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PubMed2006

The dangers of intraosseous fibrosing agent injection in the treatment of bone cysts. The origin of major complications shown in a rabbit model.

Direct intraosseous injection of fibrosing agent is widely used in the treatment of aneurysmal bone cysts. The purpose of this study was to evaluate the consequences of fibrosing agent penetrating the medulla of bones. This may be the case when, by mistake, the fibrosing agent is administered into the medulla or when the wall of the cyst ruptures and fibrosing agent is able to drift into the medulla. Twelve rabbits were injected transcutaneously with a fibrosing agent directly into the proximal metaphysis of the tibia. Prior to injection 0.5 ml of liquid-like, bloody, intraosseal tissue was aspirated, then 0.5 ml of fibrosing agent was administered. Fibrosing agent was introduced slowly (20 s) to avoid overpressure. Nine rabbits (75%) died within minutes after the introduction of fibrosing agent. A full body roentgenogram was taken of each rabbit and the animals that died underwent autopsy to find the exact cause of death. Roentgenograms of the chest showed massive multiple pulmonary emboli confirmed in all lethal cases by the autopsy. This animal model was created to draw attention to the dangers of any leakage of the fibrosing agent into the medulla of bones.

Animals↗
PubMed2001

Life-threatening vascular complications after central venous catheter placement.

The purpose of this retrospective study was to report 11 cases of severe vascular complications after central venous catheter misplacement. For each patient, data collection included body mass index, the diagnosis at admission, the site of the procedure, the type of catheter, coagulation parameters, the imaging modalities performed and the applied treatment. Eight patients had a lesion of the subclavian artery. Brachiocephalic vein perforations were assessed in three more patients. All patients had a chest roentgenogram after the procedure, six a CT examination, and four an angiographic procedure. Seven patients had a body mass index above 30, and 5 patients had coagulation disorders prior to the procedure. Seven patients were conservatively managed, 2 patients died despite resuscitation, 1 patient was treated with a stent graft, and one by superselective embolization. Subclavian or jugular vein temporary catheter positioning is a practical approach. Identification of any iatrogenic perforation of the subclavian artery or central veins urges obtaining a chest roentgenogram and, when required, a chest CT, selective angiograms or venograms. Body mass index superior to 30, previous unsuccessful catheterization attempts, and coagulation factor depletion seemed to account for risk factors. Recognition of clinical and radiological complications is mandatory.

Adult↗
PubMed2004

Unanticipated hemothorax during general anesthesia.

We experienced a case of uncommon spontaneous hemothorax during general anesthesia. A 72-year-old woman underwent emergency repair of damaged ascending colon. Her chest roentgenogram before surgery revealed no abnormalities. After the uneventful surgery, the trachea was extubated and the patient breathed without difficulty with stable vital signs. However, the S(p)(O)(2) varied around 95% with a 100% oxygen mask. Chest roentgenogram obtained after extubation showed a massive amount of fluid in the pleural cavity. A chest drainage tube was inserted, and approximately 1000 ml of frank blood was drawn without air leakage. Thereafter, her oxygenation remarkably improved. We could not determine the etiology of the hemothorax.

Aged↗
PubMed2002

The reliability of quantitative analysis on digital images of the scoliotic spine.

