Calvarial "doughnut lesions": clinical spectrum of the syndrome, report on a case, and review of the literature.

Many pathologic fractures, lumps on the head, elevated serum alkaline phosphatase (ALP) levels, and dental caries are the main characteristics of the rare autosomal dominantly inherited calvarial "doughnut lesions" (MIM 126550). We report the sporadic case of a 16-year-old patient who has had 10 pathologic fractures between age 6 weeks and 15 years. An elevated serum ALP level was found at age 11 and skull lumps at age 15; radiography showed frontal and parietal round radiolucencies surrounded by sclerotic bone comparable to doughnuts. Magnetic resonance imaging (MRI) showed skull lesions at an early stage. Because the findings are reminiscent of osteogenesis imperfecta (OI), collagen types I, III, and V were analyzed in fibroblasts and shown to be normal in terms of quantities, proportions, electrophoretic mobility, and thermostability. Thus, this rare syndrome can be distinguished from OI by collagen analysis and MRI of the skull at an early stage, even before palpable skull lesions appear.

Relation of neurological marker expression and EWS gene fusion types in MIC2/CD99-positive tumors of the Ewing family.

The Ewing family of tumors (EFT) is characterized by high MIC2/CD99 expression and specific EWS/ETS gene rearrangements, resulting in different chimeric transcripts. Further division into peripheral primitive neuroectodermal tumors and Ewing's sarcoma is still debated and, in the absence of distinct morphological parameters, has been based on the reactivity with neuroglial markers (NgM). We investigated 44 EFT in terms of a possible correlation between the type of EWS chimeric transcripts and reactivity with the following NgM: polyclonal and monoclonal neuron-specific enolase (NSE), S-100, chromogranin A, synaptophysin, Leu-7, glial fibrillary acid protein, and neurofilament. EWS/Fli1 fusion type 1 was detected in 30 of 44 and type 2 in 11 of 44 tumors. Three tumors, presenting with an uncommon morphology, carried rare chimeric transcripts. Our results indicate an association of lack of NgM staining with type 1 EWS/Fli1 translocations, found in 16 of 18 tumors with no NgM expression as detectable by any of the antibodies we applied. Using the monoclonal NSE antibody, 21 of 26 tumors without NgM staining expressed type 1 EWS/FLI1chimeric RNA, whereas in the groups with 1 or more and 2 or more NgM, only 9 of 17 and 1 of 5 tumors, respectively, carried type 1 EWS/Fli1 fusion transcripts. Despite this association of increased NgM expression with a non-type 1 EWS/Fli1 gene fusion, a strict correlation between the extent of NgM expression and certain EWS fusion types was not evident. This fortifies the concept to consider EFT as a spectrum of tumors and suggests the type of EWS fusion transcripts as one, but not the only parameter influencing the extent of differentiation.

[Neoadjuvant therapy for localized osteosarcoma of extremities. Results from the Cooperative osteosarcoma study group COSS of 925 patients]. / Neoadjuvante Therapie des lokalisierten Osteosarkoms der Extremitäten. Erfahrungen der Cooperativen Osteosarkomstudiengruppe COSS an 925 Patienten.

