Biopsy is not necessary for the diagnosis of soft tissue hemangiomas.

OBJECTIVE: To describe the clinical and ultrasonography (US) findings of soft tissue hemangiomas, and to compare with the results of histologic diagnosis after US-guided biopsy. METHOD AND MATERIALS: We retrospectively studied the files of 97 patients (48 female, 49 male; mean age, 34 years; range 4-84 years) with soft tissue hemangiomas diagnosed from 2004 to 2011. Mean follow-up was 9 years (range 7-13 years). Clinical presentation included intermittent mild pain associated with a soft tissue swelling/palpable mass in all patients, chronic pain and increased local heat in 29 patients, local swelling and decreased range of motion of the adjacent joint in 45 patients, and all the above symptoms in 23 patients. B-mode and color Doppler US evaluation included the site, location, size, shape, margins, presence of calcifications, echo structure and echogenicity. All patients had US-guided biopsy for histologic analysis. RESULTS: US-guided biopsy and histology confirmed the diagnosis of soft tissue hemangioma in 92 of the 97 lesions (94.8%). Histologic examination of the remaining five lesions showed nodular fasciitis (two lesions), endometriosis (one lesion), hemangioendothelioma (two lesions); US of these lesions showed variable size, irregular margins, and deep-seated location. Histologically documented soft tissue hemangiomas were most commonly superficial (74 lesions) and arteriovenous (45 lesions). Shape was most commonly oval (fusiform), margins were most commonly not well defined (irregular, hazing but circumscribed), phleboliths were more common in deep-seated lesions, echo structure was heterogeneous, and echogenicity was most commonly hyperechogen and involuting. CONCLUSION: Clinical presentation and typical B-mode and color Doppler US findings are adequate for the diagnosis of soft tissue hemangiomas without the need for biopsy and histologic analysis. If any clinical or US doubt, an US-guided biopsy should be performed.

Aggressive Chordomas: Clinical Outcome of 13 Patients.

The authors reviewed the files of all patients with chordomas who were admitted and treated at their institutions from 1975 to 2012. Patients were categorized by early local recurrence and metastasis. Aggressive clinical behavior was defined as local recurrence and metastasis within 24 months of diagnosis and adequate treatment (wide en bloc resection with microscopically negative tumor margins). According to these criteria, 13 patients (14.3%) had aggressive chordomas, including 7 men and 6 women, with mean age of 54 years (range, 37-65 years) at diagnosis and treatment. All patients had preoperative tumor biopsy, followed by resection with partial (7 patients) or total sacrectomy (6 patients). In all cases, biopsy and histologic analysis of resected tumor specimens showed conventional chordomas. Resection margins were wide (grossly negative) in 6 patients and wide contaminated in 7 patients. Mean maximum tumor diameter was 11.8 cm (range, 5-21 cm). Mean follow-up was 43 months (range, 8-131 months). Rates of local recurrence, metastasis, and death were evaluated. At the last follow-up, all patients had local recurrence at a mean of 13 months (range, 5-22 months). Histologic examination of recurrent tumors showed a dedifferentiated chordoma with a fibrosarcoma component in 2 patients and no histologic change in the remaining patients. In addition, 8 patients had metastases at a mean of 13 months (range, 4-24 months) and died of their disease. All histologic findings of metastatic lesions were similar to those of primary tumors. Early diagnosis of aggressive tumors requires close follow-up of patients with chordomas. Metastasis is common, with resultant poor survival. [Orthopedics. 2017; 40(2):e248-e254.].

Reconstruction of the proximal femur with a modular resection prosthesis.

