Bone metastases in the hip region: surgical treatment.

Subjective factors of the patient such as age, weight, occupation, expectations, etc. must be carefully evaluated in terms of surgery. It is always important to remember life expectancy, and the choice of a surgical procedure must be based on it. Limited survival and possible radiation therapy must eliminate methods that require long healing times: we no longer use bone grafts because the risk of healing time taking up too much of the time left for the patient is too high. Reconstructions must have an immediate solidity allowing early use of the limb. Thus, in the proximal femur, we above all use protheses (traditional or modular RPS); in acetabular lesions that do not involve the joint surface, our treatment of choice is curettage with liquid nitrogen and cement, armed with screws and nails. Prostheses, which are always cemented, are assembled using bipolar cups; cases where lysis is so wide on the cotyloid side as to require THR are rare. The cotyles, in cases such as these, are those that allow for anchoring with several sites (Octopus type), the McMinn or, at times, common cotyles in PE.

Resection of the proximal humerus for metastases and replacement with RPS prosthesis.

In the surgical treatment of metastatic lesions of the proximal humerus it is important to find solutions that eliminate pain and solve the mechanical problem in a short time and with reduced costs. In 90% of cases, intralesional curettage, freezing with liquid nitrogen and cement enhanced intramedullary instrumentation is capable of brilliantly solving the problems of these patients. When, instead, osteolysis involves the greater tuberosity and/or the joint region, resection of the proximal humerus followed by reconstruction with a modular prosthesis is indicated. Of those available on the market, the RPS system (LIMA) has features that make it equivalent to others, but at costs considerably lower. However, in reconstructions with prostheses, active abduction is significantly limited. A personal series of 20 patients is presented.

Limb salvage in lower-extremity sarcomas and technical details about vascular reconstruction.

Vascular surgery may allow limb salvage when a sarcoma of the lower limb involves the main vascular bundle. We present our experience and describe the techniques which have been employed for such surgery. From October 1995 to April 1999, vascular surgery procedures were employed in seven patients with sarcomas of the thigh: two complete subadventitia dissections of the main vascular trunks, four artery replacements (two polytetrafluoroethylene [PTFE] grafts and two autologous saphenous grafts), and five venous reconstructions (all with autogenous saphenous graft: three substitutions; two distal transpositions with one external rigid support at the anastomosis). Clinical and instrumental (sonogram, computed tomography [CT] scan, echodoppler) follow-up was carried out at 3, 6, and then every 12 months after surgery (mean, 25 months; range, 6-53 months). Operative mortality and morbidity were nil. All the grafts were patent (one arterial thrombosis was successfully treated on the first postoperative day). The functional result was good in six patients and fair in one. Two patients died, 24 and 13 months after surgery, with disseminated disease, but had no local recurrence. Five patients are alive and disease-free. Vascular techniques allow limb salvage with en-bloc resection of sarcomas of the thigh involving the main vessels. Venous reconstructions are indicated after removal of both the superficial and deep femoral veins. We suggest limiting the number of anastomoses (two transpositions in our series) and using external rigid support in those patients with a small saphenous vein graft (one patient in our series).

CT-guided percutaneous trochar-biopsy of the spine.

As is the case for tumor lesions of the limbs, for the spine, too, no treatment should be started without a pathological diagnosis. Open biopsy of the spine is always a major surgical procedure with all of the related risks, and the surgeon is frequently tempted to perform, during the same operation, biopsy and definitive treatment. This approach leads many patients to unnecessary major operations, when the final histology shows a disease which does not carry an indication for surgical resection. CT-guided percutaneous Trochar-Biopsy is a safe procedure used to obtain an adequate sample for full histological evaluation. Eliminating the need for biopsy, several major vertebral resections could be avoided. This technique deserves to become the standard first-choice procedure whenever a biopsy of the spine is required.

Radiotherapy and spinal brace: still first-choice treatment for vertebral metastases from breast cancer.

In metastatic breast cancer the goal to reach must be the best possible palliation with minimum discomfort for the patient. We reviewed our experience with radiotherapy (20 or 30 Gy), systemic therapy and brace. Among 2200 breast cancer patients, we extracted 28 potential candidates for resection. All of them developed new metastases outside the treated field within one year. Local control was achieved in 68%, and 80% of them had stable or better performance status at 3 months. From our analysis, even patients with a so called "solitary lesion" do not seem to have a better prognosis than others. We conclude that radiotherapy (with systemic therapy and a brace) is still first-choice treatment for vertebral metastases; CT-guided percutaneous biopsy can avoid worthless major operations. The role of surgery should be limited to neurological compression, severe mechanical instability and to salvage the failures of conservative treatment.

Miliary osteosarcomatosis with associated hypocalcemia.

We report the case of a patient with a rare miliary variant of osteosarcoma associated with symptomatic hypocalcemia and review the literature regarding the pathogenesis of multifocal osteosarcoma, treatment options, and the associated hypocalcemia.

Clear-cell chondrosarcoma with elevated alkaline phosphatase, mistaken for osteosarcoma on biopsy.

This paper report a case of a pelvic clear-cell chondrosarcoma that was initially diagnosed as clear-cell osteosarcoma after needle biopsy. Preoperatively, laboratory studies revealed an elevated alkaline phosphatase and needle biopsy showed clear cells producing osteoid. Internal hemipelvectomy was performed and final pathology was most consistent with clear-cell chondrosarcoma, despite a negative S-100 immunohistochemical stain. Distinguishing between these two entities is clinically important because treatment differs. In this case, the patient did not receive pre-or postoperative chemotherapy and is disease free more than 2 years later.

