The optimal treatment of soft tissue sarcoma remains a challenge for the multidisciplinary approa... more The optimal treatment of soft tissue sarcoma remains a challenge for the multidisciplinary approach in modern oncology. Only when a team of experienced clinicians, oncologists, radiotherapists, and oncologic orthopedic surgeons cooperates with the radiologist and the pathologist can optimal treatment be guaranteed. Recent advances in our knowledge of sarcomas have resulted from more detailed analysis of the cytogenetic and molecular changes in the different types of sarcoma. The prognostic significance of many biologic markers is still the subject of ongoing investigations, with sometimes conflicting results. The usefulness of adjuvant radiotherapy in the combined approach for optimal local control of both extremity and trunk sarcomas is confirmed in different studies. the discovery of antitumor activity of taxoids in this disease brings new chemotherapeutic combinations within reach.
Primary bone sarcomas of the pelvis represent the most challenging problem in limb-saving surgery... more Primary bone sarcomas of the pelvis represent the most challenging problem in limb-saving surgery. Chondrosarcoma is the most common type, followed by osteosarcoma and Ewing's sarcoma. The symp- toms are often vague, so that the diagnosis is made late, when the tumor has already reached a large size. Nowadays hindquarter amputation is reserved for complex tumors involving the sacrum, the
Chordoma is a rare slow-growing, locally invasive primary malignant bone tumour arising from noto... more Chordoma is a rare slow-growing, locally invasive primary malignant bone tumour arising from notochord remnants. It is characterised by a high local recurrence rate. Most chordomas (60%) are found in the sacrococcygeal region: only 15% originate in the mobile spine. CT-scan and MRI can help evaluate the tumour extension. En bloc resection of the tumour mass is the standard treatment. The main prognostic factor is tumour-negative surgical margins. Due to the location of spinal chordomas, adjacent to vital neural and vascular structures, this can be difficult to achieve. Therefore radiotherapy has been used when adequate excision is not possible and in case of local recurrence. We report the case of a 72-year-old female with a recurrent chordoma of the L2 vertebra, previously treated with resection and radiotherapy. The recurrent chordoma was resected using a right-sided thoraco-phreno-laparotomy as the tumour could not be resected using the left anterior approach or posterior approac...
In 40 patients undergoing arthroscopic subacromial decompression, we monitored the soft tissue pr... more In 40 patients undergoing arthroscopic subacromial decompression, we monitored the soft tissue pressure in the paratracheal region and in the deltoid and supraspinatus muscles, looking for evidence of a potentially dangerous rise in pressure, especially in the paratracheal region. Statistical analysis was used to determine predictable variables of the time of reaching maximum pressure in and between the three regions. Deltoid pressure rose quickly during surgery, and did not drop to baseline levels at the end of surgery. Supraspinatus pressures showed a similar trend but with lower maximum levels of pressure rise. Five patients had an (unexpected) rise in paratracheal pressure, with an absolute maximum of 133.4 mmHg in one. In only two patients, did "10 minutes post-op" paratracheal pressure levels not drop to baseline levels. No respiratory problems occurred during any procedure. There are no variables to predict a potentially dangerous rise in surrounding soft tissue pressure during shoulder arthroscopy. We recommend endotracheal intubation during shoulder arthroscopy.
Proximal tibia bone autograft (PTBG) is regularly used in reconstructive foot, ankle, and maxillo... more Proximal tibia bone autograft (PTBG) is regularly used in reconstructive foot, ankle, and maxillofacial surgery. Although many surgeons prefer PTBG rather than the conventional iliac crest, little is known about the remodeling capacity of the proximal tibia after harvesting cancellous bone. Via bilateral postoperative computed tomography of 17 harvesting sites, comparing the defect side with the healthy side, we measured the repair capacity of the proximal tibia in response to bone defect created by the harvest at medium-term follow-up (mean 29 months; range, 7-55 months). 16 of 17 (94%) cortical defects showed complete consolidation. Cancellous remodeling was graded 0 to 3, with 2 defects showing complete remodeling (grade 3), 4 defects partial remodeling (more than 50%), 8 defects partial remodeling (less than 50%) and 3 defects no remodeling at all (grade 0). The proximal tibia has the potential to form new cancellous bone after cancellous bone graft harvesting. More data are required to identify possible variables influencing this remodeling capacity. When performing knee surgery, knee surgeons should take into account the relatively small defect size and the consolidation of the cortical window after proximal tibia bone harvesting. Level IV, case series.
