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Objective: To describe the clinical and ultrasonography (US) findings of soft tissue hemangiomas, and to compare with the results of histologic diagnosis after US-guided biopsy. Method and materials: We retrospectively studied the files of 97 patients (48 female, 49 male; mean age, 34 years; range 4–84 years) with soft tissue hemangiomas diagnosed from 2004 to 2011. Mean follow-up was 9 years (range 7–13 years). Clinical presentation included intermittent mild pain associated with a soft tissue swelling/palpable mass in all patients, chronic pain and increased local heat in 29 patients, local swelling and decreased range of motion of the adjacent joint in 45 patients, and all the above symptoms in 23 patients. B-mode and color Doppler US evaluation included the site, location, size, shape, margins, presence of calcifications, echo structure and echogenicity. All patients had US-guided biopsy for histologic analysis. Results: US-guided biopsy and histology confirmed the diagnosis of soft tissue hemangioma in 92 of the 97 lesions (94.8%). Histologic examination of the remaining five lesions showed nodular fasciitis (two lesions), endometriosis (one lesion), hemangioendothelioma (two lesions); US of these lesions showed variable size, irregular margins, and deep-seated location. Histologically documented soft tissue hemangiomas were most commonly superficial (74 lesions) and arteriovenous (45 lesions). Shape was most commonly oval (fusiform), margins were most commonly not well defined (irregular, hazing but circumscribed), phleboliths were more common in deep-seated lesions, echo structure was heterogeneous, and echogenicity was most commonly hyperechogen and involuting. Conclusion: Clinical presentation and typical B-mode and color Doppler US findings are adequate for the diagnosis of soft tissue hemangiomas without the need for biopsy and histologic analysis. If any clinical or US doubt, an US-guided biopsy should be performed. © 2018, Italian Society of Medical Radiology.

Metastatic disease is the most common malignancy of bone. Prostate, breast, lung, kidney and thyroid cancer account for 80% of skeletal metastases. Bone metastases are associated with significant skeletal morbidity including severe bone pain, pathological fractures, spinal cord or nerve roots compression, and malignant hypercalcemia. These events compromise greatly the quality of life of the patients. The treatment of cancer patients with bone metastases is mostly aimed at palliation. Currently, modern treatments are available for the palliative management of patients with metastatic bone disease. These include modern radiation therapy, chemotherapy, embolization, electrochemotherapy, radiofrequency ablation, and high intensity focused ultrasound. This article aims to present these palliative treatments for the patients with bone metastases, summarize the clinical applications, and review the techniques and results. It gives an extensive overview of the possibilities of palliation in patients with metastatic cancer to bone. As such it is of interest for all physicians with no experience with these developments to make palliative procedures safer and more reliable.

Aim Bone metastases of the upper limb are a frequent complication of primary tumors. The aim of this study is to evaluate treatment and functional results of patients with prosthetic reconstruction of the proximal humerus. Method Between 1975 and 2007, 67 patients were treated by resection of humeral metastasis and reconstruction with prosthesis. Cemented modular prostheses of the proximal humerus were implanted in 59 cases (all MRS Bioimpianti® prostheses), uncemented prostheses in 2 (HMRS® Stryker), 4 elbow Coonrad-Morrey prostheses (in 2 cases with bone allograft), 1 elbow custom-made cemented and 1 intercalary prosthesis (Osteobridge Merete®). Sites of primary tumors: kidney (23), lung (13), bone and unknow (7 each), liver and breast (3 each), bladder, endometrium, thyroid, soft tissues and nervous tissues (2 each), ovarium (1). Complications were evaluated and univariate analysis with actuarial Kaplan-Meier curves of implant survival was performed. Functional results were assessed with the MSTS system. Results At mean follow-up 27 months oncologic outcome showed 7 patients NED (mean time 7 yrs.), 57 DOD, 3 lost to follow-up. Complications were deep infection (2 cases, 3%) and loosening (1 case, 1.5%) causing failure requiring revision. Functional results were good or excellent in 93% of patients, with average score of 71%. Conclusion Resection of metastatic lesion is indicated: 1) for patients with solitary metastases and long free interval from treatment of primary cancer, 2) for patients with meta-epiphyseal metastases not amenable to durable internal fixation even in presence multiple metastases. Indications of resections are increasing, due to prolonged survival with newer medical treatments. Different reconstructive techniques are available, depending on type of resection and soft tissues removal. Cemented prostheses are mostly used, since cemented fixation is not affected by radiotherapy. Although prognosis was poor, prosthetic reconstructions of the humerus provided satisfactory results. Trauma Copyright © 2011, British Editorial Society of Bone & Joint Surgery

