Maria Silvia Spinelli

Physiopathology of spine metastasis.

The metastasis is the spread of cancer from one part of the body to another. Two-thirds of patients with cancer will develop bone metastasis. Breast, prostate and lung cancer are responsible for more than 80% of cases of metastatic bone disease. The spine is the most common site of bone metastasis. A spinal metastasis may cause pain, instability and neurological injuries. The diffusion through Batson venous system is the principal process of spinal metastasis, but the dissemination is possible also through arterial and lymphatic system or by contiguity. Once cancer cells have invaded the bone, they produce growth factors that stimulate osteoblastic or osteolytic activity resulting in bone remodeling with release of other growth factors that lead to a vicious cycle of bone destruction and growth of local tumour.

Physiopathology of Bone Modifications in β-Thalassemia

β-thalassemia major (βTM) or Cooley anemia is characterized by significantly reduced or absent synthesis of β-globin chains, which induces important pathologic consequences including hemolytic anemia, altered erythropoiesis, and bone marrow overstimulation. The pathogenesis of bone changes in patients with βTM is not yet completely understood. However, an unbalance in bone mineral turnover resulting from increased resorption and suppression of osteoblast activity has been detected in βTM patients. The abnormal regulation of bone metabolism may be related to hormonal and genetic factors, iron overload and iron chelation therapy, nutritional deficits, and decreased levels of physical activity. Here, we review the most recent findings on the physiopathology of bone abnormalities in βTM. Clinical presentation and radiological features of βTM-related bone changes are also discussed.

Infection following bone tumor resection and reconstruction with tumoral prostheses: a literature review.

Bone resection is the choice treatment of malignant bone tumors. Tumor prosthesis is one of the most common solutions of reconstruction following resection of bone tumor located to the metaphysis of long bones. Periprosthetic infections are a frequent complication of limb-salvage surgery which is largely due to prolonged and repeated surgeries, as well as to the immunocompromised condition of these patients due to neoplastic treatment. Furthermore, the large exposure of tissues during this type of surgery and the dissection across vascular distributions also contributes to the high risk of infection. The authors reviewed the literature discussing the incidence of infections of tumor prosthesis implanted following resection of bone tumors, taking into account the different sites of implantation. In the English literature, the highest risk of infection which led to limb amputation was observed after proximal tibia resection and this difference was considered to be due to the poor condition of soft tissue and also after pelvic resection due to huge dead space after sarcoma resection not filled by implant. Independent of the location, the management of infected prosthesis is similar. That is, after one or more attempts at debridement and antibiotic therapy, it consists of implant removal and insertion of a new implant in a one- or two-stage procedure, with a decreased risk of failure with the two-stage procedure.

Management of long bone metastases: recommendations from the Italian Orthopaedic Society bone metastasis study group

The purpose of this article is to outline the current approach to patients affected by metastasis to the long bones and to present a clinical and surgical algorithm available for clinicians and for future research. A modern approach to patients affected by long bone metastasis in fact requires a multidisciplinary contest where oncologists, radiotherapists, surgeons and physical therapists cooperate with a shared vision, in order to provide the best possible integrated treatments available. The authors of this article constitute the Bone Metastasis Study Group of the Italian Orthopaedic Society (SIOT): a national group of orthopedic tumor surgeons who are dedicated to studying the approach, techniques and outcomes of surgery for metastatic tumours of the musculoskeletal system.

Surgical treatment of impending and pathological fractures of tibia

Advances in adjuvant and neoadjuvant therapies have improved the prognosis of cancer patients leading to an increasing incidence of bone metastases and consequent long bone fractures. In the present study the authors consider the indications and the different surgical options of treatment of tibial pathological lesions. 13 patients (14 lesions, 6 pathological fractures), treated according to histotype and lesion localisation, were retrospectively evaluated. Using generic outcome instruments such as the Eastern Cooperative Oncology Group (ECOG) and Quality of life questionnaire of European Organization for Research and Treatment of Cancer (QLQ-C30) pain, mobility and use of analgesics were evaluated before and after surgery. In all patients, mechanical stabilisation of the osteolytic lesion was achieved. There were no pathological fractures, and no implant mechanical failure. All patients reported pain relief, with a relevant reduction in the amount of analgesics used. Surgical treatment of tibial metastases has to be decided taking into consideration the histotype, localisation of the metastases and life expectancy. The treatment has to be all-encompassing in a solitary lesion in patients with a good prognosis but less invasive in plurimetastatic patients with poor prognosis. Acquisition of good mechanical stability is crucial for a successful outcome.

Local adjuvants in surgical management of bone metastases.

Curettage is one of the most common method for surgical treatment of bone metastasis. Local adjuvant improve most commonly used for improving the effect of curettage in local cancer surgery may exerted their effects either chemically either physically; in Orthopedic Oncology the most common are phenol, liquid nitrogen, laser, and cement. This article reviewed the main characteristics of the most common chemical and physical agents used in bone oncology, emphasizing the toxic effects of some of them, especially phenol and liquid nitrogen.

Infective complications in tumour endoprostheses implanted after pathological fracture of the limbs.

