Metastatic spread of fibrosarcoma of bone; A report on forty-nine cases, and a comparison with osteosarcoma.

Of tumours arising in otherwise normal bones, fibrosarcoma is about one-third as common as osteosarcoma and may have a very slightly better prognosis. A comparison of the aetiology and behaviour of forty-nine fibrosarcomata and 152 osteosarcomata indicates several similar features. Fibrosarcoma lacks the characteristic peak incidence in adolescence of osteosarcoma, but the age and sex distributions of both tumour types in patients of middle life--twenty-five to sixty-five years--are remarkably similar, even in their frequency. With fibrosarcoma, perhaps, lung metastases are fewer and appear later, thus contributing to the slightly better survival, but there is some increase in the proportion of extra-pulmonary secondaries. As with osteosarcoma, patients with fibrosarcoma show some increase in the length of post-metastatic survival when metastases are of later appearance. For the whole series the five-year crude survival rate was 21 per cent, better results being recorded for patients with histologically well differentiated tumours (30 per cent) and for long bone tumours when the patient was metastasis-free initially and the tumour was treated by prompt ablation (40 per cent). These are probably the best results one may expect for osseous fibrosarcoma without recourse to adjuvant antimetastatic therapy. Complete control of the primary tumour is likewise mandatory, and can be assured only by complete surgical removal when this is technically feasible.

Ewing's tumour. A study of behaviour and treatment in forty-seven cases.

Forty-seven histologically confirmed cases of Ewing's tumour are reported, with typical age, sex and skeletal distributions. The disease-free survival curves are like those for osteosarcoma of corresponding types of bone, but with higher mortality. The two-year disease-free survival rates were 24 percent for tumours of long bones and 5 per cent for those of other bones. Osseous metastases were most frequent, although the lung was the commonest single site involved. There were secondary deposits in lymph nodes in nine patients, possibly also in four more with mediastinal enlargement. Although initially radiosensitive, one-third of tumours recurred locally, almost always with the appearance of metastases. Neither whole bone irradiation nor high dosage alone ensures complete control of the primary tumour, and it is suggested that recently reported improved results of treatment should be attributed to adjuvant multi-drug chemotherapy. Inadequate control of the primary tumour diminishes the chance of survival and for some sites radical operation merits reconsideration.

Metastatic spread of osteosarcoma.

A study is presented of the rate of metastatic spread of osteosarcoma. The series consists of 123 tumours in long bones and 26 elsewhere in the skeleton. All tumours occurred in otherwise normal bones and were histologically proven. With a few stated exceptions all the cases were consecutively registered.Both the mean disease-free interval from the time of starting treatment and the crude survival curves are given. The long bone cases are analysed by groups according to the method of treatment, the patient's sex, age and tumour site. There were too few tumours of all other sites to warrant this discriminative treatment. Whilst the results of surgical treatment are better than for radiotherapy or a combined technique, the differences are not statistically significant and the information is recorded primarily to assist the evaluation of new forms of treatment of occult and overt metastases. Some problems in connection with such clinical trials are discussed briefly.

Incidence of bone sarcoma in SW England, 1946-74, in relation to age, sex, tumour site and histology.

A study is presented of all cases of primary sarcoma of bone registered during the period 1946 to 1974 for a specified population resident in south-western England. Ninety-six per cent of the 365 cases were histologically and radiologically verified and are separated into 8 categories of sarcoma. The number of tumours presenting during each hemi-decade did not markedly diverge from the 5-year mean for the period, nor was any significant change found in tumour incidence during the last 20 years of the survey. The age, sex and site distributions correspond with those reported elsewhere. Age-specific incidence rates are compared with those published for Sweden. For osteosarcoma and Ewing's tumour, both commoner in young people, the two series agree closely up to age 55 years, after which the Swedish incidence rates rise and are not exceeded when, for the present cases, Paget's osteosarcomas are included. Whilst Paget's disease may change the age incidence of some types of bone sarcoma, it is uncertain whether it increases the total number which occur. Differences in tumour incidence between males and females, whether for a specific type or for all bone sarcomas, are seldom statistically significant, but the patterns appear to be consistent.

The metastatic patterns of osteosarcoma.

The paper presents a detailed comparison of the anatomical distribution and frequency of clinically evident metastases in 152 cases of osteosarcoma, and autopsy findings in 43 cases. The behaviour of long bone tumours is contrasted with those arising elsewhere, which tend to metastasize less widely because of early death from effects of the primary tumour. In both clinical and autopsy series long bone tumours produced lung metastases (LM) in over 90% of patients dying with metastases, but the terminal frequency of extra-pulmonary metastases (EPM) rises from a clinical level of 33% to 83% at autopsy. There was little difference between tumours of the major long bones in the frequency of either LM or EPM, but EPM from the humerus tended to be fewer and sited above the diaphragm and from the femur below it. EPM most often involved other bones, notably vertebrae and pelvis. Not more than 10% of tumours invaded regional lymph nodes but terminally a quarter of the long bone tumours had metastasized to heart and abdomen. The infrequency of metastases in muscle was confirmed. The median time for LM was 5-6 months after starting treatment, for EPM 9-10. months. First metastases after 24 months were infrequent, especially in children. With delay in the appearance of metastases, whether LM or EPM, post-metastatic survival lengthened. Neither age, sex nor mode of treatment of the primary notably affected metastatic frequency, although recurrences were much more numerous when radiotherapy, even with high dosage, was the definitive treatment. Local recurrence usually appeared within 6-8 months and was shown to lead to increased frequency of osseous metastases. It is suggested that terminal dissemination may often be tertiary but not always from a pulmonary secondary.