Osseous lesions of the distal ulna: atypical location--unusual diagnosis. Report of three cases with similar imaging and different pathologic diagnoses

Three cases with destructive bone lesions of the distal end of the ulna caused by different pathologic entities (Ewing's sarcoma, osteosarcoma, rheumatoid pseudotumoral synovitis) are presented, all with similar clinical and comparable x-ray and magnetic resonance imaging features. Although the distal end of the ulna may be resected without significant functional impairment, careful evaluation of treatment strategies compatible with oncologic standards is warranted.

Giant cell tumor of rib--rare location on the anterior aspect

Giant cell tumor rarely occurs in ribs, where it presents posteriorly. We present a report of a giant cell tumor of bone occurring anteriorly in the rib with a review of the literature.

Stimulation of motility of human renal cell carcinoma by SPARC/Osteonectin/BM-40 associated with type IV collagen

SPARC is known to be important in development and tissue remodelling. Here, we examined the effects of SPARC (secreted protein, acidic and rich in cysteine; osteonectin) derived from a rat osteosarcoma cell line on migration of renal cell carcinoma (RCC) by a Boyden chamber assay. YCR RCC cells migrated through type IV collagen-coated filters without stimuli (basal level). SPARC in the lower compartment stimulated chemotactic activity to 120% of the basal level, whereas premixing of YCR with purified SPARC before inoculation reduced their migration to 72% of the basal level. Furthermore, SPARC mixed with type IV collagen more efficiently stimulated their migration in a concentration-dependent manner (up to 170% of the basal level). This suggests that SPARC bound to type IV collagen plays a role in tumor invasion.

Melanotic neuroectodermal tumor of infancy: report of two cases and review of literature

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare, distinctive neoplasm containing melanin; it primarily affects the maxilla of the infants during the first year of life. Approximately 150 instances of this tumor are reported in the medical literature. Genesis of the tumor is obscure and the diagnosis is challenging for the pathologist. Two cases operated by the first author are presented, and the diagnostic features and treatment alternatives of MNTI discussed.

Enhanced apoptosis in retrovirally transfected osteosarcoma cells after exposure to sodium butyrate

We investigated the effects of sodium butyrate (NaBu) on two retrovirally transfected osteosarcoma cell lines (1547-TK and 1547-LacZ cells) compared to the corresponding untransfected cell line. The first finding was an inhibitory effect only on the proliferation of both transfected cell lines. This antiproliferative effect was associated with apoptosis induction, which was detected using techniques that monitor either characteristic biochemical or morphological processes. Our findings show that 1547-TK and 1547-LacZ cells were much more sensitive to NaBu treatment than untransfected 1547 cells as concerns both proliferation and apoptosis induction.

Targeting tumor specific translocations in sarcomas in pediatric patients for immunotherapy

In an effort to develop more effective therapies for various sarcomas in pediatric patients, the authors have focused on using recurrent tumor-specific translocations as potential novel tumor antigens. In general, these translocations generate fusion transcription factors. Because cytotoxic T cell lymphocyte receptors recognize peptide fragments bound to major histocompatibility complex Class 1 molecules, it is possible that unique peptides spanning the translocation breakpoint region may be processed, bound to major histocompatibility complex Class I molecules and displayed on the tumor cell surface where they could be susceptible to cytotoxic T cell lymphocyte killing. The authors have investigated the PAX-3-FKHR fusion product seen in alveolar rhabdomyosarcoma, and the EWS-FLI-1 fusion product seen in Ewing's sarcoma. Peptides spanning these fusion regions contain potential major histocompatibility complex Class 1 and Class II binding motifs suggesting they may serve as novel T cell antigens. Preliminary mouse experiments suggest that cytotoxic T cell lymphocytes specific for the PAX-3-FKHR fusion peptide can be generated and can recognize and kill tumor cells bearing the PAX-3-FKHR fusion protein. Clinical trials are ongoing to determine whether this approach will be useful.

Epiphyseal plate involvement in osteosarcoma

Fourteen boys (56%) and 11 girls (44%) 4 to 17 years of age (mean, 12.2 years) who had osteosarcoma and open epiphyseal plates were studied. A possible correlation between transepiphyseal spread of osteosarcoma and radiologic and histopathologic findings was investigated. Epiphyseal plate invasion was detected radiologically in only 11 patients (44%), whereas histopathologic examination showed transepiphyseal extension in 21 patients (84%). The authors conclude that the epiphyseal plate is not a barrier against tumor growth and strongly recommend that limb salvage surgery preserving the epiphysis be planned carefully.

