Introduction: Renal cell carcinoma often metastasizes to the skeleton and less frequently soft tissues, leading to the increased risk of fracture. Previous studies have show that the survival of patients with bone metastases is frequently prolonged and that early failure of surgical implants designed for fracture fixation is high. The aim of the study was to investigate the outcomes from surgical procedures undertaken at a tertiary referral bone tumour unit. Methods: A retrospective review of consecutive patients presenting with a musculoskeletal metastasis to our unit from October 1976 to June 2007 was undertaken. There were 179 patients seen over this period, 89 with solitary and 90 with multiple mets. The mean age at presentation was 60.0 yrs. The mean follow up was 16.9 months. Kaplan-Meyer implant and patient survival analysis was undertaken. Results: The mean patient survival was 22 months (range 1 month to 16 years). The 1yr, 3yr and 10yr patient survival was 77 %, 44 % and 11 % respectively. The types of surgical treatment undertaken included EPR in 119 patients, conventional arthroplasty in 15 patients, fracture fixation in 14 patients, excision only in 12 patients, amputation in 9 patients, curettage and cementation in 9 patients, decompression stabilization of spine in 1 patient. Two femoral EPRs failed due to infection, requiring hindquarter amputations. Failure of fixation to the humerous lead to a forequarter amputation, two hip dislocations. Failure of curettage and cementation in the acetabulum and proximal tibia were treated with THR and EPR respectively. Discussion: Patients with renal cell carcinoma metastases can survive for prolonged periods. Any surgical intervention for bone metastases has to outlive the patient and EPRs are reliable with a low rate of failure or complication. We would recommend resection and reconstruction with endoprostheses for solitary renal metastases in a tertiary referral unit

Introduction: Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and show longer survival rates compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radio resistant tumour, which can often present with both back pain and neurological deficit. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. Results: All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. The other three are alive and well at 33, 40 and 54 months post-op with no radiological evidence of tumour recurrence in the spine. There were no major surgical complications. Discussion: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence. Conclusion: TES can improve symptomatic control of isolated solitary spinal metastases of the thoracolumbar spine in Renal Cell Carcinoma

Bone metastases from renal cell carcinoma are aggressive, osteolytic lesions that often require operative intervention for fracture prophylaxis, fracture fixation or palliation. The lesions are hypervascular and intraoperative bleeding is a serious challenge for the orthopaedic surgeon. The purpose of this study was to determine the efficacy of preoperative tumour embolization in reducing blood loss during operative management of renal cell carcinoma metastases to bone. Patients were identified from a prospectively accumulated database (1996–2006). Inclusion criteria included operative management for renal cell metastasis to the pelvis or appendicular skeleton. Patients that were not embolised preoperatively due to renal insufficiency or obesity were excluded. Embolizations were performed the day of surgery by an interventional radiologist. Post-embolization runs were used to determine the percentage of blood flow reduction to the tumour. Variables analyzed included patient age, gender, location of tumour, surgical procedure, surgical time, number of units of packed red blood cells (PRBC) transfused, estimated intraoperative blood loss (EBL) and percentage embolised according to the post-embolization run. Student’s t-test was used to determine the effects of percentage embolization on EBL and number of units of transfused PRBCs. Thirty-five cases (twenty-eight patients) met the inclusion criteria. There were twenty males and eight females with an average age of sixty-five years (range, forty-three to eighty-nine years). The most common metastatic sites were the femur (nineteen cases), humerus (seven cases) and pelvis (six cases). There were ten cases of intramedullary nailing and twenty-five cases of tumor resection and reconstruction. Average surgical time was 4.5 hours (range, 0.75–10 hours) and average EBL was 1.5 litres (range, 0.25–12 litres). Embolization that successfully blocked at least 75% of the blood flow to the tumour significantly decreased surgical EBL (3.2 vs 0.6 litres, P< 0.05) and units of PRBCs transfused (5.6 vs 1.9, P=0.05) compared to those that did not. Two embolization-associated complications occurred including one case of toe gangrene and one case of muscle ischemia. Preoperative embolization significantly reduces blood loss and red blood cell transfusions resulting from surgical stabilization of renal cell metastases to bone. Close communication between the orthopaedic surgeon and interventional radiologist is imperative to maximise these benefits

