Side effects of radiation in musculoskeletal oncology

Radiation therapy is applied for systemic effects to patients with bone and soft tissue tumors and for local effects that facilitate the surgical procedure. However, while it remains an essential treatment of cancers, radiation therapy is associated with unwanted complications. The purpose of this review is to summarize information regarding the complications of radiation in musculoskeletal oncology and their management. Because preoperative radiotherapy is associated with an increased risk of wound complications and postoperative radiation is associated with an increased risk of postradiation fractures, the physician requires additional information in deciding on the best method of treatment, and such information is provided in this review.     

Microsurgery in musculoskeletal oncology

European Journal of Orthopaedic Surgery & Traumatology - Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was...     

The evolution of three-dimensional technology in musculoskeletal oncology

Musculoskeletal tumours pose considerable challenges for the orthopaedic surgeon during pre-operative planning, resection and reconstruction. Improvements in imaging technology have improved the diagnostic process of these tumours. Despite this, studies have highlighted the difficulties in achieving consistent resection free margins especially in tumours of the pelvis and spine when using conventional methods. Three-dimensional technology – three-dimensional printing and navigation technology – while relatively new, may have the potential to prove useful in the musculoskeletal tumour surgeon's arsenal. Three-dimensional printing (3DP) allows the production of objects by adding material layer by layer rather than subtraction from raw materials as performed conventionally. High resolution imaging, computer tomography (CT) and magnetic resonance imaging (MRI), are used to print highly complex and accurate items. Powder-based printing, vat polymerization-based printing and droplet-based printing are the common 3DP technologies applied. 3DP has been utilized pre-operatively in surgical planning and intra-operatively for patient specific instruments and custom made prosthesis. Pre-operative 3DP models transfer information to the surgeon in a concise yet exhaustive manner. Patient specific instruments are customized 3DP instruments utilized with the intention to easily replicate surgical plans. Complex musculoskeletal tumours pose reconstructive challenges and standard implants are often unable to reconstruct defects satisfactorily. The ability to use custom materials and tailor the pore size, elastic modulus and porosity of the 3DP prosthesis to be comparable to the patient's bone allows for a potential patient-specific prosthesis with unique incorporation and longevity properties. Similarly, navigation technology utilizes CT or MRI images to provides surgeons with real time intraoperative three-dimensional calibration of instruments. It has been shown to potentially allow surgeons to perform more accurate resections. These technological advancements have the potential to greatly impact the management of musculoskeletal tumours. 3D planning models, patient-specific instruments and customized 3DP implants and navigation should not be thought of as separate, but rather, patient-specific adaptation of relevant modes of application should be selected on a case-by-case basis when taking all unique factors of each case into consideration.     

Limb salvage in musculoskeletal oncology: Recent advances

The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.KEY WORDS: Bone tumor, reconstruction, sarcoma     

Neoadjuvant chemotherapy in gynecologic oncology

The use of neoadjuvant chemotherapy in conjunction with surgery in squamous carcinoma of the uterine cervix can reduce the surgical treatment extent (to be confirmed) in small-volume tumors (diameter < 4 cm) and increase overall survival and disease-free interval in localized median-volume tumors (< or = 8 cm) and improve the quality of life of patients with large, locally advanced tumors, due to longer disease-free period. These issues have yet to be completely resolved (three randomized trials have confirmed these data), but in the meantime, neoadjuvant chemotherapy could be used as an alternative treatment in locally advanced tumors or large localized tumors. It is necessary to use high-dose chemotherapy to achieve a good tumor response and satisfactory "down-staging." Surgical treatment after neoadjuvant chemotherapy seems to be the most appealing option, especially in patients with poor response to chemotherapy. The proper extension of surgery after neoadjuvant chemotherapy is an unexplored matter for the gynecologic oncologist, and no trial has been developed to address this issue, but it seemingly must be performed according to the initial size and extension of the tumor (prior to neoadjuvant chemotherapy) despite the tumor response to it.     

