Biomedical subjects
J T Makley
Publications and source records attributed to J T Makley.
Cortical metastatic lesions of the appendicular skeleton from tumors of known primary origin.
BACKGROUND AND OBJECTIVES: Metastatic disease represents the most common neoplastic process involving bone. Recently, a small subset of cortical based metastatic lesions has been identified. We attempted to delineate the incidence, origin, location, and possible significance of these lesions within an orthopaedic patient population. METHODS: A chart and radiographic review of patients treated for metastatic disease to bone over a 17-year period was performed. Inclusion criteria for lesions were as follows: 1) an appendicular skeletal site, 2) histopathologic confirmation of origin, and 3) presence within a patient diagnosed with a single, known neoplastic process. The lesions were classified as either cortical or medullary based. RESULTS: Eighty-three lesions (70 patients) satisfied inclusion criteria. Most lesions were of pulmonary (26), breast (22), renal (16), or prostatic (8) tumor origin. Eighteen lesions (22%) from 15 patients were identified as cortical and represented initial presentation in 7 patients. These lesions were of pulmonary (11), renal (5), and breast (2) tumor origin. CONCLUSIONS: Cortical based metastases within the appendicular skeleton may occur more frequently than previously expected. While tumors of pulmonary and renal origin accounted for 42 of the 83 (51%) appendicular lesions, they were responsible for 16 of the 18 (89%) cortical metastases. This preponderance of pulmonary and renal metastases to the cortex is consistent with previously published reports. Our findings may be of value when diagnosing and treating patients whose initial presentation is a cortically based lesion.
Treatment of nonmetastatic osteosarcoma of the extremity with preoperative and postoperative chemotherapy: a report from the Children's Cancer Group.
PURPOSE: The specific aims of this study were to improve event-free survival (EFS) in patients with newly diagnosed nonmetastatic osteosarcoma of an extremity using the histologic response to neoadjuvant chemotherapy to determine postoperative chemotherapy; to evaluate a uniform histologic grading system that measures tumor response; and to identify patient characteristics that might influence EFS and survival. PATIENTS AND METHODS: Two hundred sixty-eight patients with nonmetastatic osteosarcoma of the extremity were entered between August 1983 and October 1986. Preoperative chemotherapy consisted of four courses of high-dose methotrexate (MTX) and one course of bleomycin, cyclophosphamide, and dactinomycin (BCD). Histologic response to preoperative chemotherapy was determined by morphometric analysis. Good histologic responders (< 5% residual viable tumor) were treated postoperatively with MTX, BCD, and doxorubicin (DOX); poor histologic responders were treated with BCD, DOX, and cisplatin (CDDP). RESULTS: The 8-year EFS and survival rates were 53% and 60%, respectively. Two hundred six patients had their tumors assessed for histologic response: 28% displayed a good histologic response to preoperative chemotherapy. Good histologic responders had an 8-year postoperative EFS rate of 81% and survival rate of 87%; those with a poor histologic response had an 8-year postoperative EFS rate of 46% and survival rate of 52%. A primary tumor site in the proximal humerus or proximal femur and an elevated serum alkaline phosphatase level were associated with an increased risk of an adverse event, whereas the type of surgical procedure was not. CONCLUSION: EFS and survival appear to be directly related to histologic response to neoadjuvant chemotherapy.
Knee pain and swelling in a 30-year-old woman.
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Osteoma of the long bones and the spine. A study of eleven patients and a review of the literature.
The clinical features, radiographic and histopathological findings, treatment, and results are described for eleven patients who were managed for an extracranial osteoma at our medical center between 1980 and 1993. Ten of the patients were initially seen because of dull, aching bone pain that had been present for two weeks to thirty years. Radiographs demonstrated single or multiple homogeneous, well defined, radiodense foci with smooth round or lobulated margins. The histopathological features consistently included uniformly dense, compact, cortical-like, mature lamellar bone. The preoperative diagnosis was unclear for all patients, and osteoma was rarely considered in the differential diagnosis. For four patients, a tentative diagnosis of osteosarcoma was made, and a wide excision was carried out in two of these patients. Marginal excision with less than three millimeters of normal tissue around the lesion was performed in most patients. None of the osteomas recurred, and ten patients had relief of the pain. Awareness of the clinical, radiographic, and histopathological features of osteoma, as described, is valuable for making a differential diagnosis and for distinguishing osteomas from other lesions.
Patellar tendon reconstruction augmented by a free autograft of the biceps tendon attached to the fibular head.
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Primary retroperitoneal sarcomas: common symptoms, common diagnoses, uncommon disease.