To assess the efficacy and cost of a new frontloading biopsy system, Spirotome® (system 1), in mu... more To assess the efficacy and cost of a new frontloading biopsy system, Spirotome® (system 1), in musculoskeletal lesions, and to compare the results with those obtained with commonly used biopsy devices. System 1 was used in all soft tissue lesions (STL) and osteolytic bone lesions (OBL) of patients who presented at our department for CT-guided biopsy between January 2009 and June 2010. Accuracy and cost were compared to those of Bonopty® (system 2) and Tru-cut (system 3) procedures. The efficacy of system 1 was 85% in STL and 89% in OBL. The procedure was well tolerated and caused no complications. System 3 had an efficacy of 84% in STL and OBL combined. The efficacy of system 2 in OBL was 85%. The cost of single-use system 1 and system 2 was comparable, the cost of system 3 and multiuse system 1 compared to single-use system 1 was 25 and 7%, respectively. The efficacy of system 1 in biopsy of STL and OBL was better than that of system 3. In OBL, the efficacy of system 1 was better than that of system 2. In STL at hazardous locations and small OBL with a thin cortical shell, system 1 offers the advantage of variable length and controlled loading. In these cases, single-use system 1 was cost-effective when compared to surgical biopsy. The cost per procedure of multiuse system 1 was lower than of system 3.
Objective. To evaluate MR imaging and pathology findings in order to define the characteristic fe... more Objective. To evaluate MR imaging and pathology findings in order to define the characteristic features of clear cell sarcoma of the soft tissues (malignant melanoma of the soft parts). Design and patients. MR examinations of 21 patients with histologically proven clear cell sarcoma of the musculoskeletal system were retrospectively reviewed and assessed for shape, homogeneity, delineation, sig-
A non-small cell lung cancer presenting as a superior sulcus tumor in an azygos lobe has not yet ... more A non-small cell lung cancer presenting as a superior sulcus tumor in an azygos lobe has not yet been reported. We present such a case in a 69-year-old man undergoing complete resection after induction chemoradiotherapy and discuss the specific location of a superior sulcus tumor and the aberrant anatomy of an azygos lobe.
The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus d... more The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus deformity of the hindfoot. It is versatile with significant corrective power; however, the neurovascular structures are in close proximity on the medial side and thus may be harmed during the osteotomy. Moreover, because this type of osteotomy can cause a great lateral translation, traction of the medial neurovascular structures is possible. We performed an anatomic study to evaluate the medial soft tissues after a lateralizing Scarf-type calcaneal osteotomy. The osteotomies were carried out on ten fresh-frozen cadaver specimens. We performed the osteotomy and induced valgus. Then we performed a medial dissection to identify the important medial structures: the medial and lateral plantar nerve (MPN , LPN) and the posterior tibial artery (PTA). We noted their relation to the osteotomy and their integrity. In several cases, one or more of the structures were sectioned. In five cases, all the structures crossed the osteotomy, four of which even a transection of one or both of the plantar nerves occurred. Although the PTA crossed the osteotomy in eight specimens, there was no transection of this structure. Scarf osteotomy of the calcaneus is a highly corrective osteotomy. However, caution must be exercised when performing as the medial neurovascular structures cross the osteotomy lines and transection can occur. When performing the osteotomy one should keep in mind that vigorous sawing and large displacement can cause damage to the medial neurovascular structures.
