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  • Author: C. Cîrstoiu x
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Abstract

Purpose. The purpose of this study is to correlate the existence of a unique bone metastasis of the femur, secondary to a carcinoma of the uterine cervix, the treatment plan, and the recovery of the patient. Materials and method. From previous studies, it is known that the prevalence of unique bone metastasis of the femur secondary to carcinoma of the uterine cervix is very low, in most cases the patients having multiple metastases or in other organs. The case presents a 40-year-old patient who had surgery 2 years before for a carcinoma of the uterine cervix. After the surgical treatment, the patient received chemotherapy and radiotherapy. Nowadays, the patient exhibits pain in the left hip. Following the clinical and paraclinical protocols, an incisional biopsy was made. The histopathologic result was metastasis from the uterine cervix squamous cell carcinoma. The surgical treatment consists of segmentary resection and total hip arthroplasty with tumor reconstruction prosthesis. Results. After total hip arthroplasty with tumor reconstruction prosthesis, we were able to make a segmentary resection in oncological limits, with the complete excision of the metastasis, the patient being able to start the recovery the next day after the surgery. Conclusions. As a surgical indication, the tumor prosthesis represents the best option in the segmentary resections of tumors, this allowing a reconstruction and an early recovery.

Abstract

In the last decades, immunohistochemistry (IHC) has shown an important role in tumor differential diagnosis and has proven its prognostic role. Due to the various histological subtypes of primary malignant bone tumors, its role will be more important in the future. Based on recent studies, tumor growth, cell mobility, and metastases strongly correlate to the survival of these patients. An increased number of specific IHC markers have been used to determine the aggressiveness of the metastatic capacity of these tumors in enhancing early specific oncological therapies. This study presents 15 cases of primary malignant bone tumors, over a period of 4 years (2014-2018), from the Orthopedics and Traumatology Department of the University Emergency Hospital in Bucharest, where we evaluated the proliferation index using Ki67 IHC marker, tissue remodelation, the presence of necrosis in osteosarcoma cases in which chemotherapy was applied, and the aspect of the cytoskeleton with vimentin. Besides the histological aspect, we evaluated the tumor site, invasion and extension to the surrounding tissues (Computer Tomography, Magnetic Resonance) and vascularization with angiography, all these properties having an important prognostic role. Our findings were similar to other research papers in literature; showing that a fast growing and high proliferation index with increased cell mobility has a worse prognosis. Pulmonary metastases occurred in a relative short time in high-grade osteosarcomas, despite the chemotherapy, and multiple metastases were present at 6 months in a dedifferentiated chondrosarcoma case, in which the high-grade sarcoma was an osteosarcoma. Based on the literature, we also think that some specific markers might have multiple roles regarding the tumor growth local invasion and metastasis.

Abstract

Introduction. The management of critical bone defects has experienced an unprecedented improvement in the last few decades. A good primary mechanical stability and versatility of the modular reconstruction systems allowed the conversion to universal setups and the expansion of indication. The progression and reliability of the reconstruction possibilities available nowadays are outlined using the experience of our department. Material and method. A retrospective review of critical bone defect cases and the reconstruction management using endoprosthetic systems is presented. Ten reconstruction surgeries performed in the last 18 months in our department were observed. The patients were 3 males and 7 females with a mean age of 45.3 (range 19 to 75). Modular systems were used for the reconstruction of bone defects subsequent to resections of benign or malignant musculoskeletal tumors (76%) and to non-neoplastic conditions (24%). Results. On the latest follow-up, all the patients were alive, with one case of tumoral recurrence. No aseptic loosening, soft tissue or structural failure were recorded following surgery, with one case under treatment for infection after it required an open procedure for a prosthetic hip dislocation. The early functional results were adequate in all cases, with good secondary stability and satisfactory quality of life. Conclusion. The evolution of endoprosthetic reconstruction surgery has improved the prognosis for many patients diagnosed with critical bone defects. Continuous advances in implant design, fixation, and soft tissue attachment combined with the improvement of surgical techniques will ensure a bright future for this type of procedures.

