Biomedical subjects

Michael D Neel

Publications and source records attributed to Michael D Neel.

At least 19 recordsLinked to original sources

PubMed2007

Assessing functional mobility in survivors of lower-extremity sarcoma: reliability and validity of a new assessment tool.

BACKGROUND: Reliability and validity of a new tool, Functional Mobility Assessment (FMA), were examined in patients with lower-extremity sarcoma. FMA requires the patients to physically perform the functional mobility measures, unlike patient self-report or clinician administered measures. PROCEDURE: A sample of 114 subjects participated, 20 healthy volunteers and 94 patients with lower-extremity sarcoma after amputation, limb-sparing, or rotationplasty surgery. Reliability of the FMA was examined by three raters testing 20 healthy volunteers and 23 subjects with lower-extremity sarcoma. Concurrent validity was examined using data from 94 subjects with lower-extremity sarcoma who completed the FMA, Musculoskeletal Tumor Society (MSTS), Short-Form 36 (SF-36v2), and Toronto Extremity Salvage Scale (TESS) scores. Construct validity was measured by the ability of the FMA to discriminate between subjects with and without functional mobility deficits. RESULTS: FMA demonstrated excellent reliability (ICC [2,1] >or=0.97). Moderate correlations were found between FMA and SF-36v2 (r = 0.60, P < 0.01), FMA and MSTS (r = 0.68, P < 0.01), and FMA and TESS (r = 0.62, P < 0.01). The patients with lower-extremity sarcoma scored lower on the FMA as compared to healthy controls (P < 0.01). CONCLUSION: The FMA is a reliable and valid functional outcome measure for patients with lower-extremity sarcoma. This study supports the ability of the FMA to discriminate between patients with varying functional abilities and supports the need to include measures of objective functional mobility in examination of patients with lower-extremity sarcoma.

Amputation, Surgical↗

PubMed2007

A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma.

BACKGROUND: Comparison of functional mobility and quality of life is performed in patients with lower-extremity bone sarcoma following either amputation, limb-sparing surgery, or rotationplasty with four different types of outcome measures: (1) an objective functional mobility measure that requires patients to physically perform specific tasks, functional mobility assessment (FMA); (2) a clinician administered tool, Musculoskeletal Tumor Society Scale (MSTS); (3) a patient questionnaire, Toronto Extremity Salvage Scale (TESS); and (4) a health-related quality of life (HRQL) measure, Short Form-36 version 2 (SF-36v.2). PROCEDURE: This is a prospective multi-site study including 91 patients with lower-extremity bone sarcoma following amputation, limb-sparing surgery, or rotationplasty. One of three physical therapists administered the quality of life measure (SF-36v.2) as well as a battery of functional measures (FMA, MSTS, and TESS). RESULTS: Differences between patients who had amputation, limb-sparing surgery, or rotationplasty were consistently demonstrated by the FMA. Patients with limb sparing femur surgery performed better than those patients with an above the knee amputation but similarly to a small number of rotationplasty patients. Several of the more conventional self-report measures were shown to not have the discriminative capabilities of the FMA in these cohorts. CONCLUSION: In adolescents with lower-extremity bone sarcoma, it may be advantageous to consider the use of a combination of outcome measures, including the FMA, for objective functional mobility assessment along with the TESS for a subjective measure of disability and the SF-36v.2 for a quality-of-life measure.

Adolescent↗

PubMed2006

Metastatic osteosarcoma.

BACKGROUND: The outcome of patients with metastatic osteosarcoma treated in two consecutive trials from 1986 to 1997 was analyzed to evaluate the efficacy of carboplatin-based multiagent chemotherapy and to identify prognostic factors. The initial study (OS-86) used ifosfamide, cisplatin, doxorubicin, and high-dose methotrexate, and the subsequent study (OS-91) used the same agents at similar doses, but carboplatin was substituted for cisplatin. METHODS: Twelve patients (median age, 15.1 yrs) were treated in OS-86 for osteosarcoma metastatic to the lung only (11 patients) or bone only (1 patient), and 17 patients (median age, 15.1 yrs) were treated in OS-91 for osteosarcoma metastatic to the lung only (12 patients), bone only (2 patients), lung and bone (2 patients), or other site (1 patient). RESULTS: Patients with metastatic disease enrolled in OS-86 and those with metastatic disease enrolled in OS-91 did not differ in terms of demographic features, histologic subtype, site of primary tumor, or site of metastases. There was a difference in survival according to treatment protocol (P = 0.054). All survivors (four of whom were enrolled in OS-86 and one of whom was enrolled in OS-91) had lung metastases only. Five-year survival estimates for patients with lung metastases only were 45.5 +/- 13.7% (OS-86) and 8.3 +/- 5.6% (OS-91) (P = 0.084). Unilateral lung metastases (P = 0.006), no more than three lung nodules (P = 0.014), and surgical remission (P = 0.001) were associated with improved survival probability. CONCLUSIONS: The poor outcome of patients with metastatic osteosarcoma treated in OS-91 justifies the use of cisplatin with its associated toxicity in patients with high-risk disease.

