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Background Tendinosis at the origin of the direct head of rectus femoris causing anterior hip pain is termed AIISpinitis, but no study has investigated its imaging findings. The aim of the present study was to determine the characteristic imaging findings of AIISpinitis and clarify their pathological significance. Methods We reviewed the preoperative imaging findings of 62 hips in 58 patients who had undergone endoscopy with a diagnosis of AIISpinitis. The origin of the direct head of rectus femoris was evaluated by ultrasound (US) and magnetic resonance imaging (MRI), and the positive rate of abnormal findings and their agreement with endoscopy regarding injury of the direct head of rectus femoris were measured. Signal changes in the fat pad around the anterior inferior iliac spine (AIIS fat pad) in MRI were compared with the pathological findings of that harvested endoscopically. Results Hypoechoic regions in US (53/62, 85%) and signal change in MRI (55/62, 89%) were observed with high frequency and corresponded with injury of the direct head of rectus femoris observed by endoscopy (58/62, 94%) (kappa coefficient, 0.43 [moderate agreement], 0.69 [good agreement] respectively). Hypoechoic regions had high sensitivity (85%) and specificity (86%) for AIISpinitis. Regarding the AIIS fat pad, punctate and completely hypo-intense change relative to normal fat corresponded to fibrosis and scar formation, respectively (weighted kappa coefficient, 0.51 [moderate agreement]). Conclusions Hypoechoic regions on US which had high sensitivity and specificity; and signal change at the origin of the direct head of rectus femoris and hypo-intensity of the AIIS fat pad on MRI were characteristic findings of tendinosis of the direct head of rectus femoris. These findings correspond pathologically to injury of the direct head of rectus femoris and fibrosis or scar formation in the AIIS fat pad, respectively.

Purpose The role of chemotherapy (CT) and radiotherapy (RT) for management of extraskeletal osteosarcoma (ESOS) remains controversial. We examined disease outcomes for ESOS patients and investigated the association between CT/RT with recurrence and survival. Patients and methods Retrospective review at 25 international sarcoma centers identified patients ≥18 years old treated for ESOS from 1971 to 2016. Patient/tumour characteristics, treatment, local/systemic recurrence, and survival data were collected. Kaplan–Meier survival and Cox proportional-hazards regression and cumulative incidence competing risks analysis were performed. Results 370 patients with localized ESOS treated definitively with surgery presented with mainly deep tumours (n = 294, 80%). 122 patients underwent surgical resection alone, 96 (26%) also received CT, 70 (19%) RT and 82 (22%) both adjuvants. Five-year survival for patients with localized ESOS was 56% (95% CI 51%–62%). Almost half of patients (n = 173, 47%) developed recurrence: local 9% (35/370), distant 28% (102/370) or both 10% (36/370). Considering death as a competing event, there was no significant difference in cumulative incidence of local or systemic recurrence between patients who received CT, RT, both or neither (local p = 0.50, systemic p = 0.69). Multiple regression Cox analysis showed a significant association between RT and decreased local recurrence (HR 0.46 [95% CI 0.26–0.80], p = 0.01). Conclusion Although the use of RT significantly decreased local recurrences, CT did not decrease the risk of systemic recurrence, and neither CT, nor RT nor both were associated with improved survival in patients with localized ESOS. Our results do not support the use of CT; however, adjuvant RT demonstrates benefit in patients with locally resectable ESOS.

Osteosarcoma (OS) is a highly malignant bone tumor and the prognosis for non‐responders to chemotherapy remains poor. Previous studies have shown that human sarcomas contain sarcoma‐initiating cells (SIC), which have the characteristics of high tumorigenesis and resistance to chemotherapy. In the present study, we characterized SIC of a novel OS cell line, screened for SIC‐related genes, and tried to regulate the proliferation of OS by metabolic interference. Initially, we established a new human OS cell line (OS13) and isolated clones showing higher tumorigenesis as SIC (OSHIGH) and counterpart clones. OSHIGH cells showed chemoresistance and their metabolism highly depended on aerobic glycolysis and suppressed oxidative phosphorylation. Using RNA‐sequencing, we identified LIN28B as a SIC‐related gene highly expressed in OSHIGH cells. mRNA of LIN28B was expressed in sarcoma cell lines including OS13, but its expression was not detectable in normal organs other than the testis and placenta. LIN28B protein was also detected in various sarcoma tissues. Knockdown of LIN28B in OS13 cells reduced tumorigenesis, decreased chemoresistance, and reversed oxidative phosphorylation function. Combination therapy consisting of a glycolysis inhibitor and low‐dose chemotherapy had antitumor effects. In conclusion, manipulation of glycolysis combined with chemotherapy might be a good adjuvant treatment for OS. Development of immunotherapy targeting LIN28B, a so‐called cancer/testis antigen, might be a good approach., Osteosarcoma‐initiating cell antigen LIN28B was expressed in sarcoma tissues. ES, epithelioid sarcoma; MFS, myxofibrosarcoma; OS, osteosarcoma; SS, synovial sarcoma.