Revisions of endoprosthetic reconstructions after limb salvage in musculoskeletal oncology

Of 91 limb-salvage procedures using prosthetic reconstructions because of primary or metastatic bone and soft-tissue tumors 26 revisions were performed in 16 patients. Revision was due to polyethylene wear (9 cases), aseptic loosening (8 cases), recurrent hip dislocation (3 cases), prosthetic stem fracture (2 cases), infection (2 cases), leg length discrepancy (1 case), and traumatic dislocation of a saddle prosthesis (1 case). The follow-up period for tumor control varied from 1.5 to 22 years with a median of 13.5 years. The follow-up period after the last revision operation varied from 0.5 to 12 years with a median of 3 years. At the last follow-up, the functional results had deteriorated compared with after the primary operation in 5 patients and had improved in 2 patients. In the remaining patients, the results did not change.     

Angiography for assessment of preoperative chemotherapy in musculoskeletal sarcomas

Eleven abnormal findings of digital subtraction angiography were analyzed in 25 patients with bone sarcoma and in 23 patients with soft tissue sarcoma. The relation between digital subtraction angiographic findings and the histologic effect of chemotherapy was evaluated. Digital subtraction angiography was performed with the patient under local anesthesia with the Seldinger technique, using an ADVANT X unit. Contrast medium was injected at a rate of 4 to 6 ml per second, with the usual single bolus dose of approximately 6 to 8 ml. Eleven abnormal findings included tumor stain, hypervascularity, arterial distortion, vascular stretch, arterial dilatation, arteriovenous shunt, arterial encasement, occlusion, blood pool, caliber with irregular wall, and dilatation of draining vein. Each finding after preoperative chemotherapy was compared with that before chemotherapy and divided into three grades; Grade 1, not effective; Grade 2, effective; and Grade 3, very effective. Angiographic Grades 2 and 3 were defined as responders. The histologic effect was examined and scored according to the modified classification proposed by Huvos. Histologic Grades 1 and 2 were classified as nonresponders and Grades 3 and 4 as good responders. In bone sarcomas, hypervascularity and tumor stain were seen in all patients. In soft tissue sarcomas, tumor stain was shown in all 23 patients and hypervascularity was seen in 21 patients. Tumor stain, hypervascularity, vascular stretch, and arterial encasement were correlated closely with histologic findings and showed an accuracy equal to or greater than 70%. When these four findings changed to angiographic Grade 3 after preoperative chemotherapy, 90% of patients had good histologic outcome.     

The musculoskeletal effects of smoking

Currently, there are more than 50 million smokers in this country, and approximately 800 billion cigarettes are smoked each year. Smoking is now the leading avoidable cause of morbidity and mortality in the United States. According to one report, over 500,000 deaths per year in the United States alone can be attributed to smoking. For years, orthopaedic surgeons have known about the relationships that putatively exist between smoking and an array of orthopaedic conditions and complications. It has been shown to adversely affect bone mineral density, lumbar disk disease, the rate of hip fractures, and the dynamics of bone and wound healing. Although scientific and clinical information on smoking and its consequences suggests differing degrees of correlation between smoking and orthopaedic conditions, most available data do suggest a real and reproducible relationship. In the past, there have been many individual reports that deal with these relationships separately but very few published comprehensive reviews. This summary of the current literature regarding the relationship between smoking and musculoskeletal diseases and their treatment provides information that can be used clinically by both the practitioner and the patient.     

Side effects of sirolimus

The mTOR inhibitor sirolimus improves renal transplant function compared with the nephrotoxic calcineurin inhibitors. We evaluated retrospectively the adverse events in 119 of 134 patients getting sirolimus which seemed to be caused by sirolimus. Patients were converted to sirolimus because of malignancies (n = 47), a creeping creatinine (n = 33), or hypertension (n = 26). One cohort had started sirolimus from the time of transplantation (n = 28). A rise in serum lipids and a decrease in hemoglobin were seen relatively regularly, while arthralgia, peripheral edema, gastrointestinal complaints, skin disorders, electrolyte disturbances, and infections occurred only occasionally. Interestingly, 31% of patients developed doubling or more proteinuria. Among renal biopsies, 9/13 showed a glomerulopathy which in 6 cases was de novo and in 3 cases, a presumed recurrence of the primary kidney disease. Thus, we think that caution is required, particularly in connection with preexisting glomerular disease.