INFECTIONS IN ORTHOPEDIC ONCOLOGY: INCIDENCE, TREATMENT AND OUTCOME

SURGICAL TREATMENT OF THE FEMUR FOR METASTASES: AN ANALYSIS OF IMPLANT AND ONCOLOGICAL SURVIVAL COMPARING NAILING VERSUS PROSTHETIC REPLACEMENT

EVALUATION OF QUALITY OF LIFE IN PATIENTS TREATED WITH RESECTION AND RECONSTRUCTION OF THE UPPER OR LOWER LIMB FOR BONE SARCOMAS

INCIDENCE, TREATMENT AND OUTCOME OF INFECTION IN PROSTHETIC RECONSTRUCTIONS OF THE HUMERUS AFTER RESECTION OF BONE TUMORS

INFECTIONS IN SURGERY OF PRIMARY TUMOURS OF THE SACRUM

OSTEOSARCOMA IN PAGET'S DISEASE OF BONE: A RETROSPECTIVE ANALYSIS OF THE RIZZOLI INSTITUTE EXPERIENCE

TWO STAGE REVISION FOR INFECTION IN MODULAR MEGAPROSTHESES OF THE LOWER LIMB AFTER RESECTION FOR BONE TUMOUR

INCIDENCE, TREATMENT AND OUTCOME OF INFECTION IN MAJOR SURGICAL PROCEDURE IN SKELETAL ONCOLOGY

Osteosarcoma is a common primary bone sarcoma and distal femur its most frequent site. Between 2003 and 2008 at Rizzoli, 66 patients with osteosarcoma of the distal femur had neoadjuvant chemotherapy, resection and reconstruction with modular uncemented mega-prostheses. Series included 37 males and 29 females. Mean follow up was 2 years. To measure “subjective” outcome Karnofsky scale (KPS) was assessed for each patient pre and post-treatment. Also a functional evaluation according to the MSTS system was performed. To find out the current quality of life, a questionnaire on life at work, study and sport before and after treatment was sent to 64 alive patients. Before treatment 7 patients had a Karnofsky index (KI) of 60%, 31 of 50%, 25 of 40% and 3 of 30%. After treatment 19 patients had a Karnofsky index performance of 90%, 28 of 80%, 11 of 70%, 5 of 50% and 1 of 40%. Two patients died of disease. The most represented index of KPS after teatment was “Able to carry on normal activity; minor symptoms”. Poor results were related with amputation (2), knee stiffness (3), infection (2), aseptic loosening (1). After treatment 91% of patients had a KI over 70%, while 89% a KI lower than 50% pre-treatment. MSTS system showed excellent or good results in 85% and fair or poor in 15% of the patients. Average score at MSTS evaluation was 22 (73%). Questionnaires (some still pending) confirm previous analysis. KPS is simple and effective in evaluating quality of life in patients treated for distal femur osteosarcoma. In this study it confirmed the satisfactory MSTS assessed results. It is an easy method, useful and accessible for patients. The reported analysis shows that patients treated for osteosarcoma of the distal femur can have a good quality of life.

QUALITY OF LIFE IN PATIENTS WITH OSTEOSARCOMA OF THE DISTAL FEMUR TREATED WITH CHEMOTHERAPY, RESECTION AND PROSTHETIC RECONSTRUCTION

