Mark T. Scarborough

Resection Arthrodesis of the Knee with an Intercalary Allograft

Thirty-nine patients who had a malignant or an aggressive benign bone tumor about the knee were managed with a resection arthrodesis with use of an intercalary allograft fixed with an intramedullary nail. In thirty-one patients, this was the method chosen for the initial reconstruction after resection of the tumor. In eight patients, another type of reconstruction had already failed. Both the proximal and the distal allograft-host junction healed and the functional outcome was satisfactory in thirty-two patients. Non-union developed in seven patients: at one junction in six patients and at both junctions in one. In five patients, the non-union healed after bone-grafting, repeat internal fixation, or replacement of the allograft. An above-the-knee amputation was done for two patients, both of whom had had a chronic non-union. One patient had a local recurrence, and it was treated with an above-the-knee amputation.

Allograft-prosthesis Composite Versus Megaprosthesis in Proximal Femoral Reconstruction

A review of 33 patients who underwent proximal femoral resection for primary bone tumor and reconstruction with an allograft-prosthesis composite or a megaprosthesis is presented to consider the relative merits of the 2 procedures. Clinical function, reconstruction survival, and associated complications were analyzed. Eighteen composites in 16 patients and 18 megaprostheses in 17 patients were analyzed. Infection in the composite group and instability in the megaprosthesis group were the common causes of failure and removal of reconstructions. The average functional evaluation in 14 surviving patients with composites was 87% of normal. In 10 surviving patients with megaprostheses, the average function was 80% when complications were avoided. Survival analysis of the patients with reconstructions showed a 10 year survival of 76% for the patients with composites and 58% for those with megaprostheses. Both composite and megaprosthetic reconstruction of the proximal femur seem to function equally well from the perspective of function and survival because no statistically significant difference could be shown by this review.

Percutaneous Radiofrequency Ablation of Osteoid Osteoma

Osteoid osteoma is a benign bone tumor. Patients usually require surgical treatment for reliable pain relief. Difficulties with intraoperative localization of the tumor and anatomic locations that carry a high morbidity with en bloc resection complicate open surgery. Various methods have been developed to lessen the invasiveness of surgery including computed tomography-guided percutaneous radiofrequency thermal ablation. Eleven patients in three different centers were evaluated and diagnosed with osteoid osteoma based on typical histories, physical examinations, and imaging studies. All patients were treated with computed tomography-guided percutaneous radiofrequency thermal ablation after medical treatment failed. Excellent pain relief was reported in 10 patients. One patient suffered recurrence of a femoral neck lesion despite an initial 7-month period without pain. Patients were given a questionnaire to quantify the effectiveness of percutaneous radiofrequency ablation in terms of pain relief and return to function. The current study shows that percutaneous radiofrequency thermal ablation provides reliable, excellent pain relief and early return to function with minimal morbidity as compared with traditional open techniques. The authors suggest that this technique be used for all patients with extraspinal osteoid osteomas that are not immediately adjacent to neurovascular structures.

Giant cell tumor of bone.

Objective:To discuss the treatment and outcomes for giant cell tumor (GCT) of bone. Materials and Methods:Review of the pertinent literature. Results:GCT is a rare benign bone lesion most often found in the extremities of women in the third and fourth decades of life. Surgery is the mainstay of treatment and usually consists of intralesional curettage; local control rates range from 80% to 90% after this procedure. Patients with extensive, recurrent, and/or biologically more aggressive tumors may require wide excision. A small subset of patients with incompletely resectable GCTs or with lesions that are surgically inaccessible may be treated with moderate-dose radiotherapy (45–50 Gy) and have a 65% to 80% likelihood of being locally controlled. Conclusion:The majority of patients with GCTs are effectively treated with intralesional curettage. Wide excision or radiotherapy is necessary to cure a relatively limited subset of patients with extensive, aggressive, and/or incompletely resectable GCTs.

