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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 39-43

Extracorporeal bone irradiation and reimplantation: Case report and cost–benefit evaluation


1 Department of Radiation Oncology, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India
2 Department of Surgical Oncology, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India
3 Department of Orthopedics, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India

Date of Submission07-Dec-2019
Date of Acceptance05-May-2020
Date of Web Publication08-Jul-2020

Correspondence Address:
Dr. Ashutosh Mukherji
Department of Radiation Oncology, Yashoda Super Speciality Hospital, Somajiguda, Hyderabad, Telangana,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jco.jco_24_19

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  Abstract 

Extracorporeal irradiation and reimplantation in bone tumors is the technique of surgical removal of the tumor-bearing segment of a bone, removing the tumor, and irradiating that segment of bone separated from the body to a very high dose, and then reimplanting it in its original location. This case report describes a 6-year-old boy with Ewing’s sarcoma post chemotherapy with tumor localized to left upper shaft femur, which was excised and which underwent extracorporeal irradiation. The authors have compared this technique to metallic implants with regard to cost and benefit to patient. The rates of graft failure and implant failure remain similar at 25%–30% at 2–5 years, although the graft does not have any host rejection issues as would the implant. Also, bigger series’ have shown a similar survival rate between the two techniques as well as better functional preservation compared to implants.

Keywords: Bone tumor, cost analysis, extracorporeal radiation, radiotherapy


How to cite this article:
Mukherji A, Puligolla H, Marda SS, Dachepalli S. Extracorporeal bone irradiation and reimplantation: Case report and cost–benefit evaluation. J Curr Oncol 2020;3:39-43

How to cite this URL:
Mukherji A, Puligolla H, Marda SS, Dachepalli S. Extracorporeal bone irradiation and reimplantation: Case report and cost–benefit evaluation. J Curr Oncol [serial online] 2020 [cited 2020 Aug 15];3:39-43. Available from: http://www.journalofcurrentoncology.org/text.asp?2020/3/1/39/289126




  Introduction Top


Management of malignant bone tumors has in the past centered on complete removal of the involved limb by amputation. In recent years, however, there has been a shift in focus toward limb salvage surgery and function preservation, and it is now a goal of therapy to limit resection with the use of multimodality protocols such as chemotherapy and radiotherapy; and in cases where it is not possible to preserve the bone, to plan for prostheses to maintain function. Extracorporeal irradiation and reimplantation (ECIR) in bone tumors refers to the technique of en bloc surgical removal of the tumor-bearing segment of a bone, removing the tumor from that segment of bone, irradiating that segment of bone now separated from the body to a very high dose, and then reimplanting that bone segment in its original location.[1]


  Case Report Top


A 6-year-old boy, diagnosed with Ewing’s sarcoma and having already received six cycles of chemotherapy with VAC regimen, presented to our hospital. Post-chemotherapy positron emission tomography–computed tomography (PET-CT) reported complete metabolic response. Magnetic resonance imaging (MRI) showed tumor mass, involving left femur upper one-third shaft and neck [Figure 1] and [Figure 2]. He was planned for limb salvage surgery, followed by ECIR. Surgery was performed on August 02, 2019, excision of tumor with bone was done and brought in vancomycin-soaked gauze to radiation oncology department [Figure 3] and [Figure 4]. Bone segment was delivered 50 Gy in single fraction with filter-free parallel opposed antero-posterior fields (AP-PA) fields [Figure 5] and sent back to operation theatre under aseptic precautions for reimplantation. Reimplantation was uneventful and wound closure was done [Figure 6]. Post-surgery period was uneventful, and post-op histopathology review showed complete pathologic response. The patient was then put on a Plaster of Paris hip spica cast for another 3 weeks till imaging showed new bone callus formation [Figure 7][Figure 8][Figure 9]. The cast was changed to a flexible hip spica, and the patient was discharged at 3½ weeks after CT scan showed complete sclerosis of the bone segment [Figure 10]. At follow-up after another 4 weeks, the patient had started limited weight bearing.
Figure 1: MRI of the left thigh showing tumor-bearing bone segment (T2-weighted images)

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Figure 2: MRI of the left thigh showing tumor-bearing bone segment (T1 images)

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Figure 3: Bone segment wrapped in vancomycin-soaked gauge and then sterile plastic being put in the sterile irradiation container

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Figure 4: Bone segment in the sterile irradiation container surrounded by sterile rice flour bags for dose equivalence

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Figure 5: Bone segment and surrounding rice flour bags mimicking body equivalent material as seen from a megavoltage cone beam CT scan in the linear accelerator

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Figure 6: Bone segment reimplanted and fixed

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Figure 7: X-ray of the bone post implantation and internal fixation

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Figure 8: CT scan of the bone post implantation and internal fixation

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Figure 9: Three-dimensional image of the CT scan showing bone with implanted segment and fixation screws

