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Πανεπιστημιακό Γενικό Νοσοκομείο Αθηνών "ΑΤΤΙΚΟΝ"
Ρίμινι 1, Τ.Κ. 124 62, Χαϊδάρι, Αθήνα
Χρήσιμοι σύνδεσμοι
• Mayo Clinic
http://www.mayoclinic.org
• Connective Tissue Oncology Society
http://www.ctos.org/
• MusculoSkeletal Tumor Society (MSTS)
http://www.msts.org
ΔΗΜΟΣΙΕΥΣΕΙΣ
Dedifferentiated chondrosarcoma revisited.
J Surg Orthop Adv. 2011 Summer;20(2):106-11. Review.
Mavrogenis AF, Ruggieri P, Mercuri M, Papagelopoulos PJ.
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This article reviews recent molecular, biologic, therapeutic, and clinical findings in dedifferentiated chondrosarcoma. Dedifferentiated chondrosarcoma is one of the most malignant primary bone tumors characterized by two distinct histopathologic components: a well-differentiated chondral lesion sharply juxtaposed with a high-grade noncartilaginous component. Wide or radical surgical resection is mandatory. High-dose radiation therapy is confined to inaccessible sites and palliation. Chemotherapy is administered whenever the dedifferentiated component is chemosensitive and the patient is in good general condition. Despite this approach, metastases will result in poor survival of these patients.
Anterior thigh flap extended hemipelvectomy and spinoiliac arthrodesis.
Surg Oncol. 2011 Dec;20(4):e215-21. Epub 2011 Jul 27.
Mavrogenis AF, Soultanis K, Patapis P, Papagelopoulos PJ.
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We present the technique of anterior thigh flap extended external hemipelvectomy with spinoiliac arthrodesis in treatment of the patient with recurrent low-grade pelvic chondrosarcoma extending to the lower lumbar spine. Extended hemipelvectomy involves skeletal resection beyond the standard hemipelvectomy that is the SI joint by removal of contiguous musculoskeletal structures, such as elements of the sacral and lumbar spine or contralateral pelvic bone, in addition to the affected innominate bone. Spinoiliac arthrodesis reestablishes spinopelvic stability; the anterior thigh musculocutaneous flap provides reliable well-vascularized soft tissue coverage. This technique may serve an important role in the surgical management of patients with low-grade pelvic malignancies.
Pigmented villonodular synovitis of the distal tibiofibular joint: a case report.
Clin Podiatr Med Surg. 2011 Jun;28(3):589-97. Epub 2011 Jun 8.
Mavrogenis AF, Papaparaskeva KT, Galanakos S, Papagelopoulos PJ.
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Pigmented villonodular synovitis (PVNS) is a proliferative disorder of the synovium. Monoarticular involvement is the more common process. This article presents a case of PVNS with rare location at the distal tibiofibular joint and discusses the current concepts of diagnosis and treatment of this disease.
Functional and radiographic outcome after tumor limb salvage surgery using STANMORE megaprostheses.
J BUON. 2011 Apr-Jun;16(2):353-60.
Mavrogenis AF, Mitsiokapa EA, Sakellariou VI, Tzanos G, Papagelopoulos PJ.
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PURPOSE: To report the clinical and radiological outcome of limb salvage surgery with the STANMORE megaprostheses. METHODS: We retrospectively studied 33 patients with musculoskeletal tumor limb salvage surgery using STANMORE megaprostheses. Clinical evaluation was done using the Enneking and the Toronto Extremity Salvage Score (TESS). Radiographic evaluation was done using the International Society of Limb Salvage (ISOLS) score. RESULTS: At a mean follow-up of 18 months, 21 patients were alive with no evidence of disease and two patients were alive with metastatic disease; 9 patients died of metastatic disease and one patient of causes unrelated to the primary tumor. Local recurrence was not observed in any of the patients. The mean Enneking and TESS scores were 76 and 88.4%, respectively. The ISOLS score was excellent or good in 30 cases for bone remodelling, 30 cases for the interface, in 30 cases for anchorage, in 32 cases for the implant body, and in 33 cases for the articulation. Extracortical bone bridging greater than 25% was observed in 8 prostheses. Mechanical survival of the megaprostheses was 97% (32 megaprostheses). Complications included seroma and hematoma formation (12%), skin necrosis and dehiscence at the knee wound (9%), aseptic loosening and infection (6%), quadriceps tendon rupture and peroneal nerve palsy (3%). Conclusion: The local recurrence-free survival in this series supports limb salvage surgery. The 97% survival rate of the megaprostheses suggests that the STANMORE modular megaprostheses are valuable for reconstruction of bone defects after tumor resection.
Vertebrectomy and expandable cage placement via a one-stage, one-position anterolateral retroperitoneal approach in L5 tumors.
J Surg Oncol. 2011 Oct;104(5):552-8. doi: 10.1002/jso.21910. Epub 2011 Apr 25.
Papanastassiou ID, Jain S, Baaj AA, Eleraky M, Papagelopoulos PJ, Vrionis FD.
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Spinal reconstruction of the L5 vertebrae after tumor resection remains a challenge. Complex resection followed by circumferential fixation in the same setting, or in staged fashion, is often employed. The added operative time associated with this method potentially increases morbidity and mortality in an inherently high-risk procedure and anatomy in the lumbosacral area makes reconstruction more challenging. The authors describe a technique involving L5 vertebrectomy, placement of an expandable cage, and anterolateral L4-S1 screw fixation via a one-stage, one-position, anterolateral retroperitoneal approach. Two illustrative cases are presented along with the authors overall experience in L5 tumor operations. We believe that this is a feasible reconstructive option after tumor resection in lower lumbar metastatic spine disease. The approach may be also utilized in combined anteroposterior (two-stage) procedures in primary malignant tumors or oligometastatic disease.
Embolization of bone tumors.
Orthopedics. 2011 Apr;34(4):303-10. doi: 10.3928/01477447-20110228-20.
Mavrogenis AF, Rossi G, Rimondi E, Papagelopoulos PJ, Ruggieri P.
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Outcome of the intramedullary diaphyseal segmental defect fixation system for bone tumors.
J Surg Oncol. 2011 Jul 1;104(1):83-90. doi: 10.1002/jso.21893. Epub 2011 Mar 4.
Ruggieri P, Mavrogenis AF, Bianchi G, Sakellariou VI, Mercuri M, Papagelopoulos PJ.
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BACKGROUND: Resection of diaphyseal malignant bone tumors is indicated for local control and impending pathological fracture or failure of prophylactic internal fixation. However, there are no large, long-term studies analyzing the results of intercalary reconstruction using segmental metallic spacers. MATERIALS AND METHODS: We present 24 patients treated with wide resection for primary or metastatic bone tumors involving the diaphysis of the femur, tibia, or humerus and reconstruction using a modular intramedullary diaphyseal segmental defect fixation system. The mean length of bone resection was 10 cm. The postoperative complications and outcome were evaluated. RESULTS: At a mean follow-up of 29 months, 17 patients were alive and 7 patients were dead of disease; no patient had local recurrence. Implant-related complications occurred in 8 patients, the most common being mechanical loosening and rotational instability. Loosening was most common in reconstructions of more than 10 cm length of bone resection. In all femoral reconstructions, mechanical failure occurred at the proximal stem. True limb length discrepancy of 2.0 cm was observed in one patient. Wound healing complications were not observed; range of motion and function of the adjacent joints was within normal limits. CONCLUSIONS: The modularity, ease of application and preservation of the adjacent joints are major advantages of segmental modular prostheses; however, the complications' rate is high. Complications occur most often at the proximal stem in femoral reconstructions and reconstructions for more than 10 cm length of bone resection. In these cases, the use of these implants should be reconsidered or not recommended.
Side effects of chemotherapy in musculoskeletal oncology.
J Long Term Eff Med Implants. 2010;20(1):1-12. Review.
Mavrogenis AF, Papagelopoulos PJ, Romantini M, Angelini A, Ruggieri P.
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With recent advances in medical and orthopedic oncology, radiation therapy and single- or multiple-agent perioperative chemotherapy are currently applied as an essential part of the multidisciplinary treatment to improve disease-free and overall survival of patients with primary and metastatic bone and soft tissue tumors. However, these treatments have led to unwanted complications. A better understanding of the effects of various antineoplastic agents on bone, soft tissue, and organs may provide the basis for the more efficacious use of antiproliferative drugs when fracture healing or allograft incorporation is required. This knowledge may also provide a rationale for concurrent treatment with drugs that protect against or compensate for adverse effects in osseous repair resulting from chemotherapy.
Negative-pressure wound therapy for musculoskeletal tumor surgery.
Adv Skin Wound Care. 2011 Jan;24(1):25-30.
Sakellariou VI, Mavrogenis AF, Papagelopoulos PJ.
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OBJECTIVE: To evaluate the effect of negative-pressure wound therapy in musculoskeletal tumor surgery patients. MATERIALS AND METHODS: The authors analyzed the medical records of 32 patients treated at the authors' institution for bone and soft-tissue sarcomas and secondary wound-healing complications, from 2005 to 2008; there were 11 men and 21 women, with a mean age of 56 years (range, 35-72 years). RESULTS: A statistically significant difference (P = .036) was found regarding the length of hospitalization in the conventional wound treatment group, group A (mean, 25.2 days; range, 15-52 days), compared with the negative wound pressure therapy group, group B (mean, 16.5 days; range, 12-33 days). CONCLUSIONS: The use of negative-pressure wound therapy for the management of complicated wound healing in sarcoma patients following tumor surgery is safe and effective and is associated with lower overall complications rates, infection rate, and the need for further surgery and a lower total cost of wound-healing treatment.
