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BONE SARCOMA. AN ANALYSIS OF THE CASES ADMITTED TO THE MASSACHUSETTS GENERAL AND COLLIS P. HUNTINGTON MEMORIAL HOSPITALS FROM JANUARY 1, 1911, to JANUARY 1, 1921.

GREENOUGH, ROBERT B.; SIMMONS, CHANNING C.; HARMER, TORR W.
The Journal of Orthopedic Surgery: November 1921
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1. One hundred and forty-eight cases of supposedly bone sarcoma reviewed for a ten-year period yielded for study:

Osteogenetic Sarcoma .... 27 cases

Benign Giant Cell Tumor 12 cases

Angio-Sarcoma ............... 1 case

Myeloma ................... 3 cases

2. The classification of Ewing has been adopted and of the tumors of the osteogenic group three types are distinguished, of which, however, only two are available in this series:

Sclerosing type ................ 1 case

Telangiectatic .................. 0 case

Fibro-cellular ................. 26 cases

3. Etiology: The history of trauma shortly preceding symptoms is more often obtained in cases of osteogenic sarcoma than in other classes of malignant disease (10 out of 27 cases).

4. Symptoms: Osteogenic sarcomata are more common in young adults, but occur at all ages. They affect more often the epiphyseal ends of the long bones, especially femur and tibia, but are found occasionally in other situations. The chief symptoms are pain and tumor. Spontaneous fracture may occur but is unusual.

5. Diagnosis: Errors in diagnosis are common and result from confusion of bone sarcoma with other diseases, as:

Osteomyelitis, syphilis and tuberculosis (11 cases).

Benign tumors and diseases of bone as bone cyst and osteitis fibrosa (15 cases); Paget's disease (1 case); enchondroma and osteoma (10 cases).

Sarcoma of soft parts invading bone (28 cases).

Metastatic tumors as carcinoma, hypernephroma, lymphoma, melano-sarcoma. anglo-endothelioma, myo-sarcoma, etc. (20 cases).

Neuro-blastoma (9 cases).

Chordoma (1 case).

We have examples of all these lesions being confused with bone sarcoma.

6. X-rays: The typical x-ray picture of the common form of periosteal osteogenic sarcoma is well recognized. Fourteen of this series of 28 cases were of this variety. In two cases a process of bone destruction with but little new bone formation was shown in the x-ray, -easily mistaken for metastatic cancer or osteomyelitis. In five cases the tumor was apparently central in origin, and no obvious new growth of bone beyond the cortex could be made out. The resemblance to a giant cell tumor in these cases is very marked.

7. Pathology: The attempt to distinguish osteogenic sarcoma by the intercellular substance produced by the tumor cells, or to make a hard and fast distinction between those of periosteal or medullary origin, appears to us, at present, to lead to confusion. We believe that the microscopic characteristics of the fundamental tissue of origin, -the spindle cell fibroblasts which are the progenitors of the bone-forming tissue,-are the criteria on which the classification should be based. The degree of differentiation which this tissue undergoes into cartilage, bone, etc., is of less significance than the departure from normal of the cells.

8. Treatment and Reswlts: Of 40 traced cases of osteogenic sarcoma, 23 had radical operative treatment, two had exploration only, and 15 were not operated upon. This gives an operability of 66 per cent. There was one operative death. There were three three-year cures, or 13 per cent. of radical operations. Early exploration, with permission for immediate amputation, is safer treatment in a doubtful case than delay. No material benefit was obtained by Coley serum in the four cases in which it was employed. The average duration of life of the cases dying of recurrence was 11.5 months.

Benign Giant (Cell Tumor-12 Cases.

9. Etiology: Trauma appeared as a causative agent in only three cases.

10. Symptoms: These tumors occur commonly in young adults, but are encountered at all ages. Swelling and pain are the characteristic symptoms. Spontaneous fracture occurred in only one case.

11. X-rays: The x-ray picture of a benign giant cell tumor is fairly distinctive. The tumors are of central origin, commonly near the epiphyseal ends of the long bones, but the spine, pelvis, jaw, etc., may be affected. The x-ray shows bone absorption in irregular spaces bounded by bony trabeculae. The cortex is thin and expanded. The tumor often crosses the epiphyseal line but in none of our cases perforated the joint cartilage.

12. Diagnosis: Bone cysts, osteitis fibrosa, and osteomyelitis must be excluded as well as metastatic tumors and sarcoma of the osteogenetic type.

13. Pathology: Benign giant cell tumors are composed of fairly typical fibroblasts and large numbers of endothelial foreign-body giant cells which dominate the microscopic picture. These giant cells are not significant as far as the tumor growth is concerned, and the cells of the fibroblastic tissue are regular in size, shape, and outline and show little evidence of malignancy. Osteoid tissue and cartilage may be observed but can frequently be explained by the presence of an epiphyseal line or a spontaneous fracture. New bone production is not characteristic of the tumors. We have no instance of metastasis.

14. Treatment and Results: Of the 12 traced cases of benign giant cell tumor, two have to be discarded as only six months have elapsed since operation. Of the remaining 10 cases, three had amputation performed, two had resection, while the other five cases had only in complete removal of the tumor by incision and curettage. Of these cases, one died of pneumonia immediately after operation, and one is living but with evidence of tumor still present six months after operation. The remaining eight cases have passed the three year limit without evidence of disease.

15. Recurrence: No evidence of metastasis of giant cell tumor is found in this series, and where recurrence has been observed it is local and apparently due to incomplete removal of the tumor.

Angio-Sarcoma.

16. One case of this group occurred in the series,-a man of 60, with a tumor, apparently primary, in the ilium. No treatment other than exploratory operation was attempted, and the patient died within six months.

Myeloma.

17. Nine cases appeared in the records, but pathological proof of the diagnosis was obtained in only three. All three cases showed the microscopic picture of plasma cell myeloma, but in none did it appear to be systemic, and no Bence-Jones bodies were ever demonstrated. Two were instances of single foci of disease,-one of the ilium, the other of the humerus. The first case died of hemorrhage after an exploratory operation. The second case is alive and well three months after incision and curettage. The third ease is of interest in that the tumor appeared first in the orbit; two excisions were performed, with enucleation of the eye. Two years later, another tumor developed in the lower jaw. This was excised, recurred, and again excised, and the cavity treated by radium insertion. The case is now two years under observation without recurrence.

(C) 1921 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.

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