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Two Cases Illustrate the Diversity of Musculoskeletal Tumor Surgery

Felesfa Wodajo, MD, is Medical Director of the Musculoskeletal Oncology Program at Virginia Hospital Center. He is a graduate of Princeton University and University of California, San Francisco School of Medicine. He was awarded Outstanding Chief Resident at Howard University and completed a fellowship in orthopedic oncology at Washington Hospital Center. He wrote a textbook on bone and soft tissue tumors, Visual Guide to Musculoskeletal Tumors, and leads a highly regarded annual oncology review course for regional orthopedic residents.

As an orthopedic oncologist, Felasfa Wodajo, MD, sees a broad range of musculoskeletal tumors. Sarcomas, however, are rare—less than 1 percent of diagnosed cancers. Even osteosarcoma, the most common bone sarcoma, affects an estimated 1 to 1.5 persons per million.

Despite this infrequency, sarcomas can be confused with many abnormalities seen on MRIs. Thus, “careful review of imaging studies is critical to this subspecialty,” Dr. Wodajo said. In order to differentiate between benign and malignant conditions, musculoskeletal tumor surgeons are familiar with a wide spectrum of bone and soft tissue tumors, as illustrated by these two cases.

Case 1: Large, slow-growing osteosarcoma, located in the tibia

A 26-year-old male was referred with a mildly symptomatic bulge on his tibia. After review of the imaging and biopsy, Dr. Wodajo diagnosed a surface (parosteal) osteosarcoma, a slow-growing variant with low risk of metastasis. The large (12 cm) growth engulfed much of the proximal portion of the tibia but did not involve the joint surface. This allowed Dr. Wodajo to bisect the tibia lengthwise and remove the tumor, sparing most of the muscle and tendon attachments. For reconstruction, a matched size cadaveric tibia was procured. It was painstakingly fashioned into an equivalent shape as the defect, then attached with a large metal plate and screws. “The tumor was resectable while saving most of the tibia, albeit with some technical work,” he said. “Eighteen months out, the patient has normal function, no pain, and almost zero risk of recurrence.”

Case 2: Synovial hemangioma, pain for a decade

A 34-year-old female had knee pain for more than a decade. An athlete, she had gone to multiple specialists, undergoing imaging studies and surgical procedures without relief. At her initial visit, Dr. Wodajo reviewed her MRI studies and noticed a small (11mm), intra-articular lesion consistent with a synovial hemangioma persistent over several years and almost certainly the cause of pain. He noted that venous malformations, often called hemangiomas, are most frequently found in skin, but can be found in the organs or brain. Symptomatic lesions in muscle are often treated nonsurgically by interventional radiologists; in this case, he excised the small lesion in the joint lining of the knee surgically, leaving the patient pain-free for the first time in years.

New Advances

Cyberknife radiotherapy allowing treatment with less morbidity, evolutions in implants especially for pediatric patients (see Box), and computer-aided navigation for surgery are among new techniques in the field.

—Felesfa Wodajo, MD

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New Implant Technologies for Children

Incorporating metal prostheses into the bone is particularly challenging when treating children, noted Dr. Wodajo. New implant designs now allow for the expansion of the prosthesis without additional surgery. Using a Repiphysis ™ endoprosthesis, the length of the leg is periodically lengthened by applying an electromagnetic force around the knee. The limb is lengthened more frequently, and the child avoids the multiple, painful surgical procedures of the past.

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