Background: Arthroscopic labral repair is an effective treatment for femoroacetabular impingement (FAI) and acetabular labral injury. However, the effectiveness of physiotherapy treatment is controversial. Previous studies that analyzed the outcome of physiotherapy for patients with FAI or acetabular labral tears did not consider damaged tissues or the severity of the acetabular labral tear. This study aimed to evaluate (1) the short-term outcome of physiotherapy in patients with acetabular labral tears confirmed by magnetic resonance imaging (MRI) and (2) the effectiveness of physiotherapy according to the severity of the labral tear.Methods: Thirty-five patients who underwent physiotherapy for symptomatic acetabular labral tears from August 2013 to July 2018 were enrolled. We evaluated the severity of the acetabular labral tears, which were classified based on the Czerny classification system using 3-T MRI. Clinical findings of microinstability and extra-articular pathologies of the hip joint were also examined. Outcome scores were evaluated using the International Hip Outcome Tool 12 (iHOT12) at pre- and post-intervention.Results: The mean iHOT12 score significantly improved from 44.0 to 73.5 in 4.7 months. The post-intervention iHOT12 scores were significantly higher than the pre-intervention scores at stages I (pre 51.0, post 74.4; P=0.004) and II (pre 44.8, post 81.2; PP=0.061). Furthermore, 7 patients (20.0%) had positive microinstability tests, and 22 (62.9%) had findings of extra-articular pathologies. Of 35 patients, 8 (22.9%) underwent surgical treatment after failure of conservative management, of whom 4 had Czerny stage III.Conclusions: Physiotherapy significantly improved the iHOT12 score of patients with acetabular labral tears in the short-term period. In patients with severe acetabular labral tear, improvement of clinical score by physiotherapy may be poor. Identifying the severity of acetabular labral tears can be useful in determining treatment strategies.

AimsThe aims of this study were to analyse the long-term outcome of vascularised fibular graft (VFG) reconstruction after tumour resection and to evaluate the usefulness of the method.Patients and MethodsWe retrospectively reviewed 49 patients who had undergone resection of a sarcoma and reconstruction using a VFG between 1988 and 2015. Their mean follow-up was 98 months (5 to 317). Reconstruction was with an osteochondral graft (n = 13), intercalary graft (n = 12), inlay graft (n = 4), or resection arthrodesis (n = 20). We analysed the oncological and functional outcome, and the rate of bony union and complications.ResultsFive- and ten-year overall survival rates were 89% and 86%, respectively. Local recurrence occurred in two patients. Eight patients developed pulmonary metastases. Bone union was achieved in 44 patients (90%). Fracture occurred in six patients (12%), infection in three (6%), and nonunion in five (10%). The mean Musculoskeletal Tumor Society (MSTS) scores were as follows: osteochondral graft 70%; intercalary graft 73%; inlay graft 89%; and resection arthrodesis 83%.ConclusionAlthough associated with a relatively high rate of complications, each reconstruction method is useful, with a high rate of successful limb salvage and a good long-term functional outcome. Cite this article: Bone Joint J 2017;99-B:1237–43.

Purpose: A clinical feature of myxofibrosarcoma is local recurrence, but knowledge about distant metastasis is sparse. We evaluated the tendency of clinical and histological features of metastasis in myxofibrosarcoma patients. Methods: Fifty-eight patients with myxofibrosarcoma were treated in our hospitals, and a total of 16 consecutive patients with distant metastases were included in this retrospective study (9 males and 7 females, with a mean age of 77 years). Because there was no patient complicated by both lung and lymph node metastases, we compared the age, sex, tumor size and location, French Federation of Cancer Centers Sarcoma Group (FNCLCC) grade, American Joint Committee on Cancer (AJCC) stage, and times of the first metastasis from the initial examination between the lung and lymph node groups. In addition, we examined factors affecting the prognosis. Results: The median follow-up period was 42.9 months (range 8–142). Eleven of 16 patients developed pulmonary metastases. The sites of extra pulmonary metastases were the lymph nodes in 5 patients, bone in 1, subcutaneous in 1, intramuscular in 1, and peritoneum in 1. The median time for patients to develop distant metastases was 17.4 months (range 0–59). The time until the onset of the first metastasis in the lung metastasis group was significantly shorter than in the lymph node group (p

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis. It is characterized by multiple xanthogranulomatous masses throughout the body, predominantly in the tibia. One of the characteristic radiological findings of the lesions associated with ECD is a "coated artery," which is often observed in the aorta. Although approximately one-fourth of ECD cases involve the central nervous system (CNS), an intracranial-coated artery has only been reported in four cases. We report a case of ECD that involves the CNS and has the unique appearance of a coated vertebral artery (VA). These tumors entirely encase the bilateral VAs without stenosis and are attached to the dura. Cranial magnetic resonance imaging also showed multiple extra-axial tumors in the cavernous sinus, the frontal convexity, and the orbital cavity. Further investigation revealed additional extracranial lesions around the cervical carotid artery, at the bilateral tibia, and at the elbow joint. A biopsy of the cervical and tibial lesions confirmed ECD. Steroid therapy resulted in a month-long improvement of preoperative symptoms. However, the patient's condition gradually progressed and he died of pneumonia 1 year after ECD diagnosis. The encasement of the intracranial artery by the tumor without stenosis and the dural attachment suggest ECD, which requires whole body investigation.