Although analysis of scoliotic deformity is still studied extensively by means of conventional roentgenograms, computer-assisted digital analysis may allow a faster, more accurate and more complete evaluation of the scoliotic spine. In this study, a new computer-assisted measurement method was evaluated. This method uses digital reconstruction images for quantitative analysis of the scoliotic spine. The aim of the current study was to determine the reliability of the computer-assisted measuring method, which was done by establishing coefficients of repeatability for a variety of measurements. Measurements were carried out by five observers on 30 frontal and 10 lateral scoliotic digital reconstruction images. Each image was measured on three separate occasions by placing anatomical vertebral landmarks and drawing lines with a computer pointing device. The computer then calculated a number of geometrical shape parameters from scale calibration, landmarks and lines. The intra- and interobserver results were subjected to an analysis of variance to assess the level of agreement, and the means and standard deviations were calculated. The coefficient of repeatability (CR) was taken to be equal to two standard deviations. The mean intraobserver CR was found to be 3.1 degrees for the Cobb angle on the frontal digital image and 3.3 degrees for the kyphosis Cobb angle on the lateral overview. The mean difference in the intraobserver CR of the Cobb angle between measurements made by placing landmarks and those made by drawing lines was not statistically significant (P>0.05). The mean intraobserver CR for the other parameters can be summarized as follows: for lateral deviation it was 0.8 mm, for axial rotation 4.0 degrees and for length of the spine 3.3 mm. The interobserver bias was negligible. It can be concluded that the reliability of our new method for quantifying geometrical variables on digital reconstruction images is better than measurements on conventional roentgenograms in previously published reports. The presented method is therefore considered to be more accurate for research of spinal deformities and more adequate for clinical management of scoliosis.

Adolescent↗
PubMed2005

Correlative radiological, self-assessment and clinical analysis of evolution in instrumented dorsal and lateral fusion for degenerative lumbar spine disease. Autograft versus coralline hydroxyapatite.

This prospective longitudinal randomized clinical and radiological study compared the evolution of instrumented posterolateral lumbar and lumbosacral fusion using either coralline hydroxyapatite (CH), or iliac bone graft (IBG) or both in three comparable groups, A, B and C, which included 19, 18 and 20 patients, respectively, who suffered from symptomatic degenerative lumbar spinal stenosis and underwent decompression and fusion. The patients were divided randomly according to the graft used and the side that it was applied. The spines of group A received autologous IBG bilaterally; group B, IBG on the left side and hydroxyapatite mixed with local bone and bone marrow on the right side; group C, hydroxyapatite mixed with local bone and bone marrow bilaterally. The age of the patients in the groups A, B and C was 61+/-11 years, 64+/-8 years and 58+/-8 years, respectively. The SF-36, Oswestry Disability Index (ODI), and Roland-Morris (R-M) surveys were used for subjective evaluation of the result of the surgery and the Visual Analogue Scale (VAS) for pain severity. Plain roentgenograms including anteroposterior, lateral and oblique views, and lateral plus frontal bending views of the instrumented spine and CT scan were used to evaluate the evolution of the posterolateral fusion in all groups and sides. Two independent senior orthopaedic radiologists were asked to evaluate first the evolution of the dorsolateral bony fusion 3-48 months postoperatively with the Christiansen's radiologic method, and secondly the hydroxyapatite resorption course in the spines of groups B and C. The diagnosis of solid spinal fusion was definitively confirmed with the addition of the bending views, CT scans and self-assessment scores. The intraobserver and interobserver agreement (r) for radiological fusion was 0.71 and 0.69, respectively, and 0.83 and 0.76 for evaluation of CH resorption. T(12)-S(1) lordosis and segmental angulation did not change postoperatively. There was no radiological evidence for non-union on the plain roentgenograms and CT scans. Radiological fusion was achieved 1 year postoperatively and was observed in all groups and vertebral segments. Six months postoperatively there was an obvious resorption of hydroxyapatite granules at the intertransverse intersegmental spaces in the right side of the spines of group B and both sides of group C. The resorption of hydroxyapatite was completed 1 year postoperatively. Bone bridging started in the third month postoperatively in all instrumented spines and all levels posteriorly as well as between the transverse processes in the spines of the group A and on the left side of the spines of group B where IBG was applied. SF-36, ODI, and R-M score improved postoperatively in a similar way in all groups. There was one pedicle screw breakage at the lowermost instrumented level in group A and two in group C without radiologically visible pseudarthrosis, which were considered as having non-union. Operative time and blood loss were less in the patients of group C, while donor site complaints were observed in the patients of the groups A and B only. This study showed that autologous IBG remains the "gold standard" for achieving solid posterior instrumented lumbar fusion, to which each new graft should be compared. The incorporation of coralline hydroxyapatite mixed with local bone and bone marrow needs adequate bleeding bone surface. Subsequently, hydroxyapatite was proven in this series to not be appropriate for intertransverse posterolateral fusion, because the host bone in this area is little. However, the use of hydroxyapatite over the decorticated laminae that represents a wide host area was followed by solid dorsal fusion within the expected time.

