Pulmonary function tests after whole-lung irradiation and doxorubicin in patients with osteogenic sarcoma.

PURPOSE: Because of the scarcity of information regarding long-term follow-up of pulmonary function after whole-lung irradiation, a prospective study was started at the University of Florida in 1979 to evaluate pulmonary function after treatment with whole-lung irradiation and doxorubicin in patients with osteogenic sarcoma. PATIENTS AND METHODS: Between 1979 and 1984, 57 osteogenic sarcoma patients with no evidence of metastatic disease at diagnosis received adjuvant therapy consisting of whole-lung irradiation (with the heart shielded) followed by Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH). The whole-lung irradiation schema was 1,600 cGy in 10 fractions with 8-MV x-rays via anterior and posterior fields. This was followed by five cycles of Adriamycin for a total dose of 450 mg/m2. Pulmonary function tests (PFTs) consisting of spirometry, lung volumes, and diffusing capacity were obtained before the whole-lung irradiation, at 6 and 12 months after irradiation, and at yearly intervals thereafter. RESULTS: At the time of analysis, 28 of the 57 patients were available for study, with a mean follow-up of 42 months (range, 6 to 77 months). Follow-up pulmonary function testing revealed decreased forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) during the first 6 to 12 months after whole-lung irradiation. These values returned to baseline during the second-year posttherapy and remained at baseline throughout the remainder of the follow-up period. Changes in lung volumes demonstrated a similar early trend, with significant decreases in total lung capacity (TLC) and functional residual capacity (FRC) at 6 to 12 months. These changes, however, did not improve significantly during the remainder of the follow-up period. Diffusing capacity of the lungs for carbon monoxide (DLCO) also reached a nadir at 6 to 12 months after whole-lung irradiation, with resolution by 2 years and maintenance of at least baseline values for the remainder of the follow-up period. CONCLUSIONS: Treatment with whole-lung irradiation and Adriamycin, as given in this study, caused no significant sequelae, as demonstrated by pulmonary function testing during the mean follow-up period of 42 months, although a mild, transient restrictive ventilatory defect occurred at 6 to 12 months after treatment.

Radiation therapy for giant cell tumor of bone.

PURPOSE: Giant cell tumor of bone is usually treated with surgical curettage. For recurrent tumors, tumors that are inoperable because of location, and tumors that would require amputation or another radical procedure limiting function, does radiotherapy provide an alternative for local control? METHODS AND MATERIALS: Sixteen patients with histologically confirmed, giant cell tumor of bone were treated at the University of Florida with irradiation between March 1973 and September 1988. Minimum follow-up was 32 months; 63% of the patients had follow-up for at least 5 years, 44% for greater than 10 years. All sites received doses of 35 Gy or more, and all were treated with megavoltage irradiation. RESULTS: In 12 (75%) of 16 patients, the tumor was controlled locally with irradiation. The four failures occurred at 8, 13, 13, and 25 months following initiation of treatment. Surgical salvage was successful in all four failures for an overall local control rate of 100%. One patient developed pulmonary metastasis 1 month after surgical salvage and is alive without evidence of disease after multiple courses of chemotherapy, surgical resection, and whole-lung irradiation. All patients tolerated the treatment well with no severe or chronic complications. No secondary soft-tissue sarcomas have occurred within the irradiated areas. CONCLUSION: Giant cell tumor of bone is not a radioresistant tumor as once believed, and complications seen with modern treatment regimens are minor.

Megavoltage radiotherapy for aneurysmal bone cysts.

PURPOSE: An aneurysmal bone cyst (ABC) is a rapidly expansile and destructive benign tumor of bone that is usually treated by curettage and bone graft, with or without adjuvant treatment. For recurrent tumors, or tumors for which surgery would result in significant functional morbidity, does radiotherapy (RT) provide a safe and effective alternative for local control? PATIENTS AND METHODS: Nine patients with histologically diagnosed aneurysmal bone cysts without other associated benign or malignant tumors were treated at the University of Florida with megavoltage RT between February 1964 and June 1992. The patients received local radiotherapy doses between 20 and 60 Gy, with 6 patients receiving 26--30 Gy. In 6 patients the diagnosis was made by biopsy alone; 3 underwent intralesional curettage before RT. Minimum follow-up was 20 months; 7 of 9 patients (77%) had follow-up greater than 11 years. RESULTS: No patient experienced a local recurrence (median follow-up, 17 years). One patient required stabilization of the cervical spine 10 months after RT because of dorsal kyphosis from vertebral body collapse. No other significant side effects were experienced, and no patients developed secondary malignancies. Four patients were lost to follow-up: at 20 months, 11.5 years, 17 years, and 20 years after the initiation of treatment, none with any evidence of local recurrence. All of the patients who had significant pain before RT had relief of their symptoms within 2 weeks of completion of therapy. CONCLUSIONS: Using modern-day RT, patients with recurrent or inoperable aneurysmal bone cysts can be treated effectively (with minimal toxicity) using a prescribed tumor dose of 26--30 Gy.