This article outlines the ability of MR imaging in staging, grading, tissue characterization, and... more This article outlines the ability of MR imaging in staging, grading, tissue characterization, and posttherapeutic surveillance of soft tissue tumors. Well-known staging parameters, such as extent, relationship with adjacent structures, and detection of intralesional necrosis, are used in the MR protocol for locoregional staging. Bone scintigraphy and high-resolution CT scan of the lungs are best methods for ruling out metastatic spread. A variety of (solitary or combinations of) grading parameters are described in the radiological literature. The role of MR imaging is to afford recognition of these lesions that need further aggressive work-up, excluding all others. Despite controversial reports, the definite role of MR imaging in grading of soft tissue tumors seems to become established. As for grading, a lot of individual imaging characteristics used for tissue characterization have low sensitivity, but combinations of parameters (age, site, signal intensities) are more useful and often allow to predict a specific diagnosis or to narrow down the list of differential diagnoses. Local recurrences of soft tissue tumors are frequent and can be detected accurately by an easy-to-use MR algorithm.
Pyogenic sacroiliitis (PS) is an uncommon joint infection. Clinical presentation may be misleadin... more Pyogenic sacroiliitis (PS) is an uncommon joint infection. Clinical presentation may be misleading, since it can resemble more common conditions such as sciatica, acute abdomen or septic arthritis of the hip.
Malignant degeneration in fibrous dysplasia is a rare occurrence. Most cases are reported in poly... more Malignant degeneration in fibrous dysplasia is a rare occurrence. Most cases are reported in polyostotic fibrous dysplasia with predisposition of the femur, tibia, maxilla, and mandible. The most commonly observed malignant tumors are osteosarcoma, fibrosarcoma, and chondrosarcoma. We describe a case of a low-grade osteosarcoma occurring in polyostotic fibrous dysplasia of the rib cage in a 50-year-old man.
Infrapatellar fat pad (IPFP) might be involved in osteoarthritis (OA) by production of cytokines.... more Infrapatellar fat pad (IPFP) might be involved in osteoarthritis (OA) by production of cytokines. It was hypothesised that production of cytokines is sensitive to environmental conditions. To evaluate cytokine production by IPFP in response to interleukin (IL)1β and investigate the ability to modulate this response with an agonist for peroxisome proliferator activated receptor α (PPARα), which is also activated by lipid-lowering drugs such as fibrates. Cytokine secretion of IPFP was analysed in the medium of explant cultures of 29 osteoarthritic patients. IPFP (five donors) and synovium (six donors) were cultured with IL-1β and PPARα agonist Wy14643. Gene expression of IL-1β, monocyte chemoattractant protein (MCP1), (IL-6, tumour necrosis factor (TNF)α, leptin, vascular endothelial growth factor (VEGF), IL-10, prostaglandin-endoperoxide synthase (PTGS)2 and release of TNFα, MCP1 and prostaglandin E(2) were compared with unstimulated IPFP and synovium explants. IPFP released large amounts of inflammatory cytokines, adipokines and growth factors. IL-1β increased gene expression of PTGS2, TNFα, IL-1β, IL-6 and VEGF and increased TNFα release in IPFP. MCP1, leptin, IL-10 gene expression and MCP1, leptin and PGE(2) release did not increase significantly. Synovium responded to IL-1β similarly to IPFP, except for VEGF gene expression. Wy14643 decreased gene expression of PTGS2, IL-1β, TNFα, MCP1, VEGF and leptin in IPFP explants and IL-1β, TNFα, IL-6, IL-10 and VEGF in synovium that responded to IL-1β. IPFP is an active tissue within the joint. IPFP cytokine production is increased by IL-1β and decreased by a PPARα agonist. The effects were similar to effects seen in synovium. Fibrates may represent a potential disease-modifying drug for OA by modulating inflammatory properties of IPFP and synovium.
Botryomycosis is an atypical reaction of the host to a common bacterial infection. A case of botr... more Botryomycosis is an atypical reaction of the host to a common bacterial infection. A case of botryomycosis mimicking a liposarcoma as suspected on clinical and radiological grounds is described. The diagnosis was made by biopsy and culture of the lesion. A review of the literature is given.
