The level of bone resection for osteosarcoma depends on the pre-operative evaluation of the extent of intramedullary tumour. We compared the accuracy of magnetic resonance imaging (MRI), computerised tomography (CT), and isotope bone scanning with the actual extent of the tumour in the resected specimens from 34 patients with primary osteosarcoma of a long bone. The extent of medullary tumour was defined accurately in 23 of 24 MRI scans (96%) and 24 of 32 CT scans (75%). A flexion contracture of a joint close to the tumour was an important cause for inaccurate measurements from both MRI and CT scans. Isotope bone scanning was inaccurate: its role is now confined to detecting skeletal metastases and skip lesions

1. The question whether amputation for lower femoral osteosarcoma should be by disarticulation of the hip or through the upper femur to leave a stump is discussed. 2. Sixty-eight such patients are reviewed. Thirty were treated by disarticulation and thirty-eight by through-femur amputation. 3. There was a 16 per cent incidence of stump recurrence after through-femur amputation, but none after disarticulation. Comparison of survival was not conclusive. 4. Disarticulation of the hip is advised

Three cases are reported in which an osteosarcoma developed in relation to an enchondroma in a long bone. Two of the cases were in the proximal femur whilst one occurred in the proximal humerus, both recognised sites for old calcified enchondromas or "cartilage rests". The ages of the patients at presentation were 55, 63 and 84 years and all were women. Two patients died with pulmonary metastases within six months of the onset of clinical symptoms. Despite their intimate relationship to the enchondromas, none of the osteosarcomas could be shown histologically to have arisen from tumour cartilage. It appears probable that these are cases in which independently arising tumours have merged to form a so-called "collision" tumour, but the possibility that they could have been derived by dedifferentiation of a previously benign neoplasm cannot be discounted

Bone tumours may recur locally even after wide surgical excision and systemic chemotherapy. Local control of growth may be accomplished by the addition of cytostatic drugs such as methotrexate (MTX) to bone cement used to fill the defect after surgery and to stabilise the reconstructive prosthesis. We have studied the elution kinetics of MTX and its solvent N-methyl-pyrrolidone (NMP) from bone cement and their biological activities in five cell lines of osteosarcoma and in osteoblasts, and compared them with the effects of the parent compounds alone and in combination. Our findings show that MTX is released continuously over months at concentrations highly cytotoxic to osteosarcoma cells and suggest that the impregnated bone cement would be effective in the long term. Proliferating osteoblasts, however, were much less sensitive towards MTX. The dose-response relationship for NMP and experiments with MTX/NMP-mixtures show that the eluted concentrations of solvent are not toxic and do not influence the effects of MTX. We suggest that bone cement containing MTX dissolved in NMP releases the drug in a suitable and effective way and may be of value in the treatment of bone tumours

1. The detailed findings are presented of a woman aged fifty who had widely distributed ossifying skeletal tumours, the structure and form of which have been shown to be low-grade osteoblastic osteogenic sarcoma. The patient was treated with heavy doses of P. 32. , to which is attributed some clinical improvement, but which induced a fatal aplastic anaemia. 2. The study of the several tumours, together with the history, the radiographs and the post-mortem findings, suggests that the lesions are multifocal skeletal primary tumours rather than numerous osseous metastases secondary to a solitary new growth in any one bone. 3. The focal neoplastic lesion is discussed in the light of personal experience of other osteogenic sarcomata of low grade but of solitary origin, and of the multifocal form of bone sarcoma which may complicate Paget's osteitis deformans

Forty-one cases of parosteal osteosarcoma were reviewed clinically, radiologically and pathologically. The fibrous and cartilaginous elements of each tumour were graded from I to IV for malignancy. Primary intramedullary involvement was found in one third of Grade I lesions, two-thirds of Grade II and nearly 90% of Grade III lesions. Thirty-five patients with adequate follow-up were also studied and evaluated as to the adequacy of surgical management in relation to the later development of local recurrence or metastasis or both. No metastases were seen from Grade I tumours despite a number of local recurrences. One third of patients with Grade II and half of those with Grade III tumours developed pulmonary metastases and died, all with involvement of the medullary cavity before distant spread. No patients with adequate surgical management developed local recurrence; in those with inadequate treatment there was an 88% local recurrence rate

We studied the bone mineral density (BMD) of 48 long-term survivors of highly malignant osteosarcoma who had been treated according to the chemotherapy protocols of the German- Swiss-Austrian Co-operative Osteosarcoma Study Group which include high-dose methotrexate. The mean age of the patients was 31 ± 4.2 years and the mean follow-up 16 ± 2.2 years. The BMD of the lumbar spine and of the proximal femur of the non-operated side was measured by dual- energy x-ray absorptiometry. A questionnaire was given to determine life-style factors, medical history and medication. Ten patients were osteoporotic, 21 osteopenic and 17 normal according to the WHO definition. Eighteen patients suffered fractures after receiving chemotherapy and all had significantly lower levels of BMD for all the sites measured

1. A case of primary osteosarcoma of the patella is reported. 2. A brief review of the literature has been made. 3. In the author's opinion only nine genuine cases have been reported, including the present case

The occurrence of an osteosarcoma at the site of a cobalt-chrome total hip replacement is described, and the possibility of the tumour arising as a result of the liberation of cobalt particles is discussed. The experimental and clinical evidence relating tumour formation to the presence of particulate metals, and to the presence of solid and particulate polyethylene, is presented. It is considered that the risk of tumour formation at the site of any total hip replacement is very small