Abstract

Purpose. The periprosthetic fractures are a more and more often encountered type of pathology, in which the main problem is the indication for surgery. The most important thing is the choice of the best therapeutic option in order to get a solid fixation of the fracture and, in the end, to allow an early patient’s mobilization. Materials and method. 38 cases of periprosthetic fractures have been treated in the Orthopedics and Traumatology Department of University Emergency Hospital in Bucharest, between 2010 and 2016. International Vancouver classification was used for all cases. The osteosynthesis saving the femoral stem was preferred in 22 cases, as its stability was not affected. Stem revision was performed in 16 cases, as this was unstable due to the fracture. Acetabular component was also revised in 4 cases, as the PE insert presented severe wear. The patients were aged 52 to 84 years old and sex ratio M/ F = 13/ 25. Osteosynthesis was performed using Dall-Miles plates and molded plates, with braided cables or wire cerclage. Long stems, uncemented with or without distal locking, were used in 16 cases. Results. Postoperatively, the bone repair was efficient regarding the stability in most of the cases. The patients’ mobilization was early in most of the cases, except for the very old patients with associated comorbidities and limited biological resources. Conclusions. An appropriate surgical indication, adapted on each type of peri-implant fracture, leads to a good result, with early mobilization and the best consolidation of the fracture.

Abstract

Introduction. Efficient management of a segmental resection or major osteolysis in the distal femur secondary to a tumor formation remains a controversial problem. Available options include the use of a modular or customized megaprosthetic implant. Modularity allows versatility for reconstruction and avoids the delay required to make a customized implant. Hypothesis and type of study. Performing a clinical and radiological retrospective study that aims to evaluate long-term efficiency in the use of megaprostheses in segmental distal femur resections. Elaboration of patient selection criteria for modular prosthesis. Materials and methods. We followed retrospectively 33 patients for 5 years from the time of the first surgery. We evaluated the implant stability, the late complications rate, and the long-term functional recovery of patients with distal femoral tumors who underwent segmental resections and subsequently reconstructive arthroplasty. Results. Thirty of the 33 patients maintained a mobile knee joint. An intermediate staging was performed at 30 months, which determined tumor recurrence in 2 patients, aseptic degradation of the components in 3 of them, and septic degradation in two of the evaluated cases. Because a tumoral recurrence occurred on the 45th month, the need for amputation of the prosthetic limb was imposed. The degradation of the polyethylene component (in 5 cases) was observed in the 5-year assessment. The functional results were excellent with the Musculoskeletal Tumor Society Score of 88% and a Toronto Extremity Severity Scale Score of 94%. Conclusions. Patients with distal femoral bone tumors undergoing modular reconstruction prosthetic arthroplasty have excellent functional results with retaining the affected limb and knee mobility. There was a close correlation between correctly applying the selection criteria for patients undergoing prosthesis intervention and functional recovery results.

Abstract

Introduction. The increasing number of tumor prosthesis in the last decade shows the advance in musculoskeletal oncology. Limb sparing surgery nowadays has to be the focus in surgery, maintaining the patient’s quality of life. Prognosis depends on the histological type of tumor, size, and local extension. Pain is present in almost any cases of bone tumors and can vary in intensity and character. Being the leading symptom is strongly correlated to the quality of life. The purpose of this study was to evaluate pain in patients with primary bone sarcomas before and after surgery. Material and methods. 11 patients were involved in this study over a period of 4 years (2014-2017) from the Orthopedics and Traumatology Department in the University Emergency Hospital in Bucharest. Tumor resection and reconstruction with modular prosthesis was performed in 4 cases, and tumor resection was necessary in 3 cases and amputation in 4 cases. Pain was evaluated before and after surgery using the Visual Analog Scale (VAS). Early postoperative pain control was achieved with epidural catheter, followed by opioid therapy, NSAIDs and Paracetamol in the early stages of mobilization. Results. Surface sarcomas and tumors close to the periosteum, or periosteal involvement has shown a localized and increased pain. Multimodal-analgesia was used for pain management. Within the first 48 hours, analgesia was performed with an epidural catheter by continuous infusion of ropivacaine 0.2% and fentanyl 2mcg/ ml at a rate ranging between 3-6 ml/ h, obtaining a VAS score between 0 and 3. Conclusions. Perioperative pain management has to be individualized to the localization and local soft tissue involvement of the tumor. In late stages of sarcomas or local recurrence, conventional analgesics can be inefficient. Early diagnosis and surgical removal of these tumors is the most important objective for a good prognosis.