Infected tumor prostheses.
Orthopedics. 2011 Dec 1;34(12):991-8. doi: 10.3928/01477447-20111021-24.
Mavrogenis AF, Papagelopoulos PJ, Coll-Mesa L, Pala E, Guerra G, Ruggieri P.
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Infection of tumor prostheses has been a major concern because of the extensive soft tissue dissection, long operating times, and patients' immunosuppression by cancer and adjuvant treatments. Infections most often present within 2 years postoperatively, with approximately 70% of postoperative deep infections presenting within 12 months after surgery. They are typically low organism burden infections, the pathogenesis of which is related to bacteria growing in biofilms. Staphylococci are the most common pathogens involved in prosthetic joint infections, accounting for approximately 50% of infections overall, followed by streptococci, enterococci, Enterobacteriaceae species, Pseudomonas aeruginosa, and anaerobe species. Multiple pathogens may be isolated in approximately 25% of cases, with the most common combination being coagulase-negative Staphylococcus and group-D Streptococcus. Early diagnosis and appropriate treatment are necessary. However, diagnosis may be challenging because clinical symptoms are highly variable and numerous preoperative and intraoperative diagnostic laboratory tests are nonspecific. In most cases, a 1- or 2-stage revision surgery is necessary for eradicating the megaprosthetic infection. Prevention of infection is important. The future will see technical advances for infections of tumor prostheses in areas such as microbiological diagnostics and biofilm-resistant prostheses.
Pelvic resections.
Orthopedics. 2012 Feb 17;35(2):e232-43. doi: 10.3928/01477447-20120123-40.
Mavrogenis AF, Soultanis K, Patapis P, Guerra G, Fabbri N, Ruggieri P, Papagelopoulos PJ.
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The complexity of pelvic anatomy and the extent of tumor growth makes treatment of patients with primary bone sarcomas in the pelvis difficult in terms of local control. Before the 1970s, most tumors in the bony pelvis were surgically treated with hindquarter amputation. Currently, improved techniques for clinical staging, adjuvant treatments, evolutions in metallurgy, and development of new surgical techniques make limb-salvage surgery and reconstruction possible alternatives to hemipelvectomy and resection-arthrodesis. The advantages of amputation over resections at the pelvis are a lower incidence of complications, a limited area at risk for recurrence, and a faster recovery time compared with all but the most limited pelvic resections. The disadvantages, especially after periacetabular resections, are leg-length discrepancy and impaired hip and gait function. The indication for limb salvage is the ability to obtain wide margins without compromising survival and function. Although having to resect the sciatic nerve to obtain adequate margins does not always mean that an amputation should be performed, the combination of a major pelvic resection and the functional consequences of sciatic nerve resection results in an extremity usually not worth saving; loss of femoral nerve function does not result in a significant gait disturbance, especially if the hemipelvis is stable. Reconstruction options after major pelvic resections have also evolved, but they remain difficult, especially when the acetabulum is involved.
Criteria and outcome of limb salvage surgery.
J BUON. 2011 Oct-Dec;16(4):617-26.
Mavrogenis AF, Coll-Mesa L, Gonzalez-Gaitan M, Ucelay-Gomez R, Fabri N, Ruggieri P, Papagelopoulos PJ.
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When sufficient margins of resection surrounding the tumor can be achieved, limb salvage surgery, as opposed to amputation, has become the standard of care in treating patients with bone and soft tissue sarcoma of the extremities. Currently, 90-95% of patients with primary malignant bone and soft-tissue tumors involving the extremities can be treated safely with wide resection and limb salvage surgery with a low risk of recurrence and the same disease-free survival rate as amputative surgery. However, discussions persist regarding the indications and criteria, and whether limb salvage provides superior functional results and quality of life for cancer patients. In this study we aimed to review and update the current criteria, indications and contraindications of limb salvage surgery and discuss its role in the quality of life of cancer patients.
Chondrosarcomas revisited.
Orthopedics. 2012 Mar 7;35(3):e379-90. doi: 10.3928/01477447-20120222-30.
Mavrogenis AF, Gambarotti M, Angelini A, Palmerini E, Staals EL, Ruggieri P, Papagelopoulos PJ.
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Chondrosarcomas are malignant bone tumors with pure hyaline cartilage differentiation; myxoid changes, calcification, or ossification may be present. Several subtypes of chondrosarcomas exist. Behavior patterns vary, ranging from slow-growing nonmetastasizing lesions to aggressive metastasizing sarcomas. Symptoms are usually mild, with duration ranging from several months to years, and usually consist of persistent, dull, aching pain or palpable masses. Radiographic findings include bone expansion with cortical thickening, radiolucent areas with variably distributed punctate or ring-like matrix calcifications, cortical erosion or destruction, endosteal scalloping, and scant or absent periosteal reaction; extension into the soft tissue may be present. Histological differential diagnosis from benign cartilaginous lesions can be achieved by increased cellularity, enlarged plump nuclei, binucleated cells, hyperchromatic nuclear pleomorphism, and permeation of cortical or medullary bone. Atypia is usually mild to moderate; necrosis and mitoses can be seen, particularly in high-grade lesions. Adequate surgery is the mainstay of treatment. High-grade and pelvic chondrosarcomas are best managed with wide resection. Because of the low metastatic potential and low local recurrence rate noted with intralesional surgery, low-grade chondrosarcomas can be treated with curettage (with or without treatment of the defect cavity) with a local adjuvant, such as phenol or cryotherapy. Adjuvant chemotherapy may be considered for mesenchymal and dedifferentiated chondrosarcomas. Radiation therapy can be considered after incomplete resection or if resection is not feasible or would cause unacceptable morbidity.
Expandable prostheses for the leg in children.
Orthopedics. 2012 Mar;35(3):173-5. doi: 10.3928/01477447-20120222-03.
Mavrogenis AF, Papagelopoulos PJ.
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Expandable tumor prostheses in children.
J BUON. 2012 Jan-Mar;17(1):9-15.
Mavrogenis AF, Papagelopoulos PJ, Coll-Mesa L, Pala E, Colangeli M, Manfrini M, Ruggieri P.
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Any surgical resection in the lower extremities in children will cause a leg length discrepancy from physeal resection. To avoid the resulting functional deficit, leg length discrepancy must be reconciled with surgical techniques to approximate equal leg lengths at skeletal maturity. Currently there are several manufacturers who offer options for prosthetic reconstruction with expandable implants. These implants can be expanded to a length projected on the basis of three factors: the length of bone resected, the anticipated future growth of the contralateral extremity, and the estimated discrepancy of limb length at skeletal maturity. In this article, we review the basic principles and guidelines for prediction of remaining bone growth and planning lengthening in children, and present the currently available expandable prostheses and the evolution performed over time.
Extraskeletal osteosarcoma: a case report.
Acta Orthop Traumatol Turc. 2012;46(3):215-9.
Mavrogenis AF, Papadogeorgou E, Papagelopoulos PJ.
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Extraskeletal osteosarcoma is a rare soft tissue sarcoma. Survival is related with the wide resection of the tumor. The role of adjuvant chemotherapy and radiation therapy remains controversial. In our study, we present a patient with extraskeletal osteosarcoma of the thigh which was initially misdiagnosed as lipoma.
Reconstruction of the extensor mechanism after major knee resection.
Orthopedics. 2012 May;35(5):e672-80. doi: 10.3928/01477447-20120426-21.
Mavrogenis AF, Angelini A, Pala E, Sakellariou VI, Ruggieri P, Papagelopoulos PJ.
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In periarticular knee resections, the relative lack of soft tissue coverage and need to reattach the extensor mechanism after en bloc resection of the tibial tuberosity with the tumor specimen complicate reconstructions and decrease postoperative function and stability of the knee joint. Distal femoral reconstructions are less problematic; muscular attachments are relatively few, neurovascular structures are not immediately adjacent to bone, and the knee extensor mechanism is usually not compromised from bone tumors. In the proximal tibia, the close proximity of the neurovascular structures in the popliteal fossa and peroneal nerve at the lateral aspect of the leg make reconstruction more difficult. Poor function is mostly related to unreliable options for knee extensor mechanism reattachment and poor soft tissue coverage. Successful and reliable attachment of the soft tissues has been a significant advance that improved functional outcomes.This article describes techniques for the reconstruction of the extensor mechanism of the knee after proximal tibia resections. Combined reconstruction techniques using direct reattachment of the patellar tendon with synthetic materials to megaprosthetic or allograft reconstructions for immediate stability, augmentation with autologous bone graft or substitutes at the attachment site, and coverage with the medial gastrocnemius muscle flap and supplementary flaps for long-term stability of the reattachment are currently considered the gold standard.
Successful treatment of aggressive aneurysmal bone cyst of the pelvis with serial embolization.
Orthopedics. 2012 Jun 1;35(6):e963-8. doi: 10.3928/01477447-20120525-43.
Rossi G, Mavrogenis AF, Papagelopoulos PJ, Rimondi E, Ruggieri P.
