Small-cell osteosarcoma

Small-cell osteosarcoma, a subtype of osteogenic sarcoma, consists of sheets of round cells that produce an osteoid matrix. It may be confused with Ewing sarcoma if the osteoid matrix is not included in the biopsy. The distinctive radiographic features of an osteoblastic tumor and a pattern of permeative destruction will confirm the histologic diagnosis or indicate the true nature if tumor osteoid is not included in the histological sections. We add 13 patients to the 32 previously reported in the literature. Fourteen (31%) of the 45 are living and well, though three have been followed for only 2 months (Tables 1 and 2). The treatments have been so varied that a statistically significant evaluation cannot be developed. The radiographic features are not distinctive, but the diagnosis may be suggested when a tumor has osteoblastic features in the metaphysis and extends well down into the shaft with a pattern of permeative destruction. The radiographic features are especially important when limited biopsies reveal only sheets of round cells, thus suggesting Ewing sarcoma. The presence of an osteoid-producing tumor as evidenced by osteoblastic new bone formation will lead to the correct diagnosis.

Estrogen receptors in normal salivary gland and salivary gland carcinoma

To access for possible hormone dependence, 19 samples of normal salivary gland tissue and 14 samples of salivary gland carcinoma were quantitatively analyzed for estrogen receptor (ER) content. A receptor protein content of greater than or equal to 1 fmol/mg of cytosol protein was considered positive. Ten (77%) of 13 histologically normal samples, and four (80%) of five tumor samples obtained from male patients contained ER by this criterion, as did five (83%) of six normal samples and eight (88%) of nine tumor samples obtained from female patients. Mean ER concentrations plus or minus SE in male-derived samples were 2.02 +/- .42 fmol/mg of cytosol protein for normal tissue and 4.35 +/- 1.5 fmol/mg of cytosol protein for tumor tissue; mean ER concentrations in female-derived samples were 3.48 +/- 1.1 fmol/mg of cytosol protein for normal tissue and 12.64 +/- 6.4 fmol/mg of cytosol protein for tumor tissue. Four of eight tumors in women had levels considered to be "hormonally dependent" in breast carcinoma. These findings indicate that salivary gland carcinomas may be hormone-dependent.

Osteosarcoma chemotherapy effect: a prognostic factor

Chemotherapy has become a routine part of the treatment of osteosarcoma. However, the precise role of preoperative chemotherapy remains in question. Between 1979 and 1982, a group of 40 patients were treated by multimodality therapy consisting of preoperative chemotherapy (intra-arterial cis-platinum and systemic adriamycin), surgery, and postoperative chemotherapy. Survival in this group is 64%, while continuous disease-free survival is 58%. Although age, sex, tumor size, site, and classification were found to be prognostic factors, histologic evidence of response to preoperative chemotherapy, measured as percent tumor necrosis, was found to be the most significant prognostic factor. When continuous disease-free survival was calculated as a function of tumor necrosis it was 91% in patients with greater than or equal to 90% tumor necrosis, while it was 14% in patients with less than 90% tumor necrosis. At initial presentation, 7% of patients were judged limb-salvage candidates. But due to the local effects of preoperative chemotherapy, 60% ultimately underwent limb-salvage surgery. Preoperative arteriograms were a reliable means of monitoring response to chemotherapy and served as an indicator of residual viable tumor. Using arteriogram directed planes of section, postchemotherapy, specimens were "mapped" and analyzed for chemotherapy effect. When present, residual viable tumor was preferentially found at the interface of tumor and normal anatomic structures; "sanctuary sites." It is necessary that standard methods for analyzing postchemotherapy specimens be developed; a technique is described.

"Dedifferentiated" chordoma. A clinicopathologic and immunohistochemical study of three cases

Three cases of "dedifferentiated" chordoma arising in the sacrococcygeal region are presented. In all three cases, the "dedifferentiated" component arose de novo in conjunction with conventional chordoma. Two of these patients, whose tumors had a prominent malignant fibrous histiocytoma (MFH) component, died within 6 months of diagnosis. Both patients had lung metastases, one of which was histologically documented to be MFH. The third patient, whose initial tumor contained osteosarcoma, died 76 months after diagnosis and multiple recurrences. Most notable in this case was the absence of the "dedifferentiated" component (in this instance, osteosarcoma) in all of the local recurrences as well as the lung metastases. These were composed exclusively of conventional chordoma. None of the patients had a previous history of radiation therapy. The immunohistochemical staining pattern of conventional chordoma was similar to that of previous reports, where the epithelial-like cells stained for cytokeratin and epithelial membrane antigen. In addition, they stained for alpha-1-anti-chymotrypsin and vimentin. These latter two markers were also identified in the "dedifferentiated" component. As with "dedifferentiated" chondrosarcomas and liposarcomas, "dedifferentiation" in a chordoma usually portends an accelerated clinical course.

