Giant cell tumor of the bones of the hand and foot

BACKGROUND

Giant cell tumor of the small bones of the hand and foot is suspected of having some peculiar features compared with giant cell tumor in other sites. Moreover, it could share some features with other giant cell rich lesions involving the hand and foot, and this may affect the differential diagnosis. The aim of this study was to analyze the features of lesions such as these in the files of the Rizzoli Orthopedic Institute.

METHODS

The incidence of giant cell tumors of the bones of the hand and foot seen at the Rizzoli Orthopedic Institute over 50 years (1947-1997) was taken into consideration. There were 8 lesions of the hand and 21 of the foot. Clinical information and follow-up of the patients were studied and updated. Radiographs were studied and radiographic features analyzed. Histopathologic material was thoroughly reviewed and histologic features analyzed.

RESULTS

Although the location of tumor was helpful information, radiographic features were not specific. Giant cell tumors of the small bones of the hand and foot showed a predominance in females, younger patients and more aggressive behavior than giant cell tumors of large bones. The authors did not observe multicentricity or pulmonary metastases.

CONCLUSIONS

Because the radiographic features of giant cell tumor of the hand and foot overlap those of other giant cell rich lesions in these locations, histologic diagnosis is mandatory, although it may be difficult and require the establishment of diagnostic criteria for giant cell tumor. As this tumor tends to be more aggressive than other giant cell rich lesions, treatments of choice are aggressive curettage or resection.

[Expression and significance of AR in osteosarcoma]

OBJECTIVES

To determine the relationship between AR and pathological characteristics of osteosarcoma and to investigate the potential role of AR in the pathogenesis of osteosarcoma.

METHODS

AR in the samples of the paraffin embedded tissues from 65 cases of osteosarcoma was immunohistochemically detected by streptavidin/peroxidase (SP) method. The pathology of osteosarcoma was classified and graded according to Liu Zijun's Classification.

RESULTS

The positive rate of AR was 50.8% (33/65). The positive particles were distributed in the cytoplasm and nucleus. The positive rate of AR in osteosarcoma with higher grade of cell differentiation was lower than that in the tumor with lower one. There was no significant difference in different pathological type of osteosarcoma.

CONCLUSION

AR exists in osteosarcoma and its positive rate is related to the cell differentiation of osteosarcoma.

CKbeta-8 [CCL23], a novel CC chemokine, is chemotactic for human osteoclast precursors and is expressed in bone tissues

We have previously demonstrated that a tartrate-resistant acid phosphatase (TRAP)-positive subpopulation of mononuclear cells isolated from collagenase digests of human osteoclastoma tissue exhibits an osteoclast phenotype and can be induced to resorb bone. Using these osteoclast precursors as a model system, we have assessed the chemotactic potential of 16 chemokines. Three CC chemokines, the recently described CKbeta-8, RANTES, and MIP-1alpha elicited significant chemotactic responses. In contrast, 10 other CC chemokines (MIP-1beta, MCP-1, MCP-2, MCP-3, MCP-4, HCC-1, eotaxin-2, PARC, SLC, ELC) and 3 CXC chemokines (IL-8, GROalpha, SDF-1) were inactive. None of these chemokines showed any chemotactic activity for either primary osteoblasts derived from human bone explants or the osteoblastic MG-63 cell line. The identity of the osteoclast receptor that mediates the chemotactic response remains to be established. However, all three active chemokines have been reported to bind to CCR1 and cross-desensitization studies demonstrate that RANTES and MIP-1alpha can partially inhibit the chemotactic response elicited by CKbeta-8. CKbeta-8, the most potent of the active CC chemokines (EC(max) 0.1-0.3 nM), was further characterized with regard to expression in human bone and cartilage. Although expression is not restricted to these tissues, CKbeta-8 mRNA was shown to be highly expressed in osteoblasts and chondrocytes in human fetal bone by in situ hybridization. In addition, CKbeta-8 protein was shown to be present in human osteophytic tissue by immunolocalization. These observations suggest that CKbeta-8, and perhaps other chemokines, may play a role in the recruitment of osteoclast precursors to sites of bone resorption.