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Intralesional surgery is most commonly used for aneurysmal bone cysts. Rarely is en bloc resection used for active, aggressive, recurrent lesions and those located in expendable bones. However, persistence or recurrence of aneurysmal bone cysts is common. The clinical behavior of aneurysmal bone cysts is more aggressive in younger patients. Selective embolization is used as the primary treatment for aneurysmal bone cysts in surgically difficult anatomical locations and as an adjuvant to surgical treatment to reduce intraoperative blood loss and facilitate curettage.This article describes a 3-year-old boy with an aggressive aneurysmal bone cyst of the pelvis involving the right ischiopubic rami that achieved curative treatment with 3 embolizations with N-2-butyl-cyanoacrylate. Biopsy was diagnostic; however, the clinical course was misleading. Twenty days after the first embolization, despite complete occlusion of the feeding vessels, the patient experienced severe pain, increased size of the lesion, and lateral subluxation of the right hip. Based on the imaging and histological diagnosis, intralesional hemorrhage was assumed, and repeat embolization was performed. After the second embolization, the patient experienced perineal skin necrosis from normal vessel embolization; it was treated with wound dressing changes and healed uneventfully. A third embolization was performed because of a persistent lesion. Six years after treatment, the patient was symptom free, and imaging showed complete ossification of the cyst.Selective catheterization and occlusion of the feeding arteries with the appropriate embolic agent provide tumor devascularization, size reduction, pain relief, and induction of new bone formation. Multiple procedures are often necessary, and complications may occur.
Osteosarcoma of navicular bone. En bloc excision and salvage of the foot.
Foot Ankle Surg. 2012 Sep;18(3):e29-33. Epub 2012 Apr 16.
Sakellariou VI, Mavrogenis AF, Mazis GA, Papagelopoulos PJ.
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To present foot salvage for osteosarcoma of the navicular bone with en bloc resection and reconstruction using bone allograft and talus-cuneiform arthrodesis. A 20year-old male with a history of osteosarcoma of the distal femur presented to our department 5years later with a metastatic lesion of the navicular bone of the contralateral foot. The patient received 4 cycles of neo-adjuvant chemotherapy with satisfactory response. Tumor shrinkage allowed en bloc excision of the navicular bone with clear margins. Reconstruction was done using a tricortical allograft and talus-allograft-cuneiform arthrodesis, secured with a mini-fracture plate (Synthes). Weight bearing protection was advised for 2months and partial weight bearing for another 4months. Patient received 4 cycles of adjuvant chemotherapy. Three years postoperatively, the patient was free of local recurrence or distant metastasis. There were no signs of allograft resorption, fracture or non union. The patient was asymptomatic and full weight bearing. Ankle and subtalar joint motion was within normal limits. Foot salvage after excision of osteosarcoma of the navicular bone could be possible if en bloc resection of the lesion could be performed. Talus-cuneiform fusion with allograft interposition is a viable reconstructive option.
Solid variant of aneurysmal bone cyst of the hamate.
Musculoskelet Surg. 2010 Nov 27. [Epub ahead of print]
Mavrogenis AF, Skarpidi E, Papagelopoulos PJ.
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Solid variant of aneurysmal bone cyst is a variant of aneurysmal bone cyst in which the predominant histology is that of the solid material of a cystic aneurysmal bone cyst. In this article, we present a patient with solid variant of aneurysmal bone cyst of the hamate and discuss the differential diagnosis and current treatment for this lesion.
A nonphosphaturic mesenchymal tumor mixed connective tissue variant of the sacrum.
Orthopedics. 2010 Nov 2;33(11):851. doi: 10.3928/01477447-20100924-27.
Mavrogenis AF, Sakellariou VI, Soultanis K, Mahera H, Korres DS, Papagelopoulos PJ.
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Tumor-induced or oncogenic osteomalacia is a rare paraneoplastic syndrome characterized by overproduction of fibroblast growth factor-23 as a phosphaturic agent and renal phosphate wasting. A range of predominantly mesenchymal neoplasms have been associated with tumor-induced osteomalacia and classified as phosphaturic mesenchymal tumor mixed connective tissues. However, phosphaturic mesenchymal tumor mixed connective tissues could be nonphosphaturic in the first stage of the disease, either because the tumors are resected early in the clinical course or because the patient's osteomalacia was attributed to another cause. This article presents a case of a 42-year-old woman with a 2-year history of low back and right leg pain. Laboratory examinations including serum and urine calcium and phosphorous were within normal values. Imaging of the lumbar spine and pelvis showed an osteolytic lesion occupying the right sacral wing. Histology was unclear. Reverse-transcription polymerase chain reaction analysis for fibroblast growth factor-23 was positive and confirmed the diagnosis of phosphaturic mesenchymal tumor mixed connective tissues. Preoperative selective arterial embolization and complete intralesional excision, bone grafting, and instrumented fusion from L4 to L5 to the iliac wings bilaterally was performed. Postoperative recovery was uneventful. Neurological deficits were not observed. A lumbopelvic corset was applied for 3 months. At 12 months, the patient was asymptomatic. Serum and urine values of calcium and phosphorous were normal throughout the follow-up evaluation.
Juxta-articular osteoid osteoma of the talar neck: a case report.
Clin Podiatr Med Surg. 2010 Oct;27(4):629-34. Epub 2010 Aug 11.
Mavrogenis AF, Dimitriou R, Benetos IS, Korres DS, Papagelopoulos PJ.
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Juxta-articular osteoid osteomas of the ankle are rare and tend to have an atypical presentation. Because of the proximity to the joint, patients experience symptoms that may delay or mislead the diagnosis. This article presents a 33-year-old man with juxta-articular osteoid osteoma of the talar neck. The correct diagnosis was delayed for 2 years; the patient was initially misdiagnosed and treated for ankle sprain and anterior ankle impingement. Surgical excision of the lesion was performed with excellent results. Juxta-articular osteoid osteomas should be considered in the differential diagnosis of persistent ankle pain in teenagers and young adults who do not respond to treatment directed at more common conditions.
Gorham-Stout disease.
J Surg Orthop Adv. 2010 Summer;19(2):85-90.
Mavrogenis AF, Zambirinis CP, Dimitriadis PA, Tsakanikas A, Papagelopoulos PJ.
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Gorham-Stout disease is a rare disease of unknown etiology. It is characterized by spontaneous excessive replacement of bone by proliferative non-neoplastic thin-walled lymphatic and/or blood vessels. Histology shows positive stain for the lymphatic endothelial marker LYVE-1 (lymphatic vascular endothelial hyaluronan receptor-1) and many lymphatic growth factors (PDGF-BB, VEGF-C, VEGFR-3). Patients may present with localized pain and/or weakness and radiographic evidence of massive osteolysis involving contiguous bone structures. The disease usually progresses and complications may occur with significant morbidity and mortality. Close monitoring of these patients is recommended. Treatment remains challenging. Surgical treatment has been combined with pre- and postoperative radiation therapy. Drug regimes including bisphosphonates and vitamin D have been used with various results. Currently, the most effective agent is INF-alpha due to its anti-angiogenic effect. The effect of the newer immunomodulatory agents such as the OK-432 remains to be proved.
Surgical Management of 121 Benign Proximal Fibula Tumors.
Clin Orthop Relat Res. 2010 Jul 13. [Epub ahead of print]
Abdel MP, Papagelopoulos PJ, Morrey ME, Wenger DE, Rose PS, Sim FH.
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BACKGROUND: Tumors of the fibula comprise only 2.5% of primary bone lesions. Patients with aggressive benign tumors in the proximal fibula may require en bloc resection. Peroneal nerve function, knee stability, and recurrence are substantial concerns with these resections. The incidence and fate of these complications is not well-known owing to the small numbers of patients in previous reports. QUESTIONS/PURPOSES: We therefore analyzed the incidence of peroneal nerve palsy, knee stability, and local recurrence following surgical treatment of benign proximal fibula tumors. METHODS: We retrospectively reviewed the charts of 120 patients (121 tumors) with histologically confirmed aggressive benign tumors of the proximal fibula. There were 56 males and 64 females with an average age of 24 years (range, 2-64 years). The most common diagnosis was osteochondroma (38%) followed by giant cell tumor (19%). Pain (94%), palpable mass (39%), and peroneal nerve symptoms (12%) were the most common presenting symptoms. Of the 121 tumors, 56 (46%) underwent en bloc resection. The minimum followup was 2 years (mean, 9 years; range 2 to 49 years; median, 7.4 years). RESULTS: Postoperative complications included nine peroneal nerve palsies (six transient, three permanent), one deep venous thrombosis, and one wound dehiscence. No long-term knee instability was seen with repair of the lateral collateral ligament. Ten patients had recurrences, with 70% of local recurrences occurring in patients who underwent intralesional excision. CONCLUSIONS: Given the higher recurrence rate with curettage, patients with aggressive proximal fibula tumors benefit from en bloc resection. The overall morbidity is low, but postoperative permanent peroneal palsy remains a concern (3%). LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Recurrence After and Complications Associated With Adjuvant Treatments for Sacral Giant Cell Tumor.
Clin Orthop Relat Res. 2010 Jul 10. [Epub ahead of print]
Ruggieri P, Mavrogenis AF, Ussia G, Angelini A, Papagelopoulos PJ, Mercuri M.
