Clues potentially distinguishing lytic lesions of multiple myeloma from those of metastatic carcinoma

Malignant tumors affecting the head and neck region in ancient times: Comprehensive study of the CRAB Database

In the modern world, cancer is a growing cause of mortality, but archeological studies have shown that it is not exclusive to modern populations. The aim of this study is to examine the epidemiologic, social, and clinicopathologic features of head and neck cancers in ancient populations. To do this, we extracted all records that described malignant lesions in the head and neck region available in the Cancer Research in Ancient Bodies Database (CRAB). The estimated age, sex, physical condition of the remains (skeletonized, mummified), anatomic location of tumors, geographic location, chronology, tumor type, and methods of tumor diagnosis were collected. One hundred and sixty-seven cases were found, mostly originating from Europe (51.5%). Most records were of adults between 35 and 49 years of age (37.7%). The most involved site was the skullcap (60.4%), and the most common malignancies were metastases to the bone (65.3%) and multiple myeloma (17.4%). No primary soft tissue malignancies were registered. The results of our study indicate that head and neck cancers were present in ancient civilizations, at least since 500,000 BCE. The available data can help to improve the current understanding of the global distribution of head and neck cancer and its multidimensional impacts on populations in the contemporary world.

The various meanings and uses of bone "remodeling" in biological anthropology: A review

OBJECTIVES

In modern bone biology, the term "remodeling" generally refers to internal bone turnover that creates secondary osteons. However, it is also widely used by skeletal biologists, including biological anthropologists as a catch-all term to refer to different skeletal changes. In this review, we investigated how "remodeling" is used across topics on skeletal biology in biological anthropology to demonstrate potential problems with such pervasive use of a generalized term.

METHODS

Using PubMed and Google Scholar, we selected and reviewed 205 articles that use the term remodeling to describe skeletal processes and have anthropological implications. Nine edited volumes were also reviewed as examples of collaborative work by different experts to demonstrate the diverse and extensive use of the term remodeling.

RESULTS

Four general meanings of bone "remodeling" were identified, namely, internal turnover, functional adaptation, fracture repair, and growth remodeling. Additionally, remodeling is also used to refer to a broad array of pathological skeletal changes.

DISCUSSION

Although we initially identified four general meanings of bone remodeling, they are not mutually exclusive and often occur in combination. The term "remodeling" has become an extensively used catch-all term to refer to different processes and outcomes of skeletal changes, which inevitably lead to misunderstanding and a loss of information. Such ambiguity and confusion are potentially problematic as the field of biological anthropology becomes increasingly multidisciplinary. Therefore, we advocate for precise, context-specific definitions and explanations of bone remodeling as it continues to be used across disciplines within and beyond biological anthropology.

Bone abnormalities in the middle Anisian marine sauropsids from Winterswijk

While the occurrence of skeletal pathologies in Middle Triassic marine reptiles has been poorly documented until now, massive accumulations of bone remains from the Germanic Basin provide the opportunities for documentation. Herein, we describe skeletal abnormalities in the Middle Triassic bone material from the Vossenveld Formation of Winterswijk, the Netherlands. The aim of the study is to distinguish in the studied bones pathologies resulting from malady or trauma and taphonomic alterations. Furthermore, an attempt was made to assess on how the pathologies also represent paleoecological data. Our survey led to the identification of one broken and healed bone, one case of abnormal coossification, and one case of posttraumatic fibro-osseous dysplasia. While the latter two pathologies give little insight into the ecology and function of the affected animals, the fractured dentary is attributed to Nothosaurus marchicus, a common sauropterygian macropredator. It proves that the individual survived long enough to heal, despite the injury hampering its hunting potential. One abnormally shaped humerus is interpreted as postmortem taphonomic deformation, emphasizing the necessity of utilization of detailed diagnostics to distinguish actual paleopathologies from nonbiological distortion.

Metastatic cancer and endentulism: Exploring comorbidity to assist with differential diagnosis in a case from Vico nel Lazio (Fr, Italy), 13th-15th century CE

OBJECTIVE

To differentially diagnose cranial lesions noted on a medieval skeleton and explore the importance of comorbidity.

MATERIALS

A skull of an adult female with osteolytic and osteoblastic lesions, edentulism, and an ectopic tooth from an ossuary of the Church of Santa Maria in Vico del Lazio, Frosinone Italy, dating to the Middle Ages.

METHODS

Macroscopic observations of the remains, CT scan, and differential diagnosis was undertaken.

RESULTS

A diagnosis of metastatic cancer (potentially breast cancer) or metastatic neuroblastoma (NBL) is offered.

CONCLUSIONS

Considering the noted comorbidities, this case might represent a rare case of metastatic neuroblastoma.