Adolescent↗

PubMed2006

Pediatric surface osteosarcoma: clinical, pathologic, and radiologic features.

BACKGROUND: Osteosarcoma (OS) arising from the surface of bone is far less common than its intramedullary counterpart. Although surface OSs share some radiographic and clinical features, they can be divided into three distinct histologic subtypes. PROCEDURE: We reviewed the clinical, radiographic, and pathologic features of 14 cases of pediatric surface OS treated at St. Jude Children's Research Hospital between 1970 and 2003. RESULTS: Seven patients had parosteal, five had periosteal, and two had high-grade surface OS. The median age at diagnosis was 16.2 years (range, 13.6-18.5 years). Nine patients were male; 11 were Caucasian. None had metastatic disease at diagnosis. Primary tumor sites included distal femur (n = 6), mid to proximal femur (n = 4), and mid to proximal tibia (n = 4). All 14 patients were treated with surgery, and 7 (1 with parosteal, 4 with periosteal, 2 with high-grade tumors) received chemotherapy. One patient experienced pulmonary metastasis of periosteal OS 16 months and 43 months after diagnosis; long-term disease-free survival followed resection of the metastatic tumors. Twelve patients remained alive and disease-free a median of 10 years (range, 1.5-25.4 years) after diagnosis. One patient died of high-grade surface OS 1.8 years after diagnosis, and one patient with periosteal OS died of gastric cancer 18.2 years after diagnosis of OS. CONCLUSIONS: The histologic grade predicts the clinical behavior of pediatric surface OS. Complete resection is the treatment of choice regardless of tumor subtype. Whereas chemotherapy is not indicated for parosteal OS, its role in periosteal OS remains controversial.

Adolescent↗

PubMed2006

Relationships among range of motion, functional mobility, and quality of life in children and adolescents after limb-sparing surgery for lower-extremity sarcoma.

PURPOSE: The study was designed to examine relationships between range of motion (ROM), functional mobility, and quality of life (QL) in patients with lower-extremity sarcoma (LES) after limb-sparing surgery METHODS: Sixty-eight patients with LES (age, 10-26 years) participated. The patients performed hip flexion, hip extension, knee flexion, and knee extension, Timed Up and Down Stairs (TUDS), Timed Up and Go (TUG), nine-minute run-walk (9-min), and completed the QL measure, Short-Form-36 version two (SF-36v2). RESULTS: Significant correlations (p < 0.01) were found between hip extension and SF-36v2 physical component scale (PCS; r = 0.33), TUDS (r = -0.32), TUG (r = -0.33); hip flexion and TUDS (r = -0.31), TUG (r = -0.39), 9-min (r = 0.44); knee flexion and TUDS (r = -0.52), TUG (r = -0.40), 9-min (r = 0.37); SF-36v2 PCS and TUDS (r = -0.56), TUG (r = -0.51), 9-min (r = 0.60). CONCLUSION: ROM correlates with functional mobility and QL in patients with LES after limb-sparing surgery. ROM exercises are important component of a physical therapy program for children and adolescents with LES.

Adolescent↗

PubMed2006

Reconstruction of noncontained distal femoral defects with polymethylmethacrylate and crossed-screw augmentation: a biomechanical study.