BACKGROUND: Various megaprostheses are currently available for reconstruction of the proximal femur after tumor resection. This study evaluates the survival and complications of a modular megaprosthesis for reconstruction of the proximal femur. MATERIALS AND METHODS: We studied the medical files of 109 tumor patients (age range 16-86 years) who underwent proximal femoral reconstruction with the MRP(®) megaprosthesis from 2002 to 2011. There were 70 patients with metastases, 34 patients with bone sarcomas, and five patients with hematological malignancies; 82 were primary and 27 were revision reconstructions. Mean follow-up was 2.5 years; 31 patients had a minimum five-year follow-up. We evaluated the survival and function of the patients, and the survival and complications of the megaprostheses. RESULTS: Survival was significantly higher for the patients with bone sarcomas compared to those with metastases and hematological malignancies. Mean MSTS functional score was similar between patients with bone sarcomas and those with hematological malignancies and metastases, and between patients with primary and those with revision reconstructions. Overall survival of the MRP(®) megaprostheses was 74 % at 5 and 9 years. Fourteen (13.6 %) major complications occurred at a mean period of 1.4 years (range 3 months to 4.5 years); these included infection (5.8 %), dislocation (3.9 %), local recurrence (2.9 %), and acetabular fracture (1 %). CONCLUSION: MRP(®) megaprostheses are a valuable reconstruction option after tumor resection of the proximal femur.

Modern Palliative Treatments for Metastatic Bone Disease: Awareness of Advantages, Disadvantages, and Guidance.

BACKGROUND: Metastatic disease is the most common malignancy of the bone. Prostate, breast, lung, kidney, and thyroid cancer account for 80% of skeletal metastases. Bone metastases are associated with significant skeletal morbidity including severe bone pain, pathologic fractures, spinal cord or nerve roots compression, and malignant hypercalcemia. These events compromise greatly the quality of life of the patients. The treatment of cancer patients with bone metastases is mostly aimed at palliation. OBJECTIVE: This article aims to present these palliative treatments for the patients with bone metastases, summarize the clinical applications, and review the techniques and results. METHODS: It gives an extensive overview of the possibilities of palliation in patients with metastatic cancer to the bone. RESULTS AND DISCUSSION: Currently, modern treatments are available for the palliative management of patients with metastatic bone disease. These include modern radiation therapy, chemotherapy, embolization, electrochemotherapy, radiofrequency ablation, and high-intensity focused ultrasound. As such it is of interest for all physicians with no experience with these developments to make palliative procedures safer and more reliable.

Prognostic factors in surgical resection of sacral chordoma.

BACKGROUND AND OBJECTIVES: The best treatment of sacral chordoma is surgical resection, nowadays associated with optimized radiation therapy. We analysed 1) the oncologic outcome in a large series; 2) the effect of previous intralesional surgery, resection level, tumor volume and margins on survivorship to local recurrence (LR) and 3) the complication rate. METHODS: We reviewed 71 patients with sacral chordomas. Forty-eight resections were proximal to S3. Mean tumor volume was 535 cm3. Eleven received previous intralesional surgery elsewhere. Margins were wide in 44 resections, wide-contaminated in 11, marginal in 9 and intralesional in 7. RESULTS: Overall survival was 92%, 65% and 44% at 5, 10 and 15 years. At a mean of 9.5 years 37 were NED (54.4%), 23 died with disease (33.8%) and 8 were alive with disease (11.7%). Relapses included 15 LRs, 6 distant metastases, 17 both. LR rate was significantly higher in patients with previous surgery (p=0.0217), with inadequate margins (p= 0.0339) and large tumors(p<0.01), whereas resection level was not significant. Multivariate analysis confirmed the role of tumor volume. Complication rate was high (80.9%) with an infection rate of 41.2%. CONCLUSIONS: The most prominent adverse factor for LR was previous intralesional surgery. LR rate was related with inadequate margins and tumor volume.

Infected Prostheses after Lower-Extremity Bone Tumor Resection: Clinical Outcomes of 100 Patients.