High-risk Ewing's sarcoma: end-intensification using autologous bone marrow transplantation.

Because of retrospective analysis showing survival to be related to primary tumor size, in February 1982 a study to test this hypothesis prospectively was begun at the University of Florida. Patients with primary tumors 8 cm or less in maximum diameter and no metastases received adjuvant chemotherapy consisting of vincristine, cyclophosphamide, doxorubicin, and dactinomycin plus radiotherapy or surgery (standard-risk protocol). All others received a similar regimen followed by end-intensification with high-dose melphalan and autologous bone marrow transplantation (Protocol HR-2). Because of poor results of HR-2, another high-risk protocol (HR-3) was initiated in January 1985. Patients on HR-3 received 2 cycles of chemotherapy containing vincristine, cyclophosphamide, and doxorubicin followed by local radiation therapy and maintenance chemotherapy. At the end of this therapy, autologous bone marrow transplantation (ABMT) was performed, using a preparatory regimen of total body irradiation and intensive chemotherapy. The 2-year disease-free survival rate was 70% for the standard-risk protocol, 20% for HR-2, and 80% for HR-3. The follow-up on HR-3 is still short, but the results are promising enough to warrant further clinical trials.

Preoperative irradiation for soft tissue sarcomas of the trunk and extremities in adults.

Between May 1978 and January 1987, 58 adult patients with previously untreated sarcomas of the trunk and extremities were treated with preoperative irradiation and surgery at the University of Florida. All patients had a minimum of 2 years of follow-up; 24 had a minimum of 5 years of follow-up. The preoperative dose was usually 5040 cGy, with 120-125 cGy per fraction delivered twice daily. Operations were performed 2 to 6 weeks after radiation therapy. Eight patients received adjuvant chemotherapy. The tumors were high grade in 52 (90%), measured greater than 10 cm in 45 (78%), and were extracompartmental in 49 (84%). The surgical margins were wide in 17, marginal in 31, and intralesional in 10 patients. A functional extremity was preserved in 47 of 54 patients who would have required an amputation had they been treated by operation alone. Five of 58 patients (9%) developed local failure; in three, the failure occurred outside of the irradiated volume. Survival rates (product-limit method) at 5 years according to grade and size of lesion were as follows: low grade, 100%; high grade, 10 cm or less in largest diameter, 68%; high grade, 11-20 cm, 39%. Data are insufficient for a 5-year analysis of high-grade lesions greater than 20 cm; to date, there are no 5-year survivors in these patients. Moderate and severe wound complications occurred in 16%. There were four pathological fractures in 52 long bones at risk.

Radionuclide imaging of soft tissue neoplasms.

Two classes of radiopharmaceuticals may be used for imaging tumors of the musculoskeletal system. The first is comprised of soft tissue or tumor specific agents such as gallium-67, bleomycin, and radionuclide-labeled antibodies, which may be useful for detecting and localizing these tumors. The other class of tracer is comprised of those with avidity for bone. The 99mTc-labeled-phosphate skeletal imaging compounds have been found to localize in a variety of soft tissue lesions, including benign and malignant tumors. In 1972, Enneking began to include bone scans in the preoperative evaluation of soft tissue masses. Later, he and his associates reported that these scans were useful in planning operative treatment of sarcomas by detecting involvement of bone by the tumors. Nearly all malignant soft tissue tumors take up bone-seeking radiopharmaceuticals, and bone involvement was indicated in two-thirds of the scans we reviewed. About half of benign soft tissue lesions had normal scans, but the other half showed uptake within the lesion and a few also showed bone involvement. Careful, thorough imaging technique is essential to proper evaluation. Multiple, high-resolution static gamma camera images in different projections are necessary to adequately demonstrate the presence or absence of soft tissue abnormality and to define the precise relationship of the tumor to the adjacent bone.

The management of primary lymphoma of bone.