The optimal treatment of soft tissue sarcoma remains a challenge for the multidisciplinary approa... more The optimal treatment of soft tissue sarcoma remains a challenge for the multidisciplinary approach in modern oncology. Only when a team of experienced clinicians, oncologists, radiotherapists, and oncologic orthopedic surgeons cooperates with the radiologist and the pathologist can optimal treatment be guaranteed. Recent advances in our knowledge of sarcomas have resulted from more detailed analysis of the cytogenetic and molecular changes in the different types of sarcoma. The prognostic significance of many biologic markers is still the subject of ongoing investigations, with sometimes conflicting results. The usefulness of adjuvant radiotherapy in the combined approach for optimal local control of both extremity and trunk sarcomas is confirmed in different studies. the discovery of antitumor activity of taxoids in this disease brings new chemotherapeutic combinations within reach.
Primary bone sarcomas of the pelvis represent the most challenging problem in limb-saving surgery... more Primary bone sarcomas of the pelvis represent the most challenging problem in limb-saving surgery. Chondrosarcoma is the most common type, followed by osteosarcoma and Ewing's sarcoma. The symp- toms are often vague, so that the diagnosis is made late, when the tumor has already reached a large size. Nowadays hindquarter amputation is reserved for complex tumors involving the sacrum, the
Chordoma is a rare slow-growing, locally invasive primary malignant bone tumour arising from noto... more Chordoma is a rare slow-growing, locally invasive primary malignant bone tumour arising from notochord remnants. It is characterised by a high local recurrence rate. Most chordomas (60%) are found in the sacrococcygeal region: only 15% originate in the mobile spine. CT-scan and MRI can help evaluate the tumour extension. En bloc resection of the tumour mass is the standard treatment. The main prognostic factor is tumour-negative surgical margins. Due to the location of spinal chordomas, adjacent to vital neural and vascular structures, this can be difficult to achieve. Therefore radiotherapy has been used when adequate excision is not possible and in case of local recurrence. We report the case of a 72-year-old female with a recurrent chordoma of the L2 vertebra, previously treated with resection and radiotherapy. The recurrent chordoma was resected using a right-sided thoraco-phreno-laparotomy as the tumour could not be resected using the left anterior approach or posterior approac...
In 40 patients undergoing arthroscopic subacromial decompression, we monitored the soft tissue pr... more In 40 patients undergoing arthroscopic subacromial decompression, we monitored the soft tissue pressure in the paratracheal region and in the deltoid and supraspinatus muscles, looking for evidence of a potentially dangerous rise in pressure, especially in the paratracheal region. Statistical analysis was used to determine predictable variables of the time of reaching maximum pressure in and between the three regions. Deltoid pressure rose quickly during surgery, and did not drop to baseline levels at the end of surgery. Supraspinatus pressures showed a similar trend but with lower maximum levels of pressure rise. Five patients had an (unexpected) rise in paratracheal pressure, with an absolute maximum of 133.4 mmHg in one. In only two patients, did "10 minutes post-op" paratracheal pressure levels not drop to baseline levels. No respiratory problems occurred during any procedure. There are no variables to predict a potentially dangerous rise in surrounding soft tissue pressure during shoulder arthroscopy. We recommend endotracheal intubation during shoulder arthroscopy.
Proximal tibia bone autograft (PTBG) is regularly used in reconstructive foot, ankle, and maxillo... more Proximal tibia bone autograft (PTBG) is regularly used in reconstructive foot, ankle, and maxillofacial surgery. Although many surgeons prefer PTBG rather than the conventional iliac crest, little is known about the remodeling capacity of the proximal tibia after harvesting cancellous bone. Via bilateral postoperative computed tomography of 17 harvesting sites, comparing the defect side with the healthy side, we measured the repair capacity of the proximal tibia in response to bone defect created by the harvest at medium-term follow-up (mean 29 months; range, 7-55 months). 16 of 17 (94%) cortical defects showed complete consolidation. Cancellous remodeling was graded 0 to 3, with 2 defects showing complete remodeling (grade 3), 4 defects partial remodeling (more than 50%), 8 defects partial remodeling (less than 50%) and 3 defects no remodeling at all (grade 0). The proximal tibia has the potential to form new cancellous bone after cancellous bone graft harvesting. More data are required to identify possible variables influencing this remodeling capacity. When performing knee surgery, knee surgeons should take into account the relatively small defect size and the consolidation of the cortical window after proximal tibia bone harvesting. Level IV, case series.