BACKGROUND: Curettage and cementation with polymethylmethacrylate are frequently used in the treatment of aggressive benign bone lesions such as giant-cell tumors, but strength and stiffness of the reconstructed bone have been concerns. This biomechanical study was undertaken to determine whether augmenting the cement with crossed screws would result in a stronger reconstruction. METHODS: Large noncontained defects were created in the medial femoral condyles of twenty matched pairs of human cadavera. Four groups were organized to compare three types of reconstruction: (1) polymethylmethacrylate alone, (2) polymethylmethacrylate and intramedullary Steinmann pins, and (3) polymethylmethacrylate with crossed screws engaging the opposite cortex. The specimens were subjected to 2000 compressive cycles and were subsequently monotonically loaded to failure under a controlled displacement rate. Failure load and stiffness were determined for each femur that survived the cycling process. RESULTS: Femora reconstructed with crossed screws and cement failed at higher loads and had greater stiffness than those reconstructed with cement alone (p = 0.025 and p = 0.0007) or cement augmented with intramedullary Steinmann pins (p = 0.019). Failure of femora reconstructed with cement and crossed screws occurred through an extra-articular transverse fracture, while failure in those with cement alone and cement with Steinmann pins occurred through an intra-articular (intercondylar) fracture. CONCLUSIONS: In this in vitro cadaver study, augmentation of polymethylmethacrylate cement with crossed screws resulted in a stronger reconstruction of distal femoral tumor defects than that obtained with cement alone or with cement and intramedullary Steinmann pins.

Aged↗

PubMed2006

MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 2, clinical and imaging patterns.

OBJECTIVE: This aim of this study was to explore the relationship between MRI findings and clinical symptoms of knee osteonecrosis in children and to determine the significance of this relationship. Such information is important for early diagnosis of this frequent complication and for choosing an appropriate treatment strategy. MATERIALS AND METHODS: Osteonecrotic lesion size and location were determined in a retrospective analysis of MR images of the knee obtained in our institution during the past 10 years. Association between MRI findings and clinical symptoms expressed by the knee scores was tested for a subgroup of our patient population who had clinical evaluation of the knees in the orthopedic clinic within 6 weeks of their MRI studies. RESULTS: In 80% of patients, osteonecrosis was bilateral. Lesions were distributed as follows: femur and tibia, 66% of the knees; femur alone, 26%; and tibia alone, 8%. Clinical symptoms of knee osteonecrosis were associated with lesions involving the articular surface of the distal femur, large lesions, and involvement of any part of the tibia. MR images showed milder osteonecrosis in patients who were less than 10 years old at the time of primary diagnosis. CONCLUSION: Osteonecrosis affecting the knees of children treated for leukemia and lymphoma is mostly asymptomatic. Children who are 10 years old or older have signs of more advanced osteonecrosis. Clinical symptoms often lag MRI presentation and may develop late in the course of the disease. Routine MRI evaluation is recommended for timely diagnosis of treatment-induced osteonecrosis.

Adolescent↗

PubMed2006

MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 1, observer agreement.

OBJECTIVE: The aim of this study was to determine whether a new MRI-based staging system for osteonecrosis of the knee in pediatric patients could be used with an acceptable level of intra- and interobserver agreement. MATERIALS AND METHODS: We conducted a retrospective analysis of MRI studies of the knee performed in a single institution between April 1994 and July 2003. Knee osteonecrosis was identified in 168 children with a primary diagnosis of hematologic malignancy. This substantial number prompted us to design a staging system for use with pediatric patients. To assess interobserver reliability of two primary observers in using the system, they reviewed and interpreted the same 36 imaging studies of randomly chosen patients. For the assessment of intraobserver reproducibility, each observer rereviewed 16 studies. A senior observer coded potential causes of disagreement between the primary observers. RESULTS: Interobserver agreement was substantial: the kappa value was 0.66 (95% confidence interval [CI], 0.58-0.75) in locations where the observers had to record only the presence or absence of a lesion, and the weighted kappa value was 0.65 (95% CI, 0.59-0.72) in locations where they had to classify the extent of involvement. The presence of marrow edema, punctate foci of altered signal, and mottled marrow changes was associated with a higher level of disagreement between the primary observers. CONCLUSION: Our proposed classification system, developed specifically for use with MRI, was used with substantial intra- and interobserver agreement. We think its use can contribute to a standardized approach to the interpretation of MRI findings in pediatric osteonecrosis of the knee.

Adolescent↗

PubMed2006

Osteosarcoma among children aged 5 years or younger: the St. Jude Children's Research Hospital experience.