From October 1962 through April 1982, 21 patients with the diagnosis of primary lymphoma of bone (18 monostotic, stages IE and IIE; 3 polyostotic) were treated with curative intent. A combination of chemotherapy and radiation therapy was used in 11 patients, local treatment alone in 9 patients, and chemotherapy alone in one patient. Overall 5-year survival for the patients treated with curative intent was 56%. Standard work-up has changed over the 20-year study period. Five-year survival for the subset of eight stage I and II patients with full pretherapy staging was 83%. Prognosis was significantly correlated with extent of pretherapy staging. Treatment parameters that also seemed to predict outcome were the aggressiveness of chemotherapy and the use of irradiation or surgery for local-regional disease; the only local failure occurred in the patient who received chemotherapy alone. Complications of radiation therapy alone and in combination with chemotherapy are discussed and correlated with irradiation dose. Radiation therapy techniques are described, and a management approach is recommended.

Local host response in osteosarcoma after chemotherapy referred to radiographs, CT, tumour necrosis and patient survival.

PURPOSE: The necrotic effect of chemotherapy on primary osteosarcoma has been shown to be predictive of the final outcome. Little attention has been paid to the local response of the host (LHR), which reflects the tumour-host relationship. DESIGN: A four-step grading system was developed based on distinct histological patterns of the LHR around the lesion. These responses were correlated with the chemotherapy-induced necrosis or chemosensitivity and analysed in an attempt to ascertain their influence on the patient prognosis. The ability of conventional radiographs and computed tomography to measure LHR was studied. METHODS: The grading system was applied to macroslides of specimens obtained from 72 patients with stage II B primary osteosarcoma in various limbs after wide resection and complete courses of pre- and postoperative chemotherapy who were treated between 1985 and 1991 with a median follow-up of 5 years and 9 months. The histological specimens were blindly reviewed by two pathologists and two experienced musculoskeletal oncologists to assign a grade of response. The results were correlated with tumour necrosis, patient survival and response features on conventional radiographs and CT images. RESULTS: Significant correlation was found between LHR and tumour necrosis or chemosensitivity (r=0.55) and between LHR and CT response (r=0.56). There was no correlation between LHR and the findings on conventional radiographs. A grade 4 LHR was predictive of long-term survival. CONCLUSIONS: The LHR to preoperative chemotherapy has a prognostic influence on patient survival and can be predicted by CT.

Revision surgery in dermatofibrosarcoma protuberans of the trunk and extremities.

AIMS: Dermatofibrosarcoma protuberans is a rare condition which is frequently misdiagnosed at presentation, resulting in a high incidence of local recurrence due to inadequate resection. The archives of the Department of Orthopaedics at the University of Florida were analysed to investigate the natural history and results of treatment for this tumour. METHODS: Between 1975 and 1996, 35 cases of DFSP were treated at the University of Florida. Of these, one was treated primarily, five were treated for local recurrence, 17 had tumour bed excisions following inadequate primary excisions elsewhere and 12 had tumour bed excisions following inadequate resection of local recurrences elsewhere. The data were analysed to assess the impact of age, gender, duration of symptoms, tumour site and size, surgical margin, number of operations and adjuvant treatments on survival and local recurrence outcomes. RESULTS: Complete follow-up was available for 34 patients. Mean follow-up was 58 months (range 12-144 months). Thirty-three patients remain alive and disease-free. One patient died of unrelated causes. The margins obtained were wide in 28 patients, marginal in six and intralesional in one. Of the seven patients with inadequate surgical margins, four received adjuvant radiation therapy and remain disease-free. No patient with an adequate margin developed a local recurrence, but there were three local recurrences in the patients with an inadequate margin who did not receive adjuvant radiation therapy (local recurrence rate: 8%). No patient developed lymphatic or distant metastasis. Local recurrences were more likely to be classified Stage IB (17/17) than primary tumours (1/18) (P<0.001). Local recurrence was more likely where the surgical margin was less than 2.5 cm from the lesion. CONCLUSIONS: Dermatofibrosarcoma protuberans is a low-grade tumour that has a high potential for local recurrence unless it can be completely excised. The overall rate of local recurrence in referred patients in this series was 20/35 cases (57%). All occurred after inadequate margins at previous surgery in other institutions. Revision surgery in these patients showed a local recurrence rate of 8%. To avoid extensive surgery for recurrences, initial treatment should be by wide excision incorporating the underlying deep fascia and a cuff of 2.5-3 cm of normal skin tissue. Radiation therapy provides a useful adjunct where adequate margins cannot be obtained.