To assess the efficacy and cost of a new frontloading biopsy system, Spirotome® (system 1), in mu... more To assess the efficacy and cost of a new frontloading biopsy system, Spirotome® (system 1), in musculoskeletal lesions, and to compare the results with those obtained with commonly used biopsy devices. System 1 was used in all soft tissue lesions (STL) and osteolytic bone lesions (OBL) of patients who presented at our department for CT-guided biopsy between January 2009 and June 2010. Accuracy and cost were compared to those of Bonopty® (system 2) and Tru-cut (system 3) procedures. The efficacy of system 1 was 85% in STL and 89% in OBL. The procedure was well tolerated and caused no complications. System 3 had an efficacy of 84% in STL and OBL combined. The efficacy of system 2 in OBL was 85%. The cost of single-use system 1 and system 2 was comparable, the cost of system 3 and multiuse system 1 compared to single-use system 1 was 25 and 7%, respectively. The efficacy of system 1 in biopsy of STL and OBL was better than that of system 3. In OBL, the efficacy of system 1 was better than that of system 2. In STL at hazardous locations and small OBL with a thin cortical shell, system 1 offers the advantage of variable length and controlled loading. In these cases, single-use system 1 was cost-effective when compared to surgical biopsy. The cost per procedure of multiuse system 1 was lower than of system 3.
Objective. To evaluate MR imaging and pathology findings in order to define the characteristic fe... more Objective. To evaluate MR imaging and pathology findings in order to define the characteristic features of clear cell sarcoma of the soft tissues (malignant melanoma of the soft parts). Design and patients. MR examinations of 21 patients with histologically proven clear cell sarcoma of the musculoskeletal system were retrospectively reviewed and assessed for shape, homogeneity, delineation, sig-
A non-small cell lung cancer presenting as a superior sulcus tumor in an azygos lobe has not yet ... more A non-small cell lung cancer presenting as a superior sulcus tumor in an azygos lobe has not yet been reported. We present such a case in a 69-year-old man undergoing complete resection after induction chemoradiotherapy and discuss the specific location of a superior sulcus tumor and the aberrant anatomy of an azygos lobe.
The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus d... more The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus deformity of the hindfoot. It is versatile with significant corrective power; however, the neurovascular structures are in close proximity on the medial side and thus may be harmed during the osteotomy. Moreover, because this type of osteotomy can cause a great lateral translation, traction of the medial neurovascular structures is possible. We performed an anatomic study to evaluate the medial soft tissues after a lateralizing Scarf-type calcaneal osteotomy. The osteotomies were carried out on ten fresh-frozen cadaver specimens. We performed the osteotomy and induced valgus. Then we performed a medial dissection to identify the important medial structures: the medial and lateral plantar nerve (MPN , LPN) and the posterior tibial artery (PTA). We noted their relation to the osteotomy and their integrity. In several cases, one or more of the structures were sectioned. In five cases, all the structures crossed the osteotomy, four of which even a transection of one or both of the plantar nerves occurred. Although the PTA crossed the osteotomy in eight specimens, there was no transection of this structure. Scarf osteotomy of the calcaneus is a highly corrective osteotomy. However, caution must be exercised when performing as the medial neurovascular structures cross the osteotomy lines and transection can occur. When performing the osteotomy one should keep in mind that vigorous sawing and large displacement can cause damage to the medial neurovascular structures.