We present a case of osteolytic lesion in Gruen Zone 2, 3 in a six-month post-operative cemented THR initially diagnosed as early loosening-?Septic. Investigations and biopsy revealed metastatic renal cell carcinoma. A 79 year old gentleman had a Left cemented THR and was symptom free post-operative. Six months later he had pain in the left groin and thigh. Examination revealed painless hip movements. X-ray showed lytic area in zone 2 and 3. ESR -90 mm and CRP – 50 mg/dl. Hip aspiration excluded sepsis. Bone scan showed increased uptake of left femoral shaft, right scapula and L1 vertebra. Bone chemistry, renal & liver Assay and tumour markers were normal. Open biopsy showed erosion of lateral cortex, with friable soft tissue mass with profuse bleeding. Histopathological report showed classical clear cell renal cell carcinoma. CT abdomen and chest revealed multiple nodules in lung fields, multiple nodules in liver, mass in both kidneys consistent with Renal cell carcinoma, multiple skeletal lytic lesions. Patient was referred to oncologist for palliative treatment. DISCUSSION: In case of osteolytic erosive lesions at cement bone interface, the possibility of metastatic lesions should be considered. In old age groups Biopsy is recommended to exclude malignancy after exclusion of septic and aseptic loosening and abdominal ultrasound to exclude primaries

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

Aims: Evalutation of the different surgical option (simple decompression and stabilization vs. intralesional excision vs. en bloc resection) in the treatment of spinal metastases from RCC. Methods: Sixty-one cases in 56 patients with symptomatic spine metastases secondary to Renal Cell Carcinoma (RCC) were treated between 1991 and august 2002. The metastases was located in 43 cases in the lumbar spine, in 23 cases in the thoracic spine and in 4 cases in the cervical spine. Twelve patients were submitted only to radiation therapy. Different procedure was done in the remainder cases: in 16 cases a palliative procedure, in 22 cases a curettage and in 6 cases a en bloc resection. Radiation therapy (RTR) was performed after surgery in 37 cases, Selective Arterial Embolization (SAE) in 29 cases, Chemotherapy (different protocols) in 5 cases and Immunotherapy (IL 2+IFN) in 22 cases. Results: Fifteen patients only were followed for 24 months at least. Of 3 patients submitted to palliative surgery, 1 is alive without disease (NED) at 28 months from treatment, while 2 are dead at 24 and 27 months. Of 10 patients submitted to curettage 5 are continuous disease free (CDF) (24 to 44 months; average: months); 1 is NED at 56 months, 2 are alive with disease (AWD) at 24 and 25 months and 2 are dead after 40 and 68 months. Two patients were submitted to en bloc resection and are CDF at 24 and 30 months after tretament. Conclusions: The treatment of spine metastases of RCC is multidisciplinary: the eligibility of patients to en bloc resection both on the basis of general conditions and local tumor expansion is critical for the local control of the disease. If en bloc resection is not feasible, combination of SAE, complete intralesional excision, RTR, Immunotherapy seem to be the most appropriate treatment

Introduction: The conventional approach to spinal malignancy is via intralesional piecemeal resection but the incidence of local recurrence after surgery has been increasing as survival of patients getting prolonged due to advance adjuvant treatment TES is devised to minimize the incidence of local recurrence in malignant spinal tumours. The purpose of this study is to analyse whether the radical procedure like TES is justifiable in solitary metastasis or not. Material & Methods: We analysed 6 patients who undergone surgery for metastases of spine secondary to renal cell carcinoma between1996 and 2005 out of which 4 had TES for solitary intraosseous thoracolumbar lesion. They include three men and one woman ranging an age from 51 to 64 years. Common presenting complaints were intractable back pain dependent on opiates and progressive neural deficit. Four patients had localised intraosseous thoraco-lumbar lesion. The extent of spinal lesion was assessed with X-rays, CT scans and MRI for all patients. All patient’s prognosis was analysed by Tokuhasi Scoring System.3 patients had pre-op embolisation.4 patients with solitary intra-osseous metastasis underwent radical surgery in the form of total vertebrectomy and 3- column stabilisation of spine. Total surgical time was between 9–13 hrs and total blood loss between 4–11 Litres. Results: None of the patients had surgery related major complication. No external brace used for mobilisation. The surgical outcome assessed by the pain, severity of paresis and the ability to walk before and after surgery. All patients followed up regularly to detect local tumour recurrences and position of implant. None of the patients with TES shown signs of local recurrence The follow up period for the surviving patients ranged from 9 to 32 months after TES. One patient died 9 month post-op due to widespread metastasis. Conclusion: TES offers the most aggressive mode of treatment for the solitary metastasis of Thoraco-Lumbar spine secondary to Renal Cell Carcinoma. Considering the technical demands and potential risks of TES, the indication for TES with spinal metastasis should be limited to the cases with solitary intra-osseous lesions in malignancies with good prognosis

Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding

Introduction: There is increasing evidence that surgical treatment in tumour surgery can influence survival times. Renal cell carcinoma can lead to single or few sites of metastasis that are amenable to extirpative surgery with reconstruction in the spine. 1. Such treatment can also be beneficial to improve quality of surviving years. Methods: Retrospective cohort study of 10 consecutive patients treated for spinal metastatic renal cell carcinoma. Case note review and patient or general practitioner contact was used to ascertain number of metastases, treatment given, survival time from diagnosis and survival time from surgery. All primary tumours were treated with nephrectomy. Results: Of the 10 patients, 6 had extirpative treatment, while 4 had palliative surgery including decompression of the neural elements. Patients treated with extirpative surgery to spinal metastases from a renal cell carcinoma primary had a significantly longer survival time from surgery to those treated with palliative decompressions alone. There were no significant differences in age or time from diagnosis to surgical treatment between groups. There were no cases of operative mortality, but significant intraoperative bleeding was encountered in extirpative treatment of the affected vertebra, despite preoperative embolisation. Discussion: The role of surgical treatment in metastasis to the spine is of current interest. Our results have shown significant survival times are possible with extirpative treatment of renal metastases. Whilst this may not apply directly to metastases from other primary tumours, careful selection of cases and co-operation between spinal surgeons and oncologists is important to ensure maximal quality and length of survival for these patients. These cases are surgically challenging, and care is required to minimise and anticipate blood loss

There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction

Introduction: Modern cancer treatment has substantially increased the survival of patients with various malignancies. One of the late sequelae of a successful treatment is the development of a second malignant tumor. However, in many cases of second primary cancers, exposure to chemotherapy or radiation therapy is not evident, and it should be postulated that the putative mechanism for the development of the second cancer is different. Material and Methods: Retrospective search of data files of 610 patients with soft-tissue or bone sarcomas that were treated by the authors from January 1995 through December 1999 were performed. Results: Out of 375 patients with soft-tissue sarcoma (STS), 28 (7.5%) developed other malignant neoplasm either before or after its diagnosis. The second tumor types included mainly STS and renal cell carcinoma. The time interval between the diagnosis of STS and the second malignancy was o to 21 years. Three patients developed a third primary tumor within 0–3 years after the diagnosis of the second tumor. The median overall survival was > 78 months. Conclusions: The phenomenon of two or three primary neoplasms in patients in whom one of the tumors was STS occurs in a rate of 7.5% – a significantly higher rate than the occurrence of STS among the general cancer population (1%). Most cases are detected incidentally. The clinical implications are the need to search for an occult second primary in patients with STS as an integral part of their follow-up. It is especially true in patients with primary MFH who show increased risk for developing a renal cell carcinoma