BACKGROUND: Owing to twenty years of multicentric interdisciplinary cooperation, the COSS group has been able to collect data on a large group of osteosarcoma patients treated by neoadjuvant therapy. This paper reviews results achieved in patients with localized extremity tumors. INCLUSION CRITERIA: Registration into a completed neoadjuvant COSS-Study. Histologically confirmed, primary, localized, high-grade, central osteosarcoma of an extremity; age < 40 years; no pretreatment; interval diagnosis to chemotherapy < or = 3 weeks; no severe comorbidity. Chemotherapy: HD-methotrexate +/- doxorubicin +/- cisplatin +/- ifosfamide +/- BCD. Scheduled local therapy: Surgery. RESULTS: 925 evaluable patients from 101 institutions. Median age 15 years, m:f 1.4:1. Primary site: femur 510, tibia 251, humerus 100, fibula 51, other 13. Tumor-size < 1/3 of the involved bone 616, > or = 1/3 304. Definitive surgery in 903/925 cases, 443 limb salvage procedures. Good response (> 90% necrosis) in 469/806 (58.2%) evaluated tumors. Median follow-up for surviving patients: 5.42 years. Actuarial survival after 5 and 10 years: 72.5% (95%-CI 69.3-75.7) and 66.3% (62.5-70.0), relapse-free 62.1% (58.7-65.4) and 59.4% (55.8-63.0). 683/925 alive (601 first remission), 242 deceased (212 tumor progression, 30 other causes). 66.2% (97.3%) of all relapses within 2 (5) years. Prognosis correlates with tumor-size (< vs. > or = 1/3: 69.9% vs. 58.3% at 10 years) and -site (tibia: 74.2%, humerus: 54.5%) and -response (good vs. poor: 78.2% vs. 52.5%) (all p < 0.01). Actuarial 10-year survival by response grading I-VI according to Salzer-Kuntschik 80.9%, 82.8%, 71.1%, 60.7%, 47.7%, 27.3%. COSS-studies with preoperative 4-drug therapy more efficacious than less aggressive protocols. No impact of doxorubicin scheduling (sequential: rapid vs. 48 h-continuous infusion) or cisplatin scheduling (randomized: 5 h vs. 72 h-infusion) on prognosis detected. CONCLUSIONS: Intensive multiagent chemotherapy and delayed surgery for localized extremity osteosarcoma led to excellent oncologic results in the COSS-studies. Tumor-size, -site, and -response as well as the intensity of upfront chemotherapy correlated with outcome. Giving doxorubicin and cisplatin by continuous infusions did not result in discernible prognostic disadvantages.

Long-term results of the co-operative German-Austrian-Swiss osteosarcoma study group's protocol COSS-86 of intensive multidrug chemotherapy and surgery for osteosarcoma of the limbs.

BACKGROUND: In an effort to intensify osteosarcoma therapy, systemic ifosfamide was added pre- and postoperatively to an already aggressive three-drug regimen. In a subgroup of patients, loco-regional treatment intensification was attempted by using the intraarterial route to give cisplatin. PATIENTS AND METHODS: Patients < or = 40 years at diagnosis of a localised, de novo high-grade central extremity osteosarcoma were eligible for inclusion into study COSS-86 if registered within three weeks from biopsy. Doxorubicin, high-dose methotrexate, and cisplatin were given to all patients. Patients who fulfilled one or more of three defined high-risk criteria received early systemic treatment intensification by adding ifosfamide as the fourth agent. Preoperatively, these high-risk patients received cisplatin either intraarterially or intravenously. RESULTS: 171 eligible patients were entered, of which 128 were stratified into the high-risk group. When all 171 were analysed by intention-to-treat, actuarial overall and event-free survival rates at ten years were 72% and 66%, respectively. No benefit of intraarterial cisplatin application was detected. Cumulative treatment toxicity was considerable. CONCLUSIONS: In a multicenter setting, intensive treatment of osteosarcoma according to protocol COSS-86 led to long-term disease-free survival for two thirds of patients. We saw no benefit of using the intraarterial route to administer cisplatin.

[Differential diagnosis of giant cell tumor of bone]. / Differentialdiagnose riesenzellhaltiger Knochenläsionen.

Osteoclast-like giant cells (GC) may dominate the histologic pattern not only in conventional giant-cell tumor (GCT)--originating as a radiologically pure lytic, possibly trabeculated lesion especially within the epiphyses of long tubular bones (LB) and pelvic bones of adults--but also in many tumor-like lesions as well as in various benign and malignant bone tumors which may simulate each other. Although the mononuclear cells as well as the amount of collagene fibres don't differ significantly, these lesions can be distinguished by substantial differences concerning their site, radiomorphology and the patients age. The unique lesion which can be recognized by histology only is chondroblastoma--centered in epiphyseal regions as GCT, mostly in the 2nd decade--by its typical mononuclear cells independently of the typical chondroid matrix and calcifications. The brown tumor of hyperparathyreoidism is associated with elevated serum Ca and parathormon, which is not altered in the histologically identical giant cell granuloma. In contrast to GCT aneurysmal bone cyst prefers the metaphyseal area of LB and the posterior parts of vertebras in the 2nd decade. Metaphyseal fibrous defects occurring during growth period leave the epiphyses unaffected and display typical x-rays. Villondoular synovitis sometimes can produce osteolytic defects. GC-rich malignant tumors which present with clear cut atypia except some cases of GC-variants of osteosarcoma, are: Giant-cell rich osteosarcoma, the rare malignant GCT, giant-cell ("osteoclastic") sarcoma, MFH and GC-rich metastases of carcinomas. All of them occur in middle aged and older patients except osteosarcoma and don't affect the epiphyses primarily except malignant GCT. To avoid confusion in GC-lesions it is conditio sine qua non to take into account for diagnosis not only histology but especially radiomorphology as well as site of the lesion and patients age.

