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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 276-279

Reconstruction with extracorporeal radiated bone in a primary malignant bone tumour, A doable option


1 Department of Orthopedics, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Radiotherapy, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission03-Jan-2022
Date of Decision14-May-2022
Date of Acceptance23-May-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Dr. Mohit Dhingra
Department of Orthopedics, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_1_22

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How to cite this article:
Regmi A, Dhingra M, Joseph D. Reconstruction with extracorporeal radiated bone in a primary malignant bone tumour, A doable option. J Med Evid 2022;3:276-9

How to cite this URL:
Regmi A, Dhingra M, Joseph D. Reconstruction with extracorporeal radiated bone in a primary malignant bone tumour, A doable option. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:276-9. Available from: http://www.journaljme.org/text.asp?2022/3/3/276/365847




  Introduction Top


Primary malignant bone tumour accounts for <1% of diagnosed cancers each year. Osteosarcoma, Ewing sarcoma and chondrosarcoma are the commonly encountered bone tumours associated with significant morbidity and mortality.[1] Often, the presentation of the patient is late due to its indolent course and is only brought to notice when a traumatic event occurs. Radiographic suspicion of a bone malignancy on a plain radiograph should prompt the clinician to quickly refer to the multidisciplinary care centre.[2]

The current standard of care for malignant tumours is a combination of treatment that includes neoadjuvant chemotherapy, wide surgical excision of the primary tumour and reconstructive surgery.[3] Limb salvage surgeries require either prosthesis, cement or bone as the structural material for reconstruction. In terms of biological material, allografts are one source, but due to their limited availability, a patient's own sterilised bone with high dose radiation, also known as ECRT, is a viable option for procuring biological material for reconstruction.[4] Long tumour prostheses are costlier than the conventional surface replacement prosthesis. Hence, using the sterilised bone along with the surface replacement is an economical option. Here, the bone segment is irradiated, and the articular cartilage lost due to irradiation is only replaced.[5]

This report presents a case of a histologically proven chondrosarcoma left proximal humerus with a 4-month-old ununited fracture of the distal third of the humerus who presented to a government academic tertiary care centre in hilly terrain. We here resected the proximal humerus containing tumour from the fracture site, irradiated the segment, re-implanted the segment back and replaced the articular surface of the humeral head, followed by reconstruction of the rotator cuff with the use of prolene mesh.


  Case Report Top


A 47-year-old male from hilly terrain, Hindu by religion, a farmer by occupation having a dominant right hand, presented to the Outpatient Department with complaints of pain and deformity over his left arm for 4 months. He gave an alleged history of assault 4 months back, followed by conservative treatment by a private practitioner [Figure 1]b. The patient does not have any significant past history, no significant family history, no known comorbidities, no past surgical history or no known allergic history. The patient is non-vegetarian by diet and non-smoker and does not consume alcohol. Clinically, no apparent positive findings other than the ununited fracture of the distal humerus were seen. Distal neurovascular status was found to be intact.
Figure 1: (a) Stippled calcification (1), thinning of the cortex (2), fracture (3), (b) clinical photograph, (c) MRI of the lesion. MRI: Magnetic resonance imaging

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Radiographs revealed a displaced fracture of the distal third of the humerus with diffuse stippled calcification at the proximal end of the humerus [Figure 1]a. Magnetic resonance imaging revealed a large lobulated focal lesion in the metaphysis and upper half of the diaphysis suggestive of a primary bone tumour of chondroid origin [Figure 1]c. A histopathological examination was performed, showing features consistent with chondrosarcoma. Metastatic workup was unremarkable.

