Spindle cell hemangioendothelioma of the sacrum

Spindle cell hemangioendothelioma is a rare benign vascular tumor that is not known to involve the sacrum. The authors describe the case of a 31-year-old woman presenting with low-back and radicular pain without weakness or bowel or bladder dysfunction. Admission CT and MRI studies revealed a large S1–3 lytic sacral lesion. The patient initially underwent a nondiagnostic percutaneous biopsy. She subsequently underwent an open biopsy, during which the lesion was found to be highly vascular. Histological investigation revealed a vasoformative lesion consistent with spindle cell hemangioendothelioma. Preoperative embolization followed by resection via intralesional currettage resulted in resolution of symptoms up to 9 months postintervention. Despite the authors' recommendation, the patient became pregnant at that time and requested no additional follow-up imaging. The authors present the first reported case of a spindle cell hemangioendothelioma of the sacrum and review the current literature.

Osteosarcoma of the proximal tibia: limb-sparing resection and reconstruction with a modular segmental proximal tibia tumor prosthesis

A limb-sparing resection was performed for osteosarcoma of the proximal tibia in a young patient. A special modular segmental proximal tibial endoprosthesis that includes a hinged total knee component was used for reconstruction. A medial gastrocnemius rotational flap was utilized to reconstruct the extensor mechanism of the knee. The muscle flap aids in covering the prosthesis and helps to protect against infection. Limb-sparing resection for tumors arising from the proximal tibia, and reconstruction with a modular segmental proximal tibia tumor prosthesis and gastrocnemius muscle flap, is a safe and reliable method for treating tumors involving this area.

Metastatic carcinoma of the long bones

Breast, prostate, renal, thyroid, and lung carcinomas commonly metastasize to bone. Managing skeletal metastatic disease can be complex. Pain is the most common presenting symptom and requires thorough radiographic and laboratory evaluation. If plain-film radiography is not sufficient for diagnosis, a bone scan may detect occult lesions. Patients with lytic skeletal metastases may be at risk for impending fracture. Destructive lesions in the proximal femur and hip area are particularly worrisome. High-risk patients require immediate referral to an orthopedic surgeon. Patients who are not at risk for impending fracture can be treated with a combination of radiotherapy and adjuvant drug therapy. Bisphosphonates diminish pain and prolong the time to significant skeletal complications.

Complex reconstruction in the management of extremity sarcomas

The concept of limb-sparing surgery for bony sarcomas has evolved over the past 25 years. Today, more than 90% of patients treated by surgeons with expertise in musculoskeletal oncology undergo successful limb-sparing procedures. Many large centers have abandoned osteochondral allografts and resection arthrodesis for the reconstruction of segmental bone and joint defects in favor of metallic endoprostheses. Endoprosthesis survival rates now exceed 85% at 5 years for reconstructions about the knee, which is the most common site for primary bone sarcomas. In the shoulder girdle, the type of resection and soft-tissue reconstruction is probably more important than the type of implant. Extra-articular resection is recommended for most large stage IIB tumors. New expandable prostheses able to be lengthened nonoperatively hold promise for very young children with lower extremity sarcomas. Allograft-prosthetic composites and proximal femoral prostheses provide reliable and stable hip reconstructions. Acetabular components are not required, but attention to capsular reconstruction is necessary to prevent hip dislocation. Techniques of scapula replacement have advanced and provide better upper extremity function after scapula resection than resection alone.

Effective management of bleeding during tumor resection with a collagen-based hemostatic agent

In a prospective controlled trial hemostatic effectiveness of a novel collagen-based composite (CoStasis) was compared with a collagen sponge applied with manual pressure at diffusely bleeding sites after surgical tumor resection. The proportion of subjects achieving complete cessation of bleeding within 10 minutes (i.e., hemostatic success) and the time to "complete hemostasis" were determined at raw surgical sites after tumor resection among 23 experimental and 30 control subjects. There was a similar distribution in tumor types (e.g., benign vs malignant) evaluated between treatment groups. A significantly greater proportion of experimental subjects achieved complete hemostasis within 10 minutes of observation compared with controls [23 of 23 (100%) vs 21 of 30 (70%); P = 0.003]. The median time required to achieve complete hemostasis was more than three times longer for subjects treated with the collagen sponge compared with subjects treated with CoStasis (243 vs 78 seconds; P = 0.0001). Approximately 80 per cent of experimental subjects achieved complete hemostasis within 2 minutes compared with only 35 per cent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this novel hemostatic agent to control diffuse surgical site bleeding after tumor resection at diverse anatomical locations.

