Primary Malignant Tumors Of The Long Bones; End Results In 170 Operable Cases

Abstract

The prognosis of osteogenic sarcoma of the long bones, while far from satisfactory, is by no means as hopeless as is generally believed by physicians. The prognosis depends largely on an early diagnosis and the exercise of most careful judgment in selecting the method of treatment for the individual cases; this should be based on a wide experience with a great variety of clinical and pathologic types of bone sarcoma. Amputation alone offers little hope of a permanent cure in any of these types. Primary treatment with radium or roentgen rays, even if pushed to the utmost limits of safety, while often causing very marked improvement has thus far failed to effect a permanent cure in any case in which the diagnosis has been unquestionably established by clinical and pathologic evidence. The mixed toxins of erysipelas and Bacillus prodigiosus alone have effected a cure in certain number of cases; but all of these cases have been of the round cell or spindle cell type, characterized by little production of new bone. The mixed toxins and radium combined have likewise resulted in the complete disappearance and apparent cure of an even larger number of cases of a similar type; but neither toxins nor radium, singly or combined, have effected a cure in any case associated with marked new bone production. Amputation followed by prolonged treatment with the mixed toxins in a series of thirty-eight consecutive cases shows 50 percent of the patients alive and well from three to eighteen years. This series includes all types of osteogenic sarcoma, as well as the cases associated with marked new bone formation. In a similar series of cases treated by amputation alone without toxins or radium before or after amputation, not a single patient has remained alive beyond the three-year period. The choice of treatment in a given case depends on whether it belongs to the group of round cell sarcoma (endothelioma, according to Ewing’s classification) or to the group associated with marked new bone formation. If to the first group, we believe it safe to try a combination of the systemic effect of toxins and the local effect of radium, the duration of the treatment to depend on the result obtained; if marked improvement is noted, the treatment may be continued until the tumor has entirely disappeared; but if no improvement is noted in from four to six weeks amputation should be performed, followed by prolonged systemic toxin treatment. If the case belongs in the second group, we see no advantage, but a distinct disadvantage, in preliminary treatment with radium, roentgen rays or toxins, for the reason that metastases may develop during the period of treatment or may be hastened by the rapid breaking down of a vascular tumor, which permits living cells to be carried to the lungs or to remote parts of the body. As our experience, supported by the results of other men, shows that there is no reasonable hope of saving the limb in this group of cases, we believe that amputation at the earliest possible moment followed by prophylactic toxin treatment offers the greatest hope of saving the life of the patient. The fact that ten inoperable cases of this series have been successfully treated with the mixed toxins alone or combined with radium, the patients remaining well from five to twenty-four years later, should prevent us from abandoning all hope in cases beyond surgical relief. This article, a continuation of the article which appeared in the December 1926 issue of Archives of Surgery, contains summaries of fifty-four cases of bone sarcomas treated with Coley’s mixed toxins or surgery and mixed toxins combined. Some of the cases were also treated with radium and/or amputation.