In contrast to bony metastases, soft tissue metastases from carcinoma are rare. We reviewed all referrals to our Sarcoma Unit over an eight-year period, and found an incidence of soft tissue metastases from carcinoma of 1.4%. The most common mode of presentation was a painless soft tissue lump in a patient with an occult primary. Lung and kidney were the most frequent primary sources. Overall, prognosis was poor, with a mean survival of 9.4 months. Renal tumours however had a much better prognosis that other types of tumours. Treatment should be individualised according to the underlying disease and the prognosis. Although much rarer than primary soft tissue sarcomas, soft tissue metastases from carcinoma should remain a differential diagnosis in any patient presenting with a suspicious soft tissue lump. Introduction: Carcinoma most commonly metastasises via the lymphatic system firstly to the regional lymph nodes and then into the general circulation. Dependent upon the primary site of tumour, metastases from carcinoma commonly occur to the lungs, liver and bone. Distant metastases to the soft tissues are rare. There are few published case series (. 1. ,. 2. ) – the majority of the literature containing only case reports. We report a series of 10 cases of soft tissue metastases from carcinoma, collected from retrospective review of the case notes of consecutive patients referred over a eight year period to our Sarcoma Unit with a soft tissue lump, suspicious of a sarcoma. Patients and Methods: We retrospectively reviewed the case notes of consecutive patients over a eight year period (April 1995 – April 2003) referred to our Unit with a soft tissue lump, suspicious of a sarcoma. All patients underwent magnetic resonance (MR) scanning, and then trucut or open biopsy of the lesion. Dependent on the histological and MR findings, patients then underwent computer tomography (CT) of the chest and ultrasound examination of the abdomen. Included in this series were all patients with a histologically proven, soft tissue (skeletal muscle or subcutaneous tissue) metastatic carcinomatous deposit. Demographic, diagnostic, clinical, radiological and treatment data was collected on all patients. Results: Of the 702 referrals to our Unit over the eight-year period with a soft tissue lump suspicious of a sarcoma, 10 cases proved to be soft tissue metastases from carcinomas (incidence 1.4%). Data for the 10 patients comprising the series is shown in Table 1. Eight of the patients were male, two were female. The mean age at presentation was 68 years (range 39–85 years). Two patients presented with a painful lump, and in the other eight patients the lump was asymptomatic. The involved sites included the thigh in four cases, the arm in three cases, the back, buttock and axilla one each.In nine cases, the soft tissue lump was the presenting symptom of an occult primary carcinoma, whilst in one case (Case 4); the patient had a history of previous excision of a hypernephroma. The sources of primary carcinoma were small cell carcinoma of the lung in 4 cases, renal clear cell carcinoma in 3 cases, large bowel adenocarcinoma in 1 case, prostate 1 case, and in 1 case the primary site was unknown. All but one patient (Case 6) underwent radiotherapy or chemotherapy or both. Case 6 presented with a soft tissue lump over the shoulder, which on biopsy was found to be metastatic adenocarcinoma of large bowel origin. CT scan of the head confirmed multiple brain metastases. He declined any treatment and died within 2 months of presentation. In total, nine of the ten patients have died of their disease. The mean duration from diagnosis of soft tissue metastasis to death was 9.4 months (range 2–31 months). The duration of survival was significantly better for metastatic carcinoma of the kidney (23 months) compared to the other carcinomas (7 months). Discussion: The most commonly reported primary carcinomas to result in soft tissue metastases are those of the lung, kidney and colon (. 1. –. 3. ), contrasting with those carcinomas which commonly metastasise to bone such as prostate, breast and thyroid which only very rarely metastasise to the soft tissues. Damron and Heiner (. 1. ) who reported the largest series to date however had no cases where the patients primary site of carcinoma was of renal or colon origin and suggested that these cases were over-represented in the literature. Our series differs from their findings, concurring instead with the other published literature. Histologically, the most common diagnosis is adenocarcinoma, though many have been reported (. 1. –. 3. ). Soft tissue metastases from carcinoma are rare, which again contrasts to bony metastases from carcinoma. Tolia and Whitmore (. 4. ) reviewed 586 patients with renal cell carcinoma, and whilst a quarter had evidence of distant metastases at presentation, no patient had soft tissue metastases. Chandler et al (. 5. ) reported on 726 patients who died following metastatic renal carcinoma; only 3 patients had soft tissue metastases, all of which were only found at autopsy. Our series, which reviewed all patients referred to our Unit over a eight year period with a soft tissue lump initially suspicious of a sarcoma, found an overall incidence of 1.4%. Damron and Heiner (. 1. ) reported that the most common mode of presentation was a painful soft tissue lump. In our series however, the majority were painless. Whilst for most, the lump is the first sign of an occult malignancy, renal cell carcinomas tend to be different, often presenting as a solitary soft tissue deposit a few months to up to 16 years after the initial diagnosis of renal cell carcinoma has been made (. 1. ,. 2. ). Our series agreed with these findings; only in 1 case (Case 4) was there evidence of previously documented carcinoma prior to presentation with the soft tissue lump. All patients in our series underwent pre-operative MR scans, the appearances of which were not diagnostic of metastases, though highly suggestive of malignancy. Subsequently patients underwent either Tru-cut or open biopsy which gave the definitive diagnosis. As part of the pre-operative work-up, all patients had a CT of the chest and abdominal ultrasound scanning. Rao et al (. 6. ) reported 5 cases of soft tissue metastases from primary sarcoma, concluding that metastases in these cases were seen as late events and survival was generally poor. In our series of soft tissue metastases from carcinoma, we also found that prognosis was poor (averaging 9.4 months), especially when the primary carcinoma was lung, though the prognosis, if the primary was renal carcinoma was less bleak. Conclusions: Although rare, soft tissue metastases from carcinoma should remain a differential diagnosis in any patient presenting with a suspicious soft tissue lump. Whilst the MR scan appearances were suggestive of malignancy, they were not diagnostic of metastases. Tru-cut or open biopsy was reliable in confirming the diagnosis of carcinoma and helpful in the detection of the possible origin of the primary. The most common primary sites were lung, kidney and bowel

