Pathological fracture in paediatric bone tumours and tumour-like lesions: A predictor of benign lesions?

How to distinguish a benign from a malignant tumour in children and when should a biopsy be done and by whom

Bone tumours are frequent in children but most of them are benign. Moreover, the incidence and type of tumours differ from those of adults. As an orthopaedic surgeon, we will likely encounter a bone lesion in a child and we must be able to distinguish if it is a benign lesion or has malignant characteristics and it is necessary to refer it to a centre specialized in tumours. We will discuss the key points we would have to ask in the medical history, look at the physical examination and the radiological characteristics that will allow us to distinguish between a benign and a malignant bone lesion in a child. When there are doubts about the malignancy of a bone lesion or if the diagnosis is not clear, a biopsy should be performed following certain rules in a specialized centre.

Diagnostic challenges in low-grade central osteosarcoma

Aims

Low-grade central osteosarcoma (LGCOS), a rare type of osteosarcoma, often has misleading radiological and pathological features that overlap with those of other bone tumours, thereby complicating diagnosis and treatment. We aimed to analyze the clinical, radiological, and pathological features of patients with LGCOS, with a focus on diagnosis, treatment, and outcomes.

Methods

We retrospectively analyzed the medical records of 49 patients with LGCOS (Broder's grade 1 to 2) treated between January 1985 and December 2017 in a single institute. We examined the presence of malignant features on imaging (periosteal reaction, cortical destruction, soft-tissue invasion), the diagnostic accuracy of biopsy, surgical treatment, and oncological outcome.

Results

Based on imaging, 35 of 49 patients (71.4%) exhibited malignant features. Overall, 40 of 49 patients (81.6%) had undergone a biopsy before en-bloc resection: 27 of 40 patients (67.5%) were diagnosed on the first biopsy, which was more accurate when carried out by open rather than needle biopsy (91.3% vs 35.3% diagnostic accuracy, respectively; p < 0.001). Of the 40 patients treated by en-bloc resection, surgical margins were wide in 38 (95.0%) and marginal in two (5.0%). Furthermore, nine of 49 patients (18.4%) underwent curettage (intralesional margin) without previous biopsy. All patients with a positive margin developed local recurrence. Distant metastases occurred in five of 49 patients (10.2%). The mean five-year overall survival (OS) and distant relapse-free survival (D-RFS) were 89.3% (SD 5.1%) and 85.7% (SD 5.5%), respectively. Univariate analysis showed that the occurrence of distant metastasis was a poor prognostic factor for OS (hazard ratio 11.54, 95% confidence interval (CI) 1.92 to 69.17; p < 0.001). Local recurrence was a poor prognostic factor for D-RFS (HR 8.72, 95% CI 1.69 to 45.0; p = 0.002).

Conclusion

The diagnosis of LGCOS can be challenging because it may present with non-malignant features and has a low diagnostic accuracy on biopsy. If precisely diagnosed, LGCOS can be successfully treated by surgical excision with wide margins.

Imaging of bone marrow pitfalls with emphasis on MRI

Normal marrow contains both hematopoietic/red and fatty/yellow marrow with a predictable pattern of conversion and skeletal distribution on MRI. Many variations in normal bone marrow signal and appearances are apparent and the reporting radiologist must differentiate these from other non-neoplastic, benign or neoplastic processes. The advent of chemical shift imaging has helped in characterising and differentiating more focal heterogeneous areas of red marrow from marrow infiltration. This review aims to cover the MRI appearances of normal marrow, its evolution with age, marrow reconversion, variations of normal marrow signal, causes of oedema-like marrow signal, and some common non-neoplastic entities, which may mimic marrow neoplasms.

Research of the Active Components and Potential Mechanisms of Qingfei Gujin Decoction in the Treatment of Osteosarcoma Based on Network Pharmacology and Molecular Docking Technology

Aim. Qingfei Gujin Decoction (QGD) has been shown to be effective against osteosarcoma. This research was aimed at investigating the main active ingredients and potential mechanisms of QGD acting on osteosarcoma through network pharmacology and molecular docking techniques. Methods. The active ingredients and targets of QGD were screened from the TCMSP database, and the predicted targets were obtained from the PharmMapper database. Meanwhile, the targets of osteosarcoma were collected using OMIM, PharmGKB, and DisGeNET databases. Then, GO and KEGG enrichment analyses were performed by RStudio. PPI and drug-ingredient-target networks were constructed using Cytoscape 3.2.1 to screen the major active ingredients, key networks, and targets. Finally, molecular docking of key genes and their regulatory active ingredients was performed using AutoDockTools 1.5.6 software. Results. 38 active ingredients were collected, generating 89 cross-targets; quercetin, luteolin, β-sitosterol, and kaempferol were the main active ingredients of QGD acting on osteosarcoma, and major signaling pathways such as PI3K-Akt signaling pathway, MAPK signaling pathway, and IL-17 signaling pathway were observed. TP53, SRC, and ESR1 were identified as key proteins that docked well with their regulated compounds. Conclusion. QGD is effective against osteosarcoma through multicomponent, multitarget, and multipathway. This study was helpful for finding effective targets and compounds for osteosarcoma treatment.

Imaging Diagnosis of Primary Solitary Bone Neoplasts and Its Comparison with Tumor-like Lesions

Objective. To explore the imaging diagnostic value of primary solitary bone tumor and tumor-like lesion of iliac crest. Methods. A total of 156 patients with primary solitary bone tumors and tumor-like lesions of the iliac bone treated in our hospital were selected, and the patients were diagnosed by X-ray, CT, and MRI. Sexual analysis of single diagnostic and combined diagnostic value was carried out. Results. Round high-density shadow, soft tissue mass shadow, soft tissue mass, right intestinal tube, and bladder obvious pressure were observed. The detection rates of giant cell tumor of bone, myeloma, osteochondroma, chondroma, eosinophilic granuloma, osteosarcoma, fibrous dysplasia, and Hodgkin lymphoma were 34.6%, 12.8%, 11.5%, 10.3%, 7.7%, 6.4%, 3.8%, and 2.6%, and the differences were statistically significant (P < 005); X-ray, CT, MR single diagnostic comparison, three methods joint diagnostic missed diagnosis rate and misdiagnosis rate, higher detection rate ( $P<0.05$ ); combined with X-ray, CT, MR single diagnosis, three methods joint diagnosis sensitivity, specificity, accuracy, statistical significance ( $P<0.05$ ); comparison with X-ray, CT, MR single diagnosis, three methods jointly diagnosed positive predictive value, negative predictive value higher, difference statistics significance ( $P<0.05$ ); there is a significant difference in the near-end, backbone, and distal detection rate of different bone tumors and tumor lesions, including the humerus and tibia. There is a statistical significance of the detection rate, and the difference is $P<0.05$ . Conclusion. X-ray plays an important role in the diagnosis of primary solitary bone tumor and tumor-like lesion of iliac crest and is the first choice in clinical diagnosis. In the diagnosis of tumor disease, range, and soft tissue mass, MRI and CT diagnostic value can provide effective theoretical basis for patient clinical treatment. Therefore, the appropriate diagnostic method should be selected according to the specific situation of the patient, so that the efficiency of the clinical feature is improved.