RESUMEN

Current methods of treating advanced patients with metastatic periacetabular disease are complex and result in high complication rates. The purpose of this study was to show whether the implantation of the saddle prosthesis would serve as an additional tool to help treat metastatic disease in these patients. From 1991 to 2003, 20 patients with advanced metastatic periacetabular lesions (Harrington Class III) were treated using the saddle prosthesis. Goals of surgery were a decrease in pain, functional restoration, and ambulation. The mean age was 61 years. Average length of followup was 20 months. Postoperatively, ambulation was achieved in 16 of 20 patients. There were four postoperative complications (20%) in three patients. Surgical goals were met in 18 of 20 patients. The MSTS-ISOLS emotional score was 2.9 of 5. The average total MSTS-ISOLS score was 16.6 of 30 (55%). Using the Allan scoring system consisting of analgesia, independence and ambulation, and mobility, all scores had significant improvements postoperatively. Careful surgical indications and technique should result in a stable, functional reconstruction allowing patients the ability to ambulate outside the house with a cane. Patients can expect to be emotionally satisfied with the procedure while using nonnarcotic analgesia and can expect an improved quality of life despite bone metastasis.

Asunto(s)

Asunto(s)

RESUMEN

PURPOSE: To determine clinical practice guidelines for the use of bisphosphonates in the prevention and treatment of bone metastases in breast cancer and their role relative to other therapies for this condition. METHODS: An expert multidisciplinary panel reviewed pertinent information from the published literature and meeting abstracts through May 1999. Additional data collected as part of randomized trials and submitted to the United States Food and Drug Administration were also reviewed, and investigators were contacted for more recent information. Values for levels of evidence and grade of recommendation were assigned by expert reviewers and approved by the panel. Expert consensus was used if there were insufficient published data. The panel addressed which patients to treat and when in their course of disease, specific drug delivery issues, duration of therapy, management of bony metastases with other therapies, and the public policy implications. The guideline underwent external review by selected physicians, members of the American Society of Clinical Oncology (ASCO) Health Services Research Committee, and the ASCO Board of Directors. RESULTS: Bisphosphonates have not had an impact on the most reliable cancer end point: overall survival. The benefits have been reductions in skeletal complications, ie, pathologic fractures, surgery for fracture or impending fracture, radiation, spinal cord compression, and hypercalcemia. Intravenous (IV) pamidronate 90 mg delivered over 1 to 2 hours every 3 to 4 weeks is recommended in patients with metastatic breast cancer who have imaging evidence of lytic destruction of bone and who are concurrently receiving systemic therapy with hormonal therapy or chemotherapy. For women with only an abnormal bone scan but without bony destruction by imaging studies or localized pain, there is insufficient evidence to suggest starting bisphosphonates. Starting bisphosphonates in patients without evidence of bony metastasis, even in the presence of other extraskeletal metastases, is not recommended. Studies of bisphosphonates in the adjuvant setting have yielded inconsistent results. Starting bisphosphonates in patients at any stage of their nonosseous disease, outside of clinical trials, despite a high risk for future bone metastasis, is currently not recommended. Oral bisphosphonates are one of several options which can be used for preservation of bone density in premenopausal patients with treatment-induced menopause. The panel suggests that, once initiated, IV bisphosphonates be continued until evidence of substantial decline in a patient's general performance status. The panel stresses that clinical judgment must guide what is a substantial decline. There is no evidence addressing the consequences of stopping bisphosphonates after one or more adverse skeletal events. Symptoms in the spine, pelvis, or femur require careful evaluation for spinal cord compression and pathologic fracture before bisphosphonate use and if symptoms recur, persist, or worsen during therapy. The panel recommends that current standards of care for cancer pain, analgesics and local radiation therapy, not be displaced by bisphosphonates. IV pamidronate is recommended in women with pain caused by osteolytic metastasis to relieve pain when used concurrently with systemic chemotherapy and/or hormonal therapy, since it was associated with a modest pain control benefit in controlled trials. CONCLUSION: Bisphosphonates provide a meaningful supportive but not life-prolonging benefit to many patients with bone metastases from cancer. Further research is warranted to identify clinical predictors of when to start and stop therapy, to integrate their use with other treatments for bone metastases, to identify their role in the adjuvant setting in preventing bone metastases, and to better determine their cost-benefit consequences.

