Maurício Etchebehere

Sonographically guided core needle biopsy of bone and soft tissue tumors.

To determine the value of sonographically guided core needle biopsies of musculoskeletal tumors as a reliable alternative to fluoroscopy and computed tomography.

Orthopedic pathology of the lower extremities: Scintigraphic evaluation in the thigh, knee, and leg

Radionuclide imaging (RI) of the osseous and nonosseous structures of the thigh, knee, and leg provide important diagnostic and prognostic information upon which the orthopedic surgeon can base treatment planning and management decisions. 99mTc-MDP scintigraphy is essential in overuse injuries such as stress fractures and shin splints. RI is important in assessing complications of trauma. It is the only imaging modality able to assess the magnitude of physeal stimulus caused by femoral fractures and to predict a favorable or unfavorable outcome of leg length by semiquantitative analysis; SPECT imaging can detect and locate decreased metabolism associated with posttraumatic closure of the physeal plate to predict growth arrest and deformities. Three-phase bone imaging (TPBI) is essential to differentiate hypervascular from avascular nonunions and follow delayed union. In osteonecrosis of the knee, bone scintigraphy precedes radiography changes even in stage l of the disease. 99mTc-MDP and 99mTc-HIG imaging are powerful tools in determining the outcomes of osteoarthritis and rheumatoid arthritis, respectively. Bone scintigraphy can also detect chronic ligament and acute and chronic meniscal lesions. The combined use of TPBI, gallium-67 citrate imaging, and indium-111 or 99mTc-HMPAO labeled leukocytes is important to diagnose and differentiate acute from chronic osteomyelitis, and to detect infected knee prostheses. Thallium-201 chloride imaging and 99mTc-sestamibi imaging have an important role in the assessment of tumor response to chemotherapy and in the quantification of tumor viability.

Physical activity is associated with improved subclinical atherosclerosis in spinal cord injury subjects independent of variation in traditional risk factors.

injury subjects independent of variation in traditional risk factors☆ Jose R. Matos-Souza , Anselmo A. Silva , Luis F. Campos , Debora Goulart , Roberto Schreiber , Guilherme de Rossi , Jose A. Pio-Magalhaes , Mauricio Etchebehere , Jose I. Gorla , Alberto Cliquet Jr. , Wilson Nadruz Jr. a,⁎ a Department of Internal Medicine, School of Medical Sciences, State University of Campinas, Campinas, SP, Brazil b School of Physical Education, State University of Campinas, Campinas, SP, Brazil c Department of Orthopaedics, School of Medical Sciences, State University of Campinas, Campinas, SP, Brazil d Department of Electrical Engineering, University of Sao Paulo (USP), Sao Carlos, SP, Brazil

Oxidized low-density lipoprotein, matrix-metalloproteinase-8 and carotid atherosclerosis in spinal cord injured subjects.

OBJECTIVE Previous reports have indicated that subjects with chronic spinal cord injury (SCI) exhibit increased cardiovascular risk compared to able-bodied individuals. This study investigated the relationship between plasmatic oxidized low-density lipoprotein (OxLDL), matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) levels and vascular remodeling in SCI subjects and the role of physical activity in this regard. METHODS We studied 42 men with chronic (≥2 years) SCI [18 sedentary (S-SCI) and 24 physically active (PA-SCI)] and 16 able-bodied men by clinical, anthropometric, laboratory, and carotid intima-media thickness (IMT) analysis. All enrolled subjects were normotensive, non-diabetics, non-smokers and normolipemic. Plasmatic OxLDL, MMP-2, MMP-8, MMP-9, TIMP-1 and TIMP-2 levels were determined by enzyme-linked immunosorbent assay. RESULTS Carotid IMT, IMT/diameter ratio and OxLDL levels of PA-SCI and able-bodied subjects were statistically similar. Conversely, S-SCI subjects exhibited higher IMT, IMT/diameter ratio and OxLDL levels compared to PA-SCI (p < 0.01, p < 0.001 and p = 0.01, respectively) and able-bodied (p < 0.001 for all) individuals. Results of bivariate correlation analysis including all injured subjects showed that carotid IMT and IMT/diameter ratio only correlated with OxLDL, MMP-8 and MMP-8/TIMP-1 ratio. Further stepwise regression analysis adjusted for the presence or not of physical activity and age showed that OxLDL was associated with carotid IMT and IMT/diameter ratio, while MMP-8 was associated with IMT/diameter ratio in SCI individuals. CONCLUSIONS Plasmatic OxLDL and MMP-8 levels are associated with carotid atherosclerosis and there is an interaction among physical inactivity, atherosclerosis and OxLDL in SCI individuals.

