Biomedical subjects
Publications and source records attributed to T C Shives.
Adamantinoma is a rare, primary, malignant bone tumor; only one such case involving the radius has been reported. A second case is documented. This patient was treated by en bloc excision and reconstruction with microvascular fibula transfer. Although adamantinoma is not considered to be a high-grade lesion, aggressive treatment is warranted for lesions of the radius.
At our institution from 1980 to 1985, 30 patients underwent resection of malignant or locally aggressive bone tumors, with limb salvage and reconstruction by free vascularized bone grafts. Of the 26 patients followed up for at least four months (average, 21 months), four had complications. In these four, there were three nonunions, two infections, and one stress fracture. The average duration of immobilization was 7.6 months in the lower extremity, five months in the pelvis, and 3.8 months in the upper extremity. The average time to union was 6.3 months in the lower extremity, five months in the pelvis, and five months in the upper extremity. Although the technique of oncologic reconstruction must be individualized, our experience indicates that vascularized bone grafts offer significant advantages over conventional methods in selected patients.
Sixty-nine patients were identified who had survived for at least 10 years after therapy for ordinary-type intramedullary osteosarcoma and for whom adequate follow-up data were available to determine whether second malignancies had developed. Eight patients (11.6%) had developed second malignant tumors, 5 of whom had died of their second malignancies. Although these figures are higher than those expected for cancer incidence and death rates, the differences are not statistically significant.
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Distinguishing superficial plantar fibromatosis from deep fibromatosis of the plantar aspect of the foot is difficult both clinically and histologically. An illustrative case is presented. Clinical factors suggestive of aggressive fibromatosis include presentation at an age younger than 20 years, tumor dimension exceeding 3 cm (without prior surgical excision), and multicentric occurrence in the affected limb. On histological review, the absence of nodule formation favors the diagnosis of deep aggressive fibromatosis.
A total of 422 patients with malignant lymphoma of bone who were seen at the Mayo Clinic from 1907 through 1982 were placed into four major groups based on stage of disease. There was one group with primary lymphoma of bone, one group with multifocal osseous lymphoma, and two groups with lymphoma of bone and nodal or soft tissue (or both) disease. The last-mentioned two groups were separated on the basis of time of onset of osseous lymphoma in relation to the nonosseous disease. The stage of disease was the single most important prognostic indicator of overall survival in malignant lymphoma of bone. The 5- and 10-year survival rates were, respectively, 58% and 53% for patients with primary bone lymphoma, 22% and 12.5% for patients with bone and nodal or soft tissue (or both) disease, and 42% and 35% for patients with multifocal osseous disease. Features having no significant prognostic value were sex of the patient, histologic grade of the lymphoma (according to the Working Formulation and the Kiel system), and presence of T-cell features or cleaved cells (or both). This study is not able to adequately address efficacy of treatment. In fact, treatment may be very important in outcome.
A series of 111 mesenchymal chondrosarcomas was reviewed. The ages of the patients ranged from 5 to 74 years, and approximately 60% of them were in the second and third decades of life. There was no significant sex predilection. Seventy-two tumors, including 5 that involved multiple skeletal sites, arose in bone. Thirty-eight tumors were found in extraskeletal sites. At initial diagnosis, multifocal involvement, both in bone and in soft tissue, was observed in one case. Roentgenographically, the lesions in bone frequently resembled ordinary chondrosarcomas, showing osteolytic and destructive appearances with stippled calcification. Tumors in extraskeletal sites were almost always identified as calcified masses. Histologically, a combination of cellular zones composed of undifferentiated small cells and chondroid zones typically presented a bimorphic appearance that was virtually pathognomonic in most cases. Ablative surgical treatment seemed to be the procedure of choice. The value of irradiation or chemotherapy (or both) was difficult to assess in the current study. Prognosis for patients with mesenchymal chondrosarcoma is usually poor, and long-term follow-up is necessary. In a group of 23 patients from the Mayo Clinic, the 5-year survival rate was 54.6% and the 10-year survival rate was 27.3%.
