Masatsugu Takami

A case of multiple skeletal lesions of brown tumors, mimicking carcinoma metastases

Brown tumor is not a true tumor, being an unusual reactive lesion in association with primary or secondary hyperparathyroidism. We report a 23-year-old woman, who initially presented with lower back pain caused by ureterolithiasis. The initial diagnosis of brown tumor was delayed, but later pain in her leg worsened and a sacral lesion was incidentally discovered on lumbar magnetic resonance imaging (MRI); multiple destructive bone lesions were then found radiologically. The radiological features of the multiple bone lesions, which mimicked multiple metastatic tumors, seemed to be those of the terminal stage of malignancy. However, pathological examination and abnormal laboratory data showing elevated serum calcium, alkaline phosphatase, and parathyroid hormone and low serum phosphate confirmed the diagnosis of brown tumor. Adenoma in the parathyroid gland was confirmed and surgically resected. The clinical symptoms of bone pain, and abnormal radiological findings and laboratory data were resolved 6 months after surgery. Synthetic analysis of the clinical, radiological, and laboratory findings was necessary for the definite diagnosis of brown tumor.

Clinical Problems After Initial Unplanned Resection of Sarcoma

OBJECTIVE Unplanned resection of a sarcoma is often chosen in the early phase by general physicians without any imaging scrutiny. The present study aimed to highlight the clinical problems associated with unplanned resection of sarcomas. METHODS Thirty-eight patients who underwent unplanned resection of a sarcoma and additional treatment were examined. The definite histological grading was high in 31 patients and low in 7 patients. RESULTS The tumors were located in the depth of the subfascia in 13 patients. The maximal tumor sizes exceeded 5 cm in 16 patients. Preoperative MRI was only performed in six patients. The previous surgical margins were intralesional in 20 patients and marginal in 18 patients. Inappropriate transverse skin incisions were found in 21 patients. Extensive hematoma at the initial surgical site was seen in five patients. Thirty-three patients accepted additional wide resection due to the insufficient removal of malignancy. During an average follow-up of 42.7 months, seven patients died of lung and brain metastases. CONCLUSIONS On excision of any soft tissue tumor, surgeons should be aware of the potential risk for erroneous management of malignancy. If not, careless surgery may render the treatment protocol complicated and require excessive additional tissue resection with poor function and prognosis. Appropriate salvage treatment may have a significant role to play after unplanned resection of the sarcoma.

Pleomorphic malignant fibrous histiocytoma: response of bone, lung, and brain metastases to chemotherapy

We present a case of pleomorphic malignant fibrous histiocytoma arising from the left forearm in a 45-year-old man who had undergone resection and radiotherapy for a tumor 3 years previously. At his first visit, he had multiple lung and bone metastases. Although these metastases responded well to systemic chemotherapy, brain metastases newly appeared and caused the death of the patient. These findings demonstrate that individual sarcomatous metastatic organs exhibit different sensitivities to chemotherapy. The mechanism of this phenomenon is discussed with a review of previous reports. It is suggested that the blood-brain barrier may play an important role in sensitivity to chemotherapy.

Palliative Surgery for Acetabular Metastasis with Pathological Central Dislocation of the Hip Joint after Radiation Therapy: A Case Report

Orthopedic surgery for bone metastases is mainly a palliative treatment. Pathological central dislocation of the hip joint secondary to osteonecrosis of acetabular metastasis after radiation therapy brings severe suffering to cancer patients. We performed minimally invasive palliative surgery for an elderly woman, and excellent pain relief was achieved. An 80-year-old female suffering from right hip pain was referred to our hospital. She had undergone surgery for lung cancer 5 years previously and her right acetabulum was subsequently affected by metastasis. With the aim of controlling the metastasis, radiation therapy was performed. Two years later, pathological central dislocation of the hip joint occurred with sudden onset of severe pain, and she was unable to maintain a sitting position and became bedridden. After she was referred to our hospital, we created an intentional pseudarthrosis in the femoral neck for palliation. After the surgery, excellent pain relief and remarkably improved mobility were achieved during her limited remaining lifetime. In this report, we introduce a novel method of producing a pseudarthrosis in the femoral neck for pathological dislocation. This procedure is a minimally invasive treatment and an alternative option for palliative surgery for pathological dislocation of the hip joint due to osteonecrosis after radiation therapy.

Radiation Therapy without Surgery for Spinal Metastases: Clinical Outcome and Prognostic Factors Analysis for Pain Control

The purpose of radiation therapy (RT) for patients with spinal metastases is pain relief and control of paralysis. The aim of the present study was to assess pain relief using RT and to evaluate prognostic factors for pain control. We evaluated 97 consecutive patients, of mean age 62.7 years (range 28 to 86), with spinal metastases that had been treated by RT. We evaluated the effects of RT using pain level assessed using a drug grading scale based on the World Health Organization standards. The following potential prognostic factors for pain control of RT were evaluated using multivariate logistic regression analysis: age, gender, tumor type, performance status (PS), number of spinal metastases, and a history of chemotherapy. Among the 97 patients who underwent RT for pain relief, 68 patients (70.1%) presented with pain reduction. PS (odds ratio: 1.931; 95% confidence interval: 1.244 to 2.980) was revealed by multivariate logistic regression analysis to be the most important prognostic factor for pain control using RT. In conclusion, we found that RT was more effective for patients with spinal metastases while they maintained their PS.