Osteosarcoma with multiple intramuscular metastases. A case report

A 21-year-old man with an osteosarcoma in the proximal tibia was treated by amputation, radio- and chemotherapy. Besides pulmonary metastases, intramuscular metastases repeatedly developed. Cell culture studies of pulmonary and muscular tumors showed different sensitivity patterns for cytostatic drugs; the therapy may have selected different subpopulations of the primary tumor.     

Extraskeletal myxoid chondrosarcoma with multiple skeletal metastases

Pulmonary metastases are not unusual in extraskeletal myxoid chondrosarcoma; however, only two patients have been reported with multiple bony metastases. We report here one patient with extraskeletal myxoid chondrosarcoma associated with lung and multiple bony metastases. After chemotherapy, the primary lesion was resected, but lung and multiple bony metastases were found 20 months later. The bony metastases were in the right femur, right humerus, and at multiple vertebral levels. Because of a pathologic fracture of the right femur, the metastases in the right femur and right humerus were surgically stabilized. After chemotherapy, the lung metastases were resected, and those in the vertebral bodies were treated with radiotherapy. Received for publication on March 29, 1999; accepted on Sept. 1, 1999     

A small-cell osteosarcoma with multiple skeletal metastases

Summary A 10-year-old child presented with small-cell osteosarcoma of the proximal end of the tibia. Pulmonary metastases appeared after a gap of 9 months of ablative surgery, as did late multiple extrapulmonary skeletal metastases, including the hand and foot bones after 6 months of pulmonary metastases. These late extrapulmonary metastases appear to be secondary to pulmonary metastases.

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Zusammenfassung Bei einem 10jährigen Knaben mit kleinzelligem Osteosarkom der proximalen Tibia wurden 9 Monate nach Amputation Lungenmetastasen festgestellt. Sechs Monate nach Bekanntwerden der Lungenmetastasen trat eine multiple Skelettmetastasierung auf, einschließlich des Befalls der Hand- und Fußknochen. Es sieht so aus, als ob die Metastasierung in das Skelett sekundär zu derjenigen in die Lungen aufgetreten ist.

     

Osteosarcoma with skeletal muscle metastasis

Osteosarcoma usually metastasizes to the lung or the bone, but very rarely to the soft tissue. There have been few reports of osteosarcoma patients with long-term survival after the soft tissue metastasis. We report a case of osteosarcoma in a 18-year-old man, who presented with a solitary skeletal muscle metastasis in the right vastus lateralis as the second relapse of the disease. The patient underwent excision surgery without adjuvant chemotherapy, and remains free of the disease for over 34 months after the surgery.     

Recurrence of prostate adenocarcinoma presenting with multiple myeloma simulating skeletal metastases of prostate adenocarcinoma

We present the case of a 77-year-old man with recurrence of prostate adenocarcinoma and widespread skeletal lesions. The skeletal lesions were found to be caused by multiple myeloma rather than metastatic spread of prostate adenocarcinoma. Various aspects of the radiographic imaging, evaluation of elevated prostate-specific antigen, and treatment of prostate adenocarcinoma are discussed.     

Surgery of skeletal metastases

During a period of 5 years, 74 female and 27 male patients with an average age of 63.3 years underwent a total of 117 operations for the management of impending ( n=41) or already existing ( n=76) pathologic fractures due to osseous metastases. The average stay in hospital was 17.8 days, and the average postoperative survival 15.8 months. The patients whose limbs were stabilized as a preventive measure were discharged 1.5 days earlier and survived surgery 5.9 months longer than the patients with pathologic fractures. The large percentage of female patients is due to the predominant role of mammary cancer (50%) and the comparatively long survival of patients after a primary diagnosis of this type of carcinoma. The other diagnoses involved were (in order of frequency): bronchial carcinoma (11%), hypernephroma (8%) and non-Hodgkin's lymphoma (8%). The metastases were mainly located at the proximal end or shaft of the femur (59.8%) and in the humerus (18.8%) so that in the majority of cases it was possible to implant weight-bearing prostheses or at least achieve enough stability to allow non-weight-bearing physiotherapy and thus early remobilization. The rate of systemic complications (excluding fatalities) was 14.5%. Local complications in the operated area occurred in 24.8% of cases. As a result, revision surgery was necessary in 10 cases (8.5%), and the fatality rate in hospital (6 weeks) was 7.9%. In view of the advanced stage of the disease in most of the patients, some of them with polypathia, we see these results as a basis for the generous indication for preventive stabilization of osseous metastases. Except in some cases, the primary intention of this therapy is not to cure the disease or prolong life but to improve the quality of life remaining for these patients while keeping their stay in hospital as short as possible and the rate of complications at an acceptable level.     

Pathology of skeletal metastases

Metastatic disease involving the skeleton is an unfortunate and common occurrence in cancer patients. Choosing the best diagnostic approach requires knowledge of the patient's clinical history, the radiologic appearance of the lesion, the differential diagnosis, and the ability of the diagnostic modality to answer the questions that must be addressed. In difficult cases, interaction between the pathologist and clinician before biopsy may make the difference between a rapid procedure serving to definitively diagnose and effectively stage a patient and a costly procedure that provides little or no information.     

