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Tumours of Bone*

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Tumours of Bone* TUMOURS OF BONE* By JOHN FRASER, Ch.M., M.D., F.R.C.S. {From the Departvient of Clinical Surgery, University of Edinburgh.) Thought it might be of interest to discuss to-night the Problem of the tumours which are met with in connection vvith bone. The subject is one which has lately attracted Mention because of the difficulties which arise in connection )Vlth the appreciation of much of the pathology; and the way ln which many of these difficulties have been lessened, if not completely solved, is an object-lesson of the value of con- Centrated effort and team-work in the elucidation of disease Problems. We have had an opportunity during the past five ^ears of dealing with a certain number of these cases, and it |S Principally our records and results which I propose to put efore you to-night. The Origin of Bone.?We may remind ourselves that bone ?ne of the connective tissues of the and that its ^ body, nsity and apparent hardness are but an adaptation of S^cture designed to render the connective tissue sufficiently distant and strong to bear the body weight. This may seem an Unduly obvious statement, and yet it is one which is funda- mental in the appreciation of much of the pathology of bone ^our. If we remove the mineral content by such an agent s * Penny's fluid, we are left with the connective tissue basis, it is from this that the primary tumour of bone takes s origin. Let us trace certain of the more interesting and significant f^ages in the life-history of bone. The original bone outline condensed mesoblastic tissue containing a variable amount cartilage in its constitution. As growth proceeds, the propor- ?n of cartilage increases until what is virtually a cartilaginous ?del of the later bone comes to exist. Into this cartilaginous virtually avascular tissue, blood vessels penetrate; they ter thg centre Qf the shaft through an aperture which ^ er becomes the nutrient foramen, and they penetrate the emities smaller , of the bone through openings?the epi- yseal canals. This is the stage of vascularisation, and a omark of great significance. The process has a remarkable * Read 7th May 1930. John Fraser influence, for, as the vessels penetrate and come into contact with the cartilage cell, the cytoplasm of the latter disintegrates, the nucleus is liberated and on liberation assumes new and specific functions, for it now acquires the power of assimilating calcium and of depositing it in the surrounding tissue. What was formerly the nucleus of a cartilage cell becomes an active osteoblast. It is the extension of this process from the centre of the shaft centrifugally and independently at each epiphysis which results in the ultimate ossification of the bone. The demonstration of the effect of vascularisation upon the process of ossification is not confined to embryonic and foetal tissues, it is evidenced upon a smaller scale as long as growth persists in the diaphyseal surfaces of the epiphyseal cartilage, but to this I shall refer later. I need not go into further detail regarding the development of bone?the essential point is the appreciation of the influence of vascular tissue in initiating and maintaining the cellulaf changes which result in ossification. The Growing Bone.?Let us now consider for a few minute5 the general structural arrangements of growing bone. The descriptive terms of the different regions are familiar to you ; speak of the epiphysis, of the diaphysis or shaft, of that porti?11 at of the diaphysis which comes into contact with the epiphysis the epiphyseal cartilage?the metaphysis, and of the periosteum- not These are terms in general and everyday use, and I need elaborate them; but where tumour formation is concerned) t0 there are certain peculiarities of structure in relation individual tissues to which reference must be made. The Periosteum.?The periosteum is the limiting fibr?U5 membrane which covers the bone; between it and the under lying bone there is a potential space of some significant or Ihe) This space contains bone-forming cells osteoblasts. vaO are constantly present, though their numbers and activity al1 from time to time. For example, in the early stages of acute inflammatory infection of the bone medulla (oste0^.0 myelitis), they stream in great numbers from the region the marrow into the subperiosteal area; on the other hand,1)1 the early stages of periosteal infection or injury, they leave the space and enter the bone interior. In all likelihood ^lCrJ is a ceaseless ebb and flow of osteoblastic cells into the) from the subperiosteal space, and the routes by which pass are the minute bone canaliculi and the more specials 154 * sf ** * > PippTp ? . *??Section1>?-Section of metaphysis illustrating Fig. 2.?Chondro-sarcoma2.?Chondrosarcoma of left femur. Phases of transition from cartilage cell to (A. S., 64 years.) One quadrant of micro- Psteoblast. of of bone field shows commencement of ls Deposit palisades scopical shown.shovvn. (X140.)