Purpose of this paper was to review the Rizzoli experience in prosthetic reconstruction of the knee after resection of bone tumors with special attention to major complications and functional outcome. Material: 669 knee modular uncemented prostheses were implanted between 1983 and 2006 after resection of the distal femur, total femur or proximal tibia. These prostheses include 126 first generation Kotz prosthesis (KMFTR) and 543 second generation HMRS prostheses. Methods: All patients are followed periodically in the clinic. Data for this study was obtained from clinical charts; imaging studies were reviewed with special attention to prosthesis related major complications requiring revision surgery. Revision for polyethylene wear was considered a minor complications, since it does not imply change of main prosthetic components, thus failure of the implant. Functional results were assessed according to the MSTS system. Since abrupt data could be misleading due to the oncologic population and related deaths (although 2/3 of the patients were cured or long survivors), to censore the implant unrelated events a statistical analysis of the implant survival was performed and Kaplan-Meyer curves of implant survival were studied. Results: In the 126 KMFTR group major complications included infection 13%, breakage of the stems 12%, aseptic loosening 8.7%, while revision for polyethylene wear rated 45%. In 543 HMRS prostheses major complications were infection 8%, stem breakage 2%, aseptic loosening 4%, while revision for polyethylene wear components rated 7.4%. Techniques of revisions were analyzed, as well as the outcome of revised cases, which showed that about 2/3 of the patients treated for major complications do well, although the risk for further complications is significantly incresed in revised implants. Functional results were evaluated according to the MSTS system: in KMFTR prostheses were good or excellent in 80% of the patients, while in HMRS were good or excellent in 90% of the patients. Discussion: The reduction of major complication rate with the newer designs of the modular prosthesis was statistically significant and this seems to confirm that newer materials and a modified stem design positively affected the implant survival. Also the wear of polyethylene component was dramatically decreased in the newer prosthetic design. Functional results were satisfactory in most of the patients that did not experience major complications, with a trend to improvement in the newer design. Revision surgery is technically demanding and sometimes newer ‘hybrid’ techniques are suggested, implying the use of bone allografts. Appropriate timing of revisions is crucial. An early treatment of complications can improve the final outcome.

PRIMARY AND SECONDARY RECONSTRUCTION OF THE LOWER LIMB WITH GMRS MODULAR PROSTHESES: IMPLANT SURVIVAL AND COMPLICATION IN A COMPARATIVE STATISTICAL ANALYSIS.

PROSTHETIC RECONSTRUCTION OF THE HUMERUS AFTER RESECTION OF PRIMARY TUMORS:EXPERIENCE OF THE ISTITUTO RIZZOLI IN 277 CASES

Background: bone metastases are frequent in the pelvis. Historically, the indication for surgery was very limited and is still used in selected cases. Objectives: to analyze surgery and outcome of patients with metastatic carcinoma of the pelvis. Methods: twenty-one patients with metastases of the pelvis, surgically treated between 1985 and 2009, were retrospectively reviewed. Mean age was 56 years. All patients were treated with combined therapies (radiotherapy and/or chemoteraphy and/or embolization) with the exception of one patient treated with surgery only for the inability to perform other treatments because of intercurrent medical problems unrelated with surgery. Surgery included intralesional resection (seven patients), marginal resection (two patients), wide resection (eleven patients), and external hemipelvectomy (one patient). Results: mean follow-up was 27 months (range, 1.5-152 months). Six patients were alive with no evidence of disease, 4 patients were alive with disease, and 11 patients died. The survival rate was 63% at 2 years and 30% at 5 years. Local recurrence rate was 33.3%. Conclusion: multidisciplinary treatment with radio- and chemotherapy is recommended for osseous metastases of the pelvis. Surgery has selected indications, with the aim of improving quality of life and functional outcome.

KNEE RECONSTRUCTION WITH MODULAR PROSTHESES AFTER AFTER RESECTION OF BONE TUMORS: FUNCTIONAL OUTCOME AND COMPLICATION AT LONG TERM FOLLOW UP

LONG TERM RESULTS IN KNEE RECOSTRUCTION WITH MODULAR UNCEMENTED PROSTHESES FIXED HINGE AFTER RESECTION OF BONE TUMORS: A COMPARISON OF TWO CONSECUTIVE DESIGNS OF THE SAME SYSTEM.

Background and Objectives: Thromboembolic risk in orthopedic oncology is high due to several factors. The aim of this study was to assess clinically significant thromboembolic disease in 986 patients operated on with a prosthetic reconstruction of the lower limbs after the resection of bone tumors and prophylactically treated with low-molecular-weight heparin (LMWH). Methods: Between 1983 and 2006, 986 patients had uncemented megaprostheses after a resection of the lower limbs for bone tumors. Antithromboembolic prophylaxis was always administered with LMWH from the immediate postoperative time until the time of complete weightbearing. Phlebographies and vascular ecodoppler were not performed postoperatively on a regular basis. Patients were followed in the clinic with imaging studies for several years (lower limb CT, MRI, CT of the chest for malignant tumors). The diagnosis of symptomatic venous thromboembolism (VTE) was established or excluded on clinical evidence and MRI study. Results: Among the 986 cases treated, only 11 patients (1.1%) showed a major thromboembolic event confirmed clinically and through imaging. One of these patients died with pulmonary embolism a few days after surgery. Two cases of thromboembolism occurred in patients with a vascular bypass. Conclusions: Despite general oncologic and orthopedic factors favoring VTE, the clinical occurrence of this event was extremely low in this series, probably due to a consistent and careful prophylaxis, prolonged until the time of complete weight-bearing

