Giuseppe Bianchi

Percutaneous CT-guided biopsy of the spine: results of 430 biopsies

Biopsies of lesions in the spine are often challenging procedures with significant risk of complications. CT-guided needle biopsies could lower these risks but uncertainties still exist about the diagnostic accuracy. Aim of this retrospective study was to evaluate the diagnostic accuracy of CT-guided needle biopsies for bone lesions of the spine. We retrieved the results of 430 core needle biopsies carried out over the past fifteen years at the authors’ institute and examined the results obtained. Of the 430 biopsies performed, in 401 cases the right diagnosis was made with the first CT-guided needle biopsy (93.3% accuracy rate). Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, inflammatory, and systemic pathologies. There were only 9 complications (5 transient paresis, 4 haematomas that resolved spontaneously) that had no influence on the treatment strategy, nor on the patient’s outcome. In conclusion we can assert that this technique is reliable and safe and should be considered the gold standard in biopsies of the spine.

Outcome of the intramedullary diaphyseal segmental defect fixation system for bone tumors

Resection of diaphyseal malignant bone tumors is indicated for local control and impending pathological fracture or failure of prophylactic internal fixation. However, there are no large, long‐term studies analyzing the results of intercalary reconstruction using segmental metallic spacers.

Cell Electroporation in Bone Tissue

Electroporation in the cell membrane occurs following exposure to a high-intensity electric field. Electroporation can be used to introduce large molecules into the cell or to induce cell apoptosis by the application of the electric field alone, provided that the cell damage is such that it cannot be recovered. Electroporation use in clinical practice is standardized in association with drugs, electrochemotherapy, for the treatment of cutaneous and subcutaneous tumor nodules. Effective tumor ablation requires complete membrane electroporation of all malignant cells to allow drug diffusion into the cytoplasm. We investigated the impact of the presence of bone trabeculae on electric field effect and whether the mineralized component of the bone prevented the use of electroporation to eradicate tumor cells in bone tissue. We evaluated the possibility of efficiently performing electroporation of osteoblasts and osteocytes, as well as of cells interspersed among bone trabeculae. On healthy rabbits, the effect of electroporation on the distal femoral epiphysis, an area of high osteogenetic activity, was investigated by histological and functional analysis. In bone tissue, complete cell ablation by electroporation was achieved when the absorbed energy dose in the tissue exceeded 3,500 J/Kg. This threshold value was reached with all electric fields tested by increasing the number of pulses delivered. The results of the preclinical investigation set the rationale for the use of electrochemotherapy in patients with bone metastases. Preliminary experience with the use of electrochemotherapy for bone metastases in patients will be discussed.

Osteoid osteoma simulating an osteocartilaginous exostosis

We describe a case of osteoid osteoma in the tibia of a 3-year-old patient who presented with a clinical and radiographic picture that suggested an exostosis. The formation of osteoid osteoma with a radiographic picture similar to that of osteophytes or exostosis has been previously documented only rarely. The authors hypothesize that the exostosis-like formation observed was actually the calcification of soft tissues that formed after the intense periosteal inflammatory reaction caused by the osteoid osteoma. As a result of its peculiar clinical and radiographic presentation, diagnosis of this lesion was delayed. Being located close to the medial growth plate of the tibia, it caused lengthening of the limb with a pronounced valgus deviation of the knee. An excisional biopsy provided histological evidence, clinical resolution and immediate pain relief, but incomplete resolution of the valgus deformity of the knee.

Parosteal osteosarcoma mimicking osteochondroma: A radio-histologic approach on two cases

ObjectiveParosteal osteosarcoma is a well-differentiated variant of osteosarcoma that affects the surface of the bone. The imaging pattern is very typical. We report two cases mimicking an osteochondroma, radiologically and histologically and propose an explanation.MaterialThe review of 86 parosteal osteosarcomas of bone revealed this atypical pattern only once. A consultation case was received in the same time, and added to ours. Patients were 28 years old and 56 years old females. Imaging studies included two radiographs, two CTscans, one MRI examination and one bone scan and the results were compared to histology.ResultsOn imaging, both lesions presented as ossified lobulated masses attached with a broad base to the underlying cortex. No radiolucent cleft separated the masses and the host bone and cortex continuity between the mass and the femur was seen, with medullary communication. The marrow of the mass had a different density and intensity compared to normal marrow. So, there were features of an osteochondroma (cortex and medullary continuity) and of a parosteal osteosarcoma (ossified marrow). Pathological assessment on the final specimen confirmed the presence of low-grade parosteal osteosarcomas, after an erroneous diagnosis of osteochondroma on the initial biopsy.ConclusionsParosteal osteosarcoma can be rarely confused with osteochondroma. A radiologic-pathologic correlation is essential. Cortex continuity is the most misleading imaging feature that may occur in parosteal osteosarcomas. A knowledge of this misleading pattern will help diagnose the lesion from the beginning.

