Pathologic fracture in osteosarcoma has traditionally been associated with a poor prognosis and is an immediate indication for amputation of the affected extremity. This concept has been questioned and remains an area of debate, especially because advances in osteosarcoma treatment have today resulted in better survival and limb salvage rates.

It is the objectives of this paper to analyze the survival and limb salvage rate of osteosarcoma patients presenting with pathologic fractures and compare these with the population of osteosarcoma patients without pathologic fractures.

Over a 15-year period (1993-2008), these were 84 patients presenting with non-metastatic high-grade classic osteosarcoma of the extremities (Enneking Stage IIB) who received complete treatment from the University of the Philippines-Musculoskeletal Tumor (UP-MuST) Unit and who had a follow up of at least 2 years. Ten of these 84 patients had pathologic fractures prior to surgery. Their overall survival was 50%, similar to the 50.38% overall survival of the entire group of 84 osteosarcoma patients. Limb salvage rate was 60%, similar to the 59% rate of patients without pathologic fractures.

This study shows that contrary to traditional teaching, overall survival for this subset of osteosarcoma patients with pathologic fractures is acceptable at 50% and is equal to that of the entire group of osteosarcoma patients. At the same time, successful limb salvage surgery is possible despite the presence of a pathologic fracture, especially in patients with good response to chemotherapy.

Human ; Animal ; Male ; Female ; Middle Aged ; Adult ; Young Adult ; Adolescent ; Child ; Humans ; Limb Salvage ; Fractures, Spontaneous ; Follow-up Studies ; Philippines ; Osteosarcoma ; Amputation ; Salvage Therapy ; Extremities ; Prognosis ; Bone Neoplasms

OBJECTIVE: To determine the interobserver and intraobserver reliabilities of the Enneking Classification system in staging benign bone tumors. METHODS: Photographs of traditional plain radiographs of 65 histologically benign tumors from the PGH Department of Orthopedics Tumor Registry were used in the study. Nine Orthopedic surgeons (three consultants, one fellow, and five senior residents) staged the tumors using the Enneking Classification based on radiographic tumor-host margins. The photographs were sent to the surgeons twice (batch 1 and 2), three months apart, for staging. The Fleiss and Cohen kappa statistics were used to determine interobserver and intraobserver reliabilities, respectively. This is a pilot study. RESULTS: There was only fair interobserver reliability of the Enneking Classification staging with Fleiss kappa of 0.38 and 0.26 for batches 1 and 2, respectively. Also, there was only moderate intraobserver reliability (Cohen kappa 0.48) for the staging. Moreover, there was also a relatively low intraobserver percent agreement (67%) among raters. In both reliabilities, the consultants/fellow group consistently showed better interobserver and intraobserver reliabilities compared to the residents. CONCLUSION: The Enneking Classification in staging benign bone tumors had relatively low interobserver and intraobserver reliabilities. There was also a tendency of experienced orthopedic tumor consultants and senior residents to stage the same radiograph differently upon repeat testing.
Reproducibility of Results ; Neoplasms

Objective. Classic high-grade osteosarcoma is uncommon in preadolescents (less than or equal to 10 years of age). The possibilities of clinicopathologic differences from the typical adolescent osteosarcoma patient have been raised. We sought to compare the presentation, treatment and survival of this subgroup of patients with published rates in order to determine if there is a need to use a treatment regimen different from that for regular adolescent osteosarcoma patients. Methods. Records of the University of the Philippines-Musculoskeletal Tumor Unit (UP-MuST) over a 15-year period (1993-2008) were reviewed and data collected on patients 10 years and younger with biopsy-proven classic high-grade intramedullary osteosarcoma who underwent complete treatment by the Unit. Demographics and survival rates were then compared with published rates for preadolescent and regular adolescent osteosarcoma cases. Results. There were fourteen patients; (6M:8F; age: 4-10 years). The most common presentation was a painful mass in the distal femur (8); the tumors most commonly had osteoblastic histology (12). Treatment consisted of neoadjuvant chemotherapy, wide surgical excision through ablation (9) or limb-saving surgery (5), and postoperative chemotherapy. There was a good histologic response (over 90% tumor necrosis) in four patients. Seven patients are ANED (alive no evidence of disease) 25 to 186 months after diagnosis. Five-year survival estimate is 52%, compared to a dismal 5 to 10% 15 years ago. Conclusion. Clinicopathologic presentation, clinical course, and overall survival in this subgroup of patients are comparable with published results for both preadolescent and adolescent osteosarcoma patients. There is no need to alter the present treatment regimen for this group of young patients.
Human ; Male ; Female ; Child ; Child Preschool ; OSTEOSARCOMA ; THERAPEUTICS ; THERAPY ; NEOPLASMS ; NEOPLASMS BY HISTOLOGIC TYPE ; NEOPLASMS, CONNECTIVE AND SOFT TISSUE ; NEOPLASMS, CONNECTIVE TISSUE ; NEOPLASMS, BONE TISSUE ;

BACKGROUND AND OBJECTIVE:The posterior interosseous nerve (PIN) is vulnerable to injury in the dorsal approach to the proximal radius. The goal of this study is to describe the quantitative relationship of the PIN to the supinator muscle in the context of anatomic landmarks. Knowledge of superficial landmarks related to the PIN would hopefully minimize iatrogenic injury to the posterior interosseous nerve.
METHODS: 12 cadavers (22 forearms) were dissected and analyzed. The length of the supinator muscle was determined. The oblique distances of the PIN entry and exit points to the proximal and distal borders of the supinator muscle as well as their perpendicular distances to the lateral epicondyle-Lister's tubercle (LE-LT) reference line were measured and recorded. The number of PIN branches inside the supinator substance was recorded. Mean and median values were determined and subjected to statistical analysis.
RESULTS: Mean supinator length was 5 centimeters. Ninety-one percent of the cadaveric forearms had PIN branches inside the supinator muscle substance. Twelve of the 22 forearms (55%) had 2 branches. The mean oblique distances of the PIN from the lateral epicondyle to the entry and exit points in the proximal and distal borders of the supinator muscle was 3.52 and 7.31 centimeters, respectively. The mean perpendicular distances of the PIN from LE-LT reference line to the entry and exit points in the proximal and distal borders of the supinator muscle was 1.13 and 1.26 centimeters, respectively. An imaginary danger-zone 4 centimeters wide overlying the LE-LT reference line depicts the possible area where the PIN and its branches may most likely be located.
CONCLUSION: The dorsal approach to the proximal radius may allow a safe exposure without causing iatrogenic injury to the posterior interosseous nerve through the use of superficial anatomic landmarks and reference lines in combination with mean measurements from our study.

Elbow Fractures

Osteosarcoma in pediatric patients has traditionally been treated with amputation, especially if there is a pathologic fracture through the tumor.

We report the case of a 12-year-old boy who sustained a pathologic fracture through distal femoral osteosarcoma. After neoadjuvant chemotherapy, he underwent limb saving surgery: wide excision of the osteosarcoma followed by a second-stage reconstruction with an expandable tumor endoprosthesis. He has a functional score of 93% and is free of disease 8 years since diagnosis and 2 years since the end of lengthening.

This is the first reported case in Philippine medical literature of limb saving surgery in osteosarcoma reconstructed with an expandable endoprosthesis.

Human ; Male ; Osteosarcoma