[Local recurrences after salvage operations in the therapy of osteogenic sarcoma cases - an analysis of adverse effects based on studied cases]

Therapeutic approach in osteogenic sarcoma until 1982 was connected mainly with surgery. Introduction of chemotherapy to the therapeutic protocols of osteogenic sarcoma improved the 5 years survival of patients with osteogenic sarcoma from 20% to 60-70%. The approach to surgical treatment was also changed. The principle of this treatment is usually to perform an operation to spare the limb with an intraoperative frozen section examination of bone marrow. In our Institute during the last 14 years about 300 cases were diagnosed, out of which about 200 were treated surgically, among these about 50% underwent treatment by salvage operations. Only in 7 cases local recurrences of disease were confirmed. Five of these cases were tumours of distal metaphysis of the femur, one case of proximal metaphysis of the tibia and one case of proximal metaphysis of the humeral bone. The sex range M/F was: 5/2, the average age of onset about 14 years. Various factors playing a role in therapeutic adversities were analysed. Among these were: radical surgery, grade of differentiation of the tumour, histological subtype, soft tissue infiltration, reaction to preoperative therapy and the type of chemotherapy. The conducted analysis indicates the role played by sparing surgery in adversities in therapy (3 cases). Attention was also given to the distinct tendency of osteogenic sarcoma to produce vascular embolism which is a source of haematogenously spreading metastases. In 7 cases vascular tumour embolism caused the appaerance of metastatic focuses adjacent to the primary tumour. A certain role in therapeutic adverities is played by the lack of response to preoperative chemotherapy (4/7 cases). The influence of other factors needs further investigation.

[Correlation of the histological subtype of osteogenic sarcoma with the percentage of necrosis after initial chemotherapy]

The material comprises 195 cases of osteogenic sarcoma in children and adolescents. The tumours were grouped in accordance with two classifications; gradual classification which incorporates three levels of morphological maturation of sarcoma and structural classification which distinguishes conventional and nonconventional types of sarcoma. In every case histological mapping of the tumour was performed with the aim to establish the percentage of necrosis and postnecrotic resorbtion of the tumorous mass after the initial chemotherapy. The purpose of this study was to establish the correlation of the tumour necrosis with both histopathological classifications. The main conclusion was, that the gradual classification is more accurate for the changes occurring in the tumour tissue after chemotherapy.

Intraosseous schwannoma of the metacarpal

Intraosseous schwannoma (neurilemmoma) is an extremely rare, benign neoplasm, constituting less than 0.2% of primary bone tumors. It infrequently involves the bones of the hand. We present a case of intraosseous neurilemmoma of the metacarpal.

Secondary pulmonary malignancy

Patients with pulmonary metastases were previously relegated to palliative medical management. Since the first metastasectomies in the nineteenth century, general acceptance of this technique has occurred. Although, initially, indications for resection of pulmonary metastases were limited to patients with solitary nodules, over time, indications have broadened to include multiple lesions, recurrent disease, and nearly all histologies. With appropriate patient selection and the absence of extrathoracic disease, survival may be improved. For patients with disseminated and symptomatic disease, surgical therapy may also provide some relief.

Total knee arthroplasty in patients who have massive osteoarticular allografts

The authors treated 24 patients with total knee arthroplasty who had a massive allograft used to reconstruct the knee and who later had instability, degeneration, or a fracture near the articular surface of the graft develop. Patients then were followed up for a minimum of 2 years and a mean of 8.2 years. Overall, 96% of the patients retained a functional limb, although 46% underwent revision surgery, and an additional 12% had some other major complication. Statistical analysis showed a significant negative effect of chemotherapy on revision-free survival of the prosthesis. Patients with high-grade tumors were at significantly greater risk of fracture of the allograft-prosthesis composite. Certain technical factors were identified that seemed to predispose the allograft-prosthesis reconstructions to early failure. Total knee arthroplasty can be used to treat patients with complications of massive osteoarticular allografts and may prolong the functional life of an otherwise successful limb salvage reconstruction.

Chondromyxoid fibroma of the finger

We report a case of chondromyxoid fibroma arising from the middle phalanx of the index finger. The radiographic and pathologic findings are described.