Limb salvage in periacetabular sarcomas: review of 21 consecutive cases.

The oncologic and functional outcome was reviewed in 21 consecutive patients who underwent limb salvaging surgery for periacetabular sarcoma using a new surgical approach and different types of reconstruction between 1972 and 1990. Histologic diagnosis in 86% showed osteosarcomas, chondrosarcomas, and Ewing's tumors. Age ranged from 10.0 to 61.5 years (mean age, 32.9 years). The resection margin was wide in 15 patients but marginal in 2 patients and intralesional in 4 patients. All of the latter patients died of their disease. In all cases where 3-dimensional imaging was used, wide resection margins could be achieved, whereas this was possible only in 50% of the cases with conventional imaging techniques. Seven patients died of their disease 3 to 15 months after surgery, 2 died of chemotherapy induced sepsis, and 2 patients died perioperatively. At followup, 8 patients had no evidence of disease (mean, 57.6 months; range, 12-190 months), and 2 patients were alive with disease. Fourteen patients could be observed for at least 12 months (mean, 41.1 months) and were functionally evaluated according to Enneking's criteria. If extensive resection was necessary, the best results were found if the defect had been reconstructed with a custom made prosthesis. The results were only satisfactory after implantation of saddle prostheses and poor with allografts or when no reconstruction of the bone defect was done.

[Pitfalls and typical false interpretations in bone tumors. From the viewpoint of long-term consultation]. / "Pitfalls" und typische Fehlinterpretationen bei Knochentumoren. Aus der Sicht langjähriger Konsiliartätigkeit.

Problems in diagnosis of bone tumors in routine laboratories concern very rare tumors, differentiation between chondroma and low grade chondrosarcoma, the recognition of lesions containing multinucleated giant cells, lesions with secondary cysts simulating iuvenile or aneurysmal bone cyst and sometimes the discrimination of callus from osteosarcoma. Real misdiagnoses are done in ossifying pseudotumors interpreted as osteosarcoma, metaphyseal fibrous defect confound with giant cell tumor and chondroblastoma misdiagnosed as giant cell tumor or osteosarcoma. All these mistakes are avoidable if the clinical and radiological features, especially age and exact site in bone studied on the x-rays, are taken into consideration.

[Therapy-induced changes in osteosarcoma after neoadjuvant chemotherapy (COSS 86 Therapy Study). Correlation between morphologic findings and clinical follow-up]. / Therapie-induzierte Veränderungen an Osteosarkomen nach neoadjuvanter Chemotherapie (Therapiestudie COSS 86). Beziehungen zwischen morphologischen Befunden und klinischem Verlauf.

207 osteosarcomas were examined morphologically after neoadjuvant chemotherapy according to the COSS-86 protocol using representative slides of one whole tumor plane. The rate of responders 63%. In relapse-free patients both the whole tumors and the vital areas there of were smaller than in patients with relapse during a follow-up period of 5 years. Within the subgroup of osteoblastic osteosarcomas, metastases were observed following smaller tumors than in chondroblastic osteosarcomas. Therefore, in addition to degree of regression, histological subtype and tumor size should be considered in the prognostic evaluation of osteosarcomas.

Extendable tumour endoprostheses for the leg in children.