Aged↗
PubMed2001

Prediction of the postoperative pulmonary function and complication rate in elderly patients.

We analyzed the risk factors predisposing elderly patients to develop postoperative respiratory complications (PRCs) and investigated the possibility of predicting the postoperative pulmonary function and PRC rate. The postoperative pulmonary functions were predicted according to a simplified system, which we developed using plain chest roentgenograms from patients with primary lung cancer. Both univariate and multivariate analyses of PRCs were performed in 39 elderly patients with lung cancer from July 1982 to March 1991 (the early period). Based on the results obtained, the permissible extent of lung resection to achieve a predicted postoperative % forced expiratory volume in 1 s (ppo%FEV1.0) and a predicted postoperative % vital capacity (ppo%VC) of more than 55% was selected as the basic criteria for undergoing such an operation after April 1991 (the recent period). A ppo%FEV1.0 and/or ppo%VC of 55% or less was the most significant risk factor for developing PRCs. The PRC rate decreased from 33.3% to 9.8% (P = 0.0251) and the operative mortality rate decreased from 10.3% to 0%. The survival rates for stage I, II. and III cases were not significantly different between the early and recent periods. Decisions made on the operability and the permissible extent of lung resection based on our system using plain chest roentgenograms therefore appeared to reduce the PRC rate and operative mortality rate in elderly patients.

Aged↗
PubMed1980

Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of Fallot.

Four hundred seventy-five patients underwent repair of tetralogy of Fallot from 1955 to 1964; 396 of these were hospital survivors and were followed up for 12 to 22 years. An excellent late clinical result was maintained by 87 percent of the 396 hospital survivors. A less than excellent result in the remaining 13 percent of hospital survivors was caused by late mortality in 7 percent (sudden death in 3 percent, death due to cardiac causes in 2 percnt and death due to noncardiac causes in 2 percent), required reoperation in 4 percent (mainly because of residual ventricular septal defect) and development of symptoms in 2 percent. Postoperative cardiomegaly (cardiothoracic ratio greater than 0.55) was observed in 60 (25 percent) of 246 patients who had a follow-up chest roentgenogram, and was more common among those who died late or remained symptomatic. Among the few patients with inadequate surgical relief of right ventricular hypertension who did not have transanular patch repair, the hypertension did not tend to decrease progressively, whereas it did decrease in patients who had patch repair. No late sudden deaths were encountered in 20 patients shown to have postoperative right bundle branch block plus left axis deviation (bifascicular block pattern). Pulmonary valve incompetence appeared to have relatively little harmful influence on the late result, causng cardiac disability in 1 percent of the patients and appeared to be the main contributing factor of postoperative cardiomegaly in 13 (5 percent) of the 246 patients who had a follow-up chest roentgenogram. Most late deaths and complicatins appeared within 2 years of operation, and accelerating deterioration in late results did not occur as the follow-up extended beyond 2 decades.

Cardiomegaly↗
PubMed1977

The natural history of hypertrophic gastrophy (Menetrier's disease). Report of a case with 16 year follow-up and review of 120 cases from the literature.