Purpose To evaluate the results of carbon ion radiation therapy administered to 188 patients with unresectable primary sacral chordomas. Patients and methods One hundred eighty-eight patients were treated with carbon ion radiation therapy at a single institute between 1996 and 2013 and retrospectively analyzed. The median age was 66 years. The highest proximal invasion reached past S2 level in 137 patients. The median clinical target volume was 345 cm(3). One hundred six patients received 67.2 gray equivalents (GyE)/16 fractions (fr), 74 patients received 70.4 GyE/16 fr, 7 patients received 73.6 GyE/16 fr, and 1 patient received 64.0 GyE/16 fr. Results The median follow-up period was 62 months (range, 6.8-147.5 months). Seventy percent of patients were followed for 5 years or until death. The 5-year local control, overall survival, and disease-free survival rates were 77.2%, 81.1%, and 50.3%, respectively. Forty-one patients had a local recurrence. Sex, tumor volume, level of proximal invasion, and irradiated dose were unrelated to local control. There was grade 3 toxicity of the peripheral nerves in 6 patients and grade 4 toxicity of the skin in 2 patients. Ambulation remained in 97% of patients. Conclusions Carbon ion radiation therapy was safe and effective for unresectable chordoma and provided good local control and survival while preserving ambulation.

Background: Although abduction of the acetabular component is considered to predict factors for polyethylene wear attributable to osteolysis, other radiographic factors have yet to be elucidated. The purpose of the present study was to evaluate whether anteversion or change in implantation angle of the acetabular component influences polyethylene linear wear by using standing and supine radiographs of the hip joint. Methods: Standing and supine plain anteroposterior radiographs of 62 hip joints in which cementless total hip arthroplasty was performed were examined for polyethylene linear wear rate (mm/year), pelvic inclination, and radiological inclination and anatomic anteversion of the acetabular component. Results: All correlation coefficients of measurements of polyethylene linear wear, pelvic inclination angle, anatomical anteversion angle and radiological inclination angle were calculated highly. And by the three-dimensional numerical analysis, anatomic anteversion of the acetabular component had at least some effect on the degree of polyethylene wear. Conclusion: This study suggests that increased anteversion of the acetabular component reduces polyethylene linear wear in metal-on-polyethylene total hiparthroplasty.

Groin pain is a common problem that is known to be a complex issue. The wide variety of possible pathologies in numerous anatomical structures contributes to this complexity. For patients who have anterior hip pain in Patrick's test and tenderness at Scarpa's triangle, we perform periarticular debridement based on the hypothesis that rectus femoris tendinosis, subacute/chronic fibrosis of the anterior inferior iliac spine fat pad, and gluteal muscle adhesion are responsible for such anterior hip pain. This Technical note illustrates the surgical procedure of periarticular debridement for extra-articular pathology-associated anterior hip pain. Repair of the injured labrum and correction of femoroacetabular impingement deformity have never been performed in this cohort. Arthroscopic periarticular debridement is a reliable surgical technique that can relieve anterior hip pain and provide a rapid to return to normal activities.

We present a technique of posterior femoral longitudinal split (FLS) osteotomy. This technique allows the expansion of the metaphyseal–diaphyseal region of the proximal femur facilitating extraction of well-fixed extended porous-coated stems. The extractions were performed using extended transfemoral osteotomy (ETO) and FLS osteotomy between June 2002 and March 2014. The study group, which comprised patients with well-fixed extended porous-coated stems, consisted of two men and ten women with an average age of 63.2 years. The stem was successfully removed using the FLS procedure in 8 of the 10 hips. Reimplantation surgery was performed in 6 of the 12 hips with ARMD, periprosthetic infection, or metallosis. This FLS technique may allow the easy removal of well-fixed extended porous-coated stems and become an alternative method for the removal of all stems.