From 1986 to 1991 we fitted 20 children with endoprostheses after resection of malignant bone tumours of the leg; six have reached skeletal maturity and are the subject of this study. Reconstruction of defects in growing limbs in which the eventual shortening can be predicted requires the use of extendable prostheses. The mean age at operation was 11 years (9.2 to 13.7) and the average follow-up period was 6.3 years (4.3 to 7.6). The diagnosis was osteosarcoma in five patients and Ewing's sarcoma in one. All tumours were Enneking stage-IIB. When seen for follow-up all patients were free from disease. The extendable implants used included the Pafford-Lewis prosthesis and the Kotz Modular Femur Tibia Reconstruction system with a compatible, newly-designed growth module. Telescope-like elongation of the prostheses was performed by insertion of a screwdriver through a small skin incision. Active epiphyseal growth in the adjacent growth plate was preserved by using prosthetic stems with a smooth surface. The mean length gained was 13.15 cm (4.5 to 19.5) requiring 53 planned procedures. Seven revision operations were necessary for complications. Functional evaluation showed excellent and good results in all cases. Stress-shielding at the site of anchorage of the prosthesis was more pronounced than in adults. Implantation of extendable endoprostheses in children provides a reasonable alternative to rotationplasty, but limb salvage requires more operations.

High nm23-H1/NDPK-A expression in Ewing tumors: paradoxical immunohistochemical reactivity and lack of prognostic significance.

Expression of nm23-H1/NDPK-A has been reported to correlate inversely with metastasizing potential of rodent experimental cells and some human tumors. In the search for reliable molecular prognostic indicators for Ewing tumors (ET), a group of aggressive presumably neuroectodermal malignancies in children and adolescents, we studied nm23-H1/NDPK-A expression. Northern-blot and RT-PCR analyses were employed to semi-quantificatively measure nm23-H1 mRNA levels in ET cell lines and tissue extracts. A panel of monoclonal antibodies (MAbs) were used to evaluate protein abundance by Western blotting and immunohistochemistry. The nm23-H1/NDPK-A gene was also investigated on the DNA level to define possible genomic alterations. Our results revealed neither nm23-H1 allelic loss nor gene amplification and failed to show any significant variation in nm23-H1 mRNA or NDPK-A protein levels of primary or metastatic ET. NDPK-A protein levels were high and comparable to those of MCF-7 breast-cancer cells and to aggressive stage-IV neuroblastoma cell lines. nm23-H2/NDPK-B expression in ET was slightly more variable but generally lower than in MCF-7 cells. In the immunohistochemical analysis, however, discrepancies in the reactivity patterns with different antibodies were observed. Differential sensitivity to various fixation methods and heat treatment pointed to a structurally polymorphic NDPK-A protein. nm23-H1 expression studies using immunohistochemistry for prognostic counselling should thus be interpreted with caution.

[Osteosarcoma--apoptosis and proliferation. Study of bcl-2 expression]. / Osteosarkom--Apoptose und Proliferation. Untersuchung zur bcl-2-Expression.

The relationship between the growth of tumors and the expression of the protooncogene Bcl-2 could be shown in epithelial tumors. A bcl-2 expression leads to a prolonged cell survival due to an inhibition of apoptosis. The potential meaning of bcl-2 expression in mesenchymal tumors remains still unknown. The fact, that the heterogenous group of osteosarcoma is not sufficiently characterized at present, suggested to investigate the bcl-2 expression in osteosarcoma. Thus, immunohistochemistry was used to analyze 47 specimens of different osteosarcomas of 36 patients. Sixteen cases (46%) showed a strong expression of bcl-2 and 13 cases (35%) were moderately positive for bcl-2. Seven cases (19%) were negative for bcl-2. The heterogenous, negative up to strong expression of bcl-2 yield clues, that the Bcl-2 controlled regulation of programmed cell death could be an important factor of cellular kinetics. Additionally the cellular proliferation rate was determined with the monoclonal antibody MIB 1, directed against the Ki-67 epitope. The data of bcl-2 expression and cellular proliferation rate lead to a classification correlating with the histological classification. To verify the importance of apoptosis in the genesis of mesenchymal tumors and whether Bcl-2 may play an important role as a predictive factor for the prognosis of osteosarcoma, further investigations will be needed.

Variability of EWS chimaeric transcripts in Ewing tumours: a comparison of clinical and molecular data.

