Epithelioid osteosarcoma of the scapula.

Epithelioid and epithelial neoplasms of bone are rare. They include different epithelioid variants of vascular lesions, osteoblastoma, chondroblastoma and most importantly metastatic carcinoma. Up to now, only few cases of epithelioid osteosarcoma were described. In this case the authors report a 53-year-old patient presented with a medical history of chronic shoulder pain for 3 years. Magnetic resonance imaging (MRI and computed tomography (CT) showed a destructive, partially calcified osseous lesion of the scapula with expansion into the surrounding soft tissue, suggestive of a primary bone tumor. Histologically, the tumor consisted of epithelioid cells with expression of cytokeratine and the lesion was primarily diagnosed as metastatic carcinoma. With regard to the MRI morphology untypical for metastatic disease the histopathologic slides were re-evaluated and detection of tumor osteoid led to the diagnosis of epithelioid osteosarcoma. Chemotherapy was initiated, however follow-up imaging studies showed rapidly progressive disease of both primary tumor and lung metastases. In conclusion, epithelioid neoplasms of the bone are extremetumourly rare and must be distinguished from metastatic carcinoma. Despite the presence of cytokeratine positive cells a thorough histological evaluation is mandatory and osteoid detection is essential in order to establish the correct diagnosis and further treatment. Key words: osteosarcoma, epithelioid, aneurysmal bone cyst, chondrosarcoma, pathology, immunohistochemistry.

The many faces of chondrosarcoma of bone, own cases and review of the literature with an emphasis on radiology, pathology and treatment.

Chondrosarcoma is the third most frequent primary malignant tumor of bone, constituting up to 16% of the malignant osseous neoplasms. Up to date several genetic alterations and markers were described concerning the pathogenesis and the progression of the chondrosarcoma, which represents actually a heterogeneous group of different types including conventional intramedullary, clear cell, myxoid, mesenchymal, and dedifferentiated chondrosarcoma. The pathologic appearance varies, however, in general they grow with a lobulated pattern. Histologically the hyaline cartilage demonstrates high water content and typically enchondral ossification is apparent. Imaging reflect this while radiographic findings suggest the diagnosis when the typical "ring-and-arc" chondroid matrix mineralization, endosteal scalloping and soft-tissue extension were apparent. The CT is used for detecting the mineralization of the matrix, especially when it is subtle or when the lesion is located in complex areas. MRT is the method of choice to detect the high water content of these lesions with a high signal intensity with T2-weighting and its bone marrow extend. Surgical resection is the primary and preferred treatment modality for most individuals with localized disease. In selected cases of the Grad I conventional chondrosarcoma curettage should be discussed. Systemic chemotherapy may be considered in variant forms such as mesenchymal or dedifferentiated chondrosarcomas. In knowledge of the "many faces" of the primary chondrosarcoma individualized patient assessment and optimal clinical management is possible.

Differential diagnosis of primary malignant bone tumors in the spine and sacrum. The radiological and clinical spectrum: minireview.

Although primary malignant tumors of the spine and sacrum are described in all orthopedic textbooks, it is still remarkable how little attention is paid to differential diagnosis of persisting lower back pain and how to detect in special the underlying tumor disease. Chordoma, osteosarcoma, chondrosarcoma, plasmacytoma, lymphoma and Ewing's sarcoma, their radiological manifestation, age distribution and preferred location in the spine and sacrum are reviewed and discussed.

DNA content, ploidy level and number of nuclei in the human heart after myocardial infarction.