Effective Management of Bleeding during Tumor Resection with a Collagen-Based Hemostatic Agent

In a prospective controlled trial hemostatic effectiveness of a novel collagen-based composite (CoStasis®) was compared with a collagen sponge applied with manual pressure at diffusely bleeding sites after surgical tumor resection. The proportion of subjects achieving complete cessation of bleeding within 10 minutes (i.e., hemostatic success) and the time to “complete hemostasis” were determined at raw surgical sites after tumor resection among 23 experimental and 30 control subjects. There was a similar distribution in tumor types (e.g., benign vs malignant) evaluated between treatment groups. A significantly greater proportion of experimental subjects achieved complete hemostasis within 10 minutes of observation compared with controls [23 of 23 (100%) vs 21 of 30 (70%); P = 0.003]. The median time required to achieve complete hemostasis was more than three times longer for subjects treated with the collagen sponge compared with subjects treated with CoStasis® (243 vs 78 seconds; P = 0.0001). Approximately 80 per cent of experimental subjects achieved complete hemostasis within 2 minutes compared with only 35 per cent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this novel hemostatic agent to control diffuse surgical site bleeding after tumor resection at diverse anatomical locations.

Impact of two cycles of preoperative chemotherapy with intraarterial cisplatin and intravenous doxorubicin on the choice of surgical procedure for high-grade bone sarcomas of the extremities

The authors assessed the impact of two cycles of preoperative chemotherapy (POCT) with intraarterial cisplatin (120 mg/m2) and continuous intravenous doxorubicin hydrochloride (Adriamycin; 20 mg/m2/day x 3 days) on the decision to perform a limb-sparing procedure (LSP) or amputation in 22 patients with high-grade bone sarcomas of the extremities. The tumor types were osteosarcoma (17), malignant fibrous histiocytoma (three), leiomyosarcoma (one), and malignant schwannoma (one). Surgical stages were IIA (three), IIB (17), and IIIB (two). The prechemotherapy surgical options chosen were 12 amputations (55% of patients) and ten LSPs (45%). The initial decisions to amputate were based on a combination of the following: improper biopsy (five cases), large tumors (ten) and those with neurovascular encroachment (six), and pathological fracture (one). Following chemotherapy, 18 LSPs (81%) and four amputations (19%) were performed. Nine of 12 patients (75%) initially deemed unresectable were converted to LSP. The median tumor response (necrosis; range, 0%-100%) was 70%; ten of 22 specimens had necrosis greater than 95%. Median tumor necrosis for the patients treated by amputation and LSPs was 45% and 88%, respectively. Following surgery, all patients received four additional cycles of cisplatin and doxorubicin. The median follow-up period is 30 months; six patients have developed metastatic disease, with a median disease-free interval of 16.6 months. The rate of local tumor control is 95% (21 of 22 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic imaging of human extremity musculoskeletal tumors by PET

The measurement of glucose utilization rate (GUR) by positron emission tomography (PET) using 18F-2-fluoro-2-deoxy-D-glucose (FDG) is a valuable method to assess the grade of malignancy of brain tumors. We have designed a feasibility trial to determine whether PET could be used to image and predict the grade of malignancy of human extremity musculoskeletal tumors. Five patients with extremity tumors (four soft-tissue tumors and one osteogenic tumor) were studied. Peak and mean apparent GURs were determined in the tumor region. All tumors were subsequently resected and graded in a standard fashion using the NCI grading system. Peak apparent GURs ranged from 3.3 mg/100 g/min to 15.2 mg/100 g/min, with the highest values found in the high grade tumors. Although the number of patients studied was small, a good correspondence was shown between GURs and histopathologic grading. Our results indicate that PET can be used to image and evaluate the metabolic activity of human musculoskeletal tumors.