Purpose of this study is to analyze the results of a modular reconstructive tumor prosthesis for the lower limb (GMRS®) with a comparative statistical analysis of primary and secondary implants. Material and methods: From October 2003 to September 2007 at Rizzoli 161 GMRS® prostheses were implanted, most after resection of osteosarcoma (94 cases, 58%). It is a modular system with a rotating hinge mechanism for the knee, cemented and uncemented stems, in titanium and chromium-cobalt-molybdenum, curved and straight-fluted, with or without hydroxyapatite coating. Moreover adaptors are available to revise HMRS® implants. This series includes 88 males and 73 females ranging in age from 9 to 80 years. Sites of reconstruction were 109 distal femurs, 19 proximal femurs, 1 total femur and 32 proximal tibias. There were 149 oncologic and 12 non oncologic diagnoses, including 96 primary reconstructions and 65 revisions after failure of previous implant. A retrospective analysis of imaging and complications was performed and functional results assessed according to MSTS system. Statistical analysis with Kaplan-Meier curves was used to study implant survival. Results: At a mean follow up of 2 yrs. 106 patients are continuously NED, 31 are NED after treatment of one or more local recurrence or metastasis, 7 AWD, 5 DWD. There were 10 major complications: 8 infections (4,7%) (5 in primary and 3 in secondary implants, 2 previously infected) and 2 aseptic loosening (1,2%) (1 each). There were 9 minor complications (4 wound sloughs, 1 stiff joint, 3 disrupted extensor apparatus,1 patellar instability) requiring revision. Comparative statistical analysis of primary and secondary implants survival at major complications shows no statistically significant difference. Functional results were good or excellent in 95% of the evaluated patients, without any poor. Conclusions: Middle term results are promising: good function, very low incidence of major complications, no breakage of implant components. This prosthetic reconstruction is indicated in oncological cases as well as in selected in some non oncological settings, such as challenging revisions of prosthetic failures with massive bone loss or post-radiation non unions or allografts failures. Although a higher incidence of complications was expected in secondary implants, statistical analysis shows similar survival.

The objective of this study was to assess outcome and recurrence rate after limb-salvage surgery with reconstruction for pelvic bone tumors and analyze complications and their relationship with surgery. The authors analyzed 129 patients followed for a mean of 6 years (range, 2–19 years). Chondrosarcoma was the most frequent histotype. Thirty-one cases with no acetabular involvement were reconstructed with allograft only. Acetabular resections were reconstructed with allograft prosthetic composite (n=60), allograft only (n=11), trabecular metal components (n=2), prosthesis only (n=10), saddle prosthesis (n=11), and iliofemoral arthrodesis (n=1). Margins were wide (n=94), wide contaminated (n=22), marginal (n=7), and intralesional (n=6). Oncologic outcomes were as follows: 75 patients were continuously disease free, 6 were disease free after treatment of relapse, 13 were alive with disease, 28 were dead of disease, and 5 were dead of other causes. Survival was 66% at 10 years. Local recurrence rate of malignant tumors was 22.1% and was not statistically influenced by margins ( P =.140) or site ( P =.933). Metastasis rate was 32.8%. Deep infection was observed in 30 (23.6%) cases, with no statistical difference between reconstructions with and without allograft ( P =.09). Final external hemipelvectomy was performed in 16 cases. Newer techniques of reconstruction using stemmed acetabular cups or porous metal components combined with allograft are now available. Local control and satisfactory survival is achievable long term in patients with pelvic tumors, but this surgery implies a high rate of complications. Infection is a major complication, not influenced by the use of allografts. Amputation is rarely needed. [ Orthopedics. 2015; 38(2):87–93.]