Parosteal osteosarcoma: radiologic-pathologic correlation with emphasis on CT

Parosteal osteosarcoma, a distinct entity in which the neoplasm arises on the bone surface, presents characteristic features. Thorough radiologic and histologic evaluation and early definitive surgery usually result in a favorable prognosis and make limb salvage feasible in many adult patients. Twenty-six patients with proven parosteal osteosarcoma were seen at The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston. All were examined by conventional radiography, 16 by CT, and one by both CT and MR. CT is valuable for the evaluation of tumor invasion of the medullary canal, involvement of the cortex, and extension into the soft tissues, findings frequently not demonstrable by other noninvasive techniques. Additional information is obtained regarding the presence and location of satellite lesions and intralesional radiolucent areas and the relationship of the vascular bundle to the tumor mass. These findings are important for planning both percutaneous biopsy and surgery.

Distinctive protein pattern in two-dimensional electrophoretograms of cancerous prostatic tissues

In this report, we describe methods used to analyze the protein composition of sectioned frozen prostatic tissues by two-dimensional gel electrophoresis. Our results show a high degree of homology in two-dimensional electrophoretograms of proteins extracted from frozen sections of malignant prostate glands. Such homology was not apparent in protein patterns of benign hypertrophic prostatic tissue sections. Typically, 600 discrete proteins were resolved on two-dimensional electrophoretograms and 9 proteins were present in all patterns of prostate adenocarcinomatous tissues. These nine proteins were not observed in any of the protein electrophoretograms developed from nonmalignant prostate tissue. Three proteins were found common to nonmalignant prostate glands but were not present in prostatic adenocarcinoma.

Osteoid-osteoma: intraoperative tetracycline-fluorescence demonstration of the nidus

Nine patients with a clinical and radiographic diagnosis of osteoid-osteoma received 750 to 4,000 milligrams of tetracycline preoperatively. Immediate examination of the surgically removed specimens under ultraviolet light demonstrated fluorescence of the nidus in all nine patients. Reactive and normal bone did not fluoresce. This simple technique permits quick, easy, economical, and sure verification that the nidus has been excised.

Extraosseous osteogenic sarcoma of the parotid gland

The first reported case of an extraosseous osteogenic carcinoma of the parotid gland is presented. The head and neck region is an unusual site for these unusual neoplasms, with approximately 5 per cent of all extraosseous osteogenic sarcomas originating in the soft tissues of the face and neck. The neoplasms may arise after a latent period following radiation therapy. The majority, however, arise de novo. As a group, extraosseous osteogenic sarcomas are very aggressive and lethal neoplasms with an average 5-year survival of 15.6 per cent (Rao et al., 1978).

Radiation-induced sarcomas of the chest wall

Sixteen patients are presented who had sarcomas of the chest wall at a site where a prior malignancy had been irradiated. The first malignancies included breast cancer (ten cases), Hodgkin's disease (four cases), and others (two cases). Radiation doses varied from 4200 to 5500 R (mean, 4900 R). The latency period ranged from 5 to 28 years (mean, 13 years). The histologic types of the radiation-induced sarcomas were as follows: malignant fibrous histiocytoma, nine cases; osteosarcoma, six cases; and malignant mesenchymoma, one case. The only long-term survivor is alive and well 12 years after resection of a clavicular chondroblastic osteosarcoma. Three cases were recently diagnosed. Despite aggressive multimodality treatment, the remaining 13 patients have all died from their sarcomas (mean survival, 13.5 months). All patients have apparently been cured of their first malignancies. Chemotherapy was ineffective. No treatment, including forequarter amputation, appeared to palliate the patients with supraclavicular soft tissue sarcomas. Major chest wall resection offered good palliation for seven of eight patients with sarcomas arising in the sternum or lateral chest wall. Close follow-up is needed to detect signs of these sarcomas in the ever-increasing number of patients receiving therapeutic irradiation.

