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Ultrasound is also sarcomas varies and can range from usually ill-defined discount 15mg slimex with visa weight loss xantrex, suitable for the initial scanning for metastases in the cloud-like areas of condensation to highly sclerosed generic slimex 10mg with mastercard weight loss after gallbladder surgery, abdomen. In fibrous dysplasia the CT scan formation of irregular metaplastic fibrous bone is ac- Despite the popularity of the MRI scan and its outstand- companied by collagen fiber production. Characteristi- ing discriminatory power, particularly for soft tissues, cally, the mineralization in such cases leads to a relatively computed tomography has not lost any of its importance. Such calcifications may have a stippled or by recording transverse slices. If enchondral ossification occurs at (particularly in establishing whether the tumor has pen- the periphery of cartilaginous tumors, which often ap- etrated into the joint or not), the inability to record sagit- pear to have a lobular structure on histological examina- tal and frontal slices is a drawback. Computer-assisted tion, then this non-tumorous bone calcifies, producing reconstruction in one of these planes is only helpful if the radiologically visible ring- or arc-shaped condensation resolution (which depends on the slice thickness) is good 591 4 4. In appropriate cases, targeted thin-slice CT scans Angiogram are indicated. Although the (non-invasive) MRI is very good for show- ing the relationship between the tumor and the major! The CT scan is particularly suitable for the evalua- vessels, an angiogram is occasionally indicated since it tion of the intraosseous spread of the tumor in can- is better at showing the course of the vessels and the le- cellous bone and is indicated for all tumors near a sion-related topography of the vessels. Angiography is joint that must be removed surgically (particularly indicated particularly in cases of vessel bridging or preop- outside the lesion). Vascular imaging can be performed tional x-rays or MRIs in the search for metastases in conventionally, as MR angiography (digital subtraction the lung. If abdominal metastases are suspected on angiography; DSA) or, for outstanding quality images, as the basis of the sonogram, a spiral CT with contrast spiral CT ( Chapter 2. The best information about the existence and local- ization of metastases is obtained with the combina- 4. The data from the two examina- clearly diagnosed on the basis of imaging investigations tions are digitally combined to produce an exact or if malignancy is suspected. Magnetic resonance imaging has greatly improved the diagnostic options for evaluating bone tumors. The main The fine needle biopsy only allows a tiny cylinder to advantages compared to the CT scan are as follows: be removed, which is not sufficient for confirming the ▬ better tissue characterization: better evaluation of the diagnosis of an unclear tumor, which often shows a het- tumor matrix, erogeneous structure. For bone tumors, CT-guided fine ▬ clearer definition of the tumor in the soft tissues and needle biopsy is recommended only in very experienced bone marrow, centers [10, 13]. All too often the material is unusable, or ▬ any spatial slicing possible (sagittal, horizontal and conditions are misdiagnosed. It is also important to mark the entry The tissue characterization is achieved primarily by the site so that the contaminated biopsy channel can subse- differing weighting of the MRI images. A standard trephine (or core niques such as fat suppression and the effect of contrast trephine) used for removing broken screws is not suit- medium. In view of its superior performance in tissue tion, the biopsy material is thermally damaged as a result differentiation, the ability to evaluate the spread of the build-up of heat, rendering it almost impossible of tumors in the soft tissues and bone marrow and to evaluate. More appropriate instruments are special their relationship with the major nerves and ves- trephines that transport the bone fragments outwards sels, an MRI scan is essential nowadays before the and that incorporate a special device for ejecting the surgical resection of any malignant bone and soft cylinder. On Because it is not possible to identify a benign lesion the other hand, a good result can usually be achieved solely on the basis of the history, clinical findings when such a trephine is used in cancellous bone. In and a conventional x-ray or sonogram, this certainly most cases, however, an open biopsy is indicated. Ex- does not mean that an expensive MRI scan is al- amination of a frozen section may reveal whether rep- ways indicated, particularly since it may not reveal resentative lesional tissue was biopsied, rather than the the diagnosis in any case. But in any more appropriate to send the patient, or at least case, frozen sections should only be evaluated by a pa- the images, to a colleague with more experience in thologist with considerable experience in bone tumor the diagnosis and treatment of bone tumors. Vessels and nerves are not contaminated by the provide the pathologist at least with general x-rays in biopsy. These tend to be located at the pe- knowledge of the x-ray findings may amount to mal- riphery of the tumor, where the most aggressive areas of practice, especially when cartilaginous tumors are being osteolysis are visible on the x-ray. Since bone tumors are usually mineralized, a should never be used to expose the bone.