(x 140.) sarcomatous change. (XI40.) P PjQIq ' ^ of 3-?Parosteal sarcoma of femur.femur, Fig. 4.?Myeloma of bone. Section C., 42 years.) Shows structure of a of child (H. D.) aged 2 years. jp.1 years.) myeloma 'bro-sarcoma,r?~sarcoma, originated from outer layer Characteristic giant-cell formation shown. Periosteum. ( x 60.) (XI40.)( x 140.) Tumours of Bone aversian and Volkmann's canals. Apart from this relation- JP vve cannot regard the periosteum as other than a limiting brous membrane. The Epiphyseal Cartilage and Metaphysis.?Where the eP'physis joins the shaft of the bone there exists the disc-like of the epiphyseal cartilage, and the actual area ^lucture. surface contact between epiphyseal cartilage and diaphysis !S *-he area of the metaphysis. This latter is of peculiar lnterest: it is the area in which activity is manifest as long as growth continues; it is also, as we might anticipate, the r_ea in which much of the pathology of bone arises?such )Vldely differing diseases as rickets, scurvy, syphilis, acute infections, tuberculosis, and certain of the tumour ^mmatory_r'nations demonstrating their activities in this area. Structur- y is a vascular space lined by a single layer of endothelium an<J interdigitated by a sequence of incomplete palisades and fcesses where the blood and bone fluids come into contact with e cartilage cells and, as we believe, liberate the nuclei of the ^rtilage cells so that these may assume active osteoblastic nctions. It is, in fact, an area where the influence of cularisation in initiating and maintaining ossification is as long as growth in length continues, an area in ^arentich we see a continuance of that process which was the 'gmal step in the ossification of foetal bone (Fig. I.) The Texture of the Shaft.?The structure of the bone Per (as, for example, the cortical or the cancellous tissue 0j- the shaft) is a dense lamellar arrangement of sheets of nective tissue impregnated with lime, grouped concentrically und canals or arranged so as to fill the spaces between the ?rls. Between the lamellae there are the ^ centipede-shaped cunai with their canaliculi. The lacunas contain the bone c s relatively large cells filling the lacuna and provided with ^?cesses which extend into the diverging canaliculi. As far as ^n?w' these cells have no bone-forming properties; they are ^ homologous with the cells of ordinary connective tissue, an in the nutritive of k tl:1ey play important part processes In a11 Probability they are identical in their origin w?h?"h the within the j ordinary osteoblasts, but, being imprisoned fuCUnar sPace, they become altered in appearance and in -^nct^0n- True osteoblasts are scattered throughout the tissue, every space and canal, beneath the periosteum and in the . u^a, in perivascular areas and even in the lacunae. i55 L John Fraser The Marrow.?This structure concerns us in only ?,ie particular?with its blood-forming cells, leucocyte series and hsemoglobin-holding series we are not concerned?but it may be that we are concerned with its giant cells, mono-nucleated, multi-nucleated, with the connective tissue cells of its reticulum and with the endothelial cells of its vascular and lymph spaces. 0 Such is a brief survey of the origin and the structure the composite tissue called bone, and if I am asked to indicate lieS its most outstanding general feature, I would say that it in the remarkable co-ordination of coincident tissue growth and absorption?an adjustment which implies a constant sub' periosteal and endosteal growth balanced by a regular proce^5 the of absorption in the medulla in order to retain intact sufficiency of marrow space, an adjustment which involve5 the most accurate balance of anabolic and katabolic activity' suC so that we are not surprised that certain influences as trauma upset the balance and lead to an erratism vvhi we recognise as tumour formation. ? ? has Classification.?The classification of bone tumours IJ the until recently been unsatisfactory, and I cannot say that position is yet completely stabilised. It has been impi"?ve ha5 and the problem greatly elucidated by the efforts of what come to be known as the American Registry of Bone Tum?urS inaugurated by Codman and sponsored by the American Colle?e of Surgeons. The American classification, modified in certai11 minor particulars, is the one upon which we have worked. way* If we regard the problem of classification in a logical we shall ask ourselves the question: What are the individ tissues existent in bone from which tumours may arise? ^ answer will be: the fibrous and connective tissues of periosteum and medulla, the cartilage of the epiphyseal af the osteoblastic cells wherever they occur, the mono-nucleate and multi-nucleated cells of the marrow, and the endotne j( tissues of the blood and lymph vessels.
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