Thirteen cases of giant sacral schwannomas with erosion of the anterior aspect of the sacrum and associated intrapelvic extension are reviewed. These tumors showed no sex predilection; the patients' mean age was 38.6 years at the time of diagnosis, and their symptoms predated the diagnosis by an average of 5.2 years. The most common symptoms were low-back pain and lower-extremity dysesthesiae. Plain roentgenograms, myelography, and computerized tomography constituted essential and complementary studies in the preoperative assessment. Choice of surgical approach (anterior transabdominal vs. posterior transsacral) was dependent upon the amount of sacral destruction, intrapelvic extension, and sacroiliac joint involvement. Microscopic examination revealed classic features of benign schwannoma in all but three cases, which were classified as cellular schwannomas. Patients who presented with pain and dysesthesiae reported immediate and complete relief of symptoms following surgery. In addition, all 13 patients were ambulatory and able to resume their routine daily activities postoperatively. At the last reported follow-up examination, which ranged from 5 months to 33 years and 3 months (mean 9 years) after surgery, two patients had died of unrelated causes, two reported return of preoperative symptoms, and the remainder were asymptomatic. This experience suggests that these histologically benign but neurologically devastating tumors should be aggressively resected with the intent of complete extirpation, and that this goal may be accomplished with minimal risk and an excellent prognosis.
This study was done to describe the magnetic resonance imaging (MRI) characteristics of osteosarcomas and to determine the clinical usefulness of MRI in the evaluation of patients with these tumors. Ten patients with osteosarcomas were examined with a Picker MRI scanner (0.15 Tesla resistive magnet). All had computed tomograms available for comparison. For demonstrating tumor extent in marrow, MRI was superior to computed tomography (CT) in 60% and about equal to CT in 40%. For defining soft tissue mass, MRI was superior to CT in 40% and about equal to CT in 60%. Direct sagittal and coronal images on MRI and superior contrast differences between tumor and normal tissues with MRI were the reasons for the advantage of MRI in these instances. CT was superior in all cases for demonstrating calcifications. Overall, MRI is better than CT for defining local extent of osteosarcomas. It is of greatest value in the peripheral skeleton, in the medullary canal, and in soft tissues.
Primary osteosarcoma of bone has originated in the spine in only a few patients. This report concerns twenty-seven of thirty patients who had the original diagnosis made and surgical treatment, if any, performed at the Mayo Clinic. The patients' ages ranged from eleven to eighty years. Pain in the area of involvement was the first symptom in all patients. In addition, nineteen patients (70 per cent) had neurological symptoms and signs when they were first seen. All patients had a surgical biopsy of the lesion, often combined with decompressive laminectomy. Twenty-one of the twenty-seven patients received postoperative radiation therapy in various dosages. Only five patients received adjunctive chemotherapy. All but one patient died of the disease, with a median length of survival of ten months (range, one to thirty-eight months). Although rare, osteosarcoma of the spine can usually be suspected on roentgenograms, and then the most aggressive therapy is justified.
Thirteen patients with titanium fibermetal segmental bone/joint prostheses at a minimum follow-up period of six months were reviewed. Detailed radiographic data were analyzed quantitatively in terms of stem/bone interface radiolucency and bone bridging over the segmental portion of the prosthesis at predefined zones. Although stem radiolucent lines were common in this series, only one case had clinical loosening and required reoperation. There were two cases of stem fracture; one achieved extracortical bone union without revision, and the other case required implant removal and revision. Analysis of the retrieved specimen revealed histologic evidence of bony ingrowth. The use of a long side plate for initial implant fixation might have been partially responsible for this complication because of inhibition of new bone formation over the porous-coated segment. Sequential study of radiograms at different follow-up time periods with the same zonal analysis criteria revealed that no progression of radiolucency occurred at the bone/prosthesis interface, and bone formation over the segmental portion either increased or stabilized with time. The patients' functional results and implant performance seemed to indicate that the porous-coated segmental prosthetic system was effective in bridging skeletal/joint defects. However, further improvements are needed in prosthetic design and implant quality control in order to minimize device-related complications.