Resection of the tumour and reconstruction was planned. After taking the patient's consent for the planned procedure, the patient was taken under general anaesthesia in a beach chair position. The procedure was performed by a team of consultant orthopaedic oncology surgeons. The tumour was resected with R-0 margins from the fracture site.[6] All the vital soft tissue structures were identified, tagged and kept away from the resected specimen [Figure 2]. The bone so resected was devoid of any soft tissue and washed with an antibiotic solution [Figure 3]a. Then, the bone segment was packed in double-layered sterile C-arm covers, followed by the sterile sheet [Figure 3]b. The resected specimen was sent for ECRT, and a single midplane dose of 50 Gy was given over 15 min[7] [Figure 3]c. The specimen brought back to the operation theatre was again washed with antibiotic solution and re-implanted into the surgical wound with the help of a locking plate. The cartilage of the head of the humerus, which is anticipated to have been destroyed due to radiation, was replaced by a cemented Neer's prosthesis.[8] The rotator cuff loss was compensated using prolene mesh winded around the prosthesis [Figure 3]d. The final reconstruction was confirmed under C-arm, and then, the closure was completed in layers.
Figure 2: Intraoperative images showing arm after en bloc removal of the tumour-bearing bone segment

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The post-operative period was uneventful. Intravenous analgesics and antibiotics continued for post-operative 2 days, and the patient got discharged on a post-operative day 3 on a maintained arm pouch sling. A shoulder with arm X-ray was taken, which showed articulating prosthesis and satisfactory fixation [Figure 4]a.
Figure 3: (a) Resected specimen, (b) preparation of transport in a saline-soaked bed, (c) radiation exposure to the specimen in the box, (d) surgical reconstruction with the locking compression plate (LCP) and mesh, arrow showing the normal saline used for soaking the graft

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Figure 4: (a) Immediate post-operative X-ray, (b) follow-up X-ray at 3 months, (c) movement at 3 months

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The patient was followed up for 4 months and showed satisfactory clinical and radiological results. The MSTS scoring of upper limb was 14 at 2 months and 20 at 4 months. the follow up xray and clinical movement is shown in [Figure 4]a and [Figure 4]b. The grade of complications was recorded to be grade 1 according to Clavien-Dindo classification.[9]


  Discussion Top


Appendicular chondrosarcomas are a comparatively rarer variety in adults after 40 years.[10] The management of malignant bone tumours has changed in the last couple of years because of the advancement in pathology, imaging, surgical techniques, chemotherapy and radiation therapy (RT).[11] Limb preservation management, which comprises chemotherapy (neoadjuvant and adjuvant) and surgical resection, is the preferred option for managing malignant bone tumours nowadays.[12] Custom-made prostheses or osteoarticular allografts can be an option for reconstruction, but the cost is an important constraint in developing countries. The biological option of an allograft is a viable option, but due to its limited availability, risk of graft rejection, the transmission of disease and dependence on bone banks make its usage difficult for many surgeons.[13] Comparison to its use of patient's own bone as autograft after ECRT is proving to be promising when used judiciously.[14],[15] Spira and Lubin first documented the use of ECRT bone to be used in musculoskeletal malignancies.[16] The technique has evolved over time and is now being used by different surgeons for biological reconstruction. It gives the added advantage of being part of the patient's body and fits well from where it has been removed. The only limiting factor is the destruction of articular cartilage with radiation which can be replaced as done in surface replacement arthroplasty.

Sharma et al. suggested that the ECRT is technically feasible at the setup of developing countries and provides decent local control and short-term survival rates. Furthermore, they suggested that a higher dose of ECRT be explored in future trials to improve the local control rates further.[17] Chauhan et al. suggested that the changes in strength and deformation in bone after irradiation were found to be consistent with the compositional investigations. Mineralisation, amount of calcium and bone stiffness were found to be decreased with an increase in bone deformation over time. Overall, all these changes affect bone healing.[5]

Our case is unique in:

  • Incidental pickup when the patient came just for non-union
  • The rarity of chondrosarcoma in the appendicular skeleton
  • Use of long segment of irradiated bone back in the patient
  • Replacing the articular cartilage of the irradiated bone with surface replacing implant, thus decreasing the cost and increasing the functionality.



  Conclusion Top


The limb salvage approach involving a multidisciplinary team is the current recommended treatment for primary malignant bone tumours. Extracorporeal irradiation is a convenient alternative to prostheses since affordability is a matter of concern in developing countries. However, determinants of the feasibility of ECRT include location and extent of the tumour and appropriate selection of patients. Although the cost-effectiveness and convenience of extracorporeal radiotherapy (ERCT) in developing countries are superior, the quality of bone, mineralisation, its strength following irradiation and its healing potential are still questionable. A multicentric large sample-sized randomised control trial with long-term follow-up is needed to compare the outcomes and complications following ECRT.

