Lack of c-kit overexpression in soft tissue sarcomas.
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Aged↗
Biomedical subjects
J Bickels
Publications and source records attributed to J Bickels.
ErbB-4 expression in limb soft-tissue sarcoma: correlation with the results of neoadjuvant chemotherapy.
ErbB-4 is a recently described growth factor receptor. Relatively little is known about its expression in human tumours. In this study, we assessed the possible role of erbB-4 as a tissue marker for soft-tissue sarcomas (STS) and its correlation with the response to chemotherapy. The histological specimen of 29 patients with STS of a limb who had received preoperative doxorubicin (ADR)-based chemotherapy were studied for the degree of necrosis and the expression of erbB-4 (by an avidin-biotin-peroxidase technique). ErbB-4 expression in the preoperative tissue samples was compared with the expression in the postchemotherapy resected tumour. The true objective response rate to preoperative chemotherapy was 34%. Wide resection of the tumour was done in 12 patients, marginal in 14, amputation in 2 and no surgery in 1. The tumour necrosis was above 90% in 9 patients, 60-90% in 12, and less than 60% in 7 patients. An increase in erbB-4 expression was more common in cases with no response to chemotherapy, while no change or a decrease in erbB-4 was more common in responsive tumours (P=0.004). No correlation could be found between the degree of necrosis or the chemotherapeutic regimen and the change in expression of erbB-4. The median disease-free survival (DFS) was longer for patients with a decrease or no change in expression of erbB-4 than for patients with increased expression. It is believed that postchemotherapy new expression or no downregulation of the erbB-4 molecule represents tumour aggressiveness and increased capability of growth and spread.
Adult↗
Multiple primary malignancies in association with soft tissue sarcomas.
BACKGROUND: Modern cancer treatment has increased the survival of patients with various malignancies substantially. One of the late sequelae of successful treatment is the development of a second malignant tumor. However, in many cases of second primary tumors, exposure to chemotherapy or radiation therapy is not evident, and it should be postulated that the putative mechanism for the development of the second tumor is different. In the current series, the association between soft tissue sarcoma (STS) in adults and the development of other primary malignancies was studied. METHODS: A retrospective search of the data files of 610 patients with STS or bone sarcomas who were treated at the study institution between January 1995 and December 1999 was performed. All files regarding patients with STS who developed a second malignant tumor were retrieved for analysis. RESULTS: Of 375 patients with STS, 28 (7.5%) developed other malignant neoplasms either before or after the diagnosis of STS. STS as the first tumor occurred in 14 patients (ages 16-72 years). Only three patients were treated with chemotherapy for their sarcoma. Radiation therapy was administered to five patients as an adjuvant to surgery for the first tumor. The second tumor types mainly included STS and renal cell carcinoma. The time interval between the diagnosis of the STS and the second malignancy was 0 (for synchronous tumors) to 21 years. Three patients developed a third primary tumor within 3 years after the diagnosis of the second tumor. The median overall survival was > 78 months. Fourteen patients (ages 35-87 years) had a first primary tumor other than STS (mainly breast carcinoma and genitourinary malignancies). The second tumors (mainly STS) appeared within 0 (for synchronous tumors) to 27 years. The median overall survival for the 14 patients in this group from the time of diagnosis of the first tumor was > 102 months. CONCLUSIONS: The phenomenon of two or three primary neoplasms developing in patients in whom one of the tumors was STS occurs at a rate of 7.5%, a significantly higher rate than that reported for the occurrence of STS among the general cancer population (1%). The majority of cases occur incidentally. The clinical implication includes the need to search for an occult second primary tumor in patients with STS as an integral part of their follow-up. This is especially true in patients with primary malignant fibrous histiocytoma who demonstrate a risk for developing a renal cell carcinoma.
Adolescent↗
Palliative forequarter amputation for metastatic carcinoma to the shoulder girdle region: indications, preoperative evaluation, surgical technique, and results.