Ewing's sarcoma of the pelvis. Long-term survival and functional outcome

Fifty patients with Ewing's sarcoma of the pelvis were treated using a multidisciplinary approach; followup of surviving patients averaged 137 months (range, 40-276 months). The addition of surgical resection to the multidisciplinary treatment for all patients was associated with improved survival compared with survival of patients treated with chemotherapy and radiation therapy alone; the addition of surgery to the treatment regimen of 37 patients without metastases also was associated with improved survival. There were no significant differences between the surgical and nonsurgical groups in terms of tumor size, stage of disease, patient age, duration of symptoms before diagnosis, or anatomic site. Surgery was used more often in recently treated patients, but the year of diagnosis and treatment did not significantly affect overall survival, secondary to large confidence intervals. The Short Form-36 and the Musculoskeletal Tumor Society functional evaluation instruments showed a superior level of function in the nonsurgical group, but this difference was not statistically significant. There have been many advances in the treatment of patients with Ewing's sarcoma during the past 3 decades, resulting in improved survival for patients with Ewing's sarcoma of the pelvis. The addition of surgery significantly improved survival and did not show a significant difference in functional outcome.

Expression of osteoclast differentiation signals by stromal elements of giant cell tumors

The mechanisms by which primary tumors of the bone cause bone destruction have not been elucidated. Unlike most other lytic bone tumors, osteoclastomas, otherwise known as giant cell tumors (GCT), contain osteoclast-like cells within the tumor stroma. A new member of the TNF-ligand superfamily member, osteoclast differentiation factor (ODF/OPGL/RANKL/TRANCE), was recently identified. ODF was shown to directly stimulate osteoclastogenesis, in the presence of M-CSF. In this study, the expression of ODF was examined in a number of tumor samples associated with bone lysis in vivo. In addition, we investigated expression of the ODF receptor on osteoclast precursors, RANK, as well as the ODF inhibitor osteoprotegerin (OPG), and another TNF-ligand superfamily member, TRAIL, previously shown to abrogate the inhibitory effects of OPG. We report here the novel finding that GCT stromal cells contain abundant ODF mRNA, whereas the giant cell population exclusively expresses RANK mRNA. These results are consistent with the osteoclast-mediated bone destruction by these tumors. We also report the expression of OPG and TRAIL mRNA in GCT samples. A comparison with other lytic and nonlytic tumors of bone showed that GCT express more ODF and TRAIL mRNA relative to OPG mRNA. In addition, GCT were found to express a number of cytokines previously reported to play central roles in osteoclastogenesis, namely, IL-1, -6, -11, -17, as well as TNF-alpha. Importantly, GCT were also found to express high levels of M-CSF mRNA, a cytokine shown to be an essential cofactor of ODF, and a survival factor for mature and developing osteoclasts. Furthermore, expression of these molecules by stromal cells isolated from GCT continued in vitro. Thus GCT constitutively express all of the signals that are currently understood to be necessary for the differentiation of osteoclasts from precursor cells.

Intraosseus teratoma of the iliac bone

We present a 4-year-old child with a large iliac bone mass incidentally discovered in a plain abdominal radiograph. The pathological examination revealed a benign mature teratoma. To the best of our knowledge, the occurrence of intraosseous mature teratoma has not been previously reported. The child had had an immature teratoma of the neck discovered in a fetal ultrasound, and resected on day 6 of life. The neck teratoma recurred twice, at 16 months and at 3.5 years of age. In these two recurrences the lesion appeared progressively more mature. At the time of discovery of the iliac bone teratoma there was no evidence of residual neck disease. The radiological and pathological characteristics, differential diagnosis, and clinical course are discussed.

Osteosarcoma in preadolescent patients

The medical records of boys younger than 11 years and girls younger than 10 years of age with osteosarcoma of the pelvis or extremity were reviewed. Thirty patients were identified who were newly diagnosed but untreated for osteosarcoma. None of these patients had pulmonary metastases. The same four protocols were used to treat the patients in the current study as were used to treat adolescents. The event-free and overall survival was calculated and prognostic factors were assessed. The median followup time was 8 years (range, 6-14 years). The results were compared with the results of older patients treated with the same protocols and with published results. Fourteen patients had pulmonary metastases (47%); among these patients, four also had skeletal metastases (in two of the latter, skeletal metastases appeared before the pulmonary metastases). Event-free survival was 53% and overall survival was 57%. This result is comparable with current survival results in adolescent and older patients. Serum alkaline phosphatase and serum lactic dehydrogenase levels before treatment, height percentile greater than 50%, chemotherapy-induced tumor necrosis, surgical procedure, tumor site, tumor histologic features, and patient gender were not prognostic indicators. The prognosis for prepubertal patients with osteosarcoma is similar to the prognosis of their adolescent and older counterparts. There does not seem to be any indication to treat preadolescent patients with osteosarcoma using alternate therapies.

