[Tumors of the hand bones]

The article is devoted to an actual problem of surgical treatment of hand bone tumors. It presents a classification of hand bone tumors, pathogenesis, clinical course of the most common tumors, methods of surgical treatment. Results of treatment of 108 patients with hand bone tumors are described.

Secondary amyloidosis and gastrointestinal stromal tumors. A case report and discussion of pathogenesis

A 69-year-old man presented with a malignant gastrointestinal stromal tumor associated with secondary amyloidosis. The tumor had classic features of a malignant gastrointestinal stromal tumor with interlacing fascicles and whorls of spindled cells, numerous and conspicuous mitotic figures, and extensive coagulative necrosis. The cells stained diffusely for CD117 (c-Kit), confirming the diagnosis of gastrointestinal stromal tumor. The spleen, 1 adrenal gland, and part of the pancreas were removed en block with the stomach. By microscopy, the spleen and adrenal gland were partially replaced with amyloid deposits confirmed by Congo red staining, electron microscopy, and immunohistochemistry. In contrast, neither the tumor nor the surrounding vasculature showed amyloid deposition. To our knowledge, this represents only the second case of systemic amyloidosis associated with a gastrointestinal stromal tumor. This case is unique in that extensive, diffuse amyloid deposits were observed in the spleen, adrenal gland, and liver.

Prognostic factors influencing surgical management and outcome of gastrointestinal stromal tumours

BACKGROUND

The purpose of this study was to review surgical experience with gastrointestinal stromal tumours (GISTs) at a single tertiary university hospital, and to identify morphological and genetic prognostic markers of tumour progression.

METHODS

Forty-eight GISTs from 39 patients were reviewed retrospectively. The prognostic significance of DNA copy number changes, measured by comparative genomic hybridization (CGH), and morphological markers in low-risk and high-risk tumours were investigated.

RESULTS

Significantly more patients died from disease after incomplete tumour resection than after complete primary resection (P = 0.020). Tumour size of 5 cm or greater, mitotic count of 2 or more, and proliferative activity greater than 10 per cent were significantly associated with a shorter recurrence-free survival (P = 0.020, P = 0.001 and P = 0.002 respectively). Patients with low-risk tumours had a significantly better outcome than those with high-risk GISTs, both in terms of overall and recurrence-free survival (P < or = 0.001). CGH performed on 16 tumours revealed fewer DNA sequence copy number changes in low-risk than in high-risk GISTs. Non-progressive GISTs contained significantly fewer genetic alterations than recurrent or metastatic tumours (P < 0.001). Only tumours with more than five changes showed disease progression.

CONCLUSION

Complete surgical resection is the most important means of cure for GISTs. DNA copy number changes are related to the behaviour of these tumours and may serve as additional prognostic markers.

[Stromal tumor of the stomach with exo-gastric growth]

A 60 year-old male patient presented with a giant stromal tumor of the stomach that showed predominant extragastric growth. Surgery consisted of total tumor resection with partial gastrectomy. The stromal origin of the tumor was established by immunohistochemistry. In spite of its large size and the presence of necrotic foci, the tumor was considered to be of low grade in view of the low mitosis index. The patient was maintained on careful surveillance. The histological features which characterize these tumors and their implications for prognosis and therapy are briefly discussed.

Elastofibroma dorsi. Report of five cases and review of the literature

Five cases of elastofibroma dorsi are described. The location of the lesions (bilateral in one case) was typical, in the thoracoscapular region. In the first case the diagnosis was established by biopsy; in the remaining cases the diagnosis was suspected based on clinical and magnetic resonance imaging findings and was confirmed by histopathological study after surgical excision. Although these lesions are benign, histological study is advisable to establish a differential diagnosis with malignant neoplastic processes.