[Roles of magnetic resonance imaging in management of bone tumors]

The roles of magnetic resonance imaging (MRI) in the diagnosis and treatment of bone tumors are reviewed. Most bone tumors can be detected on plain radiography or bone scintigraphy. MRI is helpful in detecting tumors that do not destroy bone matrix or suppress reactive bone formation. Detailed analysis by plain radiography is still the most reliable method for differentiating between benign and malignant bone tumors. The T1 and T2 values, internal texture, and peritumoral edema depicted on MRI are not helpful for this differentiation. In characterizing the histologic types of bone tumors, MRI is of some advantage. For example, MRI can demonstrate cartilage matrix, hemoglobin metabolites, vascular components, and fat contents more clearly than conventional radiological techniques. MRI is now indispensable for the preoperative delineation of malignant bone tumors, because of its excellent soft tissue contrast and multiplanar imaging capability. In this article, the guidelines for evaluation of the surgical margin advocated by the JOA Musculo-skeletal Tumor Committee are introduced for radiologists. MRI monitoring of malignant bone tumors after chemotherapy or surgery can reveal change in the size of enhanced areas that may reflect viable tumors. Dynamic MRI is helpful to differentiate recurrent tumors from granulation tissue.

[Bone tumors and tumor-like lesions of the jaw. Findings from the Basel DOSAK reference registry]

Within this chapter, tumors which produce bone matrix (osteoid) or other bone-forming tissues, like cartilage, connective tissue, and cementum or originate within the bone marrow are described. In addition, those lesions are mentioned which, according to the WHO, are typical for the jawbones and are therefore included within the 1992 WHO classification of odontogenic tumors. Vascular and epithelial tumors which may also be observed in the jaws are not described. All the lesions and tumors reported have in common a more or less similar clinical and radiological appearance. A precise diagnosis, therefore, can only be established by a sufficient biopsy which should be seen by a pathologist with experience in this field. In addition to clinical, radiological, and histological appearances, therapeutic necessities are described. The data from recent publications are taken into account. This presentation is based on the data collected within the reference registry of the German-Austrian-Swiss Study Group of Tumors of the Face and Jaws (DOSAK) in Basel.

Leptin and apoptosis inhibitor soluble Fas antigen in the serum of patients with osteosarcoma and neuroectodermal bone tumors

Serum contents of leptin and soluble Fas antigen were measured in 28 patients with osteosarcoma, 7 with neuroectodermal bone tumors, and 17 healthy subjects. The incidence and levels of soluble Fas antigen in patients with osteosarcoma and neuroectodermal bone tumors were higher than in healthy subjects and did not depend on sex and age in both healthy subjects and patients. Serum concentration of leptin in women was higher than in men (both in healthy controls and patients) and was lower in healthy subjects compared to patients with osteosarcoma and neuroectodermal bone tumors. A trend to a negative correlation between the concentrations of leptin and soluble Fas antigen in female patients with osteosarcoma and male patients with neuroectodermal bone tumors was revealed. The role of leptin and soluble Fas antigen in the pathogenesis of primary bone tumors is discussed.

h-Caldesmon as a specific marker for smooth muscle tumors. Comparison with other smooth muscle markers in bone tumors

Caldesmon is a protein widely distributed in smooth and non-smooth muscle cells and is thought to regulate cellular contraction. Its isoform, high-molecular-weight caldesmon (h-CD), was demonstrated to be specific for smooth muscle cells and smooth muscle tumors of the soft tissue and to never be expressed in myofibroblasts. We performed an immunohistochemical study to examine h-CD expression in the following bone tumors: conventional and non-conventional osteosarcoma, 13; malignant fibrous histiocytoma of bone, 5; giant cell tumors of bone, 5; chondroblastoma, 3; metastatic leiomyosarcoma, 2; and rhabdomyosarcoma, 1. Frequent immunoreactivity for muscle actin (alpha-smooth muscle actin or muscle-specific actin) was seen in 11 of 13 osteosarcomas and all other tumors, whereas h-CD was expressed intensely only in 2 leiomyosarcomas. h-CD is considered a specific and useful marker to distinguish smooth muscle tumor from bone tumors with myoid differentiation.

Giant cell tumor of the fourth metacarpal bone

Giant cell tumor is among the rare tumors of the bone. We present a case of metacarpal giant cell tumor with radiographic, computed tomographic (CT) and histologic findings, as well as grey scale and Doppler sonographic features. We also present the "doughnut"-shaped appearance on scintigraphy of the lesion, which has not been shown on a metacarpal giant cell tumor.

Pathological diagnosis of bone sarcoma

The diagnosis of bone lesions should be established in every case by combined clinical, radiologic and pathologic investigations. For pathologic investigation, a surgical biopsy or needle biopsy should be carried out. Before attempting to make a diagnosis, the pathologist must determine that the tissue to be studied is representative. If clinical and radiologic information is not readily available, the pathologist must insist on its submission before rendering a diagnosis on a slide. It is said that to merely "read slides" without full comprehension of the clinical setting and the radiologic clues of the biologic behavior of the tumor can easily lead to an erroneous diagnosis. A specimen from aspiration biopsy is generally adequate for immediate diagnosis for some bone tumors, but in many cases it is not sufficient for accurate classification of either benign or malignant tumors.