BACKGROUND: Surgical treatment of pelvic tumors with or without acetabular involvement is challenging. Primary goals of surgery include local control and maintenance of good quality of life, but the procedures are marked by significant perioperative morbidity and complications. QUESTIONS/PURPOSES: We wished to (1) evaluate the frequency of infection after limb salvage surgical resection for bone tumors in the pelvis; (2) determine whether infection after these resections is associated with particular risk factors, including pelvic reconstruction, radiotherapy or chemotherapy, type of resection, and age; and (3) analyze treatment of these infections, particularly with respect to the need of additional surgery or hemipelvectomy. METHODS: From 1975 to 2010, 270 patients with pelvic bone tumors (149 with chondrosarcoma, 40 with Ewing's sarcoma, 27 with osteosarcoma, 18 with other primary malignant tumors, 11 with metastatic tumors, and 25 with primary benign tumors) were treated by surgical resection. Minimum followup was 1.1 years (mean, 8 years; range, 1-33 years). The resection involved the periacetabular area in 166 patients. In 137 patients reconstruction was performed; in 133 there was no reconstruction. Chart review ascertained the frequency of deep infections, how they were treated, and the frequency of resection arthroplasty or hemipelvectomies that occurred thereafter. RESULTS: A total of 55 patients (20%) had a deep infection develop at a mean followup of 8 months. There were 20 infections in 133 patients without reconstruction (15%) and 35 infections in 137 patients with reconstruction (26 %). Survivorship rates of the index procedures using infection as the end point were 87%, 83%, and 80% at 1 month, 1 year, and 5 years, respectively. Infection was more common in patients who underwent pelvic reconstruction after resection (univariate analysis, p = 0.0326; multivariate analysis, p = 0.0418; odds ratio, 1.7718; 95% CI, 1.0243-3.0650); no other risk factors we evaluated were associated with an increased likelihood of infection. Despite surgical débridements and antibiotics, 16 patients (46%) had the implant removed and five (9%) underwent external hemipelvectomy (four owing to infection and one as a result of persistent infection and local recurrence). CONCLUSIONS: Infection is a common complication of pelvic resection for bone tumors. Reconstruction after resection is associated with an increased risk of infection compared with resection alone, without significant difference in percentage between allograft and metallic prosthesis. When infection occurs, it requires removal of the implant in nearly half of the patients who have this complication develop, and external hemipelvectomy sometimes is needed to eradicate the infection. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Modular megaprostheses are now the most common method of reconstruction after segmental resection of the long bones in the lower extremities. Previous studies reported variable outcome and failure rates after knee megaprosthetic reconstructions. QUESTIONS/PURPOSES: The objectives of this study were to analyze the results of a modular tumor prosthesis after resection of bone tumor around the knee with respect to (1) survivorship; (2) failure rate; (3) comparative survivorship against different sites of reconstructions and of primary and revision implants; and (4) functional results on the Musculoskeletal Tumor Society (MSTS) scoring system. METHODS: Between 2003 and 2010, 247 rotating-hinge Global Modular Reconstruction System (GMRS) knee prostheses were implanted in our institute for malignant and aggressive benign tumors. During this time, that group represented 23% of the patients who had oncologic megaprosthesis reconstruction about the knee after resection of primary or metastatic bone tumors (247 of 1086 patients). In the other 77% of cases we used other types of oncologic prostheses. Before 2003 we used the older Howmedica Modular Resection System and Kotz Modular Femur/Tibia Replacement from 2003 we used mostly the GMRS but we continued to use the HMRS in some cases such as patients with poor prognoses, elderly patients, or metastatic patients. Sites included 187 distal femurs and 60 proximal tibias. Causes of megaprosthesis failure were classified according to Henderson et al. in five types: Type 1 (soft tissue failure), Type 2 (aseptic loosening), Type 3 (structural failure), Type 4 (infection), and Type 5 (tumor progression). Followup was at a minimum oncologic followup of 2 years (mean, 4 years; range, 2-8 years). Kaplan-Meier actuarial curves of implant survival to major failures were done. Functional results were analyzed according to the MSTS II system; 223 of the 247 were available for functional scoring (81%). RESULTS: At latest followup, among 175 treated patients for primary reconstruction, 117 are continuously disease-free, 26 have no evidence of disease after treatment of relapse, eight are alive with disease, and 24 died from disease. The overall failure rate of the megaprostheses in our series was 29.1% (72 of 247). Type 1 failure occurred in 8.5% (21 of 247) cases, Type 2 in 5.6% (14 of 247), Type 3 in 0%, Type 4 in 9.3% (23 of 247), and Type 5 in 5.6% (14 of 247). Kaplan-Meier curve showed an overall implant survival rate for all types of failures of 70% at 4 years and 58% at 8 years. Prosthetic survivorship for revisions was 80% at 5 years and for primary reconstructions was 60% at 5 years (p = 0.013). Survivorship to infection was 95% at 5 years for revision patients and 84% at 5 years for primary patients (p = 0.475). The mean MSTS score was 84 (25.2; range, 8-30) with no difference between sites of localization (24.7 in proximal tibia versus 25.4 in distal femur reconstruction; p = 0.306). CONCLUSIONS: Results at a minimum of 2 years with this modular prosthesis are satisfactory in terms of survivorship (both oncologic and reconstructive) and causes and rates of failure. Although these results seem comparable with other like implants, we will continue to follow this cohort, and we believe that comparative trials among the available megaprosthesis designs are called for. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND: The prognosis of patients with metastatic, recurrent, and/or unresectable osteosarcoma is poor. Aggressive local and medical treatments are available for palliation. Palliative treatments include isolated limb perfusion, radiation therapy, embolization, chemoembolization, thermal ablation, and cryoablation. Their aim is pain relief and tumor size reduction with minimum complications. MATERIALS AND METHODS: We present 19 patients with metastatic, recurrent, and/or unresectable osteosarcoma of the pelvis and lower lumbar spine treated with palliative selective embolization using N-2-butyl cyanoacrylate. All patients had chemotherapy. At the time of embolization, they experienced severe pain refractory to analgesics. Diagnostic angiography was performed pre-embolization to determine the vascular mapping and hemodynamic status of the tumor. Post-embolization angiography was done to evaluate for complete occlusion of the pathological vessels. Mean follow-up was 18 months. Local pain, tumor necrosis and size, and complications were recorded. RESULTS: In all patients, pre-embolization angiography showed hypervascularity of the tumor from extensive neovascularization. Five patients had repeat embolization. All patients experienced pain relief at a mean of 3 days post-embolization. No patient had recurrent pain with the intensity of that before embolization. Variable tumor necrosis was observed in follow-up imaging, and reduction in tumor size was minimum. All patients experienced pain at the site of embolization, which resolved completely 1-5 days after embolization. Four patients with pelvic osteosarcomas experienced paraesthesias at the distribution of the sciatic nerve. CONCLUSION: Selective arterial embolization is a useful local palliative treatment for patients with advanced osteosarcoma for pain relief.