Osteosarcoma primarily affects adolescents. The authors reviewed the records of eight patients aged 5 years or younger (of 470 patients with osteosarcoma) treated at their institution. Tumors (seven of high grade and one of low grade) arose mostly in the appendicular skeleton; one patient had metastases. One patient with low-grade osteosarcoma survived after surgery alone. Two with active disease died of chemotherapy toxicity. The remaining five (three received chemotherapy) underwent surgery and are long-term survivors. Two who underwent hemipelvectomy or hip disarticulation would likely have undergone limb-sparing surgery today. These findings and a review of the similar cases in the literature suggest that osteosarcoma's clinical characteristics are similar among young children and older children.

Age Factors↗

PubMed2005

MR safety and compatibility of a noninvasively expandable total-joint endoprosthesis.

A noninvasively expandable total-joint endoprosthesis is now available for pediatric patients; the prosthesis can be lengthened by external application of a magnetic field. We investigated the risks of unintentional heating or lengthening of the prosthesis during MR imaging and evaluated the effect of the device on the diagnostic efficacy of MR imaging of surrounding tissues. We performed MR imaging at 1.5 T by using standard pulse sequences and pulse sequences with high-gradient and high-radiofrequency duty cycle. MR imaging caused no measurable change in prosthesis length, and the temperature of the prosthesis increased by less than 1 degrees C during repeated 14-min exposures. Despite significant signal loss and image distortion around the prosthetic joint, clinically useful images were obtained as close as 12 cm from the ends of the prosthetic stems, measured toward the body of the device. Thus, the prosthesis can be safely exposed to MR imaging pulse sequences at 1.5 T, and the visualization of some tissue surrounding the device is clinically useful.

Bone Neoplasms↗

PubMed2005

Infections in children and young adults with bone malignancies undergoing limb-sparing surgery.

BACKGROUND: The epidemiology, risk factors, and efficacy of therapy for infections complicating limb-sparing surgery (LSS) are not understood completely. METHODS: The authors conducted a retrospective review of children and adolescents with bone malignancies who underwent LSS. RESULTS: One hundred three patients underwent 104 LSS procedures. Patients experienced a median of 4 infections (range, 0-13 infections), including focal bacterial infections in 67% of patients and bacteremia in 21% of patients. Infections at the LSS site occurred in 26% of patients, and 21% of patients developed orthopedic device infections (ODIs). Compared with patients without ODIs, patients who developed ODIs were more likely to be African American and to have wound infections, and they were less likely to have tumors of the femur than the tibia. In a multivariate analysis, only African-American race and local infection at the LSS site retained a significant association with ODIs. Among survivors, patients who developed ODIs were more likely to undergo amputation (odds ratio [OR], 24.0; 95% confidence interval [95%CI], 5.1-114.0; P < 0.001) and were less likely to have good functional outcomes (OR, 0.02; 95%CI, 0.002-0.15; P < 0.001) compared with patients who did not have an ODI. Overall, only 1 of 22 patients with an ODI was treated successfully without removal of the orthopedic device or amputation. CONCLUSIONS: Current treatment for bone malignancies is complicated by an unexpectedly high incidence of infection. ODI was the most common reason for amputation and poor functional outcomes. The identification of risk factors for ODI may allow modifications of therapy that reduce the incidence and severity of infection, but prevention of all ODIs will require novel strategies.

Adolescent↗

PubMed2005

Definitive surgery and multiagent systemic therapy for patients with localized Ewing sarcoma family of tumors: local outcome and prognostic factors.

BACKGROUND: The local management of Ewing sarcoma family of tumors (ESFT) often centers on the surgical resectability of the primary lesion and physician biases regarding differences in the morbidity between primary surgical and radiotherapeutic management. METHODS: The authors retrospectively reviewed the records of 33 patients with localized ESFT who underwent surgery and received systemic chemotherapy at St. Jude Children's Research Hospital (Memphis, TN). Two multiagent systemic chemotherapy regimens were used: 14 patients received vincristine, doxorubicin, cyclophosphamide, and actinomycin D (VACA), and 19 received VACA in combination with ifosphamide and etoposide. The primary tumor was surgically resected via a wide, local excision (n = 32) or a marginal excision (n = 1)performed either at diagnosis or after 3-5 months of systemic chemotherapy. Clinical outcome and prognostic factors for disease control were reported in the current study. RESULTS: The median follow-up for patients was 9.9 years. The 5-year and 10-year survival rates were 84.5% and 75.8%, respectively. At 5 years, the cumulative incidence of local disease recurrence was 12.5%, and the event-free survival (EFS) rate was 71.7%. The same values were found at 10 years. The site of tumor origin was a significant predictor of EFS. The survival rate of patients whose tumors arose in bone was 78.6%, and the survival rate of patients whose tumors originated in soft tissue was 25.0% (P = 0.028). No other factors investigated were predictive of outcome. CONCLUSIONS: Local disease control and overall outcome for patients with ESFT managed by multiagent systemic therapy and surgery was excellent. Local disease control rates remained near 90% at 10-year follow-up. Patients with extraosseous primary sites of disease may fare less well with this approach to therapy.