SIGNIFICANCE

The exploration of comorbidity, in this case the presence of metastatic carcinoma and edentulism, has tremendous potential to expand our knowledge about cancer in the past.

LIMITATIONS

Lack of postcranial elements.

SUGGESTIONS FOR FURTHER RESEARCH

Clinical and paleopathological investigation of comorbidity in modern and archeological populations to develop an evolutionary perspective on the presence of cancer in the past.

Differentiation of multiple myelomas from osteolytic bone metastases: Diagnostic value of tumor homogeneity on Contrast-Enhanced CT

OBJECTIVES

To investigate the diagnostic value of tumor homogeneity on contrast-enhanced (CE) computed tomography (CT) to differentiate multiple myeloma (MM) from osteolytic bone metastases (Mets).

METHODS

This retrospective study included patients who were diagnosed with MM or Mets and had multiple (≥2) osteolytic bone tumors on pre-treatment CE-CT. Intratumoral homogeneity was assessed by coefficient of variation (CV, ratio of standard deviation to mean) of the density of a single lesion (CV-lesion). Intertumoral homogeneity was assessed as the CV of the densities of multiple lesions in one patient (CV-patient). A classification model was built from CT parameters using classification and regression tree (CART) analysis. Diagnostic performance of the model was evaluated using C-statistics.

RESULTS

A total of 272 lesions (81 MM and 191 Mets) of 105 patients were analyzed. The mean CV-lesion and CV-patient of MM were significantly lower than those of Mets: 0.17 vs 0.26 for CV-lesion (p = 0.005) and 0.16 vs 0.23 for CV-patient (p = 0.013). Thickened struts were more common in MM than in Mets (49.1% vs 12.8%, p ≤ 0.001). In CART analysis, CV-lesion was the first partitioning predictor, followed by thickened struts and by CV patient. The CART model could distinguish MM from Mets in both the model development cohort (C-statistic: 0.843) and the temporal validation cohort (0.721, 0.686, and 0.686 for three reviewers, respectively).

CONCLUSIONS

MM showed intratumoral and intertumoral homogeneity compared with Mets on CE-CT. The combination of CV-lesion and CV-patient can be helpful to radiologists in differentiation of MM from Mets.

ADVANCES IN KNOWLEDGE

Our study showed that MM had intratumoral and intertumoral homogeneity compared with Mets on contrast-enhanced CT.

Metastatic cancer along ancient Silk Road: A possible case from Xinjiang (China)

OBJECTIVE

Palaeopathological evidence of cancer, especially metastatic cancer, is rare in China. This paper describes and diagnoses a cranium with multiple lytic lesions recovered from the Sampula cemetery in Xinjiang, attempting to diagnose the type of disease that could have caused the pathological lesions observed.

MATERIAL

A cranium from an adult male (#00106) was recovered from the Sampula cemetery (dated to 55 BCE to 335 CE) located in the Luopu County, the Hotan River oasis on the southern edge of the Tarim Basin in southern Xinjiang.

METHODS

The cranium was assessed macroscopically and radiographically (CT).

RESULTS

Multiple osteolytic lesions with irregular and "moth-eaten" margins were detected in cranium #00106. CT scans revealed the development of the lesions began at the diploe and identified a "button sequestrum".

CONCLUSIONS

Based on lesion characteristics, metastatic carcinoma was likely the cause of lesions found in cranium #00106.

SIGNIFICANCE

This case has expanded our knowledge of the malignant neoplasms of ancient populations in northwest China and discusses the possible risk factors in the occurrence of cancer in the Sampula site, as well as the possible impacts of skeletal metastases on the individual.

LIMITATIONS

The distribution of osteolytic lesions over the complete skeleton cannot be observed because of the unavailability of postcranial bone.

SUGGESTIONS FOR FUTURE RESEARCH

With the increasing number of reports describing diseases in ancient China, the patterns of diseases occurrence and development can be further explored from spatial and temporal perspectives.

Assessing the relative benefits of imaging with plain radiographs and microCT scanning to diagnose cancer in past populations

OBJECTIVE

To determine the degree to which plain radiographs (x-rays) and microCT scans can improve accuracy in the diagnosis of cancer in human remains from past populations.

MATERIALS

The skeletal remains of 143 individuals from medieval Cambridgeshire, dating from 6th-16th century CE.

METHODS

Visual inspection of the skeletons for lesions compatible with malignancy, coupled with plain radiographs and microCT scans of the pelvis, femora and vertebra.

RESULTS

Three individuals had visually apparent metastases on their skeletons. Plain radiographs did not identify further individuals with cancer, but did show further lesions in bones with normal external appearance. MicroCT scans identified cancer in two further individuals with normal visual appearance and normal plain radiographs.