Argentaffin endocrine carcinoma (carcinoid) of the pancreas with concomitant breast metastasis: an immunohistochemical and electron microscopic study

A pancreatic carcinoid tumor that metastasized to the breast is reported. The breast tumor was originally diagnosed as adenocarcinoma of the breast. Silver impregnation revealed the presence of argentaffin cytoplasmic granules. Immunocytochemical studies demonstrated immunoreactivity for serotonin but not for lactalbumin, a marker for breast epithelial cells. These features, together with the electron microscopic observation of pleomorphic secretory granules, permitted recognition of the tumor as metastatic carcinoid. This report illustrates the importance of the combined histochemical, immunocytochemical, and electron microscopic studies of breast tumors with a carcinoid pattern.

Giant cell tumor of bone. A cytologic study of 24 cases

Twenty-three patients with radiologic diagnoses of giant cell tumor of bone underwent fine needle aspiration cytology and needle biopsy for tissue diagnosis before curettage or resection. One patient had two tumors, making a total of 24 cases. The accuracy of the cytologic diagnosis was compared with that of tissue biopsy. Cytologically there were mononucleated and multinucleated cells. The former often occurred in clusters or, less often, were dispersed. They had spindle or plump cell bodies with moderate amounts of cytoplasm and well-defined cytoplasmic membranes. The oval nuclei demonstrated fine, evenly distributed chromatin and small nucleoli. The multinucleated cells were osteoclastlike and were associated with the clusters of mononucleated cells or lying freely. They had a well-demarcated cytoplasm and contained from a few to several dozen monomorphic nuclei. Cytologic diagnosis was made in 20 of 24 cases, and histologic diagnosis was made in 21 of 24. Insufficient diagnostic material for cytology was the reason for failure in 4 cases. This was attributed to faulty technique (2 cases), cystic change (1 case), and massive necrosis (1 case). As other benign and malignant bone tumors may contain benign giant cells, cytologic or histologic findings alone are not diagnostic of giant cell tumor of bone, but should be complemented with the clinicoradiologic findings. Aspiration cytology is as accurate as tissue needle biopsy, may be of high diagnostic value in deeply located lesions not amenable to cutting needle biopsy, and should be done with full knowledge of the clinicoradiographic information.

Primary renal malignant fibrous histiocytoma

The ninth case of a primary renal malignant fibrous histiocytoma to appear in the English literature is described. The patient underwent preoperative renal artery embolization followed by radical nephrectomy and adjuvant chemotherapy. While adjuvant chemotherapy has prolonged the disease-free interval and improved the survival rates for patients with tumor arising at other sites, its use in our patient did not prevent the development of metastasis and the patient's early death.

The pathologist's role in the diagnosis and treatment of osteosarcoma in children

Tumor specimens from 24 children under 15 years of age were studied. The children had osteosarcoma and received intra-arterial infusions of cis-platinum before resection or amputation. There were 13 boys and 11 girls, and the median age was 12 years. Fifteen lesions were located in the femur, four in the humerus, three in the tibia, one in the pubis, and one in the radius. Sixteen patients underwent diagnostic needle biopsies and the remainder, open biopsies. Eleven patients had excellent tumor response, with over 90 per cent tumor destruction in six and 65 to 75 per cent in five. One patient had 50 per cent tumor destruction, and in nine patients the response was insignificant. Two patients had good clinical responses to treatment and refused limb amputation; one additional patient died of the disease without amputation or resection. The systematic study of pathology specimens is being undertaken to determine the utility of such a study as a guide to the selection of adjuvant chemotherapy. Patients in whom no responses are obtained should receive alternative treatment, and those in whom responses are optimal should retain the original agent in their adjuvant chemotherapy regimen.

Collagenous colitis

Collagenous colitis is a newly described entity that clinically manifests itself as watery diarrhea of long-standing duration. The main histopathologic characteristic is the presence of a collagen band immediately beneath the colonic surface epithelium. Ultrastructurally, the collagen is deposited beneath the basement membrane, which is intact. Pathogenetically, an aberrant function of the pericryptal fibroblastic sheath may be involved.