Multidrug resistance-1 gene expression does not increase during tumor progression in the MGH-OGS murine osteosarcoma tumor model

In addition to its possible role in drug resistance, expression of the multidrug resistance-1 gene may also be associated with a more malignant phenotype and tumor progression. This study evaluated its expression during tumor progression in the MGH-OGS transplantable murine osteosarcoma tumor model. Three variables of tumor progression were analyzed: tumor size, local recurrence, and metastasis. With a highly sensitive reverse transcription-polymerase chain reaction method, mRNA levels of multidrug resistance-1 were compared in primary tumors of different sizes. In addition, the levels were compared in primary, locally recurrent, and metastatic tumors isolated from individual mice. No significant difference was found in the levels of expression with increasing primary tumor size. In addition, the levels in primary, locally recurrent, and metastatic tumors were not significantly different. Our results indicate that--at least in the MGH-OGS tumor model, which is analogous to the majority of spontaneously occurring human osteosarcomas in that it has low levels of multidrug resistance-1/P-glycoprotein and is sensitive to doxorubicin--there is no evidence of upregulation of multidrug resistance-1 expression during tumor progression.

Antiestrogens specifically up-regulate bone morphogenetic protein-4 promoter activity in human osteoblastic cells

Bone morphogenetic protein-4 (BMP-4) plays an important role in the onset of endochondral bone formation in humans, and a reduction in BMP-4 expression has been associated with a variety of bone diseases. Here we describe, by transient transfection assays in bone cells, that the human BMP-4 promoter recently characterized in our laboratory can be stimulated specifically by antiestrogens but not by estrogens or other steroid hormones. This activity is dependent on the presence of the estrogen receptor (ER)-alpha, although the promoter lacks a consensus estrogen-responsive element. No activity was observed in the presence of ERbeta, but synergy was observed when both ER subtypes were cotransfected. The observed stimulation of BMP-4 promoter activity by antiestrogens appeared bone cell specific and was reversed upon addition of estrogens. Since antiestrogens are known to be effective in hormone replacement therapies for postmenopausal women, this observation may help to develop new strategies for treatment and prevention of osteoporosis.

Clinical significance of tenascin-C expression in osteosarcoma: tenascin-C promotes distant metastases of osteosarcoma

Tenascin-C (TN-C) is one of extracellular matrix glycoproteins. We have immunohistochemically examined the TN-C expression of 33 primary osteosarcoma paraffin-embedded samples. The TN-C expression of the patient group with metastases was higher than that of the group without metastases at significant difference, and the survival curves show a tendency for poor outcome in the high grade staining group. Moreover, the supplemental TN-C had an effect of easier migration of a human osteosarcoma cell line (HOS) in vitro. The results may suggest that TN-C help osteosarcoma cells to migrate and to metastasize.

Fine-needle aspiration cytology of unsuspected metastatic thyroid carcinoma initially presenting in bone: report of three cases and a review of the literature

We present a series of three cases of unsuspected thyroid carcinoma presenting as bony lesions and initially studied by fine-needle aspiration (FNA). This series consists of two cases of follicular carcinoma and a third case of Hurthle cell carcinoma. FNA was performed on all three lesions. In two of these cases, a definitive diagnosis of metastatic thyroid carcinoma was made based on the FNA material. FNA smears of both follicular carcinomas displayed cohesive clusters of atypical round cells with nuclear overlapping and positive immunoperoxidase staining for thyroglobulin. The aspirates of the Hurthle cell carcinoma were composed of sheets and individually scattered oval oncocytic cells with prominent nucleoli. All three cases demonstrated the presence of marginal vacuoles consistent with "flame" cells. To the best of our knowledge, this is the first series discussing the cytologic features and differential diagnosis of unsuspected thyroid carcinoma initially presenting as metastatic bone lesions.

Fine needle aspiration cytology of the Ewing's sarcoma family of tumors

OBJECTIVE

To study the cytomorphologic features of the Ewing's sarcoma (ES) family of tumors.

STUDY DESIGN

During a period of eight years (1990-1997), 123 soft tissue tumors and 65 bone tumors were evaluated by fine needle aspiration cytology (FNAC); 14 cases were diagnosed as in the ES family of tumors. The ages of the patients ranged from 8 to 30 years. All the cases were histologically confirmed.