The magnetic resonance (MR) imaging characteristics of bone tumors are described and the clinical utility of MR imaging in patient evaluation is reported. Fifty-two patients with skeletal lesions were examined with a Picker MR imager (0.15-T resistive magnet). Twenty-five patients had primary malignancies, seven had benign bone neoplasms, 15 had skeletal metastases, and five had neoplasm simulators. Forty-five patients had CT scans available for comparison. For demonstrating the extent of tumor in marrow, MR was superior to CT in 33% of cases, about equal to CT in 64%, and inferior to CT in 2%. For delineating the extent of tumor in soft tissue, MR was superior to CT in 38% of cases and about equal to CT in 62%. CT was superior in all cases for demonstrating calcific deposits and pathologic fractures. In four patients with metal prostheses or surgical clips, MR was superior to CT in documenting recurrent tumor because of artifactual degradation of the CT image. Direct sagittal and coronal images from MR permit accurate assessment of the relationship of tumor to adjacent normal structures, including the physis, joints, and neurovascular structures. MR is useful in the evaluation of bone tumors: it is of greatest value in evaluations of the peripheral skeleton, the medullary canal, soft tissues, and postoperative tumor recurrence. With a 0.15-T magnet, MR is less useful in the evaluation of the axial skeleton and cortical bone.
Nine patients with Maffucci's syndrome were seen at our institution; chondrosarcoma developed in five. On the basis of the cases of these patients and those reported in the English literature since 1973, we determined that the incidence of chondrosarcoma in patients with Maffucci's syndrome is 17.8 per cent.
A case of aneurysmal bone cyst is presented, and the radiographic, computed tomographic, and magnetic resonance imaging findings are discussed. The potential advantages of magnetic resonance imaging compared with those of computed tomography are explained. The case is presented to illustrate the potential value of magnetic resonance imaging in the evaluation of bone and soft tissue tumors.
Thirty-five cases of neurogenic sciatic nerve tumors are described. Pain is the major clinical manifestation but may give rise to diagnostic confusion because of its often prominent site far distant from the neoplasm. Nonpalpable tumors are best identified by computed tomographic scan of the pelvis and thighs. Early surgical therapy is advisable. Neurilemomas are treated by simple enucleation with preservation of the sciatic nerve. They rarely recur. For neurofibromas, total excision is often not possible. As long as they are small and neurologically nondestructive, subtotal excision with preservation of the nerve trunk is recommended. When they are large or have caused marked neurologic dysfunction, radical tumor and nerve resection is required. In the usually highly malignant neurofibrosarcomas, disarticulation of the hip joint or hindquarter amputation affords the best chance for cure and should not be delayed once the diagnosis has been established.
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At the Mayo Clinic between 1950 and 1975, initial fusion of the interphalangeal joint of the great toe was attempted 166 times in 139 patients utilizing a Kirschner wire for stabilization. Follow-up examination of these patients disclosed an overall pseudarthrosis rate of 44%. Because of these disappointing results, a technique involving use of a longitudinal mini-cancellous bone screw was devised which provides increased stability and compression at the arthrodesis site. With this method, used 20 times in 18 patients, the pseudoarthrosis rate was decreased to 10%.
Forty-six patients with Kienböck's disease were evaluated over a 2- to 27-year period; 72% had a history of wrist injury prior to diagnosis; 67% had evidence of fracture or fragmentation of the lunate. Documented fractures of the lunate were identified followed by both the presence and absence of subsequent Kienböck's disease and this may be explained by the variable blood supply of the lunate. Ten patients were not treated; 36 patients were treated surgically. Patients were relieved of pain and had functional wrists whether they were treated or not and regardless of the type of surgical treatment.