing, periprosthetic fracture and aseptic loosening, tumor outcome (evaluated by tumor control evaluation criteria), and length difference of lower limbs were recorded. Response evaluation criteria in solid tumor (RECIST) was used to evaluate tumor outcomes. Prosthetic-bone interface healing was evaluated postoperatively, and the function was evaluated based on Musculoskeletal Oncology Society (MSTS) 93.Results:The length of lesions was 70-240 mm in 34 patients, with an average of 125.5±35.4 mm. The length of osteotomy was 80-275 mm, with an average of 160.2±33.9 mm. No tumor was found on the osteotomy surface. The customized prosthesis was firmly installed and closely matched with the side of the preserved articular surface. There were 2 patients with local incision fat liquefaction and 4 patients with superficial wound infection, which healed after debridement and antibiotic treatment. One distal tibia osteosarcoma case developed severe periprosthetic infection 2 months after surgery, resulting in prosthesis implantation failure, limb movement pain and poor ankle function. After removal of the prosthesis, infection control and osteogenesis with the Ilizarov technique, the infection was completely controlled and local osteogenesis was possible. The remaining 33 patients had a good prosthetic-bone interface union. One case was found to have localized bone resorption on the contact surface of the prosthesis 7 months after operation, but the metal prosthesis and screws were not loose. The incisions healed well in other patients, without infection, prosthesis loosening, fracture or other complications. All patients survived and were followed up for 13.8±5.6 months (range, 7-27 months). During the follow-up, there was no recurrence of tumor at the osteotomy end in all patients, but 5 patients developed lung metastasis. At the end of the last follow-up, all patients survived. Among them, 16 patients had unequal length of lower limbs, including 10 cases within 2 cm, 3 cases between 2-5 cm, and 3 cases over 5 cm. With the exception of one patient whose prosthesis was removed due to infection, the MSTS 93 of the other patients was 24.9±2.2 (range, 19-28), and were rated as excellent in 26 cases and good in 7 cases. According to the RECIST evaluation criteria, 26 of 34 patients had complete response, 5 had disease progression, and 3 had stable disease.Conclusion:3D printed metal prosthesis is one of the effective methods for the treatment of bone defects after resection of malignant bone tumors in lower limbs, which is safe, reliable and has satisfactory early curative effect.

Application of newly designed modular hinged ankle prosthesis in the reconstruction of defect after surgical treatment of malignant tumor at the distal tibia / 中华骨科杂志

Objective:To investigate the outcome of surgical treatment of malignant tumor at the distal tibial after reconstruction with modular hinged ankle prosthesis.Methods:The data of 9 patients with malignant tumor at the distal tibia at Musculoskeletal Tumor Center of PKUPH from June 2020 to November 2021 were analyzed retrospectively. They were male patients with age of 17 (14, 24) years (range 11-56 years). There were five tumors at the left sides and four at the right sides. There were eight patients with osteosarcoma who received the neo-chemotherapy. Among eight osteosarcomas, one was Enneking IIA and seven Enneking IIB. Furthermore, there was only one patient with renal carcinama and with solitary metastatic lesion at the distal tibia. After the resection of tumor at the distal tibia, talus cartilage was removed and talus component was fixed by lag screws. The proper tibia component was used to restore the defect of tibia and the reduction of tibia and talus components were performed. The following clinical data were collected: baseline demographic features, surgical and follow-up data. The baseline demographic features included gender, age, side, lung or/and other metastasis at initial diagnosis, Enneking stage or systematic progression for renal carcinama, histological type. The surgical data included: surgery time, blood loss, length of bone involved by the tumor, prosthesis type. Monitoring data was also recorded: complications (ankle pain when loading, talar collapse, component loosing, infection and wound dehiscence), local recurrence, pulmonary and systematic metastasis, radiological image and the function at the last follow-up (MSTS and VAS evaluation).Results:Among these nine patients, the average blood loss was 245.6±103.9 ml (range 100-400 ml) and the mean surgery time was 178.9±56.9 mins (range 120-300 min). No patient was lost during the follow-up period and the average follow-up was 21.4±5.6 months (range 12.5-27.2 months). The excision length of tibia was 14 (11, 17) cm (range 11-28 cm). There were one case with 2# prosthetic base, three cases with 3# and five cases with 4#. Five had cement fixation of prosthetic stem and four had the pressing fixation. No pulmonary and other organ metastasis occurred among eight patients with osteosarcoma and one patient with distal tibia matastasis of renal carcinama. One patient with OShad the local recurrence and received the resection. One sustained the deep infection after four months and received the removal of prosthesis and spacer implant. At the final follow-up, except one with deep infection and receiving the removal of prosthesis and spacer implant, eight patients were assessed for the function. The average MSTS was 97.1%±3.3% (range 93%-100%). The VAS of all patients was 0. One patient with prosthesis removal had no functional evaluation. At the final follow-up, all patients walked without crutch. No breakage and loosening of prosthetic stem, talar collapse, prosthetic sinking and ankle pain occurred at the final follow-up.Conclusion:The early satisfactory outcome can be obtained for patients with segmental defect after resection of malignant tumor at the distal tibia, who received the newly designed modular hinged ankle prosthesis. Meanwhile, it's worth promoting in the reconstruction of large segmental defect at the distal tibia.

