Citations

ABSTRACTBackgroundSkip lesions in bone sarcoma are a poorly described entity. Reports on skip lesions in osteosarcoma and Ewing sarcoma suggest that whole bone MRI should be obtained to evaluate for additional tumor foci given the association with worse outcomes. However, there is limited evidence to support whole bone imaging in chondrosarcoma.MethodsBetween 1995 and 2022, 129 patients with long bone chondrosarcoma were evaluated at our institution. Lesions were located most commonly in the femur in 64 patients and the humerus in 54 patients. All imaging studies and pathology reports were reviewed to determine the presence of skip lesions, defined as an area of histology‐confirmed chondrosarcoma that was separated from the primary lesion by normal bone on pathology.ResultsWhole bone imaging was obtained during initial staging in 107 patients with two‐thirds of patients receiving MRI, CT, or bone scan. Five patients (3.9%) were found to have skip lesions in the same bone as the primary tumor. There were no transarticular skip lesions. Skip lesions were detected in three patients with low grade chondrosarcoma (4.6%) and two patients with high grade chondrosarcoma (3.2%). All lesions were within 2 cm of the primary tumor. All were visible on MRI and CT of the primary site and one was visible on plain radiographs. The presence of skip lesions did not alter the type of surgical treatment in any patients.ConclusionSkip lesions in long bone chondrosarcoma are rare. All skip lesions in this study were in close proximity to the primary tumor and the same grade as the main lesion. Our results suggest that advanced imaging of the whole bone may be of low utility for evaluating the presence of skip lesions. The clinical significance of skip lesions in chondrosarcoma remains unclear, however, their presence did not impact the treatment plan in this series.

OBJECTIVE The aim of this study was to determine independent risk factors for vertebral compression fracture (VCF) following stereotactic body radiation therapy (SBRT) in metastatic spine disease. METHODS Patients treated with SBRT for spinal metastasis at a single tertiary care center between 2008 and 2019 were retrospectively identified. Patients with CT scans obtained within 1 year of SBRT completion were included. Variables collected included demographics, Spine Instability Neoplastic Score (SINS), primary tumor pathology, Weinstein-Boriani-Biagini (WBB) classification, chemoradiation treatment details, and bone quality as assessed by Hounsfield units (HUs) on CT. HUs were measured for the medullary bone of the metastatic level, the tumor, and the vertebral bodies cephalad and caudal to the metastasis. Multivariable logistic regression was used to identify predictors of post-SBRT pathological fracture. RESULTS A total of 292 patients (mean age 66 years) with 392 unique lesions were included. The most common pathologies were prostate (n = 193), kidney/renal cell (n = 46), and lung (n = 33). The most common tumor levels were thoracic (n = 206 lesions) and lumbar (n = 128 lesions). SBRT was generally delivered in 1–3 fractions with doses ranging from 16 to 24 Gy in 1 fraction and 24–36 Gy in 3 fractions. Of the 392 lesions, 73 suffered VCF: 21 (29%) with < 25% height loss, 15 (21%) with 25%–40% height loss, and 37 (51%) with > 40% height loss. On univariate analysis, patients with VCF had lower average HUs (156 ± 52 vs 202 ± 89, p < 0.001), more WBB sectors involved (3 ± 2 vs 3 ± 1, p < 0.001), higher SINSs (8 ± 3 vs 6 ± 2, p < 0.001), were more commonly female (33% vs 22%, p = 0.05), and more commonly had nonprostate pathology (67% vs 47%, p = 0.003). VCF rates were similar between moderate (< 20 Gy in 1 fraction, < 30 Gy in 3 or 5 fractions) and high-dose (> 20 Gy in 1 fraction, > 30 Gy in 3 or 5 fractions) radiation schema (15% VCF vs 16% no VCF, respectively; p = 0.99). On multivariable logistic regression, independently significant predictors of VCF were HUs ≤ 229 (OR 6, p < 0.001), affected levels ≥ 3 WBB segments (OR 3, p < 0.001), and an SINS ≥ 8 (OR 2, p = 0.02). CONCLUSIONS Low pre-radiation HUs, involvement of more WBB sectors, and a higher SINS were independent predictors of VCF following SBRT for metastatic spine disease.

Ewing sarcoma and osteosarcoma constitute 36% of all primary bone cancers. However, these 2 subtypes represent the most commonly diagnosed bone cancer types in the pediatric and adolescent population. Although still largely unknown, certain genetic mutations, rearrangements, and/or predisposition syndromes likely play a role in the pathogenesis of bone cancer. Osteosarcoma may also develop as a direct result of the long-term side effects of radiation therapy. With the implementation of a multimodality approach to treatment, including multiagent neoadjuvant and adjuvant chemotherapy regimens, targeted therapy options, surgery, and radiation, individuals with Ewing sarcoma and osteosarcoma are showing higher cure rates and improved overall survival. The NCCN Guidelines for Bone Cancer provide a consensus and evidence-based framework for the workup, management, and surveillance of local and recurrent/metastatic disease.

