Bone Infarct Associated Osteosarcoma: Epidemiologic and Survival Trends

Background Bone tumors are not a frequent occurrence and bone-infarct-associated sarcomas are even rarer. The prognosis of this disease is poor and its treatment remains a challenge. Nevertheless, hardly any analyses in literature report on secondary osteosarcoma (SO) on bone infarct and most of the data available do not provide sufficient details. We evaluated whether this condition could be further characterized and if prognosis could be influenced by the chemotherapy treatment. In particular, we sought to determine (1) the main features of this rare disease; (2) the overall survival (OS) rate; (3) the OS rate associated to chemotherapy treatment; (4) the correspondence between our results and published data in terms of survival. Methods We retrospectively reviewed patients admitted at Rizzoli Orthopedic Institute of Bologna between 1992 and 2018 (1465 total cases of osteosarcoma). We identified a list of 11 cases of SO on bone infarct (cohort 1). We conferred about the epidemiology, surgical and chemotherapy (ChT) treatment and surveillance of infarct-associated osteosarcoma showing the correlation to data present in literature, corresponding to 15 case reports published within 1962-2018 (cohort 2). Results (1) cohort 1 was made of 11 patients: six females and five males, median age was 55 years. Nine (81%) were grade 4, two (19%) grade 3. Tumor predominantly arise on distal femur (64%). Most of patients had localized osteosarcoma at the diagnosis (81%); resection surgery was the elective treatment (73%) followed by amputation (18%). Of 11 patients, seven received also ChT (64%). (2) Five-years OS was 62% (95% CI: 28-84). Median OS was 74 months (95% CI: 12-not reached). The cumulative incidence of cancer-related deaths (CICRD) was 37.7% (95% CI: 11.4-64.5) at 120 months. (3) In the group treated with only surgery OS was 50% at 5 years. For patients treated with any form of ChT, OS was 71% at 5 years (p=0.4773) and hazard ratio (HR) 0.56. The CICRD was 29% (at 2 years of follow-up. Instead, it was of 50% for patients treated only with surgery. (4) Median survival was 74 months and 19 months for cohort 1 and cohort 2 respectively (p=0.09). Data analysis showed a decreased HR for cohort 1 compared to cohort 2 (HR 0.378). Results confirmed also stratifying for age and ChT administration (HR 0.355). Conclusions Based on this work, our opinion is that the choice to undergo the patients to ChT combined to surgery could improve their prognosis.

Bone infarct (osteonecrosis) as late side effect of steroid in acute lymphoblastic leukemia survivor

Survivors of acute lymphoblastic leukemia (ALL), though cured of their primary disease may suffer from long-term complications such as bone infarction contributing to a major morbidity. Here, we report a very rare case of bone infarct in bilateral tibia and femur of a patient of acute lymphoblastic leukemia, post completion of maintenance chemotherapy. With this case report, we suggest that appropriate preventive measures are necessary to decrease the risk of this very rare morbidity.

Bone Infarct as an Indicator of Acute Spinal Ischaemia

Acute spinal cord infarct in childhood is extremely rare, generally secondary to spinal/cardiovascular surgery or severe vertebral injuries. However, spontaneous spinal cord infarct cases have been described. We present a clinical case of a teenager who developed an acute weakness and paraesthesia in lower limbs after playing piggyback. Laboratory tests and MRI (magnetic resonance imaging) were normal. During her hospital admission, her motor strength improved. After 10 days, MRI was repeated, and a bone infarct was observed. She was medicated with acetylsalicylic acid, and she completed a rehabilitation program.

P.095 Holey Spinal Cord - A case of spinal cord stroke secondary to fibrocartilaginous embolism

Background: Fibrocartilaginous embolism (FCE) is a rare reported cause of spinal cord infarction and likely underdiagnosed due to clinical unfamiliarity. FCE can present after a mild trauma and is characterized by back or neck pain along and a rapidly progressive myelopathy. We present a case of FCE and discuss how this clinical entity can break the typical rules of stroke. Methods: Case presentation Results: An otherwise healthy, 56-year-old professional sports coach presented a couple day history of progressive leg paresthesias and mild back pain, followed by unsteady gait and then inability to void. The left leg demonstrated mild weakness, hyperreflexivity, ataxia and an upgoing plantar response. The right leg became spastic and he then developed bilateral impairment of vibration and proprioception at the toes. An initial limited MRI lumbar spine was negative. A repeat MRI spine showed mild diffusion restriction of T10-11 and T11-12 and evidence of a bone infarct L2. He was diagnosed with a spinal cord infarct secondary to FCE. Conclusions: FCE should be considered in the differential for acute myelopathy. It can present with a progressive nature like transverse myelitis and MRI may be non-diagnostic. As more cases are being reported, FCE is becoming better defined and recognized.