The actual management of tumor and vertebral compression fractures.

Tumor related fractures of the spine frequently dictate surgical management. The most critical factors influencing the need and type of surgery are degree of epidural cord compression, radiosensitivity of the tumor, presence of spinal instability and patient medical status/ estimated survivorship. There is a wide spectrum of therapeutic options: major en bloc resections in primary or oligometastatic disease; decompression and fusion in non-radiosensitive tumors with cord compression followed by adjuvant radiation therapy (RT); kyphoplasty/ vertebroplasty for stable compression fractures or minimally invasive corpectomy for more unstable fractures and RT- only for radiosensitive tumors not causing overt instability. Radiation therapy has always been essential component of the treatment algorithm although it has been displaced from principal treatment modality in the last 2 decades. However, the advent of more targeted and efficient forms of RT (radiosurgery) may be a new treatment paradigm for more radioresistant tumors and may obviate the need for major operations.

Chemoembolization facilitates limb salvage surgery in stage III soft tissue sarcoma.

A 26 year-old male was referred to our unit because of a stage III soft tissue sarcoma in the shoulder girdle-axillary area and reduced forearm-distal arm strength. Imaging studies revealed that the tumor encompassed the axillary artery and brachial plexus. We chemoembolized it using vincristine, adriamycin and cyclophosphamide (VAC) plus gel foam and performed limb salvage surgery (LSS) afterwards. The patient received adjuvant chemotherapy (ifosfamide/mesna, adriamycin, and dacarbazine/MAID) and finally radiation therapy (RT; 6500 cGy total dose). Thirty-six months after the operation the patient remains free of disease, without local recurrence and excellent neurological recovery and functional rehabilitation. In stage III soft tissue sarcomas, especially in proximity with major nerve/arterial bundles, a multimodality approach is mandatory; chemoembolization is very effective in shrinking the tumor and defining its margins so as to make feasible a LSS.