En bloc resection, intraoperative extracorporeal irradiation and re‑implantation of involved bone for the treatment of limb malignancies

Zhang,Shuai; Wang,Xu‑Quan; Wang,Jia‑Jia; Xu,Mei‑Tao

doi:10.3892/mco.2017.1456

En bloc resection, intraoperative extracorporeal irradiation and re‑implantation of involved bone for the treatment of limb malignancies

Authors:
- Shuai Zhang
- Xu‑Quan Wang
- Jia‑Jia Wang
- Mei‑Tao Xu
View Affiliations

Affiliations: Department of Orthopedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, P.R. China
Published online on: October 18, 2017 https://doi.org/10.3892/mco.2017.1456
Pages: 1045-1052

Metrics: Total Views: 0 (Spandidos Publications: | PMC Statistics: )

Metrics: Total PDF Downloads: 0 (Spandidos Publications: | PMC Statistics: )

Cited By (CrossRef): 0 citations Loading Articles...

Abstract

Reconstruction of the defect following limb‑sparing resection of malignant bone tumors is controversial and extremely challenging. Extracorporeal irradiation (ECI) and re‑implantation have been used for limb salvage surgery for patients, with major advantages, including biological reconstruction, ready availability and preservation of bone stock, over replacement with a megaprosthesis. The purpose of the present study was to present our experience and details of all patients treated with this surgery. Between June 2005 and December 2014, we followed‑up 23 patients with limb malignancies who were treated with en bloc excision followed by 50‑Gy single dose ECI and re‑implantation of involved bone segments. All cases were evaluated based on clinical and radiological examinations, complications and Musculoskeletal Tumor Society (MSTS) score. Mean follow‑up period was 77.6 months (range, 17‑116 months). A total of 17 patients (73.9%) demonstrated no evidence of disease, 5 (21.7%) patients succumbed to the disease and 1 (4.3%) patient was alive with the disease at the final follow‑up. Local recurrence occurred in 3 patients (recurrence rate, 13.0%) in the bed outside of the irradiated graft, and 4 of the 5 patients that lost their lives did so due to associated metastatic disease. The mean value of the MSTS score was 78.8% (50‑93.3%). The majority of patients demonstrated solid bony union; however, 3 patients had non‑union (13.0%) and 1 had a delayed union (4.3%). Early or late complications occurred in 11 patients (47.8%). Although the complication rate (47.8%) and re‑operation rate (39.1%) were high, ECI and re‑implantation may be a useful and cheap technique following en bloc resection for limb salvage in appropriately selected patients.