CONCLUSIONS

Imaging human skeletal remains increases the detection rate of cancer in human skeletal remains. We found microCT scanning to be a much more sensitive imaging modality than plain radiography. It improved our diagnostic accuracy and enabled us to more reliably distinguish between malignant lesions and taphonomic change.

SIGNIFICANCE

Future studies investigating the prevalence and nature of malignancy in past populations would benefit from systematic microCT scanning of pelvis, femora and vertebrae of skeletons to optimise their diagnostic accuracy.

LIMITATIONS

MicroCT scanning is more expensive than plain radiographs, and may not be easily accessible to biological anthropologists.

SUGGESTIONS FOR FURTHER RESEARCH

To apply this approach to skeletal series from different time periods and geographical regions, where the types of cancer existing in the local population may differ from those we studied in medieval Britain.

Computed tomography characteristics of multiple myeloma and other osteolytic metastatic bone lesions

BACKGROUND

Differentiation of multiple myeloma (MM) from osteolytic metastatic (OM) bone lesions may be critical in patients with lytic bone lesions but can be challenging for radiologists.

PURPOSE

To determine whether computed tomography (CT) can be used to distinguish between MM and other OM bone lesions.

MATERIAL AND METHODS

In this retrospective study, 320 lesions of 207 patients diagnosed with MM or OM, based on biopsy or clinical examination, were evaluated. Eight qualitative features were evaluated by two radiologists blinded to the diagnoses. The chi-square and Fisher exact tests, and logistic regression analysis, were used to evaluate the relationships between the CT findings and diagnoses.

RESULTS

High-density areas were more common in OM than MM lesions (85.2% and 19%, P < 0.001), as were perilesional sclerosis (38.9% vs. 13.2%, P < 0.001), heterogeneity (on non-contrast CT images, 60% vs. 19.1%, P < 0.001; on contrast enhanced CT images, 80.6% vs. 28.2%, P < 0.001), and ill-defined margins (34.6% vs. 9.1%, P < 0.001). Similarly, OM lesions showed high-density areas more than MM in evaluation of skeletal system subgroups (vertebrae, 93.8% vs. 29.8%, P < 0.0001; thoracic cage bones, 69.6% vs. 19.2%, P < 0.001; pelvic bones and sacrum, 84.8% vs. 7.7%, P < 0.001; peripheral skeletal bones, 81.5% vs. 8.3%, P < 0.001). Logistic regression analysis revealed that the presence of a high-density area in the lesion increased the probability of a metastasis 25.88-fold (R² = 0.516, P < 0.001).

CONCLUSION

MM and OM lesions can be differentiated by CT; OM lesions exhibit high- density areas.

Cancers as rare diseases: Terminological, theoretical, and methodological biases

OBJECTIVE

Was cancer a rare disease in the past? Our objective is to consider the various terminological, theoretical, and methodological biases that may affect perceptions of the rarity of cancer in the past.

MATERIALS AND METHODS

We discuss relevant malignant neoplastic biomedical and paleopathological literature and evaluate skeletal data. We selected 108 archaeological sites (n = 151 cancer cases) with published malignant neoplasms and that were amenable to calculating cancer crude prevalence. Furthermore, datasets from four medieval/postmedieval Portuguese and 12 postmedieval UK sites were used to compare age-adjusted rates for metastatic bone disease and tuberculosis.

RESULTS

In the literature review, mean cancer crude prevalence (1.2 %; 95 % CI = 0.96-1.4) exceeded the threshold for a rare disease (RD). Age-standardized rates of MBD and TB were not markedly different in the sites surveyed.

CONCLUSIONS

Methodological, theoretical and historical factors contribute to assumptions that cancers were rare diseases. The assumption that cancers are extremely rare in the paleopathological literature was not fully supported. Cancer is a heterogeneous concept, and it is important to view it as such. If a disease is considered rare, we may fail to recognize it or dismiss it as unimportant in the past.

SIGNIFICANCE

We present a re-evaluation of the idea that cancer is a rare disease. We present a more nuanced way of comparing rates of pathological conditions in archaeological contexts.

LIMITATIONS

Variation in the amount of useable information in published literature on malignant neoplasms.

SUGGESTIONS FOR FURTHER RESEARCH

More large-scale studies of cancer in the past alongside comparative studies of cancer prevalence with other assumed rare diseases.

A probable case of multiple myeloma from Bronze Age China

OBJECTIVE

Paleopathological evidence of cancer from past populations is rare, especially outside of Europe and North Africa. This study expands upon the current temporal and spatial distribution of cancer by presenting a probable case of multiple myeloma from Bronze Age China.

MATERIAL

The human skeletal remains of an adult male from the Qijia culture horizon (1750-1400 BCE) of the Bronze Age cemetery of Mogou (), located in Gansu Province, Northwest China.