SEREX was used to identify candidate tumor antigens in the nonimmunogenic fibrosarcoma (NFSA) tumor model. One of the six clones identified was of particular interest. NFSA-5 was identified as the receptor for hylaronan-acid-mediated motility (RHAMM), which is involved in cell growth and metastasis. RHAMM is expressed in a variety of human tumors. RHAMM is differentially expressed, with significant levels not found in normal tissues other than testis, placenta, and thymus. Therefore, RHAMM may be an appealing target for human tumor vaccines. The identification of murine homologs to human tumor antigens may aid in the preclinical development of human tumor vaccines. The goal of our studies was to use serological analysis of antigens by recombinant expression cloning (SEREX) to identify candidate tumor antigens in a nonimmunogenic murine fibrosarcoma model. SEREX provides a rapid means of identifying candidate tumor antigens in murine cancer models. The identification of murine homologs to human tumor antigens may aid in the preclinical development of human tumor vaccines. The SEREX approach included construction of a cDNA expression library from NFSA tumors followed by immunoscreening of the library with sera from C3H mice growing NFSA tumors. The nucleotide sequence of insert cDNA was determined for positive clones. Sequence alignments were performed with BLAST software on GenBank database. Six positive clones were identified. Two clones coded for proteins with known expression in normal tissues. Two clones represented heat-shock proteins, known to be upregulated in human and murine tumors. Two of the clones were of particular interest. Clone NFSA-1 was the homolog to NY-REN-58, an antigen previously identified by SEREX analysis of renal cell carcinoma patients. NFSA-5 was identified as the receptor for the hylaronan-acid-mediated motility (RHAMM), which is involved in cell growth and metastasis. RHAMM was recently identified as a leukemia-associated antigen and is expressed in a variety of human solid tumors including renal cell carcinoma, breast carcinoma, and ovarian carcinoma. RHAMM is differentially expressed, with significant levels not found in normal tissues other than testis, placenta, and thymus. Therefore, RHAMM may be an appealing target for human tumor vaccines. Funding: This study was supported by a grant received from the William E. McElroy Charitable Foundation