Magnetic resonance imaging of low-grade fibromyxoid sarcoma

. We present theMR imaging features of a surgically confirmed case ofLGFMS affecting the shoulder.A 30-year-old man presented with a 20-year history ofa painless slow-growing mass in the right shoulder. Mag-netic resonance images were obtained on a 2.0T scanner(Elscint, Haifa, Israel), demonstrating a well-defined soft-tissue mass measuring 12.0 x 7.0 x 9.0 cm located betweenthe deltoid muscle, rotator-cuff muscles, and proximal hu-merus. No peri-tumoral edema in adjacent subcutaneous tis-sues or muscles was noted. The signal intensity (SI) of thebone marrow was normal. The mass had an intermediate,heterogeneous SI on T1-weighted images [repetition time(TR) / time to echo (TE), 600/25] (Fig. 1a). Heterogene-ous low to high SI with multiple hypointense intralesionalnodules was seen on T2-weighted fast spin-echo images(TR/TE, 3500/90) (Fig. 1b). The mass enhanced heteroge-neously on T1-weighted fat-suppressed images (TR/TE,720/20) after intravenous injection of gadolinium (Fig. 1c),predominantly in corresponding T2-weighted hyperintenseareas.The lesion was surgically removed with negative mar-gins. The surgical specimen consisted of a soft-tissue tumor,measuring 14.5 x 9.5 x 5.0 cm and weighing 290 g. Thecut sections showed a firm, grossly circumscribed, andlobulated mass, with a yellow-white color and glisteningappearance secondary to the accumulation of myxoidground substance (Fig. 2a). Microscopically, the tumor hadlow to moderate cellularity composed of bland spindle-shaped cells with a fibroblast pattern, arranged mainly in

Intraoperative localization of an osteoid-osteoma using a gamma probe

The purpose of this study was to evaluate whether intraoperative nidus detection with a hand-held gamma probe was efficient enough for use as a routine procedure. Thirty-seven patients with osteoid-osteomas were submitted to surgical treatment. The first group consisted of 19 patients submitted to open nidus resection using a hand-held gamma probe as guide. The control group consisted of 18 patients operated on by conventional technique. The procedures were classified as successful if nidus resection could be confirmed by histology or postoperative imaging studies. Patients in the gamma group were followed for a mean of 13 months; patients in the control group for a mean of 39 months. In the gamma group, 17/19 procedures were successful; in the control group, only 12/18 procedures were successful. The gamma probe helped to locate the osteoid-osteoma nidus, and the same probe could be used in various hospitals.RésuméLe but de cette étude était d’évaluer si la découverte intra-opératoire du nidus par sonde gamma était assez effective pour l’envisager comme une procédure habituelle. Trente-sept malades avec un ostéome ostéoïde ont eu un traitement chirurgical. Le premier groupe a consisté en 19 malades traités par résection du nidus guidée par la sonde manuelle. Le groupe témoin a consisté en 18 malades opérés sur par la technique conventionnelle. Les procédures étaient classées comme efficaces si la résection du nidus pouvait être confirmée par l’histologie ou l’étude postopératoire des images. Les malades dans le groupe gamma ont été suivis avec une moyenne de 13 mois, malades dans le groupe témoin avec une moyenne de 39 mois. Dans le groupe Gamma 17/19 procédures étaient éfficaces, dans le groupe témoin seulement 12/18 l’étaient. La sonde gamma aide à localiser le nidus de l’ostéome ostéoïde et la même sonde pourraient être utilisée dans les plusieurs hôpitaux.

Analysis of angiogenic factors and cyclooxygenase-2 expression in cartilaginous tumors: clinical and histological correlation

OBJECTIVES: To study the role of angiogenesis and cyclooxygenase-2 expression in cartilaginous tumors and correlate these factors with prognosis. INTRODUCTION: For chondrosarcoma, the histological grade is the current standard for predicting tumor outcome. However, a low-grade chondrosarcoma can follow an aggressive course—as monitored by sequential imaging techniques—even when it is histologically indistinguishable from an enchondroma. Therefore, additional tools are needed to help identify the biological potential of these tumors. The degree of angiogenesis that is induced by the tumor could assist in this task. Angiogenesis can be quantified by measuring the expression of vascular endothelial growth factor and CD34, and cyclooxygenase-2 can induce angiogenesis by stimulating the production of pro-angiogenic factors. METHODS: In total, 21 enchondromas and 58 conventional chondrosarcomas were studied by examining the clinical and histopathological findings in conjunction with the immunostaining markers of angiogenesis and cyclooxygenase-2 expression. RESULTS: The significant variables that were associated with poor outcome were 1) higher-grade chondrosarcomas, 2) tumors that developed in flat bones, and 3) over-expression of CD34 (with a median count that was higher than 5.9 vessels in 5 high power fields). Moreover, CD34 expression (measured using the Chalkley method) revealed significantly higher microvessel density in flat bone chondrosarcomas. DISCUSSION: Previous studies have shown a positive correlation between Chalkley microvessel density and histological grade; however, in our sample, we found that the former is predictive of the outcome. Chondrosarcomas in flat bones have been shown to correlate with a poor prognosis. We also found that CD34 microvessel density values were significantly higher in flat-bone chondrosarcomas. This could explain—at least in part—the more aggressive biological course that is taken by these tumors. CONCLUSIONS: These results provide evidence that CD34 microvessel density in chondrosarcomas can be helpful in predicting patient outcome and may add to our understanding of chondrosarcoma pathogenesis.