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Figure 10: Axial section of CT scan showing complete sclerosis of irradiated bone segment

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  Discussion Top


The use of endoprosthesis made of steel or titanium has allowed for increased limb-sparing surgeries. Patients are able to retain their limb functions after a gap of 5–7 months, recover rapidly, and bear weight early.[2] They are usually allowed partial weight bearing within 1–2 weeks and are then progressed to full weight bearing by 4–6 weeks to 3–4 months after their operation. Myers et al.,[2] in their review of 335 patients receiving endoprosthesis, reported that the risk of revision for any reason was 17% at 5 years, 33% at 10 years, and 58% at 20 years. This study also reported that the risk of subsequent amputation at 5 years was 10.7%. Other similar series have also reported risk of revision of the prosthesis at around 35% at 5 years. A number of studies have been published with survival rates of up to 87% at 3 years and 67%–88% at 5 years, but only 48%–65% at 10-year survival and very limited data at 20 years, with rates up to 53%.[3],[4]

Thus, on an average, one in every three patients is expected to have his or her implant revised, and an improved survival means that a large number of patients may require implant revision. This imposes a big burden on patients, especially in a country such as India, where private funding by the patient accounts for nearly 60% of health-care cost coverage. A prosthesis may cost more than US$10,000 or more than 500,000 rupees in India for foreign-made implants and more than 150,000 rupees for Indian-made implants. This imposes a cost on treatment, which many patients may not afford.[5] Even government-aided procurement can result in delays due to paperwork. This may impose a delay in the management of the patient. A prosthesis must be customized for best fitting, and if not done properly, it will have problems such as loosening and instability. Recently, there has been an increase in interest in using the patient’s own tumor-bearing bone for reconstruction to preserve the limb function. This technique is called “extracorporeal irradiation and reimplantation (ECIR)” and is a useful technique for limb salvage, when there is a reasonable residual bone stock left beyond tumor. This technique can result in good and lasting biological reconstruction, if there is an effective reattachment of tendons. ECIR can bring down the cost of treatment as the patient’s own bone is used as a prosthetic implant. This can also bring down the instances of implant rejection by the body, and can have comparable complication due to infection rates compared to artificial implants.

The authors would also like to discuss the results of three papers here from large volume institutions in India as well as inputs from discussions with the authors. A study was done at the Tata Memorial Centre at Mumbai, India, in which Puri et al.[6] reported on the results of ECIR in 12 patients with Ewing’s sarcoma who had undergone en bloc resection and reconstruction between March 2006 and March 2008. The femur was the most common bone involved, and the mean length of bone resected was 20 cm (range, 11–25 cm). ECIR dose given was 50 Gy in single fraction, and after reimplantation and internal fixation, functional status was assessed using the Musculoskeletal Tumor Society Scoring (MSTSS) system. The mean follow-up duration was 29 months (range, 12–57 months). In this study, implant failure was noted in 3 of 12 patients (25%), whereas the mean time taken for union was 7.2 months (5.9 months for metaphyseal osteotomy sites and 8.3 months for diaphyseal sites).[6] Mean follow-up of patients was 27 months, and of the initial 12, six patients died of tumor recurrence/metastases. But none of the recurrences were in the irradiated reimplanted bone. Nine of ten patients with lower limb involvement retained ambulation and movement without any aid.

Another similar study was conducted at the All India Institute of Medical Sciences (AIIMS), Delhi, India, from 2009 to 2010, and involved 14 patients. The authors Sharma et al.[1] used a similar dose of 50 Gy single fraction to the bone fragment, and then this irradiated segment was reimplanted. Of the 14 patients (nine with osteosarcoma and five with Ewing’s sarcoma) studied, 13 had disease in the long bones of the lower limb, that is, femur (8) and tibia (5). The median follow-up was 22 months, the local control rate was 79%, and the 2-year local relapse-free survival (LRFS) was 73%. Two patients had local wound infection, of whom one responded to antibiotic treatment without need for surgical intervention, whereas the second required wound debridement.[1] This study also quoted another contemporary study by Poffyn et al.,[7] wherein 107 patients were treated by ECIR to a dose of 300 Gy. At 5-year follow-up, there was no local relapse (LR), but only 64% of patients had well-healed graft. The 0% LR rate could be because of the high-dose radiation used in their study.[7] ECIR had the advantage of not provoking a graft–host response unlike in artificial prosthesis.

