Timothy A. Damron

Distant soft tissue metastases: a series of 30 new patients and 91 cases from the literature.

Background: Thirty patients with soft-tissue metastases were reviewed retrospectively and compared with 91 cases previously reported. Soft tissue metastases were most commonly presented to the musculoskeletal oncologist as a painful mass in patients with no history of cancer. In this setting, lung carcinoma was the most frequent primary source. The purpose of this article is to report the largest single series of distant soft-tissue metastases and to compare the findings with those of the literature.Methods: Thirty consecutive patients were referred to musculoskeletal oncologists. Their cases were reviewed retrospectively for comparison with 91 cases from the clinical literature.Results: The most common clinical presentation of the soft-tissue mass was as the presenting symptom of previously undiagnosed cancer or concurrent with the primary source of cancer. A minority of cases were discovered in the setting of widespread metastases. Twenty-one new patients had carcinomas, 6 sarcomas, and 1 each multiple myeloma, lymphoma, and melanoma. Lung carcinoma was the most common primary source. The most common presenting symptom was that of a painful mass. Skeletal muscle of the thigh was the most common site. Radiological features were not specific. Soft tissue sarcoma was a common clinical misdiagnosis. Twenty-one new patients were dead of disease at a mean 5.4 months (range 1–19 months) after diagnosis of the metastasis: this percentage was similar to that reported in the literature.Conclusions: In this musculoskeletal oncology referral-based clinical series, soft tissue metastases most commonly occur in patients with a painful soft tissue mass and no history of cancer. Lung is the most frequent primary source. Treatment should be individualized according to the underlying disease and its prognosis.

Idiopathic Necrosis of Skeletal Muscle in Patients Who Have Diabetes. Report of Four Cases and Review of the Literature

Infarction of skeletal muscle in patients who have diabetes is an infrequently recognized clinicopathological entity1-17. Most of the reports on this condition have appeared in journals and textbooks on internal medicine and radiology. Radiographically, the lesion may be misinterpreted as a soft-tissue sarcoma or infection, in which case the patient may be referred to an orthopaedic surgeon. The mean age of the four patients reported on here was forty-two years (range, twenty-eight to fifty-nine years). The patients had sought medical attention because of an exquisitely tender swelling of the anterior aspect of the thigh, which had been present for ten days to four weeks before the initial evaluation. Two patients had a history of insulin-dependent diabetes, one had a history of non-insulin-dependent diabetes, and one was diagnosed with diabetes at the time of the initial evaluation. Three patients had no evidence of recurrence after a mean duration of follow-up of thirty-one months (range, twenty-four to forty-two months). The fourth patient had recurrence of the muscular necrosis and died six months later as a result of diabetic complications. CASE 1. A fifty-nine-year-old white man who had insulin-dependent diabetes mellitus was seen because of a three-week history of swelling of the distal two-thirds of the right thigh. The swelling had decreased during the week before the evaluation, leaving an exquisitely tender palpable mass. The patient had a twelve-year history of diabetes mellitus and had used thirty-five units of neutral protamine Hagedorn insulin each day for ten years. He had diabetic retinopathy and neuropathy but no evidence of nephropathy. He also had hypertension and coronary artery disease. Physical examination revealed an extremely tender mass, eight by five centimeters, in the anteromedial aspect of the distal part of the right thigh. Mild swelling was observed in the region of the …

Distinction of well-differentiated liposarcoma from lipoma in two patients with multiple well-differentiated fatty masses

Abstract. This case report describes the features of gadolinium-enhanced MRI in well-differentiated liposarcoma with histologic correlation and addresses the usefulness of this imaging technique in distinguishing well-differentiated liposarcoma from lipoma. Gadolinium-enhanced MRI revealed significantly enhanced signal in well-differentiated liposarcoma in a background of multiple well-differentiated benign fatty masses by showing the increased vascularity in the septa of well-differentiated liposarcoma. Although such signal enhancement can be seen in some types of benign lipomatous tumors with increased blood vessels, this technique is helpful in selection of biopsy site, especially in a clinical setting of multiple fatty masses.