Asunto(s)

RESUMEN

Because of the wide variety of anatomic locations and patient factors, there is no one treatment that is appropriate for all desmoid tumors. The type of treatment depends on tumor characteristics and location, as well as patient characteristics and preferences. Desmoid tumors can be persistent and frustrating to manage because no one treatment modality offers a high likelihood of remission. Multiple modalities may be necessary in some patients. Although mortality is rare and is usually due to local complications, significant disability or morbidity can result from desmoid tumors, their treatment, and complications arising from treatment. The entire clinical picture and the patient's preferences must be taken into account when deciding on an appropriate treatment plan. Patients with desmoid tumors are optimally managed in a multidisciplinary setting with close collaboration between surgeon, pathologist, diagnostic radiologist, radiation oncologist, and medical oncologist. When possible, surgical resection with negative margins is the preferred modality. When surgical resection with negative margins may prove disabling, surgery can be followed by postoperative radiation, although the role and efficacy of this are controversial. In locations where surgical extirpation is difficult or unfeasible, primary radiation, hormonal therapy, or chemotherapy should be considered. Familiar adenosis polyposis (FAP)-associated mesenteric lesions, sporadic tumors present without change for months or years, or tumors present in areas where progression will not present significant additional morbidity are candidates for observation only.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Sarcoid myopathy presenting as a tumorlike lesion is an exceedingly rare presentation of sarcoidosis. Concurrent extramuscular involvement is common. Chest radiographs, if abnormal, may suggest the diagnosis. Magnetic resonance imaging is the preferred study for diagnosis and follow-up of tumorous sarcoid myopathy. Optimal therapy is not clear. Favorable responses have been cited with surgery or corticosteroids (alone or in combination). Azathioprine or alternative immunosuppressive agents (for example, antimalarials or methotrexate) may have a role in corticosteroid-recalcitrant patients. The role of local radiotherapy is controversial and should be reserved for severe localized disease refractory to aggressive medical therapy.

Asunto(s)

Asunto(s)

RESUMEN

PURPOSE: To evaluate the effect that increased numbers of women medical school graduates have had on the composition of orthopedic surgery residencies, and to evaluate trends over time in the likelihood of women medical students to select orthopedic residencies. METHOD: The author analyzed JAMA's "Reports on Graduate and Undergraduate Medical Education" for the years 1977 to 1996, calculating the numbers of women and men in orthopedic surgery and other surgery residencies, and medical school composition. RESULTS: Although there have been modest gains in the number of women in orthopedic surgery training programs in the United States, women continue to choose orthopedics only one-seventh as often as do men. CONCLUSION: Orthopedics remains an unattractive career choice for women medical students compared with their men counterparts. Biases and stereotypes about women and about orthopedic surgery may account for this difference.

Asunto(s)

Asunto(s)

RESUMEN

The last two decades have shown exciting and dramatic improvements in the management of osteogenic sarcoma, while progress in soft tissue sarcomas has lagged behind considerably. Osteogenic sarcoma treatment has been a model of multidisciplinary collaboration. Orthopedic surgeons working together with medical and pediatric oncologists have improved disease-free survival while improving limb salvage rates and limb function. In contrast, the care of soft tissue sarcoma remains fragmented among many disciplines and specialties. Medical and pediatric oncologists, radiation oncologists, and a myriad of surgical specialists are all involved in the care of soft tissue sarcomas, and significant treatment (usually surgical) often occurs before referral to a center. Significant variation in managment leads to considerable difficulty in assessing the effects of treatment on outcome. Improvement in soft tissue sarcoma management will occur only when physicians recognize the need to centralize care to appropriate physicians within referral centers where patients can be treated on standardized cooperative protocols.

Asunto(s)

Asunto(s)

RESUMEN

We performed a retrospective study of thirteen patients who had had sixteen pathological fractures of the shaft of the humerus secondary to metastatic disease. All but one fracture was stabilized with interlocking intramedullary nailing with use of a closed technique. The mean operative time for the sixteen procedures was ninety-two minutes (range, fifty to 180 minutes), the mean blood loss was 116 milliliters (range, fifty to 200 milliliters), and the mean duration of hospitalization was five days (range, two to ten days). Fourteen extremities had a return to nearly normal function within three weeks after nailing. Relief of pain was rated as good or excellent in all but one patient. Eleven patients (fourteen humeri) received radiation therapy at a mean of seven days (range, three to fourteen days) after the operation. Nine patients died at a mean of four months (range, one to twelve months) postoperatively; the remaining four patients were still alive at a mean of ten months (range, nine to fifteen months). There were no problems related to the wound, deep infections, nerve palsies, or failures of the implant. The fracture was united in all seven of the eleven extremities in patients who survived for at least three months and had radiographs available. Interlocking intramedullary nailing of the humerus for pathological fractures provides immediate stability and can be accomplished with a closed technique, brief operative time, and minimum morbidity, with a resultant early return of function to the extremity.

Asunto(s)