Adjuvant radiotherapy with brachytherapy boost in soft tissue sarcomas

Purpose The standard primary treatment for soft tissue sarcoma (STS) is a wide surgical resection, preceded or followed by radiotherapy. Purpose of this retrospective study was to assess the efficacy of perioperative brachytherapy (BRT) plus postoperative external beam radiation therapy (EBRT) in patients with intermediate-high risk STS. Material and methods BRT delivered dose was 20 Gy. External beam radiation therapy was delivered with 3D-technique using multiple beams. The prescribed dose was 46 Gy to the PTV. Neoadjuvant and adjuvant chemotherapy (CHT) was used in patients with potentially chemosensitive histological subtypes. The primary aim of the study was to analyze overall survival (OS) and local control (LC) in a large patient population treated with surgery, perioperative BRT, and adjuvant EBRT ± CHT. Secondary objective was to identify prognostic factors for patients outcome in terms of LC, disease-free survival (DFS), and OS. Results From 2000 to 2011, 107 patients presenting 2-3 grade (FNLCC) primary or recurrent STS were treated with surgery, perioperative BRT, and adjuvant EBRT ± CHT. Five-year LC and OS were 80.9% and 87.4%, respectively. At univariate analysis, a higher LC was recorded in primary vs. recurrent tumors (p = 0.015), and in lower limb tumors vs. other sites (p = 0.027). An improved DFS was recorded in patients with lower limb tumors vs. other sites (p = 0.034). Conclusions The combination of BRT and EBRT was able to achieve satisfactory results even in a patients population with intermediate-high risk STS. Patients with recurrent or other than lower limb sited tumors show a worse LC.

Is unicondylar osteoarticular allograft still a viable option for reconstructions around the knee

BACKGROUND Unicondylar osteoarticular allografts (UOAs) represent a possible technique for reconstructing massive bone defects around the knee when only one condyle is affected. The aim of this retrospective study is to evaluate the outcome of UOAs and describe the possible salvage procedures in case of graft failure. METHODS Twenty-five deep-frozen UOAs were implanted at Rizzoli Orthopedic Institute (Bologna, Italy). Twenty-two followed bone tumor resection, two cases were post-traumatic defects and one case followed UOA failure. Mean age at surgery was 33years (range: 15 to 63). Eighteen UOAs were in distal femur, seven in proximal tibia. RESULTS Three patients died (only one because of the tumor). One UOA was removed for chondrosarcoma relapse and one for allograft fracture. Mean overall survival with UOA failure as a primary endpoint was 129months (range 12 to 302), with differences in the femur (85%) and in the tibia (40%) at 150months. Six UOAs had to be converted into knee prostheses due to osteoarthritis after a mean follow-up of 146months. No complications were recorded in UOAs converted into knee prostheses after a mean three year follow-up. Fourteen patients with UOAs still in place at the last follow-up (mean 123months) were radiologically and functionally evaluated: no correlation was found between function and the degree of osteoarthritis. CONCLUSIONS In selected cases, UOAs offer good clinical results and postpone the need for knee prosthesis. Despite short-term encouraging results, longer-term follow-up is needed in order to evaluate the outcome of knee prosthesis after UOA.

Sonication Improves the Diagnosis of Megaprosthetic Infections

Limited data are available for the diagnosis of patients with tumors with infected endoprosthetic reconstructions. The purpose of this study was to evaluate whether sonication is effective for the diagnosis of infection and to compare it with tissue cultures. The files of 58 patients who underwent revision surgery for suspected infected endoprosthetic reconstructions were reviewed. Cultures were performed on 5 tissue samples obtained from each patient and on fluid obtained by sonication of the megaprosthesis. The sensitivity, specificity, and negative and positive predictive values of tissue and sonication fluid cultures were evaluated. Overall, tissue and sonication fluid cultures confirmed an infection in 42 of the 58 patients. In 36 of the 42 infected endoprosthetic reconstructions, tissue and sonication fluid cultures identified the same bacterial isolate. In 5 cases, a bacterial isolate was identified only in sonication fluid cultures, and in 1 case, a bacterial isolate was identified only in tissue cultures. The sensitivity and negative predictive value of sonication fluid cultures were statistically significantly better than those of tissue cultures, while the specificity and positive predictive value were not different between the 2 culture types. Compared with tissue cultures for the diagnosis of infected megaprostheses in patients with tumors, sonication fluid cultures are associated with a better sensitivity and negative predictive value and a similar specificity and positive predictive value. Therefore, sonication should be considered a useful adjunct for the optimal diagnosis and management of these patients. [Orthopedics. 2019; 42(1):28-32.].

Can radical margins improve prognosis in primary and localized epithelioid sarcoma of the extremities

Epithelioid sarcoma (ES) has a tendency to locally recur, spread proximally, and metastasize, in particular to lymphnodes and lungs. The aim of this report is to study the role of surgery and the extent of margins required for optimal management of patients with localized epithelioid sarcoma of the extremities.

Is Arthrodesis a Reliable Salvage Option following Two-Stage Revision for Suspected Infection in Proximal Tibial Replacements? A Multi-Institutional Study

The aim of this multicentric retrospective study was to verify whether knee arthrodesis (KA) is a viable reconstructive option after two-stage revision for infection of proximal tibia (PT) endoprosthetic reconstruction (EPR). Sixty patients who underwent a two-stage revision were included. Definitive EPR or a KA with a modular system was performed following consideration of soft tissue and extensor mechanism conditions. Patients were evaluated with Musculoskeletal Tumor Society Score and Oxford Knee Score. Implant survival was assessed on the basis of recurrence of infection. Five patients did not receive any reconstruction after the first stage. In 14 cases, a KA was performed, and in 41, an EPR was implanted. At 5 years follow-up, reinfection rate in the KA group was lower (10 vs. 17.5% in KA and EPR groups, respectively). In reinfected patients, the KA group had a reduced rate of amputation when compared with those with EPR (50 vs. 88%). Functional evaluation did not show any significant differences between the two groups. A successful KA using a modular implant can eradicate infection and allow preservation of the limb with good function and good pain relief in after two-stage revision for an infected PT EPR.