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BACKGROUND: The best treatment of giant cell tumor of the sacrum is controversial. It is unclear whether adjuvant treatment with intralesional surgery reduces recurrences or increases morbidity. QUESTIONS/PURPOSES: We therefore asked whether adjuvants altered recurrence rates and complications after intralesional surgery for sacral giant cell tumors. METHODS: We retrospectively studied 31 patients with sacral giant cell tumors treated with intralesional surgery with and without adjuvants. Survival to local recurrence was evaluated using Kaplan-Meier analysis. The differences in survival to local recurrence with and without adjuvants were evaluated using multivariate Cox regression analysis. Complications were recorded from clinical records and images. The minimum followup was 36 months (median, 108 months; range, 36-276 months). RESULTS: Overall survival to local recurrence was 90% at 60 and 120 months. Survival to local recurrence with and without radiation was 91% and 89%, with and without embolization was 91% and 86%, and with and without local adjuvants was 88% and 92%, respectively. Adjuvants had no influence on local recurrence. Mortality was 6%: one patient died at 14 days postoperatively from a massive pulmonary embolism and another patient had radiation and died of a high-grade sarcoma. Fifteen of the 31 patients (48%) had one or more complications: eight patients (26%) had wound complications and seven patients (23%) had massive bleeding during curettage with hemodynamic instability. L5-S2 neurologic deficits decreased from 23% preoperatively to 13% postoperatively; S3-S4 deficits increased from 16% to 33%. CONCLUSIONS: Adjuvants did not change the likelihood of local recurrence when combined with intralesional surgery but the complication rate was high. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Chondrosarcoma in metachondromatosis: a case report.
J Bone Joint Surg Am. 2010 Jun;92(6):1507-13.
Mavrogenis AF, Skarpidi E, Papakonstantinou O, Papagelopoulos PJ.
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P53 expression as a prognostic marker in giant cell tumor of bone: a pilot study.
Orthopedics. 2010 May 12;33(5). doi: 10.3928/01477447-20100329-15.
Papanastassiou I, Ioannou M, Papagelopoulos PJ, Arealis G, Mihas C, Iakovidou I, Demertzis N.
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P53 is the best known tumor suppressor gene. If p53 is mutated, the ability of the cell to sense and repair DNA defects is lost. Failure of this mechanism increases the risk of malignant transformation and tumorigenesis. P53 overexpression is implicated in many carcinomas. P53 alterations appear to be frequent in bone and soft tissue sarcoma and have a strong negative impact on survival in various subtypes of sarcoma like Ewing's sarcoma, synovial sarcoma, and myxoid liposarcoma. There is also evidence in the literature that p53 may be implicated in bone giant cell tumor behavior. The goal of this pilot retrospective study was to detect p53 mutation in giant cell tumor of bone and correlate it with clinical outcome. We analyzed the presence of p53 mutation in 39 patients with giant cell tumor of bone by means of immunohistochemical staining; 8 tumors expressed mutated p53 protein. Seven of them recurred locally (P<.001) and 2 metastasized to the lung (P<.05). In multivariate analysis/subgroup analysis, local recurrence was still strongly correlated, while metastasis had a weaker correlation. Our findings suggest that p53 mutation in giant cell tumor of bone can be useful in predicting tumor behavior, especially in regard to local recurrence. Limitations of this study include the retrospective data collection, the limited number of patients, and the multifactorial nature of the disease; tumor grade, surgical margins, use of adjuvant therapy, and thoroughness of excision may influence the therapeutic outcome. Despite these limitations, this correlation should be further investigated with larger clinical studies. P53 may be used as a marker for the biologic behavior of giant cell tumor of bone.
Posterior decompression and stabilization, and surgical vertebroplasty with the vertebral body stenting for metastatic vertebral and epidural cauda equina compression.
J Surg Oncol. 2010 Mar 1;101(3):253-8.
Mavrogenis AF, Papadopoulos EC, Starantzis K, Korres DS, Papagelopoulos PJ.
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We present the technique of combined posterior decompression and spinal instrumentation, and surgical (open) vertebroplasty using a novel system called vertebral body stenting (VBS) during a single session in a patient with metastatic vertebral and epidural cauda equina compression.
Adamantinoma of the tibia mimicking a benign cystic lesion: a case report.
Clin Podiatr Med Surg. 2010 Jan;27(1):157-65.
Mavrogenis AF, Galanakos S, Savvidou OD, Papagelopoulos PJ.
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Adamantinoma of the long bones is a rare primary malignant bone tumor accounting for less than 1% of all primary malignant bone tumors. Most typical imaging findings include heterogeneous osteolytic cortical lesions showing multiple sharply circumscribed lucent zones of various sizes with sclerotic bone surroundings, interspersing between, and extending above and below the lucent zones by the thinning and bulging cortex. Advanced or recurrent lesions may be associated with destruction of the cortex and soft tissue extension. In this article, the authors present a case report of a patient with a distal tibia adamantinoma mimicking a benign cystic lesion.
Adamantinoma of the tibia treated with a new intramedullary diaphyseal segmental defect implant.
J Int Med Res. 2009 Jul-Aug;37(4):1238-45.
Mavrogenis AF, Sakellariou VI, Tsibidakis H, Papagelopoulos PJ.
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In this case report, a 75-year old male presented with a mass on the anterior surface of the mid-shaft of the right tibia. Imaging studies showed a well-circumscribed radiolucent lesion in the anterior tibial cortex, without soft tissue extension. Plain radiographs and computed tomography scan of the chest were negative. Histological diagnosis was consistent with adamantinoma, a rare primary bone tumour. Wide tumour resection of approximately 16 cm of the tibial diaphysis with a surrounding cuff of normal tissue was performed. The bone defect was reconstructed using an intramedullary diaphyseal segmental defect fixation system. At 26 months post-operatively the patient is alive with no evidence of local recurrence, distant metastases or implant failure. The intramedullary diaphyseal segmental defect fixation system is associated with excellent oncological and functional outcomes. Intra-operative modularity, ease of application, immediate post-operative stability and rapid rehabilitation are the major advantages of this diaphyseal prosthesis.
Metastatic epidural spinal cord compression.
Orthopedics. 2009 Jun;32(6):431.
Mavrogenis AF, Pneumaticos S, Sapkas GS, Papagelopoulos PJ.
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Metastatic epidural spinal cord compression is an emergency complication of systemic cancer. Early diagnosis and appropriate management will prevent paraplegia in most patients. Corticosteroids and radiation as adjuvant or primary therapy is a treatment option for the majority of patients. Circumferential direct decompressive surgery should be considered for selected patients. The role of high-precision radiation therapy techniques is promising for local tumor control and helps the patient avoid surgery. Survival and quality of life are directly related to the patients’ pretreatment ambulatory status. Treatment results are better in ambulatory patients with preserved bladder and bowel control.
Total scapulectomy and constrained reverse total shoulder reconstruction for a Ewing's Sarcoma.
J Surg Oncol. 2009 Jul 6. [Epub ahead of print]
Mavrogenis AF, Mastorakos DP, Triantafyllopoulos G, Sakellariou VI, Galanis EC, Papagelopoulos PJ.
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BACKGROUND: Total scapulectomy and intra-articular resection of the glenohumeral joint indicates the Malawer Type III shoulder girdle resection. MATERIALS AND METHODS: The modified Tikhoff-Linberg total scapulectomy and constrained reverse total shoulder reconstruction for a Ewing's sarcoma of the scapula is presented. A combined approach has been used. The deltoid, trapezius, rhomboids, levator scapulae, latissimus dorsi, and serratus anterior were preserved. the tumor was removed en bloc by disarticulation of the acromioclavicular and the glenohumeral joints. The scapular prosthesis was suspended by the muscles. A constrained reverse humeral prosthesis was implanted after osteotomy of the humeral head. RESULTS: There were no intraoperative or postoperative complications; surgical margins were clear. At 12 months postoperatively, the patient has a stable and painless shoulder. CONCLUSION: The goal of shoulder reconstructions is to provide a stable and painless joint that allows positioning of the arm and hand in space. Compared to those patients left without a scapula reconstruction, prosthetic replacement of the scapula and shoulder partially restores abduction and external rotation and improves cosmesis. J. Surg. Oncol.
Tumors of the sacrum.
Orthopedics. 2009 May;32(5):342.
Mavrogenis AF, Patapis P, Kostopanagiotou G, Papagelopoulos PJ.
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The management of tumors of the sacrum is challenging. Radical resection through partial or complete sacrectomy can prolong the overall survival of patients with primary malignant or aggressive benign tumors. However, establishing immediate stability through spinopelvic reconstruction is necessary for early ambulation and preservation of the quality of life, especially for patients with a limited life expectancy. Modern radiation therapy and stereotactic radiosurgery have the potential to reduce complications by including higher treatment doses with lower volumes of normal tissue within treatment fields. Embolization can be used effectively to treat hypervascular benign and malignant tumors of the sacrum as an adjunct to surgery.
Extraskeletal myxoid chondrosarcoma of the perineum.
Orthopedics. 2009 Mar;32(3):216.
Mavrogenis AF, Patapis P, Papaparaskeva KT, Galanis EC, Papagelopoulos PJ.