Background CD109, a TGF-β co-receptor, is reported to be preferentially expressed during the early stages of tumorigenesis in several carcinoma types. Myxofibrosarcoma is one of the most common soft-tissue sarcomas found in elderly patients. This study aimed to elucidate the impact of CD109 expression in myxofibrosarcoma on prognosis and recurrence. Methods Immunohistochemical staining for CD109 was performed on archival specimens from 37 patients. The Fisher exact test was used to evaluate association between CD109 expression and other clinicopathological features. Survival analysis was performed using Kaplan–Meier curves, and the prognostic significance was evaluated using the log-rank test. Multivariate analysis of factors was performed using Cox regression analysis. Results CD109 overexpression was significantly associated with surgical stage and distant metastasis (P = 0.00499, and 0.011, respectively). The frequency of CD109 overexpression was approximately 10% and CD109 overexpression was significantly associated with decreased overall survival (P = 0.004). Five-year overall survival rates 77% and 0% for CD109-negative and CD109-positive patients, respectively. In multivariate analysis, CD109 overexpression was the only independent risk factor for poor outcome (P = 0.02; hazard ratio, 10.64; 95% confidence interval, 1.47–76.91). Conclusions Immunohistochemical CD109 expression in myxofibrosarcoma was associated with poor prognosis. J. Surg. Oncol. 2015 111:975–979. © 2015 Wiley Periodicals, Inc.

The objective of this study was to investigate the association between ligamentum teres injury and the hip joint cartilage damage pattern in patients with femoroacetabular impingement.We compared articular cartilage damage between ligamentum teres-intact and-ruptured hips. Data were collected for 77 consecutive patients with femoroacetabular impingement who underwent hip arthroscopy. The locations of the chondral lesions were recorded on anatomic articular maps using the geographic zone method. The patients were divided into 2 groups (ligamentum teres-intact and-injured groups), and the incidence and degree of cartilage injury were compared between the 2 groups by use of the Mann-Whitney U test.In patients with ligamentum teres injury, chondral damage extended to the middle-inferior area of the acetabulum (7.6% [grade 1] in ligamentum teres-intact group and 66.6% [grade 1, 12.1%; grade 2, 42.4%; grade 3, 12.1%] in ligamentum teres-injured group, P.01) and the apex of the femoral head (anterior apex: 7.1% [grade 1, 3.8%; grade 2, 3.3%] in intact group and 42.4% [grade 1, 30.3%; grade 2, 12.1%] in injured group, P.01; middle apex: 7.6% [grade 1, 3.8%; grade 2, 3.8%] in intact group and 63.5% [grade 1, 42.4%; grade 2, 18.1%; grade 3, 3.0%] in injured group, P = .04; posterior apex: 7.6% [grade 1, 3.8%; grade 2, 3.8%] in intact group and 42.4% [grade 1, 30.3%; grade 2, 12.1%] in injured group, P.01).This study showed the association between ligamentum teres injury and articular cartilage damage in the inferior middle part of the acetabulum and the apex of the femoral head in patients treated for femoroacetabular impingement.Level IV, case-control study.

Chordomas are rare, low grade, malignant tumours derived from the ectopic remnants of the notochord that line the axial skeleton. They are characterised by their slow growth, long disease course and propensity for local relapse. Furthermore, up to 40% of non-cranial chordomas metastasise. We describe the first reported case of a hand metastasis arising from a conventional sacral chordoma after carbon ion radiotherapy. The common occurrence of distant metastasis with chordomas makes it important to perform a systemic examination, in part because their resection might improve patient prognosis.

Soft tissue angiofibroma (STA), a recently suggested new histologic entity, is a benign fibrovascular soft tissue tumor composed of bland spindle-shaped tumor cells with abundant collagenous to myxoid stroma and branching small vessels. The lesion has a characteristic AHRR-NCOA2 fusion gene derived from chromosomal translocation of t(5;8)(p15;q13). However, morphologically similar tumors containing abundant fibrovascular and myxoid stroma can complicate diagnosis. We designed an original DNA probe for detecting NCOA2 split signals on fluorescence in situ hybridization (FISH) and estimated its utility with 20 fibrovascular tumors: 4 each of STAs, solitary fibrous tumors (SFTs), and cellular angiofibromas and 3 each of low-grade myxofibrosarcomas, myxoid liposarcomas, and low-grade fibromyxoid sarcomas. We also performed FISH for 13q14 deletion and immunohistochemistry (IHC) staining for estrogen receptor, progesterone receptor, retinoblastoma protein, and MUC-4 expression. Furthermore, IHC for Stat6 was conducted in the 20 cases analyzed by FISH and in an additional 26 SFTs. We found moderate to strong nuclear Stat6 expression in all SFTs but no expression in the other tumors. Both estrogen receptor and progesterone receptor expressions were observed in STAs, SFTs, and cellular angiofibromas. Expression of retinoblastoma protein was found in less than 10% of cells in all tumor types except myxoid liposarcoma. The low-grade fibromyxoid sarcomas were strongly positive for MUC-4. All STAs showed NCOA2 split signals on FISH. All tumors, regardless of histologic type, had 13q14 deletion. The NCOA2 FISH technique is a practical method for confirming STA diagnosis. The combination of NCOA2 FISH and Stat6 IHC proved effective for the differential diagnosis of STA, even when using small biopsy specimens.

