A case of long term survival with skeletal only metastatic breast cancer.

INTRODUCTION: The prognosis of patients with metastatic breast cancer is very poor. Because of this, treatment of skeletal metastasis is often palliative with limited goals rather than cure. However, there are those patients, such as presented here, who survive for an extended time. PRESENTATION OF CASE: This thirty-six year old female presented with lytic lesions to one ulna and rib five years after mastectomy for breast cancer. Despite radiation and chemotherapy, the ulnar lesion expanded and resulted in an elbow dislocation. The rib lesion was resected and the arm amputated above the elbow. She developed local recurrence in both her above elbow amputation stump and chest wall and a more proximal below shoulder amputation was performed with resection of chest wall lesion. Even though she had locally aggressive disease, she has survived for 31 years after diagnosis without any evidence of disease. DISCUSSION: Reports of metastatic breast cancer survival indicate the five year survival to be 15%. There have been few reports indicating that those patients with skeletal only or oligometastatic disease have improved prognosis. It is not clear what biological properties of these tumors results in the improved survival. CONCLUSION: This case highlights the challenges of giving patients the optimal treatment in the light of limited ability to predict prognosis. It also highlights the need to further investigate the phenotypes of breast cancer that can, despite metastatic disease and with modern treatment go on to long survival. In addition this case demonstrates the importance of long term followup.

Spread of squamous cell carcinoma from the thumb to the small finger via the flexor tendon sheaths.

We report the development of metastatic squamous cell carcinoma at the tip of the small finger following the development of a thumb distal phalanx squamous cell carcinoma caused by chronic osteomyelitis. The spread of hand infections from the flexor tendons of the thumb to the small finger through a tendon sheath connection at the wrist is a well-described phenomenon. The evidence from this case suggests that the spread of the squamous cell carcinoma from the tip of the thumb to the tip of the small finger occurred in a similar fashion. This information is important in understanding how malignant tumors spread in the hand and wrist, and it might influence the management of such tumors.

Case reports: Osteogenic sarcoma of the patella spread to lateral meniscus after arthroscopy.

Our patient presented with a rare lesion, a patella osteogenic sarcoma that spread to the anterior horn of the lateral meniscus via the arthroscope. He was treated arthroscopically for a torn medial meniscus of his right knee. A lesion in the patella was observed and a biopsy specimen was obtained through the arthroscope. The specimen was diagnosed as an osteogenic sarcoma. After 2 weeks of neoadjuvant chemo-therapy, the patient refused additional chemotherapy. Re-section of the knee and allograft arthrodesis were done 4 months after the initial arthroscopy. Pathologic examination of the resected specimen showed osteogenic sarcoma of the patella and a completely separate 1.0-cm nodule of osteogenic sarcoma tissue growing in the anterior horn of the lateral meniscus. The patient died 15 months after knee re-section with multiple pulmonary metastases. We are unaware that such an occurrence of an osteosarcoma spread through an arthroscope has been documented pathologically and reported.

James Platt White, MD (1811-1881): his interesting and remarkable accident.

James Platt White, MD (1811-1881), one of the founders and leading figures of the Buffalo Medical College and a pioneer in American obstetrics and gynecology, suffered an interesting and remarkable accident to his neck at the age of 26 while traveling in a stagecoach in Western New York. He was confined to bed until after 45 days, a piece of bone was discharged into his pharynx and then expectorated. The segment of bone proved to be the anterior arch of his atlas (C1) vertebra. He recovered completely from this injury except for permanent loss of rotation of his head and neck. However, he was without functional disability until his death, 44 years later, at the age of 70. This case documents the clinical result during a 44-year period after traumatic loss of the anterior arch of C1. Such cases have been reported only rarely in the literature. Only limited information is available regarding the long-term clinical significance of a Jefferson fracture with exfoliation of the anterior arch of C1. My analysis suggests that White suffered an open Jefferson's fracture that became infected. The anterior arch of C1 became a sequestrum and was discharged spontaneously into his pharynx and then expectorated. This case report with decades of followup should be of interest to all who care for patients with cervical spine injuries and those who are interested in the history of medicine in Western New York.

Pioneers in musculoskeletal oncology: Musculoskeletal Tumor Society Founders Lecture.

I was invited to deliver the third annual Musculoskeletal Tumor Society's Founder's Lecture, at our annual meeting on May 2, 2003 in Chicago, IL. The Musculoskeletal Tumor Society began in 1977 when a small group of physicians, mainly orthopaedic surgeons, met to discuss ways of improving the outcome of the rare and usually fatal primary malignant neoplasms of bone. Treatment of patients with these types of cancers most often was amputation. Initial criteria for membership included participation in group clinical studies. As individuals and collectively as a tumor society, we have witnessed and participated in a revolution in the care of these patients resulting in markedly increasing survival from less than 20% to nearly 70% and dramatically lessening disabilities by using limb-sparing surgery instead of amputation. I have elected to present brief descriptions of some of the individuals and their contributions that have led to these noteworthy improvements in patient care and final results. These individuals lived in different countries during different times and are from various fields of medicine. The time constraints imposed by the lecture have made it impossible to include all the deserving pioneers.

Osteonecrosis after powered core decompression.

A 44-year-old man with alcohol-related osteonecrosis of his left femoral head, Ficat Stage 2, was treated by femoral head decompression. During this procedure the (1/4)-inch trephine driven by a power reamer became lodged in the femoral head and became hot to the touch. The trephine eventually was removed with difficulty after the decompression was completed. Four and a half years later, the patient continued to have progressive pain and difficulty ambulating. A radiograph at the time revealed a wide zone of symmetric increased density about the core decompression track. A total hip arthroplasty was done, yielding the femoral head and neck for study. Histologic sections of the femoral head and neck showed that the entire length of the core decompression track in the specimen was surrounded by 2.7 cm of unrepaired necrotic bone. The evidence suggests that extensive additional necrosis was produced iatrogenically during the core decompression with the powered trephine. Necrosis secondary to either heat generation or increased pressure along the trephine track is presented as possible mechanisms for this unusual finding.