RESULTS

Of 14 cases of the ES family of tumors, 7 were ES, 3 extraosseous ES (EOE), 2 peripheral primitive neuroectodermal tumor (PPNET) and 2 Askin tumor. Cytologically, smears from all the cases showed round tumor cells with a high nuclear/cytoplasmic ratio. On detailed examination, subtle differentiating features were observed. The cells in ES had finer nuclear chromatin in comparison to those of PPNET and Askin tumor, and punched-out clear cytoplasmic vacuoles were present. PPNET showed nuclear molding, unipolar cytoplasmic tags and Homer-Wright rosettes. Histologically, all cases of ES and EOE and one case of Askin tumor showed periodic acid-Schiff-positive inclusions.

CONCLUSION

FNAC features coupled with clinical findings enable a rapid diagnosis of the ES family of tumors, from which treatment modalities can be determined.

Delay in Diagnosis of High-Grade Osteosarcoma of the Extremities. Has it any Effect on the Stage of Disease?

In 965 patients with high-grade osteosarcoma of the extremities, we investigated the correlation between diagnostic delay and the stage of the tumor at presentation. The mean interval between the onset of first symptoms and the final diagnosis was significantly shorter in patients with metastatic disease than in patients with localized disease at the time of the diagnosis. The difference was due to a late presentation of patients with localized disease to the physician and not to delays in performing radiologic examinations or in referring patients to a specialized hospital for biopsy and treatment. We conclude that in high-grade osteosarcoma of the extremity the shorter interval between onset of symptoms and diagnosis observed in patients with disseminated disease at the time of the diagnosis reflects a more aggressive behavior of tumors that are metastatic at presentation.

Bizarre parosteal osteochondromatous proliferation (Nora's lesion) of the sesamoid: a case report

We report the a case of Nora's lesion (Bizarre Parosteal Osteochondromatous Proliferation) of the sesamoid. A 32-year-old woman presented with a painless, enlarging mass of two years duration on the plantar aspect of the first metatarsophalangeal joint of the left foot. Radiographs, Computerized Tomographs and Magnetic Resonance images, initially suggested a parosteal osteosarcoma arising from the tibial sesamoid. The mass was excised, and a histological diagnosis of Bizarre Parosteal Osteochondromatous Proliferation of bone (Nora's lesion) was made. The aggressive growth of this lesion may suggest a neoplasm clinically. Histological features, however, are those of a reactive lesion.

Theoretical study of convergent ultrasound hyperthermia for treating bone tumors

This study investigates the optimal external parameters for using an ultrasound applicator for treating bone tumors. This system utilized spherically arranged applicators such as scanned focused ultrasound, and spherically focused multielement applicators. The power deposition pattern is modeled as geometric gain with exponential attenuation. The specific absorption rate ratio (SARR) criteria have been used to determine the proper heating domain of ultrasound driving frequency and therapeutic tumor diameter. The results demonstrate that the optimal driving frequency depends on tumor depth, ultrasound absorption of bone marrow, and diameter of bone, but it is independent of the acoustic window area and SARR. The treatable diameter of bone tumor increased when the absorption ratio of bone marrow to tumor, acoustic window of surface skin, and diameter of bone were elevated. However, the treatable diameter of bone tumor decreased when muscle thickness, SARR of bone tumor site to the surface skin, bone marrow, and bone declined. To deliver the ultrasound energy into the tumor site and to avoid the potential damage to the normal tissue as much as possible, the specific absorption rate (SAR) in the bone tumor site has to be three times higher than that in the surface skin, tumor/marrow, and marrow/bone interfaces. The temperature distributions can verify the SARR criteria in this model. This study provides the information for choosing the optimal operating frequency of the ultrasound transducer and the acoustic window on the skin surface, and for designing the ultrasound applicator for clinical implementation.

Cutaneous metastases as initial manifestation of dedifferentiated chondrosarcoma of bone. An autopsy case with review of the literature

Metastases of chondrosarcoma to the skin are uncommon. We report a case of dedifferentiated chondrosarcoma that manifested as cutaneous metastases and had an outcome of three weeks. A 69-year-old male presented with two cutaneous nodules, one in the chest and other in the inguinal area. The punch biopsy of the latter showed a poorly differentiated mesenchymal metastatic tumor. Shortly before death, an X-ray revealed a proximal epiphyseal lesion in the right humerus, radiographically interpreted as chondrosarcoma. The autopsy showed this lesion to be a dedifferentiated chondrosarcoma whose nonchondroid mesenchymal part was akin, histologically and immunohistochemically, to the cutaneous metastases. While ten previous reports of chondrosarcoma metastatic to the skin are known, we believe that this is the first case to report the cutaneous metastases of the dedifferentiated variety. Furthermore, skin metastasis preceding the diagnosis of chondrosarcoma has not been previously reported. The fact that one part of this kind of tumor can be highly undifferentiated or, else, differentiated along lines not usually reminiscent of bone tumors, can make the diagnosis of such cases extremely difficult. Most chondrosarcomas metastatic to the skin arise in bones of the extremities, including the hand. The most common type of tumor is conventional chondrosarcoma. These metastases can be either single or multiple with a slight predilection for the head and neck region. Most patients die in a mean time of 6 months after the appearance of cutaneous metastases.