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Extraskeletal myxoid chondrosarcoma is an aggressive tumor with significant metastatic potential. A 40-year-old man presented with an asymptomatic mass at the left ischial fossa. Magnetic resonance imaging showed a 9x6-cm mass with variable signal intensity and cystic formations. A computed tomography scan of the chest showed multiple pulmonary nodules. A computed tomography-guided core needle biopsy was consistent with low-grade extraskeletal myxoid chondrosarcoma. Despite the presence of lung metastases, wide resection of the primary tumor was performed. Wide resection included the perineal mass and the adjacent ischiopubic ramus. Postoperative recovery was uneventful. One month postoperatively, thoracotomy was performed, and approximately 20 pulmonary nodules were excised. Histological analysis of the excised specimens was consistent with extraskeletal myxoid chondrosarcoma metastases. Two years postoperatively, the patient is alive without evidence of local recurrence or distant disease. Extraskeletal myxoid chondrosarcoma is an unusual soft tissue sarcoma with ultrastructural and molecular features distinct from that of skeletal myxoid chondrosarcoma. The EWS-CHN gene fusion is highly specific to extraskeletal myxoid chondrosarcoma; the gene fusion is positive in >or=75% of cases. Treatment should include wide excision for local tumor control. Resection of the lung metastases is feasible. Because of the prolonged survival of patients with extraskeletal myxoid chondrosarcoma, long-term follow-up is recommended for early detection of local recurrence or distant metastases.
Skeletal osteochondromas revisited.
Orthopedics. 2008 Oct;31(10). pii: orthosupersite.com/view.asp?rID=32071
Mavrogenis AF, Papagelopoulos PJ, Soucacos PN.
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Skeletal osteochondromas or osteocartilaginous exostoses represent the most common of all benign bone tumors and 10% to 15% of all bone tumors. Osteochondromas are solitary or multiple, pedunculated or sessile exophytic outgrowths from the bone surface that are composed of cortical and medullary bone with an overlying hyaline cartilage cap. Marrow and cortical continuity with the underlying parent bone defines the lesion. Osteochondromas usually occur in children or adolescents between 10 and 15 years, and increase in size throughout childhood, ranging from 1 to 10 cm. After adolescence and skeletal maturity, osteochondromas usually exhibit no further growth. In adults, growth or imaging alterations of an osteochondroma suggest the rare diagnosis of malignant transformation; however, extensive growth of osteochondromas without histological evidence of malignancy has been reported
Current concepts for management of soft tissue sarcomas of the extremities.
J Surg Orthop Adv. 2008 Fall;17(3):204-15.
Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, Patapis P, Soucacos PN.
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Wide resection and limb-salvage surgery remain the gold standard for the management of patients with soft tissue sarcomas of the extremities. Innovations in understanding tumor biology and limb-salvage techniques have led amputation rates to decline. Radiation therapy and novel chemotherapy agents and dosing regimens are supplementing oncology-related surgical treatment. A multidisciplinary team approach with input from oncologists, pathologists, radiation oncologists, and orthopaedic and plastic surgeons is necessary for the management of patients with soft tissue sarcomas of the extremities.
Painful Ulnar Lesion in a 16-year-old Boy.
Clin Orthop Relat Res. 2008 Sep 24. [Epub ahead of print]
Kontakis GM, Karantanas AH, Papagelopoulos PJ.
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Free vascularised tissue transfer and brachytherapy for soft-tissue sarcomas of the extremities.
Injury. 2008 Aug 5. [Epub ahead of print]
Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, Vlastou C, Vrouvas J, Soucacos PN.
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We reviewed the medical files of nine patients with localised soft-tissue sarcomas of the extremities treated with surgical resection, free vascularised tissue transfer, and computerised after-loading iridium-192 high dose rate brachytherapy over a period of 8 years. All patients had external beam radiation therapy in fractions with a total dose of 48-52Gy, followed by surgery at approximately 4-5 weeks post-irradiation. Surgical treatment included wide resection of the primary tumour in six patients, and marginal resection in three patients. Microsurgical reconstruction of the soft-tissue defect used a free vascularised musculocutaneous flap that included the gracilis flap in five patients, the latissimus dorsi flap in four patients, and the radiovolar flap in one patient. Postoperative brachytherapy dose ranged from 12 to 24Gy. Adjuvant chemotherapy was administered in five patients with large tumours and marginal resection. At a mean follow-up of 36 months, eight patients were still alive with no evidence of local recurrence or distant metastases; all these patients had good cosmetic and functional outcomes. Two patients died with lung metastases; one of these patients had local tumour recurrence. Wound healing problems and seroma formations were observed in two patients. Intramedullary nailing was required in one patient for a pathological fracture. Tumour resection for soft-tissue sarcomas combined with microsurgical reconstruction of the soft-tissue defect, preoperative external beam radiation and high dose rate brachytherapy results in a high degree of local control with acceptable complications.
A 56-year-old Woman with a Right Arm Mass.
Clin Orthop Relat Res. 2008 Feb 21 [Epub ahead of print]
Papagelopoulos PJ, Mavrogenis AF, Skarpidi E, Nikolaou I, Soucacos PN.
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Diagnosis Intraneural hemangioma of the median nerve.
Pathological fractures in primary bone sarcomas.
Injury. 2008 Apr;39(4):395-403. Epub 2007 Dec 3.
Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Benetos IS, Galanis EC, Soucacos PN.
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Pathological fractures in patients with primary bone sarcomas should not be considered an absolute indication for amputation. Initial fracture management should include cast immobilisation or external fixation avoiding tumour-cell dissemination. The extent of fracture displacement and the type of fracture stabilisation may affect the outcome of patients with primary bone sarcomas presenting with pathological fractures. Patients with high-grade primary bone sarcomas should be treated by neo-adjuvant chemotherapy, and limb-salvage surgery. Pathological fractures in chemo-resistant primary bone sarcomas are a relative contraindication for limb salvage surgery.
Osteoid osteoma of the radial styloid mimicking de quervain tenosynovitis.
South Med J. 2007 Oct;100(10):1045-7.
Chloros GD, Themistocleous GS, Papagelopoulos PJ, Khaldi L, Efstathopoulos DG, Soucacos PN.
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A very unusual location of osteoid osteoma arising in the radial styloid is presented, which strongly mimicked de Quervain tenosynovitis, thereby resulting in the patient undergoing an additional unnecessary operation and a substantial delay of more than 2 years in diagnosis.
Elastic intramedullary nailing and DBM-bone marrow injection for the treatment of simple bone cysts.
World J Surg Oncol. 2007 Oct 4;5:111.
Kanellopoulos AD, Mavrogenis AF, Papagelopoulos PJ, Soucacos PN.
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BACKGROUND: Simple or unicameral bone cysts are common benign fluid-filled lesions usually located at the long bones of children before skeletal maturity. METHODS: We performed demineralized bone matrix and iliac crest bone marrow injection combined with elastic intramedullary nailing for the treatment of simple bone cysts in long bones of 9 children with a mean age of 12.6 years (range, 4 to 15 years). RESULTS: Two of the 9 patients presented with a pathological fracture. Three patients had been referred after the failure of previous treatments. Four patients had large lesions with impending pathological fractures that interfered with daily living activities. We employed a ratio to ascertain the severity of the lesion. The extent of the lesion on the longitudinal axis was divided with the normal expected diameter of the long bone at the site of the lesion. The mean follow-up was 77 months (range, 5 to 8 years). All patients were pain free and had full range of motion of the adjacent joints at 6 weeks postoperatively. Review radiographs showed that all 7 cysts had consolidated completely (Neer stage I) and 2 cysts had consolidated partially (Neer stage II). Until the latest examination there was no evidence of fracture or re-fracture. CONCLUSION: Elastic intramedullary nailing has the twofold benefits of continuous cyst decompression, and early immediate stability to the involved bone segment, which permits early mobilization and return to the normal activities of the pre-teen patients.
Prognostic value of bax, bcl-2, and p53 staining in primary osteosarcoma.
J Surg Oncol. 2008 Mar 1;97(3):259-66.
Kaseta MK, Khaldi L, Gomatos IP, Tzagarakis GP, Alevizos L, Leandros E, Papagelopoulos PJ, Soucacos PN.
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BACKGROUND AND OBJECTIVES: To investigate the immunohistochemical expression of three apoptosis-related genes (bax, bcl-2, and p53) and apoptosis (TUNEL) in patients with primary osteosarcoma, and examine potential correlations between gene expression and clinicopathological characteristics in these patients. MATERIALS AND METHODS: Thirty-five primary osteosarcoma specimens and 18 tissue specimens deriving from non-malignant osseous lesions were immunohistochemically stained for bax, bcl-2, and p53 proteins, while apoptosis was investigated by the TUNEL method. The results were statistically analyzed. RESULTS: P53, bax, and bcl-2 protein expression was observed in 22 (62.9%), 29 (82.9%), and 18 (51.4%) osteosarcoma patients, respectively. Non-specific positive TUNEL staining (+/-) was observed in two primary osteosarcoma cases (5.7%). None of the benign controls expressed any of the genes studied. None of the apoptosis-related genes studied was able to predict overall or disease-free survival in our group of patients. Nevertheless, increased bax/bcl-2 protein expression ratio was associated with a decreased 4-year survival and disease free survival (P = 0.0229 and P = 0.0370, respectively). Furthermore, all the patients who were bax(+)/bcl-2(-)/p53(+) relapsed within the 4-year follow-up period (P = 0.0385). CONCLUSIONS: The increased apoptotic rate as determined by an elevated bax/bcl-2 protein expression ratio or by the bax(+)/bcl-2(-)/p53(+) protein expression pattern, appears to identify groups of osteosarcoma patients with unfavorable prognosis.
Distal leg wear debris mass from a rotating hinged knee prosthesis.