BACKGROUND: Infection of megaprostheses after bone tumor resection is a major concern; management is challenging. This study evaluated the survivability from such infections, the microbial isolates, treatment tactics, and outcome of megaprosthesis reconstructions. MATERIALS AND METHODS: We studied 1,161 patients retrospectively who underwent megaprosthesis reconstruction for limb salvage after a sarcoma from 1983 to 2010. The mean followup was 9 y (range 3-20 y). We evaluated the overall survival of the megaprosthesis reconstructions in patients with infection and the survival with respect to the type of megaprosthesis, site of reconstruction, cemented or cementless fixation, type of tumor, adjuvant treatments, microbial isolate(s), treatment tactics, and outcome. RESULTS: The incidence of infection was 8.6%. The most common microbial isolate was Staphylococcus epidermidis (47%). Overall survival with definitive management of infection was 88% at 10 y and 84% at 20 y. Survival was higher for cementless reconstructions and not different with respect to the type of megaprosthesis, site of reconstruction, or adjuvant therapy. Infections resolved completely with one- or two-stage surgery in 75% of patients. The rate of amputation because of infection was 21%. CONCLUSIONS: Megaprosthesis reconstructions may be infected in 8.6% of cases. Infections more commonly occur late, caused usually by S. epidermidis. The survival rate is higher with cementless megaprosthesis reconstructions and no different with respect to the type of tumor or megaprosthesis or the adjuvant treatments. One-stage revision is effective for acute post-operative infections; however, two-stage revision surgery is necessary for early and late infections. The rate of amputation because of occurrence or persistence of megaprosthesis infection is 21%.

Resection and reconstruction of pelvic bone tumors.

The objective of this study was to assess outcome and recurrence rate after limb-salvage surgery with reconstruction for pelvic bone tumors and analyze complications and their relationship with surgery. The authors analyzed 129 patients followed for a mean of 6 years (range, 2-19 years). Chondrosarcoma was the most frequent histotype. Thirty-one cases with no acetabular involvement were reconstructed with allograft only. Acetabular resections were reconstructed with allograft prosthetic composite (n=60), allograft only (n=11), trabecular metal components (n=2), prosthesis only (n=10), saddle prosthesis (n=11), and iliofemoral arthrodesis (n=1). Margins were wide (n=94), wide contaminated (n=22), marginal (n=7), and intralesional (n=6). Oncologic outcomes were as follows: 75 patients were continuously disease free, 6 were disease free after treatment of relapse, 13 were alive with disease, 28 were dead of disease, and 5 were dead of other causes. Survival was 66% at 10 years. Local recurrence rate of malignant tumors was 22.1% and was not statistically influenced by margins (P=.140) or site (P=.933). Metastasis rate was 32.8%. Deep infection was observed in 30 (23.6%) cases, with no statistical difference between reconstructions with and without allograft (P=.09). Final external hemipelvectomy was performed in 16 cases. Newer techniques of reconstruction using stemmed acetabular cups or porous metal components combined with allograft are now available. Local control and satisfactory survival is achievable long term in patients with pelvic tumors, but this surgery implies a high rate of complications. Infection is a major complication, not influenced by the use of allografts. Amputation is rarely needed.

Survival of modern knee tumor megaprostheses: failures, functional results, and a comparative statistical analysis.