Observations on massive retrieved human allografts.

Radiographic and histological studies of sixteen massive retrieved human allografts were carried out after the allografts had been in situ for four to sixty-five months. The studies demonstrated that union between the allograft and the host took place slowly at cortical-cortical junctions by the formation of an external callus derived from the cortex of the host, and it took place more rapidly at cancellous-cancellous junctions by internal callus advancing from the host into the allograft. Internal repair took place very slowly, was confined to the superficial surface and the ends of the graft, and had involved only 20 per cent of the graft by five years. The deep unrepaired portions of the graft retained their architecture, and where bone cement had been used to fix a prosthetic stem or an intramedullary rod to the allograft, there was no evidence of resorption of bone or loosening of the device. Soft tissues of the host became attached to the graft by deposition of a thin seam of new bone on the surface of the graft. A previous fracture of two grafts had healed before the time of retrieval. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing. The necrotic cartilage functioned well for as long as five years, and as it degenerated, it was covered by a pannus of fibrovascular reparative tissue. Two allografts that had been removed because of rejection were surrounded by an envelope of chronic inflammatory tissue that prevented union, adherence of soft tissue, and internal repair. Internal repair was more advanced about sites of fracture and adjacent to recurrent tumors than in other portions of the graft. These findings suggest that large frozen allografts in humans are osteoconductive rather than osteoinductive.

Fibrous dysplasia of the femoral neck. Treatment by cortical bone-grafting.

Fibrous dysplasia of the femoral neck is difficult to treat. In a series of fifteen young patients, ten had a monostotic lesion and five, the polyostotic form of the disease. Twelve patients were first seen with a fatigue fracture. Grafts of cortical bone were used. The objectives of relief of pain, union of the fracture, and prevention of deformity were achieved in all fifteen patients. Two patients required a repeat procedure. None of the patients had important deformity of the femoral neck, and none needed an osteotomy.

Resection and reconstruction for primary neoplasms involving the innominate bone.

Using described criteria for the selection of patients for excision or resection of tumors involving various portions of the innominate bone, as opposed to hemipelvectomy, fifty-seven out of the more than 200 patients evaluated were judged to be candidates for a curative procedure. Of these, twenty-five were selected for hemipelvectomy and thirty-two, for non-amputative procedures. Depending on the location and extent of the lesion as determined by complete preoperative work-ups, three types of procedures were performed singly or in combination:(1) wide excision or radical resection of the iliac wing; (2) periacetabular wide excision or radical resection; or (3) wide excision or radical resection of the pubis. Reconstruction was accomplished when the hip joint was excised by fusion or the creation of a pseudarthrosis either medially in relation to the pubis or laterally in relation to the ilium or wing of the sacrum. The results after follow-ups of one to seventeen years were assessed in terms of the immediate goals of surgery, control of the disease, and function. The findings were as follows: With the preoperative assessment and operative techniques described, an oncologically adequate procedure was performed in two-thirds of the cases. In the remaining cases, the adequacy of the procedure was compromised by poorly planned biopsies, occult microextensions, and surgical errors. The recurrence rate was high after the inadequate procedure (100 per cent) and low (4 per cent) after the adequately accomplished procedures. Function was nearly normal when the hip joint was preserved. If the hip joint was removed and fusion was obtained, the results were good, but fusion was obtained in only 50 percent of the cases in which it was attempted. If the hip joint was removed and pseudarthrosis resulted, the results ranged from good to poor. Sciatic-nerve involvement necessitating resection of the nerve was not a contraindication to a non-amputative procedure.

Prognosis for patients who have osteosarcoma with skip metastasis.

We analyzed the cases of twenty-three patients who had Stage-IIB osteosarcoma and skip metastasis to determine the rates of disease-free and long-term survival. The regimens of preoperative and postoperative chemotherapy varied. The patterns of relapse and long-term survival were studied in relation to the skip lesions, and these patterns were compared with those of 224 patients who had Stage-II osteosarcoma but no skip lesion. Of the twenty-three patients who had a skip lesion, twenty-two had either a local recurrence or a distant metastasis; twenty-two patients died, and one remained disease-free at thirty-eight months. Kaplan-Meier analysis showed significant differences in the rates of local recurrence and distant metastasis (Mantel-Cox test statistic, p less than 0.0001) and in the over-all survival (Mantel-Cox test statistic, p less than 0.0001) between the patients who had and those who did not have skip metastasis. The cases of fourteen patients who had skip metastasis from a lesion in the distal end of the femur were compared with those of eighty-seven patients who had a similarly situated primary lesion but no skip metastasis. The difference was significant, although less so than when lesions in all anatomical sites were analyzed. The follow-up data indicated that the use of adjuvant chemotherapy did not improve the poor prognosis of patients who had skip metastasis. Therefore, we regard a skip lesion, along with regional lymphatic metastasis or metastasis to a distant organ, as another criterion for considering an osteosarcoma to be Stage III.

