Non-neurogenic soft tissue tumours of the axilla: prospective review of 16 cases

Sixteen consecutive patients entered in a prospective study of non-neurogenic soft tissue tumours had lesions in the axilla. Delayed diagnosis and inappropriate biopsy prior to referral to a surgical oncologist were frequent findings. Sarcoma and fibromatosis were diagnosed in 14 cases, and the approaches used for these two diseases were fundamentally different. The functional outcome with limb salvage surgery in these patients is presented.

High-volume, high-pressure pulsatile lavage during cemented arthroplasty

To determine the efficacy of high-volume, high-pressure pulsatile lavage in the prevention of cardiopulmonary dysfunction and fat embolism during cemented arthroplasty, we studied twenty-eight mongrel dogs that had had a bilateral cemented arthroplasty. Significant increases in pulmonary-artery pressure and pulmonary vascular resistance, accompanied by decreases in arterial oxygen tension and increases in intrapulmonary shunt fraction (Qs/Qt), characterized cardiopulmonary dysfunction after bilateral cemented arthroplasty when no lavage was used. Low-volume, low-pressure manual lavage did not significantly alter these physiological changes, but there was a significant reduction in the number of fat emboli that were demonstrated in the lungs as compared with the no-lavage group. High-volume, high-pressure pulsatile lavage of the intramedullary cavity after reaming significantly reduced the changes in pulmonary-artery pressure, pulmonary vascular resistance, arterial oxygen tension, and intrapulmonary shunt fraction (Qs/Qt). In the pulsatile-lavage group, the number of fat microemboli that were found in the lungs was reduced to 25.7 per cent of those found in the no-lavage group. We concluded that meticulous high-volume, high-pressure pulsatile lavage reduces both pulmonary physiological derangements and fat emboli during bilateral cemented arthroplasty in dogs.

Importance of magnetic resonance imaging in osteoid osteoma: a case report

A 23-year-old man presented with a femoral osteoid, which, because of its small calcified nidus and extensive osteoblastic response, could not be localized on bone scanning, computed tomography or angiography. Magnetic resonance imaging clearly defined the nidus and permitted excision with minimal morbidity.

Growth factor production by sarcoma cells in primary culture

Cell lines derived from human sarcomas have been previously shown to produce a protein growth factor which, similar to platelet-derived growth factor (PDGF), can induce competence for mitosis in fibroblasts. Whether this factor production is an important feature of sarcomas in vivo or simply an artefact caused by long-term culture conditions is unclear, however. We demonstrated growth factor activity in conditioned medium from six of 11 primary sarcoma cultures, utilizing flow cytometric analysis of DNA to monitor the presence of sarcoma cells in cultures. Cells isolated from control tissues failed to show a similar mitotic effect.

Complications and functional results after limb-salvage surgery and radiotherapy for difficult mesenchymal neoplasms: a prospective analysis

Wide resection with adjuvant radiotherapy is generally accepted as the optimal treatment for patients with extremity soft-tissue sarcomas. However, there is a subset of patients with "difficult" tumours who sustain such marked loss of function from limb-salvage procedures that amputation might offer a superior functional alternative. To evaluate this issue, the authors prospectively designated 19 of 52 patients registered in Toronto's Princess Margaret Hospital Prospective Sarcoma Database in 1986 as "difficult" cases, on the basis of tumour size and anatomical location. Complications and functional results of wide resection and adjuvant radiotherapy were documented. The most frequent complication was related to wound healing (8 of 19 patients). Functional analysis at 1 year follow-up demonstrated that all 19 patients had results superior to those that would be expected with amputation.

Timing of chemotherapy and surgery in a murine osteosarcoma model

The sequential use of chemotherapy and surgery in the treatment of osteosarcoma developed in an empirical fashion without the benefit of investigations in animal models. The MGH-OGS murine osteosarcoma is a transplantable tumor that resembles the human disease with respect to histology, local invasiveness, metastatic characteristics, tumor ploidy, and its response to chemotherapy. We have used this tumor model to investigate the efficacy of preoperative, perioperative, and postoperative chemotherapy on the development of pulmonary metastases in three different experimental protocols. In each experimental design, perioperative chemotherapy demonstrated a significant advantage in preventing systemic relapse.

Evaluation of fluorescein diacetate for flow cytometric determination of cell viability in orthopaedic research

Accurate estimation of cellular viability is important both in research and in aspects of orthopaedic clinical practice. We have been interested in the potential for flow cytometric application of fluorescein diacetate (FDA) in evaluating chondrocyte survival following cryopreservation of osteochondral allografts as well as in the assessment of sarcoma necrosis following preoperative chemotherapy. In order to evaluate the suitability of this method for cell viability assays, this study compared FDA with more traditional methodology (trypan blue, clonigenic assay, metabolic activity analysis, measurement of DNA synthesis, and histological assessment of necrosis). Both chondrocytes and sarcoma cells were exposed to various experimental injuries prior to viability analysis. Although it is evident from these experiments that FDA accurately reflects cell survival after physical injury, it underestimates the effect of chemotherapy on cell reproductive potential in vitro. However, FDA is highly correlated with histological assessment of tumor viability after chemotherapy in vivo. It is apparent that the methodology chosen for determination of viability should be appropriate for the type of experimental injury and should analyze the cell function (i.e., metabolic activity or reproductive capacity) that is appropriate for the experimental model.

Kinetic effects of adriamycin and bleomycin on two osteosarcoma models

Although chemotherapeutic drugs are frequently administered to patients with osteosarcoma, there has been little research into the effect of cytotoxic drugs on osteosarcoma cell biology. The effect of two drugs (Adriamycin and bleomycin) on cell cycle kinetics was investigated in vitro in an established line of human osteosarcoma cells and in vivo using the Dunn osteosarcoma model. The cell cycle changes were consistent with G2 arrest for both drugs in vivo and in vitro. The alteration in cell cycle distribution was correlated with inhibition of 3H-thymidine incorporation in vitro. In vivo, the greater change in cell cycle distribution caused by Adriamycin was reflected in the increased inhibition of tumor growth found with this drug.