Review of cellular mechanisms of tumor osteolysis

The cellular and biochemical mechanisms that direct the destruction of bone at sites of tumor osteolysis are unknown. To better understand the mechanisms through which tumors direct bone resorption, research has focused on developing in vivo and in vitro experimental models that are useful for studying this process. In vivo experimental systems have been developed that permit study of tumor osteolysis from human and murine tumors, and that permit the study of tumors that arise from (sarcoma) or can metastasize (breast cancer) to bone. Recent research has focused on three questions: (1) Are osteoclasts or tumor cells responsible for bone resorption during tumor osteolysis? (2) What are the cellular mechanisms that are responsible for bone resorption during tumor osteolysis, and (3) what are the tumor cell products that regulate the cellular mechanisms that are responsible for tumor osteolysis? It has been determined that osteoclasts are responsible for bone resorption at sites of tumor osteolysis by enhancing the binding of osteoclast to bone, by inducing osteoclastic bone resorption, and by stimulating osteoclast formation. Attempts to identify tumor cell products that regulate these cellular mechanisms are in progress, and findings suggest that production of macrophage colony stimulating factor may be required for tumor osteolysis to occur with some tumors.

Short-term tumor cell lines from renal cell carcinoma for use as autologous tumor cell vaccines in the treatment of kidney cancer

OBJECTIVE

We have tried to establish short-term cultures of autologous tumors from patients with renal cell carcinoma that could be used as active specific immunotherapy (i.e., autologous vaccine) in such patients after resection of primary kidney cancer, and/or for the treatment of metastatic cancer.

METHODS

Between 10/90 and 9/99 the cell biology laboratory of the Hoag Cancer Center received 69 kidney tumor samples that had been surgically excised, including 43 primary tumors and 26 metastatic lesions. Efforts were made to establish short-term tumor cell cultures, as defined by the growth of 10(8) cells; malignant nature and renal cell origin were confirmed by morphology and antigenic phenotyping. Variables associated with successful growth of short-term cell lines were examined.

RESULTS

Short-term cell lines were successfully established from 55/69 samples [80%] including 36/43 (84%) from primary tumors and 19/26 (73%) from metastatic lesions. The success rate for tumors harvested at Hoag Hospital was 40/50 (80%); the success rate for tumors obtained from other geographic areas was 15/19 (79%). Tumor cell lines were successfully established from metastatic lesions ranging in size from a 0.5 g vertebral lesion to a 22 g rib/lung chest wall metastasis, and from primary renal cell lesions ranging in size from 1.5 g to 39.7 g.

CONCLUSIONS

Short-term cell lines can be established for most patients with primary or metastatic renal cell carcinoma making a pure autologous tumor-cell vaccine approach feasible. Vaccines have been prepared for 41 patients and a vaccine therapy trial is in progress.

Photodynamic inactivation with acridine orange on a multidrug-resistant mouse osteosarcoma cell line

Overcoming multidrug resistance (MDR) is an urgent issue to improve the prognosis of osteosarcoma patients. In this study, we undertook to clarify the effect of photodynamic therapy (PDT) with acridine orange (AO) on the MDR mouse osteosarcoma (MOS / ADR1) cell line, by comparing the outcome with the effect on a chemosensitive osteosarcoma (MOS) cell line. Cultured cells of MOS and MOS / ADR1 cell lines were exposed to AO at various concentrations for various times, followed by long- or short-term (10 or 1 min) illumination with blue light (466.5 nm) for excitation. Living cells were counted by means of the trypan blue exclusion test. The results showed that AO rapidly bound to DNA, RNA and lysosomes of living MOS and MOS / ADR1 cells and also that most tumor cells in both cell lines died rapidly (viability ratio to untreated cells: 1/1000) within 48 h under conditions of continuous or 15-min flash exposure to AO at concentrations above 1.0 microg/ml plus 10-min illumination with blue light. Even after flash exposure to AO at concentrations above 1.0 microg/ml plus 1-min illumination, the viability of MOS/ADR1 cells decreased to a viability ratio of less than 1/ 1000 within 72 h. Based on these results, we concluded that AO with photo-excitation has a strong cytocidal effect, not only on chemosensitive mouse osteosarcoma cells, but also on MDR mouse osteosarcoma cells. These results suggested that photodynamic therapy with AO may be a new approach to treating MDR human osteosarcomas.

