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Abstract: In the last few decades significant advances have occurred in the diagnosis and therapy of bone and soft tissue sarcomas of the extrimities, which has made it possible to avoid amputations and conserve the limb in many cases. But careful case selection has to be done and consideration has to be given to the influence of adjuant modalities needed in the management.This article reviews the various aspects of limb salvage in extrimity sarcomas including the methods of reconstruction in deatil. Problems of reconstruction in a growing child is also dealt with separately.

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Orthopedic Oncology – “The Challenges Ahead”
Ajay Puri
Frontiers in Surgery , 2014, DOI: 10.3389/fsurg.2014.00027

Abstract:

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Treatment of giant cell tumor of bone: Current concepts
Puri Ajay,Agarwal Manish
Indian Journal of Orthopaedics , 2007,

Abstract: Giant cell tumor (GCT) of bone though one of the commonest bone tumors encountered by an orthopedic surgeon continues to intrigue treating surgeons. Usually benign, they are locally aggressive and may occasionally undergo malignant transformation. The surgeon needs to strike a balance during treatment between reducing the incidence of local recurrence while preserving maximal function. Differing opinions pertaining to the use of adjuvants for extension of curettage, the relative role of bone graft or cement to pack the defect and the management of recurrent lesions are some of the issues that offer topics for eternal debate. Current literature suggests that intralesional curettage strikes the best balance between controlling disease and preserving optimum function in the majority of the cases though there may be occasions where the extent of the disease mandates resection to ensure adequate disease clearance. An accompanying treatment algorithm helps outline the management strategy in GCT.

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Osteosarcoma: Lessons Learned and Future Avenues
Ajay Puri,Norman Jaffe,Hans Gelderblom
Sarcoma , 2013, DOI: 10.1155/2013/641687

Abstract:

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Osteosarcoma: Evolution of Treatment Paradigms
Norman Jaffe,Ajay Puri,Hans Gelderblom
Sarcoma , 2013, DOI: 10.1155/2013/203531

Abstract: This paper reviews the contribution of chemotherapy in the conquest of osteosarcoma. It discusses how the treatment of osteosarcoma has evolved over the last five decades, resulting in a more than fivefold increase in survival. Though the initial improvements in survival were dramatic, essentially there has been no change in the outlook for this disease over the past 30 years. The paper also highlights the necessity of a multidisciplinary approach to combat this disease and stresses the need to explore newer treatment agents in order to build on the lessons learnt from the past while striving to achieve greater levels of success. 1. Introduction Bone cancers are rare in humans. In 2009, it is estimated that 2570 new cases of bone sarcomas were diagnosed in the United States [1]. Osteosarcoma is the most common. The term “osteosarcoma” as opposed to “osteogenic sarcoma” is preferred by the World Health Organization (WHO). The eponym was introduced by Boyer in 1805 [2]. In 1879, Gross published a paper entitled “Sarcoma of the Long Bone Based upon a Study of One Hundred and Sixty-five Cases” [3]. Most, if not all the tumors, were probably osteosarcoma. He advocated treatment by early amputation. The outcome was dismal; nonetheless it was accepted as the “standard” of treatment. In the course of the ensuing one and a half century, osteosarcoma became established as a distinct pathological and radiological entity with no change in the “standard” of therapy. The survival rate was less than 10%; in rare publications, it occasionally rose to 20%. The dismal survival was due to the biological behavior of the malignancy: pulmonary micrometastases were present in at least 80% of patients at diagnosis. These metastases were not visible on conventional imaging studies. However, they surfaced 8–12 months after amputation and were responsible for the patient’s demise within 12 to 24 months of their appearance. Osteosarcoma therefore had to be considered a systemic disease with systemic therapy required for cure. Until the mid-20th century, no such therapy was available. 2. Radiation Therapy In view of the poor prognosis with primary surgical ablation, Sir Stanford Cade a British Surgeon Radiotherapist in 1931 advocated radiation therapy to treat the primary tumor [4]. Following completion of therapy (6000？rad over six weeks) the patient was observed for the possible emergence of pulmonary metastases for 6–9 months; if metastases failed to appear, an elective amputation was performed. The intent was to avoid “futile mutilation” in a patient destined to die. It was