AimsThe Birmingham Orthopaedic Oncology Meeting (BOOM), held in January 2024, convened 309 delegates from 53 countries to discuss and refine 21 consensus statements on the optimal management of chondrosarcoma.MethodsWith representation from Europe (43%; n = 133), North America (17%; n = 53), South America (16%; n = 49), Asia (13%; n = 40), Australasia (5%; n = 16), the Middle East (4%; n = 12), and Africa (2%; n = 6), the combined experience of treating bone sarcomas among attendees totalled approximately 30,000 cases annually, equivalent to 66 years of experience in the UK alone. The meeting’s process began with the formation of a local organizing committee, regional leads, and a scientific committee comprising representatives from 150 specialist units across 47 countries. Supported by major orthopaedic oncology organizations, the meeting used a modified Delphi process to develop consensus statements through online questionnaires, thematic groupings, narrative reviews, and anonymous pre-meeting polling.ResultsStrong (> 80%) consensus was achieved on 19 out of 21 statements, reflecting agreement among delegates. Key areas of consensus included the role of radiology in diagnosis and surveillance, the management of locally recurrent disease, and the treatment of dedifferentiated chondrosarcoma. Notably, there was agreement that routine chemotherapy has no role in chondrosarcoma treatment, and radiological surveillance is safe for intraosseous chondrosarcomas. Despite the overall consensus, areas of controversy remain, particularly regarding the treatment of atypical cartilage tumours and surgical margins. These unresolved issues underscore the need for further research and collaboration within the orthopaedic oncology community.ConclusionBOOM represents the largest global consensus meeting in orthopaedic oncology, providing valuable guidance for clinicians managing chondrosarcoma worldwide. The consensus statements offer a reference for clinical practice, highlight key research priorities, and aim to improve patient outcomes on a global scale.Cite this article: Bone Joint J 2025;107-B(2):246–252.

Objective: Pediatric patients with non-rhabdomyosarcoma soft tissue sarcoma (NRSTS) undergo aggressive multimodality treatment. This single institutional analysis of outcomes in this group explored factors associated with local control and survival. Methods: Patients ≤18 years old diagnosed with NRSTS between 10/1990-11/2021 who received radiotherapy (RT) were retrospectively identified. Overall Survival (OS) and disease-free survival (DFS) analyses were performed using Kaplan Meier methods. Cumulative incidence of local and distant failure were estimated. Univariate analysis was performed. Results: Fifty-one pediatric patients with NRSTS were included. Extremity tumors were most common (33/51, 65%), with 80% T1 or T2 (AJCC 8 th ) and 90% non-metastatic. Surgery in 49/51 (96%) resulted in 32 (65%) R0 resections. All received RT (median EQD2 50 Gy, range 42.4-76.9), with brachytherapy or intraoperative (IORT) boosts in 21 cases (41%) (mean EQD2 24.5 Gy). Thirty-four (66.7%) received chemotherapy. With 5.7 years median follow up, 5-year OS and DFS were 70.7% and 67.9%, respectively. Positive margins were significantly associated with worse OS on univariate analysis. Two-year local failure incidence for EBRT was 18.1% and 5.3% for EBRT+boost (HR 3.67, p=0.24). Among 6 observed local failures, 5 occurred after EBRT alone, 3 of which had positive margins. Among the EBRT+boost group, 2 had positive margins, neither with local recurrence. Conclusion: Multimodality treatment of pediatric NRSTS results in 5-year OS and DFS around 70%. R0 resection is essential to optimize outcomes in this population. Although incidence of R1 resections has declined in the modern era, IORT/brachytherapy boost may have a role in selected patients at high-risk for local recurrence.

ABSTRACT Background Flat bone chondrosarcomas have worse outcomes than extremity tumors, but there is no data directly comparing the different flat bones. The aim of this study was to examine differences in recurrence and survival between pelvic and scapular chondrosarcoma. Methods One hundred and sixty‐nine (42 scapula, 127 pelvic) patients with chondrosarcoma who underwent surgical resection were reviewed. High‐grade tumors were defined as lesions that were Grade 3 or dedifferentiated on surgical pathology. Results Patients with low‐intermediate grade lesions of the scapula were more likely to have positive margins during definitive surgical management (14% vs. 3%, OR 5, 95% CI [1.15, 22.6], p = 0.02), however, this did not translate to differences in recurrence or survival ( p > 0.05). The presence of an associated soft tissue mass in low‐intermediate grade lesions was not associated with increased recurrence. Among high‐grade tumors, patients with scapular lesions had worse DSS (HR 2.99, 95% CI [1.05, 8.51], p = 0.04). One‐ and 2‐year DSS for high‐grade pelvic tumors was 75% and 57%, respectively, and 50% and 33% for scapular tumors. Conclusion Survival for high‐grade chondrosarcoma of the flat bones is poor, particularly for those of the scapula. Despite a higher rate of positive margins for low‐intermediate grade lesions of the scapula, there was no significant difference in survival compared to low‐intermediate grade lesions of the pelvis. Additional studies with larger sample sizes are needed to further elucidate differences between these locations.