METHODS

The human skeletal remains were assessed macroscopically and radiographically using plain x-rays.

RESULTS

Multiple ovoid-shaped osteolytic lesions with sharply demarcated margins were observed. The axial skeletal had the greatest involvement, specifically the vertebrae, ribs, and sternum. Radiographic imaging revealed more extensive destruction of cancellous than cortical bone, indicating that the marrow was the focal point of the disease.

CONCLUSION

Based on the nature, distribution, and radiographic appearance of the lesions, the most likely diagnosis is multiple myeloma.

SIGNIFICANCE

This is one of the only cases of cancer identified in archaeological human skeletal remains from East Asia and is the first published case of a hematopoietic malignancy from mainland China. The analysis and publication of examples of neoplasia from areas that expand upon the current known temporal and spatial distribution is necessary in order to better reconstruct the history and evolution of cancer.

LIMITATIONS

Poor skeletal preservation prevented the full extent of osteolytic lesions to be observed.

SUGGESTIONS FOR FUTURE RESEARCH

By placing case studies such as this into a temporal and spatial framework, it is possible for future research to begin to interrogate possible underlying causes of cancer in ancient populations within the context of changing environmental conditions and subsistence strategies.

Examining variation in skeletal tuberculosis in a late pre-contact population from the eastern mountains of Peru

OBJECTIVE AND MATERIALS

This research evaluates the presence and chronology of tuberculosis (TB) in the northeastern highlands of Peru (CE 800-1535) through the analysis of osseous lesions from Pre-Contact Kuelap, Chachapoyas.

METHODS

We examined macroscopic lesion morphology and distribution from the skeletal series (MNI = 207).

RESULTS

We determined that skeletal evidence was highly consistent with advanced multifocal and spinal tuberculosis in 13 individuals. Destructive lesions of the lower thoracic and/or lumbar vertebra bodies and sacroiliac joints are evident in most cases, but we also observed lesions within the manubriosternal, hip, and knee joints. Both adult males (n = 7) and females (n = 6) present skeletal lesions from young adult to older adults, but there is only one late adolescent. Only three individuals demonstrate similar lesion distributions.

CONCLUSIONS

Variation in lesion distribution in this population-based study shows the importance of identifying extra-vertebral tuberculosis and suggests that the disease may have manifested differently than at other coastal sites. These cases confirm the presence of tuberculosis both before and after Inca occupation across this central Andean highlands region.

SIGNIFICANCE

This evidence for the likely endemic presence of TB in the New World prior to European Contact furthers our understanding of the distribution of this infectious disease across the region as well as elucidating lesion distribution.

LIMITATIONS

The diagnosis of tuberculosis is based on skeletal lesions and it should be confirmed by molecular analysis.

FUTURE RESEARCH

Additional examination of vertebral bodies (including juvenile remains) for evidence of earlier manifestations of infection.

Suggested Case of Langerhans Cell Histiocytosis in a Cretaceous dinosaur

Susceptibility to diseases is common to humans and dinosaurs. Since much of the biological history of every living creature is shaped by its diseases, recognizing them in fossilized bone can furnish us with important information on dinosaurs' physiology and anatomy, as well as on their daily activities and surrounding environment. In the present study, we examined the vertebrae of two humans from skeletal collections with Langerhans Cell Histiocytosis (LCH), a benign osteolytic tumor-like disorder involving mainly the skeleton; they were diagnosed in life, along with two hadrosaur vertebrae with an apparent lesion. Macroscopic and microscopic analyses of the hadrosaur vertebrae were compared to human LCH and to other pathologies observed via an extensive pathological survey of a human skeletal collection, as well as a three-dimensional reconstruction of the lesion and its associated blood vessels from a µCT scan. The hadrosaur pathology findings were indistinguishable from those of humans with LCH, supporting that diagnosis. This report suggests that hadrosaurids had suffered from larger variety of pathologies than previously reported. Furthermore, it seems that LCH may be independent of phylogeny.

The synergy between radiographic and macroscopic observation of skeletal lesions on dry bone

The diagnosis of bone lesions is a fundamental part of the study of skeletal remains, both in the archeological and forensic context. On the one side, the literature proved the relevance of radiography for the detection of bone lesions; on the other side, the careful macroscopic observation of the morphology of bone lesions is often underestimated. For this study, we examined and performed plain radiography on 14 skeletons of the CAL Milano Cemetery Skeletal Collection diagnosed with rheumatoid arthritis, diabetes, multiple myeloma, metastatic cancer, and osteomalacia to compare the macroscopic morphology and radiographic visualization of bone lesions. At least 200 osteolytic lesions and 65 areas of proliferative bone reaction (either spongiosclerotic or periosteal) were studied. We realized "comparative sets" of macroscopic pictures and radiographic imaging of the same skeletal elements to allow comparisons of detection and recognition of bone lesions. As a result, while trabecular lesions may be lost through naked eye observation, many lesions can also be unperceived on radiographs due to contrast, including periosteal reactions, osteolytic lesions, and spongiosclerosis. The aim of this research was to investigate the strengths and pitfalls of digital radiography and macroscopic analysis and to demonstrate the synergy of a complementary approach between the two methods for lesion analysis in dry bone.