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The soft tissue covering occasionally represents a We have not had much experience with the combination critical problem buy slimex 10mg on-line weight loss guide, hence the frequent use of gastrocne- of a homogenous osteocartilaginous graft (allograft) 3 b ⊡ Fig buy slimex 10mg cheap weight loss help for women. AP and lateral x-rays (a top row) and frontal and sagittal MRI scans (a bottom row) of the right knee of a 17-year old girl with a chondrosarcoma of the distal femur in the area of the medial femoral condyle. AP and lateral x-rays (a) of a 14-year old girl with an osteosarcoma in the metaphyseal/diaphyseal area of the proximal tibia. Such combinations are usual and is occasionally required if the use of a prosthesis is not useful at the proximal femur, but less so in the knee possible. The literature only offers a few reports on such Another alternative in children under 10 years of age combinations. There are only isolated reports on is the extendable prosthesis [10, 11, 13]. Some centers the procedure involving removal of the tumor with the now have over 20 years’ experience with such prostheses. An arthrodesis triggered by forced knee flexion, thereby minimizing the a b c ⊡ Fig. Bottom row (d, e): Situation 1 year after resection and insertion of a tumor prosthesis with 2 rotating axes (»rotating hinge«) and partial preservation of the tibial tuberosity and thus the d e extensor apparatus 360 3. Nevertheless, the prob- tiple enchondromatosis (Ollier’s disease): an autopsy-based mo- lecular genetic study. Hum Pathol 31: p1299–303 lems associated with this method should not be ignored. A Since the bone grows not only in length but also in width, new clinical entity. Ital J Orthop Traumatol 2: 221–38 the anchorage of the prosthesis deteriorates with advanc- 6. The lengthening also means a loss of power, M (1994) Modular uncemented prosthetic reconstruction after and the epiphyseal plate on the other, unaffected and resection of tumours of the distal femur. J Bone Joint Surg (Br) 76: 178–86 healthy side of the knee (where the prosthesis must also be 3 7. Carey RPL (1983) Synovial chondromatosis of the knee in child- anchored) shows reduced growth. J Bone Joint Surg (Br) 65: 444–7 tion is relatively high because of the size of the prosthesis 8. Chew D, Menelaus M, Richardson M (1998) Ollier’s disease: varus and the necessary number of operations. Clohisy DR, Mankin HJ (1994) Osteoarticular allografts for re- construction after resection of a musculoskeletal tumor in the Popliteal cysts almost never require treatment as they proximal end of the tibia. Cool W, Carter S, Grimer R, Tillman R, Walker P (1997) Growth occur after resections and can be avoided only if a part of after extendible endoprosthetic replacement of the distal femur. Resection only needs to be considered if the popliteal Growth prediction in extendable tumor prostheses in children. Clin Orthop 390: 212–20 In patients with synovial chondromatosis the cartilage 12. Donati D, Di Liddo M, Zavatta M, Manfrini M, Bacci G, Picci P, Ca- fragments must be carefully removed from the joint. A panna R, Mercuri M (2000) Massive bone allograft reconstruction complete synovectomy (from the ventral and dorsal sides) in high-grade osteosarcoma. Eckardt JJ, Safran MR, Eilber FR, Rosen G, Kabo JM (1993) Ex- is required in cases of pigmented villonodular synovitis. Clin Orthop 297: this method, a chemical synovectomy with osmic acid or 188–202 radiocolloids may be required, although this treatment 14. Gebhardt MC, Ready JE, Mankin HJ (1990) Tumors about the knee can be administered only after the patient has stopped in children. Gitelis S, Mallin BA, Piasecki P, Turner F (1993) Intralesional exci- growing (for further details see chapter 4. Clin The survival rate after the treatment of malignant bone Orthop 270: 29–39 tumors in the knee area in children and adolescents has 17. J Bone Joint Surg (Am) 73: 1365 the five-year survival rate for both osteosarcoma and 18. Hasbini A, Lartigau E, Le Pechoux C, Acharki A, Vanel D, Genin J, Ewing sarcoma was below 15% in the 1970’s, a survival Le Cesne A (1998) Les chondrosarcomes sur maladie d’Ollier.

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