Overview of issues related to imatinib therapy of advanced gastrointestinal stromal tumors: a discussion among the experts

Information regarding the activity of imatinib in patients with metastatic gastrointestinal stromal tumors (GISTs) has accumulated rapidly. Nevertheless, several important issues about imatinib therapy as well as these tumors themselves remain to be answered. Importantly, the optimal dose and duration of imatinib therapy are unknown, with daily doses of 400 mg and 600 mg producing comparable response rates in a phase II study. Moreover, the role of surgery following maximal responses to imatinib and those of functional imaging and use of biopsies in monitoring treatment responses need to be investigated. Further understanding of the molecular and pathologic characteristics of GISTs that are responsive or resistant to imatinib is also needed. This paper summarizes a symposium that was held in Helsinki, Finland, in September 2001.

Clinical presentation of gastrointestinal stromal tumors and treatment of operable disease

Gastrointestinal stromal tumors (GISTs) are generally found in the stomach or small intestine and less commonly in the colon, rectum or an intra-abdominal site. The patients symptoms on presentation are most commonly gastrointestinal bleeding. Surgery remains the standard treatment for nonmetastatic GISTs, but rates of disease recurrence are significant--5% in primary disease and 90% in locally advanced disease. Five-year survival following surgical resection varies between 35% and 65% on the basis of several published studies. Clinical knowledge of the prognosis of patients with GISTs remains rather limited--small tumor size, low-grade mitotic index and stomach location are factors associated with a more favorable prognosis.

Familial generalized multiple glomangiomyoma: report of a new family, with immunohistochemical and ultrastructural studies and review of the literature

Glomus tumors are benign lesions which often appear as solitary bluish nodules. They can also be multiple, and can be either acquired or congenital. Histopathologically glomus tumors are classified into three different variants: solid glomus tumor, glomangioma, and glomangiomyoma, which is the least frequent type. We report three instances of familial generalized multiple glomangiomyoma in a woman and her two children. Seven members of the family in two consecutive generations were affected, suggesting autosomal dominant inheritance. We performed a thorough clinical study, complete blood and platelet counts, stool for occult blood, karyotype, abdominal echography (which showed an asymptomatic solitary hepatic vascular lesion in one of the patients), gastrointestinal endoscopy, and skin biopsy with immunohistologic and ultrastructural studies. We believe that the terms glomangioma and glomangiomyoma actually designate the same lesion, with transitional areas from typical glomus cells to well-defined conventional smooth muscle cells. Although complete evaluation should be performed in all patients with multiple glomus tumors in order to detect possible occult systemic lesions, we only recommend treatment for symptomatic lesions. To our knowledge, this is the first report of an instance of familial multiple glomangiomyoma.

Giant gastrointestinal stromal tumor, associated with esophageal hiatus hernia

An 85-year-old woman was admitted to our hospital because of vomiting. An upper gastrointestinal series what showed a large esophageal hiatus hernia, suggesting an association with extrinsic pressure in the middle portion of the stomach. An upper gastrointestinal endoscopic examination showed severe esophagitis and a prominent narrowing in the middle portion of the stomach, however, it showed normal gastric mucosa findings. CT and MRI revealed a large tumor extending from the region of the lower chest to the upper abdomen. From these findings, the tumor was diagnosed as gastrointestinal stromal tumor (GIST), which arose from the gastric wall and complicated with an esophageal hiatus hernia. We performed a laparotomy, however, the tumor showed severe invasion to the circumferential organs. Therefore, we abandoned the excision of the tumor. Histologically, the tumor was composed of spindle shaped cells with marked nuclear atypia and prominent mitosis. The tumor cells were strongly positive for CD34 and c-kit by immunohistochemical examination. From these findings, the tumor was definitely diagnosed as a malignant GIST. As palliative treatment, we implanted a self-expandable metallic stent in the narrow segment of the stomach. The patient could eat solid food and was discharged. In the treatment of esophageal hiatus hernia, the rare association of GIST should be considered.