RESUMEN

We performed a prospective study of sixty-two patients who were managed with a closed core needle biopsy in an outpatient clinic for a soft-tissue mass or a bone tumor with soft-tissue extension between August 1, 1992, and June 1, 1994. Eight (13 percent) of the closed core needle biopsies yielded no neoplastic tissue. Two needle biopsies (3 percent), which were of myxomatous masses, did not allow distinction between a benign and a malignant neoplasm; both masses were extraskeletal myxoid chondrosarcomas. Additionally, the histological grade of four resected specimens (6 percent) differed from that determined with the closed needle biopsy. The diagnostic accuracy of the closed needle biopsies was 84 percent (fifty-two of sixty-two). All ten diagnostic errors involved soft-tissue tumors. A retrospective study of a similar cohort of patients who had open biopsy in an outpatient operating room by the same surgeon in a contemporary period in the same institution and with analysis by the same pathologist, revealed a diagnostic accuracy of 96 percent (forty-eight of fifty). The hospital charges for the closed core needle biopsy were $1106, compared with $7234 for the open biopsy. We concluded that core needle biopsy can be performed in an outpatient clinic with use of local anesthesia and that it is substantially less expensive and more convenient than open biopsy. This technique has an acceptable but definitely lower rate of accuracy compared with open biopsy, especially for soft-tissue tumors, and it should be used only in a small subset of patients (those who have a large soft-tissue mass or a bone tumor with palpable soft-tissue extension). However, given the small size of the tissue sample, the clinician must recognize possible disadvantages, including a non-diagnostic biopsy, an indeterminate biopsy, or a potential error in the histological grade. These problems are much more likely to occur after core needle biopsy of soft-tissue masses. Because of the potential for errors in diagnosis when core needle biopsy is used, the musculoskeletal oncologist must rely on his or her clinical acumen. When a diagnosis is in reasonable doubt, there is no radiographic confirmation, the biopsy shows no tumor cells, or there is a combination of these findings, operative decisions should be made as if no biopsy had been performed. The management of patients who, after core needle biopsy, have a diagnosis of a bone or soft-tissue tumor, is best carried out by an experienced musculoskeletal oncologist working in close collaboration with an experienced musculoskeletal pathologist.

Asunto(s)

RESUMEN

This article discusses important aspects of the biopsy of neoplasms in skin, soft tissues, and bone. There are a variety of clinical conditions in which specific biopsy techniques are indicated. Inappropriate biopsy of tumors in these sites may compromise subsequent definitive therapy.

Asunto(s)

RESUMEN

Twenty-five patients with infected nonunions of the tibia and segmental bone loss were treated by one of two methods: resection and bone transport, or conventional treatment using less extensive debridement, external fixation, bone grafting, and soft-tissue coverage. The two groups were comparable except for gender distribution. Each group experienced similar rates of healing; eradication of infection; treatment time; final angulation; number of complications; and total number of surgical procedures. However, the final limb-length discrepancy was significantly less in the bone transport group.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Halothane is metabolized by an oxidative pathway to stable, nonvolatile end products, trifluoroacetic acid (TFAA) and bromide (Br-), and by reductive pathways to Br-and inorganic fluoride (F-). There is evidence that both oxidatively and reductively formed intermediates may produce hepatotoxicity, although the exact etiology of the fulminant hepatic necrosis seen in humans is unproven. Obese patients receiving volatile anesthetics exhibit higher serum anesthetic metabolite concentrations than do normal-weight patients, and thus might be at greater risk of hepatotoxicity because of higher concentrations of reactive intermediates from halothane metabolism. To eliminate the variables inherent in human clinical studies leading to confounding interpretation of data, this study determined the contributions of oxidative and reductive pathways to halothane metabolism in an animal model of human hypertrophic obesity, the most common form of human obesity. Eight pairs of obese (high-fat diet) and normal-weight (standard chow), male Fischer 344 rats were anesthetized with halothane for 4 h at an inspired concentration of 0.78%. Serum and urinary concentrations of TFAA, Br-, and F-were measured. Thirty-six hours following halothane anesthesia, mean serum TFAA concentrations peaked at 7.3 +/- 1.1 mM in obese rats and 4.7 +/- 0.7 mM in nonobese rats. TFAA urinary excretions during the 180-h period postanesthesia were 519 +/- 69 and 336 +/- 22 mumol, respectively. Peak serum Br- concentrations were 9.1 +/- 1.0 and 6.9 +/- 0.6 mM for obese and nonobese rats, respectively, and Br-urinary excretions were 127 +/- 30 and 79 +/- 14 mumol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Asunto(s)

RESUMEN

Different dosing regimens with diazepam were evaluated in male Fischer 344 rats for their ability to enhance the metabolism of several inhalation anesthetics. In vitro metabolism was assessed by the rate of microsomal anesthetic defluorination as measured by the appearance of inorganic fluoride ion (i.e., defluorinase activity). Single daily doses of diazepam, 40 mg/kg, were delivered by gavage for either 7 or 14 days; more continuous dosing was achieved by administration of diazepam at 0.03% or 0.10% in food pellets. Hepatic microsomes isolated from treated rats showed significant dose-related elevations in methoxyflurane defluorinase activity, but not in enflurane or isoflurane defluorinase activities. The microsomal content of cytochromes P-450 and b5 and the NADPH-cytochrome-c-reductase activity was not significantly different among treated and untreated groups. Para-nitroanisole O-demethylase activity expressed per nmole cytochrome P-450 increased in the diazepam-treated groups. Extrapolation of these animal data to humans suggests that surgical patients treated chronically with diazepam are probably not at increased risk for inorganic fluoride-induced nephrotoxicity due to increased metabolism of the fluorinated inhalation anesthetics.

Asunto(s)