Abstract BACKGROUND Myxopapillary ependymomas (MPE) are slow-growing tumors of the spine typically involving the medullary conus and cauda equina. MPE is regularly managed with surgical resection with radiation therapy reserved for cases where gross total resection cannot be achieved. Management of inoperable cases represents a clinical challenge. No systemic therapy is approved for treatment of MPE. Addition of chemotherapy may improve outcomes for cases not amenable to resection. MATERIAL AND METHODS We report feasibility and preliminary efficacy of combination treatment with proton beam radiation therapy and temozolomide chemotherapy for a patient with large, unresectable MPE. RESULTS A 19-year-old female presented with one year of gradually worsening hip and back pain despite treatment with physical therapy. MRI Lumbar spine identified a destructive and expansile T2-heterogenous and hyperintense intraosseous mass (14 x 12 x 13 cm) with extraosseous expansion involving the sacrum, coccyx, and left SI joint with abnormal soft tissue enhancement extending along the posterior spine. No additional lesions were identified on neuro-axis imaging. Biopsy of the mass was consistent with a WHO grade 2 myxopapillary ependymoma. Standard treatment of care would include complete surgical resection. Unfortunately, this would require a morbid procedure in an en block fashion with immediate and permanent loss of bowel, bladder, sexual, and ambulatory function in a young patient whose primary symptom was pain and mild weakness. It was therefore elected to treat the patient in an unconventional approach and begin with proton beam radiation therapy (59.4 Gy in 33 fractions) with concurrent temozolomide followed by 6 cycles of adjuvant temozolomide. Mild clinical improvement and significant radiographic response were achieved (size reduced to 8 x 7 x 11 cm). CONCLUSION This case suggests a potential role for use of proton radiation therapy with concurrent and adjuvant temozolomide for management of myxopapillary ependymoma not amenable to surgical resection.

Abstract Managing pelvic osteomyelitis (POM) in the setting of stage IV pressure injuries requires multidisciplinary evaluation as well as patient and caregiver engagement and is complicated by the lack of high-evidence data to guide best practices. In this review, we describe our approach to pressure injury and POM evaluation and management through multidisciplinary collaboration and highlight areas of future research that are necessary to enhance patient outcomes, reduce healthcare costs, and improve the quality of life of those affected by POM.

Background: Synovial sarcoma is rare and may present as a small, slow-growing mass. These tumors are often mistaken as benign and are therefore prone to unplanned and/or non-oncologic excision. We sought to identify the rate of unplanned excision of synovial sarcoma and risk factors for recurrence and survival among this cohort. Methods: The medical records of 246 patients evaluated at a single institution for synovial sarcoma between 1997 and 2022 were retrospectively reviewed. Of these, 87 (35%) underwent unplanned, non-oncologic excision. The mean age of the cohort was 49 years. Primary tumors were located in the extremity (n = 63), abdomen (n = 6), thorax (n = 7), head/neck (n = 8), and paraspinal region (n = 3). The median maximum pre-treatment dimension of the primary tumor was 4.8 cm (IQR 7–2.4). Seventy-seven (86%) patients underwent re-excision of the tumor bed, 39 (45%) received chemotherapy, and 63 (72%) received radiation therapy. Results: Among patients who underwent unplanned excision, local recurrence-free survival (LRFS) was 98% at 1 year and 82% at 5 years. Metastasis-free survival (MFS) was 91% at 1 year and 72% at 5 years. Disease-specific survival (DSS) was 98% at 1 year and 72% at 5 years. When adjusting for tumor size, tumors which underwent unplanned excision did not have worse recurrence or survival compared to those which had planned excision (p > 0.10). Size > 5 cm, monophasic subtype, and axial location were associated with increased risk of disease recurrence. Forty-six patients had residual tumor following re-excision, which was associated with worse MFS (HR 8.17, 95% CI [1.89, 35.2], p < 0.01) and DSS (HR 7.66, 95% CI [1.76, 33.4], p < 0.01). Patients who received radiotherapy had improved MFS (HR 6.4, 95% CI [1.42, 29.0], p = 0.02) and DSS (HR 5.86, 95% CI [1.27, 26.9], p = 0.02). Conclusions: One-third of patients presenting with synovial sarcoma were diagnosed after unplanned, non-oncologic excision. Patients with large, axial tumors had worse survival. Approximately half of patients who underwent unplanned excision had no residual tumor after pre-operative radiation. The use of radiation was associated with decreased rates of recurrence and improved disease-specific survival. Our results suggest that margin-negative re-resection and radiotherapy should be considered when feasible following unplanned excision of synovial sarcoma.