Resection-arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts.

Twenty patients with malignant or potentially malignant tumors (osteogenic sarcoma, giant-cell tumor, synovial-cell sarcoma, chondrosarcoma, and chondroblastoma) located in the proximal end of the tibia or distal end of the femur were treated by local resection and arthrodesis employing an intramedullary rod and autogenous segmental cortical grafts obtained from the same extremity. Use of a customized bent, fluted rod in the most recent cases provided more stable fixation. There was only one local recurrence. In properly selected patients, the method provided a stable extremity that permitted resumption of a vigorous life-style within approximately one year.

The management of soft-tissue sarcomas of the extremities.

Of fifty-four patients with a soft-tissue sarcoma of an extremity, having a projected five-year survival rate of 62 per cent, forty-six treated by an "adequate" surgical procedure (either radical local resection or ablation at an appropriate level, depending on defined circumstances) had a local recurrence rate of 2 per cent. In the other eight patients, whose surgical procedures were not adequate for one reason or another, the local recurrence rate was 100 per cent. The combined recurrence rate after both the adequate and the inadequate procedures was 16.7 per cent. The recurrences were noted prior to thirty months post-operatively and the metastases, prior to sixty months. Histogenesis of the sarcoma, one or more recurrences after previous operations, and treatment by an immediate definitive procedure at the time of biopsy and diagnosis by frozen section had no significant relationship to the rates of local recurrence or metastasis. Adequate radical local resection controlled these sarcomas as well as ablative surgery in terms of local recurrence and metastasis. The significant factors affecting local recurrence that were identified in this study were the location of the sarcoma and the adequacy of the surgical procedure.

Retrieved human allografts : a clinicopathological study.

BACKGROUND: We studied seventy-three massive preserved human allografts, retrieved from two to 156 months after implantation, to provide insight into the mechanisms of their repair. METHODS: The specimens were studied with radiographic and histological techniques that permitted time-related quantitative analysis of the reparative mechanisms of union, cortical repair, soft-tissue attachment, fracture, and characteristics of the allograft-cement interface and the articular cartilage. RESULTS: Union at cortical-cortical junctions occurred slowly (approximately twelve months) by host-derived external callus that bridged the junction and filled the gap between abutting cortices. The bone in the gap did not undergo stress-oriented remodeling even after many years, and, when the union was intentionally disrupted, failure occurred at the cement line that marked the allograft-host junction. Repair of the necrotic graft matrix was both external and internal. External repair consisted of the apposition of a thin seam of host bone on the outer surface of the graft, coating about 40% of the surface at one year and 80% at two years. Internal repair was confined to the ends and the periphery of the cortices and penetrated so slowly that only 15% to 20% of the graft was repaired by five years, after which deeper repair seldom occurred. Graft fractures in specimens retrieved soon after fracture showed only necrotic bone adjacent to the fracture site, whereas those retrieved after fracture-healing showed a marked increase in internal repair of the bone about the fracture site. When bone cement had been used to fix a prosthesis, there was no evidence of bone resorption or loosening of the device. The osteoarticular specimens showed no survival of chondrocytes in the articular cartilage. However, the architecture of the acellular cartilage was well preserved after two to three years and occasionally after as many as five years. Late degenerative changes in the articular cartilage coincided with subchondral revascularization and fragmentation, and the articulating surfaces became covered by a pannus of fibrovascular reparative tissue. Degenerative changes in articular cartilage occurred earlier and were more advanced in specimens retrieved from patients with an unstable joint than in those retrieved from patients with a stable joint. CONCLUSIONS: Repair of massive human allografts is an indolent process that follows a fairly predictable course during the first few years and is influenced by other biological activities, such as fracture repair, supplementary autografting, and tumor recurrence.

Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects.

