Dempsey S. Springfield

Aneurysmal bone cyst of the spine.

The cases of twenty-two patients with an aneurysmal bone cyst of the spine above the sacrum were analyzed with regard to sex, age, site, symptoms, and radiographic findings. Four patients had extension of the lesion to the adjacent vertebra or rib, and twelve patients had neurological deficits. The primary treatment was either radiotherapy or surgery alone, or surgery and radiotherapy combined. No recurrences were found in patients who were treated with surgery alone or with surgery and radiotherapy, while three of the six patients who were treated with radiotherapy had a local recurrence, two of which were fatal. The patients with neurological deficits recovered after healing of the cyst.

Chondroblastoma. A review of seventy cases

We reviewed the cases of seventy patients with chondroblastoma who were treated at the Istituto Ortopedico Rizzoli between 1949 and 1983 and found that the proximal end of the humerus was the most common location (eighteen), with the proximal end of the femur (fifteen), distal end of the femur (fifteen), and proximal end of the tibia (twelve) being the other frequently involved sites. Sixty-three of the patients were between eleven and thirty years old. Fifty-eight patients sought medical attention because of an aching pain, usually referred to the adjacent joint. Fifty patients were followed for two years or longer after treatment. Seven patients had a local recurrence: four were successfully treated with a repeat curettage and one, by two subsequent marginal excisions; one was advised to have a repeat curettage; and the seventh was advised to have a resection and arthrodesis of the knee. The final functional results were considered to be excellent in forty-seven of the fifty patients who were followed for two years or more.

The prognostic significance of soft tissue extension in Ewing's sarcoma

From January 1969 through December 1977, 28 patients were treated at the University of Florida with the diagnosis of Ewings sarcoma. All patients received radiation therapy to the primary site and adjuvant chemotherapy according to several different regimens. A retrospective analysis was carried out to determine the prognostic significance of gross extraosseous extension by the primary lesion. Gross soft tissue extension at the primary site was found to be of prognostic importance. Patients with soft tissue extension more often presented with metastatic disease (39 versus 10%). The five‐year survival rate for patients presenting without distant metastasis and whose primary lesions were grossly confined to bone was 87% compared to 20% for those with extraosseous extension. The decrease in survival with soft tissue extension resulted from an increase in distant metastasis as well as local failure, and was independent of primary site location. The proportion of patients with extraosseous extension should be reported in subsequent analyses of local control and survival.

Surgical treatment for osteosarcoma.

Fifty-three patients who had a high-grade osteosarcoma had either a limb-salvage resection or an amputation. They all received adjuvant therapy that consisted of administration of Adriamycin (doxorubicin) and whole-lung irradiation. At the time of follow-up, the surgical margin was assessed by examination of the surgical specimen. Each patient was followed for at least three years or until death. The data suggested that a wide surgical margin is adequate to control a primary osteosarcoma. When a wide surgical margin can be used and a functional limb can be salvaged, an amputation probably is not required.

Transforming growth factor-β: Possible roles in Dupuytren's contracture*†

Transforming growth factor-β (TGF-β) is a multifunctional polypeptide that stimulates extracellular matrix deposition and fibroblast proliferation. Because both these features characterize Dupuytrens contracture, we investigated a possible role for TGF-β in the etiology of this disorder. We studied receptor expression for TGF-β, effects of TGF-β1 on DNA-synthesis, and in vitro production of TGF-β1 and TGF-β2 in both normal and Dupuytren-derived fibroblasts. We also studied the effects of epidermal growth factor (EGF) on growth of the different cell types. TGF-β receptor profiles were different between the two cell types, as were TGF-β1 and EGF-induced stimulation of cell growth. Both cell types secreted both active and latent TGF-β. Our results suggest that growth factors such as TGF-β and EGF may play a role in Dupuytrens contracture.