The overlooked primary: bladder cancer metastases on dry bone. A study of the 20th century CAL Milano Cemetery Skeletal Collection

OBJECTIVE

The aim of this article is to provide additional documentation of bone metastases to help anthropologists recognize the condition and potentially suggest the diagnosis of bladder carcinoma in differential diagnosis.

MATERIALS AND METHODS

Thirteen individuals clinically diagnosed with bladder carcinoma from the 20^th century Milano Cemetery Skeletal Collection were macroscopically studied to document bone metastases in bladder cancer.

RESULTS

Bone metastases were found through macroscopic observation in three individuals or 23% of the study sample. Metastases were mostly of a mixed nature (45%), although both osteoblastic (13%) and osteolytic (9%) also occurred. In particular, mixed and osteoblastic metastases exhibited different distribution patterns, even when affecting the same bones. The vertebrae (24.7%), skull (12.9%), ribs (11.7%), proximal humeri (7.8%), pelvis (5.2%), proximal femora (2.6%), sacrum (1.3%) and sternum (1.3%) were the most commonly affected. Osteolytic lesions included coalescing superficial pits or lesions perforating the bone cortex. Proliferative lesions manifested as spongiosclerosis or periosteal new bone. Mixed metastases were osteolytic lesions exposing a thickened trabecular bone or coalescent porosity with reactive new bone.

CONCLUSIONS

Bladder carcinoma metastases were mostly mixed, exhibiting periosteal reactions, perforations of bone cortex, spongiosclerosis and coalescing porosity.

SIGNIFICANCE

Bladder carcinoma is rarely considered in the differential diagnosis of the primary organ. This study reports the macroscopic aspect of bone metastases in bladder carcinoma and may help anthropologists diagnose the condition in skeletons.

LIMITATIONS

Absence of evidence is not evidence of absence; some lesions may have been hidden from macroscopic observation and therefore missed.

FURTHER RESEARCH

Radiographic analysis and comparison with other neoplasms should provide additional details for the diagnosis of bladder cancer bone metastases.

A possible case of mycosis in a post-classical burial from La Selvicciola (Italy)

An examination of an adult male buried from the post-classical necropolis of La Selvicciola (Viterbo, Latium, Italy; 4^th-6^th centuries AD) revealed a series of skeletal lesions. The lesions, both proliferative and lytic, ranging in size from small (around 0.01 mm) to extensive (up to 16.00 mm) pits, occurred at multiple sites. A holistic approach assessed lesion type, frequency and location in a differential diagnosis, which included myeloma, metastatic carcinoma, tuberculosis, leukemia, osteomyelitis, and mycoses. It was concluded that a mycosis, specifically Cryptococcosis, was the most likely cause of these lesions. Both macroscopic analyses and X-ray scans support our diagnosis. We also provide a methodological scheme as a model for examining unknown lesion patterns.

Multiple myeloma in paleopathology: A critical review

This paper provides a critical literature review concerning paleopathological evidence of multiple myeloma discovered both in the Old and in the New World. A critical assessment of the bioarchaeological and paleopathological documentary sources permitted to identify a total of 25 ascertained cases of multiple myeloma from different geographical areas in the world ranging from Prehistoric times up to the Contemporary age. The distribution of multiple myeloma findings in past times shows that the majority of cases have been discovered in the Old World (n = 18) and extend back to the Middle Ages, while the evidences in the New World (n = 7) seems to date back to the pre-Columbian era. The demographic profile suggests a sex ratio of 1.3:1, while 91.7% of affected individuals (n = 24) are adults. This critical review also discusses the diagnostic criteria and methodological issues commonly attempted in paleo-oncological research, with particular regard to the differential diagnosis of multiple myeloma. As such, the main focus of this work is to present a comprehensive and exhaustive scrutiny of the skeletal manifestations identified as multiple myeloma in order to improve the accuracy of diagnoses within the field of paleopathology.