Primary retroperitoneal sarcomas may present with symptoms and signs that mimic common musculoskeletal disorders of the extremities that are quite remote from the source of the problem. This often misleads the clinician and results in delays in diagnosis. The authors present 6 patients with retroperitoneal sarcoma who had a common or nonspecific orthopaedic condition of the extremity. Delays in diagnosis ranged from 2 to 30 months. No patient survived his or her tumor. Clinicians should be alerted to the possibility of a retroperitoneal tumor that presents primarily or initially with extremity signs and symptoms but with few or no clues of the presence of a localized sarcoma in the retroperitoneal space.
Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection.
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Atraumatic posterior pelvic ring fractures simulating metastatic disease in patients with metabolic bone disease.
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Resection arthrodesis of the knee for tumor: large intercalary allograft and long intramedullary nail technique.
Twenty-five patients had a procedure consisting of resection of the distal femur or proximal tibia for aggressive or malignant neoplasms. The resulting bony gap was bridged by allografts averaging 18 cm in length. Fixation was achieved using a long fluted intramedullary nail. The average follow-up time and time to union were 3 years (range, 0.25 to 9 years) and 13 months (range, 6 to 28 months), respectively. Eleven patients had nononcologic complications related to the index surgical procedure, including two patients with allograft nonunion. There were no infections. Three patients had amputations for local recurrence of their tumor. Twenty patients (80%) had no evidence of tumor at the time of follow-up. According to the Evaluation System of the Musculoskeletal Tumor Society, 80% of patients had a satisfactory result. No patient had a nononcologic complication resulting in total failure or amputation. The procedure of resection-arthrodesis of the knee using a large allograft with a long intramedullary nail provides patients with a stable, durable biological reconstruction that allows early weight-bearing, and the procedure carries a low incidence of infection.
The effects of cisplatin on the incorporation of fresh syngeneic and frozen allogeneic cortical bone grafts.
Allograft transplantation with concomitant chemotherapy has proven successful in the treatment of malignant bone tumors. However, these chemotherapeutic agents may delay tissue healing, resulting in clinical complications. To clarify the effects of cisplatin on the healing of bone grafts, we studied the incorporation of stably fixed massive diaphyseal femoral syngeneic and allogeneic grafts in rats treated with cisplatin. These data were compared with those of historical controls from animals that did not receive cisplatin. Rats that were to receive a fresh syngeneic graft or frozen allogeneic graft were given cisplatin every 4 weeks starting 9 weeks preoperatively and continuing until the time of death. The total bone area of the graft in animals that received cisplatin was smaller than that of the graft in untreated control rats that did not receive cisplatin. The area of the frozen allograft did not increase between 2 and 4 months. Revascularization was incomplete in cisplatin-treated groups at 2 months, but by 4 months, vessel ingrowth in fresh syngeneic grafts approached control values. Frozen allografts remained poorly revascularized at 4 months. Host-graft union was poor at 2 months in cisplatin-treated rats compared with controls. In cisplatin-treated rats, the host-graft union of the frozen allograft remained inferior at 4 months while that of the syngeneic graft improved. Allogeneic cortical bone grafts are incorporated more slowly and incompletely than syngeneic grafts, and this handicap is exacerbated by the administration of cisplatin.
Case report 736: Retained surgical sponge (gossypiboma) with a foreign body reaction and remote and organizing hematoma.
This 50-year-old woman presented with progressive pain in the left thigh. Radiographs showed a 9 x 6 cm soft-tissue mass located at the lateral border of the left femur. Magnetic resonance (MR) examination showed an eccentric, nonhomogeneous, soft-tissue mass abutting the femur. The preoperative differential diagnosis was schwannoma, low-grade neurogenic tumor, large periosteal ganglion, or fibroma. At operation, the cut surface of the specimen had features of an organizing hematoma with recent remote hemorrhage and areas of fibrosis. Histopathological examination confirmed the presence of polarizable foreign body material in a background of foreign body reaction. The specimen represented a retained surgical sponge which had been present since the patient's surgery for a comminuted fracture 35 years earlier. Gossypiboma, or cotton balloma, is a term used to describe a mass within the body composed of cotton matrix. Radiopaque markers are now present on surgical sponges, and their appearances have been well documented. The gossypiboma, however, may still present a diagnostic problem if the marker is distorted by folding, twisting, or disintegration over a period of time. Without the radiopaque markers, retained sponges are difficult, if not impossible, to diagnose, as was the situation in this case.
Diffuse and localized tenosynovial giant cell tumor and pigmented villonodular synovitis: a clinicopathologic and flow cytometric DNA analysis.