BACKGROUND: Modular megaprostheses are now the most common method of reconstruction after segmental resection of the long bones in the lower extremities. Previous studies reported variable outcome and failure rates after knee megaprosthetic reconstructions. QUESTIONS/PURPOSES: The objectives of this study were to analyze the results of a modular tumor prosthesis after resection of bone tumor around the knee with respect to (1) survivorship; (2) failure rate; (3) comparative survivorship against different sites of reconstructions and of primary and revision implants; and (4) functional results on the Musculoskeletal Tumor Society (MSTS) scoring system. METHODS: Between 2003 and 2010, 247 rotating-hinge Global Modular Reconstruction System (GMRS) knee prostheses were implanted in our institute for malignant and aggressive benign tumors. During this time, that group represented 23% of the patients who had oncologic megaprosthesis reconstruction about the knee after resection of primary or metastatic bone tumors (247 of 1086 patients). In the other 77% of cases we used other types of oncologic prostheses. Before 2003 we used the older Howmedica Modular Resection System and Kotz Modular Femur/Tibia Replacement from 2003 we used mostly the GMRS but we continued to use the HMRS in some cases such as patients with poor prognoses, elderly patients, or metastatic patients. Sites included 187 distal femurs and 60 proximal tibias. Causes of megaprosthesis failure were classified according to Henderson et al. in five types: Type 1 (soft tissue failure), Type 2 (aseptic loosening), Type 3 (structural failure), Type 4 (infection), and Type 5 (tumor progression). Followup was at a minimum oncologic followup of 2 years (mean, 4 years; range, 2-8 years). Kaplan-Meier actuarial curves of implant survival to major failures were done. Functional results were analyzed according to the MSTS II system; 223 of the 247 were available for functional scoring (81%). RESULTS: At latest followup, among 175 treated patients for primary reconstruction, 117 are continuously disease-free, 26 have no evidence of disease after treatment of relapse, eight are alive with disease, and 24 died from disease. The overall failure rate of the megaprostheses in our series was 29.1% (72 of 247). Type 1 failure occurred in 8.5% (21 of 247) cases, Type 2 in 5.6% (14 of 247), Type 3 in 0%, Type 4 in 9.3% (23 of 247), and Type 5 in 5.6% (14 of 247). Kaplan-Meier curve showed an overall implant survival rate for all types of failures of 70% at 4 years and 58% at 8 years. Prosthetic survivorship for revisions was 80% at 5 years and for primary reconstructions was 60% at 5 years (p = 0.013). Survivorship to infection was 95% at 5 years for revision patients and 84% at 5 years for primary patients (p = 0.475). The mean MSTS score was 84 (25.2; range, 8-30) with no difference between sites of localization (24.7 in proximal tibia versus 25.4 in distal femur reconstruction; p = 0.306). CONCLUSIONS: Results at a minimum of 2 years with this modular prosthesis are satisfactory in terms of survivorship (both oncologic and reconstructive) and causes and rates of failure. Although these results seem comparable with other like implants, we will continue to follow this cohort, and we believe that comparative trials among the available megaprosthesis designs are called for. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Infection after surgical resection for pelvic bone tumors: an analysis of 270 patients from one institution.

BACKGROUND: Surgical treatment of pelvic tumors with or without acetabular involvement is challenging. Primary goals of surgery include local control and maintenance of good quality of life, but the procedures are marked by significant perioperative morbidity and complications. QUESTIONS/PURPOSES: We wished to (1) evaluate the frequency of infection after limb salvage surgical resection for bone tumors in the pelvis; (2) determine whether infection after these resections is associated with particular risk factors, including pelvic reconstruction, radiotherapy or chemotherapy, type of resection, and age; and (3) analyze treatment of these infections, particularly with respect to the need of additional surgery or hemipelvectomy. METHODS: From 1975 to 2010, 270 patients with pelvic bone tumors (149 with chondrosarcoma, 40 with Ewing's sarcoma, 27 with osteosarcoma, 18 with other primary malignant tumors, 11 with metastatic tumors, and 25 with primary benign tumors) were treated by surgical resection. Minimum followup was 1.1 years (mean, 8 years; range, 1-33 years). The resection involved the periacetabular area in 166 patients. In 137 patients reconstruction was performed; in 133 there was no reconstruction. Chart review ascertained the frequency of deep infections, how they were treated, and the frequency of resection arthroplasty or hemipelvectomies that occurred thereafter. RESULTS: A total of 55 patients (20%) had a deep infection develop at a mean followup of 8 months. There were 20 infections in 133 patients without reconstruction (15%) and 35 infections in 137 patients with reconstruction (26 %). Survivorship rates of the index procedures using infection as the end point were 87%, 83%, and 80% at 1 month, 1 year, and 5 years, respectively. Infection was more common in patients who underwent pelvic reconstruction after resection (univariate analysis, p = 0.0326; multivariate analysis, p = 0.0418; odds ratio, 1.7718; 95% CI, 1.0243-3.0650); no other risk factors we evaluated were associated with an increased likelihood of infection. Despite surgical débridements and antibiotics, 16 patients (46%) had the implant removed and five (9%) underwent external hemipelvectomy (four owing to infection and one as a result of persistent infection and local recurrence). CONCLUSIONS: Infection is a common complication of pelvic resection for bone tumors. Reconstruction after resection is associated with an increased risk of infection compared with resection alone, without significant difference in percentage between allograft and metallic prosthesis. When infection occurs, it requires removal of the implant in nearly half of the patients who have this complication develop, and external hemipelvectomy sometimes is needed to eradicate the infection.