Another study from the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) in Pondicherry in south India, reported on local control, complications, and functional outcome of 49 cases of primary malignant bone tumors treated with ECIR.[5] This study was conducted from 2007 to 2015, and the median duration of follow-up was 24 months (range, 4–108 months). Femur and tibia were the most common tumor locations. Osteosarcoma was the most common histology (74%). The local control rate achieved was 94%, and the 8-year local recurrence-free survival and distant metastasis-free survival were 89% and 84%, respectively. Recurrences were seen in 10 patients, of whom only two had local recurrence and one more had both local and distant recurrence. An overall complication rate of 20% was observed, with wound infections being the most common (46%). Of 49 patients, 40 had reported a good range of movements. This study and those by Poffyn et al.[7] and by Davidson et al.[8] are the largest published series involving the use of ECIR. The series by Davidson et al.[8] also had 50 patients, wherein a dose of 50 Gy was used in single fraction, and of which four recurrences at a mean follow-up of 38 months were reported.

The corresponding author (AM) also had the opportunity to discuss with the authors of two of the major Indian publications on a cost–benefit analysis of ECIR vis-à-vis use of external prosthesis. The average time in which a patient starts bearing weight on his operated limb varies from 3–8 months in case of prosthesis but is not much more in case of ECIR, varying from 4 to 14 months, depending on the length of segment reimplanted. A discussion with operating surgeons suggested that the fitting with these prostheses was on many occasions not very good, and this affected the functionality of these prostheses. These prostheses cannot be compared to hip or knee joint replacement prostheses and are much more basic. Also, their average life span is 5–6 years, which may mean that more than half of the patients who survive 5 years or beyond may require a revision, which would then add up to the cost. The main factors determining the degree of function retained after ECIR are the amount of normal bone left beyond the irradiated segment as well as the involvement of the cartilage. If the cartilage or the joint capsule is involved by disease then post ECIR, there is the expected near-complete or complete calcification of the cartilage, which will impact joint functionality. A dose of 50 Gy in single fraction was found to be sufficient in all three studies[1],[5],[6] and the study by Davidson et al.[8]. This dose helped achieve complete bone sterilization and at the same did not increase the bone brittleness post-irradiation which can occur with use of higher doses. Dose of 50 Gy in single fraction has bone intracorporeal EQD2 of 250 2 Gy Equivalent Dose, whereas the dose in a study by Poffyn et al.[7] was 300 Gy in single fraction (>600 Gy2 EQD2), which increased the brittleness of the irradiated bone. Finally in a well-selected patient, an ECIR will score over external prosthesis as the tendons and ligaments can be reattached to the implanted bone segment and can provide better limb mobility and functionality compared to an external prosthesis, which is attached to the bone only with no scope for use of the tendons or ligaments and limited use of mobile parts of the prosthesis.


  Conclusion Top


Extra corporeal irradiation and reimplantation is a convenient and affordable alternative to prosthesis, as affordability is a matter of concern in developing countries. The decision whether or not an ECIR is possible in a particular patient will depend on factors such as tumor location and extent of spread, amount of remaining bone left uninvolved to provide support for internal fixation, and surgeon’s proficiency in reimplantation.

Declaration of Patient Consent

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

Acknowledgements

We would like to thank the following for their valuable inputs on ECIR based on their practice experience:

  1. Dr. K. Gunaseelan, Additional Professor and Head of Department, Department of Radiation Oncology, Regional Cancer Centre, JIPMER, Puducherry


  2. Dr. Deep Sharma, Additional Professor and Head of Department, Department of Orthopedics, JIPMER, Puducherry


  3. Dr. D. N. Sharma, Professor and Head of Department, Department of Radiation Oncology, Regional Cancer Centre, AIIMS, New Delhi


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
[PUBMED]  [Full text]  
2.
Myers GJC, Abudu AT, Carter SR, Tillman RM, Grimer RJ. Endoprosthetic replacement of the distal femur for bone tumours, long-term results. J Bone Joint Surg [Br] 2007;89-B:521-6.  Back to cited text no. 2
    
3.
Kawai A, Muschler GF, Lane JM, Otis JC, Healey JH. Prosthetic knee replacement after resection of a malignant tumour of the distal part of the femur: Medium to long term results. J Bone Joint Surg [Am] 1998;80-A:636-47.  Back to cited text no. 3
    
4.
Gundavda MK, Agarwal MG. Growing without pain: The noninvasive expandable prosthesis is boon for children with bone cancer, as well as their surgeons! Indian J Orthop 2019;53:174-82.  Back to cited text no. 4
    
5.
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. 5
    
6.
Puri A, Gulia A, Agarwal M, Jambhekar N, Laskar S. Extracorporeal irradiated tumor bone: A reconstruction option in diaphyseal Ewing’s sarcomas. Indian J Orthop 2010;44:390-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Poffyn B, Sys G, Mulliez A, Van Maele G, Van Hoorebeke L, Forsyth R, et al. Extracorporeally irradiated autografts for the treatment of bone tumours: Tips and tricks. Int Orthop 2011;35:889-95.  Back to cited text no. 7
    
8.
Davidson AW, Hong A, McCarthy SW, Stalley PD. En-bloc resection, extracorporeal irradiation, and re-implantation in limb salvage for bony malignancies. J Bone Joint Surg Br 2005;87:851-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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