BACKGROUND AND OBJECTIVES: Uncontrolled metastatic carcinoma of the shoulder girdle is a difficult oncologic problem. This study reviews our experience with palliative forequarter amputation with emphasis on patient selection criteria, preoperative radiologic assessment, surgical technique, epineural postoperative analgesia, and clinical outcome. METHODS: Eight patients who underwent palliative forequarter amputation for metastatic carcinoma between 1980 and 1999 were analyzed retrospectively. Diagnoses included breast carcinoma (n = 3), squamous cell carcinoma (n = 2), hypernephroma (n = 2), and carcinoma of unknown origin (n = 1). All patients presented with severe, intractable pain and a useless extremity. Venography demonstrated obliteration of the axillary vein in each of the patients in whom this procedure was performed. Exploration of the brachial plexus confirmed tumor encasement and unresectability in all patients. Epineural catheters for bupivacaine infusion were placed for postoperative pain control. RESULTS: All patients experienced dramatic pain relief and improved mobility and overall function. Life-threatening hemorrhage and sepsis were alleviated. There were no instances of phantom limb pain or adverse psychological reactions, and no complications related to epineural analgesia. CONCLUSIONS: Palliative forequarter amputation is relatively safe and reliable and provides effective pain relief for selected patients with unresectable metastatic carcinoma to the axilla and bony shoulder girdle in whom radiotherapy and/or chemotherapy has not been effective. The triad of pain, motor loss, and an obliterated axillary vein is indicative of brachial plexus infiltration and unresectability.
Adult↗
Giant cell tumor of the hand: superior results with curettage, cryosurgery, and cementation.
At our institution giant cell tumors arising in all locations are treated with curettage, cryosurgery, and cementation to avoid resection or amputation, increase local tumor control over curettage alone, and avoid the morbidity associated with immobilization. We report the oncologic and functional results of 3 patients with giant cell tumors arising from the tubular bones of the hand who were treated in this manner. At a mean follow-up period of 54 months there were no local recurrences. No patient complained of pain. Digital range of motion and grip strength were within normal limits for all 3 patients. All patients returned to their previous occupational and recreational activities. One instance of minor wound necrosis was successfully treated conservatively. There were no other complications (fractures, infections, neuropraxias, or vascular damage). Curettage, cryosurgery, and cementation performed by experienced surgeons appears to be a safe, effective, and reliable method for treating selected giant cell tumors of the hand.
Adolescent↗
Reconstruction of the extensor mechanism after proximal tibia endoprosthetic replacement.
The proximal tibia is a difficult area in which to perform a wide resection of a bone tumor. This difficulty is due to the intimate relationship of tumor in this location to the nerves and blood vessels of the leg, inadequate soft tissue coverage after endoprosthetic reconstruction, and the need to reconstruct the extensor mechanism. Competence of the extensor mechanism is the major determinant of functional outcome of these patients. Between 1980 and 1997, 55 patients underwent proximal tibia resection with endoprosthetic reconstruction for a variety of malignant and benign-aggressive tumors. Reconstruction of the extensor mechanism included reattachment of the patellar tendon to the prosthesis with a Dacron tape, reinforcement with autologous bone-graft, and attachment of an overlying gastrocnemius flap. All patients were followed for a minimum of 2 years; 6 patients (11%) had a transient peroneal nerve palsy, 4 patients (7.2%) had a fasciocutaneous flap necrosis, and 2 patients (3.6%) had a deep wound infection. Full extension to extension lag of 20 degrees was achieved in 44 patients, and 8 patients required secondary reinforcement of the patellar tendon. Function was estimated to be good to excellent in 48 patients (87%). Reattachment of the patellar tendon to the prosthesis and reinforcement with an autologous bone-graft and a gastrocnemius flap are reliable means to restore extension after proximal tibia endoprosthetic reconstruction.
Adolescent↗
Is forequarter amputation justified for palliation of intractable cancer symptoms?