J Arthroplasty. 2007 Sep;22(6):909-15. Epub 2007 Jul 25.
Papagelopoulos PJ, Mavrogenis AF, Karamitros AE, Zahos KA, Nomikos G, Soucacos PN.
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An 18-year-old woman presented with a gradually increasing distal leg mass 8 years after wide resection for an osteosarcoma and reconstruction of the proximal left tibia with a rotating hinged knee megaprosthesis. Open biopsy of the distal leg mass showed necrobiotic tissue, metallosis, fibroblasts, osteoblasts, histiocytes, and multinucleated giant cells. The patient underwent debridement of the distal leg mass, metallosis, and wear debris surrounding the tibial component, followed by revision of the destructed polyethylene-bearing components. At the latest follow-up, 4 years after the revision surgery, the patient is alive and tumor-free, asymptomatic, and has no clinical or imaging evidence of wear and metallosis.
Ewing's sarcoma of the hip presenting as a benign cystic lesion.
J Surg Orthop Adv. 2007 Summer;16(2):84-8.
Papagelopoulos PJ, Mavrogenis AF, Benetos IS, Papaparaskeva K, Galanis EC, Soucacos PN.
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A 14-year-old girl with a Ewing's sarcoma of the left femoral head and neck is presented. The imaging features mimicked a benign cystic lesion. Biopsy and molecular analysis confirmed the diagnosis. The patient was treated with chemotherapy, wide tumor resection, and proximal femoral reconstruction using an allograft-prosthesis composite. Differential diagnosis, imaging, and pathologic features of Ewing's sarcoma are discussed.Comment in: J Surg Orthop Adv. 2007 Winter;16(4):207; author reply 207.
Total en bloc spondylectomy of C5 vertebra for chordoma.
Spine. 2007 Apr 20;32(9):E294-9.
Currier BL, Papagelopoulos PJ, Krauss WE, Unni KK, Yaszemski MJ.
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STUDY DESIGN: En bloc resection of a chordoma of the C5 vertebra with wide surgical margins. OBJECTIVE: To present the surgical technique of total spondylectomy for a chordoma of the C5 vertebral body. SUMMARY OF BACKGROUND DATA: Malignant bone tumors require wide resection. Wide resection by total en bloc spondylectomy is difficult or not feasible for malignant vertebral tumors of the cervical spine due to the peculiar anatomic complexity of this region, including the vertebral arteries and the neural structures. There are no previous reports of en bloc resection of cervical spine tumors with wide surgical margins. METHODS: Using staged posterior and anterior approaches, a total en bloc spondylectomy and spine arthrodesis was performed. En bloc excision of a C5 chordoma was achieved using a threadwire T-saw (Tomita and Kawahara, Kanazawa, Japan) with surgical margins free of tumor. The patient received postoperative adjuvant proton beam radiation therapy. RESULTS: The patient remains disease-free 9 years after the operation. CONCLUSION: Total en bloc spondylectomy with wide surgical margins is feasible for malignant bone tumors of the cervical spine.
Evaluation and treatment of pelvic metastases.
Injury. 2007 Apr;38(4):509-20. Epub 2007 Mar 29.
Papagelopoulos PJ, Mavrogenis AF, Soucacos PN.
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Advances in systemic treatment of cancer have improved patients' survival and increased the number of patients presenting with metastases of the pelvic ring. Pelvic metastatic lesions may cause severe pain and functional disability. A multidisciplinary approach is fundamental for the management of these lesions. Lesions of the pelvis not directly involving the hip joint such as the ischium, pubis or sacroiliac area can generally be treated non-operatively with radiation alone or using minimally invasive procedures of radiofrequency ablation, cryosurgery and percutaneous osteoplasty. Periacetabular destructive lesions may require total hip replacement with reconstruction of the acetabulum dependent on the extent of the defect. Operative treatment should restore the mechanical stability of the hip joint, and preserve the mobility, independence and comfort of these patients
Extraskeletal chondroma of the foot.
Joint Bone Spine. 2007 May;74(3):285-8. Epub 2007 Feb 27.
Papagelopoulos PJ, Savvidou OD, Mavrogenis AF, Chloros GD, Papaparaskeva KT, Soucacos PN.
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Benign extraskeletal chondromas are uncommon lesions with a predilection for the hands and the feet and can exhibit worrisome radiographic and histologic features mimicking chondrosarcomas. The authors present herein the case of a 74-year-old man with a painful mass at the dorsomedial aspect of the left foot. At 34 months after surgery the patient is disease-free with no evidence of recurrence.
Clinicopathological features, diagnosis, and treatment of adamantinoma of the long bones.
Orthopedics. 2007 Mar;30(3):211-5; quiz 216-7.
Papagelopoulos PJ, Mavrogenis AF, Galanis EC, Savvidou OD, Inwards CY, Sim FH.
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Alveolar soft part sarcoma of the forearm: a case report.
J Surg Orthop Adv. 2006 Winter;15(4):209-13.
Benetos IS, Mavrogenis AF, Soultanis KCh, Zoubos AB, Papagelopoulos PJ, Soucacos PN.
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Alveolar soft part sarcoma (ASPS) is a rare soft tissue sarcoma that most commonly arises in the deep soft tissues of the lower extremities of adults. Median survival of patients with metastatic ASPS has been reported to be from 3 to 3.3 years. The time between detection of metastases and death varies from 10 months to 6.2 years. In this article, a case of an 11-year-old male with primary ASPS of the right forearm is presented. Successful long-term local control of the primary tumor was achieved with wide margin surgical resection and adjuvant radiation therapy. Three years after diagnosis, the patient developed pulmonary metastases. Chemotherapy was unsuccessfully used to control the metastatic disease. Despite that, the patient survived longer than expected, and passed away 9 years after the detection of pulmonary metastases. This time to death after the development of metastases vastly exceeded the previously reported survival rates of patients with metastatic ASPS.
Radiofrequency ablation of intra-articular osteoid osteoma of the hip.
J Int Med Res. 2006 Sep-Oct;34(5):537-44.
Papagelopoulos PJ, Mavrogenis AF, Kyriakopoulos CK, Benetos IS, Kelekis NL, Andreou J, Soucacos PN.
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Diagnosis and treatment of intra-articular osteoid osteoma is challenging. We present 16 patients with intra-articular osteoid osteomas of the hip treated with percutaneous radiofrequency ablation. Eight osteoid osteomas were located in the femoral head, six in the femoral neck, and two in the acetabulum. Three of the 16 patients had had an incorrect previous diagnosis. Percutaneous radiofrequency ablation was a clinical and technical success in all 16 patients. Within the first 24 h after the procedure, pain improved in all patients. Five patients had pain relief within the first 3 days after the procedure, nine patients within the first week and two patients within 2 weeks. Residual or recurrent symptoms were not reported by the last follow-up. At the 12-month follow-up, computed tomography and magnetic resonance imaging showed complete ossification and bone regeneration at the site of the lesion in three patients, partial ossification in six patients and no changes in seven patients. Computed tomography-guided percutaneous radiofrequency ablation is a simple, minimally invasive, safe and effective method for the treatment of most intra-articular osteoid osteomas.
Advances and challenges in diagnosis and management of skeletal metastases
Orthopedics. 2006 Jul;29(7):609-20; quiz 621-2.
Papagelopoulos PJ, Savvidou OD, Galanis EC, Mavrogenis AF, Jacofsky DJ, Frassica FJ, Sim FH.
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The treatment of metastatic disease remains challenging. The number of patients who will be diagnosed with metastatic bone disease will continue to increase as survival from the primary cancer diagnosis continues to improve. Although it often is impossible to cure these patients, the task of maximizing their quality of life must be met with valiant efforts. Although a large number of medical and technological advances have occurred, perhaps the recognition of the importance of a well-qualified multidisciplinary team approach to treatment of these complex patients has done more to improve the field than any other single achievement. As basic science continues to further unravel potential treatment options, we must not forget this integrated approach and we must embrace "the bench" at the bedside.
Survivorship analysis in patients with periosteal chondrosarcoma.
Clin Orthop Relat Res. 2006 Jul;448:199-207
Papagelopoulos PJ, Galanis EC, Mavrogenis AF, Savvidou OD, Bond JR, Unni KK, Sim FH.
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To investigate outcome and identify prognostic factors, we retrospectively reviewed 24 consecutive patients with periosteal chondrosarcomas. There were 17 males and seven females with a mean age of 37.6 years (range, 15-73 years). The femur was involved in 12 patients, the proximal humerus in five, the tibia in two, and the distal fibula, ilium, pubis, metatarsal, and rib in one patient each. The mean greatest dimension of the lesions was 8.1 cm (range, 1.5-27 cm). Based on the histologic pattern, there were 18 Grade 1 tumors and six Grade 2 tumors. All patients were treated surgically. Two patients had intralesional excisions, five patients had marginal excisions, and 17 patients had wide resections. With a mean followup of 17 years (range, 28 months-47 years), seven of 24 patients (29%) had one or more local recurrences. The 5-year local recurrence-free survival was less in patients treated with intralesional or marginal excisions (25%) than for patients treated with wide resections (93%). At the latest followup, six of 24 patients (25%) had died of pulmonary metastases. The overall 5-year metastasis-free survival was 83%. The 5-year metastasis-free survival was less for patients with Grade 2 tumors (50%) than for patients with Grade 1 tumors (94%).
Percutaneous osteoplasty for pelvic and spine metastases.