The results of using segmental cortical autogenous bone grafts to reconstruct defects created by resection of tumors were analyzed in forty patients. Thirty-three patients had dual grafts while seven had a single fibular graft. Dual grafts were used for major bones (humerus, femur, and tibia without fibula) while single grafts were used for the radius and for the tibia when the ipsilateral fibula was intact. Thirty patients had good or excellent results; seven, fair; and three, poor results. In twenty-five patients primary union was achieved within tweleve months and in two, in twenty months, while twelve patients required a second, supplementary cancellous graft at the site of non-union to obtain stability. One patient required removal of an infected graft and had a poor result. Stress fractures of the grafts occurred in eighteen of the forty patients after union had occurred. The stress fractures healed in fifteen of these patients: in six with no treatment (the fracture was identified retrospectively), in seven with external immobilization, and in two after bone-grafting of the ununited fracture. There were three persistent non-unions of stress fractures despite bone-grafting, internal fixation, and electrical stimulation, and these account for two of the three poor results. The length of the defect did not affect the incidence of non-union but it did affect the number of fatigue fractures. The shorter grafts (7.5 to twelve centimeters) were associated with a 33 per cent incidence of non-union (four non-unions of twelve grafts) while the longer grafts (twelve to twenty-five centimeters) had a 32 per cent rate of non-union (nine non-unions of twenty-eight grafts). The incidence of fatigue fractures in the longer grafts (58 per cent) was much greater than that in the shorter grafts (17 per cent). The grafts decreased in density during the first six months but gradually regained their mass and were generally comparable to normal cortical bone at two years. As the patients became functiona, most (55 per cent) of the the grafts became more dense than normal, some (34 per cent) remained the same, and a few (11 per cent) became less dense. Similarly, some (32 per cent) hypertrophied, most (58 per cent) remained the same size, and a few (9 per cent) atrophied. There was little morbidity (three of forty patients) associated with graft procurement. In twelve patients an additional graft was implanted experimentally, labeled with tetracycline, and subsequently removed at the time of a secondary procedure. These grafts were analyzed to determine if human grafts were repaired in the same fashion as grafts in experimental animals. The studies showed that human grafts are repaired in the same fashion, but that the sequence takes approximately twice as long as it does in the dog.

Repair of experimental autologous grafts of cortical bone.

Fresh autologous segmental grafts of fibula, four centimeters long, were obtained from thirteen adult dogs. Holes were drilled in each before replantation. The amount of repair was determined after intervals of from four to twenty-four weeks. Torsional stress testing showed that the six drill holes 500 micrometers in diameter confined within an expanse of two centimeters did not mechanically weaken the transplants at the time of surgery. The drill holes were rapidly filled with cancellous bone which matured to cortical bone within twelve weeks. Microradiography and tetracycline labeling of drilled and non-drilled grafts demonstrated similar biological reparative patterns.

The surgical treatment of parosteal osteosarcoma in long bones.

The cases of twenty-five patients with Stage-I parosteal osteosarcoma were analyzed to ascertain the incidence of recurrence after forty-two various surgical procedures that produced an intracapsular, marginal, wide, or radical excisional margin. Ten intracapsular resections were followed by local recurrence in each patient. This procedure usually was done to shell-out a presumably benign lesion. Marginal excision was successful in nine of seventeen patients. When a marginal excision was knowingly done to preserve a major neurovascular bundle, the risk of recurrence was less (three of eleven) than when it was done to shell-out a presumptively benign lesion (five of six). The fourteen procedures that achieved wide margins obtained local control--that is, there was no recurrence--in each patient. There was one radical procedure without recurrence.

Giant-cell tumor of bone with pulmonary metastases.

We reviewed the cases of seven patients with histologically benign primary giant-cell tumor of bone and histologically proved metastases to the lung. All seven had a Stage-3, aggressive, benign lesion with interruption of the cortex and soft-tissue extension. The main histological features of the primary lesion were identical to those of the pulmonary metastases. In only one of the seven patients were the metastases detected simultaneously with the primary lesion. All seven patients were treated by surgical resection of the lung nodules and chemotherapy. Of the seven patients, four were alive and free of disease after an average follow-up of nine years; two were receiving chemotherapy; and one, who had had immunosuppression for an allograft transplant, died less than one year after the discovery of the pulmonary lesions. Based on this small series, we concluded that patients with a Stage-3 giant-cell tumor of bone may be at risk for pulmonary spread of the disease. This lesion, with its benign histological picture even in lung lesions, has a favorable prognosis when treated with pulmonary resection of the nodules. However, the role for chemotherapy after pulmonary surgery is still unclear.