Clinical importance

Limb salvage surgery with the patient's own bone stock is a viable option even in the presence of high-grade malignancy.

Patient's perspective

The patient was satisfied with the outcome.

Informed consent for publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The 2020 WHO Classification of Tumors of Bone: An Updated Review – PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/33480599/. [Last accessed on 2021 Dec 21].  Back to cited text no. 1
    
2.
Ferguson JL, Turner SP. Bone cancer: Diagnosis and treatment principles. Am Fam Physician 2018;98:205-13.  Back to cited text no. 2
    
3.
The Current and Future Therapies for Human Osteosarcoma. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730918/. [Last accessed on 2021 Dec 21].  Back to cited text no. 3
    
4.
The Mechanical Effect of Extracorporeal Irradiation on Bone – University of Strathclyde. Available from: https://pureportal.strath.ac.uk/en/publications/the-mechanical-effect-of-extracorporeal-irradiation-on-bone. [Last accessed on 2021 Dec 21].  Back to cited text no. 4
    
5.
Chauhan S, Manoj K, Rastogi S, Khan SA, Prasad A. Biomechanical investigation of the effect of extracorporeal irradiation on resected human bone. J Mech Behav Biomed Mater 2017;65:791-800.  Back to cited text no. 5
    
6.
Hermanek P, Wittekind C. The pathologist and the residual tumor (R) classification. Pathol Res Pract 1994;190:115-23.  Back to cited text no. 6
    
7.
Hong A, Stevens G, Stalley P, Pendlebury S, Ahern V, Ralston A, et al. Extracorporeal irradiation for malignant bone tumors. Int J Radiat Oncol Biol Phys 2001;50:441-7.  Back to cited text no. 7
    
8.
Saintigny Y, Cruet-Hennequart S, Hamdi DH, Chevalier F, Lefaix JL. Impact of therapeutic irradiation on healthy articular cartilage. Radiat Res 2015;183:135-46.  Back to cited text no. 8
    
9.
Dindo D. The Clavien-Dindo classification of surgical complications. In: Cuesta MA, Bonjer HJ, editors. Treatment of Postoperative Complications After Digestive Surgery. London: Springer; 2014. p. 13-7. Available from: https://doi.org/10.1007/978-1-4471-4354-3_3. [Last accessed on 2021 Dec 29].  Back to cited text no. 9
    
10.
Vrionis FD. Chordomas and chondrosarcomas of the skull base and spine. Neuro Oncol 2004;6:166-7.  Back to cited text no. 10
    
11.
Review of Therapeutic Strategies for Osteosarcoma, Chondrosarcoma, and Ewing's Sarcoma. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539609/. [Last accessed on 2021 Dec 29].  Back to cited text no. 11
    
12.
Gebhardt MC. What's new in musculoskeletal oncology. JBJS 2002;84:694-701.  Back to cited text no. 12
    
13.
Gunaseelan K, Patro DK, Lal A, Kannan P, Biswajit D, Vijayaprabhu N. Efficacy of extracorporeal irradiation in primary malignant bone tumours: A tertiary cancer centre experience. Asian Pac J Cancer Care 2019;4:53-7.  Back to cited text no. 13
    
14.
Hejna MJ, Gitelis S. Allograft prosthetic composite replacement for bone tumors. Semin Surg Oncol 1997;13:18-24.  Back to cited text no. 14
    
15.
Mankin HJ, Gebhardt MC, Jennings LC, Springfield DS, Tomford WW. Long-term results of allograft replacement in the management of bone tumors. Clin Orthop Relat Res 1996;324:86-97.  Back to cited text no. 15
    
16.
Spira E, Lubin E. Extracorporeal irradiation of bone tumors. A preliminary report. Isr J Med Sci 1968;4:1015-9.  Back to cited text no. 16
    
17.
Sharma DN, Rastogi S, Bakhshi S, Rath GK, Julka PK, Laviraj MA, et al. Role of extracorporeal irradiation in malignant bone tumors. Indian J Cancer 2013;50:306-9.  Back to cited text no. 17
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