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

The rate of fracture and subsequent nonunion after radiation therapy for soft-tissue sarcomas and bone tumors has been demonstrated to quite high. There is a paucity of data describing the optimal treatment for these nonunions. Free vascularized fibular grafts (FVFG) have been used successfully in the treatment of large segmental bone defects in the axial and appendicular skeleton, however, their efficacy with respect to treatment of radiated nonunions remains unclear. The purpose of the study was to assess the 1) union rate, 2) clinical outcomes, and 3) complications following FVFG for radiation-induced femoral fracture nonunions. We identified 24 patients who underwent FVFG for the treatment of radiation-induced femoral fracture nonunion between 1991 and 2015. Medical records were reviewed in order to determine oncologic diagnosis, total preoperative radiation dose, type of surgical treatment for the nonunion, clinical outcomes, and postoperative complications. There were 11 males and 13 females, with a mean age of 59 years (range, 29 – 78) and a mean follow-up duration of 61 months (range, 10 – 183 months). Three patients had a history of diabetes mellitus and three were current tobacco users at the time of FVFG. No patient was receiving chemotherapy during recovery from FVFG. Oncologic diagnoses included unspecified soft tissue sarcomas (n = 5), undifferentiated pleomorphic sarcoma (UPS) (n = 3), myxofibrosarcoma (n = 3), liposarcoma (n = 2), Ewing's sarcoma (n = 2), lymphoma (n = 2), hemangiopericytoma, leiomyosarcoma, multiple myeloma, myxoid chondrosarcoma, myxoid liposarcoma, neurofibrosarcoma, and renal cell carcinoma. Mean total radiation dose was 56.3 Gy (range, 39 – 72.5), given at a mean of 10.2 years prior to FVFG. The average FVFG length was 16.4 cm. In addition to FVFG, 13 patients underwent simultaneous autogenous iliac crest bone grafting, nine had other cancellous autografting, one received cancellous allograft, and three were treated with synthetic graft products. The FVFG was fixed as an onlay graft using lag screws in all cases, additional fixation was obtained with an intramedullary nail (n = 19), dynamic compression plate (n = 2), blade plate (n = 2), or lateral locking plate (n = 1). Nineteen (79%) fractures went on to union at a mean of 13.1 months (range, 4.8 – 28.1 months). Musculoskeletal Tumor Society scores improved from eight preoperatively to 22 at latest follow-up (p < 0.0001). Among the five fractures that failed to unite, two were converted to proximal femoral replacements (PFR), two remained stable pseudarthroses, and one was converted to a total hip arthroplasty. A 6th case did unite initially, however, subsequent failure lead to PFR. Seven patients (29%) required a second operative grafting. There were five additional complications including three infections, one wound dehiscence, and one screw fracture. No patient required amputation. Free vascularized fibular grafts are a reliable treatment option for radiation-induced pathologic femoral fracture nonunions, providing a union rate of 79%. Surgeons should remain cognizant, however, of the elevated rate of infectious complications and need for additional operative grafting procedures

Six patients underwent wide segmental resection and limb salvage surgery for primary or metastatic bone tumors involving the diaphysis of the femur, the tibia and the humerus using a modular intramedullary diaphyseal segmental defect fixation system. There were 4 men and 2 women with a mean age of 62 years (range, 40 to 77 years). Histological diagnosis included adamantinoma, dedifferentiated synovial sarcoma attached to the tibia, multiple myeloma, and metastatic renal cell carcinoma, myeloid carcinoma of the thyroid gland and metastatic adenocarcinoma of the stomach. The mean follow-up was 16 months (range, 11 to 24 months). At the latest examination, 5 patients were free of local or distant disease; one patient had deceased with distant disease, without evidence of local recurrence. Revision surgery was necessary in one patient because of mechanical loosening of the proximal fixation of the prosthesis. The mean increase of the Enneking rating from the pre to the postoperative status was 87.82%. The intramedullary diaphyseal segmental defect fixation system used herein is associated with a satisfactory functional and oncological outcome after wide resection of diaphyseal bone tumors

Aim. To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery. Material and Methods. From January 2003 to December 2009, 243 patients (148 men and 95 women; age range, 20–87 years) with painful bone metastases were treated with N-2-butyl Cyanoacrylate. Overall, 309 embolizations were performed; 56 patients had more than one embolization. Embolizations were performed in the pelvis (168 procedures), in the spine (83 procedures), in the upper limb (13 procedures), in the lower limb (38 procedures) and in the thoracic cage (21 procedures). Primary cancer included urogenital, breast, gastrointestinal, thyroid, lung, musculoskeletal, skin, nerve and unknown origin. Renal cell carcinoma was the most commonly treated tumor. In all patients, selective embolization was performed by transfemoral catheterization. Results. Complete or significant resolution of pain for more than 6 months was observed in 236 patients (97%), in 56 of them (23%) after repeated embolization; 12 patients had subsequent surgical treatment. Function was restored to normal in the patients with extremity tumors. In 21 cases, after angiography embolization was judged infeasible due to arteriovascular reasons or high risk. Skin and subcutaneous necrosis at the pelvis occurred in one patient after multiple embolizations for a metastatic paraganglioma. Conclusions. Selective embolization of bone metastases with N-2-butyl Cyanoacrylate is safe and effective for the palliative and/or adjuvant management of painful bone metastases. It can be used for surgically inaccessible or irresponsive to radiation therapy lesions, and as an adjuvant to surgical treatment