The treatment of unresectable multiple lung metastasis of giant cell tumor of bone (GCTB) is challenging. In the current manuscript, we present a case who presented with multiple lung metastases of GCTB and was successfully managed with the use of denosumab allowing for surgical resection of the metastatic lesions that was previously deemed unresectable. Pathologic examination also clearly demonstrated the histological effects of denosumab. We emphasize on effective response to denosumab even in metastatic GCTB.

MRI is the most sensitive imaging modality in the staging, surgical planning, and following up of malignant soft tissue tumors. However, the ability of MRI to separate benign from malignant lesions is still of limited value for this purpose. We often observe that benign soft tissue tumors are accompanied by a peritumoral fat signal on MRI. The purpose of this study was to determine the value of the peritumoral fat signal in separating benign from malignant soft tissue tumors. We retrospectively reviewed 121 patients with soft tissue tumors (52 men, 69 women; median age 54 years). Two musculoskeletal oncologists reviewed the MRI independently and reported on the presence or absence of a peritumoral fat signal. The sensitivity, specificity, and the positive and negative predictive values of the peritumoral fat signal for the prediction of benignancy of soft tissue tumors were calculated. Peritumoral fat signals were identified in 54 of 64 (84.3 %) benign and 10 of 57 (17.5 %) malignant tumors (p

Athroscopic treatment of acetabular labral tears is commonly performed for these patients. However, conservative treatment is generally considered to be the first choice of the treatment. We analyzed the clinical and radiological factors contributing to failure of conservative treatment of acetabular labral tears. In this study, 75 patients (82 hips) with positive physical symptoms and radiologic evidence of labral tears were enrolled. All patients underwent conservative treatment for at least 6 weeks. Surgical treatment was carried out if the hip pain was not completely relieved. Clinical and radiological factors contributing to failure of conservative treatment were evaluated using univariate and multivariate analysis. There were 37 patients who improved with nonsurgical treatment, and the remaining patients (47 hips) underwent surgery (6 periarticular osteotomy, 11 partial debridement, and 28 labral refixation). Multivariate analysis indicated that the factor contributing to the response to conservative treatment was a tear of the ligamentum teres (p

Pleomorphic rhabdomyosarcoma is a rare and aggressive variant of rhabdomyosarcoma that usually occurs only in adults aged 45 years or older. Gastric metastasis from a soft-tissue sarcoma of the extremity is likewise very rare, with only a few previously reported cases. Here, we describe the case of a 52-year-old man with gastric metastasis who underwent en bloc excision of the primary tumor and distal gastrectomy but died 6 months after surgery due to lung metastases. This is, to our knowledge, the first reported case of gastric metastasis from pleomorphic rhabdomyosarcoma of the extremity. In cases such as these, patients may have widespread disease, and thus, surgery may only have a limited role in its management.

Neurolymphomatosis is a rare manifestation of malignant lymphoma. The involvement of peripheral nerves has mostly been described as dissemination of a systemic lymphoma. In contrast, primary peripheral nerve lymphoma is extremely rare. A 68-year-old man presented in January 2014 with a sensory disturbance in the left lower extremity. There were no obvious findings on MRI or CT that could account for his symptoms. After 1 year of symptomatic treatment, the patient was managed conservatively for an additional year. However, his symptoms worsened. FDG-PET/CT showed high FDG uptake in the left sciatic nerve. Biopsy of the lesion revealed diffuse large B cell lymphoma.

It is necessary to clarify the prognostic factor for the patients with osteosarcoma to improve their clinical results. Many research works have been published in several fields including clinical, molecular, and genetic aspect and immunology.

Background We followed up four patients receiving reconstructive hip arthrodesis with a free-vascularized fibular graft (FVFG) for malignant bone tumor in order to restore lower limb function after wide resection of the periacetabular bone tumor.

Fifteen fresh frozen cadavers were used for a simulation of the modified Watson-Jones anterolateral approach in an anatomical study. Several parameters were measured to evaluate the relation between the piriformis tendon insertion and hip joint capsule insertion. The anteroposterior diameter of the piriformis tendon was found to be greater than the medial–lateral diameter, and that the posterior part of the incised hip joint capsule is distant from the piriformis tendon as the piriformis is inserted into the extra-articular portion. We also found that it was important not to dissect the anteroproximal portion of the greater trochanter to prevent rupture of the piriformis tendon, whereas the posterior portion was relatively safe. Clin. Anat. 26:610–613, 2013. © 2012 Wiley Periodicals, Inc.

Giant cell tumor of the sacrum is extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. In this manuscript, we report an early clinical result of a case of giant cell tumor of the sacrum successfully managed with selective arterial embolization. A 56-year-old woman underwent selective embolization for management of giant cell tumor of the sacrum. Radiologically, massive shrinkage of the extraosseous mass and increased peripheral ossification were obvious. Clinically, rapid pain relief was achieved and gait disability recovered. At final follow-up 28 months after completion of treatment, she retained normal activity in daily life. We stress the effectiveness of selective arterial embolization as a less invasive and less complicated primary treatment of giant cell tumors of the sacrum.