[Gastrointestinal stromal tumors]

There are two main types of gastrointestinal connective tissue tumors: differentiated connective tissue tumors arising from smooth muscle tissue, schwanommas or fibroblastic tissue, and non-differentiated connective tissue tumors with no precise origin. Pathologically non-classifiable tumors comprise a group of real gastrointestinal stromal tumors. Stromal tumors are rare and generally develop in the stomach. Immunohistochemistry has been able to identify three entities: stromal tumorswith skenoid fibers, gastoinestinal autonomic nerve tumors, and intraabdominal desmoplastic small round-cell tumors. After resection, survival is almost 50% at 5 years and depends particulary on tumors size, the presence of synchronous metastases and mitosis count.

Chondromyxoid fibroma of the nasal bone with extension into the frontal and ethmoidal sinuses: report of one case and a review of the literature

Chondromyxoid fibroma is a rare benign tumor that usually occurs in the long bones. A 50-year-old patient presented with chondromyxoid fibroma of the nasal bone with extension into the frontal and ethmoidal sinuses. This is the fourth case reported to date in the literature. The clinical manifestations of the tumor were very limited, and the appearance at rhinoscopy was misleading. Radiologic imaging showed a soft tissue lesion invading the adjacent bony structures and the dura mater. Surgery was performed by a combined team of otorhinolaryngologists and neurosurgeons, and total excision of the tumor was achieved. The histologic diagnosis of this tumor is difficult because of its similarities to chondrosarcoma. [Editorial comment: The authors concisely review management of this rare tumor, emphasizing that complete surgical excision, rather than curettage, is required for long term control.]

[Gastrointestinal stromal tumor: individualized treatment for a special class of tumors]

HISTORY AND ADMISSION FINDINGS

Case 1: A 36-year-old woman was admitted because of dizziness and weakness. Her skin and mucosae were pale. There was rather dark stool on the gloved finger at rectal examination, but the patient had not noticed any tarry stools. Case 2: An 89-year-old man in excellent general condition presented with dyspepsia. Physical examination was unremarkable except for a small epigastric hernia.

INVESTIGATIONS

Endoscopy in Case 1 revealed, at the lesser curvature of the gastric antrum, a submucous tumour covered by a slightly haemorrhagic mucosal erosion. In Case 2 endoscopy similarly revealed an antral submucous tumour. There was no evidence of metastasis in either case.

TREATMENT AND COURSE

Exploratory laparotomy was performed in both patients. A subtotal gastric resection with gastrojejunostomy was undertaken in Case 1, a submucous excision via an anterior gastrostomy in Case 2. In both cases histology showed a gastrointestinal stromal tumour, but its benignity could not be firmly established even after detailed immunohistological examination.

CONCLUSION

Gastrointestinal tumours are rare. Although they have particular immunohistological characteristics their benignity cannot usually be definitively established even on the excised specimen. Because more extensive resection does not increase survival time, a resection margin of 1-2 cm is considered adequate. Neither radio- nor chemotherapy are successful. Life-long follow-up is indicated because the tumor's uncertain benignity.

Fibroma of a tendon-sheath presenting as toe deformity

We describe a rare manifestation fibroma in a tendon-sheath in an 83-year-old man. The patient complained initially of a slowly progressive spreading, apart of the right second and third toes. A mass was found in the plantar aspect of the foot. It was completely excised at surgery. Histological examination revealed sparse spindle or stellate cells with slit-like vessels in the dense collagenous matrix. There had been no recurrence at follow-up 17 months after surgery.

Blood transfusion and bone allografts. Effect on infection and outcome

Intraoperative and postoperative blood replacement have been implicated in increased rates of wound infection, decreased rates of renal allograft transplant rejection, and increased rates of local recurrence and metastasis of certain kinds of tumors, all presumably on the basis of some alteration in the immune system. Because patients who have bone allograft surgery for tumors often require transfusion and because the procedure is associated with a high rate of failure (20%), infection (9%-10%), and local recurrence (10% for high grade tumors), the effect of transfusion (range, 0-4750 ml) was studied for 264 patients who had proximal humeral, proximal or distal femoral resections, and massive cadaveric allografts but who did not have adjuvant chemotherapy or radiation. An attempt was made to statistically correlate the tumor and allograft outcome and rate of infection with patient age and gender, anatomic site, diagnosis, stage, type of graft, number of subsequent procedures, surgical margins, perioperative transfusions, blood loss, duration of operative procedures, and number of pregnancies. Of the variables studied, only blood loss, transfusion, and duration of surgery had an effect on outcome and, more specifically, on infection rate and time to union. No effect was observed on metastasis, recurrence, or the ultimate outcome of the procedure.