OBJECTIVE: Cardiac hypertrophy due to a prolonged functional activity is associated with an increase of cell size and polyploidization of the myocyte nuclei. Myocardial infarction is characterized by loss of myocytes. Increased load and as a consequence hypertrophic growth of the surviving myocardium has to be expected. The aim of this study was to investigate the response of cardiomyocytes after infarction. METHOD: Biochemical and cytophotometric analysis was performed on myocyte and connective tissue nuclei to determine whether the human heart after myocardial infarction is accompanied by an increase in the ploidy level, DNA content and in the number of nuclei. A total of 15 hearts obtained from autopsy material was studied, among them 8 after myocardial infarction. The number of nuclei was measured by indirect computation. RESULTS: We found a decrease of 4c and no significant difference of 2c nuclei in infarcted hearts. DNA ploidy level (> 8c) as well as the proportion of aneuploid myocyte nuclei were increased in infarcted hearts. DNA concentration and total DNA content were increased in the hearts after myocardial infarction. Numerical ratio of connective tissue nuclei/myocyte nuclei, total number of nuclei, number of myocyte nuclei and number of connective tissue nuclei were increased in infarcted hearts. CONCLUSION: Polyploidization and nuclear hyperplasia of myocytes may represent an adaptive response of the myocardium to an ischemic injury.

Fibromyxoma of the femoral neck.

A case of fibromyxoma of the long bone is presented. This benign bone tumor is more often found in the bones of the jaw, but is a rare lesion in extragnathic bones. IN the presented case of a 28-year-old man the tumor was situated in the right femoral neck. In the roentgenograms it showed a cast-like osteolytic defect with unclear marginal sclerosis and patchy densities within the lesion. Histologically, the tumor consisted of a proliferating hypocellular myxomatous tissue with some focal calcification and fibrous areas. No chondroid pattern was present and there was no clear lobulation. Differential diagnostic considerations include ganglia of bone, chondromyxoid fibroma, chondrosarcoma and fibrosarcoma, all of which may contain prominently myxoid zones.

Regeneration processes in human myocardium after acute ischaemia--quantitative determination of DNA, cell number and collagen content.

We examined and compared 22 human hearts (6 normal hearts, 4 with hypertrophic cardiomyopathy and 12 after acute ischaemia) for their DNA and collagen content and their cell number. A positive correlation between total heart weight and DNA content was demonstrated in all hearts. The relative DNA content decreased and the rate of polyploidy increased in the infarcted and hypertrophied hearts. An aneuploid DNA content was found only in the infarcted hearts. Both hypertrophied and infarcted hearts showed a significantly higher collagen content than did the normal hearts. There was a positive correlation between collagen content and total heart weight in the hypertrophied hearts but not in the infarcted hearts. In the infarcted hearts, the increase in the relative collagen content in the left ventricle was significantly larger than that in the right ventricle. Heart cell number was higher than normal in some hearts with acute ischaemia, which was possibly a sign of compensatory regeneration of heart cells in hearts damaged by ischaemia.

Variability of cardiomyocyte DNA content, ploidy level and nuclear number in mammalian hearts.

DNA content, ploidy level, cell size and nuclear number were investigated in 54 mammalian hearts from nine species. DNA content was determined biochemically and ploidy level of cells was studied by the means of Feulgen cytophotometry. Nuclear number was calculated by a new method, while cell size was determined by using ocular micrometry. In most mammals diploid cell nuclei predominate. Higher ploidy levels were found in the human and the pig hearts. The total amount of DNA correlated with the myocardial weight. Eight million heart muscle cell nuclei were found in mice (myocardial weight 160 mg), and 2600 million heart muscle cell nuclei in the human heart (myocardial weight 210 g), but in the hearts of horses up to 35000 million heart muscle cell nuclei (myocardial weight 3.4 kg) were found. The number of heart muscle and connective tissue cell nuclei was correlated with myocardial weight. The ratio of connective tissue cell nuclei to heart muscle cell nuclei was between 2:1 and 3:1. In cardiac growth this ratio shifted towards connective tissue cell nuclei. Increased heart weight corresponds to an increase in cell size. Diameter between 11 microns and 18 microns may be an optimum for heart muscle cells of mammals.

DNA-image cytometry and clinical staging systems in multiple myeloma.