The pathology of head and neck tumors: papillomas of the upper aerodigestive tracts, Part 18

The human papillomavirus class of DNA viruses are more than circumstantially related to oral and airway papillomas. Whether they are fully oncogenic, in the malignant sense, without other agents is questionable. Recent advances in molecular virology and the use of genus-specific (common) antigen-antibody reactions have identified papillomavirus in laryngeal and oral papillomas. Laryngeal and oral papillomas could be precancerous lesions, but they show a low-risk and long-time interval leading to malignancy unless significant iatrogenic or host variables--such as radiotherapy or immuno-incompetence--are added. Two different papillomas in the larynx can be recognized; a nonkeratinizing, papillomavirus-related lesion, and a keratinizing, usually solitary papilloma, which may or may not be related to a virus genesis and may be equated with a keratosis or clinical leukoplakia.

Radiation therapy for primary lymphoma of bone

The records of 30 patients with primary lymphoma of bone (PLB) who were treated with radiation therapy were reviewed. The probability of NED-survival and overall survival at five-year follow-up was 53 and 63%, respectively. There were three local failures following treatment. The cumulative incidence of local recurrence was 14% at five years. No local failures were observed when tumors received doses higher than 50 Gy, or equivalent to a TDF of 70 or greater. The number of failures was too small to examine for a correlation between histologic subclassification and local control frequency if doses higher than 50 Gy were utilized. Complications of treatment occurred in four patients. Functional results were excellent in all except two patients. These data provide guidelines for determination of a clinically appropriate radiation dose level for PLB.

Primary lymphoma of bone: the relationship of morphologic diversity to clinical behavior

Since primary lymphoma of bone (PLB) exhibits morphologic diversity and variability in individual survival, we analyzed the relationship between histopathologic features and biological behavior in 33 patients treated at the Massachusetts General Hospital. Three major histologic subgroups were identified, based on a variety of criteria, the most important of which were the predominance of cells with or without nuclear clefts and the degree of pleomorphism. The probability of NED survival at five years was 64% for patients with tumor predominantly composed of cleaved cells, 13% for those with tumors classified in the noncleaved cell tumor group, and 0% (no survivors) for the pleomorphic subgroup. When tumors were subclassified according to the size of the predominant cell (small versus large), this parameter was found to be of no value in preceding NED survival. Factors that could have potentially influenced the results were analyzed. Since this is a retrospective review, the questions addressed in this study should be further studied in a prospective way.

Primary lymphoma of bone: relationship of radiographic appearance and prognosis

A retrospective review was made of the pretreatment radiographs of 20 patients with well-documented primary lymphoma of bone. Nine radiographic signs were defined, and the presence or absence of each was recorded for each patient. When the radiographic findings were compared with disease-free survival for each patient, it was found that patients who had a relapse had a higher mean number of positive radiographic signs than those who remained disease free (p less than 0.02). Also, those who relapsed early had more positive signs than those who relapsed late (p less than 0.05). Certain signs, i.e., pathologic fracture, layered periosteal new bone, broken periosteal new bone, cortical breakthrough, soft-tissue mass, and soft-tissue swelling, were more helpful than others for making a prognosis. These signs appear to be related to radiologic evidence of imminent or actual soft-tissue extension of the tumor.

Esophageal-atrial perforation due to recurrent esophagitis 18 years after esophageal bypass surgery

A 62-year-old man presented with a grand mal seizure, progressive abdominal distention, and refractory hypotension 18 years after colonic bypass of a benign stricture of the low middle third of the esophagus. He died 3 hours after admission to the hospital. The patient had a history of liniment ingestion in childhood plus a long history of dysphagia and substernal pain. Autopsy disclosed a large ulcer of the anterior wall of the distal esophagus, which had eroded through the posterior wall of the left atrium. Histologic examination revealed chronic esophagitis with fibrous obliteration of the esophageal wall, pericardium, and left atrial myocardium near the site of perforation. Foreign material was present within small arteries of multiple viscera, and in several of these fragments transverse striations were demonstrated. Esophageal-atrial perforation is a rare but fatal complication of chronic esophageal ulceration. The clinical and pathological features of this and previously reported cases of nontraumatic esophageal-atrial perforation are reviewed.