Malignant cartilaginous tumors of the mediastinum: clinicopathological study of six cases presenting as extraskeletal soft tissue masses

Cartilage and bone-forming tumors of the mediastinum are extremely rare neoplasms with very few cases having been reported in the literature. We studied six cases of primary malignant cartilaginous tumors presenting as extraskeletal soft tissue masses in the posterior mediastinum. The patients were five women and one man aged 11 to 63 years (median, 31 years). Histologically, the lesions showed a spectrum of features that ranged from mesenchymal chondrosarcoma, to extraskeletal myxoid chondrosarcoma, to moderately well to poorly differentiated chondrosarcoma. In all cases, the lesions presented as well-circumscribed tumor masses centered in the soft tissues in the posterior mediastinum without radiographic evidence of origin from bone. Because of their relatively small size, good circumscription, focal areas of calcification, and posterior mediastinal location, the preoperative clinical diagnoses included benign neurogenic tumor and neuroblastoma. All of the lesions were treated by complete surgical excision, followed in two cases by postoperative radiation therapy. Clinical follow-up was available in five cases: two patients with mesenchymal chondrosarcoma presented with local recurrence after 3 and 7 years, one developed metastases to the sacrum 8 years after initial diagnosis and died, and one was alive and well without evidence of disease after 6 years. The patient with myxoid chondrosarcoma of the posterior mediastinum developed bilateral pulmonary metastases 10 months after surgery and has been lost to follow-up since. Our findings reinforce previous observations on the occurrence of extraskeletal cartilaginous tumors in the mediastinum and indicate that these tumors can show a propensity for local aggressive behavior with high recurrence rate and a definite potential for distant metastases. Such tumors should be considered in the differential diagnosis of malignant neoplasms presenting as a soft tissue mass in the posterior mediastinum.

Malignant gastrointestinal stromal tumor of the small intestine: radiologic-pathologic correlation

Neoplasms of the small intestine are very rare. Gastrointestinal stromal tumors (GISTs) are one of the new undifferentiated stromal tumors of the gastrointestinal tract diagnosed by immunohistochemistry. We present a case of a malignant GIST arising from the small intestine and report the radiologic characteristics of the tumor and pathological correlation. CT showed a very large, enhancing mass with extensive central necrosis located on the mesenteric side of the jejunum. A perforation into the jejunal lumen was observed by upper GI series. MRI showed a very large tumor which was hypointense on T2-weighted images. Ultrasound revealed a mixed solid and cystic mass. Grossly, the tumor was solid peripherally with extensive central necrosis. Microscopically, it consisted of spindle and epithelioid cells. Immunohistochemically, the cells stained positive for CD34, which is diagnostic of GIST.

Malignant giant cell tumor of the tendon sheaths and joints (malignant pigmented villonodular synovitis)

Malignant pigmented villonodular synovitis (PVNS) is a rare lesion whose existence may be debatable. We studied eight cases that we consider to be examples of malignant PVNS. The three male and five female patients were aged 12 to 79 years. The knee was involved in three cases; the ankle in two; and the cheek, dorsum of the foot, and thigh in one each. Four patients had swelling for 6 months to 17 years before presentation. Three cases of malignant PVNS were secondary, arising in patients in whom PVNS had been documented previously, and five cases were primary, with histologic features similar to those of the secondary ones. Important histologic features of malignancy were (a) a nodular, solid infiltrative pattern of the lesion; (b) large, plump, round or oval cells with deep eosino philic cytoplasm and indistinct borders; (c) large nuclei with prominent nucleoli; and (d) necrotic areas. Atypical mitoses were occasionally seen. Four patients died with pulmonary metastasis (two also had metastasis to inguinal lymph nodes). Four patients are alive from 3 1/2 to 5 years after the last surgical treatment. The malignant nature of this lesion, the histologic architecture similar to that of PVNS, and the fibrohistiocytic appearance of the cells suggest that malignant PVNS is an entity.

Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors

STUDY DESIGN

The study of seven patients with primary malignant or benign aggressive tumors who underwent a new aggressive surgical technique termed "total en bloc spondylectomy" is reported.

OBJECTIVES

To report a new surgical technique of total en bloc spondylectomy for complete, resection of primary spinal malignancy and for oncologic curability.

SUMMARY OF BACKGROUND DATA

The conventional approach for primary spinal malignancy is via intralesional piecemeal resection, and very few reports have described en bloc extralesional resectioning with histopathologically wide or marginal surgical margins.

METHODS

Total en bloc spondylectomy, consisting of en bloc laminectomy and en bloc corpectomy followed by anterior instrumentation with spacer grafting and posterior spinal instrumentation, was performed in five patients with primary malignant tumors and two patients with giant cell tumors. Patients were observed for 2 years to 6.5 years, except for one patient who died 7 months after surgery because of a mediastinal metastasis.

RESULTS

All patients, except one, attained significant clinical improvement after surgery with no major complications. Histologically, the margins were wide or marginal except for the pedicles, and occasionally the spinal canal and the posterior, where they were accepted to be intralesional. One patient died of metastasis that was not directly related to surgery itself. There was no local recurrence.

CONCLUSIONS

The advantages of total en bloc spondylectomy include resection of the involved vertebra(e) in two major blocs, rather than in a piecemeal pattern, and completion of the procedure during one surgical session posteriorly. The "total en bloc spondylectomy" offers one of the most aggressive modes of therapy for primary spinal malignancy.

Oncogenic osteomalacia caused by a phosphaturic mesenchymal tumor of the oral cavity: a case report

We report a case of oncogenic osteomalacia associated with a phosphaturic mesenchymal tumor in a 31-year-old woman. She was presented with severe generalized bone and muscle pain and was restricted to bed. She lost 20 cm in height over the 8 years since she had first noticed a pain in her thigh. A walnut-sized, hard, soft tissue tumor was found very easily beside her lower molar teeth Radiologic examination revealed a remarkable decrease in bone density and multiple pathologic fractures of spine, femur and phalangeal bones. Severe hypophosphatemia, hyperphosphaturia, low plasma 1,25-dihydroxyvitamin D3 level and high plasma PTH level were disclosed at presentation. Histomorphometric examination revealed an extensive area of unmineralized osteoid and little mineralizing activity. A pharmacologic dose of 1 alpha-hydroxyvitamin D3 or or 1,25-dihydroxyvitamin D3 slightly increased the serum phosphate level and renal tubular reabsorption of phosphate, and slightly decreased plasma PTH level without any symptomatic improvement. Histologic examination of the tumor revealed a mixed connective tissue tumor that consisted of central woven bones and surrounding primitive spindle cells with prominent vascularities. After removal of the tumor, all biochemical, hormonal and radiologic abnormalities disappeared with remarkable symptomatic improvement.

[Large abdominal wall reconstruction by free flap after recurrence of a dermatofibrosarcoma protuberans]

Based on a case of recurrence of a dermatofibrosarcoma protuberans of the abdominal wall, the authors discuss the need for initial wide resection of this type of skin tumour and the possibilities of repair of extensive full thickness defects of the abdominal wall by means of a latissimus dorsi myocutaneous free flap.