We undertook a prospective study to evaluate the prognostic significance of the serum levels of vascular endothelial growth factor (VEGF) in predicting the survival of patients with osteosarcoma. The levels were measured by an enzyme-linked immunosorbent assay in 15 patients with osteosarcoma before commencing treatment. The patients were divided into two groups, with a high or a low serum VEGF level, and the incidence of metastases and overall survival rate were compared. No significant relationship was observed between the serum VEGF levels and gender, age, the size of the tumour or the response to pre-operative chemotherapy. Patients with a serum VEGF > 1000 pg/ml had significantly worse survival than those with a level < 1000 pg/ml (p = 0.002). The serum VEGF level may be useful in predicting the prognosis for survival in patients with osteosarcoma.

The periosteal chondrosarcoma is an uncommon juxtacortical malignant bone tumor. Most are low-grade (grade 1), and their relatively good prognosis is emphasized even if treatment is local resection. Once periosteal chondrosarcomas recur, however, the grade of malignancy may become higher and it may be diffi cult to excise the tumor completely. Therefore, it is important to demonstrate the extent of the tumor accurately. We report a case of grade 2 periosteal chondrosarcoma of the femur and focus on tumor invasion into the underlying cortex.

Background We retrospectively reviewed 137 consecutive total hip arthroplasties performed with AML-A stems and Tri-Lock cups to see whether design modifications made to these components would achieve durable biological fixation in the Japanese population in whom developmental dysplasia of the hip (DDH) is relatively common. Patients from our initial clinical series using these components are available for more than 10 years’ follow-up. Methods Between April 1988 and June 1994, we performed 137 total hip arthroplasties using the AML-A prosthesis for the patients with osteoarthritis of the hip joint. We excluded 26 hips with less than 10 years’ follow-up and five hips from patients who died before the 10-year follow-up. The mean follow-up for the 105 remaining THAs is 155.2 months (range 120–237 months). The average age of these patients at the time of surgery was 53.1 years (range 22–81 years). Results In total, 17 THAs required component revisions. In seven cases, the first revision was limited to a liner exchange for polyethylene wear or osteolysis. Another seven hips underwent revision surgery for recurrent dislocation. Three cups have been revised owing to aseptic loosening. Because of the high incidence of wear-related revisions, Kaplan-Meier survivorship at the 15-year follow-up, using acetabular component revision for any reason as an endpoint, was 75.0% (95% CI 69.4%–83.8%). In contrast, no revision of the femoral stem was performed. Severe stress shielding occurred in 12 hips. Thigh pain was mild, however, and all of the femoral stems remained stable. Conclusions Despite revisions for wear-related complications, the fixation achieved with these porous-coated components remained durable throughout the 15-year follow-up. Acetabular osteolysis has been associated with cup reoperation, but femoral stress shielding has never resulted in stem loosening.

We evaluated triple-phase bone scintigraphy in the differential diagnosis of peri-prosthetic infection in 46 patients with a total hip replacement or bipolar hemiarthroplasty who were due for revision surgery. There were 18 men and 28 women, with a mean age at operation of 64.6 years (28 to 81). We defined peri-prosthetic infection as an increased uptake of radioisotope in all the phases of triple-phase bone scintigraphy and validated these results against the histological and/or microbiology results in every case. The positive and negative predictive values for the presence of infection were 83% and 93%, respectively. The diagnostic sensitivity was 88% and the specificity was 90%. This study indicates that triple-phase bone scintigraphy is a useful tool in the detection of peri-prosthetic infection and offers a cost-effective method of screening.

To develop peptide-based immunotherapy for osteosarcoma, we previously identified papillomavirus binding factor (PBF) as a cytotoxic T lymphocytes (CTL)-defined osteosarcoma antigen in the context of human leukocyte antigen (HLA)-B55. In the present study, we analyzed the distribution profile of PBF in 83 biopsy specimens of osteosarcomas and also the prognostic impact of PBF expression in 78 patients with osteosarcoma who had completed the standard treatment protocols. Next, we determined the antigenic peptides from PBF that react with peripheral T lymphocytes of HLA-A24+ patients with osteosarcoma. Immunohistochemical analysis revealed that 92% of biopsy specimens of osteosarcoma expressed PBF. PBF-positive osteosarcoma conferred significantly poorer prognosis than those with negative expression of PBF (P = 0.025). In accordance with the Bioinformatics and Molecular Analysis Section score, we synthesized 10 peptides from the PBF sequence. Subsequent screening with an HLA class I stabilization assay revealed that peptide PBF A24.2 had the highest affinity to HLA-A24. CD8+ T cells reacting with a PBF A24.2 peptide were detected in eight of nine HLA-A24-positive patients with osteosarcoma at the frequency from 5 × 10−7 to 7 × 10−6 using limiting dilution/mixed lymphocyte peptide culture followed by tetramer-based frequency analysis. PBF A24.2 peptide induced CTL lines from an HLA-A24-positive patient, which specifically killed an osteosarcoma cell line that expresses both PBF and HLA-A24. These findings suggested prognostic significance and immunodominancy of PBF in patients with osteosarcoma. PBF is the candidate target for immunotherapy in patients with osteosarcoma. (Cancer Sci 2008; 99: 368–375)

