Earl W. Brien

Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology. II. Juxtacortical cartilage tumors

Abstract In part I, we reviewed the varied clinical presentations, pathogenesis, histologic findings, radiologic findings, and treatment of intramedullary cartilaginous lesions of bone. In this section, we will evaluate our cases and consultations of juxtacortical cartilaginous tumors. Radiographic differential diagnosis includes the numerous juxtacortical lesions particularly osteochondroma, parosteal chondroma, Trevor’s disease, trauma (fracture and periostitis ossificans), and the low- and high-grade surface osteosarcomas. By emphasizing pathogenesis in conjunction with radiographic and histologic findings, pitfalls in diagnosis and subsequent treatment can be avoided in such cases.

Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology

Abstract We reviewed 845 cases of benign and 356 cases of malignant cartilaginous tumors from a total of 3067 primary bone tumors in our database. Benign cartilaginous lesions are unique because the epiphyseal plate has been implicated in the etiology of osteochondroma, enchondroma (single or multiple), periosteal chondromas and chondroblastoma. In the first part of this paper, we will review important clinical, radiologic and histologic features of intramedullary cartilaginous lesions in an attempt to support theories related to anatomic considerations and pathogenesis.

Paget's disease of bone: review with emphasis on radiologic features, part I

Distinctive clinical, radiologic and pathologic features are seen in Pagets disease of bone. These distinct features can be divided into three phases; initial phase, midphase and late phase. The clinical features may vary from patients being asymptomatic (involving a single bone) to patients having severe, multiple bone involvement with systemic disease. Radiologically, there are unique features which can differentiate Pagets disease from other bone diseases. The radiologic features follows the histologic findings on light microscopy. The correlation of the different phases with the clinical, radiologic and pathologic features of Pagets disease allows for early accurate diagnosis and treatment.

Benign giant cell tumor of bone with osteosarcomatous transformation ('dedifferentiated' primary malignant GCT): Report of two cases

Abstract It is not uncommon for sarcomatous transformation of giant cell tumor (GCT) of bone to occur after radiation, but rarely does malignant transformation occur spontaneously, with less than 15 cases reported up to 1995. Only four of these cases have been documented in detail. We report two additional cases of GCT of bone spontaneously transforming or ”dedifferentiating” into osteosarcoma without radiation therapy. The first case is absolutely unique and most interesting in that the dedifferentiation process occurred in one of multiple GCT lung metastases 6 years after successful eradication of a primary tibial tumor. The right lung was resected due to development of a large tumor, and at pathologic examination, demonstrated several small nodules of conventional GCT and a much larger, 14-cm mass composed of a mixture of GCT and high-grade osteosarcoma. The second case involved a physician, who had a large tumor in the sacrum with vague symptoms for 8 years. Open biopsy revealed conventional, benign GCT of bone with a secondary aneurysmal bone cyst. Complete curettage 2 weeks later revealed, in addition to areas of conventional, benign GCT a second component of very high grade osteosarcoma. Both patients died less than 1.5 years from diagnosis. This report of osteosarcomatous transformation of a conventional GCT of bone strengthens the theory that there is a mesenchymal cell line in GCT that may spontaneously tansform to sarcoma.

Pigmented villonodular synovitis of the foot and ankle

Background: Pigmented villonodular synovitis (PVNS) is a rare disease of uncertain etiology usually affecting the synovium of weightbearing joints. Methods: We retrospectively evaluated 11 patients who were diagnosed and treated for PVNS of the ankle and foot over a 13-year period with a minimum of 2-year followup. Four patients with ankle joint PVNS and one patient with PVNS of the fifth metatarsophalangeal joint were seen initially at our institution and were treated with surgery alone. Six patients with ankle joint PVNS were referred to our institution for recurrent PVNS lesions; two of these patients were treated with excision alone, and the other four patients had surgical excision followed by radiation therapy with dosages ranging from 3600-4000 cGy. Results: No recurrence was noted at a mean followup of 9 years for primary lesions and 3.5 years for recurrent lesions. Conclusion: Based on these results, surgical excision of primary lesions and excision with postoperative radiation for recurrent lesions are recommended.