Surgical technique and results of limb sparing surgery for high grade bone sarcomas of the knee and shoulder

Thirty-three patients with high grade bone sarcomas of the knee and shoulder treated by limb sparing surgery were evaluated. The histological diagnoses were osteosarcoma (25), chondrosarcoma (3), malignant fibro-histiocytoma (3), fibrosarcoma (1) and unclassified (1). The Surgical Stages were: Stage IIA (3), Stage IIB (28) and Stage III (3). The operative procedure consisted of three phases: tumor resection, skeletal reconstruction and soft tissue reconstruction. All resections obtained negative margins and were classified as, marginal excision (3), intracompartmental resections (28) and radical resections (2). Overall survival was 77%. Four of 33 patients (12.4%) required a secondary amputation. Local recurrence was 6% (2/33) with an average follow-up of 37.2 months. The most common complications were flap necrosis (33%) and transient nerve palsies (33%). There were 2 infections and one prosthetic dislocation. We believe that limb salvage surgery for high grade bone sarcomas need not be reserved for only those without extraosseous extension. Careful preoperative selection and attention to the three stages of a limb sparing procedure are important for a successful outcome. Presently, we consider the following as contraindications to resection: vascular involvement, pathologic fracture, inappropriate biopsy and infection.

Scintigraphic features of giant cell tumor

The scintigraphic appearance of giant cell tumor of bone in six patients is presented. Patients were studied by means of Tc-99m MDP bone scanning. On early blood pool and delayed imaging, markedly increased activity was noted, characteristically displaying a "ring" pattern that is readily discernible from patterns seen in bone cysts and nonosteogenic fibroma. The extent of the lesion, as judged by scintigraphic techniques, was roughly equal to estimates of extent by other radiographic modalities. Only one example of a different lesion mimicking giant cell tumor was encountered in over 100 cases of a variety of primary bone neoplasms reviewed. We conclude that giant cell tumor has a characteristic scintigraphic appearance.

Intraosseous schwannoma: histologic features, ultrastructure, and review of the literature

Intraosseous schwannoma, a rare benign neoplasm, has a characteristic radiographic appearance. The histologic features, although similar to those of soft tissue schwannomas, may be obscure when the lesions are highly cellular and the Antoni Types A and B patterns are subtle. Four additional cases of intraosseous schwannoma are presented, with ultrastructural studies from two tumors, one of which was highly cellular and presented a diagnostic problem. The ultrastructural features of intraosseous schwannomas have not been documented previously; however, the findings are essentially the same as those observed in soft tissue schwannomas. The radiographic, histologic, and ultrastructural findings in the cases reported are discussed in relation to published data for intraosseous and soft tissue schwannomas. The authors propose that the comparatively high frequency of mandibular involvement by intraosseous schwannoma may be related to the fact that schwannomas, in general, arise most frequently in the head and neck regions. Furthermore, since schwannomas arise mainly in association with sensory nerves, probably the dearth of such fibers within bone accounts for the rarity of intraosseous schwannoma.

Fluorescent histochemical demonstration of estrogen and progesterone binding in giant cell tumors of bone: preliminary observations

Hormonal receptors of giant cell tumors (GCTs) have not been previously reported. Five cases of GCT of bone were analyzed for estrogen and progesterone binding. Frozen sections were studied by a histochemical method, using 17-beta-6-CMOBSA-FITC and 11-alpha-hydroxyprogesterone-HS-BSA-TMRITC. Cytoplasmic fluorescence with estradiol-BSA-FITC was seen in stromal cells of all five tumors; three also showed cytoplasmic staining with progesterone-BSA-TMRITC. No fluorescence was seen in the giant cells. Two cases were also analyzed by a dextran-coated charcoal cytosol assay. No estrogen or progesterone receptor was detected by cytosol assay. This study suggests that the estrogen and progesterone binding is present in GCT of bone, possible to low-affinity sites rather than high-affinity receptors. Further investigation of hormonal receptors of GCTs of bone is warranted.