Construction and application of a bone tumor database / 中华骨科杂志

Objective:To explore the construction and application methods of multicenter bone tumor-specific database.Methods:Experts from multiple centers including Shanghai General Hospital, Shanghai Changzheng Hospital, Zhongshan Hospital, Shanghai Sixth People's Hospital, Ruijin Hospital, Fudan University Shanghai Cancer Center and Shanghai Ninth People's Hospital established a standard dataset for bone tumors through research and discussion. Clinical data will be automatically collected and standardized according to standard fields. A database will be built and a users' interface will be developed to ensure secure data storage, while providing services such as exporting raw data, visualizing statistical analysis, establishing clinical queue research projects, et al. Finally, the bone tumor database will be shared by integrating with the Shenkang's Big Data Platform to achieve multi-center data integration.Results:A standard data set for bone tumors containing 603 fields has been established and published. An automated data collection system for bone tumors has been established, including complete data collection, data collation and visualization functions. The data categories include modules such as patients' electronic case information, laboratory information on blood routine, biochemistry and tumor markers, imaging information, surgery information, pathology information and radiotherapy records. Personal information such as patients' names and ID numbers are desensitized and encrypted and can be exported for further research. From 2015 to 2023, the total number of bone tumor cases collected in the database was 10,789. From 2015 to 2019, 112 cases of the osteosarcoma cohort were retrospectively analyzed for admission, with a statistical 5-year survival rate of 68%.Conclusion:A regional bone tumor specialty big data network and data sharing platform has been established, along with data sharing mechanisms and standards including data standards, security standards, and quality evaluation standards. This provides data and efficient new solutions for the construction of China's bone tumor database, as well as a research and development platform for standardized diagnosis and treatment of bone tumors and new technologies.

Application of indocyanine green-based fluorescence imaging in bone and soft tissue tumors / 中华骨科杂志

Objective:To explore the role and value of indocyanine green (ICG) fluorescence imaging in the surgery of bone and soft tissue tumors.Methods:A total of 38 patients with bone and soft tissue tumors, including 17 males and 21 females, aged 36±21 years (range 5-75 years), who underwent resection with application of ICG-based NIR imaging were retrospectively analyzed. ICG was intravenously administrated at a dose of 2 mg/kg on the day before surgery. Intraoperative NIR imaging was performed to confirm the tumor fluorescence and to detect residual tumor after tumor resection. The NIR imaging was post hoc analyzed to explore the influence factor of tumor stain rate and SBR value.Results:Tumor staining with ICG was successful in 34 of the 38 patients, with an overall staining rate of 90%. The ICG tumor stain rate was not influenced by different pathology types, malignant or benign pathology, the reception of neoadjuvant chemotherapies or not, and the length of time between drug administration and surgery ( P>0.05). The median SBR of 34 patients with successful tumor staining was 2.9 (2.3, 5.7). Different pathological types, malignant or benign pathology, whether to receive neoadjuvant chemotherapy, preoperative ICG administration time, preoperative dose of denosumab administration in giant cell tumor of bone patients and tumor response to neoadjuvant chemotherapy had no significant effects on SBR ( P>0.05). After tumor resection, a total of 57 pieces of tissue with residual fluorescence signals were detected and resected under the fluorescence guidance, 30 of which were pathologically confirmed to contain residual tumor lesions, with an overall accuracy of 53%. The accuracy of intralesional resection was significantly higher than that of en bloc resection (71% vs. 16%, χ 2=15.51, P=0.000). Conclusion:A high percentage of bone and soft tissue tumors can be stained with ICG. The tumor stain of ICG was stable and not easily influenced by external factors. This technique was useful to detect residual tumors, especially after piecemeal resection.

Three-dimensional printing technology in reverse shoulder arthroplasty after resection of proximal humeral tumors / 中华骨科杂志