Adolescent↗

PubMed2005

Childhood cancer survivors: an at-risk cohort for ankle osteonecrosis.

UNLABELLED: We aimed to determine if the ankle is at risk for corticosteroid-induced osteonecrosis as a cause of pain in a cohort of childhood cancer survivors. We retrospectively reviewed magnetic resonance imaging scans of the ankle in patients treated at our institution between 1993 and 2003. Among the 15 patients who met study criteria, 20 of 30 (67%) ankles were involved. Older children had the highest incidence of the disease. The tibial metaphysis, epiphysis, and talus were the most frequent sites of osteonecrotic lesions. Ten patients were symptomatic with extended weightbearing activity. Surgery was required in four with continued amelioration of pain at last followup (17-44 months). As early detection and intervention lead to prevention of ankle morbidity, childhood cancer survivors would benefit from a prospective multi-institutional study that would provide understanding of ankle osteonecrosis and development of effective interventions. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study).

Adolescent↗

PubMed2004

Definitive irradiation in multidisciplinary management of localized Ewing sarcoma family of tumors in pediatric patients: outcome and prognostic factors.

PURPOSE: To assess the effect of radiation dose on local tumor control of the Ewing sarcoma family of tumors in 79 patients with localized disease treated at a single institution. METHODS AND MATERIALS: Thirty-seven patients received vincristine, actinomycin D, cyclophosphamide, and doxorubicin, and 42 received vincristine, actinomycin D, and cyclophosphamide, with alternating cycles of ifosfamide and etoposide; all underwent definitive radiotherapy (median dose, 37.5 Gy) with either low-dose (<40 Gy) or standard dose (> or =40 Gy) radiation delivered according to the protocol. We calculated the cumulative incidence of local treatment failure, disease recurrence, and overall survival and analyzed the effect of known prognostic factors and radiation dose. RESULTS: The cumulative incidence of local treatment failure at 10 years was 30.4% and that of disease recurrence was 40%. The overall survival rate was 64.5%. Patient age > or =14 years and tumor size > or =8 cm were adverse prognostic factors for local treatment failure; patient age > or =14 years was also associated with worse survival. Although the radiation dose alone did not predict for local treatment failure, the cumulative incidence of local failure at 10 years was 19% when tumors <8 cm were treated with <40 Gy, and no patient treated with standard doses (> or =40 Gy) developed local recurrence (p = 0.084). CONCLUSION: Tumor size and patient age predict for local tumor control in patients with Ewing sarcoma family of tumors treated with systemic therapy and definitive radiotherapy. Patients treated with reduced-dose radiotherapy experienced unacceptably high rates of local recurrence.

Adolescent↗

PubMed2004

Valgus and varus deformity after wide-local excision, brachytherapy and external beam irradiation in two children with lower extremity synovial cell sarcoma: case report.

BACKGROUND: Limb-salvage is a primary objective in the management of extremity soft-tissue sarcoma in adults and children. Wide-local excision combined with radiation therapy is effective in achieving local tumor control with acceptable morbidity and good functional outcomes for most patients. CASE PRESENTATION: Two cases of deformity after wide-local excision, brachytherapy and external beam irradiation for lower-extremity synovial cell sarcoma are presented and discussed to highlight contributing factors, time course of radiation effects and orthopedic management. In an effort to spare normal tissues from the long-term effects of radiation therapy, more focal irradiation techniques have been applied to patients with musculoskeletal tumors including brachytherapy and conformal radiation therapy. As illustrated in this report, the use of these techniques results in the asymmetric irradiation of growth plates and contributes to the development of valgus or varus deformity and leg-length discrepancies. CONCLUSIONS: Despite good functional outcomes, progressive deformity in both patients required epiphysiodesis more than 3 years after initial management. There is a dearth of information related to the effects of radiation therapy on the musculoskeletal system in children. Because limb-sparing approaches are to be highlighted in the next generation of cooperative group protocols for children with musculoskeletal tumors, documentation of the effects of surgery and radiation therapy will lead to improved decision making in the selection of the best treatment approach and in the follow-up of these patients.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2004

Efficacy of combined surgery and irradiation for localized Ewings sarcoma family of tumors.