High-risk ewing's sarcoma: end-intensification using autologous bone marrow transplantation

Because of retrospective analysis showing survival to be related to primary tumor size, in February 1982 a study to test this hypothesis prospectively was begun at the University of Florida. Patients with primary tumors 8 cm or less in maximum diameter and no metastases received adjuvant chemotherapy consisting of vincristine, cyclophosphamide, doxorubicin, and dactinomycin plus radiotherapy or surgery (standard-risk protocol). All others received a similar regimen followed by end-intensification with high-dose melphalan and autologous bone marrow transplantation (Protocol HR-2). Because of poor results of HR-2, another high-risk protocol (HR-3) was initiated in January 1985. Patients on HR-3 received 2 cycles of chemotherapy containing vincristine, cyclophosphamide, and doxorubicin followed by local radiation therapy and maintenance chemotherapy. At the end of this therapy, autologous bone marrow transplantation (ABMT) was performed, using a preparatory regimen of total body irradiation and intensive chemotherapy. The 2-year disease-free survival rate was 70% for the standard-risk protocol, 20% for HR-2, and 80% for HR-3. The follow-up on HR-3 is still short, but the results are promising enough to warrant further clinical trials.

Radiology of giant cell tumors of bone: Computed tomography, arthro-tomography, and scintigraphy

Radiologic studies of 50 giant cell tumors of bone in 48 patients were useful in assessing the anatomic extent for planning surgical treatment. Contrast-enhanced computed tomography (CT) provided the most useful and complete evaluation, including soft tissue extent and relationship to major vessels. Angiography was useful when the extraosseous extent and vascular relationships were not entirely clear on CT. Arthro-tomography was the best way to evaluate tumor invasion through subchondral cortex and articular cartilage. Reactive soft tissues, with edema and hyperemia, were difficult to distinguish from tumor tissue on CT and angiograms. Bone scintigrams often showed intense uptake beyond the true tumor limits.

Editorial - Biopsy: Complicated and Risky

Tumors of the musculoskeletal system, especially malignant tumors, are rare. The practicing orthopaedic surgeon will see fewer than one primary malignant tumor of the musculoskeletal system every three years. This means that only orthopaedic oncologists will have much experience in the treatment of sarcomas, and there can be little, if any, argument that a patient who has a sarcoma should be referred to a medical center at which there are physicians who have expertise in the treatment of musculoskeletal neoplasia. We suspect that this happens when the referring surgeon knows that the lesion is malignant. All too often, however, the referring surgeon either does not think that the patient has a malignant tumor or finds the temptation to perform a biopsy too strong to resist. When the possibility of malignancy is not even considered, the lesion usually is excised inadequately. An inadequately excised or poorly biopsied sarcoma makes a difficult situation worse. The biopsy of musculoskeletal tumors is not easy and requires careful thought and planning. This issue of The Journal contains three articles that address this topic. Skrzynski et al. compare the diagnostic accuracy and monetary cost of open biopsy performed in an operating room with those of needle biopsy done in an outpatient clinic and report that, for selected patients who have a musculoskeletal tumor, the latter procedure is just as accurate and is less expensive than the former. Noria et al. examine the problem of residual tumor in patients who have had an unplanned excision and report that macroscopic or microscopic tumor often is present even when the referring surgeon thinks that the entire tumor has been removed and when no tumor is seen on postoperative cross-sectional computerized tomographic or magnetic resonance imaging studies. Mankin et al. revisit the issue of complications associated with biopsy and report …

Juxtaepiphyseal aneurysmal bone cyst.

Nine cases of aneurysmal bone cyst arising in juxtaepiphyseal locations with gross invasion of the adjacent growth plate are reported. In five of these patients an abnormality of growth, due to premature fusion of the affected growth plate, ultimately developed. Treatment of these lesions should attempt to avoid this complication, which appears to be more common than has been appeaciated in the past. These nine cases represent 23% of 39 cases of aneurysmal bone cyst occurring in a long bone adjacent to an open epiphyseal plate. This series was extrapolated from a total of 198 cases of aneurysmal bone cyst in the files of the Istituto Ortopedico Rizzoli, Bologna, Italy.

Neoadjuvant chemotherapy for osteosarcoma of the extremity

Eighty-five patients with nonmetastatic, high-grade osteosarcoma of an extremity received intravenous methotrexate and intraarterial cisplatinum and then a definitive surgical resection. The preliminary results suggest that preoperative chemotherapy with a delayed surgical resection is as safe as immediate surgery. More patients are candidates for limb salvage after chemotherapy. The tumor response to the preoperative chemotherapy also has prognostic value. Reducing the postoperative chemotherapy can be dangerous. A high dose methotrexate may not be necessary.