Objective:To analyze the efficacy of the reconstruction of the proximal humerus by reverse shoulder arthroplasty with three-dimensional (3D) printing technology after tumor rescetion.Methods:A retrospective analysis was conducted on the data of eight patients undergoing semi-constrained reverse shoulder arthroplasty with 3D printing technology after the resection of bone tumors in proximal humeri at the Affiliated Wuxi People's Hospital of Nanjing Medical University from December 2017 to January 2021. There were four males and four females with an average age of 55.1 (range, 31-73) years, all of whom had unilateral onset, 2 on the left and 6 on the right. There was one case of leiomyosarcoma (Enneking IIB), two cases of chondrosarcomas (one Enneking IA and one Enneking IB), four cases of Campanacci grade 3 giant cell tumor of bone, and one case of bone metastasis of lung adenocarcinoma. Individualized prosthesis and implantation protocol were completed preoperatively in all patients. The glenoid baseplate was manufactured using 3D printing technology. During the surgery, Malawer type I tumor resection and semi-constrained reverse shoulder arthroplasty were performed, with 6 cases simultaneously using allograft-prosthetic composite reconstruction. The follow-up was scheduled, and the patient received X-ray examination of the shoulder. The range of motion of the shoulder was measured, the Constant-Murley score and musculoskeletal tumor society (MSTS) score were recorded.Results:All 8 patients successfully completed the surgery, with a surgical time of 173.8±46.7 min (range, 130-260 min), intraoperative blood loss of 487.5±334.6 ml (range 200-1,200 ml), and proximal humeral resection of 9.9±4.6 cm (range, 4.5-19.0 cm). All patients were followed up for a period of 45.6±12.5 months (range, 24-60 months). At the last follow-up, the abduction ranges of motion of the affected shoulders increased from 27.5°±14.4° pre-operatively to 106.3°±21.8° post-operatively, with a statistically significant difference ( t=11.37, P<0.001). The forward flexion ranges increased from 28.1°±12.8° pre-operatively to 115.6°±24.0° post-operatively, with a statistically significant difference ( t=11.49, P<0.001). The Constant-Murley score was improved from 40.5±14.3 pre-operatively to 79.3±11.2 post-operatively, with a statistically significant difference ( t=9.58, P<0.001). The MSTS score was 25.6±2.2 (range, 23-28), including 6 excellent cases and 2 good cases. At 2 weeks after surgery, one patient experienced joint dislocation that was successfully reduced manually. Up to the final follow-up, all patients had survived without local tumor recurrence, metastasis, prosthesis infection and loosening. Conclusion:3D printing technology assisted shoulder arthroplasty is helpful for effective reconstruction and shoulder joint function recovery after resection of proximal humeral tumors, with satisfactory outcomes in the early and middle stages.

Application of minimally invasive ultrasonic osteotome in robotic-assisted sacral tumor resection / 中华骨科杂志

Sacral tumors are surgically challenging and at a high risk of complications. In recent years, robotic-assisted resection has been gradually applied in sacral tumors, but it is difficult to remove bone tissue by present robotic instruments, which limits the application of surgical robot in sacral tumor. The present study aimed to explore the application range and therapeutic effect of minimally invasive ultrasonic osteotome in robotic-assisted sacral tumor resection. Eighteen patients underwent robotic-assisted sacral tumor resection in the First Affiliated Hospital of Sun Yat-Sen University from May 2015 to March 2021 by the Da Vinci robotic surgical system. Among them three patients who underwent osteotomy with minimally invasive ultrasonic osteotome were enrolled. There were 2 males and 1 female, aged 24, 32, 71 years, respectively. The tumors included 2 schwannomas and 1 ganglioneuroma. The operation time, bleeding volume and postoperative hospitalization days were recorded. The recurrence and complications were evaluated during follow-up. The operative time of the 3 patients was 80, 240 and 300 minutes, and the intraoperative bleeding volume was 30, 30 and 100 ml. Complete resection was performed in 2 cases and intralesional resection in 1 case. The postoperative hospital stay was 5, 3 and 7 days respectively. The follow-up time was 58, 17 and 31 months respectively. No tumor recurrence was found during the follow-up. As regards complications, only one patient had left foot pain after operation, and there were no other intraoperative or postoperative complications. The therapeutic advantages of ultrasonic osteotome combined with the Da Vinci robotic surgical system can achieve precise osteotomy, reduce intraoperative bleeding and accelerate postoperative recovery for certain patients with sacral tumors.

Analysis of the application of orthopedic robot assisted technology in bone tumor surgery / 中华骨科杂志

Intellectualization and precision are important directions of development and research highlights of orthopaedic surgery at present. The orthopaedic robot-assisted technology is gradually applied to various orthopaedic specialties. However the application of robot-assisted technology in bone tumor surgery started relatively late and the scenarios suitable for clinical application are relatively limited. By searching PubMed, Embase, ScienceDirect, CNKI and Wanfang database about the application of orthopaedic robot-assisted technology in the field of bone tumor surgery, we analyzed its intelligence and precision requirements, sorted and analyzed the current clinical application of orthopaedic robot in bone tumor surgery. The robot-assisted puncture biopsy of bone tumor could improve the accuracy and positive rate, especially for tumors with small size, deep location and complex local anatomical structure. For robot-assisted precise osteotomy for bone tumors, the accuracy and error analysis of manual osteotomy and robot-assisted osteotomy in the literatures were compared. The robot-assisted technology has the potential to improve the accuracy of tumor resection at complex anatomical structures such as sacrum and pelvic tumors. For the application of robot-assisted technology in spinal tumor surgery, literature reports suggested that it can improve the accuracy of pedicle screw placement and the safety of minimally invasive vertebroplasty, and can be used for minimally invasive precise surgical resection of spinal tumors. At the same time, the existing problems and development directions were analyzed, such as cost-effectiveness, accuracy of registration, soft tissue recognition and feedback, error superposition and error correction, so as to provide reference basis for further clinical application and study.