Distal upper extremity function following proximal humeral resection and reconstruction for tumors: Contralateral comparison

AbstractBackground: Most functional analyses after limb salvage operations about the shoulder have focused on proximal function with the assumption that distal function is largely unaffected. This analysis examines distal function objectively. Methods: Objective laboratory data regarding distal upper extremity strength after reconstructive procedures for tumors near the shoulder joint was collected over a 16-year period. Thirty-two patients were able to participate fully in the data collection at an average most recent follow-up duration of >3.5 years. Results: Statistically significant reductions on the involved side compared with the uninvolved side in grip, forearm pronation, forearm supination, elbow flexion, and elbow extension strength were documented (p<0.05). The magnitude of reduction in strength diminishes distally, with the greatest effect in this group of patients being observed in elbow extension, followed by elbow flexion, forearm supination, and forearm pronation. Grip strength consistently showed the least amount of strength reduction compared with the uninvolved side, even within resection and reconstruction groups. Subjective patient rating of dexterity was no less than 3 of 5. Ninety percent of patients rated their dexterity 4 of 5 (52%) or 5 of 5 (38%). Conclusions: Despite the insistence of “normal” function in the distal upper extremity after limb salvage procedures, complete normality is not maintained. However, the degree of maintenance of distal function appears to be high, especially for grip strength and forearm pronation strength, and patient satisfaction is acceptable.

Sclerotic Lesion of the Tibia without Involvement of Lymph Nodes. Report of an Unusual Case of Rosai-Dorfman Disease*

Rosai-Dorfman disease, or sinus histiocytosis with massive lymphadenopathy, was first described in 1969 and is characterized by widespread adenopathy, fever, leukocytosis, an elevated sedimentation rate, and hypergammaglobulinemia12,13. Since 1969, extranodal involvement has been noted in 182 of the 423 patients in the registry of Rosai-Dorfman disease2,16. Osseous involvement is typically lytic and was observed in thirty-three of the 423 patients in the registry2. We report on a patient who was first seen because of symptoms due to a predominately sclerotic tibial lesion but who had no evidence of lymphadenopathy, a characteristic of Rosai-Dorfman disease. A seventeen-year-old black boy sustained a hyperextension injury of the left knee while playing in a high-school football game in September 1994. He was able to continue playing and did not notice any swelling about the knee until three days after the injury. He completed the football season, but he reported intermittent swelling and repeated episodes of giving-way of the knee associated with pain in the proximal part of the tibia. The pain was severe enough to awaken him at night periodically. When he was first seen in December 1994, the findings on radiographs of the knee were unremarkable. When he was seen again in March 1995, the pain had worsened progressively and continued to awaken him at night. However, he still had been able to participate in weight-training. Aspirin relieved most, but not all, of the pain for short periods. He reported occasional epistaxis and rhinorrhea, but he had no systemic symptoms. Computerized tomography scans and repeat radiographs of the knee were made, and the patient was referred for orthopaedic oncological evaluation with a presumptive diagnosis of osteosarcoma. Physical examination revealed a robust boy who was six feet (183 centimeters) tall, weighed 240 pounds (109 …

Humeral blade plate fixation of intercalary allografts and segmentally comminuted proximal humeral fractures: a preliminary report

The AO 90 degrees humeral blade plate is a relatively new device, whose primary indication and previously described use is for proximal humeral fracture non-union. This study describes the use of the humeral blade plate for extended indications-fixation of segmentally comminuted proximal humeral fractures in two patients and fixation of humeral intercalary allografts after primary humeral neoplasm resection in three patients. A mean follow-up of 20 months revealed union in both fractures and five of the six allograft-host junctions. One patient required subsequent bone grafting for non-union at a proximal allograft-host junction. Functional results were excellent in three patients, good in one, and fair in one. Problems encountered intraoperatively were directly related to the limited array of implants. The long plates which were needed had blades which were too long and required intra-operative trimming in three cases. In four cases, additional plates were used to supplement the blade plate for distal fixation. In conclusion, the humeral blade plate is a useful device for fixation in these extended indications, but longer plates with 30.0 and 40.0-mm blade lengths should be made available.

MANAGEMENT OF METASTATIC DISEASE TO SOFT TISSUE

Metastases to soft tissue are rare clinical problems. Most metastases are caused by carcinomatous deposits in the skeletal muscle, with lung carcinoma being the most common primary cause. Pain is more commonly observed in association with metastatic soft tissue masses than for soft tissue sarcomas. Treatment should be individualized, but for most carcinomas, initial radiotherapy treatment is recommended. Prognosis varies with the underlying disease, but for the typical patient with a metastatic carcinoma, mean survival duration is approximately 6 months.