[Is radiotherapy still the first choice treatment in spinal metastases from breast cancer?]. / La radioterapia è ancora il trattamento di prima scelta delle metastasi vertebrali da cancro della mammella?

The skeletal system is a frequent site of metastatic involvement from breast cancer, whose pattern of spread is such that cure becomes practically impossible. The best palliation with the minimum discomfort for the patient must therefore be the major objective. With an increasing number of reports about major surgical procedures for spinal metastases, we reviewed our series of patients submitted to radiotherapy. Of 2,189 breast cancer patients, we selected 28 who might have been potential candidates for surgical resection (with lesions only in the spine, only one or no more than three contiguous bodies involved and no other metastases). All these patients had been treated with 20 or 30 Gy plus systemic (chemo, hormone, or both) therapy. Follow-up revealed that all of them had developed new metastases outside the treated field within one year. Local control was achieved in 68% of patients and 75% of them had stable or better performance status at 3 months. Median survival was 36 months. From our analysis, even patients with a so called "solitary lesion" seem not to have a better prognosis than others. We conclude that radiotherapy is still the method of choice to treat vertebral metastases from breast cancer. The role of surgery should be limited to patients with neurologic compression or severe mechanical instability.

Chondroblastoma arising from a nonepiphyseal site.

Chondroblastoma is a rare, benign primary bone tumor usually involving secondary centers of enchondral ossification. The consistent epiphyseal location in the great majority of chondroblastomas signifies that the tumor may arise from an aberrant germ cell of the physeal plate. This case report describes a chondroblastoma located in a atypical nonphyseal location, namely in the right fourth metatarsal base. Cases such as these imply that the cell of origin may not exclusively be derived form the physeal plate. The clinical-radiographic significance is that historically chondroblastoma is considered an epiphyseal lesion, but rare cases such as the one reported here and those of the skull demonstrate that this is not always a characteristic of these tumors. The implication from a histogenetic standpoint is that chondroblastoma may, on rare occasions, occur in an area of an enchondrally formed bone other than adjacent to the physeal plate. We are presently investigating the histogenetic relationship of the chondroblastoma (CB) of bone to CB of soft tissue, giant-cell tumor of tendon sheath (GCT-TS), pigmented villonodular synovitis (PVNS) and chondroma of tendon sheath (chondroma of soft parts). We now have collected about 15 cases of GCT-TS and PVNS with extensive areas of chondroid and/or cartilage differentiation that cannot be distinguished from CB of bone by histologic or electron microscopic features alone. From these interesting observations we are developing the histogenetic concept that all of these lesions are interrelated to multipotential mesenchymal and/or synovial cells of the tendon sheath.(ABSTRACT TRUNCATED AT 250 WORDS)

Case report 827: Miliary osteosarcomatosis.

We presented the case of a 26-year-old woman with a blastic, miliary form of osteosarcomatosis involving the axial skeleton, skull, and long bones to the elbow and knee joint regions who subsequently developed hypocalcemic tetany. Radiologically the lesions mimicked the spread of breast carcinoma, and because of the distribution of the lesions we surmised that the spread was by means of Batson's vertebral plexus of veins. The literature on multiple osteosarcomas was reviewed and an updated clinical subclassification of patients with multiple skeletal osteosarcomas presented.

Case report 797: "Dedifferentiated" lipoma-like liposarcoma of soft tissue with focal transformation to high-grade "sclerosing" osteosarcoma.

We have presented the first case of a lipoma-like liposarcoma of the soft tissues with high-grade malignant transformation to a high-grade osteosarcoma, the latter component of which responded well to systemic chemotherapy. With 4 months of follow-up the patient is without evidence of disseminated disease. The various types of liposarcoma are listed and several described in some detail. Of particular importance is the potential for development of a highly malignant sarcoma from a relatively indolent low-grade liposarcoma, with even osteosarcoma developing.

Case report 771: Melorheostosis in association with desmoid tumor.

Melorheostosis is a rare congenital disease, some 300 cases have been reported in the literature. The main purpose of this case report is twofold: (1) to present an unusual case of melorheostosis of the right hand, beginning in infancy, with serial radiographic studies to show the gradual progression of the disease; and (2) to present the first case with the development of "aggressive" fibromatosis (desmoid tumor) of the adjacent soft tissues, associated with melorheostosis.

An analysis of burn mortality: a report from a Spanish regional burn centre.

This paper reports an analysis of the mortality rates and related factors in our Burn Centre, based on 710 patients treated between 1985 and 1988. The average age of the patients was 23.8 years and the average burn size was 14 per cent of the body surface area. Burning injury affected mainly men (66 per cent), and their mortality rate was higher than that of women. The overall mortality rate was 6.6 per cent, the average age of the fatally injured patients being 54 years. We confirm that mortality in burned patients is closely related to: age (51 per cent of the patients were over 60 years of age); burn size (68 per cent of the patients had burns covering more than 30 per cent TBS); burn depth (57.4 per cent had full skin thickness burns); inhalation injury (present in 66 per cent of the fatally injured); and associated risk factors. The main cause of the burning injury was flames, chiefly from domestic accidents. The average survival time for the fatally injured patients was 10 days. Finally, our expected mortality followed a linear regression model, the LA50 for patients with only full skin thickness burns was 50 per cent.