The appearance of breast cancer metastases on dry bone: Implications for forensic anthropology

Breast carcinoma is a major cause of morbidity and mortality in women. The study of bone pathologies presents considerable potential in anthropology, paleopathology, forensic science and medicine. In this paper, we present and discuss metastatic lesions found in the skeletons of known individuals from the CAL Milano Cemetery Skeletal Collection, clinically diagnosed with breast cancer during life. Fourteen skeletons from a contemporary and identified collection were macroscopically studied and metastases were identified by comparison with clinical literature. As a result, bone metastases were observed in 43% of the study sample. They were located most commonly on the ribs (28.1%), pelvic girdle (19.8%), vertebrae (15.6%), skull (15.6%), scapulae (10.2%) as well as proximal segment of the femora (8.4%) and humeri (2.4%) respectively, favoring sites of high vascularization. The majority of the lesions were osteolytic, although osteoblastic and mixed metastases did occur. Osteolytic metastases appear as coalescent porosity or round to oval perforating lesions on bones with denticulated margins and pitted surrounding bone, whereas osteoblastic metastases thickened the existing trabecula (spongiosclerosis). Mixed metastases were perforating lytic lesions exposing the osteoblastic activity in the underlying trabecular bone. These results, consistent with the data from the literature, strengthen the diagnostic criteria for metastases and illustrate the aspect of bone metastases in breast carcinoma.

A probable case of metastatic carcinoma in the medieval Netherlands

Despite recent considerable gains, our knowledge of cancer in antiquity is still limited. This paper discusses an adult individual from a Dutch medieval hospital site who demonstrates osteoblastic and osteolytic lesions on the ribs, scapula, clavicle, and vertebrae. The morphology, radiographic appearance, and distribution of the skeletal lesions suggest that this individual was affected by metastatic carcinoma. This case increases the number of publications that present an osteoblastic and osteolytic response to cancer and contributes to the body of evidence for archaeological neoplastic disease. For the Netherlands, this individual presents the first published case of probable metastatic carcinoma with mixed skeletal lesions.

Paleo-oncology in the Dakhleh Oasis, Egypt: Case studies and a paleoepidemiological perspective

This article describes six cases of cancer from the Dakhleh Oasis, Egypt. A mummy had a confirmed 'primary' diagnosis of adenocarcinoma of the rectum. The remaining diagnoses were based on the distribution and types of skeletal lesions in conjunction with age, sex, and/or the molecular phylogeny of the Human Papillomavirus (HPV). HPV is a confirmed cause of cancer of the uterine cervix (UC) and testes (TC) and it evolved in Africa long before Homo sapiens emerged. Today these cancers are common in young adult females and males, a fact which was pivotal in respectively including them in the differential diagnosis of UC and TC. The remaining diagnoses were acute lymphocytic leukemia in a 3-5 year old child and an older female with metastatic carcinoma. Due to problems of determining specific diagnoses and their prevalence in 'paleo' populations, we opted for a lifetime cancer risk statistic (LTCR). The LTCR in ancient Dakhleh was ∼5/1000 (6/1087). In modern Western societies the LTCR cancer approaches 50% (500/1000). Thus the LTCR in today's western societies is 100 times greater than in ancient Dakhleh. These cases demonstrate that oncogenes and their environmental cofactors were present in antiquity, but were significantly less pervasive than today.

Assessing cancer risk factors faced by an Ancestral Puebloan population in the North American Southwest

Ancestral Puebloan people in the North American Southwest suffered high rates of disease, poor health, and early age-at-death. Four individuals with skeletal expressions of cancer were found in a pre-Columbian population in the Taos Valley - Reports of malignant neoplasms in the archaeological record are uncommon and their presence in four of 82 individuals is a high occurrence. This study continues Whitley and Boyer's (2012) research testing whether concentrations of ionizing radiation were sufficiently high to induce cancer and related health issues. Access to a preserved and partly reconstructed subterranean pit structure inhabited between AD 1120 and 1170, allows us to test radon concentrations in a residential dwelling. This study found radon occurring in high levels, 19.4-20.3 pCi/L (717.8-751.1 Bq/m3) within the structure. Epidemiological reports are inconsistent when linking specific cancers and radon exposure. However, this study can control for many of the confounding factors plaguing other studies, provide unique data that have the potential to initiate dialogue on the etiology of neoplastic disease in the American Southwest, and add new dimensions to the study of the living conditions and health of the Ancestral Puebloans and their descendants.

The utility of 3D medical imaging techniques for obtaining a reliable differential diagnosis of metastatic cancer in an Iron Age skull

In this report we present a case of neoplastic disease affecting an Iron Age skull that provides some of the earliest evidence of metastatic cancer (MC) in Western Europe. The cranium comes from the indigenous site of Baucina (Palermo, Sicily) and was recovered in a multiple burial context dated to the 6th-5th centuries BCE. The skull was attributed to an adult female and was characterized by numerous perforating lytic lesions. CT and 3D imaging analyses were crucial for obtaining a diagnosis of MC. Based on the morphology of the lytic lesions and the biological profile of our specimen, we can tentatively suggest breast carcinoma as the primary origin of the clinical manifestations recorded on the skull. This work also highlights the importance of utilizing an analytical approach to paleopathology that incorporates up-to-date CT and 3D imaging techniques.