Ewing tumours (ET), including Ewing's sarcoma and peripheral primitive neuroectodermal tumour, are well characterised at the molecular level by a unique chromosomal rearrangement which fuses the EWS gene to one of two closely related ETS proto-oncogenes, FLI-1 or ERG. Expression of the resulting chimaeric transcripts can be readily detected by reversed transcriptase polymerase chain reaction (RT-PCR). This approach led to the identification of a number of different exon combinations at the junction site of coding sequences. The physiological consequences of the observed variability in the hinge region of EWS chimaeric proteins are not known. We have analysed tumour-derived material from 30 ET patients with well-documented clinical course (18 with localised and 12 with metastatic disease at diagnosis) for the presence of EWS/FLI-1 or EWS/ERG RNA. Karyotypes were obtained in 21 out of 27 cases and analysed by routine cytogenetics. A chromosome 22 rearrangement was demonstrated in 18 cases (67%). In contrast, RT-PCR revealed the presence of chimaeric transcripts in 28 tumours (93%), with fusions of EWS exon 7 to FLI-1 exons 6 (19/28), 5 (4/28) and 7 (1/28). In addition, EWS/FLI-1 exon combinations 10/5 and 9/4 were observed in one case each. In the last tumour, the presence of at least four additional splicing variants corresponding to fusion of EWS exon 7 to FLI-1 exons 4, 6, 8 and 9 was demonstrated. Two tumours expressed EWS/ERG fusion transcripts involving EWS exon 7 and ERG exon 6. In this study, EWS/FLI-1 exon combinations 7/6 (type I) predominated over 7/5 (type II) in localised ET (14 versus 1) and were more abundant in tumours affecting the long bones (9 versus 0), whereas in central axis tumours and metastatic disease there was only little difference in the frequency of the two types. So far, no correlations between different chimaeric EWS transcripts and any other clinical parameters have been identified.

[The EWS gene rearrangement in Ewing tumors: key to the disease]. / Das EWS-Genrearrangement in Ewing Tumoren: Schlüssel zur Erkrankung.

The family of Ewing tumors (ET) is characterised by a unique gene rearrangement which is represented by a translocation t(11;22) (q24;q12) or a deletion del 22q12 in most cytogenetically analysable cases. The recent cloning of the underlying gene fusion provides the basis for the diagnostic detection of minimal amounts of residual tumor cells at resection margins, in blood and bone marrow. In addition, the very first steps in ET tumorigenesis can be studied on a functional basis. In this study, a variety of fusion products were identified with a sensitivity of 10(-6) by means of RT-PCR. In 20 of 22 ET, a gene rearrangement was identified which resulted in the substitution of the effector domain of one of the closely related DNA-binding oncogenes, FLI-1 or ERG, by the transactivating domain of a new gene, EWS. Presumably, the oncogene and consequently its target genes are activated by this type of translocation. If the EWS domain was replaced with a transcriptionally irrelevant domain by transfection of a recombinant gene into ET cells, competition with the endogenous chimeric oncogene-product for DNA-binding was observed resulting in a partial growth inhibition. Activation of FLI-1 has been previously shown to occur as a primary event in Friend virus induced mouse erythroleukemia. During progression of this disease, inactivating p53 mutations have been observed frequently. In contrast, such aberrations were found to be extremely rare in ET.

Translocation (12;13) in a case of infantile fibrosarcoma.

Cytogenetic analysis of an infantile fibrosarcoma showed the presence of a t(12;13) and numerical changes of chromosomes 15 and 20. Until now only non-random gain or loss of total chromosomes as well as one case with a deletion at 17p have been reported for this kind of tumor. This report represents the first cytogenetic description of an aggressive infantile fibrosarcoma with a translocation.

Narrow spectrum of infrequent p53 mutations and absence of MDM2 amplification in Ewing tumours.

The p53 and MDM2 genes are part of a physiological pathway frequently impaired in human cancer. With the exception of tumours occasionally associated with hereditary predisposition, childhood malignancies have not been studied in detail yet. This is the first report on the analysis of p53 and MDM2 in a group of non-hereditary paediatric neoplasms referred to as the Ewing tumours (ETs). Thirty-seven primary tumours and cell lines from 19 patients were screened for the presence of p53 mutations. Only 5% of the primary tumour specimens were found to carry an alteration within this gene. However, p53 mutations were 10-fold enriched in ET cell lines, thus indicating a selective growth advantage in vitro. Strikingly, five out of nine alterations detected were missense mutations within codon 273, which were previously reported to impair only partially the normal p53 function. Two single-base substitutions occurred at codons 277 and 176, and two alterations were loss-of-function mutations. Investigation of the MDM2 gene revealed neither gene amplification in the primary tumours and cell lines nor significant overexpression in any of the cell lines. Our data therefore suggest that impairment of cellular mechanisms involving p53 is rare in a distinct group of childhood malignancies.