Multicentric giant cell tumor of bone

Giant cell tumor of bone accounts for 4% to 5% of primary bone tumors in the United States. Multicentric giant cell tumors occur in <1% of all patients with giant cell tumors, and only 43 patients with multicentric giant cell tumor have been reported on in the literature. This series presents 3 additional cases of multicentric giant cell tumor, includes updated data for 2 patients previously reported on in the literature, and reviews 24 cases previously reported on in detail in the literature. The mechanism by which giant cell tumor involves multiple locations is not known. Multicentric giant cell tumor, in contrast to unifocal giant cell tumor, has a tendency to involve the hands, feet, and metaphysis/diaphysis of long bones and to occur in a slightly younger population. In 15 of the 29 patients reviewed, a second lesion did not develop for >2 years after their initial presentation. Eighteen of those 29 patients had >2 sites of tumor involvement, 1 of whom had 11 lesions. Two of the 5 patients in the authorsseries presented with a spectrum of disease activity, with latent, active, and aggressive lesions present throughout the observation period.

Giant cell tumor of the pelvis and sacrum: 17 cases and analysis of the literature.

The optimal treatment of giant cell tumors of the pelvis and sacrum is controversial. Our current patient series was combined with cases identified in a review of the literature published in the past 50 years, yielding a combined group of 239 lesions for study. Recurrence rates were 49% for patients who had radiation therapy alone, 47% for patients who had surgery with intralesional margins, 46% for patients who had surgery with intralesional margins and radiation therapy, and 0% for patients who had surgery with wide margins. Six percent of patients had benign lung metastases develop, 2% of patients had secondary malignancies, 2% of patients died in the perioperative period, and less than 1% of patients had multicentricity. Radiation-induced sarcoma developed in 11% of patients who received radiation for primary or recurrent lesions. Larger doses of radiation therapy did not decrease the rate of local recurrence. Recurrence after surgery and radiation was not lower than after either treatment alone. Local recurrence was more likely in the patients with sacral tumors (48%) than in the patients with pelvic tumors (34%). Disease status was worse in the patients with sacral lesions (23% died of disease) than in the patients with pelvic lesions (6% died of disease).

Radiation therapy for giant cell tumors of bone.

For giant cell tumors of bone, does radiotherapy provide a safe and effective treatment? This retrospective review includes 24 patients with 26 histologically diagnosed tumors treated with megavoltage radiotherapy between March 1972 and July 1996. Of the 10 recurrent tumors, five had an intralesional resection, two had a biopsy, and three had no biopsy before radiotherapy. Of the 16 previously untreated tumors, one was irradiated after a marginal resection, five after an intracapsular resection, and 10 after biopsy alone. The total doses ranged from 35 to 55 Gy (median, 43 Gy) in fractions of 1.67 to 2.33 Gy per day. Twenty of 26 tumors (77%) were controlled locally. All of the local recurrences occurred within the irradiated field. Five of six patients with local recurrence were treated successfully with additional surgery. Salvage surgery after local recurrence required amputation of an extremity in three patients and a total knee replacement in one patient. The ultimate local control rate was 96% with one patient alive with progressive disease. Lung metastases in one patient were treated successfully with surgery, chemotherapy, and radiotherapy. In one patient a radiation-induced sarcoma developed 22 years after treatment. The authors conclude that radiation therapy is a safe and effective treatment option for benign giant cell tumors of bone. A total dose greater than 40 Gy is the only variable found to significantly influence local control.

Radiotherapy for local control of aggressive fibromatosis

PURPOSE To evaluate local control rates in patients treated with radiotherapy for aggressive fibromatosis. METHODS AND MATERIALS Fifty-three patients with histologically confirmed aggressive fibromatosis were treated with radiotherapy at the University of Florida between march 1975 and June 1992. The minimum length of follow-up was 2 years; 81% of the patients had follow-up for at least 5 years. The lesions arose in an extremity or limb girdle (39 patients), the trunk (10 patients), or the head and neck area (4 patients). Twenty-four patients were treated for gross disease and 29 for presumed microscopic residual disease after one or more operations. Patients were treated with total doses between 35 and 70 Gy; 83% of patients received 50 to 60 Gy. RESULTS Local control was achieved in 23 of 29 patients (79%) treated postoperatively for microscopic residual disease and in 21 of 24 patients (88%) treated for gross disease; gross disease was controlled in all 8 patients with previously untreated lesions and in 13 of 16 patients treated postoperatively for gross residual or recurrent disease. Overall, aggressive fibromatosis was locally controlled in 83% of treated patients. All nine treatment failures occurred in patients with extremity lesions 4 to 68 months after initiation of treatment. Three recurrences were in the irradiated field, two were out of the field, and four were at the field margin. Eight patients were salvaged with surgery alone or combined with postoperative radiotherapy. A functional limb was maintained in 38 of 39 patients with extremity or limb girdle lesions. Pathologic fracture occurred in three patients; two patients required rod fixation for treatment. CONCLUSIONS Radiotherapy is a valuable adjunct to surgery in the management of aggressive fibromatosis and can be used alone in patients with unresectable or inoperable disease.