Managing patients with advanced bone sarcomas - namely, recurrent, unresectable and metastatic - is mostly aimed at palliation. The role of embolisation for pain relief for these patients has not been previously reported. We therefore performed this study to emphasise the palliative role of embolisation for pain relief of advanced bone sarcoma patients.We retrospectively studied 43 patients with advanced bone sarcomas treated with palliative embolisation with N-2-butyl-cyanoacrylate from 2004 to 2011. All patients had primary treatments including chemotherapy, radiation therapy, radiofrequency thermal ablation, and/or surgery for their advanced sarcomas and were referred for embolisation as end-stage treatment for continuous severe local pain. The effect of embolisation was evaluated with a pain score scale and analgesic use. Mean follow-up was 7 (range, 1-19) months); all patients were dead at the last follow-up.In all patients, angiography showed increased pathological vascularisation of the sarcomas; three to six feeding vessels were embolised in each procedure. Almost complete pain relief and50% reduction in analgesic use was experienced by 36 patients with highly hypervascular sarcomas and sarcomas in the pelvis and shoulder girdle. Moderate pain relief and 50% reduction in analgesic use was experienced by seven patients with spinal and sacral lesions. Within the available follow-up, no patient had recurrent pain with the same intensity as before embolisation. All patients experienced ischaemic pain at the site of embolisation that resolved completely with analgesics. Six patients with advanced pelvic bone sarcomas experienced paraesthesias at the distribution of the sciatic nerve that resolved completely with methylprednisolone.Embolisation is a safe and effective local palliative treatment for patients with advanced sarcomas, providing optimum pain relief with the least discomfort and the possibility of minor complications only.

no abstract available

Radiation-induced sarcomas are rare, high-grade sarcomas that may arise within the radiation volume at a mean latency period of 3-55 years after radiation therapy, doses of which range from 45 to 60 Gy. Radiation-induced osteosarcomas, fibrosarcomas, and malignant fibrous histiocytomas are the most common. Extensive surgery with microscopically negative-margin resection, or amputation is recommended for improved survival. Adjuvant radiation therapy and chemotherapy have not been shown to improve survival rates significantly. The prognosis is poor.