BACKGROUND: Limb-sparing surgery has replaced the radical surgical approach for treating limb sarcomas in most cases. Amputation has been advocated as a palliative procedure for symptomatic locally advanced disease that has already failed to respond to radiation therapy, chemotherapy and limited surgery. METHODS: Twelve patients with advanced malignant tumors involving the shoulder girdle or the proximal humerus underwent forequarter amputation (FQA) for palliative purposes. The tumor-related local problems were severe pain, limb dysfunction, tumor fungation, bleeding (requiring emergency FQA in one case) and infection. The preoperative Karnofsky performance status (KPS) in our series ranged from 30 to 70%. RESULTS: No perioperative mortality was observed. The morbidity was well tolerated by the patients. The KPS improved in most of the patients, and was assessed as 90-100% in 9 of the 12 patients. Overall, quality of life was reported to be at least moderately improved by 2 out of 3 patients. Survival was measured in months (3-24 months), but ultimately had no meaning since the procedure was palliative. Lung metastases were the dominant cause of death in our patients. CONCLUSIONS: The results of FQA in our series point to its feasibility and the gain in quality of life and performance status in severely ill patients with advanced malignancies. Local symptoms and signs were controlled, and quality of life was restored.
Adolescent↗
Internal hemipelvectomy for bone sarcomas in children and young adults: surgical considerations.
AIMS: Pelvic bone sarcomas in children and young adults are rare, and associated with a poor prognosis and a high rate of local recurrence. Primary goals of treatment include prevention of local recurrence and distant metastases. A secondary goal is maintenance of quality of life by avoiding major amputative surgery. This is why internal hemipelvectomy (a limb-sparing surgery) is advocated whenever possible. The focus of our presentation is surgical issues in the context of resection and reconstruction of the pelvis in the first two decades of life. MATERIALS AND METHODS: Between January 1988 and June 1998, 27 patients were treated and operated on (follow-up time 1.5-12 years). There were 17 males and 10 females. Their age ranged between 2 and 22 years. There were 24 patients with Ewing's sarcoma (ES) and three with other bone sarcomas. In 19 patients the tumour involved the entire or part of the iliac bone (in some cases with extension to the sacrum). In five patients the tumour involved the pubis and/or ischium. In three patients the tumour involved the sacrum with some extension to the posterior iliac bone. All patients received neoadjuvant and adjuvant chemotherapy and radiotherapy with different protocols (related to the origin of referral). RESULTS: Twenty-seven patients underwent internal hemipelvectomy. According to Enneking's classification there were: type I-10; type II-one; type III-six; type IV-five (including one localized sacrectomy); type I+IV-five patients. In 15 patients some kind of reconstruction was needed and in 12 no reconstruction was done. Four wound infections occurred that were managed successfully by surgical debridement, antibiotics and local wound care. In one case removal of the 'implant' was needed. No primary or secondary amputations were performed in the series. The rate of local recurrence was 22%. Functional status at the last follow-up visit or before death, according to the AMSTS functional rating system: excellent-six; good-17; fair-three and poor-one. All patients except the one poor result maintained their walking ability during the follow-up time. CONCLUSIONS: Internal hemipelvectomy is achievable in most cases and justified for better quality of life in children, adolescents and young adults with sarcomas. Further efforts are needed to improve the reconstructive options in the pelvis.
Adolescent↗
Reconstruction of hip stability after proximal and total femur resections.
Dislocation is the most common complication after proximal and total femur endoprosthetic reconstruction. The current study describes a surgical technique of acetabular preservation and reconstruction of the joint capsule and abductor mechanism that recreates joint stability and avoids dislocation. Between 1980 and 1996, 57 patients underwent proximal or total femur resection with endoprosthetic reconstruction. Forty-six patients had primary sarcoma of bone, nine had other bone tumors, and two had metabolic bone disease. The acetabulum was spared and not resurfaced in all patients. Bipolar hemiarthroplasty was performed in 49 patients, and fixed unipolar hemiarthroplasty was performed in eight. Soft tissue reconstruction included Dacron tape capsulorrhaphy over the prosthetic neck, reattachment of the abductor mechanism to the prosthesis, and extracortical bone fixation. The average followup period was 6.5 years (range, 2-18.2 years). Dislocation occurred in only one (1.7%) patient, and aseptic prosthetic loosening occurred in three (5.3%) patients. Four patients with primary bone sarcoma had local recurrence, of whom one required amputation of the limb. The limb salvage rate was 98%. Eighty-one percent of the patients had a good to excellent functional outcome. Acetabular preservation, capsulorrhaphy, and reconstruction of the abductor mechanism recreate hip stability and avoid dislocation after proximal and total femur endoprosthetic reconstruction.