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Clinicopathologic Features of Two Rare Cases of Dedifferentiated Adamantinomas, Including Diagnostic Implications
Ajay Puri,Ayushi Sahay,Bharat Rekhi
- , 2019, DOI: 10.1177/1066896918790388

Abstract: A dedifferentiated adamantinoma is a rare subtype of an adamantinoma, associated with a relatively aggressive clinical course, with less than 10 such cases reported so far. A 25-year-old-male presented with pain in his right leg of 1-year duration. Imaging disclosed a well-defined lytic, destructive lesion in his proximal tibia with a cortical break and a soft tissue component. Microscopic examination of the biopsy and resected specimen showed nests and clusters of atypical epithelial cells, along with significant areas showing markedly pleomorphic and spindly sarcomatous cells with interspersed mitotic figures and areas of stromal hyalinization. By immunohistochemistry, the areas of epithelial differentiation showed intense positivity for cytokeratin and p63, whereas the sarcomatous areas showed reduced to absent immunostaining. A 51-year-old lady presented with a recurrent tumor in her right tibia, which was initially diagnosed as an adamantinoma, along with metastatic lesions in her lung. Microscopic examination of the recurrent and metastatic tumors showed areas of epithelial differentiation along with spindly sarcomatous cells, arranged in fascicles. By immunohistochemistry, the areas of epithelial differentiation showed positivity for pan cytokeratin. Additionally, p63 was diffusely positive. p53 showed diffuse and intense staining pattern in the sarcomatous component (dedifferentiation). While the first case is disease-free, the second case is on follow-up. The 2 cases of dedifferentiated adamantinoma further confirm the rare occurrence of this tumor in our population. Its correct diagnosis has treatment implications. Differential diagnoses and literature review of similar reported cases are also presented in this article

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Does Reconstruction with Reimplantation of Sterilized Tumor Bone Provide Survival Benefit in Diaphyseal Osteosarcoma?
Gulia, Ashish,Nayak, Prakash,Puri, Ajay
- , 2020, DOI: https://doi.org/10.1155/2020/4092790

Abstract: Does reimplantation of sterilized tumor bone for reconstruction provide outcome benefits in intercalary osteosarcoma based on the potential immunogenic effect of reimplanted sterilized tumor tissue? Of 720 cases of surgically treated high-grade osteosarcoma patients treated at our institute from 2006 to 2013, 61 had predominantly diaphyseal disease. All patients were nonmetastatic at presentation. Patient and tumor characteristics, treatment details, and local recurrence-free, metastasis-free, and overall survival were compared for 24 patients who had reconstruction with sterilized tumor bone reimplantation vs 37 who did not. Both the groups were well matched in terms of baseline characteristics. Means were compared with the t-test, proportions with the chi-square test, and survival with the log-rank test. The Kaplan‐Meier method was used to construct time to event curves. Cox proportional hazard regression modeling was employed for multivariate time to event analysis. Twenty-two had extracorporeal radiation and reimplantation (ECRT) with or without the vascularised fibula. Fifty-gray single dose was used in all cases. Two had pasteurization and reimplantation. Thirty seven had non-reimplantation reconstructions (including intercalary or osteoarticular endoprosthesis, pedicled bone grafts, rotation-plasty, and amputations). Five-year local recurrence-free survival was 85% for reimplantation and 97% for non-reimplantation groups ( ). Five-year metastasis-free survival was 63% and 54%, respectively ( ). Five-year overall survival was 70% and 58%, respectively ( ). The data from this study did not demonstrate significantly better local recurrence-free, distant relapse-free, or overall survival benefit in the tumor bone reimplantation group

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Should We Be Concerned? Comparison of Catheter and CT Angiogram for Arterial Distensibility at the Site of Carotid Stenosis during Catheter Angiography [PDF]
Aly Abayazeed, Juan Diego Lozano, Gabriela Santos-Nunez, Srinivasan Vendantham, Ajit Puri, Ajay Wakhloo, Deepak Takhtani
Open Journal of Medical Imaging (OJMI) , 2017, DOI: 10.4236/ojmi.2017.74022