Background We have previously offered data suggesting a positive linkage of postoperative up-regulation of systemic angiogenic activity and postoperative progression of pulmonary metastasis in osteosarcoma. The finding that the significant down-regulation of endostatin was critical in angio-genic elevation after primary tumor removal suggests that endostatin is a candidate for antiangiogenic therapy for osteosarcoma. Methods In the current study, we evaluated the effect of anti-angiogenic therapy using endostatin on postoperative progression of pulmonary metastasis from osteosarcoma. Mouse osteosarcoma cell line LM 8 cells were inoculated in subcutaneous layer of nude mice. Two weeks after tumor inoculation, the primary tumor was removed surgically, and antiangiogenic therapy using adenovirus encoding endostatin expression vector (Ad5CMV-mEnd) was performed. Two weeks after the antiangiogenic treatment, pulmonary metastasis was evaluated by counting the number of metastatic nodules. The evaluation of systemic angiogenic activity was performed using Matrigel plug assay. Results Two weeks after the viral injection, mice were sacrificed, and the macroscopic pulmonary metastases were counted. Notably, the number of pulmonary metastases was smaller in the mice injected with Ad5CMV-mEnd than in controls, accompanied by significant suppression of systemic angiogenic activity. In addition, the sizes of the pulmonary metastases of the mice injected with Ad5CMV-mEnd were smaller than in the control group. Conclusions Our results indicate that antiangiogenic therapy using endostatin has the potential to prevent postoperative progression of pulmonary metastasis from osteosarcoma. Although this therapeutic strategy cannot provide a cure for osteosarcoma, it should enable osteosarcoma patients to coexist with dormant pulmonary metastasis and lead to improvement of their prognosis.

Acetabular chondral carpet delamination is a frequent finding at hip arthroscopy. The cartilage is macroscopically normal but deboned from the subchondral bone, without a disruption at the chondrolabral junction. Arthroscopic anatomic repair of delaminated cartilage is challenging. We propose that a combination of microfracture and use of stitches to press the delaminated cartilage against the subchondral bone using a suture limb offers an effective method to provide an environment for cartilage repair. This article describes the technique of bridging suture repair for carpet delamination in detail; the technique enables the surgeon to stabilize the delaminated acetabular cartilage. Intra-articular soft anchors and an acetabular rim knotless anchor footprint provide a stable repair for delaminated cartilage. This technique is especially helpful in cases with acetabular cartilage carpet delamination.

With the goal of establishing efficacious peptide-based immunotherapy for patients with bone and soft tissue sarcomas, we previously identified the cytotoxic T lymphocyte-defined osteosarcoma antigenic gene Papillomavirus binding factor. The present study was designed to determine the status of HLA class I expression in osteosarcoma and other bone and soft tissue sarcomas. Seventy-four formalin-fixed paraffin-embedded specimens of various bone and soft tissue sarcomas, including 33 osteosarcomas, were stained with the anti-HLA class I monoclonal antibody EMR8-5, which we recently generated. The expression of HLA class I was lost or downregulated in 46 of these specimens (62%). With respect to osteosarcoma, loss or downregulation of HLA class I expression was seen in 13 (52%) of 25 primary tumors and seven (88%) of eight metastatic tumors. In six of 11 HLA class I-negative osteosarcoma specimens, the expression of beta-2 microglobulin was also lost. Subsequently the prognostic significance of HLA class I expression was analyzed in 21 patients with osteosarcoma who had completed multidrug neoadjuvant chemotherapy and undergone adequate surgery. Patients with osteosarcoma highly expressing HLA class I showed significantly better overall and event-free survival than those with HLA class I-negative osteosarcoma. In contrast, such prognostic significance of HLA class I expression was not found in 15 patients with malignant fibrous histiocytoma of soft tissue. These findings suggest that the class I-restricted cytotoxic T lymphocyte pathway plays a major role in immune surveillance of patients with osteosarcoma.

We retrospectively reviewed 11 hip arthroplasties in 7 patients receiving long-term (15 years) hemodialysis for chronic renal failure. Osteonecrosis of the femoral head, osteoarthritis, and amyloid arthropathies were treated by total hip arthroplasty (THA) or bipolar hemiarthroplasty (BHA) using cementless anatomic medullary locking stem. The average follow-up period was 8 years and 3 months (range, 3-13 years). The D'Aubigne and Postel hip score was restored to 14.5 postoperatively from 7.7 preoperatively. All femoral cementless components achieved bone-ingrown fixation. Although 1 BHA resulted in central migration, there was no loosening of the cementless acetabular component. We are encouraged by the predictable long-term stability of the bone-implant interface achieved by cementless fixation with an extensively coated implant. Cementless THA remains a useful treatment option for patients on long-term hemodialysis.