View Figures

View References

1	Gitelis S, Bayne CO, Frank JM, Fillingham YA and Kent PM: Surgery in malignant bone tumors. Curr Probl Cancer. 37:192–197. 2013. View Article : Google Scholar : PubMed/NCBI
2	Unwin PS, Cannon SR, Grimer RJ, Kemp HB, Sneath RS and Walker PS: Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb. J Bone Joint Surg Br. 78:5–13. 1996.PubMed/NCBI
3	Matejovsky Z Jr, Matejovsky Z and Kofranek I: Massive allografts in tumour surgery. Int Orthop. 30:478–483. 2006. View Article : Google Scholar : PubMed/NCBI
4	Spira E and Lubin E: Extracorporeal irradiation of bone tumors. A preliminary report. Isr J Med Sci. 4:1015–1019. 1968.PubMed/NCBI
5	Böhm P, Fritz J, Thiede S and Budach W: Reimplantation of extracorporeal irradiated bone segments in musculoskeletal tumor surgery: Clinical experience in eight patients and review of the literature. Langenbecks Arch Surg. 387:355–365. 2003.PubMed/NCBI
6	Davidson AW, Hong A, McCarthy SW and Stalley PD: En-bloc resection, extracorporeal irradiation, and re-implantation in limb salvage for bony malignancies. J Bone Joint Surg Br. 87:851–857. 2005. View Article : Google Scholar : PubMed/NCBI
7	Hong A, Stevens G, Stalley P, Pendlebury S, Ahern V, Ralston A, Estoesta E and Barrett I: Extracorporeal irradiation for malignant bone tumors. Int J Radiat Oncol Biol Phys. 50:441–447. 2001. View Article : Google Scholar : PubMed/NCBI
8	Enneking WF, Dunham W, Gebhardt MC, Malawar M and Pritchard DJ: A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 241–246. 1993.PubMed/NCBI
9	Hsu RW, Wood MB, Sim FH and Chao EY: Free vascularised fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br. 79:36–42. 1997. View Article : Google Scholar : PubMed/NCBI
10	Muramatsu K, Ihara K, Hashimoto T, Seto S and Taguchi T: Combined use of free vascularised bone graft and extracorporeally-irradiated autograft for the reconstruction of massive bone defects after resection of malignant tumour. J Plast Reconstr Aesthet Surg. 60:1013–1018. 2007. View Article : Google Scholar : PubMed/NCBI
11	Sluga M, Windhager R, Lang S, Heinzl H, Bielack S and Kotz R: Local and systemic control after ablative and limb sparing surgery in patients with osteosarcoma. Clin Orthop Relat Res. 120–127. 1999.PubMed/NCBI
12	Bacci G, Ferrari S, Bertoni F, Rimondini S, Longhi A, Bacchini P, Forni C, Manfrini M, Donati D and Picci P: Prognostic factors in nonmetastatic Ewing's sarcoma of bone treated with adjuvant chemotherapy: Analysis of 359 patients at the Istituto Ortopedico Rizzoli. J Clin Oncol. 18:4–11. 2000. View Article : Google Scholar : PubMed/NCBI
13	Heller L and Kronowitz SJ: Lower extremity reconstruction. J Surg Oncol. 94:479–489. 2006. View Article : Google Scholar : PubMed/NCBI
14	Kawai A, Muschler GF, Lane JM, Otis JC and Healey JH: Prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur. Medium to long-term results. J Bone Joint Surg Am. 80:636–647. 1998. View Article : Google Scholar : PubMed/NCBI
15	Natarajan MV, Annamalai K, Williams S, Selvaraj R and Rajagopal TS: Limb salvage in distal tibial osteosarcoma using a custom mega prosthesis. Int Orthop. 24:282–284. 2000. View Article : Google Scholar : PubMed/NCBI
16	Araki N, Myoui A, Kuratsu S, Hashimoto N, Inoue T, Kudawara I, Ueda T, Yoshikawa H, Masaki N and Uchida A: Intraoperative extracorporeal autogenous irradiated bone grafts in tumor surgery. Clin Orthop Relat Res. 196–206. 1999.PubMed/NCBI
17	Singh VA, Nagalingam J, Saad M and Pailoor J: Which is the best method of sterilization of tumour bone for reimplantation? A biomechanical and histopathological study. Biomed Eng Online. 9:482010. View Article : Google Scholar : PubMed/NCBI
18	Bickels J, Meller I, Shmookler BM and Malawer MM: The role and biology of cryosurgery in the treatment of bone tumors. A review. Acta Orthop Scand. 70:308–315. 1999. View Article : Google Scholar : PubMed/NCBI
19	Puri A, Gulia A, Agarwal M, Jambhekar N and Laskar S: Extracorporeal irradiated tumor bone: A reconstruction option in diaphyseal Ewing's sarcomas. Indian J Orthop. 44:390–396. 2010. View Article : Google Scholar : PubMed/NCBI
20	Tsuchiya H, Wan SL, Sakayama K, Yamamoto N, Nishida H and Tomita K: Reconstruction using an autograft containing tumour treated by liquid nitrogen. J Bone Joint Surg Br. 87:218–225. 2005. View Article : Google Scholar : PubMed/NCBI
21	Abdel Rahman M, Bassiony A and Shalaby H: Reimplantation of the resected tumour-bearing segment after recycling using liquid nitrogen for osteosarcoma. Int Orthop. 33:1365–1370. 2009. View Article : Google Scholar : PubMed/NCBI
22	Donati D, Capanna R, Campanacci D, Del Ben M, Ercolani C, Masetti C, Taminiau A, Exner GU, Dubousset JF, Paitout D, et al: The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study. Chir Organi Mov. 78:81–94. 1993.(In English, Italian). PubMed/NCBI
23	Hong AM, Millington S, Ahern V, McCowage G, Boyle R, Tattersall M, Haydu L and Stalley PD: Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: The oncological outcomes of 101 patients. Ann Oncol. 24:2676–2680. 2013. View Article : Google Scholar : PubMed/NCBI
24	Chen WM, Chen TH, Huang CK, Chiang CC and Lo WH: Treatment of malignant bone tumours by extracorporeally irradiated autograft-prosthetic composite arthroplasty. J Bone Joint Surg Br. 84:1156–1161. 2002. View Article : Google Scholar : PubMed/NCBI
25	Sabo D, Bernd L, Buchner M, Treiber M, Wannenmacher M, Ewerbeck V and Parsch D: Intraoperative extracorporeal irradiation and replantation in local treatment of primary malignant bone tumors. Orthopade. 32:1003–1012. 2003.(In German). View Article : Google Scholar : PubMed/NCBI
26	Kotb SZ and Mostafa MF: Recycling of extracorporeally irradiated autograft for malignant bone tumors: Long-term follow-up. Ann Plast Surg. 71:493–499. 2013. View Article : Google Scholar : PubMed/NCBI
27	Sabo D, Brocai DR, Eble M, Wannenmacher M and Ewerbeck V: Influence of extracorporeal irradiation on the reintegration of autologous grafts of bone and joint. Study in a canine model. J Bone Joint Surg Br. 82:276–282. 2000. View Article : Google Scholar : PubMed/NCBI
28	Currey JD, Foreman J, Laketić I, Mitchell J, Pegg DE and Reilly GC: Effects of ionizing radiation on the mechanical properties of human bone. J Orthop Res. 15:111–117. 1997. View Article : Google Scholar : PubMed/NCBI
29	Uyttendaele D, De Schryver A, Claessens H, Roels H, Berkvens P and Mondelaers W: Limb conservation in primary bone tumours by resection, extracorporeal irradiation and re-implantation. J Bone Joint Surg Br. 70:348–353. 1988.PubMed/NCBI
30	Donati D, Di Liddo M, Zavatta M, Manfrini M, Bacci G, Picci P, Capanna R and Mercuri M: Massive bone allograft reconstruction in high-grade osteosarcoma. Clin Orthop Relat Res. 186–194. 2000. View Article : Google Scholar : PubMed/NCBI
31	Cara JA, Laclériga A and Cañadell J: Intercalary bone allografts. 23 tumor cases followed for 3 years. Acta Orthop Scand. 65:42–46. 1994. View Article : Google Scholar : PubMed/NCBI
32	Krieg AH, Davidson AW and Stalley PD: Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery. J Bone Joint Surg Br. 89:366–371. 2007. View Article : Google Scholar : PubMed/NCBI
33	Muramatsu K, Fukano R, Ihara K, Iwanaga R and Taguchi T: Reconstruction of the proximal humerus by combined use of extracorporeally-irradiated osteochondral graft and free vascularized fibula following resection of Ewing sarcoma. J Plast Reconstr Aesthet Surg. 63:2177–2180. 2010. View Article : Google Scholar : PubMed/NCBI