Orthopedics. 2006 Apr;29(4):315-23.
Papagelopoulos PJ, Mavrogenis AF, Kelekis AD, Katonis P, Galanis EC, Wenger DE, Sim FH, Soucacos PN.
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Current trends in the management of extra-abdominal desmoid tumours.
World J Surg Oncol. 2006 Apr 3;4:21.
Papagelopoulos PJ, Mavrogenis AF, Mitsiokapa EA, Papaparaskeva KT, Galanis EC, Soucacos PN.
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Extra-abdominal desmoid tumours are slow-growing, histologically benign tumours of fibroblastic origin with variable biologic behaviour. They are locally aggressive and invasive to surrounding anatomic structures. Magnetic resonance imaging is the modality of choice for the diagnosis and the evaluation of the tumours. Current management of desmoids involves a multidisciplinary approach. Wide margin surgical resection remains the main treatment modality for local control of the tumour. Amputation should not be the initial treatment, and function-preserving procedures should be the primary treatment goal. Adjuvant radiation therapy is recommended both for primary and recurrent lesions. Chemotherapy may be used for recurrent or unresectable disease. Overall local recurrence rates vary and depend on patient's age, tumour location and margins at resection.
A 60-year-old man with right hip pain.
Clin Orthop Relat Res. 2006 Feb;443:342-9.
Papagelopoulos PJ, Mavrogenis AF, Chloros GD, Galanis EC, Papaparaskeva KT.
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Minimally invasive techniques in orthopedic oncology: radiofrequency and laser thermal ablation.
Orthopedics. 2005 Jun;28(6):563-8.
Papagelopoulos PJ, Mavrogenis AF, Galanis EC, Kelekis NL, Wenger DE, Sim FH, Soucacos PN.
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Image-guided percutaneous thermal ablation is a safe and effective method to reduce pain in patients with painful bone tumors. Computed tomography-guided radiofrequency or laser ablation is the modality of choice for most osteoid osteomas. Radiofrequency or laser thermal ablation also offers an alternative method for palliation of localized, painful osteolytic metastatic lesions. Pain can be reduced and neural damage prevented, improving the quality of life for patients with cancer who often have multimorbid conditions and limited life expectancy. A multidisciplinary approach that includes orthopedic surgeons, neurosurgeons, medical and radiation oncologists, and interventional radiologists is essential to manage these patients.
Unusual presentation of osteoid osteoma of the scaphoid.
Arch Orthop Trauma Surg. 2005 Sep;125(7):482-5.
Themistocleous GS, Chloros GD, Mavrogenis AF, Khaldi L, Papagelopoulos PJ, Efstathopoulos DG.
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The small carpal bones are infrequent sites for osteoid osteomas, and their clinical and imaging pictures may be quite confusing leading to suspect other etiologies. The authors present herein an unusual case of osteoid osteoma of the scaphoid superimposed on a wrist injury caused by a fall on the outstretched hand.
Lateral malleolus en bloc resection and ankle reconstruction for malignant tumors.
Clin Orthop Relat Res. 2005 Aug;(437):209-18.
Papagelopoulos PJ, Savvidou OD, Mavrogenis AF, Galanis EC, Shaughnessy WJ, Unni KK, Sim FH.
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Four children and six adults required en bloc resection of the lateral malleolus for malignant tumors. There were four osteosarcomas, three chondrosarcomas, two Ewing's sarcomas, and one adamantinoma. Surgical margins were wide in seven patients, marginal in two, and intralesional in one. A primary ankle arthrodesis was done in four adults and bracing without any reconstruction was done in four children and two adults. During a mean followup of 14.5 years (range, 3-30 years), there were two local recurrences (two of 10 patients) after a marginal excision and an intralesional excision. One patient had reoperation for a skip osteosarcoma lesion in the proximal fibula. Other complications included chronic osteomyelitis, a lateral talus subluxation and cavovarus deformity, and recurrent ankle instability and degenerative changes of the ankle. At the latest followup, all 10 patients showed no evidence of disease. Five patients who had primary or late ankle arthrodesis had a Musculoskeletal Tumor Society and International Society of Limb Salvage functional score of 28 points (92%), and two adolescents who had postoperative bracing alone had a functional score of 24 points (80%). The three remaining patients had a salvage amputation.
Bizarre parosteal osteochondromatous proliferation of the second metatarsal bone (Nora's lesion).
Orthopedics. 2005 Feb;28(2):168-70.
Efstathopoulos NE, Papagelopoulos PJ, Lazarettos IT, Savvidou OD, Kaseta MA, Giannakou N, Papachristou GK.
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Malignant fibrous histiocytoma of bone associated with type-1 neurofibromatosis. A case report.
J Bone Joint Surg Am. 2005 Feb;87(2):399-403.
Papagelopoulos PJ, Mavrogenis AF, Galanis EC, Chloros GD, Papaparaskeva KT.
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A 23-year-old woman with complete paraplegia and anesthesia below the T8 level.
Clin Orthop Relat Res. 2005 Jan;(430):258-65.
Themistocleous GS, Papagelopoulos PJ, Petraki KD, Stilianessi EV, Partsinevelos AA, Sapkas GS.
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Chordoma of the spine: clinicopathological features, diagnosis, and treatment.
Orthopedics. 2004 Dec;27(12):1256-63; quiz 1264-5.
Papagelopoulos PJ, Mavrogenis AF, Galanis EC, Savvidou OD, Boscainos PJ, Katonis PG, Sim FH.
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Primary malignant tumors of the cervical spine.
Orthopedics. 2004 Oct;27(10):1066-75; quiz 1076-7.Links
Papagelopoulos PJ, Mavrogenis AF, Currier BL, Katonis P, Galanis EC, Sapkas GS, Korres DS.
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Foot malignancies: a multidisciplinary approach.
Foot Ankle Clin. 2003 Dec;8(4):751-63.
Papagelopoulos PJ, Mavrogenis AF, Badekas A, Sim FH.
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Malignant osseous and soft tissue tumors of the foot are rare and should be considered in patients who have foot-related symptoms. Most sarcomas affect patients who are older than 55 years; however, many young patients who are otherwise healthy, may present with malignant foot and ankle lesions. In addition to benign and malignant neoplasms, pseudotumorous conditions mimic neoplastic lesions and should be differentiated before any treatment is undertaken. Invasiveness is a characteristic of sarcomas. The foot is a terminal anatomic structure, with closed and tight compartments and well-vascularized tissues, that predispose it to hematogenous and lymphatic metastases. Patients who have a malignant foot tumor should be referred to an orthopedic oncologist for further evaluation and treatment. The goals of treatment include local tumor control, restoration of function and stability during standing and walking, long-term survival, and improved quality of life. In most cases, wide surgical margins require a ray, Syme, midtarsal, or below-the-knee amputation. Recent advances in chemotherapy and radiotherapy have allowed limb salvage procedures with wide tumor resections. Because overall survival is greatly improved in these patients, the reconstruction of skeletal defects needs to be more functional and durable. After tumor resection, reconstruction of the skeletal and soft tissue defects is possible by using bone allografts or vascularized autografts, arthrodesis, and free vascularized musculocutaneous flaps.
Advances and challenges in the surgical treatment of metastatic bone disease.
Clin Orthop Relat Res. 2003 Oct;(415 Suppl):S14-8.
Jacofsky DJ, Papagelopoulos PJ, Sim FH.
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There are numerous challenges facing the orthopaedic surgeon who treats metastatic bone disease in the twenty-first century. The orthopaedic surgeon must be familiar with the indications for surgical intervention, the available implants for fixation of a given anatomic lesion, the appropriateness of fixation versus resection and replacement, and the viability of newer, less invasive treatment options for a given lesion. Determination of the best surgical candidates still is controversial, especially in the arena of prophylactic treatment. Recent advances have made fixation with intramedullary devices and standard plates simpler and more rigid. The advent and improvement of megaprostheses has made complex joint reconstructions more durable. Advances in interventional radiology such as radiofrequency ablation and percutaneous vertebroplasty and acetabuloplasty with polymethylmethacrylate (PMMA) continue to be promising options for future treatment. Better methods are necessary to evaluate the status of the patients preoperatively and postoperatively, to classify functional improvement after surgical treatment, and to determine the impact of treatment on the quality of life.
Periosteal chondrosarcoma.
Orthopedics. 2002 Aug;25(8):839-42.
Papagelopoulos PJ, Galanis EC, Boscainos PJ, Bond JR, Unni KK, Sim FH.
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Vertebra plana caused by primary Ewing sarcoma: case report and review of the literature.
J Spinal Disord Tech. 2002 Jun;15(3):252-7.
Papagelopoulos PJ, Currier BL, Galanis E, Grubb MJ, Pritchard DJ, Ebersold MJ.
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A 7-year-old boy presented with vertebra plana of T11. The presumptive diagnosis suggested by clinical presentation, conventional radiographs, and computed tomographic scans was eosinophilic granuloma. Progressive neurologic symptoms required surgical excision of the lesion and decompression. Histopathologic examination of the surgical specimen confirmed the diagnosis of Ewing sarcoma.
Clinicopathologic features, diagnosis, and treatment of fibrosarcoma of bone.
Am J Orthop. 2002 May;31(5):253-7.
Papagelopoulos PJ, Galanis EC, Trantafyllidis P, Boscainos PJ, Sim FH, Unni KK.