Malignant bone tumors.

Malignant bone tumors represent a small percentage of cancers nationwide and also are much less common than malignant soft-tissue tumors. The rarity of the condition makes it imperative that orthopaedic surgeons in nononcologic practices are able to recognize the symptoms that suggest a possible bony malignancy to avoid inappropriate or delayed treatment. The most common primary malignant bone tumors, osteosarcoma and Ewings sarcoma, occur in childhood. Chondrosarcoma occurs more frequently in older adults. Rare tumors such as chordoma and adamantinoma have anatomic predilections for the sacrum and tibia, respectively. The primary symptom of a patient with a malignant bone tumor is pain, which often occurs at rest or at night. There are also characteristic findings on physical examination such as swelling or decreased joint range of motion. Patients with a likely malignancy require thorough staging to determine the extent of disease and a well-planned biopsy for accurate diagnosis. The biopsy can be an image-guided needle biopsy or an open incisional biopsy. Knowledge of specific tumor characteristics and treatment options for osteosarcoma, Ewings sarcoma, chondrosarcoma, malignant fibrous histiocytoma, chordoma, and adamantinoma is important. Patients with osteosarcoma and resectable Ewings sarcoma are treated with chemotherapy followed by surgical resection. Secondary sarcomas can occur in previously benign bone lesions and require aggressive treatment. Specific techniques are available for the resection of malignant bone tumors from the upper extremities, lower extremities, pelvis, and spine. Reconstruction options include the use of allografts, megaprostheses, and vascularized autografts. There has been a trend toward more prosthetic reconstructions because of early complications with allografts. The care of patients with primary malignant bone tumors requires a multidisciplinary approach to treatment. The orthopaedic oncologist is a vital member of a team composed of musculoskeletal radiologists and pathologists, radiation oncologists, medical and pediatric oncologists, and microvascular surgeons.

External beam radiotherapy for primary and adjuvant management of aggressive fibromatosis

PURPOSE To review a large single-institution experience in the management of aggressive fibromatosis to determine the effectiveness of external beam radiotherapy (EBRT) and identify the presentation and treatment variables predictive of locoregional control. METHODS AND MATERIALS Between 1975 and 2000, 72 patients were treated with EBRT for a pathologically confirmed diagnosis of aggressive fibromatosis. Thirty patients were treated at the primary presentation and 42 at the time of a locoregional recurrence. Minimal 2-year follow-up data were available for 65 patients (median 6 years). Megavoltage irradiation with 60Co to 20 MV photons or electron therapy was used for all patients. Most patients were treated after attempted complete surgical resection; 16 patients underwent pretreatment biopsy alone. The prescribed treatment was standard (1.8 Gy) daily fractions in 42 cases and 1.2 Gy fractions b.i.d. in 23 cases. The median prescribed dose was 54 Gy. The prognostic variables and treatment results were evaluated by Kaplan-Meier actuarial analysis. RESULTS Locoregional control was achieved in 52 of 65 patients. The 5-year actuarial locoregional control was 83%. Locoregional failure occurred in 13 patients (11 in patients with recurrent tumors). Only two failures occurred within the irradiation fields; nine failures occurred at the field margins. Eleven patients were salvaged by surgery: wide excision in nine and amputation in two. The only prognostic factor significant for locoregional control was primary vs. recurrent presentation (p = 0.0193). The 5-year locoregional control rates for irradiation at initial presentation and at recurrence were 96% and 75%, respectively. The variables without significance for locoregional control included primary tumor location, surgical procedures performed, resection margins, and gross vs. microscopic residual tumor at irradiation. Lymphedema was the most common late effect, occurring in 7 patients, 5 with prior treatment. Bone fracture occurred in 3 patients; all 3 had fibromatosis involving the bone at presentation but without recurrence at the time of fracture. CONCLUSION EBRT is effective treatment for aggressive fibromatosis. The probability of locoregional control decreases with multiple prior recurrences.