INTRODUCTION Pathological fractures represent an adverse prognostic factor in primary and metastatic bone tumours. The purpose of this study was to evaluate the results of tumour silver-coated prosthesis implanted after pathological fractures. MATERIALS AND METHODS A retrospective analysis was conducted on 30 patients with pathological limb fracture after primary or metastatic bone tumours treated by the same surgeon with wide margin resection and tumour prosthesis implant between 2005 and 2015. Silver-coated prostheses were implanted in 17 patients and uncoated prostheses were implanted in 13 patients. The primary outcome of the study was to evaluate the infective risk, the secondary outcomes were survival and functional level (visual analogue scale [VAS], 36-Item Short Form Health Survey [SF 36], and Musculoskeletal Tumour Society [MSTS] score) obtained at the longest follow-up available. A multivariate analysis was performed considering age, sex, tumour histology, grading and location, resection size, concomitant radiotherapy/chemotherapy, use of mesh for soft tissue reconstruction and local complications (dislocation, relapse, implant breakage). Scanning electron microscopy (SEM) analysis of explanted prosthesis was performed to study the residual silver-coating. RESULTS The average age of patients in the study was 56.2 years (range 12-78 years). Silver-coated prostheses were implanted in 56.7% of patients, and uncoated tumour prostheses were used in the remaining 43.3%. The mean follow-up was 40.7 months. A total of 26.7% of patients died at a median time of 28.6 months after surgery. The overall rate of complications was 30%, with 16.7% due to infection. A total of 11.8% of the patients treated with silver-coated implants developed infection compared with 23.1% of the patients treated with uncoated tumour prostheses. There were no cases of early infection in the silver-coated prosthesis group, whereas early infection occurred in 66.7% of patients in the uncoated prosthesis group. All the functional outcomes were significantly improved after surgery. None of the other parameters analysed can be considered a significant negative prognostic factor for infection. The SEM analyses showed severe silver-coating degradation 2 years after first implant. No case of silver toxicity was demonstrated. DISCUSSION There are few papers in the literature about infective complications in tumour prosthesis after pathological fracture. Silver-coated implants showed a protective action against early infection. Late infection rate was similar between the groups, thereby indicating a reduction of antimicrobial activity for the silver-coating over time. CONCLUSIONS Silver-coated prostheses are a protective factor against early infections in limb salvage surgery after pathological fractures, so may represent the first-choice of implants in this type of surgery.

Management of patients with metastasis to the vertebrae: recommendations from the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group

The purpose of this article is to outline the current approach to patients affected by metastasis to the spine and to present a clinical and surgical algorithm available for clinicians and for future research. A modern approach to the patients affected by spinal metastasis in fact requires a multidisciplinary contest where oncologists, radiotherapists, surgeons and physical therapists cooperate with shared vision to provide the best possible integrated treatments available. The authors of this article constitute the Bone Metastasis Study Group of the Italian Orthopaedic Society (SIOT): a national group of orthopedic tumor surgeons who are dedicated to studying the approach, techniques and outcomes of surgery for metastatic tumors of the musculoskeletal system.

Morphological Modifications in Osteoarthritis: A Scanning Electron Microscopy Study

The chondrocyte, the only cellular component of adult articular cartilage, plays a key role in the pathogenesis of osteoarthritis (OA). The evolution of this process is very slow: the first changes involve the cell-matrix morphofunctional unit known as chondron. In this study we analyzed the cartilage of 10 patients with primary osteoarthritis. The cartilage was retrieved during total knee replacement (TKR) and maxillofacial surgery procedures. All patients presented an osteoarthritis of at least grade III. The preparation of the specimens was made by taking cartilage from both well-preserved and macroscopically degenerated areas. Specimens underwent histological evaluation with conventional staining and ultrastructural analysis. Age appeared to be a high risk factor in the development of articular cartilage damages. Depth of injury was also found to be age-related as more extensive lesions were found in the elderly, either in the knee or in the mandibular condyle. Whatever the cause of possible damage, Scanning Electron Microscopy (SEM) observations showed that at the beginning most degenerative changes in articular cartilage involved the chondron unit, a concept first introduced by Benninghoff. These changes generally go through three phases. During OA progression all degenerative changes begin from the chondron, which is why it is extremely important to understand the molecular anatomy and physiology of this pericellular microenvironment and its form, function and failure in adult articular cartilage. It is also fundamental to understand the mechanism of adaptation of the cartilage and bone disruptions, given the physiological relationship between these tissues, essential to maintain normal joint structure and function.

Clinical management and surgical treatment of distal fibular tumours: a case series and review of the literature

PurposeStudy reports clinical and functional outcomes of surgical treatment in a case series of nine patients with distal fibular tumours.MethodsNine patients with distal fibular tumours were observed between 2005 and 2010. A PubMed search was performed using the terms “fibula”, “lower limb tumour [cancer]”, “sarcoma”, “Ewing”, “peroneal”, “fibular metastasis”, and “limb-salvage surgery”.ResultsIn all our patients, lesions were unilateral. All patients complained of pain; limping was present in 5 of 9 tumours. Patients were managed surgically, except one who underwent local radiotherapy. In six patients, a benign or tumor-like lesion was detected. Malignancies consisted of metastatic lung adenocarcinoma (two cases) or multifocal mesenchymal cancer (one case). Non-malignant lesions were treated by curettage and filling, followed by internal fixation when needed. In malignant or locally aggressive lesions, metadiaphyseal fibular resection was performed. The literature search retrieved either case reports or small case series, reflecting the rarity of distal fibular tumours. Surgical treatment was successful in all patients with benign lesions, whereas the rate of success was 40–100 % in case of malignancies.ConclusionsGiven the low incidence of distal fibular tumours, controversies exist about the optimal surgical management. Clinical observation and imaging should be reserved to asymptomatic benign lesions. In non-malignant tumours causing pain, limping, and pathological fractures; in malignancies, surgery is recommended. Finally, in patients with asymptomatic lesions of uncertain nature, biopsy and histological examination should be performed to plan appropriate management.