Theodore R. Miller

Bone Sarcomas Arising in Fibrous Dysplasia

Twelve patients with histologically proved sarcoma arising in fibrous dysplasia of bone (six monostotic, six polyostotic) are described. In five (Group I) the existence of the dysplasia was known years before the sarcoma arose, and in seven (Group II) the discovery of both lesions was concurrent. The average age of patients in Group I [See figure in the PDF file] was fifteen years when compared with thirty-five years in Group II. In only one instance could the history of previous radiotherapy be elicited. The histological examination of the primary bone sarcomas revealed eight osteosarcomas, two chondrosarcomas, and two spindle-cell sarcomas.

Primary reticulum cell sarcoma of bone. Significance of clinical features upon the prognosis.

Primary reticulum cell sarcoma of bone was found to have a relatively good prognosis in a review of 47 cases. It was also found that age, sex, or duration of symptoms had nothing to do with the prognosis. Although any statistical validity was not obtained, a large amount of radiation therapy during short periods on the whole bone seems the treatment of choice, and Coleys toxin may be combined with it for better results, at least for symptomatic improvement. Radiation therapy on the local area should be abandoned. The most important factor influencing the prognosis is the extent of the disease, an aspect of which may be reflected in the roentgenographic appearance in the long tubular bone involvement. Pelvic girdle involvement has a poor prognosis regardless of roentgenographic appearance. Surgery is indicated for the failure of control of local recurrence or complications due to radiation therapy.

An Analysis of Thirty Patients Surviving Longer than Ten Years after Treatment for Osteogenic Sarcoma

An analysis of the clinicopathological features of thirty long-term survivors of osteogenic sarcoma has been presented. We could not identify any specific features which would separate these patients from non-survivors of osteogenic sarcoma. The one common feature shared by all thirty patients was that amputation was the only effective therapeutic method in eradicating the primary disease.

Embryonal adenocarcinomas (a type of malignant teratoma) of the sacrococcygeal region. Clinical and pathologic aspects of 21 cases

Sacrococcygeal teratomas in 21 consecutive patients admitted to Memorial Hospital were all embryonal adenocarcinomas having a common histologic appearance. Seventeen of the patients were female, and all except one were Caucasians. The average age at diagnosis was 2 years, and the average survival after diagnosis was 1 year, with a range of 1 to 68 months. All had large presacral tumors, but 2 had no external deformity. Seven had a midline external protuberance, and 12 presented with enlargement of a buttock. Prior to diagnosis, in 12 patients, the primary tumor produced one or more of a symptom triad of constipation, urinary frequency, and lower extremity weakness, and, in 12 patients, the tumor had metastasized. The primary tumor was resected in 6 patients but recurred in 4 of the 5 patients surviving the operation. Eighteen patients received radiation therapy to the primary tumor and/or metastases, and tumor regression occurred in all. Regression was also obtained in several patients who received chemotherapy. Because of the large size of the tumors and the metastases present at the time of diagnosis at a relatively young age, it is likely that the tumors were present in the presacral space at birth. The failure of surgery to cure the tumors in this series and tumor sensitivity to radiation and chemotherapy suggest that their treatment should consist of a combination of therapeutic modalities.

HEMOSTASIS IN MAJOR EXTIRPATIVE SURGERY FOR CANCER

The avoidance of hemorrhage in major extirpative surgery for cancer is most important for the successful conduct of the case. The operative and postoperative course of the patient in whom hemorrhage has been avoided is much smoother and healing is much more rapid. The cause of hemorrhage may exist in the preoperative state, or may be the result of changes owing to blood loss occurring during operation and the efforts a t replacement of blood and fluid. In the preoperative state, hemorrhagic diatheses, liver damage with prolonged prothrombin time, pancytopoenia in the lymphomas and in patients undergoing radiation therapy and chemotherapy, and jaundice can be anticipated and corrected by careful preoperative study and treatment. Changes caused by blood loss occurring during operation, such as changes in blood coagulation in shock, interdonor incompatibilities, age of blood in massive transfusion, hypotension with subsequent blood loss when blood pressure has been restored, and fibrinolysis can be prevented in many patients by planned operations in which preliminary ligation of the blood supply to the tissues or organs to be extirpated is performed. Some major operations, such as radical mastectomy, radical groin dissection, and prostatectomy do not lend themselves to planned ligation, but one must depend on meticulous local control of bleeding by clamp and ligature, packing, etc. Preliminary ligations are possible in many operations such as pelvic exenteration and radical hysterectomy with node dissection in which the internal iliac arteries are ligated prior to the dissection, interscapulothoracic amputation in which the subclavian vessels are ligated at the initial step in the. operation, rectal resection with ligation of the inferior mesenteric artery, right hemicolectomy with ligation of the iliocolic vessels, thyroid lobectomy with ligation of the inferior and superior thyroid arteries, splenectomy with preliminary ligation of the splenic vessels, gastrectomy with ligation of the right and left gastric arteries a t their origin, pulmonary resections, and other major amputations, such as hip joint disarticulations and hemipelvectomy, and controlled hepatic lobectomy. We have reported over 100 hemipelvectomies in which the average blood loss was only 1,000 cc. because we practiced the technique of preliminary ligation of the common iliac artery and its branches. Some of these patients lost less than 500 cc. of blood, as determined by weight. Most of these pa-