The DNA content and proliferative indexes of seven cases of tenosynovial giant cell tumor of tendon sheath, diffuse type (TGCT-D); 11 cases of tenosynovial giant cell tumor of tendon sheath, localized type (TGCT-L); and seven cases of pigmented villonodular synovitis (PVNS) were analyzed by flow cytometry in an attempt to assess objectively their biologic differences. Three cases of TGCT-D manifested an aneuploid DNA content and four had a diploid DNA pattern. All cases of TGCT-L and PVNS showed a diploid DNA content. The proliferative indexes for TGCT-D were significantly higher than those found in the other two groups. There was no histopathologic feature that correlated with the aneuploid DNA pattern found in two of the three cases of TGCT-D. Only one of the three aneuploid DNA content TGCT-D cases displayed marked cellular pleomorphism with dense fibrous stroma; in that case there was recurrence 4 years after initial excision. Our data further support that TGCT-D, TGCT-L, and PVNS are histopathologically similar but clinically distinct lesions. The high proliferative indexes of TGCT-D may reflect a rapid, uncontrolled growth that may explain its aggressive biologic behavior. The presence of an aneuploid DNA pattern in some cases of TGCT-D in this study, coupled with the reported chromosomal abnormalities and occurrence of malignant transformation in these lesions, clearly supports their neoplastic nature.
Comparison of PET with CT, MRI, and conventional scintigraphy in a benign and in a malignant soft tissue tumor.
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Noninvasive grading of musculoskeletal tumors using PET.
Twenty-five patients with mass lesions involving the musculoskeletal system were studied with positron emission tomography (PET) in order to determine if a relationship exists between histologic grade and tumor uptake of [fluorine-18]2-deoxy-2-fluoro-D-glucose (FDG). There were 6 benign lesions and 19 malignant lesions of various grades. A high correlation (Rho = 0.83) was found between the normalized uptake of tracer and the NCl grade. The high-grade malignancies had significantly greater (p = 0.0091) uptake of FDG than the combination of benign lesions and low-grade malignancies. All lesions with a normalized uptake value of 1.6 or greater were high-grade, while all lesions less than 1.6 represented either benign tumors or low grade malignancies. This strong relationship between FDG uptake and grade among neoplasms from a wide variety of cell types within a single organ system suggests that the technique may be useful in predicting grade even when the cell type is unknown.
Bone metastasis from gynecologic carcinomas: a clinicopathologic study.
Between 1948 and 1984, autopsies were performed on 305 patients with primary carcinomas of the cervix, endometrium, ovaries, fallopian tubes, vulva, and vagina. Skeletal metastases were detected premortem and at autopsy in 49 cases (16.1%): cervix, 20 (40.8%); endometrium, 17 (34.7%); ovary, 7 (14.3%); vulva, 4 (8.2%); fallopian tube, 1 (2%). There were no cases of osseous metastasis from vaginal carcinoma. The incidence and sites of metastasis from these gynecologic carcinomas were correlated with their clinical and histopathologic classifications. This clinicopathologic study, based on autopsy data, demonstrates that osseous metastases are not uncommon, are significantly greater than clinically appreciated, and correlate with advanced anatomic stage and histopathologic type and grade.
Chondrosarcoma of small bones of the hand arising from enchondroma.
We report the clinicopathologic findings in two cases of chondrosarcoma of the small bones of the hand arising from a preexisting solitary enchondroma. A critical review of the previously reported 18 cases shows that only one is actually well-documented.
Primary neoplasms of the thoracic and lumbar spine. An analysis of 29 consecutive cases.
Primary osseous neoplasms of the thoracic and lumbar spine are uncommon lesions. Between 1965 and 1982, of 1971 patients with musculoskeletal neoplasms, only 29 (1.5%) had primary osseous tumors in these locations. There were eight children and 21 adults. Back pain was the most common complaint in 25 patients (86%), and neurologic symptoms or deficits were present in 16 patients (55%). All lesions were visible on routine spine roentgenograms, while computed tomography and myelography demonstrated spinal canal encroachment and extradural spinal cord compression in 19 patients (66%). The histologic diagnoses included 11 benign and 18 malignant lesions. Benign lesions occurred predominantly in children and malignant tumors in adults. Treatment was individualized, based on the histologic diagnoses. Twenty-two patients had surgical resection of their lesions. Laminectomy without stabilization and arthrodesis resulted in late instability and neurologic deterioration in three of seven patients (43%) with malignant lesions. Resection and decompression combined with arthrodesis did not predispose to late instability. Twenty-one patients were followed for a mean of 4.1 years (range, two to 14 years). Eight patients died from malignant disease between one month and seven years after diagnosis.