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1.
BackgroundPulmonary metastases are a poor prognostic factor in patients with osteosarcoma; however, the clinical significance of subcentimeter lung nodules and whether they represent a tumor is not fully known. Because the clinician is faced with decisions regarding biopsy, resection, or observation of lung nodules and the potential impact they have on decisions about resection of the primary tumor, this remains an area of uncertainty in patient treatment. Surgical management of the primary tumor is tailored to prognosis, and it is unclear how aggressively patients with indeterminate pulmonary nodules (IPNs), defined as nodules smaller than 1 cm at presentation, should be treated. There is a clear need to better understand the clinical importance of these nodules.Questions/purposes(1) What percentage of patients with high-grade osteosarcoma and spindle cell sarcoma of bone have IPNs at diagnosis? (2) Are IPNs at diagnosis associated with worse metastasis-free and overall survival? (3) Are there any clinical or radiologic factors associated with worse overall survival in patients with IPN?MethodsBetween 2008 and 2016, 484 patients with a first presentation of osteosarcoma or spindle cell sarcoma of bone were retrospectively identified from an institutional database. Patients with the following were excluded: treatment at another institution (6%, 27 of 484), death related to complications of neoadjuvant chemotherapy (1%, 3 of 484), Grade 1 or 2 on final pathology (4%, 21 of 484) and lack of staging chest CT available for review (0.4%, 2 of 484). All patients with abnormalities on their staging chest CT underwent imaging re-review by a senior radiology consultant and were divided into three groups for comparison: no metastases (70%, 302 of 431), IPN (16%, 68 of 431), and metastases (14%, 61 of 431) at the time of diagnosis. A random subset of CT scans was reviewed by a senior radiology registrar and there was very good agreement between the two reviewers (κ = 0.88). Demographic and oncologic variables as well as treatment details and clinical course were gleaned from a longitudinally maintained institutional database. The three groups did not differ with regard to age, gender, subtype, presence of pathological fracture, tumor site, or chemotherapy-induced necrosis. They differed according to local control strategy and tumor size, with a larger proportion of patients in the metastases group presenting with larger tumor size and undergoing nonoperative treatment. There was no differential loss to follow-up among the three groups. Two percent (6 of 302) of patients with no metastases, no patients with IPN, and 2% (1 of 61) of patients with metastases were lost to follow-up at 1 year postdiagnosis but were not known to have died. Individual treatment decisions were determined as part of a multidisciplinary conference, but in general, patients without obvious metastases received (neo)adjuvant chemotherapy and surgical resection for local control. Patients in the no metastases and IPN groups did not differ in local control strategy. For patients in the IPN group, staging CT images were inspected for IPN characteristics including number, distribution, size, location, presence of mineralization, and shape. Subsequent chest CT images were examined by the same radiologist to reevaluate known nodules for interval change in size and to identify the presence of new nodules. A random subset of chest CT scans were re-reviewed by a senior radiology resident (κ = 0.62). The association of demographic and oncologic variables with metastasis-free and overall survival was first explored using the Kaplan-Meier method (log-rank test) in univariable analyses. All variables that were statistically significant (p < 0.05) in univariable analyses were entered into Cox regression multivariable analyses.ResultsFollowing re-review of staging chest CTs, IPNs were found in 16% (68 of 431) of patients, while an additional 14% (61 of 431) of patients had lung metastases (parenchymal nodules 10 mm or larger). After controlling for potential confounding variables like local control strategy, tumor size, and chemotherapy-induced necrosis, we found that the presence of an IPN was associated with worse overall survival and a higher incidence of metastases (hazard ratio 1.9 [95% CI 1.3 to 2.8]; p = 0.001 and HR 3.6 [95% CI 2.5 to 5.2]; p < 0.001, respectively). Two-year overall survival for patients with no metastases, IPN, or metastases was 83% [95% CI 78 to 87], 65% [95% CI 52 to 75] and 45% [95% CI 32 to 57], respectively (p = 0.001). In 74% (50 of 68) of patients with IPNs, it became apparent that they were true metastatic lesions at a median of 5.3 months. Eighty-six percent (43 of 50) of these patients had disease progression by 2 years after diagnosis. In multivariable analysis, local control strategy and tumor subtype correlated with overall survival for patients with IPNs. Patients who were treated nonoperatively and who had a secondary sarcoma had worse outcomes (HR 3.6 [95% CI 1.5 to 8.3]; p = 0.003 and HR 3.4 [95% CI 1.1 to 10.0]; p = 0.03). The presence of nodule mineralization was associated with improved overall survival in the univariable analysis (87% [95% CI 39 to 98] versus 57% [95% CI 43 to 69]; p = 0.008), however, because we could not control for other factors in a multivariable analysis, the relationship between mineralization and survival could not be determined. We were unable to detect an association between any other nodule radiologic features and survival.ConclusionThe findings show that the presence of IPNs at diagnosis is associated with poorer survival of affected patients compared with those with normal staging chest CTs. IPNs noted at presentation in patients with high-grade osteosarcoma and spindle cell sarcoma of bone should be discussed with the patient and be considered when making treatment decisions. Further work is required to elucidate how the nodules should be managed.Level of EvidenceLevel III, prognostic study.  相似文献   
2.