Whole-body 99mtc-octreotide Scintigraphy With Spect/ct to Detect Occult Tumor Inducing Paraneoplastic Osteomalacia

A 32-year-old woman presented with progressive myalgia, bone pain, fatigue, insufficiency hip fractures, high urine phosphate, and low serum phosphate and vitamin D levels. These findings were suggestive of oncogenic osteomalacia. A whole-body Tc-octreotide scintigraphy with SPECT/CT showed uptake on a sclerotic intramedullary lesion in the left medial tibia plateau. MRI depicted a solid lesion. The lesion was surgically removed; the patient became asymptomatic, and follow-up laboratory results normalized. Histopathologic examination revealed a vascular hemangiopericytoma-like tumor, positive for somatostatin receptor (SSR-2). Whole-body Tc-octreotide scintigraphy with SPECT/CT may detect occult oncogenic osteomalacia tumors.

Comparative study of planned and unplanned excisions for the treatment of soft tissue sarcoma of the extremities

OBJECTIVE: Unplanned excision of soft tissue sarcomas is common because benign soft tissue lesions are very frequent. This study evaluated the impact of unplanned resections on overall survival, local recurrence and distant metastasis in patients with soft tissue sarcomas of the extremities. METHODS: In total, 52 patients who were diagnosed with soft tissue sarcomas between May 2001 and March 2011 were analyzed in a retrospective study. Of these patients, 29 (55.8%) had not undergone previous treatment and the remaining 23 (44.2%) patients had undergone prior resection of the tumor without oncological planning. All subsequent surgical procedures were performed at the same cancer referral center. The follow-up ranged from 6 to 122 months, with a mean of 39.89 months. Age, lesion size and depth, histological grade, surgical margins, overall survival, local and distant recurrence and adjuvant therapies were compared. RESULTS: Residual disease was observed in 91.3% of the re-resected specimens in the unplanned excision group, which exhibited greater numbers of superficial lesions, low histological grades and contaminated surgical margins compared with the re-resected specimens in the planned excision group. No differences were observed in local recurrence and 5-year overall survival between the groups, but distant metastases were significantly associated with planned excision after adjustment for the variables. CONCLUSIONS: There was no difference between patients undergoing unplanned excision and planned excision regarding local recurrence and overall survival. The planned excision group had a higher risk of distant metastasis, whereas there was a high rate of residual cancer in the unplanned excision group.

Evaluation of soft-tissue lesions with 18F-FDG PET/CT: initial results of a prospective trial

Purpose of the reportAlthough MRI is utilized for planning the resection of soft-tissue tumors, it is not always capable of differentiating benign from malignant lesions. The risk of local recurrence of soft-tissue sarcomas is increased when biopsies are performed before resection and by inadequate resections. PET associated with computed tomography using fluorodeoxyglucose labeled with fluorine-18 (18F-FDG PET/CT) may help differentiate between benign and malignant tumors, thus avoiding inadequate resections and making prior biopsies unnecessary. The purpose of this study was to evaluate the usefulness of 18F-FDG PET/CT in differentiating benign from malignant solid soft-tissue lesions. Materials and methodsPatients with solid lesions of the limbs or abdominal wall detected by MRI were submitted to 18F-FDG PET/CT. The maximum standardized uptake value (SUVmax) cutoff was determined to differentiate malignant from benign tumors. Regardless of the 18F-FDG PET/CT results all patients underwent biopsy and surgery. ResultsMRI was performed in 54 patients, and 10 patients were excluded because of purely lipomatose or cystic lesions. 18F-FDG PET/CT was performed in the remaining 44 patients. Histopathology revealed 26 (59%) benign and 18 (41%) malignant soft-tissue lesions. A significant difference in SUVmax was observed between benign and malignant soft-tissue lesions. The SUVmax cutoff of 3.0 differentiated malignant from benign lesions with 100% sensitivity, 83.3% specificity, 89.6% accuracy, 78.3% positive predictive value, and 100% negative predictive value. Conclusion18F-FDG PET/CT seems to be able to differentiate benign from malignant soft-tissue lesions with good accuracy and very high negative predictive value. Incorporating 18F-FDG PET/CT into the diagnostic algorithm of these patients may prevent inadequate resections and unnecessary biopsies.