A probable case of multiple myeloma in a female individual from the Simon Identified Skeletal Collection (late 19th-early 20th century, Vaud, Switzerland)

We present the case of an individual from the Simon Identified Skeletal Collection (Vaud, Switzerland) who appears to have been affected by a form of neoplastic disease. A detailed description and differential diagnosis of the lesions was conducted and is presented here. Considering the biological profile of the individual, the distribution of the lesions, and their appearance, a case is made for multiple myeloma as the most likely diagnosis. This case study demonstrates the importance of adopting a detailed approach for recording the metric and non-metric traits of lesions, using multiple methods of analysis, and providing graphic and photographic documentation in order to provide valuable comparison material through publication. The good preservation of the remains and the background information available for the individual also make this case ideal for inclusion in future comparative studies.

Refractory actinomycosis of the humerus

Actinomycosis is a chronic, opportunistic infection caused by Actinomyces species, such as Actinomyces bacillus. Actinomycosis in long bones is very rare. To the best of our knowledge, isolated primary actinomycosis of the humerus is rarely reported in literature. We present a rare case of a refractory primary actinomycosis of the humerus. A 66-year-old man with no history of concomitant conditions was admitted to our hospital with a history of a tumour on the distal third of the left arm as a result of a closed trauma without fracture 20 years before. Pathological anatomy samples showed the presence of Actinomyces. Cultures were subjected to a prolonged incubation of 21 days under aerobic and anaerobic conditions and were always negative. He underwent several surgical procedures and received long-term antibiotic therapy with poor outcome. Primary actinomycosis in long bones is uncommon. Diagnosis may be challenging: considering the small number of case studies reported in the literature, symptoms are not specific, and the organism is difficult to isolate. Antibiotic treatment may not be sufficient to improve the clinical condition, and surgical alternatives should be considered.

Paleopathological description and diagnosis of metastatic carcinoma in an Early Bronze Age (4588+34 Cal. BP) forager from the Cis-Baikal region of Eastern Siberia

Extensive osteolytic and osteoblastic lesions were observed on the skeletal remains of an adult male excavated from an Early Bronze Age cemetery dated to 4556+32 years BP, located in the Cis-Baikal region of Siberia (Russian Federation). Lytic lesions ranged in size from several mm to over 60 mm in diameter and had irregular, moth-eaten borders. Many of these lesions destroyed trabecular bone, though a hollowed shell of cortical bone often remained observable. Radiographic analysis revealed numerous lytic lesions within trabecular bone that had not yet affected the cortex. Blastic lesions were identified as spiculated lines, bands, or nodules of mostly immature (woven) bone formed at irregular intervals. Anatomical elements with the greatest involvement included those of the axial skeleton (skull, vertebrae, sacrum, ribs, and sternum) as well as proximal appendicular elements (ossa coxae, proximal femora, clavicles, scapulae, and proximal humeri). Osteocoalescence of destructive foci was observed on the ilium and frontal bone, with the largest lesion found on the right ilium. Differential diagnoses include metastatic carcinoma, mycotic infections, tuberculosis, Langerhan's cell histiocytosis, and multiple myeloma. Based on lesion appearance and distribution, age and sex of the individual, as well as pathogen endemism, the most likely diagnostic option for this set of lesions is metastatic carcinoma. The age and sex of this individual and appearance of the lesions may reflect carcinoma of the lung or, possibly, prostate. This represents one of the earliest cases of metastatic carcinoma worldwide and the oldest case documented thus far from Northeast Asia.

On the antiquity of cancer: evidence for metastatic carcinoma in a young man from ancient Nubia (c. 1200 BC)

Cancer, one of the world’s leading causes of death today, remains almost absent relative to other pathological conditions, in the archaeological record, giving rise to the conclusion that the disease is mainly a product of modern living and increased longevity. This paper presents a male, young-adult individual from the archaeological site of Amara West in northern Sudan (c. 1200BC) displaying multiple, mainly osteolytic, lesions on the vertebrae, ribs, sternum, clavicles, scapulae, pelvis, and humeral and femoral heads. Following radiographic, microscopic and scanning electron microscopic (SEM) imaging of the lesions, and a consideration of differential diagnoses, a diagnosis of metastatic carcinoma secondary to an unknown soft tissue cancer is suggested. This represents the earliest complete example in the world of a human who suffered metastatic cancer to date. The study further draws its strength from modern analytical techniques applied to differential diagnoses and the fact that it is firmly rooted within a well-documented archaeological and historical context, thus providing new insights into the history and antiquity of the disease as well as its underlying causes and progression.

