What was the survival of megaprostheses in lower limb reconstructions after tumor resections?

Analisi retrospettiva delle ricostruzioni dell'arto inferiore con protesi modulariBackground: Prosthetic replacement is the most commonly used option for reconstruction of osteoarticular bone loss resulting from bone neoplasm resection or prosthetic failure. Starting in late 2001, we began exclusively using a single system for large-segment osteoarticular reconstruction after tumor resection; to our knowledge, there are no published series from one center evaluating the use of this implant. Questions/purposes: We investigated the following issues: (1) What is the overall survival, excluding local tumor recurrence, for these endoprostheses used for tumor reconstructions of the lower extremities (knee and hip)? (2) What types of failure were observed in these reconstructions? (3) Do the survival and complications vary according to site of implant? Methods: Between September 2001 and March 2012, we exclusively used this implant for tumor reconstructions. During that time, 278 patients underwent tumor reconstructions of the hip or knee, of whom 200 (72%) were available at a minimum 2 years followup. Seventy-eight patients were excluded from the study for insufficient followup as a result of early death (42) or loss at followup (36). The reconstruction types were the following: proximal femur (69 cases), distal femur (87), proximal tibia (32), and total knee (12). Failures were classified according to the Henderson classification. Nine patients among those with followup shorter than 2 years had presented one or more failures and they were included in our analysis but separately evaluated. Results: Overall survival (no further surgical procedures of any type after primary surgery), excluding Type 5 failure (tumor recurrence), was 75.9% at 5 years and 66.2% at 10 years. Seventy-one failures occurred in 58 implants (29%). Mechanical failures accounted for 59.2% and nonmechanical failures for 40.8%. The first causes of failure of the implants were the result of soft tissue failure in 6%, aseptic loosening in 3%, structural failure in 7%, infection in 8.5%, and tumor recurrence in 4.5% of the whole series. Nine implants sustained two or more failures. Overall incidence of infection was 9.5%. No statistically significant differences were observed according to anatomical site. Conclusions: Like in the case with many such complex oncologic reconstructions, the failure rate at short- to midterm in this group was over 20%. Comparative trials are called for to ascertain whether one implant is superior to another. Infection and structural failure were the most frequent modes of failure in our experience. Level of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence

Risks and benefits of combining denosumab and surgery in giant cell tumor of bone-a case series

BACKGROUND The RANK ligand inhibitor denosumab is being investigated for treatment of giant cell tumor of bone, but the available data in the literature remains sparse and controversial. This study analyzes the results of combining denosumab with surgical treatment and highlights possible changes for the oncologic surgeon in daily practice. METHODS A total of 91 patients were treated surgically for giant cell tumor of bone between 2010 and 2014 in an institution, whereas 25 patients of the total additionally received denosumab and were part of this study. The average age of the patients was 35 years. Eleven patients received denosumab pre- and postoperatively, whereas with 14 patients, the denosumab treatment was applied either before (7 patients) or after (7 patients) the surgery. The average preoperative therapy duration was 3.9 months and the postoperative therapy 6 months by default. RESULTS Sixteen patients presented a large tumor extension necessitating a resection of the involved bone or joint. In 10 of these patients, the indication for a resection procedure was abandoned due to the preoperative denosumab treatment and a curettage was performed. In the remaining six cases, the surgical indication was not changed despite the denosumab treatment, and two of them needed a joint replacement after the tumor resection. Also with patients treated with curettage, denosumab seems to facilitate the procedure as a new peripheral bone rim around the tumor was built, though a histologic analysis reveals viable tumor cells persisting in the denosumab-induced bone formation. After an average follow-up of 23 months, one histologically proven local recurrence occurred, necessitating a second curettage. A second patient showed a lesion in the postoperative imaging highly suspicious for local relapse which remained stable under further denosumab treatment. No adverse effect of the denosumab medication was observed in this study. CONCLUSIONS Denosumab can be a help to the oncologic surgeon by reconstituting a peripheral rim and switching the stage from aggressive to active or latent disease. But as tumor cells remain in the new-formed bone, the surgical technique of curettage has to be changed from gentle to more aggressive to avoid higher local recurrence rates

How do we estimate survival? External validation of a tool for survival estimation in patients with metastatic bone disease-decision analysis and comparison of three international patient populations

How do we estimate survival? External validation of a tool for survival estimation in patients with metastatic bone disease-decision analysis and comparison of three international patient population

Denosumab in patients with aneurysmal bone systs: A case series with preliminary results

Abstract PURPOSE:: Aneurysmal bone cyst (ABC) is a rare skeletal tumor usually treated with surgery/embolization. We hypothesized that owing to similarities with giant cell tumor of bone (GCTB), denosumab was active also in ABC. METHODS:: In this observational study, a retrospective analysis of ABC patients treated with denosumab was performed. Patients underwent radiologic disease assessment every 3 months. Symptoms and adverse events were noted. RESULTS:: Nine patients were identified (6 male, 3 female), with a median age of 17 years (range 14-42 years). Primary sites were 6 spine-pelvis, 1 ulna, 1 tibia, and 1 humerus. Patients were followed for a median time of 23 months (range 3-55 months). Patients received a median of 8 denosumab administrations (range 3-61). All symptomatic patients had pain relief and 1 had paresthesia improvement. Signs of denosumab activity were observed after 3 to 6 months of administration: bone formation by computed tomography scan was demonstrated in all patients and magnetic resonance imaging gadolinium contrast media decrease was observed in 7/9 patients. Adverse events were negligible. At last follow-up, all patients were progression-free: 5 still on denosumab treatment, 2 off denosumab were disease-free 11 and 17 months after surgery, and the last 2 patients reported no progression 12 and 24 months after denosumab interruption and no surgery. CONCLUSIONS:: Denosumab has substantial activity in ABCs, with favorable toxicity profile. We strongly support the use of surgery and/or embolization for the treatment of ABC, but denosumab could have a role as a therapeutic option in patients with uncontrollable, locally destructive, or recurrent disease

Expandable distal femur megaprosthesis : a European Musculoskeletal Oncology Society study on 299 cases

Background and Objectives Expandable distal femur prostheses have become more popular over the last decades, but scientific data is limited. Methods A retrospective study was performed, including cases treated between 1986 and 2019 in 15 European referral centers for bone sarcomas. Results A total of 299 cases were included. Average follow-up was 80 months (range, 8-287 months). Mean patient age was 10 years. Most (80%) of the implants were noninvasive growers and a fixed hinge knee was used more often (64%) than a rotating hinge. Most prosthetic designs showed good (>80%) implant survival at 10 years, but repeat surgery was required for 63% of the patients. The most frequent reason for revision procedure was the completion of lengthening potential. Noninvasive expandable implants showed less risk of infection compared to invasive growers (11.8% vs 22.9% at 10 years). No difference in aseptic loosening was found between cemented and uncemented stems. Conclusions This study shows the increasing popularity of expandable distal femur prostheses, with overall good results for function and implant survival. However, repeat surgery is frequently required, especially in patients under the age of 10 years old. Infection is less frequent in noninvasive growers compared to implants that require invasive lengthening procedures