Adolescent↗
Metastatic renal cell carcinoma of bone: indications and technique of surgical intervention.
PURPOSE: We describe the efficacy of surgical excision of metastatic renal cell carcinoma of bone for achieving local tumor control, pain control and functional outcome with emphasis on the indications and techniques of surgical intervention as well as oncological outcome. MATERIALS AND METHODS: Between 1980 and 1997 we performed surgery on 45 patients (56 lesions) with metastatic renal cell carcinoma of bone. Indications for surgery were solitary bone metastasis, intractable pain, or impending or present pathological fracture. Surgery involved wide excision in 29 cases, marginal excision with adjunctive liquid nitrogen in 25 and amputation in 2. RESULTS: None of the patients had significant bleeding intraoperatively. Mean hospital stay was 9.8 days, during which there was no flap necrosis, deep wound infection, nerve palsy or thromboembolic complication. Postoperatively pain was significantly relieved in 91% of patients, while 89% achieved a good to excellent functional outcome, and 94% with metastatic lesions of the pelvic girdle and lower extremities were ambulatory. Local recurrence developed in only 4 of the 56 lesions (7.1%), including 3 after marginal resection. Survival was more than 2 years in 22 patients (49%) and more than 3 in 17 (38%). CONCLUSIONS: Surgical excision is safe and reliable for restoring mechanical bone stability, relieving pain and providing good function in most patients with metastatic renal cell carcinoma who meet the criteria for surgical intervention. Relatively prolonged survival in these cases justifies considering surgical intervention when feasible.
Adult↗
Extraspinal bone and soft-tissue tumors as a cause of sciatica. Clinical diagnosis and recommendations: analysis of 32 cases.
STUDY DESIGN: Between 1982 and 1997, the authors treated 32 patients with sciatica who subsequently were found to have a tumor along the extraspinal course of the sciatic nerve. SUMMARY OF BACKGROUND DATA: Extraspinal compression of the sciatic nerve by a tumor is a rare cause of sciatica. Signs and symptoms overlap those of the more common causes of sciatica (i.e., herniated disc and spinal stenosis). OBJECTIVE: To characterize the unique clinical presentation of these patients and to formulate guidelines that may lead to early diagnosis. METHODS: All pertinent clinical data and studies were reviewed retrospectively, and standard demographic data were collected for analysis. RESULTS: These patients typically sought treatment for an insidious onset of sciatic pain that was constant, progressive, and unresponsive to change in position or bed rest. The mean time to final diagnosis was 11.9 months (median, 6 months). Seventeen patients were able to locate their pain to a specific point along the extraspinal course of the sciatic pain, and a mass was noted in 13 patients. Eighteen of these tumors were in the pelvis, 10 in the thigh, and 4 in the popliteal fossa and calf. CONCLUSIONS: A high index of clinical suspicion is the key to early diagnosis of bone or soft-tissue tumors as a cause of sciatica; special attention should be given to pain pattern, physical examination of the entire course of the sciatic nerve, and selection of proper imaging studies. Routine anteroposterior plain radiography of the pelvis as part of the initial imaging screening process is recommended.
Bone Neoplasms↗
Isolated limb perfusion with tumour necrosis factor-alpha and melphalan for unresectable bone sarcomas of the lower extremity.
AIMS: Isolated limb perfusion (ILP) with recombinant tumour necrosis factor-alpha (rTNF-alpha) and melphalan has recently been reported to induce major tumour responses and permit limb salvage in over 80% of patients with unresectable soft-tissue sarcomas of the extremities. We investigated whether TNF-based ILP could allow limb-sparing surgery in patients with primary, recurrent or metastatic bone sarcoma to the lower extremity who met the criteria for an amputation and had failed or refused chemotherapy. METHODS: From August 1992 to December 1997, we employed ILP with rTNF-alpha and melphalan in 13 patients with unresectable bone sarcoma of the lower extremity, all of whom were candidates for amputation. The aim was to reduce tumour size and allow the performance of a limb-sparing surgery (LSS). RESULTS: Following ILP, none of the patients had severe local toxicity and only one patient experienced significant systemic side-effects. LSS was subsequently performed in nine of the 13 patients. LSS was feasible in an additional three patients but was not performed because of the emergence of diffused metastatic disease. CONCLUSIONS: ILP with rTNF-alpha and melphalan can allow limb salvage in patients wih locally advanced bone sarcomas who had failed standard treatment options. Its potential role in the treatment of unresectable bone sarcomas of the extremities merits further evaluation.