[Primary intraosseous rhabdomyosarcoma]

We report a case of primary intraosseous pleiomorphic rhabdomyosarcoma located in the pelvis of a 21-year-old woman followed for 4 years. The lytic tumor involved the acetabulum and the isthma with moderate extension to soft tissue. First line chemotherapy was unable to arrest tumor progression. Hemipelvectomy with saddle prosthesis reconstruction was performed, but septic complications dictated a secondary inter-ilio-abdominal amputation. Recurrence-free remission was achieved for 4 years, suggesting this was indeed a primary tumor. Primary intraosseous rhabdomyosarcomas are exceptional. Bone localizations generally suggest metastasis from a primary tumor often situated in an intraperitoneal localization. When search for a primary tumor is negative, intraosseous lesions can be considered as primary tumors warranting curative treatment. Radical surgical resection is recommended within the framework of a multidiscipinary management protocol associating radiotherapy and chemotherapy to improve prognosis.

Repeated dedifferentiation of low-grade intraosseous osteosarcoma

Low-grade intraosseous osteosarcoma is an uncommon bone tumor that is characterized by minimum cytological atypism and a much better prognosis than conventional osteosarcoma. This report describes a patient who had a low-grade osteosarcoma that mimicked fibrous dysplasia (FD). The tumor had an area of high-grade sarcoma at the initial diagnosis. Ten years after incomplete resection of FD-like tumor, local recurrence with areas of high-grade tumor developed. This case illustrates the potential of dedifferentiation in low-grade intraosseous osteosarcoma.

Loose fragments and other debris: miscellaneous synovial and marrow disorders

Conventional MR imaging evaluation of the knee focuses mainly on the effects of acute trauma and degenerative conditions. Numerous other conditions that affect the knee may mimic clinical characteristics of common traumatic and degenerative disorders. Synovial and marrow abnormalities are frequently encountered and often unsuspected on routine MR imaging studies of the knee. This article presents the MR imaging appearance of the normal synovium, bone marrow, and commonly encountered abnormalities of these structures.

Regulation by IGF-I and TGF-beta1 of Swarm-rat chondrosarcoma chondrocytes

The growth factors transforming growth factor-beta 1 and insulin-like growth factor-I influence a wide range of cellular actions, including the growth of several neoplastic cell types. Their role in the regulation of neoplastic chondrocytes remains unclear. We tested the hypotheses that transforming growth factor-beta 1 and insulin-like growth factor-I differentially regulate neoplastic chondrocytes and interact to modulate the mitotic and matrix synthetic activities of neoplastic chondrocytes. We used Swarm-rat chondrosarcoma chondrocytes to investigate the effect of each factor individually and of both factors in combination on [(3)H]thymidine incorporation into DNA and on [(35)S]sulfate incorporation into glycosaminoglycans. Each factor increased [(3)H]thymidine incorporation 2.7-fold: transforming growth factor-beta 1 achieved this effect at a 20-fold lower concentration than insulin-like growth factor-I. In contrast, insulin-like growth factor-I stimulated [(35)S]sulfate incorporation 3.5-fold; this was twice the maximal effect of transforming growth factor-beta 1. Transforming growth factor-beta 1 and insulin-like growth factor-I each decreased the proportion of newly synthesized glycosaminoglycans that were retained in the cells and pericellular matrix, indicating that the anabolic effect of these factors is only partly directed toward cell-associated matrix production. The mitogenic and matrix synthetic actions of insulin-like growth factor-I and transforming growth factor-beta 1 were synergistic. In concert, they increased [(3)H]thymidine incorporation approximately 12-fold, an effect three times greater than the sum of the maximal stimulation achieved by each factor individually. Similarly, transforming growth factor-beta 1 and insulin-like growth factor-I together increased glycosaminoglycan synthesis approximately two times more than the sum of their maximal individual effects. Taken together, these data indicate that these chondrosarcoma chondrocytes are positively regulated by insulin-like growth factor-I and transforming growth factor-beta 1 and that these growth factors interact to augment the mitotic and matrix synthetic actions of the chondrocytes. If supported in human models, the sensitivity to growth factors of these cells suggests that interventions directed toward growth factor inhibition may be of therapeutic value.