Clinical and hematological parameters, and three derived major staging systems were compared with DNA-cytometric parameters in 73 patients with newly diagnosed multiple myeloma (MM) and correlated in univariate analysis with survival to assess their predictive value. Regarding diagnostic validity, a multi-parameter system including STL, 5cER, PRF and MNA correctly classified 92% of MM as malignant (sensitivity 92%) at a 100% specificity. Regarding prognosis, the most powerful single clinical parameter was serum creatinine (p < 0.001, median survival [ms] 51 vs. 14 months) followed by platelet count (p < 0.01, ms 67 vs. 11 months). Mean nuclear area of plasma cells was the only cytometric parameter with prognostic relevance (p < 0.05, ms 43 vs. 14 months). Neither the original Salmon-Durie staging (p < 0.05 for I vs. II, p > 0.05 for II vs. III) nor the revised Salmon-Durie staging by Cavo et al were able to discriminate three patient groups at statistically significant levels. Only the staging system proposed by the British Medical Research Council (MRC) was found to be able to predict survival for all three groups significantly (p = 0.01 for A vs. B, p < 0.01 for B vs. C; ms A/B/C = 68/37/14 months, respectively).

Comparison of MR sequences in quantifying in vitro cartilage degeneration in osteoarthritis of the knee.

Magnetic resonance imaging of amputated human knees was performed to determine optimal sequences for depicting articular cartilage. 24 knees were examined with eight different sequences in a 1.0 T imager. Each cartilage lesion was graded from 1 to 4 (Outerbridge staging system). The results of each sequence were compared with the macroscopic findings and statistically tested against each other. The FLASH sequence (TR = 50 ms) with combination of flip angle of 40 degrees and echo time of 10 ms and the FISP sequence (TR = 40 ms) with combination of flip angle of 40 degrees and echo time of 11 ms were best for depicting cartilage structure and internal detail. There was no significant difference between fat-saturated three-dimensional FLASH (FS-3D-FLASH) and FS-3D-FISP (p = 0.05). These FS-3D sequences were significantly better than sequences without fat saturation (p = 0.05). There was no significant difference between magnetization transfer (MT) 3D-FLASH, MT-3D-FISP and 3D-FISP. All 3D sequences showed significantly (p = 0.05) better results than spin echo or fast spin echo sequences. The T1 weighted SE pulse sequence was significantly (p = 0.005) better than the T2 weighted TSE sequence. Fast T2 weighted spin echo was not suitable for early and accurate detection of cartilage lesions.

Radiologic findings in peripheral neurilemoma.

Neurilemoma is a primary nerve sheath tumour that usually arises from a peripheral nerve. In a series of eight solitary neurilemomas four benign and four malignant tumours are observed. Three neoplasms are of intrathoracic origin, four tumours arise in the retroperitoneal space and one tumour develops in the duodenal wall. Radiographic findings using computed tomography, ultrasonography and arteriography are presented. All neurilemomas show relatively low density in CT compared with other parenchymal tumours. All benign and three of the malignant neurilemomas reveal good contrast enhancement. Arteriography has an important role in defining the tumour's blood supply and establishing the origin of the tumour. Five of six neurilemomas show hypervascularity in arteriography. Ultrasonography shows cystic degeneration in three malignant and in one benign neurilemoma. Pathologic correlation of peripheral neurilemoma is discussed by using a special immunoperoxidase technique.

Value of angiography, sonography, and CT in renal infarction.

The value of angiography, sonography, and computed tomography as diagnostic methods for renal infarction is discussed. In all cases the infarct could be demonstrated angiographically, but not by sonography. In the case of a former infarct, the involved area appeared as a tumour mass by sonography and enhanced CT-scan showed contrast enhancement of the mass.

Differential diagnosis of cartilage tumors.