Purpose

We report the outcome of intercalary resection of the femoral diaphysis and extracorporeal irradiated autologous bone graft reconstruction, without the use of vascularized fibular graft.

Methods

Six patients with Ewing sarcoma of the mid-shaft femur who were treated by limb sparing tumour resection and reconstruction with extracorporeal irradiated autologous bone graft with intramedullary cement between 2002 and 2010 were studied.

Results

Mean age at the time of surgery was ten years (range, four–23). The length of resected femoral bone averaged 23 cm (15–32 cm). The ratio of bone resection length to total femoral length averaged 60 % (56–66 %). The patients had been followed up for between 16 and 79 months (mean, 41 months) at the time of the study. There was no infection nor fracture in this series. Primary union of the distal and proximal osteotomy sites was achieved in three patients. Delayed union of the proximal osteotomy site occurred in one patient that was successfully treated with iliac crest bone grafting. One patient developed non-union at the distal osteotomy site which failed to heal with bone grafting and was therefore converted to endoprosthetic replacement, and another patient was converted to rotationplasty at five months post-surgery because of contaminated margins. Function was excellent in all patients with surviving re-implanted bone. Local recurrence arose in one patient.

Conclusion

Our experience suggests that cement augmentation of extracorporeal irradiated and re-implanted bone autografts offer a useful method of reconstructing large femoral diaphyseal bone defects after excision of primary malignant bone tumours.  相似文献   
3.
BACKGROUND: Autograft stabilization uses free semitendinosus tendon grafts to anatomically reconstruct the anterior talofibular ligament. Study aims were to evaluate the biomechanical properties of Mitek GII anchors compared with the Arthrex Bio-Tenodesis Screw for free tendon reconstruction of the anterior talofibular ligament. NULL HYPOTHESIS: There are no differences in load to failure and percentage specimen elongation at failure between the 2 methods. STUDY DESIGN: Controlled laboratory study using porcine models. METHODS: Sixty porcine tendon constructs were failure tested. Re-creating the pull of the anterior talofibular ligament, loads were applied at 70 degrees to the bones. Thirty-six tendons were fixed to porcine tali and tested using a single pull to failure; 10 were secured with anchors and No. 2 Ethibond, 10 with anchors and FiberWire, 10 with screws and Fiberwire, and 6 with partially gripped screws. Cyclic preloading was conducted on 6 tendons fixed by anchors and on 6 tendons fixed by screws before failure testing. Two groups of 6 components fixed to the fibula were also tested. RESULTS: The talus single-pull anchor group produced a mean load of 114 N and elongation of 37% at failure. The talus single-pull screw group produced a mean load of 227 N and elongation of 22% at failure (P <.05). Cyclic preloading at 65% failure load before failure testing produced increases in load and decreases in elongation at failure. Partially gripped screws produced a load of 133 N and elongation of 30% at failure. The fibula model produced significant increases in load to failure for both. The human anterior talofibular ligament has loads of 139 N at failure with instability occurring at 20% elongation. CONCLUSIONS: Interference screw fixation produced significantly greater failure strength and less elongation at failure than bone anchors. Clinical Relevance: The improved biomechanics of interference screws suggests that these may be more suited to in vivo reconstruction of the anterior talofibular ligament than are bone anchors.  相似文献   
4.
Endoprosthetic replacements are commonly used for limb salvage following surgical excision of bone tumours. Advantages include initial reliability, rapid restoration of function and their ready availability. Potential long-term problems include loosening, infection and mechanical failure. Increasing problems may lead to the necessity for amputation; this paper assesses that risk. A total of 1,261 patients have undergone endoprosthetic replacements in our centre in the past 34 years, with a total of 6,507 patient years of follow up. A total of 112 patients have had subsequent amputation. The reasons for amputation were local recurrence in 71, infection in 38, mechanical failure in two and chronic pain in one. The proximal tibia had the greatest risk of amputation (n=38/245). The time to amputation varied from 2 days to 16 years, with a mean of 31 months. The risk of amputation decreased with time, although 10% took place after more than 5 years.  相似文献   
5.
Secondary bone tumours are tumours that spread to bone from another primary site in the body. Histologically they often resemble the cells of the tumour they originated from. Traditionally the presence of a metastatic bone deposit has been seen as a terminal event, however, with the increased survival of patients with carcinoma and improved treatment, long-term survival is possible with metastatic bone disease and treatment can prolong life, or even be curative. Implants used in reconstruction need to be sufficiently robust to survive the patient, and the expertise of reconstruction available within tertiary bone tumour units is increasingly required. Autopsy studies have shown that 70% of patients with breast and prostate carcinoma develop skeletal metastases. The most commonly involved bone sites are those with persistent red marrow, such as the vertebrae, proximal femur, ribs, sternum, pelvis and skull. Theories regarding tumour spread include the Soil and Circulation theories, however, the understanding of the molecular biology of metastases is becoming increasingly important in providing new therapeutic targets in their treatment. The types of treatment of metastases include medical treatments, radiotherapy and surgery. Bone metastases can cause many complications and have significant morbidity.  相似文献   
6.
Pathologic fractures of the proximal femur resulting from primary bone sarcomas are often difficult to treat and some are often not recognized resulting in inappropriate interventions prior to the correct diagnosis being made. The aim of the study was to identify factors determining the survival after pathologic fractures of the proximal femur resulting from nonosteogenic primary bone sarcomas.