151 endoprosthetic reconstructions for patients with primary tumors involving bone

As part of the UCLA limb salvage program, 151 patients received 151 endoprostheses for primary tumors involving bone. Follow-up of all patients was to death (56), revision (21), or a minimum two years for the 74 additional survivors (range: 24-114 months; mean: 52 months). Endoprosthetic replacements were of the distal femur (81), proximal femur (19), proximal humerus (13), proximal tibia (11), scapula (11), total femur (8), total humerus (4), intercalary prostheses (2), and one each of the distal humerus and the pelvis. There were three soft tissue sarcomas, five benign bone lesions, and 143 primary malignant tumors of bone. MSTS function was good-excellent in 78%. There were 64 local complications in 55 patients (36%). Mechanical failure occurred in 24 patients (15.9%), local recurrence occurred in ten (6.6%), minor wound healing problems in nine (5.9%), and infection in eight (5.3%). Few systemic complications were reported. Function appeared to be location dependent. All of the 29 patients with benign or low grade malignant tumors (parosteal, IA, IB) have survived. Of the 116 patients with stage IIA and IIB disease, 59% survived three years, and a Kaplan-Meier analysis projects that 56% are expected to survive at five years. Only 17 (11%) of these 151 endoprostheses have been revised; an additional four (3%) eventually came to amputation. The Kaplan-Meier analysis revealed that 91% of the prostheses survived three years and 83% survived five years. The Cox Proportional Hazards model revealed that for patients with stage IIA and IIB disease, the risk of death is four times the risk of the need for revision at five years. Although endoprosthetic reconstructions have their own unique complications, they have proven durable in this series of patients. Local problems usually can be managed without amputation, and patient satisfaction is high.

Resection arthrodesis of the knee for tumor: large intercalary allograft and long intramedullary nail technique

Twenty-five patients had a procedure consisting of resection of the distal femur or proximal tibia for aggressive or malignant neoplasms. The resulting bony gap was bridged by allografts averaging 18 cm in length. Fixation was achieved using a long fluted intramedullary nail. The average follow-up time and time to union were 3 years (range, 0.25 to 9 years) and 13 months (range, 6 to 28 months), respectively. Eleven patients had nononcologic complications related to the index surgical procedure, including two patients with allograft nonunion. There were no infections. Three patients had amputations for local recurrence of their tumor. Twenty patients (80%) had no evidence of tumor at the time of follow-up. According to the Evaluation System of the Musculoskeletal Tumor Society, 80% of patients had a satisfactory result. No patient had a nononcologic complication resulting in total failure or amputation. The procedure of resection-arthrodesis of the knee using a large allograft with a long intramedullary nail provides patients with a stable, durable biological reconstruction that allows early weight-bearing, and the procedure carries a low incidence of infection.

The use of corundum ceramic implants after excision of tumours of the extremities

Implants of corundum ceramic have been used in the treatment of 38 patients with bony tumours of the limbs. Data are presented concerning the replacement with ceramic implants of the joint ends and diaphyseal defects of long bones, as well as in various bones of the hand and foot. Experiments carried out over a long period have shown that corundum ceramic is a strong material and is biologically inert.

[Spontaneous fractures and tumors (author's transl)]

During childhood, pathologic fractures are found in systemic diseases of the skeleton (e.g. osteogenesis imperfecta or rachitis), but especially when bone tumors or tumorlike changes are present. Conservative measures such as continuous traction and application of a plaster cast lead to healing of the fracture only in a limited number of cases. Treatment of benign and potentially malignant and tumors and of tumorlike growths by excochleation and by resection and subsequent filling of the defect with autologous spongiosa and in some cases metallic fixation respectively has proved useful. The surgical treatment of malignant tumors depends on the king of tumor and its localization.

[Surgical treatment of benign and semimalignant tumors (author's transl)]

The differential diagnosis of of benign, semimalignant (or, more correctly, potentially malignant) tumors from malignant tumors or pathologic tumorlike changes is often difficult. Routine angiography and scintigraphy certainly help a great deal in differential diagnosis. The major causes of threatened or pathologic fractures are primary bone tumors and pathologic tumorlike changes. In this connection, a spontaneous fracture is a sign of a benign tumor. Excochleation or resection, with subsequent filling of the defect with homologous bone chips and fixation with a metal aid if necessary, has proved successful as a treatment for benign and potentially malignant tumors and for tumorlike changes. Joint replacement and amputation are necessary only in exceptional cases.