Palaeopathological survey of a population of Mapusaurus (Theropoda: Carcharodontosauridae) from the Late Cretaceous Huincul Formation, Argentina

Paleoepidemiology (the study of disease and trauma in prehistoric populations) provides insight into the distribution of disease and can have implications for interpreting behavior in extinct organisms. A monospecific bonebed of the giant carcharodontosaurid Mapusaurus (minimum number of individuals = 9) from the Cañadón del Gato site, Neuquén Province, Argentina (Cenomanian) provides a rare opportunity to investigate disease within a single population of this important apex predator. Visual inspection of 176 skeletal elements belonging to a minimum of nine individuals yielded a small number of abnormalities on a cervical vertebra, two ribs, pedal phalanx, and an ilium. These are attributed to traumatic (two cases), infectious (two cases) and anomalous (one case) conditions in a minimum of one individual. The emerging picture for large theropod (abelisaurids, allosaurids, carcharodontosaurids, tyrannosaurids) populations suggests that 1) osseous abnormalities were relatively rare (7–19% of individuals) but consistently present, and 2) trauma was a leading factor in the frequency of pathological occurrences, evidence of an active, often perilous lifestyle.

History of multiple myeloma

Multiple Myeloma has been recognized since Ancient Times. The first well-documented case was reported in 1844 by Samuel Solly. The most commonly recognized case is that of Thomas Alexander McBean, a highly respectable tradesman from London in 1850. Mr. McBean excreted a large amount of protein that was described by Henry Bence Jones in the middle of the 19th century. Jones was a well-known physician and made many contributions to medicine. One of the best known cases of multiple myeloma was that of Dr. Loos that was reported by Otto Kahler. The recognition of plasma cells and subsequently their product, a monoclonal protein has been described in detail. The authors have reviewed the treatment of multiple myeloma including the novel agents, thalidomide, bortezomib and lenalidomide.

Comparative frequency of osseous macroscopic pathology and first report of gout in captive and wild-caught ratites

This systematic survey of museum ratite (Pterocnemia, Rhea, Casuarius, Struthio, Dromias and Apteryx) skeletal collections was performed to reevaluate previous perspectives and assess effect of captivity on macroscopically detectable pathology. Trauma-related pathology (e.g. focal periosteal reaction, malformed vertebrae) was significantly more common in captive birds (chi2 = 13.414, P < 0.0001) with variable timing of the different injuries. Pathology unrelated to trauma was equally represented in captive and wild-caught ratites. The latter included osteophytes of osteoarthritis, osteochondritis dissecans, infectious arthritis, gout (reported for the first time in a ratite) and neoplasia.

Bone manifestations of actinomycosis

Actinomycosis, originally classified as a fungus, is now considered a branching bacteria. Although jaw involvement often presents with classic pathognomonic signs, postcranial disease has not been so characterized. Affected bones from individuals diagnosed in life with actinomycosis were macroscopically and radiologically examined for their macroscopic character. The bones were riddled with spheroid, occasionally coalescing defects associated with periosteal reaction. Erosion penetrated cortical bone as readily as through cortical bone or subchondral bone. X-ray revealed circular lesions with a slight sclerotic margin. Actinomycosis apparently has unique features, which should allow it to be distinguished from multiple myeloma (because of presence of reactive new bone formation) and from fungal disease (because of lack of "fronts of resorption" and penetrating spicules). Similarity to fungal infection is especially of interest because of the earlier phylogenetic classification question.

Skeletal clues apparently distinguishing Waldenstrom's macroglobulinemia from multiple myeloma and leukemia

This study was conducted to characterize macroscopically and by conventional radiography the bony lesions in a case of Waldenstrom's macroglobulinemia and to compare and contrast it with those of the other major hematologic lymphoproliferative disorders, multiple myeloma and leukemia. Two varieties of lytic skeletal lesions were found in Waldenstrom's macroglobulinemia. One was sharply defined, spheroid lesions with smooth borders and effaced/erased trabeculae. The second was in the form of coalescing pits (holes) with smooth, minimally remodeled edges. The appearance combined features of multiple myeloma and leukemia, but were mutually exclusive in those diseases. Spheroid lesions with effaced edges were absent in leukemia, while pits were absent in multiple myeloma. Fronts of resorption were not noted in Waldenstrom's macroglobulinemia. The combination of some of the features of leukemia and myeloma appear to allow recognition of Waldenstrom's macroglobulinemia.

Metastatic cancer in the Jurassic

Recognition of cancer in extreme antiquity has been limited to osteomas in mosasaurs and haemangiomas and growths of unclear origin in dinosaurs. We describe a metastatic cancer in a dinosaur.