G. Iacobescu, R. Ene, A. Cursaru, D. Anghelescu and C. Cîrstoiu
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.
A. Lupu, R. Ene, A. Cursaru, D. Anghelescu, E. Popescu and C. Cîrstoiu
Introduction. After a time when amputation was the only treatment option for musculoskeletal malignancies, a major breakthrough was the tumoral arthroplasty with limb preservation. Material and method. The study included a group of 28 patients, of whom 20 had pelvic limb tumor formation. Malignant bone tumors were present in 18 patients and benign tumors in 10 patients. The most commonly encountered was osteosarcoma in 12 patients, Ewing sarcoma in 4 patients and giant cell tumor in 3 patients. Patient follow-up was conducted within 4 years (with an average of 3-5 years). Results. 5 of our patients developed pulmonary metastases 8 months after surgery and, for 4 of the patients, pulmonary determinations were extirpated without subsequent relapse. The survival rate was 75% at the last follow-up (6 of 12 patients with osteosarcoma, 1 of 4 patients with Ewing’s sarcoma has died), and 32% had local tumor recurrence. The infection remains an inherent danger by using implants in immunosuppressed patients. 18% of the patients had amputations secondary to long-term complications involving the following prosthesis causes: vascular compromise, aseptic loosening, periprosthetic fractures, and metallosis. Sarcoma was associated with a higher infection rate. Radiotherapy and chemotherapy (not in combination) were statistically associated with an increased infection. Debridement with retention of the implant has reached a remission of the infection rate of 70%, 62% for two-step treatment to 100% in the case of amputations. Conclusions. Regardless of the stage of the tumor, amputation has a narrower indication nowadays, the goal being the retention of the limb and reconstruction. The amputation post-tumoral arthroplasty is of a primary intention in the case of aggressive local recurrences and massive infections. Staphylococcus aureus remains the bacterium with the highest incidence of infection complications.
A. Cursaru, A.G. Lupu, D. Anghelescu, G. Mardare, R. Ene and C. Cîrstoiu
Introduction. The osteosarcoma represents the most frequently encountered primitive malignant bone tumor, representing 30% of the malignant bone tumors with an unpredictable evolution. Materials and methods. A retrospective study realized over a period of 3 years (Jan. 2016-Jan. 2018), which included 6 patients diagnosed with osteosarcoma and treated through the reconstruction with tumor prosthesis technique in the Orthopaedics and Traumatology Clinic of the University Emergency Hospital in Bucharest. Results. Of the total 6 patients, 5 were male and 1 was a female with ages between 20 and 61 years old, with an average of 30.6 years. The localization of the tumor was at the distal femur (3 cases) and at the proximal tibia (3 cases). In 3 cases, the reattachment of the extensor apparatus of the knee to the prosthesis was needed, while for 3 of the cases, a musculocutaneous flap was created for the coverage of the implant. All the 6 patients were monitored and had postoperative follow-ups at 3, 6 and 12 months by having clinical and imagistic evaluations in search of the eventual local recurrences or metastases in other tissues and organs. The postoperative evaluation of the function of the joint was realized with the Knee Society Score Questionnaire and recorded very good results (76-91) with an average of 82 points. Conclusions. The short-term results of this study about the treatment of the knee osteosarcoma with modular prostheses show that this treatment has a low tumoral recurrence rate and restores the joint function.
D. Anghelescu, E. Popescu, A. Cursaru, A. Dimitriu, R. Ene and C. Cîrstoiu
Objectives. Sacral tumors represent about 1-4,3% of all bone tumors. They typically present with an abundance of blood vessels. Due to their anatomical localization, they are hard to approach surgically. Thus, a presurgical neoadjuvant therapy is indicated. The preoperative angiography with the embolization of the nutritive arteries decreases the perioperative blood loss and the symptomatology, and even decreases the volume of the tumors that cannot be surgically approached. Materials and methods. The principle of embolization consists in the targeting of the nutritive tumoral artery and in obturating it with embolic agents (polyvinyl alcohol, embospheres, etc.) through selective catheterization under angiographic control. The biopsy of the tumor is essential for certain diagnosis. The histological type of the tumor and the degree of differentiation influence the tumor’s physiopathology and often influence the therapeutic decision regarding its degree or recurrence. In some cases in which the tumor’s degree of extension increases the surgical risk, serial embolization can be used as a primary method of treatment. Because of the late onset symptomatology, when they are discovered they are extended and the degree of invasion in adjacent tissues is so high that it requires en bloc resection with nerve root sacrifice to assert complete excision and low recurrence rates. Results. The patients who undergo surgical treatment usually bleed, and the perioperative blood loss and the need for blood transfusion volumes were halved in the cases in which presurgical transarterial embolization was performed. Conclusions. Transarterial embolization of sacral tumors is a procedure indicated as a neoadjuvant presurgical therapy to decrease the blood loss risks and for the tumors that cannot be surgically removed it is used in the palliative treatment to reduce symptomatology.
M.I. Costache, Mihai Ioana, Sevastiţa Iordache, D. Ene, Cornelia Alexandra Costache and A. Săftoiu
Angiogenesis is a crucial event for tumor growth and it is regulated predominantly by several different growth factors. Vascular endothelial growth factor protein family (VEGF) and its receptors are probably the most important tissue factors responsible for angioblast differentiation and tube formation. VEGF protein family currently comprises several members: VEGF (or VEGF-A), VEGF-B, VEGF-C and VEGF-D, VEGF-F, placental growth factor (PlGF), and their receptors VEGFR-1, VEGFR-2 and VEGFR-3. VEGF is a key angiogenic growth factor and its level of expression is a critical marker for detection of the angiogenic diseases. The potent role of VEGF in tumor angiogenesis has been widely described in the past decade, being expressed in most types of nondigestive and digestive cancers. VEGF family members play an important role in the development of pancreatic cancer (especially VEGF-A, VEGF-C, VEGF-D, VEGFR-1 and VEGFR-2). VEGF-A is the most specific and prominent angiogenic factor among all family members and VEGFR-2 is the most important receptor in evaluating the angiogenesis in pancreatic cancer. Thus, VEGF overexpression may be considered as a diagnostic marker and as a poor prognostic factor of the disease.