Palliative embolization for osteosarcoma.

BACKGROUND: The prognosis of patients with metastatic, recurrent, and/or unresectable osteosarcoma is poor. Aggressive local and medical treatments are available for palliation. Palliative treatments include isolated limb perfusion, radiation therapy, embolization, chemoembolization, thermal ablation, and cryoablation. Their aim is pain relief and tumor size reduction with minimum complications. MATERIALS AND METHODS: We present 19 patients with metastatic, recurrent, and/or unresectable osteosarcoma of the pelvis and lower lumbar spine treated with palliative selective embolization using N-2-butyl cyanoacrylate. All patients had chemotherapy. At the time of embolization, they experienced severe pain refractory to analgesics. Diagnostic angiography was performed pre-embolization to determine the vascular mapping and hemodynamic status of the tumor. Post-embolization angiography was done to evaluate for complete occlusion of the pathological vessels. Mean follow-up was 18 months. Local pain, tumor necrosis and size, and complications were recorded. RESULTS: In all patients, pre-embolization angiography showed hypervascularity of the tumor from extensive neovascularization. Five patients had repeat embolization. All patients experienced pain relief at a mean of 3 days post-embolization. No patient had recurrent pain with the intensity of that before embolization. Variable tumor necrosis was observed in follow-up imaging, and reduction in tumor size was minimum. All patients experienced pain at the site of embolization, which resolved completely 1-5 days after embolization. Four patients with pelvic osteosarcomas experienced paraesthesias at the distribution of the sciatic nerve. CONCLUSION: Selective arterial embolization is a useful local palliative treatment for patients with advanced osteosarcoma for pain relief.

The role of embolization for hemangiomas.

We retrospectively studied 31 patients with painful bone (15 patients) and soft-tissue (16 patients) hemangiomas treated with 39 embolizations using N-2-butyl cyanoacrylate from 2003 to 2010. The mean tumor size before embolization was 6 cm for bone and 7 cm for soft-tissue hemangiomas. The technique of embolization was the same for bone and soft-tissue lesions. Preoperative embolization was done in six patients, while the remaining patients had embolization as only treatment. The mean follow-up was 47 months (11-89 months). The clinical and imaging effect of treatment was evaluated at follow-up with a pain score scale, tumor size, and ossification. In four patients, embolization was not feasible because of the inability to catheterize and low blood flow of the feeding vessels. Nine patients with bone and 10 with soft-tissue hemangiomas experienced complete pain relief. Four patients with bone and four with soft-tissue hemangiomas experienced recurrence of pain and were treated with repeat embolization. Re-recurrences were not observed in any of the patients with soft-tissue hemangiomas until the period of this study. Ossification and tumor size reduction were higher for bone hemangiomas. Embolization-related complications were more common for soft-tissue hemangiomas.

Survival analysis of patients with femoral metastases.

BACKGROUND: Previous studies reported on surgical indications for patients with femoral metastases. However, few studies analyzed the spectrum of femoral metastatic presentation. We performed this study to evaluate the survival of patients with femoral metastases, and clarify the treatment of femoral impending and actual pathological fractures. MATERIALS AND METHODS: We retrospectively studied 110 patients with femoral metastases from various cancers treated with nailing or resection and megaprosthetic reconstruction from 1995 to 2010. The mean follow-up was 18 months. Survival was analyzed with respect to different metastatic presentations regarding gender, type of cancer, number, and location of femoral metastases, type of surgery, and pathological fracture. RESULTS: Univariate predictors of survival were the pathological fracture and type of surgery; multivariate predictor was only the pathological fracture. Survival was significantly higher in patients with resection compared to nailing, impending compared to actual fracture, solitary metastasis and impending fracture, actual fracture treated with resection, proximal femoral actual fracture and distal femoral impending fracture treated with resection. CONCLUSIONS: Patients with femoral metastases have better survival when present with impending compared to actual pathological fracture. Although with a higher rate of complications, patients with pathological fractures of the proximal and distal femur may benefit from resection.