Abstract: Purpose: During catheter angiogram (CA) there is momentary increase in intravascular volume and pressure due to intra-arterial injection that can potentially cause vascular distention at the stenotic site, whereas on CT angiogram (CTA) is unlikely due to intravenous administration. Methods: CA and CTA of the carotid artery from 29 patients were retrospectively studied. CA and CTA were obtained for each patient. Curved sagittal MPRs mirroring the carotid artery on CA were used to measure the diameter at stenosis and at the distal lumen. Mural plaque calcium content was graded on axial CTAs. Results: Accounting for repeated measurements, the likelihood that the lumen diameter from CA will be larger than CTA was higher at stenosis than distal to it but the difference in lumen diameters at stenosis was similar to CTA. There is insufficient evidence that intra-arterial hand-injection during CA leads to underestimation of the degree of stenosis. Percentage stenosis using the NASCET criteria differed between the 3 measurements, post hoc analysis showed significant difference between CA and axial CTA (p < 0.0001), but not between CA and curved sagittal CTA (p > 0.99). The difference in lumen diameter did not depend on our calcium grading (p = 0.484). Conclusions: There is insufficient evidence to suggest that intra-arterial hand-injection contributes to vessel distention and underestimation of percent stenosis during CA in this study. Mural plaque calcium does not affect the degree of stenosis on CTA.

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Extracorporeal irradiated tumor bone: A reconstruction option in diaphyseal Ewing′s sarcomas
Puri Ajay,Gulia Ashish,Agarwal M,Jambhekar N
Indian Journal of Orthopaedics , 2010,

Abstract: Background: Limb salvage in extremity tumors is now established as an oncologically safe option without compromising long-term survival. En bloc resection followed by extracorporeal radiation and reimplantation is a biological reconstruction option in diaphyseal Ewing′s sarcomas. We analyzed the results of 12 cases of diaphyseal Ewing′s sarcomas treated using this modality. Materials and Methods: Between March 2006 and March 2008, 12 patients with Ewing′s sarcoma underwent enbloc resection and reconstruction, with reimplantation of the sterilized tumor bone, after extracorporeal irradiation. There were eight males and four females, with a mean age of 14 years (range 2 to 22 years). The femur was the most common bone involved (n=8) followed by the tibia and the humerus (two cases each). All these patients were non-metastatic at presentation and received chemotherapy as per the existing hospital protocol. The mean length of the bone resected was 20 cm (range 11 to 25 cm). The specimen was irradiated with 50 Gy prior to reimplantation and stabilized with the host bone, using suitable internal fixation. Standard biplanar radiographs were assessed for evidence of union on the follow-up visits. The functional status was assessed using the Musculoskeletal Tumor Society Scoring system at the time of the last follow up. The mean follow up duration was 29 months (range 12 to 57 months). Results: Two patients (17%) had early infection with graft removal, hence are excluded from any analysis of union, however they are included when analysing complications such as infection. Rest 10 cases were analyzed for bony union at the osteotomy sites. Sixteen (84%) of the 19 osteotomy sites united primarily, without any intervention. Implant failure and non-union was seen at three diaphyseal osteotomy sites. The average time for union of all osteotomy sites was 7.2 months (range 3 to 13 months).The average time for union of the metaphyseal osteotomy sites was 5.9 months (range 3 to 12 months) and of diaphyseal osteotomy sites was 8.3 months (range 4 to 13 months). The mean Musculoskeletal Tumor Society Score was 27 (range 19 to 30) with a mean of 27. Nine of the ten patients with lower limb involvement were independent ambulators without additional aids. At the time of the last review, six patients were free of disease and six patients had died from the disease. There were two recurrences around the operative site. Both were associated with disseminated disease and in both the recurrences were in the soft tissue, away from the irradiated graft. Conclusion: Extracorporeal irrad

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