Purpose To evaluate the clinical and imaging effect of selective embolization using N -butyl cyanoacrylate (NBCA) as palliation for bone metastases. Materials and Methods The procedures and effect of 309 embolizations performed in 243 patients were retrospectively analyzed; 56 patients had repeat embolization at the same location at 1–3 months; 197 patients had embolization for progressive bone metastases after radiation therapy. The mean tumor diameter before embolization was 7.8 cm (range 5–30 cm). In all patients, embolizations were performed under local anesthesia through transfemoral catheterization using NBCA in 33% ethiodized oil. The technical success of embolization was evaluated by angiography after completion of the procedure. The clinical and imaging effect was evaluated at follow-up examinations with a pain score scale and use of analgesics, hypoattenuating areas, tumor size, and ossification. Results In all 309 embolizations, postprocedural angiography showed complete occlusion of metastatic blood supply and greater than 80% devascularization of the lesions. Greater than 50% reduction of pain score and analgesic doses was achieved in 97% of procedures. The mean duration of pain relief was 8.1 months (range 1–12 months). The mean maximal tumor diameter after embolization was 5.5 cm (range 2–20 cm). Variable ossification appeared in 65 patients. Postembolization syndrome, ischemic pain at the site of embolization, paresthesias, skin breakdown, and subcutaneous necrosis were observed in 87 patients. Conclusions Selective embolization with NBCA is a safe and effective palliative treatment for metastatic bone lesions of various primary cancers; pain relief is temporary.

Paget's disease is a disorder of bone remodelling affecting 1-2% of the general population, most frequently men over 50 years of age. Sarcomatous degeneration occurs in 0.1-0.95% of patients with Paget's disease. It can be observed in monostotic and polyostotic disease. Osteosarcomas account for more than 80% of pagetic sarcomas; osteoblastic pagetic osteosarcomas are rare. In this article, we present the case of a 75-year-old man with secondary osteosarcoma arising in monostotic Paget's disease, initially misdiagnosed as rotator cuff tendinopathy. Imaging studies and biopsy were diagnostic.

Long bone pathological fractures in patients with primary and metastatic bone tumours are difficult to treat and their management may alter the prognosis of the disease and jeopardize survival. The aim of this article was to review the relevant studies reporting on the management of tumour patients with pathological fractures of the long bones, to discuss the most suitable approach in these patients, to highlight specific treatment recommendations, and finally based on this analysis and our clinical practice, to propose a treatment algorithm for decision making and treatment. © 2010 Elsevier Ltd. All rights reserved.

Introduction: Biopsy of the musculoskeletal system is useful in the management of bone lesions particularly in oncology but they are often challenging procedures with a significant risk of complications. Computed tomography (CT)-guided needle biopsies may decrease these risks but doubts still exist about their diagnostic accuracy. This retrospective analysis of the experience of a single institution with percutaneous CT-guided biopsy of musculoskeletal lesions evaluates the results of these biopsies for bone lesions either in the appendicular skeleton or in the spine, and defines indications. Materials and methods: We reviewed the results of 2027 core needle biopsies performed over the past 18 years at the authors' institution. The results obtained are subject of this paper. Results: In 1567 cases the correct diagnosis was made with the first CT-guided needle biopsy (77.3% accuracy rate), in 408 cases the sample was not diagnostic and in 52 inadequate. Within 30 days these 408 patients underwent another biopsy, which was diagnostic in 340 cases with a final diagnostic accuracy of 94%. Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, flogistic, and systemic pathologies. There were 22 complications (18 transient paresis, 3 haematomas, 1 retroperitoneal haematoma) which had no influence on the treatment strategy, nor on patient outcome. Conclusion: This technique is reliable and safe and should be considered nowadays the gold standard for biopsies of the musculoskeletal system.