Wagner resurfacing arthroplasty of the canine hip

Twelve surface replacement arthroplasties were performed on the hips of ten mongrel dogs using scaled-down replicas of the Wagner prosthesis. The contralateral hips and two further animals served as nonoperated controls. Animals were killed 5 months postoperatively. Clinical, radiological, histological and fluorochrome-labelling studies were employed to assess the bony and soft tissue reaction to resurfacing arthroplasty. There was no clinical or radiographic evidence of prosthetic loosening. Histological examination disclosed a thick foreign body and chronic inflammatory membrane containing acrylic cement and polyethylene wear particles at the bone-cement interface of both components. Generally, the bone marrow and trabecula were viable. There was evidence of increased bony remodelling and new bone formation in the subchondral area. The similarity between the above findings and those of aseptic component loosening in man suggests a mechanism whereby wear debris initiate a biological foreign body reaction culminating in component loosening.

Osteomyelitis in Gaucher disease

A relatively common complication of Gaucher disease, the so-called crisis, frequently is difficult to differentiate from acute osteomyelitis. We reviewed the cases of forty-nine patients with Gaucher disease who were treated at the Massachusetts General Hospital and found that eleven patients had required admission to the hospital for an acute symptom complex that represented either a crisis or an infection. Five of the patients proved to have acute hematogenous osteomyelitis. The delayed diagnosis of the infection in three of the patients with osteomyelitis led to an unsatisfactory outcome.

A study of implant failure in the Wagner resurfacing arthroplasty

Using clinical, radiographic, and pathological data, we investigated eighteen cases of early aseptic failure of an implant in patients who had undergone reconstruction of the hip with a Wagner resurfacing prosthesis. Sixteen patients required revision for loosening of the acetabular component, with eight of them also demonstrating loosening of the femoral component. One patient had loosening of the femoral component without failure of the acetabular component, and one patient sustained a femoral neck fracture that was associated with osteonecrosis. Six of the patients with loosening of the acetabular component had an associated significant loss of acetabular bone stock. Loosening was associated with the development of a membrane at the bone-cement interface in all patients. Histological examination of the membrane demonstrated a marked foreign-body response to wear products from the arthroplasty. Bone resorption appeared active at the bone-membrane interface. We concluded that the acetabular component of the Wagner prosthesis is prone to early loosening and that the early loosening is potentiated by a foreign-body response to debris resulting from arthroplastic wear.

Ollier's disease with multiple sarcomatous transformations

A 53-year-old man had the monomelic form of Ollier's disease, which resulted in deformity of the left leg. The patient was otherwise well until pain and increasing size of the left thigh led him to seek treatment. Biopsy revealed chondrosarcomatous transformation in the distal left femur. Hip disarticulation was performed. This case is unusual in that multiple foci of chondrosarcomatous transformation at various stages of development were present throughout the left femur, tibia, and fibula.

Supervoltage radiotherapy in the treatment of difficult giant cell tumors of bone

Fifteen patients with giant cell tumor were treated by supervoltage radiotherapy. Each patient had been referred for therapy because adequate surgery would have been difficult or disfiguring. No patient who received appropriate therapy experienced a recurrence, and there were no cases of malignant transformation of a giant cell tumor after a mean follow-up period of 12 years. Radiotherapy is not recommended for primary treatment of giant cell tumor but may be indicated in exceptional circumstances.

Coccygeal glomus tumors: a case of mistaken identity?

We undertook an anatomical and histological study to differentiate glomus-cell tumors of the pericoccygeal tissues from the normal coccygeal body. Removal of the coccyx was performed on five consecutive autopsy specimens from patients with no history of coccygeal symptoms. In each specimen, the coccygeal body (glomus coccygeum) was identified grossly and histologically. The histological appearance was indistinguishable from that of photomicrographs published in case reports of patients with glomus tumors of the coccyx. It is likely that the so-called tumors reported previously were in actuality normal glomus bodies.

Bilateral total hip replacement in a diastrophic dwarf

This article reports a case of bilateral total hip replacement in a diastrophic dwarf. We were unable to find reports of any similar cases in the world literature, although we do know that Hungerford performed a total hip replacement in a diastrophic dwarf in 1974 (personal communication). In addition to the case report, this article reviews some of the salient characteristics that set diastrophic dwarfism apart from other chondrodystrophies.

Efficacy...what's that??

We need to develop techniques for measuring the usefulness of medical services. If resources are limited, and we cannot do all the diagnostic tests we would like to do, we must be able to select those that are most useful. To do this we need to known how to weigh benefits against risks and how to measure the worth of a given outcome. This article discusses efficacy, in diagnosis, management, and outcome. Diagnostic efficacy of a test is measured by its ability to change the probability of disease (pre- versus post-test likelihood). Management efficacy is a measure of how the test changes patient management. Outcome efficacy, which may take years to evaluate, is the ultimate yardstick of usefulness. Even though there are many problems in estimating the likelihood of a disease (subjectivity, varying terminology, etc.), physicians can make reasonably close estimates, as shown by the American College of Radiology's Efficacy Study, which analyzed the diagnostic process in 9000 cases. Efficacy studies may be a mixed blessing, however, as they may result in overly strict criteria and sweeping economic changes. They may be ignored because of the difficulty in following the "perfect" protocol for a given clinical situation, and it remains to be shown that they themselves are efficacious. Nevertheless, we are finally coming to grips with the question of how useful our tests are in patient management.