We describe a 33 year old man who presented with epigastric pain, weight loss and hematemesis. Roentgenograms of the upper gastrointestinal tract and endoscopy demonstrated giant rugal folds, and the diagnosis of hypertrophic gastropathy was confirmed by operative biopsy. This patient's symptoms and abnormalities noted on the roentgenograms persisted until his death 16 years later. Postmortem examination confirmed the persistence of hypertrophic gastropathy and revealed, in addition, a hepatocellular carcinoma metastatic to the stomach and regional lymph nodes. A review of 120 previously reported cases of hypertrophic gastropathy with special attention to its natural history indicates that the chronic nature of this patient's illness is typical. In addition, the chance of gastric carcinoma developing in these patients is appreciable. Since the reported long-term results of operative therapy appear favorable, patients with persistent and sufficiently distressing symptoms should be considered for gastric resection.

Adult↗
PubMed1977

The clinical assessment of roentgenographically atypical pulmonary sarcoidosis.

We studied 89 patients in whom the clinical diagnosis of sarcoidosis was supported by the findings on tissue biopsy. A chest roentgenogram in 14 of the patients showed one of the following atypical features: large pulmonary nodules, an alveolar parenchymal pattern or a pleural effusion. Diagnoses of infection, malignancy or vasculitis were suggested by interpretations of atypical chest roentgenograms in eight of these 14 patients. Nonspecific and misleading clinical information contributed. The diagnosis of sarcoidosis was corroborated by extrathoracic tissue biopsies in 11 of the 14 patients. Over an average observation period of 38 months, the 14 patients remained classified as having sarcoidosis. This suggests that an extrathoracic tissue biopsy, whose findings are consistent with sarcoidosis, is often sufficient to support a clinical diagnosis of some forms of roentgenographically atypical pulmonary sarcoidosis.

Adrenal Cortex Hormones↗
PubMed1981

Early diagnosis of spinal epidural metastases.

Early signs of spinal cord injury on neurologic examination have been the primary indication to proceed with myelography in patients with possible spinal epidural metastases. With this approach, loss of ambulation occurs in more than one half of the patients. In an attempt to diagnose epidural metastases before the onset of myelopathy, we designed a prospective study based on the development of back pain, a precursor of spinal cord injury in nearly all cancer patients. Eighty-seven patients were studied. A high incidence of epidural metastases was found in patients with myelopathy (78 percent). In addition, patients with radiculopathy alone frequently had epidural tumor (61 percent). In 36 percent of the patients who presented with back pain but who had normal neurologic findings, there was evidence of epidural metastases on myelography; all of those patients had vertebral metastases on plain roentgenogram. Over-all, the plain roentgenogram of the spine correctly predicted the presence or absence of epidural tumor in 83 percent of the patients. Whereas 93 percent of the patients with myelopathy had more than 75 percent myelographic block, this occurred in 53 percent of those with radiculopathy and in only 33 percent of those with back pain and normal neurologic findings. In most cancer patients, spinal epidural metastases are both detectable and significantly less extensive before the onset of spinal cord injury.

Adolescent↗
PubMed1990

Running, osteoarthritis, and bone density: initial 2-year longitudinal study.

PURPOSE: The purpose of this study was to present the 2-year follow-up results examining associations of repetitive long-term physical impact (running) with osteoarthritis and osteoporosis in 34 members of a running club now aged 52 to 74 years and 34 matched control subjects. PATIENTS AND METHODS: Roentgenograms of the hands, lateral lumbar spine, and knees were assessed in pairs (1984 and 1986) without knowledge of running status. Computerized scans of the first lumbar vertebrae were obtained to quantify bone mineral. RESULTS: A decrease in bone density over the 2-year period was statistically significant for nearly all subjects, especially for runners who decreased their running habits. At the 2-year follow-up, runners maintained greater bone density. Progression of the roentgenographic scores for osteoarthritis demonstrated a statistically significant increase in almost all groups in this normative population over the 2-year period. Female runners had more spur formation in the weight-bearing knee roentgenograms than did control subjects. CONCLUSION: With the possible exception of spur formation in women, running did not appear to influence the development of radiologic osteoarthritis in the populations studied.

Aged↗
PubMed1991

Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care.