A total of 1187 cartilage tumors have been diagnosed at the Reference Center for Bone Tumors of the University of Freiburg; 67 of these were chondrosarcomas. All tumors were coded in terms of their frequency, age distribution, and localization. The typical radiographic, macroscopic, and histologic architecture is described for each tumor, and differential diagnostic aspects are described. Special attention is devoted to the distinction between proliferating chondromas and well-differentiated chondrosarcomas. which are often very difficult or even impossible to distinguish histologically. A grading system for chondrosarcomas is described. Cytophotometric DNA measurements may be applied to cartilage tumor cells in an effort to objectify the radiologic and histologic findings, and to make possible a decision between "benign" and "malignant". With the help of these modern histochemical methods it should be possible to solve differential diagnostic problems in cartilage tumors.

Cytophotometric measurements of the DNA in Hodgkin lymphomas and non-Hodgkin lymphomas.

In smear preparation of lymph nodes excised from 36 patients with a malignant lymphoma the DNA content was estimated in different tumor cells following Feulgen staining by means of quantitative cytophotometric measurements. The tumors investigated included 11 Hodgkin lymphomas and various types of Non-Hodgkin lymphomas (altogether 25). Whereas the small lymphoid cells found in Hodgkin lymphomas show a diploid DNA content with a wide scattering, in the large mononuclear reticular cells (Hodgkin cells) as well as in Sternberg's giant cells only aneuploid DNA values are seen lying in the hyperdiploid, hypertetraploid and hyperoctoploid regions. DNA stemlines are found in the aneuploid regions, but in some cases they are missing. This indicates that we are dealing with malignant tumor cells. In Non-Hodgkin lymphomas with a low grade of malignancy (centrocytic-centroblastic lymphoma, centrocytic lymphoma, CLL) an aneuploid DNA content is found particularly in the large cells (centroblasts, lymphoblasts) with or without a DNA stemline. These cells must be considered as primary malignant tumor cells. In the immunoblastic lymphoma of high malignancy only aneuploid tumor cells are present showing a particularly intense DNA content in the large immunoblasts, whereas a DNA stemline is usually missing. The range of aneuploid values, the number of polyploid tumor cells and the presence or absence of a DNA stemline are important criterions in determining the degree of malignancy. By means of cytophotometric measurements of the DNA content in the tumor cells of malignant lymphomas it is possible to assertain the degree of malignancy and to establish an objective prognosis.

Cytophotometric DNA-analysis of bone-tumors. A new method for preparing formalin-fixed tissue and the regarding of DNA-malignancy grade and its prognostic value.

78 benign and malign, formalin-fixed bone or bone-associated tumors of different origin were prepared for image-cytophotometric measuring with a new method of preparing. The DNA-content of the tumors and the so resulting malignancy-grade were determined and compared with the corresponding measurements of unprepared fresh tumors respectively paraffin-embedded tissue sections. Regarding the comparison of the fresh material with the formalin-fixed material, no significant difference (p < or = 0.01) of the data could be found. There was also no significant difference (p < or = 0.01) concerning the comparison of the data obtained from the formalin-fixed material and the data from the tissue sections. The criterium aneuploidy showed a sensitivity of 86% and a specificity of 100% in regards to identifying a malignant tumor, irrespective of the preparation method. A strong correlation could be found (p < 0.001) between the DNA-malignancy grade and the survival rate of the patients.

Change in size, number and morphology of the nucleoli in human hearts as a result of hyperfunction.

In the present study we examined light-microscopically the nuclei of 16 hearts (7 normal hearts, 7 hearts with hypertrophy and 2 hearts with atrophy) for the size, number and morphology of their nucleoli. The size of the nucleoli, defined as the total area of all nucleoli per nucleus, was an early and sensitive indication of a beginning hypertrophy of the myocardium. It increased in parallel to the total heart weight and to the total area of the nucleus of the cell, but initially the size of the nucleoli changed earlier than the other parameters. We found an increase of the ratio in the total area of the nucleoli per nucleus to the total area of the nucleus at the beginning of clinical hyperfunction. This ratio normalised during chronic hyperfunction. The number of the nucleoli also increased during hyperfunction, but it did not exceed the number of nucleolus organiser regions (NOR) given by the number of chromosomes. Nevertheless, we found numbers of nucleoli higher than 10 because, the number of NORs increases during polyploidization. Regarding the morphology of the nucleoli in hearts with hypertrophy, we found a predomination of the nucleoli with a highly branched nucleolonemal structure as an indication of an increased RNA synthesis.