Patients and methods

We retrospectively reviewed 72 patients with nonosteogenic primary bone sarcomas of the proximal femur (chondrosarcoma in 34 patients, spindle cell sarcoma in 25 and Ewing’s sarcoma in 13). There were 40 male and 32 female patients. The mean age was 49 years. We analyzed patient, tumor, and treatment factors in relation to overall survival. The mean follow up was 55 months (range 0-302 months).

Results

The overall 5-year survival rate was 44% (Ewing’s sarcoma 60%, chondrosarcoma 57%, spindle cell sarcoma 30%, and dedifferentiated chondrosarcoma 0%). The diagnosis of spindle cell sarcoma and dedifferentiated chondrosarcoma was the only significant factor adversely affecting survival. There was no difference in survival resulting from timing of the fracture, site of the fracture, age at diagnosis, surgical margin, limb salvage or amputation.

Conclusions

The key-factor adversely affecting the survival after pathologic fractures of the proximal femur resulting from nonosteogenic primary bone sarcomas is the histological diagnosis of dedifferentiated chondrosarcoma and spindle cell sarcoma.  相似文献   
7.
Revision total hip arthroplasty has excellent results but is challenging surgery. A myriad of considerations and complications face the surgeon but careful planning and careful execution of that plan can reduce the likelihood of failure. This review article attempts to give practical advice on managing preoperative planning, intraoperative considerations and postoperative complications for the reader.  相似文献   
8.

Background

Adherence with medication taking is a major barrier to physiologic control in diabetes and many strategies for improving adherence are in use. We sought to describe the use of mnemonic devices and other adherence aids by adults with diabetes and to investigate their association with control of hyperglycemia, hyperlipidemia and hypertension.

Methods

Cross sectional survey of diabetic adults randomly selected from Primary Care practices in the Vermont Diabetes Information System. We used linear regression to examine the associations between the use of various aids and physiologic control among subjects who used oral agents for hyperglycemia, hypercholesterolemia, and hypertension.

Results

289 subjects (mean age 65.4 years; 51% female) used medications for all three conditions. Adherence aids were reported by 80%. The most popular were day-of-the-week pill boxes (50%), putting the pills in a special place (41%), and associating pill taking with a daily event such as a meal, TV show, or bedtime (11%). After adjusting for age, sex, marital status, income, and education, those who used a special place had better glycemic control (A1C -0.36%; P = .04) and systolic blood pressure (-5.9 mm Hg; P = .05) than those who used no aids. Those who used a daily event had better A1C (-0.56%; P = .01) than patients who used no aids.

Conclusion

Although adherence aids are in common use among adults with diabetes, there is little evidence that they are efficacious. In this study, we found a few statistically significant associations with adherence aids and better diabetes control. However, these findings could be attributed to multiple comparisons or unmeasured confounders. Until more rigorous evaluations are available, it seems reasonable to recommend keeping medicines in a special place for diabetic adults prescribed multiple medications.  相似文献   
9.
We investigated the eventual diagnosis in patients referred to a tertiary centre with a possible diagnosis of a primary bone malignancy. We reviewed our database from between 1986 and 2010, during which time 5922 patients referred with a suspicious bone lesion had a confirmed diagnosis. This included bone sarcoma in 2205 patients (37%), benign bone tumour in 1309 (22%), orthopaedic conditions in 992 (17%), metastatic disease in 533 (9%), infection in 289 (5%) and haematological disease in 303 (5%). There was a similar frequency of all diagnoses at different ages except for metastatic disease. Only 0.6% of patients (17 of 2913) under the age of 35 years had metastatic disease compared with 17.1% (516 of 3009) of those over 35 years (p < 0.0001). Of the 17 patients under 35 years with metastatic disease, only four presented with an isolated lesion, had no past history of cancer and were systematically well. Patients under the age of 35 years should have suitable focal imaging (plain radiography, CT or MRI) and simple systemic studies (blood tests and chest radiography). Reduction of the time to biopsy can be achieved by avoiding an unnecessary investigation for a primary tumour to rule out metastatic disease.  相似文献   
10.
Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records. A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p < 0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02). Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.  相似文献   
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