Seven patients who had malignant proximal femoral tumours were selected for resection and limb salvage with a modular megaprosthesis. Histopathological diagnosis confirmed one solitary bone metastasis from renal cell carcinoma, one dedifferentiated chondrosarcoma, two primary non-Hodgkin lymphomas non-responsive to adjuvant chemo- and radiotherapy and three low-grade chondrosarcomas. The mean age at the time of surgery was 53.5 years. Post-operative survival averaged 54.5 months. The mean functional status score was satisfactory. There was no local tumour recurrence or dislocation of the prosthesis. There were one superficial wound infection and one post-surgical haematoma. Care must be taken in selecting patients to for resection of the proximal femur and implantation of modular megaprostheses. We reserve such treatment only for tumours that, because of the histopathological diagnosis and spread, chemotherapy or radiotherapy alone is not enough. Modular megaprosthesis is currently the method of choice in the treatment of malignant proximal femoral tumours. With this implant joint function can be restored after wide resection, too, offering a valid alternative to the bony massive allografts that are characterised by a high rate of complications and failure

Aim. To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery. Material and Methods. From January 2003 to December 2009, 243 patients (148 men and 95 women; age range, 20-87 years) with painful bone metastases were treated with N-2-butyl Cyanoacrylate. Overall, 309 embolizations were performed;. 56 patients had more than one embolization. Embolizations were performed in the pelvis (168 procedures), in the spine (83 procedures), in the upper limb (13 procedures), in the lower limb (38 procedures) and in the thoracic cage (21 procedures). Primary cancer included urogenital, breast, gastrointestinal, thyroid, lung, musculoskeletal, skin, nerve and unknown origin. Renal cell carcinoma was the most commonly treated tumour. In all patients, selective embolization was performed by transfemoral catheterization. Results. Complete or significant resolution of pain for more than 6 months was observed in 236 patients (97%), in 56 of them (23%) after repeated embolization; 12 patients had subsequent surgical treatment. Function was restored to normal in the patients with extremity tumours. In 21 cases, after angiography embolization was judged infeasible due to arteriovascular reasons or high risk. Skin and subcutaneous necrosis at the pelvis occurred in one patient after multiple embolizations for a metastatic paraganglioma. Conclusions. Selective embolization of bone metastases with N-2-butyl Cyanoacrylate is safe and effective for the palliative and/or adjuvant management of painful bone metastases. It can be used for surgically inaccessible or irresponsive to radiation therapy lesions, and as an adjuvant to surgical treatment

There is limited literature available on the use of metal prosthetic replacements for the treatment of non-traumatic lesions of the proximal radius. This study discusses the implant survivorship and the functional outcome of the elbow following insertion of metal proximal radius endoprostheses performed at the Royal National Orthopaedic Hospital. We present a series of six patients treated with endoprosthetic reconstruction of the proximal radius following resection of non-traumatic pathologies. The patients included four females and two males, with a mean age of 39 years at the time of surgery. Their diagnoses included Ewing’s sarcoma, chondroblastoma, benign fibrous histiocytoma, radio-ulna synostosis and renal carcinoma metastases in two patients. Follow-up extended to 192 months with a mean of 76 months. During this time there were no complications with the prostheses, the most recent radiographs demonstrated secure fixation of the implants and none required revision. One patient developed posterior interosseuous nerve neuropraxia following surgery, which partially recovered, and another patient passed away as a result of disseminated metastatic renal cell carcinoma which was present preoperatively. The patient with radio-ulna synostosis had a 25° fixed flexion deformity of the elbow post-operatively but good flexion, supination and pronation. All other patients had full ranges of movement at the elbow. Functional scores were assessed using the Mayo Elbow Performance Score with patients achieving a mean score of 86 out of 100. The results of the use of proximal radial endoprostheses for treatment of non-traumatic lesions are encouraging with regards to survivorship of the implant and functional outcome of the elbow