[Malignant fibrous histiocytoma of soft tissue. Pathology and radiology of an unusual sarcoma]. / Malignes fibröses histiozytom der Weichteile. Pathologie und Radiologic eines eigenartigen Sarkoms.

Four cases of malignant fibrous histiocytomas are reported. An attempt is made to determine some characteristic roentgenologic features of this disease. There is no pathognomonic radiologic sign; however, angiographic documentation of hypervascularization together with neovascularity and absorption values of about 35 HE in computed tomography suggest a predominantly fibrous sarcoma. Differential diagnosis on abscess formation, tumours of the fat tissue and primary vascular neoplasms should be performed and these conditions ruled out if not applicable.

[Angiographic examinations of the stomach following Billroth II resections with special reference to the gastro-jejunostomy (author's transl)]. / Angiographische Untersuchungen am Billroth II resezierten Magen mit besonderer Berücksichtigung der Gastrojejunostomie.

The arterial blood supply of the anastomosis in 6 stomach resected dogs (Billroth II) is examined by common angiographic technique in vivo, microangiography, and microscopy. In all animals there are at the site of the gastrojejunostomy bizarre tortuous vessels which cross the anastomosis. These arteries have a diameter between 50 to 2000 mu. They are newly formed vessels which cannot be demonstrated by common coeliaco- and mesentericography in animal experiments or in patients.

[MR tomography of aneurysmal bone cyst]. / MRT der aneurysmalen Knochenzyste.

The preoperative findings of magnetic resonance imaging (MRI) in six histology-proven aneurysmal bone cysts (ABC) are examined and compared with previous publications concerning MRI of ABC. The signal intensities differ considerably, and not all of our cases conform with the literature data. They can be summarised in three different subheadings: one form that is very inhomogeneous in T1- and T2-weighting, with fluid-fluid levels in the cystic spaces; one intermediate form without fluid-fluid levels, which is inhomogeneous only in T2-weighted images; and finally, an unusual form of ABC that has homogeneous low signal both in T1- and T2-weighting, and which has not been described in literature so far.

[Giant-cell reaction of the short tubular bones of the hand and foot]. / Die riesenzellige Reaktion der kurzen Röhrenknochen von Hand und Fuss.

Giant cell reactions in the short tubular bones comprise mainly enchondromas, aneurysmal bone cysts and giant cell tumours. In both cases a history of trauma can be related. We therefore agree with Aegerter and Lorenzo that an intra-osseous haematoma due to minor trauma is likely to be of pathogenic significance.

Differential diagnosis of benign tumors and tumor-like lesions in the spine. Own cases and review of the literature.

Although benign tumors and tumor-like lesions of the spine are shown in every orthopedic teaching book, it is often surprising how little attention is paid to the differential diagnosis and diagnostic investigations, respectively, since surgical treatment and postoperative control depends on exact diagnosis. Clinically the importance of this fact can not be over-emphasized. The most common complaint is pain, either local or radicular in nature. Bone deviations are diagnosed radiologically. Different types of benign bone tumors and tumor-like lesions of the spine including osteochondroma, osteoblastoma, osteoid osteoma, aneurysmal bone cyst, eosinophilic granuloma, hemangioma, and giant cell tumor, their appearance relation to the age and location in the spine were reviewed and the common histologic subtypes described. Clinical, laboratory and histopathologic findings, radiologic inclusive MRT and scintigraphic features are evaluated. Diagnostic investigations including the invasive techniques of CT guided needle biopsy, Yamshidi needle biopsy and costotransversectomy for biopsy are shown. Treatment including radiation, chemotherapy and the surgical procedure as well as the postoperative treatment of patients with benign tumors and tumor-like lesions of the spine are discussed.