1. Two girls with non-familial osteogenesis imperfecta who subsequently developed osteosarcoma of the femur are described. One is of special interest in that there were multiple bone metastases. 2. It is suggested that the tumours arose spontaneously and were not related to the underlying bone disorder. 3. Because of the relative frequency of hyperplastic callus formation in osteogenesis imperfecta it is most important that adequate biopsy material of any suspicious lesion is examined because the early clinical picture may be indistinguishable from a tumour

We studied 55 patients with stage-IIB osteosarcoma around the knee with respect to the expression of matrix metalloproteinase (MMP)-9 in the surviving tumour cells in surgical resection specimens. They were followed up for a minimum of 2.5 years. Factors significantly associated with poor overall survival were a high serum level of alkaline phosphatase at diagnosis and tumour cells expressing MMP-9 in the resection specimens. The only factor strongly associated with disease-free survival was the immunohistochemical status of tumour cells for MMP-9 in the resection specimens. The percentage of necrosis after chemotherapy failed marginally to reach statistical significance. On Cox regression analysis only MMP-9 remained significant for overall and disease-free survival

1. A patient of sixty-eight suffering from enchondromatosis (Ollier's disease) is described. 2. A malignant tumour developed in the region of the lesser trochanter of the femur. Histological investigation established that it was an osteosarcoma. 3. Other features of interest are the radiographic appearance of Ollier's disease at an advanced age, and the presence of subcutaneous subcostal and retroperitoneal haemangiomata

The aim of this study was to determine whether the level of circulating C-reactive protein (CRP) before treatment predicted overall disease-specific survival and local tumour control in patients with a sarcoma of bone. We retrospectively reviewed 318 patients who presented with a primary sarcoma of bone between 2003 and 2010. Those who presented with metastases and/or local recurrence were excluded. Elevated CRP levels were seen in 84 patients before treatment; these patients had a poorer disease-specific survival (57% at five years) than patients with a normal CRP (79% at five years) (p < 0.0001). They were also less likely to be free of recurrence (71% at five years) than patients with a normal CRP (79% at five years) (p = 0.04). Multivariate analysis showed the pre-operative CRP level to be an independent predictor of survival and local control. Patients with a Ewing’s sarcoma or chondrosarcoma who had an elevated CRP before their treatment started had a significantly poorer disease-specific survival than patients with a normal CRP (p = 0.02 and p < 0.0001, respectively). Patients with a conventional osteosarcoma and a raised CRP were at an increased risk of poorer local control. We recommend that CRP levels are measured routinely in patients with a suspected sarcoma of bone as a further prognostic indicator of survival. Cite this article: Bone Joint J 2013;95-B:411–18

We have reviewed 20 cases of parosteal osteosarcoma treated by wide local resection and prosthetic replacement and followed up for six to 17 years. Limb function was excellent in 85%. One patient with grade III histological disease developed pulmonary metastases. Four patients had local recurrences, which were related to repeated preliminary biopsies, inappropriate siting of biopsy and vascular encroachment by the tumour. After this mode of treatment, the outcome was not related to medullary invasion by the tumour

Above-knee amputation has been the traditional treatment for osteosarcoma of the proximal tibia. Recent advances in chemotherapy have encouraged the development of limb-salvage techniques. Van Nes rotationplasty for malignant lesions of the distal femur has increased in popularity as a reconstructive technique, but no similar procedure has been described for lesions of the proximal tibia. We have developed a modified rotationplasty for this lesion and have performed it in four children. The surgical technique, postoperative management and results of the procedure are described. Two patients had delayed wound healing. No other complications have developed and our patients were disease-free at follow-up, while the appearance of the leg was well accepted by the patients and their parents. This procedure is a useful addition to the armamentarium of the tumour surgeon for the treatment of malignant lesions of the proximal tibia

1. The average number of cases of osteogenic sarcoma found in the years 1946-58 inclusive in the northern division of the South-west Hospital region of England was 6·7 for each year, varying from three to ten. 2. The annual incidence of this sarcoma in this area was one tumour per 230,000 population. 3. These figures were compared with similar figures from Norway which indicate a rather similar tumour incidence among juveniles, but a very much smaller number of tumours in elderly persons. 4. Among the eighty-seven sarcomata collected in the specified area in thirteen years twenty-Six were associated with Paget's disease. 5. It is estimated that among the population of the specified area there were probably 26,000 persons at any time with Paget's disease, of whom one in 650 (0·15 per cent) would eventually develop sarcoma. 6. This study suggests that Paget's disease increases the risk of sarcoma about thirty-fold in persons over forty years of age. 7. It is tentatively suggested that the incidence of Paget's disease is influenced more by heredity than environment

1. The relationship between histological grading and survival has been studied in a consecutive series of eighty-eight patients with osteogenic sarcomata. The grading has been based entirely upon the mitotic activity of these tumours.

2. There is a positive correlation ("r"=+0·59) between the two variates mitotic ratio and survival in months.

3. The frequency distributions of the mitotic ratios and survivals are similar and, from the observed range, mean and mode of mitotic ratios a more precise definition is proposed for the terms "low," "medium" and "high" malignancy.

4. Comment is made on those patients (20 per cent) in whom actual survival was very different from that expected on the basis of histological grading.

5. The five-year survival rates were: Grade I–67 per cent, Grade II–15 per cent, Grade III–nil, all–17 per cent. For the whole series the average survival period from the time of the presenting symptom was thirty-six months.

6. The five-year survival rate for forty-five tumours of the femur was 20 per cent; no further analysis by sites is attempted.