Radiation-induced sarcomas.

Radiation-induced sarcomas are rare, high-grade sarcomas that may arise within the radiation volume at a mean latency period of 3-55 years after radiation therapy, doses of which range from 45 to 60 Gy. Radiation-induced osteosarcomas, fibrosarcomas, and malignant fibrous histiocytomas are the most common. Extensive surgery with microscopically negative-margin resection, or amputation is recommended for improved survival. Adjuvant radiation therapy and chemotherapy have not been shown to improve survival rates significantly. The prognosis is poor.

Selective embolization with N-butyl cyanoacrylate for metastatic bone disease.

PURPOSE: To evaluate the clinical and imaging effect of selective embolization using N-butyl cyanoacrylate (NBCA) as palliation for bone metastases. MATERIALS AND METHODS: The procedures and effect of 309 embolizations performed in 243 patients were retrospectively analyzed; 56 patients had repeat embolization at the same location at 1-3 months; 197 patients had embolization for progressive bone metastases after radiation therapy. The mean tumor diameter before embolization was 7.8 cm (range 5-30 cm). In all patients, embolizations were performed under local anesthesia through transfemoral catheterization using NBCA in 33% ethiodized oil. The technical success of embolization was evaluated by angiography after completion of the procedure. The clinical and imaging effect was evaluated at follow-up examinations with a pain score scale and use of analgesics, hypoattenuating areas, tumor size, and ossification. RESULTS: In all 309 embolizations, postprocedural angiography showed complete occlusion of metastatic blood supply and greater than 80% devascularization of the lesions. Greater than 50% reduction of pain score and analgesic doses was achieved in 97% of procedures. The mean duration of pain relief was 8.1 months (range 1-12 months). The mean maximal tumor diameter after embolization was 5.5 cm (range 2-20 cm). Variable ossification appeared in 65 patients. Postembolization syndrome, ischemic pain at the site of embolization, paresthesias, skin breakdown, and subcutaneous necrosis were observed in 87 patients. CONCLUSIONS: Selective embolization with NBCA is a safe and effective palliative treatment for metastatic bone lesions of various primary cancers; pain relief is temporary.

Osteoblastic osteosarcoma in monostotic Paget's disease.

Paget's disease is a disorder of bone remodelling affecting 1-2% of the general population, most frequently men over 50 years of age. Sarcomatous degeneration occurs in 0.1-0.95% of patients with Paget's disease. It can be observed in monostotic and polyostotic disease. Osteosarcomas account for more than 80% of pagetic sarcomas; osteoblastic pagetic osteosarcomas are rare. In this article, we present the case of a 75-year-old man with secondary osteosarcoma arising in monostotic Paget's disease, initially misdiagnosed as rotator cuff tendinopathy. Imaging studies and biopsy were diagnostic.

Percutaneous CT-guided biopsy of the musculoskeletal system: results of 2027 cases.

INTRODUCTION: Biopsy of the musculoskeletal system is useful in the management of bone lesions particularly in oncology but they are often challenging procedures with a significant risk of complications. Computed tomography (CT)-guided needle biopsies may decrease these risks but doubts still exist about their diagnostic accuracy. This retrospective analysis of the experience of a single institution with percutaneous CT-guided biopsy of musculoskeletal lesions evaluates the results of these biopsies for bone lesions either in the appendicular skeleton or in the spine, and defines indications. MATERIALS AND METHODS: We reviewed the results of 2027 core needle biopsies performed over the past 18 years at the authors' institution. The results obtained are subject of this paper. RESULTS: In 1567 cases the correct diagnosis was made with the first CT-guided needle biopsy (77.3% accuracy rate), in 408 cases the sample was not diagnostic and in 52 inadequate. Within 30 days these 408 patients underwent another biopsy, which was diagnostic in 340 cases with a final diagnostic accuracy of 94%. Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, flogistic, and systemic pathologies. There were 22 complications (18 transient paresis, 3 haematomas, 1 retroperitoneal haematoma) which had no influence on the treatment strategy, nor on patient outcome. CONCLUSION: This technique is reliable and safe and should be considered nowadays the gold standard for biopsies of the musculoskeletal system.