Chondroblastoma arising from a nonepiphyseal site

Chondroblastoma is a rare, benign primary bone tumor usually involving secondary centers of enchondral ossification. The consistent epiphyseal location in the great majority of chondroblastomas signifies that the tumor may arise from an aberrant germ cell of the physeal plate. This case report describes a chondroblastoma located in a atypical nonphyseal location, namely in the right fourth metatarsal base. Cases such as these imply that the cell of origin may not exclusively be derived form the physeal plate. The clinical-radiographic significance is that historically chondroblastoma is considered an epiphyseal lesion, but rare cases such as the one reported here and those of the skull demonstrate that this is not always a characteristic of these tumors. The implication from a histogenetic standpoint is that chondroblastoma may, on rare occasions, occur in an area of an enchondrally formed bone other than adjacent to the physeal plate. We are presently investigating the histogenetic relationship of the chondroblastoma (CB) of bone to CB of soft tissue, giant-cell tumor of tendon sheath (GCT-TS), pigmented villonodular synovitis (PVNS) and chondroma of tendon sheath (chondroma of soft parts). We now have collected about 15 cases of GCT-TS and PVNS with extensive areas of chondroid and/or cartilage differentiation that cannot be distinguished from CB of bone by histologic or electron microscopic features alone. From these interesting observations we are developing the histogenetic concept that all of these lesions are interrelated to multipotential mesenchymal and/or synovial cells of the tendon sheath.(ABSTRACT TRUNCATED AT 250 WORDS)

Serial thallium-201 scintigraphy in osteosarcoma. Correlation with tumor necrosis after preoperative chemotherapy.

In 27 patients with extremity lesions (24 osteosarcoma, three malignant fibrous histiocytoma), a notable decrease in thallium-201 uptake was correlated with a good response to preoperative chemotherapy of the primary tumor. A good response is indicated by a greater than 95% tumor necrosis. Serial quantitative thallium-201 uptake of malignant bone tumors in patients receiving preoperative chemotherapy therefore can accurately predict a good histologic response and prognosis. Serial thallium scintigraphy can furthermore identify poor responses within two weeks after the initiation of treatment, or can prompt an early change in preoperative chemotherapy and facilitate limb salvage surgery.

Florid Reactive Periostitis Ossificans of the Proximal Aspect of the Tibia: A Lesion That Must Be Distinguished from Osteosarcoma. A Case Report*

Florid reactive periostitis ossificans is a benign lesion that was first described, to the best of our knowledge, by Spjut and Dorfman in 198113. It has been reported exclusively in the tubular bones of the hands and feet1-8,10-14. Typically, this lesion affects adolescents and young adults and presents as a swollen, painful, and erythematous finger or toe. Spjut and Dorfman reported that the lesion appears benign radiographically but could be mistaken for a variety of malignant lesions, especially osteosarcoma, on histological examination13. Magnetic resonance imaging scans often demonstrate massive signal changes within the soft tissue that are consistent with infection, trauma, or a tumor of the soft tissue or bone. We report the case of a five-year-old girl who was followed clinically and radiographically after the diagnosis of florid reactive periostitis ossificans involving the proximal aspect of the tibia. To our knowledge, we are the first to describe the occurrence of this lesion in a long bone. A five-year-old girl was seen because of a two-month history of progressive pain in the left knee that was increasing in frequency and duration. The pain was aggravated by walking, and the patient was unable to bear full weight on the extremity. There was no history of fever, chills, night sweats, or injury. Physical examination revealed fullness and tenderness in a six by three-centimeter area about the proximal-medial aspect of the posterior part of the left tibia. Measurement of the circumferences of the thighs demonstrated 1.5 centimeters of atrophy of the quadriceps muscle on the left. The lower extremities were of equal length. The circumference of the proximal aspect of the calf was bilaterally symmetrical. Neurovascular function was intact distal to the lesion, and there was no evidence of adenopathy proximal …

Avulsion of the ischial tuberosity simulating neoplasm—a report of 2 cases

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Grading system for gunshot injuries to the femoral diaphysis in civilians.

One hundred patients had surgical treatment for a gunshot injury to the femur at the authors’ hospital. Each injury was classified (Grade 1–3) based on clinical and radiographic signs of deep soft tissue necrosis. All patients were followed up for a minimum of 6 months (average, 18 months; range, 6 months–72 months). Grade 1 injuries are defined by small entry and exit wounds (< 2 cm) and the absence of high-energy characteristics on plain radiographs. Grade 2 gunshot injuries have small wounds (< 5 cm) and radiographic evidence of a high-energy injury. Grade 3 gunshot injuries are diagnosed by physical examination whenever necrotic muscle is present at the fracture site. Radiographs show extensive superficial and deep soft tissue disruption and segmental bone destruction. Seventy-nine patients with Grade 1 fractures had intramedullary nailing without wound exploration; all fractures united without infection. Seven patients with Grade 2 injuries had wound exploration; a necrotic cavity was discovered in five patients and three (43%) patients had deep infection develop. Fourteen patients with Grade 3 injuries had one or more debridements followed by skeletal stabilization, and seven patients (50%) had deep infection develop. Important decisions regarding wound debridement and fracture stabilization are determined by examination of the wound and radiographs, and not by determining muzzle velocity.