Treatment of osteosarcoma: experience of the Cooperative Osteosarcoma Study Group (COSS).

Using high-dose methotrexate, doxorubicin, and cisplatinum (or BCD) for adjuvant chemotherapy in osteosarcoma of the extremities, we achieved 8-year metastasis-free survival rates of 60-70%. No relapse has been observed after that time. A dose of 12 g/m2 of high-dose methotrexate seems superior to 6 g; doxorubicin was found to be indispensable for efficient therapy and administering ifosfamide in addition seemed to be beneficial. Primary chemotherapy appeared to be safe and to facilitate surgery. The response on chemotherapy provided valuable prognostic information. Salvage of poor responders by alternative postsurgical chemotherapy was unsuccessful. Intraarterial, as opposed to intravenous, use of cisplatinum, in addition to systemic three-drug chemotherapy, did not improve the local tumor response rate. The local failure rate was low (4.7%); it was higher, however, after limb-salvage procedures than after amputation and rotationplasty (11.1% vs. 2.2%, p < 0.05). The outcome after local failure was almost universally fatal. The most intriguing late sequelae of chemotherapy were cardiomyopathy due to doxorubicin and hearing loss due to cisplatinum. Given the limited number of effective drugs, it might be difficult to further improve the cure rate and also to diminish late toxicity. Exploration of the most effective but least toxic mode of drug administration might be one possibility. Another might be reduction of the cumulative doses and therapy duration, while simultaneously increasing the dose rate.

[Current classification of primary malignant bone tumors]. / Aktuelle Klassifikation primär maligner Knochentumoren.

The classification of primary malignant bone tumors has to include: 1. Histologic diagnosis, iusing immunohistochemistry especially in small-round- and spindle-cell tumors. 2. Grading of malignancy, iusing proliferation factors. 3. Definition of compartmentalisation. 4. Staging. Only when all these factors are defined it is possible to plan the best therapy, to compare the results of different centers and to overwork it scientifically. Investigation of chromosomes, oncogenes, chemotherapy resistance a.o. are to be added for classification in next future.

[The limits of saving the extremity--amputation versus resection]. / Die Grenzen der Extremitätenerhaltung--Amputation Versus Resektion.

On the basis of the extensive data contained in the Vienna Bone Tumor Register, i.e. 839 primary malignant bone tumors, as well as of 554 cases treated at the Orthopedic Department of the University of Vienna Medical School, a comparison between the methods of surgery applied at pelvis and extremities during the past two decades can be drawn. Resectional therapy had been performed in twice as much patients as amputation therapy, and barely 20%, mostly with multiple metastases, had been merely treated with palliative surgery or were just biopsied and underwent chemo- and radiotherapy. An analysis of amputations and resections, subdivided into pelvis and sacrum resections, resectional reconstructions and resectional reimplantations at the extremities, shows approximately the same low incidence of local recurrences in the groups amputation versus resection, but a significantly higher involvement of pelvis and sacrum resections as well as no local recurrences in the group of 48 resectional reimplantations. As regards the oncologic radicality of surgical margins, in cases of resections, as compared to amputations, about twice as much inadequate operations had to be accepted, though. The fact that the local recurrences did not increase to the same degree, but were approximately equilibrated, seems to be due to the new chemotherapeutic treatment which had been initiated at the same time as the frequent application of resectional therapy. The conservation of extremities contains twice as high a risk of inadequate operation, but it is, in cases of effective chemotherapy, comparable with the former results of amputations, as regards local recurrences.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphometric analysis of cartilaginous tumors.

144 chondromas and chondrosarcomas have been investigated. Morphometry has been performed: the relative volume density of tumor cell nuclei (Vv%n) and the nuclear area have been measured. The results show that the relative volume density of nuclei is a useful parameter, regarding the localisation of the tumors, to discriminate chondromas and chondrosarcomas, while the nuclear area is no safe criterion to separate these entities.