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Fibrosarcoma of bone is a relatively rare tumor; it accounts for less than 5% of bone sarcomas. The anatomical sites most commonly involved are the metaphyses of long tubular bones. Local pain, swelling, limitation of motion, and pathologic fracture are the common clinical signs and symptoms. Typical imaging findings include eccentrically located lytic lesions, with a geographic, moth-eaten, or permeative pattern of bone destruction, and extension into adjacent soft tissues. Surgery is the treatment of choice. The type of surgical procedure depends mainly on histologic grade, local conditions, and tumor location. With a high probability of metastases (>70%) after surgical treatment, perioperative adjuvant treatment modalities should be considered for high-grade tumors. The most important prognostic factors affecting survival include tumor grade, patient's age, and tumor location.
Treatment of aneurysmal bone cysts of the pelvis and sacrum.
J Bone Joint Surg Am. 2001 Nov;83-A(11):1674-81.
Papagelopoulos PJ, Choudhury SN, Frassica FJ, Bond JR, Unni KK, Sim FH.
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BACKGROUND: Aneurysmal bone cysts are benign, non-neoplastic, highly vascular bone lesions. The purpose of this study was to describe the prevalence, the clinical presentation, and the recurrence rate of aneurysmal bone cysts of the pelvis and sacrum and to examine the diagnostic and therapeutic options and prognosis for patients with this condition. METHODS: Forty consecutive patients with an aneurysmal bone cyst of the pelvis and/or sacrum were treated from 1921 to 1996. Their medical records and radiographic and imaging studies were reviewed, and histological sections from the cysts were examined. Seventeen lesions were iliosacral, sixteen were acetabular, and seven were ischiopubic. Seven involved the hip joint, and two involved the sacroiliac joint. All twelve sacral lesions extended to more than one sacral segment and were associated with neurological signs and symptoms. Destructive acetabular lesions were associated with pathological fracture in five patients and with medial migration of the femoral head, hip subluxation, and hip dislocation in one patient each. The mean duration of follow-up was thirteen years (range, three to fifty-three years). RESULTS: Thirty-five patients who were initially treated for a primary lesion had surgical treatment (twenty-one had excision-curettage and fourteen had intralesional excision); two patients also had adjuvant radiation therapy. Of the thirty-five patients, five (14%) had a local recurrence noted less than eighteen months after the operation. Of five patients initially treated for a recurrent lesion, one had a local recurrence. At the latest follow-up examination, all forty patients were disease-free and twenty-eight (70%) were asymptomatic. There were two deep infections. CONCLUSION: Aneurysmal bone cysts of the pelvis and sacrum are usually aggressive lesions associated with substantial bone destruction, pathological fractures, and local recurrence. Current management recommendations include preoperative selective arterial embolization, excision-curettage, and bone-grafting.
Current concepts in the evaluation and treatment of osteosarcoma.
Orthopedics. 2000 Aug;23(8):858-67; quiz 868-9.
Papagelopoulos PJ, Galanis EC, Vlastou C, Nikiforidis PA, Vlamis JA, Boscainos PJ, Fragiadakis EG, Stamos KG, Pantazopoulos T, Sim FH.
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Clinicopathologic features, diagnosis, and treatment of malignant fibrous histiocytoma of bone.
Orthopedics. 2000 Jan;23(1):59-65; quiz 66-7.
Papagelopoulos PJ, Galanis EC, Sim FH, Unni KK.
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Primary fibrosarcoma of bone. Outcome after primary surgical treatment.
Clin Orthop Relat Res. 2000 Apr;(373):88-103.
Papagelopoulos PJ, Galanis E, Frassica FJ, Sim FH, Larson DR, Wold LE.
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To investigate outcome and evaluate prognostic factors in primary fibrosarcoma of bone, all patients at the authors' institution who had surgical treatment for primary fibrosarcoma of bone from 1910 to 1995 were studied. Medical records, surgical reports, radiographs, and histologic slides of 92 patients (51 males, 41 females; mean age, 38 years; range, 8-84 years) were reviewed. The most common tumor locations were the femur (28 patients), tibia (21 patients), and pelvis (14 patients). Sixty-one tumors (66%) were Enneking Stage IIB. Twenty-nine patients (31.5%) had adjuvant therapy: 16 had radiation, nine had chemotherapy alone, and four had radiation and chemotherapy. Amputation or disarticulation was performed in 61 patients (66%), wide excision was performed in 13 (14%), marginal excision was performed in 15 (16%), and intralesional excision was performed in three (3.3%). Local recurrence occurred in 14 patients (15%) at a median time of 7 months (range, 3-21 months). Metastases developed in 58 of the 85 patients (68%) with Stage I or II tumors at presentation, at a median of 9 months (range, 1-51 months). Survivorship analysis showed that the overall probability of survival was 33.4% at 5 years after surgery. Multivariate analysis showed that the main prognostic risk factors affecting overall survival included age older than 40 years, tumor location in the axial skeleton, and high-grade tumor (Grade 3 or 4). With the high incidence of systemic failure after surgical treatment, perioperative adjuvant treatment modalities should be considered.
Periosteal osteosarcoma.
Orthopedics. 1999 Oct;22(10):971-4.
Papagelopoulos PJ, Galanis E, Sim FH, Unni KK.
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Vertebra plana of the lumbar spine caused by an aneurysmal bone cyst: a case report.
Am J Orthop. 1999 Feb;28(2):119-24.
Papagelopoulos PJ, Currier BL, Galanis EC, Sim FH.
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The patient was a 15-year-old girl who had a lesion of the fourth lumbar vertebra. Plain radiographs suggested vertebra plana, with complete collapse of the body of the fourth lumbar vertebra and no involvement of the intervertebral disk spaces. The presumptive diagnosis was eosinophilic granuloma. Progressive neurologic symptoms required surgical excision of the lesion, decompression, and fusion. Histopathologic examination of the operative specimen confirmed the diagnosis of an aneurysmal bone cyst.
Clinicopathologic features, diagnosis, and treatment of osteoblastoma.
Orthopedics. 1999 Feb;22(2):244-7; quiz 248-9.
Papagelopoulos PJ, Galanis EC, Sim FH, Unni KK.
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Osteoblastoma of the acetabulum.
Orthopedics. 1998 Mar;21(3):355-8.
Papagelopoulos PJ, Galanis EC, Sim FH, Unni KK.
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Aneurysmal bone cyst of the spine. Management and outcome.
Spine. 1998 Mar 1;23(5):621-8.
Papagelopoulos PJ, Currier BL, Shaughnessy WJ, Sim FH, Ebsersold MJ, Bond JR, Unni KK.
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STUDY DESIGN: The clinical records, radiographs, histologic sections, and operative reports of 52 consecutive patients with an aneurysmal bone cyst of the spine were reviewed to evaluate diagnostic and therapeutic options and to correlate treatment and outcome. OBJECTIVES: To define the incidence, clinical presentation, diagnostic and therapeutic options, and prognosis of patients with aneurysmal bone cyst of the spine. SUMMARY OF BACKGROUND DATA: There are special considerations in the management of spinal lesions: relative inaccessibility of the lesions, associated intraoperative bleeding, necessity of removing the entire lesion to avoid the possibility of recurrence, proximity of the lesion to the spinal cord and nerve roots, and potential postoperative bony spinal instability. METHODS: Fifty-two consecutive patients with an aneurysmal bone cyst of the spine were treated from 1910 to 1993. Forty patients initially treated for a primary lesion had operative treatment (19 intralesional excision and bone grafting and 21 intralesional excision); four also had adjuvant radiation therapy. Preoperative arterial embolization was performed in two. RESULTS: There was a recurrence rate of 10% within 10 years. All recurrences were noted less than 6 months after surgery. Of 12 patients treated for a recurrent lesion, two had a subsequent recurrence (16.7%) within 9 years. At last follow-up examination, 50 patients (96%) were free of the disease. One patient died of postradiation osteosarcoma, and one died of intraoperative bleeding. CONCLUSION: Current treatment recommendations involve preoperative selective arterial embolization, intralesional excision curettage, bone grafting, and fusion of the affected area if instability is present.
Prosthetic hip replacement for pathologic or impending pathologic fractures in myeloma.
Clin Orthop Relat Res. 1997 Aug;(341):192-205.
Papagelopoulos PJ, Galanis EC, Greipp PR, Sim FH.
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The authors retrospectively reviewed 53 hip replacements performed in 50 patients (mean age, 65 years) for plasmacytoma (four lesions) or multiple myeloma (49 lesions) of the hip region. Perioperatively, 49 patients received chemotherapy. Twenty-four hip lesions had radiation therapy. Within a mean followup period of 32.6 months, 15 (28%) complications occurred. Late deep infection, dislocation, and aseptic loosening with medial migration of the acetabular component occurred in one patient each. Three patients died during the first postoperatively month. All of the remaining patients postoperatively regained their previous ambulatory status; hip pain relief was achieved in 98% of patients. At the time of the latest followup evaluation, 84% of the patients had died (median survival time, 18 months) and 16% were still alive (median survival time, 76 months). Patients with plasmacytoma had longer survival than did patients with multiple myeloma (median survival, 6.3 years versus 18 months, respectively). No significant association was found between patient survival and the stage of disease at diagnosis, age, gender, type or location of the myeloma lesion, or the type of implant used. Because of the relatively long survival time, prosthetic replacement is indicated for extensive hip lesions in patients with plasmacytoma or multiple myeloma.