Fine needle aspiration biopsy of primary bone tumors

A review of 66 consecutive fine needle aspiration biopsies of primary bone tumors revealed that 48 (73%) were diagnostic. Twelve (18%) yielded inadequate specimens unsatisfactory for diagnosis, and five (8%) yielded specimens adequate for partial diagnosis. The only error, presumably attributable to sampling error, was an unappreciated dedifferentiated osteosarcoma arising in an otherwise typical giant cell tumor. Fine needle aspiration biopsy obviated the need for open biopsy in 24 patients and simplified surgery in an additional 24 patients by establishing the diagnosis before surgical intervention. A solitary soft tissue recurrence of a giant cell tumor has been the only local recurrence. A review of 26 consecutive patients with osteosarcoma revealed that seven tumors were diagnosed by primary open biopsy. Nineteen patients had fine needle aspiration biopsy, of which 15 were diagnostic and four required supplemental open biopsy. The elapsed time between the initial office visit and the diagnostic confirmation averaged 5 days for patients requiring open biopsy compared with 0 days for patients whose fine needle aspiration biopsy was diagnostic. The total estimated charge for fine needle aspiration biopsy of a distal femoral osteosarcoma was $1060.00 compared with $4312.25 for open biopsy. There have been no local recurrences in patients in either group. Fine needle aspiration biopsy provides an accurate, safe, efficient, well tolerated, and cost-effective method for diagnosing classic primary bone tumors, including osteosarcoma.

P-glycoprotein levels predict poor outcome in patients with osteosarcoma

To evaluate the relationship between the expression of P-glycoprotein by osteosarcomas and the rate of metastasis and death, a retrospective review of 172 patients who were diagnosed with osteosarcoma between 1987 and 1992 was performed. Forty patients had P-glycoprotein levels available. The majority of the osteosarcomas were Stage II-B (33 patients), with the remaining seven being Stage III. Tumor sites included 25 femurs, seven humeri, five tibias, and one each of pelvis, radius, and fibula. The patients with Stage III disease at presentation were treated differently from the time of diagnosis and therefore, these seven patients with Stage III osteosarcoma were excluded from additional analyses. The expression of P-glycoprotein by cultured tumor cells from biopsy specimens was determined using immunofluorescent microscopy. In the 33 patients with Stage IIB osteosarcoma with detectable P-glycoprotein, 67% (10 of 15) had metastases develop as compared with 28% (five of 18) of patients with undetectable P-glycoprotein. Similarly, 53% (eight of 15) of patients with tumors expressing P-glycoprotein died of disease compared with 11% (two of 18) with no detectable P-glycoprotein. Expression of P-glycoprotein by tumor cells seems to be associated with an estimated ninefold increase in the odds of death and a fivefold increase in the odds of metastases in patients with Stage IIB osteosarcoma. Kaplan-Meier survivorship analysis revealed that patients with detectable P-glycoprotein fared worse in terms of survival time and metastasis-free survival. Adjusting for covariates in the Cox proportional hazards model, expression of P-glycoprotein and its level were significantly predictive of time to death in patients with Stage IIB osteosarcoma.

[Solitary osteochondroma of the limbs. Clinical review of 76 cases and pathogenic hypothesis]

The authors report a retrospective study of 76 solitary osteochondromas of the appendicular skeleton treated between 1981 and 1995. The ages of the patients ranged from 13 to 55 years with a mean of 21 years. The male/female-ratio was 1.37. Tumefaction with or without associated pain was the reason for consultation in 68 cases (89%). In 62 cases the osteochondroma was localized in the distal part of the femur or the proximal part of the tibia. All lesions were surgically resected; the resection was complete in all cases. Six patients were lost to follow-up; the other 70 were seen on a regular basis over a time period ranging from 1 to 12 years. The result from surgical treatment was assessed based on pain, joint motion, cosmetic consequences, nerve compression and recurrence of osteochondroma. The results were good in 68 cases and fair in two cases. Based on a review of previous experimental studies, the authors suggest a hypothesis to explain the rotation of a fragment of the growth plate which is needed for the development of osteochondroma. This rotation occurs as a result of the mechanical action from the periosteum under tension.