Adolescent↗
Cryosurgery in the treatment of giant cell tumor. A long-term followup study.
Between 1983 and 1993, 102 patients with giant cell tumor of bone were treated at three institutions. Sixteen patients (15.9%) presented with already having had local recurrence. All patients were treated with thorough curettage of the tumor, burr drilling of the tumor inner walls, and cryotherapy by direct pour technique using liquid nitrogen. The average followup was 6.5 years (range, 4-15 years). The rate of local recurrence in the 86 patients treated primarily with cryosurgery was 2.3% (two patients), and the overall recurrence rate was 7.9% (eight patients). Six of these patients were cured by cryosurgery and two underwent resection. Overall, 100 of 102 patients were cured with cryosurgery. Complications associated with cryosurgery included six (5.9%) pathologic fractures, three (2.9%) cases of partial skin necrosis, and two (1.9%) significant degenerative changes. Overall function was good to excellent in 94 patients (92.2%), moderate in seven patients (6.9%), and poor in one patient (0.9%). Cryosurgery has the advantages of joint preservation, excellent functional outcome, and low recurrence rate when compared with other joint preservation procedures. For these reasons, it is recommended as an adjuvant to curettage for most giant cell tumors of bone.
Adolescent↗
The role and biology of cryosurgery in the treatment of bone tumors. A review.
The application of liquid nitrogen as a local adjuvant to curettage in the treatment of bone tumors was introduced three decades ago. This technique, termed cryosurgery, was shown to achieve excellent local control in a variety of benign-aggressive and malignant bone tumors. However, early reports showed that cryosurgery was associated with a significant injury to the adjacent rim of bone and soft-tissue, resulting in high rates of fractures and infections. These results reflected an initial failure to appreciate the potentially destructive effects of liquid nitrogen and establish appropriate guidelines for its use. We review the biological effect of cryosurgery on bone, surgical technique, and current indications for its use.
Bone Cements↗
The use of three-dimensional computed tomography in evaluating snapping scapula syndrome.
This article evaluates imaging of the scapula and scapulothoracic joint in patients with snapping scapula syndrome. Between 1990 and 1996, a total of 20 patients (10 men and 10 women) with snapping scapula syndrome were evaluated. Diagnosis was based on patient complaints and physical examination findings. There were 26 affected scapulae (6 patients had bilateral presentation). Imaging of the scapula included plain radiography, computed tomography (CT), and 3-dimensional computed tomography (3-D CT) reconstruction. Plain radiography revealed bony incongruity between the anterior aspect of the scapula and the chest wall in 7 scapulae, CT revealed such incongruity in 19 scapulae, and 3-D CT revealed incongruity in all 26 scapulae. Treatment was conservative, consisting of nonsteroidal anti-inflammatory drugs, a physiotherapy program, and subscapular injection of a local anesthetic and steroids. In 5 patients who responded poorly to conservative treatment, the region responsible for the snapping was resected. Pain relief and resolution of the snapping were complete following surgery in 4 patients, while pain and crepitation persisted in the fifth. Three-dimensional CT is recommended as the main imaging modality in the evaluation of any patient with snapping scapula syndrome who is a candidate for surgical intervention.
Adult↗
Biopsy of musculoskeletal tumors. Current concepts.
Biopsy is a key step in the diagnosis of bone and soft tissue tumors. An inadequately performed biopsy may fail to allow proper diagnosis, have a negative impact on survival, and ultimately necessitate an amputation to accomplish adequate margins of resection. Poorly performed biopsy remains a common finding in patients with musculoskeletal tumors who are referred to orthopaedic oncology centers. The principles by which an adequate and safe biopsy of musculoskeletal tumors should be planned and performed are reviewed, and the surgical approach to different anatomic locations is emphasized.
Biopsy↗
[Bone sarcomas: experience of an orthopedic oncology unit in the treatment of 180 consecutive cases, 1988-1995 (Part II)].
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Adolescent↗