Protocol of surgical treatment of long bone pathological fractures.

Long bone pathological fractures in patients with primary and metastatic bone tumours are difficult to treat and their management may alter the prognosis of the disease and jeopardize survival. The aim of this article was to review the relevant studies reporting on the management of tumour patients with pathological fractures of the long bones, to discuss the most suitable approach in these patients, to highlight specific treatment recommendations, and finally based on this analysis and our clinical practice, to propose a treatment algorithm for decision making and treatment.

Clinically significant thromboembolic disease in orthopedic oncology: an analysis of 986 patients treated with low-molecular-weight heparin.

BACKGROUND AND OBJECTIVES: Thromboembolic risk in orthopedic oncology is high due to several factors. The aim of this study was to assess clinically significant thromboembolic disease in 986 patients operated on with a prosthetic reconstruction of the lower limbs after the resection of bone tumors and prophylactically treated with low-molecular-weight heparin (LMWH). METHODS: Between 1983 and 2006, 986 patients had uncemented megaprostheses after a resection of the lower limbs for bone tumors. Antithromboembolic prophylaxis was always administered with LMWH from the immediate postoperative time until the time of complete weight-bearing. Phlebographies and vascular ecodoppler were not performed postoperatively on a regular basis. Patients were followed in the clinic with imaging studies for several years (lower limb CT, MRI, CT of the chest for malignant tumors). The diagnosis of symptomatic venous thromboembolism (VTE) was established or excluded on clinical evidence and MRI study. RESULTS: Among the 986 cases treated, only 11 patients (1.1%) showed a major thromboembolic event confirmed clinically and through imaging. One of these patients died with pulmonary embolism a few days after surgery. Two cases of thromboembolism occurred in patients with a vascular bypass. CONCLUSIONS: Despite general oncologic and orthopedic factors favoring VTE, the clinical occurrence of this event was extremely low in this series, probably due to a consistent and careful prophylaxis, prolonged until the time of complete weight-bearing.

The role of surgery and adjuvants to survival in Pagetic osteosarcoma.

BACKGROUND: Osteosarcoma is a rare complication of Paget's disease with a very poor prognosis. Treatment is controversial: the older age of the patients affected by Paget's disease may limit the use of chemotherapy and axial involvement may limit the practicality of surgery. QUESTIONS/PURPOSES: The purposes of this study are (1) to report the survival in patients treated for osteosarcoma in Paget's disease; (2) to identify correlations between type of treatment and survival comparing our data with those in the literature; (3) to determine if the extent of Paget's disease and risk of malignant transformation are associated; (4) to assess if prognosis is related with site; and (5) to identify the variations of histologic subtypes of these osteosarcomas. METHODS: We retrospectively reviewed the medical records of 26 patients treated between 1961 and 2006 who had bone sarcoma arising from a site of Paget's disease. Twenty two of the 26 patients had surgery. In six surgery only was performed; three had surgery, adjuvant chemotherapy, and radiotherapy; one surgery and radiotherapy; 12 underwent surgery and chemotherapy, adjuvant in 10 patients and neoadjuvant in two; two had only radiotherapy and two had only chemotherapy. We performed survival analyses between various combinations of treatment. RESULTS: At last followup four patients had no evidence of disease (NED) at a minimum followup of 42.6 months (mean, 139 months; range, 42.6-257.4 months) and 22 died with disease (DWD) at a minimum time of 1 month (mean, 20.2 months; range, 1-84 months). One of the six patients (11%) treated with surgery only had NED at 10 years; the other five died from disease at a mean of 30 months. Three of 12 patients (25%) treated with surgery and chemotherapy are NED at a mean followup of 12 years; nine died of disease at a mean of 24 months. All patients treated without surgery died at a mean of 7.5 months (range, 1-13.7 months). CONCLUSIONS: Despite improvements in surgery and medical treatments the prognosis remains poor in patients with Paget's sarcoma.