Surgery of skeletal metastases

During a period of 5 years, 74 women and 27 men with an average age of 63.3 years underwent a total of 117 operations for management of impending (n=41) or already existing (n=76) pathologic fractures due to osseous metastases. The average stay in hospital was 17.8 days and the average postoperative survival was 15.8 months. The patients whose limbs were stabilized as a preventive measure were discharged 1.5 days earlier and survived surgery 5.9 months longer than the patients with pathologic fractures. The large percentage of female patients is due to the predominant role of mammary cancer (50%) and the comparatively long survival of patients after primary diagnosis of this type of carcinoma. The other diagnoses involved were: bronchial carcinoma (11%), hypernephroma (8%), and non-Hodgkin's lymphoma (8%). The metastases were mainly located at the proximal end or shaft of the femur (59.8%) and in the humerus (18.8%) so that in the majority of cases it was possible to implant weight-bearing prostheses or at least achieve-enough stability to allow non-weight-bearing physiotherapy and thus early remobilization. The rate of systemic complications (excluding fatalities) was 14.5%. Local complications in the operated area occurred in 24.8% of cases. As a result, revision surgery was necessary in 10 cases (8.5%) and the fatality rate in hospital (6 weeks) was 7.9%. In view of the advanced stage of the disease in most of the patients, some of them with polypathia, we see these results as a basis for the generous indication for preventive stabilization of osseous metastases. Except in some cases, the primary intention of this therapy is not to cure the disease or prolong life, but to improve the quality of life remaining for these patients while keeping their stay in hospital as short as possible and the rate of complications at an acceptable level. Received: 16 August 2001/Accepted: 4 September 2001     

A case of multiple skeletal lesions of brown tumors, mimicking carcinoma metastases

Brown tumor is not a true tumor, being an unusual reactive lesion in association with primary or secondary hyperparathyroidism. We report a 23-year-old woman, who initially presented with lower back pain caused by ureterolithiasis. The initial diagnosis of brown tumor was delayed, but later pain in her leg worsened and a sacral lesion was incidentally discovered on lumbar magnetic resonance imaging (MRI); multiple destructive bone lesions were then found radiologically. The radiological features of the multiple bone lesions, which mimicked multiple metastatic tumors, seemed to be those of the terminal stage of malignancy. However, pathological examination and abnormal laboratory data showing elevated serum calcium, alkaline phosphatase, and parathyroid hormone and low serum phosphate confirmed the diagnosis of brown tumor. Adenoma in the parathyroid gland was confirmed and surgically resected. The clinical symptoms of bone pain, and abnormal radiological findings and laboratory data were resolved 6 months after surgery. Synthetic analysis of the clinical, radiological, and laboratory findings was necessary for the definite diagnosis of brown tumor.     

The development of skeletal metastases

The search into the way in which skeletal metastases develops has not only shown that there are several mechanisms for the progressive bone destruction and bone formation that occur simultaneously in the majority of skeletal metastases, but also that an understanding of these basic mechanisms has significant therapeutic implications. Our results have shown that there are two main mechanisms for the bone formation: stromal bone formation and reactive bone formation. The former occurs in tumours which tend to be acellular, with a large fibrous stroma, whereas the latter occurs in virtually all metastases. There is no difference in the basic pathological process of sclerotic or lytic metastases, the radiographic appearance purely indicating the net balance between the different types of bone formation and the simultaneous progressive bone destruction. An understanding of the pathophysiological response to skeletal metastases explains why skeletal scintigraphy can be used to diagnose these lesions and the different mechanisms underlying the 'three-phase scintigram'. The first phase indicates the vascularity of the lesion; the second phase or 'blood-pool' image indicates the concentration in the extracellular fluid and the third phase or 'skeletal or delayed image' indicates the uptake in the reactive new bone. The secretion of an osteoblast inhibiting factor by myeloma indicates why there is no reactive bone produced by the majority of lesions in the absence of a fracture, and why scintigraphy is less reliable than plain radiographs for the detection of the lesions. There are two main mechanisms for the bone destruction, the most important being mediated via osteoclasts. An understanding of the humoral mechanisms stimulating the osteoclast proliferation may lead to more effective treatment of malignant hypercalcaemia and lytic metastases. Early results of use of APD are encouraging, and our results also suggest that clinical trials should be established to evaluate the effect of combination therapy with APD or prostaglandin inhibitor combined with the agents normally used in the management of patients with disseminated mammary carcinoma. The development of treatments to inhibit tumour-induced osteolysis will minimise the complications of pathological fracture, spinal instability, etc., and even if these treatments do not affect the primary tumour, its ability to metastasize, or the patient's survival, such treatment will be a major advance in the management of patients with carcinoma, because of the significant morbidity currently associated with the development of skeletal metastases and their complications.(ABSTRACT TRUNCATED AT 400 WORDS)     

Distribution of skeletal metastases in prostatic and lung cancer. Mechanisms of skeletal metastases

The distribution of skeletal metastases in prostatic and lung cancer was examined to test the hypothesis that prostatic carcinoma spreads by a unique hematogenous route. Abnormal technetium-99m methylene diphosphonate bone scans were retrospectively reviewed in 71 patients with prostatic carcinoma and 41 patients with lung cancer comparing patterns of osseous involvement. Differences in the distribution of lesions were not significant. It is concluded that prostatic carcinoma does not metastasize to specific skeletal sites by a singular hematogenous pathway.     

Accessory scrotum with multiple skeletal abnormalities

Accessory scrotum is very uncommon. Here we report a 5-year old Caucasian boy presenting with an accessory scrotum localized to the left side of the pubic area. The penis and the primary scrotum were completely normal, containing two dependent testicles. On the right side of the body there was type B proximal femoral focal deficiency and there was also diastasis of the symphisis pubis. As observed in this case, abnormalities of two different embryological organ systems (accessory labioscrotal fold and proximal femoral focal deficiency) may occur concurrently at the same intrauterine time point as part of an overall embryologic mesenchymal disorder.