This article outlines the ability of MR imaging in staging, grading, tissue characterization, and... more This article outlines the ability of MR imaging in staging, grading, tissue characterization, and posttherapeutic surveillance of soft tissue tumors. Well-known staging parameters, such as extent, relationship with adjacent structures, and detection of intralesional necrosis, are used in the MR protocol for locoregional staging. Bone scintigraphy and high-resolution CT scan of the lungs are best methods for ruling out metastatic spread. A variety of (solitary or combinations of) grading parameters are described in the radiological literature. The role of MR imaging is to afford recognition of these lesions that need further aggressive work-up, excluding all others. Despite controversial reports, the definite role of MR imaging in grading of soft tissue tumors seems to become established. As for grading, a lot of individual imaging characteristics used for tissue characterization have low sensitivity, but combinations of parameters (age, site, signal intensities) are more useful and often allow to predict a specific diagnosis or to narrow down the list of differential diagnoses. Local recurrences of soft tissue tumors are frequent and can be detected accurately by an easy-to-use MR algorithm.
Pyogenic sacroiliitis (PS) is an uncommon joint infection. Clinical presentation may be misleadin... more Pyogenic sacroiliitis (PS) is an uncommon joint infection. Clinical presentation may be misleading, since it can resemble more common conditions such as sciatica, acute abdomen or septic arthritis of the hip.
Malignant degeneration in fibrous dysplasia is a rare occurrence. Most cases are reported in poly... more Malignant degeneration in fibrous dysplasia is a rare occurrence. Most cases are reported in polyostotic fibrous dysplasia with predisposition of the femur, tibia, maxilla, and mandible. The most commonly observed malignant tumors are osteosarcoma, fibrosarcoma, and chondrosarcoma. We describe a case of a low-grade osteosarcoma occurring in polyostotic fibrous dysplasia of the rib cage in a 50-year-old man.
Infrapatellar fat pad (IPFP) might be involved in osteoarthritis (OA) by production of cytokines.... more Infrapatellar fat pad (IPFP) might be involved in osteoarthritis (OA) by production of cytokines. It was hypothesised that production of cytokines is sensitive to environmental conditions. To evaluate cytokine production by IPFP in response to interleukin (IL)1β and investigate the ability to modulate this response with an agonist for peroxisome proliferator activated receptor α (PPARα), which is also activated by lipid-lowering drugs such as fibrates. Cytokine secretion of IPFP was analysed in the medium of explant cultures of 29 osteoarthritic patients. IPFP (five donors) and synovium (six donors) were cultured with IL-1β and PPARα agonist Wy14643. Gene expression of IL-1β, monocyte chemoattractant protein (MCP1), (IL-6, tumour necrosis factor (TNF)α, leptin, vascular endothelial growth factor (VEGF), IL-10, prostaglandin-endoperoxide synthase (PTGS)2 and release of TNFα, MCP1 and prostaglandin E(2) were compared with unstimulated IPFP and synovium explants. IPFP released large amounts of inflammatory cytokines, adipokines and growth factors. IL-1β increased gene expression of PTGS2, TNFα, IL-1β, IL-6 and VEGF and increased TNFα release in IPFP. MCP1, leptin, IL-10 gene expression and MCP1, leptin and PGE(2) release did not increase significantly. Synovium responded to IL-1β similarly to IPFP, except for VEGF gene expression. Wy14643 decreased gene expression of PTGS2, IL-1β, TNFα, MCP1, VEGF and leptin in IPFP explants and IL-1β, TNFα, IL-6, IL-10 and VEGF in synovium that responded to IL-1β. IPFP is an active tissue within the joint. IPFP cytokine production is increased by IL-1β and decreased by a PPARα agonist. The effects were similar to effects seen in synovium. Fibrates may represent a potential disease-modifying drug for OA by modulating inflammatory properties of IPFP and synovium.
Botryomycosis is an atypical reaction of the host to a common bacterial infection. A case of botr... more Botryomycosis is an atypical reaction of the host to a common bacterial infection. A case of botryomycosis mimicking a liposarcoma as suspected on clinical and radiological grounds is described. The diagnosis was made by biopsy and culture of the lesion. A review of the literature is given.
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Papers by Johan Somville