Aspiration (puncture of needle) biopsy in bone lesions.

In certain bone tumor cases bone puncture is more profitable than sample excision. Whenever necessary we are using both methods in our practice. The results of 7165 puncutre biopsies are presented. A definite diagnosis by needle biopsy could be established in 771 tumors, including 254 myelomas and 174 osteogenic sarcomas. The aspiration or needle biopsy will require some experience not only on the part of the pathologist, but also of the surgeon. The pathologist must be sufficiently familiar with the clinical and radiographic evidence before interpreting the cytologic or the histopathologic specimen.

Osteosarcomas arising on the surfaces of long bones.

Malignant bone-forming tumors that arise from the surfaces of long bones are far less common than those that arise from within bone. These surface osteosarcomas are clinically and radiographically similar, yet histologically they are quite distinct. In reviewing the literature, we classified the tumors according to three subgroups: parosteal (juxtacortical) osteosarcoma, periosteal osteosarcoma, and high-grade surface osteosarcoma. We also studied the clinical, radiographic, and histological findings in eighty patients who had been treated for an osteosarcoma over a forty-four-year period. Adequate follow-up data existed for forty-eight of the eighty patients. The duration of follow-up ranged from two to fifteen years after the initial operation (amputation or resection). Patients who had a parosteal osteosarcoma had the best prognosis; those who had a periosteal osteosarcoma, the next best; and those who had a high-grade surface osteosarcoma, the poorest. Because of these widely varying prognoses, the lesions require different treatment.

Tissue-typing in human massive allografts of frozen bone.

The cases of twenty-six patients who received a massive allotransplant of frozen bone, with a known degree of histocompatibility between the donor and the recipient, were studied. Twenty-two patients were followed for more than two years (range, twenty-four to ninety-two months). Twenty-three biopsies were performed in sixteen patients from nine to seventy-eight months after transplantation. No clear relationship could be established between the degree of histocompatibility of the donor and the recipient and the incorporation of the graft, probably in part due to the number of variables involved and the polymorphism of the HLA system. However, no early massive resorption of the transplant was seen in this series, in which, by the design of the protocol, no recipients had pre-existing circulating antibodies to the antigens of the donor. Two allografts showed infiltration by round cells and vascular lesions in the absence of infection, which is suggestive of an immune response against antigens from the donor. Both matched poorly with the donor for HLA antigens. The individual who had the strongest reaction was the only recipient in the series who had a massive failure of the transplant.

Metal carcinogenesis: a study of the carcinogenic activity of solid metal alloys in rats.

The carcinogenic activity of seven metallic alloys was studied by implanting solid rods of each alloy in the gluteal muscles of Sprague-Dawley rats which were killed after twenty-four months. When the number of tumors in these rats was compared with the numbers in rats not operated on, in rats which had a sham operation, and in rats implanted with Silastic rods, no statistically significant differences in the incidences of the tumors in the several groups were found.

The treatment of Paget's bone disease with sodium ethidronate.

Of 58 patients with Paget's disease treated with disodium ethane-1-hydroxy-1,1-diphosphonate (EHDP) in doses of 20 and 10 mg/kg/day, a group of 20 patients with the oligostotic form of the disease showed a significantly greater incidence of complications, such as worsening of bone pains, when compared with a group of 38 patients with the polyostotic disease (P less than 0.05). The group of 32 patients that received 20 mg/kg/day showed a greater although not significant incidence of clinical complications than the group of 26 patients treated with 10 mg/kg/day. Bone biopsies performed in one polyostotic and three oligostotic cases who suffered episodes of bone pain worsening during treatment with 20 mg/kg/day disclosed a severe osteomalacia. Both groups treated with 20 and 10 mg/kg showed a highly significant decrease of urinary hydroxyproline (THP) excretion and of serum alkaline phosphatase (P less than 0.01) after two and six months of treatment although the trend comparison between doses was not significant. It is suggested that the dose of EHDP should be related to the extent of the disease.

Juxtacortical chondrosarcoma.

The features are described of seven cases of "juxtacortical" chondrosarcoma, the term introduced by Jaffe for a rare but distinct entity and now accepted in the World Health Organisation classification as preferable to the term "periosteal" chondrosarcoma. In all cases the lesion involved the shaft of a long bone, most often the femur, and in two cases two different long bones were affected. Six of the seven patients were male and all were in the second decade. The characteristic appearance was that of a small tumour adjacent to the cortex with areas of spotty calcification often accompanied by radiating bone spicules perpendicular to the bone shaft and a typical Codman's triangle. Histologically all the tumours showed a cartilaginous lobular pattern, well limited on the surface and seldom infiltrating the cortex; areas of spotty calcification and enchondral ossification were often present but tumour osteoid and bone were conspicuously absent. Despite the ominous histological aspect, the prognosis proved to be relatively favourable compared with the usual central chondrosarcoma of a similar grade of malignancy.

Malignant osteoblastoma.