PURPOSE: Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP). PATIENTS AND METHODS: Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 +/- 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18). RESULTS: Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 +/- 0.5 versus 2.8 +/- 0.6, p less than 0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p less than 0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg. CONCLUSION: Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion.

Adult↗
PubMed1991

Accuracy of precordial percussion in detecting cardiomegaly.

STUDY OBJECTIVE: To assess the value of precordial percussion in detecting cardiomegaly, and to compare it with palpation of the apical impulse. DESIGN: Descriptive study. SETTING: Hospitals and clinics of a university medical center. PATIENTS: Light indirect percussion of the precordium was performed on 72 inpatients and 28 outpatients. All patients had a posteroanterior radiograph of the chest. Percussors were unaware of the clinical history and of chest roentgenogram results. MEASUREMENTS AND MAIN RESULTS: Thirty-six patients (36%) had cardiomegaly, defined as a cardiothoracic ratio of greater than 0.5 on chest roentgenogram. The cardiothoracic ratio was significantly correlated with percussion distance from the midsternal line in the left fourth (r = 0.35, p less than 0.0006), fifth (r = 0.65, p less than 0.00001), and sixth (r = 0.40, p less than 0.0001) intercostal spaces. After adjustment for clinical symptoms and systolic and diastolic blood pressures, percussion distance in the left fifth intercostal space remained a significant independent predictor of the cardiothoracic ratio. Percussion distance in the left fifth interspace discriminated cardiomegaly with a receiver-operating characteristic (ROC) area of 0.95. Percussion dullness more than 10.5 cm from the midsternal line in the left fifth interspace had a sensitivity of 94.4% (95% confidence interval [CI], 79.9% to 99.0%) and a specificity of 67.2% (CI, 54.2% to 78.1%). Distance of the apical impulse from the midsternal line discriminated with an ROC area of 0.95, but an impulse was palpated in only 40% of cases. CONCLUSIONS: Percussion in the left fifth intercostal space accurately discriminates patients with and without cardiomegaly, and adds information beyond that obtainable from the history and other parts of the physical examination.

Adolescent↗
PubMed1994

The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients.

PURPOSE: To determine whether bronchoalveolar lavage (BAL) remains a useful technique in assessing human immunodeficiency virus (HIV)-infected patients with pulmonary symptoms. PATIENTS AND METHODS: All HIV-infected patients with pulmonary symptoms referred to a university hospital-based pulmonary service underwent bronchoscopy and BAL within 24 hours of referral. All samples were handled in a standardized fashion. The results of the lavage were compared with chest roentgenograms and clinical results. RESULTS: A total of 894 lavages were performed on HIV-infected patients over a 7-year period. The overall diagnostic yield was 60%, with 420 patients having Pneumocystis carinii. Infections other than P carinii were found in 185 cases, including 75 lavages with P carinii and another infection. The other infections included Mycobacterium tuberculosis (17 patients), Mycobacterium kansasii (15 patients), Histoplasma capsulatum (24 patients), Cryptococcus neoformans (17 patients), and bacterial infection (103 patients). For 364 lavages, no diagnosis was made. Chest roentgenograms were not useful in predicting what infection would be diagnosed. There was no difference in the yield of BAL over the 7-year period, despite the introduction of aerosol pentamidine prophylaxis and antiretroviral therapy. CONCLUSION: Bronchoscopy with BAL continues to have a role in the evaluation of HIV-infected patients with pulmonary symptoms.

AIDS-Related Opportunistic Infections↗
PubMed1978

The development of cholecystography: the first fifty years.

Visualization of the gallbladder by x-ray was first achieved in 1923 by the intravenous introduction into the body of a halogenated compound which was excreted by the liver into the bile ducts and gallbladder [1--4]. This was the first time that visualization of an organ had been accomplished by introducing a substance into the body and obtaining a roentgenogram after the substance had been metabolized and localized primarily in one organ. Previously, visualization of an organ had been achieved only by introducing a substance opaque to the x-ray directly into the lumen and obtaining a roentgenogram to outline its inner wall. By 1925 visualization of the gallbladder had also been accomplished by the oral administration of halogenated compounds [5,6]. The drugs employed for intravenous and oral cholecystography had been synthesized specifically for that purpose based on earlier experimental work of other investigators. The following account describes in detail the experimental background of cholecystography, its origin, and its development and use during the ensuing fifty years.