Abstract

Introduction. Gestational choriocarcinoma (GC) is a malignant condition that develops form trophoblastic cells originating from a previous pregnancy, eutopic or ectopic. Metastatic choriocarcinoma is often diagnosed in the absence of a primary uterine or ovarian tumor, presumably because the latter has undergone complete necrosis. GC rapidly metastasizes spreading to lungs, brain, bones, bone marrow, liver, and other organs, but responds well to chemotherapy. Material and methods. We present the case of a 25-year-old woman with critical evolution after being diagnosed with choriocarcinoma following a complete hydatidiform mole pregnancy. Even though the patient initially received proper treatment, due to poor follow-up compliance, the condition led to invasive metastases. When it spread to the musculoskeletal system and other organs, doctors were able to link symptoms to the choriocarcinoma diagnosis and chemotherapy was initiated. Unfortunately, the patient succumbed due to intracranial hemorrhage. Discussions. GC is a highly and fast invasive malignancy, with rapidly growing tumors. It is often associated with hemorrhage, ischemic necrosis, and secondary inflammation. Often, by the time the tumor is discovered, X-rays of the chest and bones already show metastatic lesions. Chemotherapy success depends on early detection and diagnosis of tumors after pregnancy. Conclusions. Even though the initial diagnosis and treatment should have led to a favorable outcome, the patient’s poor compliance was followed by rapid progression of the disease and, finally, exitus.

Abstract

Introduction. Gestational choriocarcinoma (GC) is a malignant condition that develops from trophoblastic cells originating from a previous pregnancy, eutopic or ectopic. Metastatic choriocarcinoma is often diagnosed in the absence of a primary uterine or ovarian tumor, presumably because the latter has undergone complete necrosis. GC rapidly metastasizes spreading to lungs, brain, bones, bone marrow, liver, and other organs, but responds well to chemotherapy. Material and methods. We presented the case of a 25-year-old woman with critical evolution after being diagnosed with choriocarcinoma following a complete hydatidiform mole pregnancy. Even though the patient initially received proper treatment, due to poor follow-up compliance, the condition led to invasive metastases. When it spread to the musculoskeletal system and other organs, doctors were able to link symptoms to the choriocarcinoma diagnosis and chemotherapy was initiated. Unfortunately, the patient succumbed due to intracranial hemorrhage. Discussions. GC is a highly and fast invasive malignancy, with rapidly growing tumors. It is often associated with hemorrhage, ischemic necrosis, and secondary inflammation. Often, by the time the tumor is discovered, X-rays of the chest and bones have already shown metastatic lesions. Chemotherapy success depends on the early detection and diagnosis of tumors after pregnancy. Conclusions. Even though the initial diagnosis and treatment should have led to a favorable outcome, the patient’s poor compliance was followed by rapid progression of the disease and, finally, exitus.

Abstract

Pigmented villonodular synovitis is a benign proliferative condition that causes the synovium of the joints and tendons to thicken and overgrow. The causes have not been completely discovered, with trauma and repetitive inflammation being the most incriminated. Genetic aberrations have been reported in most cases and could suggest a neoplastic origin of the disease. It appears in 2 forms: localized or diffuse. Although it can affect all joints, the most common location is the knee. The treatment options include anti-inflammatory medication, surgical removal (open or arthroscopic) and radiotherapy (mixed results). We present the case of a 31-year-old male who came to our Clinic with pain and tumefaction of the right popliteal fossa. From the patient’s medical history, it resulted that he had developed a tumoral growth in the popliteal fossa 20 months before, which was removed. After extensive investigations (X-ray, CT, and MRI), a biopsy was performed. The result was pigmented villonodular synovitis. The proliferation was removed for the second time. The immediate post-surgery evolution was good and the patient is scheduled for periodic follow-ups. Although the proliferation was removed entirely, studies show that this disease has a high chance of recurrence (46% for the diffuse form). Also, in time, repeated excisions can force the surgeon to choose more radical options (joint reconstruction or even amputation).

Abstract

Introduction. Giant cell tumors of soft tissue (GCTs) have a relatively low incidence and their low prognosis is reserved to local relapses and distant metastases. This type of pathology usually affects adults and the elderly and it is localized in the extremities, most frequently in the thigh. Materials and methods. GCT is a relatively low aggressive tumor; approximately 85% of the patients survive at least 5 years after diagnosis. The risk factors for low prognosis are old age, metastases at the time of diagnosis, local relapse. We conducted this study in the University Emergency Hospital, Bucharest for a period of 3 years, between 01.01.2015 and 01.01.2018, which included 20 patients with ages between 22 and 83 years, of whom 9 were women and 11 were men. Results. Excision with safety margins was performed for all patients. During surgery, tissue samples from 6 different areas were sent for extemporaneous examination. After excision, the histopathological examination was performed and the diagnosis of GCT was established. Localized forms were described in 16 cases; diffuse forms were identified in 4 cases and loco-regional recurrences in 3 cases. Pre or postoperative adjuvant treatment was not applied in any of the cases. Conclusions. GCT is a rare, potentially malignant pathology, in which case evolution is unfavorable. From the clinical and imaging point of view, it is difficult to establish this diagnosis due to the large variety of pathologies it can be mistaken for, making biopsy an essential step within the diagnostic algorithm. Election treatment is represented by local excision with safety margins.