The clinical, radiographic and pathological features are described of eight cases of a bone tumour which we propose to classify as "malignant osteoblastoma". It presents the characteristics of genuine osteoblastoma but of an aggressive pattern, with more abundant and often plump hyperchromatic nuclei, greater nuclear atypia, and numerous giant cells of osteoclastic type. This rare tumour is regarded as the malignant counterpart of osteoblastoma and appears to be only locally aggressive. It should be separated from conventional osteosarcoma not only because of its peculiar histological pattern, but also because of its different clinical and radiological features and better prognosis. Thus seven of the eight patients were alive and free of disease from one and a half to eleven years after the initial surgical treatment, which in only two cases included amputation. Excision or block resection is the preferred method of treatment.

Sarcoma complicating Paget's disease of bone. A clinicopathological study of 62 cases.

Out of 21 900 cases filed at the Latin-American Registry of Bone Pathology between April 1940 and July 1981, there were 987 with Paget's disease (4.51 per cent); 62 of these (6.28 per cent) were complicated by sarcoma and two were associated with giant-cell tumours of bone (osteoclastoma) without signs of malignancy. There was a slight predominance of men and the ages ranged from 45 to 87 years, with an average of 66 years. The most frequent sites were the femur (23 cases), the humerus (nine), the pelvis (10), and the tibia (nine). The low incidence of vertebral involvement (five cases) is noteworthy and is in sharp contrast to uncomplicated Paget's disease. The most common tumour type was osteosarcoma (39 cases), followed by fibrosarcoma (15 cases); other varieties (chondrosarcoma, malignant fibrous histiocytoma and reticulum-cell sarcoma) were much rarer. Most of the sarcomata occurred when the Paget's disease was polyostotic. Tumours often developed simultaneously, or at short time intervals, in the same or different bones; these bones had, in all cases, been affected by Paget's disease. The histological features of the osteosarcomata were characteristic, with large numbers of osteoclast giant cells, alternating with atypical osteoblasts, thus exaggerating the anarchic remodelling process of Paget's disease. The neighbouring areas of the pagetic bone showed an increased number of osteoclasts. These facts suggest a possible pathogenetic relationship between sarcoma and Paget's disease; the possibility of both processes having a viral aetiology is discussed.

Juxta-articular bone cysts (intra-osseous ganglia): a clinicopathological study of eighty-eight cases.

The clinical, radiographic and pathological features of eighty-eight cases of histologically verified intra-osseous ganglia in eighty-three patients are described. All were located in the subchondral bone adjacent to a joint and most frequently involved the hip, the ankle (medial malleolus), the knee and the carpal bones. Forty-seven of the eighty-three patients were male and all the patients were between fourteen and seventy-three years of age, with an average age of forty-one years. There are two fundamental types of intra-osseous ganglia, one apparently arising by penetration of juxta-osseous ganglion into the underlying bone, a mechanism proved in fourteen of our eighty-eight cases (16 per cent); in the remaining seventy-four cases, the ganglion cyst was primarily intra-osseous ("idiopathic"). The initial cause of the intramedullary mucoid degeneration is discussed. We believe that mechanical stress and repeated minor trauma near the surface of the bone may lead to intramedullary vascular disturbance with consequent foci of aseptic bone necrosis. The revitalisation of these areas causes fibroblastic proliferation, followed by mucoid degeneration of the connective tissue, possibly due to some unknown local factor. Curettage or excision is usually effective, and recurrence (only four cases) is exceptional.

Intracortical haemangioma simulating osteoid osteoma.

A case of intracortical haemangioma in the tibial diaphysis is reported. The radiological and macroscopic features were identical with osteoid osteoma. In view of this similarity, haemangiomata, despite their rarity at this site, must be considered in the differential diagnosis of osteoid osteoma.

Familial idiopathic hyperphosphatasia: a study of two young siblings treated with porcine calcitonin.

A study of two siblings with a severe infantile form of familial idiopathic hyperphosphatasia is reported. A girl aged one year was followed for two years while receiving intermittent treatment with porcine calcitonin. This induced a clinical remission, a reduction of both the high serum level of alkaline phosphatase and the raised urinary excretion of hydroxyproline, and a remarkable improvement in bone structure as seen radiologically. Her sister aged two months received porcine calcitonin for three weeks, during which clinical improvement, no change in the serum level of alkaline phosphatase and a marked decrease of the excretion of hydroxyproline were recorded.

Cystic angiomatosis (hamartous haemolymphagiomatosis) of bone. A clinicopathological study of three cases.

The clinical and radiological features in three cases of cystic angiomatosis of bone are reported. Although these features are generally diagnostic except from histiocytosis X, the definitive diagnosis must be established by a pathological study, preferably of a segment of an involved rib or fibula. The prognosis varies according to the type of clinical presentation-in particular upon whether the lesions are solely skeletal or whether there is extraskeletal visceral involvement. Whereas these last cases may often prove fatal, those with only skeletal involvement have a favourable prognosis: indeed, the cystic bone lesions may regress without any treatment, as occurred in some cases reported in the literature and in two of our three cases.

Osteoid osteoma and osteoblastoma.

In conclusion, while similar histologically, osteoid osteoma and osteoblastoma have the potential of being significantly different clinically. Osteoid osteoma tends to be a problem of pain and not of great oncologic significance. Osteoblastoma, on the other hand, has the potential for local bone destruction and aggressiveness as well as the rare occurrence of metastases. For this reason, the latter tumor needs to be respected from an oncologic standpoint and appropriate surgical excision performed.