Administration, Oral↗
PubMed1983

Metastatic malignant disease of unknown origin.

The charts of 106 patients with metastasis from an unknown primary cancer were reviewed to formulate a more appropriate investigative strategy than is presently employed. The spinal column was the most common site for initial presentation of metastatic disease (26.5 percent). The primary tumor was identified before death in 31.3 percent of patients and after death in 6.6 percent. Lung cancer was found in 40 percent of patients with identified primary tumors. Diagnostic studies directed at specific symptoms had a significantly greater yield. Electroencephalograms, gallium scans, thyroid scans, and mammograms were not useful as screening studies. Conversely, bone scans were positive in 46.5 percent of asymptomatic patients and in 88 percent of symptomatic patients. Chest roentgenograms were suggestive of malignant tumors in 43.6 percent of patients. Results of liver scans were predictable on the basis of changes in the alkaline phosphatase level and clinical liver examination. History and physical examination should clearly document the stage of disease, evaluate possible primary sites, and rule out impending acute complications. Chest roentgenograms and bone scans should be obtained early and open biopsy of accessible lesions scheduled promptly. Efforts should be directed at ruling out the more treatable malignant tumors. Further work-up is then indicated only by the development of specific symptomatology. Since median patient survival after initial presentation is only 6.6 months, prolonged hospitalization for numerous nonproductive diagnostic tests seems inappropriate.

Adult↗
PubMed1989

Elevated hemidiaphragm after cardiac operations: incidence, prognosis, and relationship to the use of topical ice slush.

We have reviewed chest roentgenograms of 745 patients before hospital dismissal after cardiac operations and serially to determine the incidence and prognosis of elevated hemidiaphragm and any relationship to the use of topical ice slush (TIS) in myocardial preservation. All patients had similar myocardial preservation techniques including moderate systemic hypothermia and 4 degrees C saline solution poured over the heart at aortic clamping. During a 12-month period, TIS was added to the saline bath. Two (2.4%) of 84 patients before TIS and 5 (2.5%) of 201 consecutive patients operated on since discontinuing TIS had elevated hemidiaphragm on the predismissal roentgenogram. Of 460 patients in whom TIS was employed, 109 (23.7%) had elevated hemidiaphragm (p less than 0.001). When TIS was employed, elevated hemidiaphragm developed in 72 (26%) of 280 patients without internal mammary artery takedown versus 13 of 33 patients (39.4%) with takedown of the internal mammary artery (p = 0.047). Ninety-nine patients with elevated hemidiaphragm were available for follow-up at 1 month, at which time 79 (79.8%) continued to have elevated diaphragm. At 1 year, 14 (21.9%) of 64 patients had persistent diaphragm elevation. We conclude that TIS predisposes to elevated diaphragm and that the incidence is increased when the internal mammary artery is harvested.

Coronary Artery Bypass↗
PubMed1991

Mesenchymoma of the chest wall in children.

Benign chest wall mesenchymoma in children is an extremely rare disease. Only 20 patients have been reported in the world literature. We report a chest wall mesenchymoma in a 2-year-old boy who was admitted to the hospital after a routine chest roentgenogram showed a mass in the right upper chest wall. The patient was asymptomatic. Clinical examination was negative, but chest roentgenograms and computed tomography showed a mass in the right upper chest wall involving the third rib. A 2 x 2 x 1.5-cm tumor was excised totally with partial resection of the third rib. The histology of the lesion corresponded to a mesenchymoma (hamartoma) of the chest wall. Our patient has been followed up for 8 years without recurrence.

Bone Neoplasms↗