Pathological hip fracture in the elderly: review and proposal of an algorithm

Objective. Current Italian guidelines recommend surgery within 24 hours from admission for hip fractures of the elderly. In such patients, a pathologic fracture of the proximal femur is not an uncommon event and may be consequent to bone metastases or primary tumours. This paper aims to investigate the current literature and to propose an algorithm to manage patients more securely. Methods. A review of the literature on diagnostic and therapeutic tools in pathologic fractures of the hip was conducted. Evidence from the literature was merged to define a flowchart for a safe clinical-diagnostic pathway. Results. Proper imaging is essential in the management of bone metastases, along with appropriate laboratory tests and within a multi-disciplinary setting. While bone metastases are the expression of a systemic disease, bone sarcomas have an extremely aggressive local course and an incorrect surgical procedure could heavily affect prognosis of the patient. The surgeon should not rush to treat a suspicion of a pathological fracture without having performed all necessary investigations. Conclusions. Orthopaedists must doubt a pathologic fracture. An algorithm could help standardise procedures and provide a tool for safe management of these patients

Small Subcutaneous Soft Tissue Tumors (<5 cm) Can Be Sarcomas and Contrast-Enhanced Ultrasound (CEUS) Is Useful to Identify Potentially Malignant Masses

Subcutaneous masses smaller than 5 cm can be malignant, in contrast with the international guidelines. Ultrasound (US) and magnetic resonance imaging (MRI) are useful to distinguish a potentially malignant mass from the numerous benign soft tissue (ST) lesions. Contrast-enhanced ultrasound (CEUS) was applied in ST tumors, without distinguishing the subcutaneous from the deep lesions. We evaluated CEUS and MRI accuracy in comparison to histology in differentiating malignant from nonmalignant superficial ST masses, 50% smaller than 5 cm. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) with their 95% confidence intervals (CI) were calculated. Of malignant cases, 44.4% measured &le;5 cm. At univariate analysis, no statistically significant differences emerged between benign and malignant tumors in relation with clinical characteristics, except for relationship with the deep fascia (p = 0.048). MRI accuracy: sensitivity 52.8% (CI 37.0, 68.0), specificity 74.1% (CI 55.3, 86.8), PPV 73.1% (CI 53.9, 86.3), and NPV 54.1% (CI 38.4, 69.0). CEUS accuracy: sensitivity 75% (CI 58.9, 86.3), specificity 37% (CI 21.5, 55.8), PPV 61.4% (CI 46.6, 74.3), and NPV 52.6% (CI 31.7, 72.7). CEUS showed a sensitivity higher than MRI, whereas PPV and NPV were comparable. Also, masses measuring less than 5 cm can be malignant and referral criteria for centralization could be revised

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

Bone Metastasis from Solid Tumors: Biologic and Clinical State of the Art

Bone metastases are a frequent and debilitating consequence for many tumors, of which breast, lung, prostate, and kidney cancer are the most common. The dialog among cancer cells, bone microenvironment, and immune system regulates bone metastasis formation. Indeed, bone and immune system are strictly linked to each other because bone regulates the hematopoietic stem cells from which all cells of the immune system derive. Many immunoregulatory cytokines influence the fate of bone cells and promote the growth of tumor cells in bone, contributing to sustain the vicious cycle of bone metastasis. Bone is an attractive soil for cancer cells, which can remain dormant for years or directly form bone lesions. The fate of cancer cells after their arrival to bone marrow depends on a complex cross-talk among cancer, bone, and immune cells in the microenvironment. This review provides an overview of the different steps occurring during bone metastatic process, with particular attention to the osteoimmunology field. Furthermore, we will revise the current available clinical approaches for the therapy of bone metastatic patients

Body Schema Self-Awareness and Related Dream Content Modifications in Amputees Due to Cancer

Purpose: the evaluation of body image perception, pain coping strategies, and dream content, together with phantom limb and telescoping phenomena in patients with sarcoma who underwent surgery for limb amputation. Material and Methods: consecutive outpatients were evaluated at T0 (within 3 weeks after surgery) and T1 (4–6 months after surgery) as follows: demographic and clinical data collection; the Groningen Questionnaire Problems after Arm Amputation; the West Haven-Yale Multidimensional Pain Inventory; the Body Image Concern Inventory, a clinical trial to identify telescoping; and a weekly diary of dreams. Dream contents were coded according to the Hall and Van de Castle coding system. Results: Twenty patients completed the study (15 males and 5 females, mean age: 53.9 ± 24.6, education: 7.8 ± 3.4). All subjects experienced phantom limb and 35% of them experienced telescoping soon after surgery, and 25% still after 4–6 months. Both at T0 and T1, that half of the subjects reported dreams about still having their missing limbs. At T1 the patients’ perceptions of being able to deal with problems were lower, and pain and its interference in everyday life were higher yet associated with significant engagement in everyday activities and an overall good mood. The dream content analysis highlighted that males were less worried about health problems soon after amputation, and women showed more initial difficulties that seemed to be resolved after 4–6 months after surgery. Conclusions: The dream content analysis may improve clinicians’ ability to support their patients during their therapeutic course

Electrochemotherapy and Simultaneous Photodynamic Bone Stabilization of Upper Limbs in Metastatic Renal Cancer Disease: Case Report and Literature Review

Introduction. Metastatic bone disease represents a systemic pathology that heavily affects the quality of life of oncologic patients causing pain and functional disability. Methodology. We present the case of a patient with a history of renal cell cancer presenting pathologic fractures of both humeri and proximal right radius. Results. After a careful multidisciplinary approach, an adjuvant anticancer therapy and a photodynamic bone stabilization procedure were performed with a minimally invasive technique aiming to minimize pain and local disease progression, while restoring functional autonomy and improving the patient’s quality of life. Electrochemotherapy was delivered on the lytic bone lesions with extraskeletal involvement of the proximal left humerus and the proximal right radius, and then polymeric bone stabilization was performed on both humeri. At two months of follow-up, the patient presented satisfactory functional scores (MSTS score: 12/30 bilaterally; DASH scores: 46.7/100 for the right side and 48.3/100 for the left one), and pain was well controlled with opioid analgesics. Radiographs showed good results in terms of ossification of lytic bone lesions and durability of polymeric stabilization. At four months of follow-up, the patient reported a stable clinical scenario. Six months after surgery, due to extremely poor prognosis after the progression of primary disease, the patient was referred to palliative care and died shortly thereafter. Conclusion. Over the last decade, the management of metastatic bone disease has changed. Low-toxicity and minimally invasive procedures such as electrochemotherapy and polymeric bone stabilization might be performed concomitantly in selected patients, as an alternative to radiation therapy and to more demanding surgical procedures such as plating and adjuvant cementing