Concomitant tumour resistance (CTR) is a unique phenomenon in which animals harbouring large primary tumours are resistant to the growth of smaller metastatic tumours by systemic angiogenic suppression. To examine this clinically, in ten patients with osteosarcoma, we investigated the effects of removal of the primary tumour on the development of pulmonary metastases, the systemic angiogenesis-inducing ability and the serum levels of several angiogenesis modulators. We found that removal of the primary tumour significantly elevated systemic angiogenesis-inducing ability in five patients who had post-operative recurrence of the tumour. Post-operative elevation of the angiogenesis-induced ability was suppressed by the addition of an angiogenic inhibitor, endostatin. Also, primary removal of the tumour decreased the serum levels of vascular endothelial growth factor and endostatin. These findings suggest, for the first time, the presence of CTR in patients with osteosarcoma for whom postoperative antiangiogenic therapy may be used to prevent the post-operative progression of micrometastases.

Background It is generally believed that tumor size is an indicator that predicts whether the tumor is benign or malignant. Small size tumor tends to be a benign tumor compared to large tumor more than 5 cm in diameter. This often leads an unplanned inadequate resection.

A retrospective review was conducted of giant cell tumors treated between 1984 and 1998 using the technique of aggressive curettage through a large bone window followed by acrylic cement reconstruction. Fifteen patients with a mean follow-up time of 46 months (range, 24–188 months) were identified. One patient had a local recurrence 24 months postoperatively. All the patients showed a radiolucent zone at the bone–cement interface up to 2.5 mm in width during the first 6 months after operation. However, the radiolucent zones were nonprogressive and did not affect the stability of the bone cement. Osteoarthritis of the knee joint occurred 14 years postoperatively in one patient with an intraarticular fracture at presentation. A stress fracture occurred in one patient who had the largest tumor in the distal femur. Acrylic cement reconstruction is a safe and effective procedure that provides local adjuvant therapy. Giant cell tumors with an associated intraarticular fracture remain a challenging problem to treat.

To investigate the clinical significance of circulating angiogenic factors, especially in association with early relapse of osteosarcoma, we quantified pre-therapeutic levels of vascular endothelial growth factor, basic fibroblast growth factor and placenta growth factor in the sera of 16 patients with osteosarcoma using an enzyme-linked immunosorbent assay. After a 1-year follow-up, the serum level of angiogenic factors was analysed with respect to microvessel density of the biopsy specimen and clinical disease relapse. The serum vascular endothelial growth factor levels were positively correlated with the microvessel density with statistical significance (P=0.004; Spearman rank correlation) and also significantly higher in seven patients who developed pulmonary metastasis than the remaining nine patients without detectable disease relapse (P=0.0009; The Mann–Whitney U-test). In contrast, the serum levels of basic fibroblast growth factor or placenta growth factor failed to show significant correlation with the microvessel density or relapse of the disease. Although there was no significant correlation between serum vascular endothelial growth factor levels and the tumour volume, the serum vascular endothelial growth factor levels were significantly higher in patients with a vascular endothelial growth factor-positive tumour than those with a vascular endothelial growth factor-negative tumour. These findings suggest that the pre-therapeutic serum vascular endothelial growth factor level reflects the angiogenic property of primary tumour and may have a predictive value on early disease relapse of osteosarcoma. British Journal of Cancer (2002) 86, 864–869. DOI: 10.1038/sj/bjc/6600201 www.bjcancer.com © 2002 Cancer Research UK

CD109, a TGF-β co-receptor, is reported to be preferentially expressed during the early stages of tumorigenesis in several carcinoma types. Myxofibrosarcoma is one of the most common soft-tissue sarcomas found in elderly patients. This study aimed to elucidate the impact of CD109 expression in myxofibrosarcoma on prognosis and recurrence.Immunohistochemical staining for CD109 was performed on archival specimens from 37 patients. The Fisher exact test was used to evaluate association between CD109 expression and other clinicopathological features. Survival analysis was performed using Kaplan-Meier curves, and the prognostic significance was evaluated using the log-rank test. Multivariate analysis of factors was performed using Cox regression analysis.CD109 overexpression was significantly associated with surgical stage and distant metastasis (P = 0.00499, and 0.011, respectively). The frequency of CD109 overexpression was approximately 10% and CD109 overexpression was significantly associated with decreased overall survival (P = 0.004). Five-year overall survival rates 77% and 0% for CD109-negative and CD109-positive patients, respectively. In multivariate analysis, CD109 overexpression was the only independent risk factor for poor outcome (P = 0.02; hazard ratio, 10.64; 95% confidence interval, 1.47-76.91).Immunohistochemical CD109 expression in myxofibrosarcoma was associated with poor prognosis.