BACKGROUND: Local tumor control for patients with Ewings sarcoma family of tumors (ESFT) is favorable when the primary tumor is resectable or small. Local failure rates for patients who received combined surgery and RT were reviewed to determine outcome and prognostic factors. PROCEDURES: We performed a retrospective review of all patients with localized ESFT treated with combined definitive surgery and RT between 1978 and 2001, at St. Jude Children's Research Hospital. Rates of local failure, survival, and prognostic factors for recurrence were determined in 39 patients who received combined local therapy. Systemic treatment included vincristine, actinomycin D, cyclophosphamide, and doxorubicin (6 patients), with the addition of ifosfamide and etoposide (33 patients). RESULTS: With a median follow-up of 8.7 years the 5- and 8-year survival estimates were 89.2 +/- 5.4% and 82.8 +/- 7.3%. The 8-year incidence of local failure was 10.8 +/- 5.2%. The 8-year local failure rate for patients with positive surgical margins was 17% and for negative surgical margins 5% (P = 0.25). Overall survival was improved for patients with negative surgical margins (94 vs. 71%, P = 0.052). Tumor size, site, histologic response, and radiation dose did not significantly alter the rate of local failure. CONCLUSIONS: Patients with ESFT managed with definitive surgery and irradiation have favorable local control rates. Even among patients with unfavorable prognostic factors local tumor control remained excellent.

Adolescent↗

PubMed2004

Use of a smooth press-fit stem preserves physeal growth after tumor resection.

We conducted this study to determine whether the small-diameter, press-fit stem of a novel, noninvasive expandable endoprosthetic device implanted in the limbs of 6 pediatric patients with Stage IIB osteosarcoma affected the growth of the physis through which the stem was inserted. Local control of the tumor necessitated resection of the involved growth plate, and implantation of the device required penetration of the adjacent uninvolved bone, through the growth plate, by the stem of the device. We measured longitudinal growth and the rate of growth of the adjacent uninvolved bone in the salvaged limb and of the equivalent bone in the unoperated contralateral limb. In all cases but one (in which the patient's growth in the contralateral limb appeared complete), longitudinal growth continued in the limb into which the device was implanted: the adjacent uninvolved bone in the salvaged limb grew by an average of 2.4 cm, and the equivalent bone in the unoperated contralateral limb grew by an average of 2.3 cm. We conclude that implantation of a smooth, press-fit stem through the central portion of the uninvolved adjacent physis does not result in growth retardation or arrest.

Bone Development↗

PubMed2004

The incidence and prognosis of osteosarcoma skip metastases.

The poor prognosis for patients with osteosarcoma skip metastases has been established in the literature; however, most of the data in the literature concerning osteosarcoma skip metastases were collected before routine use of magnetic resonance imaging and before the use of modern multiagent chemotherapy regimens. This retrospective multiinstitutional study was done to evaluate the efficacy of magnetic resonance imaging to detect skip metastases and to evaluate the prognosis for these patients when treated with modern multiagent chemotherapy protocols. In a group of 155 patients who were younger than 26 years when diagnosed and treated for high-grade osteosarcoma of the long bones, 10 (6.5%) patients with skip metastases were identified. Eight of the 10 lesions were detected on pretreatment magnetic resonance imaging scans and two were detected only from the surgical pathology specimens. Five patients had concomitant pulmonary metastases at presentation and five patients had no other known site of diseases. All 10 patients died, with an average survival of 32.5 months (range 11-71 months). The five patients with only skip metastases at presentation survived an average of 27.2 months (range 15-44 months). Despite advances in the treatment of patients with osteosarcomas, those with skip metastases continue to have a poor prognosis, and they should be counseled regarding the limitations of current therapies.

Adolescent↗