Faculty Bibliography

We report the findings from an aspiration biopsy and resection of a chordoma-like tumorous mass in the wall of the thorax of a 36-yr-old man with immunohistochemical, ultrastructural, and cytogenetic studies. The 4-cm oval tumor was an incidental finding on physical examination, and no other lesions were identified after comprehensive radiologic studies. The aspirate was composed of sheets and nests of cells with distinct borders in a myxoid and fibrillary extracellular matrix. The neoplastic cells were uniform and round or polygonal with abundant pale blue vacuolated cytoplasm and small round, central or eccentric nuclei. On electron microscopy, mitochondrial rough endoplasmic reticulum complexes were seen in neoplastic cells. These features were similar to those of a conventional chordoma. However, the cytogenetic pattern, 43, XY ,-1, -2, der (5)t(1p;5q), -6, add(8p) ,add(10q), was not typical. In addition, the neoplastic cells were positive for vimentin, S-100, AE1/AE3, CAM 5.2, and CK 19; were focally positive for EMA and smooth muscle actin; and were negative for cytokeratin 1 and 10 (34 beta E12), CK 7, CK 8 (35H 11B), CK 17, and CK 20. The cytogenetic and immunohistochemical patterns were different from conventional chordoma and its peripheral counterpart, chordoma periphericum, suggesting the diagnosis of parachordoma. To the best of our knowledge, this is the first report of fine-needle aspiration of this newly defined and rare entity

OBJECTIVE: To report, in 4 patients, the occurrence of 2 different primary tumours in proximity in the same bone. Three patients had osteosarcomas, and 1 had a giant cell tumour; all had coincident metaphyseal fibrous defect. METHODS: Four patients (2 women, 1 man and 1 boy; 18, 25, 24 and 10 years of age, respectively) presented with progressive pain in the knee and distal thigh. All were studied by radiography, magnetic resonance imaging was done in 3 patients, and diagnostic open biopsy was performed for all. RESULTS: Radiologic studies demonstrated tumours in the distal end of the femur in all 4 patients. Biopsy tissue showed a metaphyseal fibrous defect in all, with coexistence of an associated giant cell tumour in 1 patient and an osteosarcoma in each of the others. In all cases, the metaphyseal fibrous defect was penetrated by the adjacent tumour. CONCLUSIONS: Despite the relative prevalence of metaphyseal fibrous defect, giant cell tumour and osteosarcomas in the distal end of the femur and their occurrence in approximately the same age group, their association has rarely been reported. As both giant cell tumours and osteosarcomas are usually diagnosed late in their clinical course, they may outgrow and destroy any evidence of pre-existing metaphyseal fibrous defect. The rate of destruction is also influenced by the distance between the 2 lesions--the shorter the distance, the earlier the destruction

BACKGROUND: Recently, intra-articular viscosupplementation with hyaluronate-derived products has gained popularity as a palliative modality for the treatment of osteoarthritis of the knee. Mild pain or swelling at the site of injection may occur in up to 20% of patients, although severe local inflammation, warmth, and joint effusion are rare. We present a series of six cases in which granulomatous inflammation of the synovium was observed after hyaluronate viscosupplementation of the knee. METHODS: Six knees (five patients) treated with intra-articular Hylan G-F 20 viscosupplementation underwent a surgical procedure because of persistent symptoms. Routine histopathological evaluation, supplemented by alcian-blue staining and hyaluronidase digestion, was performed in each case. RESULTS: Chronically inflamed synovium with areas of histiocytic and foreign-body giant-cell reaction was observed surrounding acellular, amorphous material. The material stained with alcian blue, a stain for hyaluronate, which disappeared after hyaluronidase digestion. CONCLUSIONS: We believe that the injected hyaluronate (Hylan G-F 20) may have been responsible for the synovitis in our patients and thus may be a pathological cause of recalcitrant symptoms after such injection. It is not known whether the responsible pathological agent was the hyaluronate derivative, a contaminant of the purification process, or a component of the carrier substance. Importantly, it appears that the findings in these patients most likely represent a previously unreported pathological response to a viscosupplementation product. This report should raise clinical awareness about this potential complication

Ochronotic arthropathy is a progressive joint disorder resulting from the deposition of a derivative of homogentisic acid into connective tissues, especially meniscal and articular cartilage. Patients may present with symptoms, physical examination results, and radiographic changes consistent with degenerative joint disease. We present a case in which an operative arthroscopy of the knee was highly suggestive of ochronotic arthropathy. The definitive diagnosis of ochronosis was subsequently confirmed by laboratory and pathologic evaluation

Indium-111-oxine labeled leukocyte ((111)In-WBC) scintigraphy is well known for its ability to localize in areas of active infection, but not in areas of lymphomatous involvement. We present a case of Ki-1-positive anaplastic large-cell lymphoma that was initially thought to be a case of multifocal osteomyelitis because of positive uptake on a (111)In-WBC scan. The areas of abnormal uptake on the indium scan were demonstrated histopathologically to be sites of lymphomatous involvement in bone

The ability to identify intraoperatively patients with an infected prosthesis at the time of a revision procedure assists the surgeon in selecting appropriate management. The results of 413 intraoperative Gram stains were compared with the results of operative cultures, permanent histology, and the surgeon's intraoperative assessment to determine the ability of Gram stains to identify periprosthetic infection. Gram staining correctly identified the presence of infection in 10 of the 68 cases that met study criteria for infection (sensitivity of 14.7%). Four false-positive Gram stains were encountered. Intraoperative Gram stains do not have adequate sensitivity to be helpful in identifying periprosthetic infection and should not be performed on a routine basis. They may be helpful, however, in cases in which gross purulence is encountered to assist in the selection of initial antibiotic therapy. The use of intraoperative Gram staining alone is inadequate for ruling out infection at the time of revision total joint arthroplasty

BACKGROUND: Despite the effectiveness of a two-stage exchange protocol for the treatment of deep periprosthetic infection, infection can persist after resection arthroplasty and treatment with antibiotics, leading to a failed second-stage reconstruction. Intraoperative analysis of frozen sections has been shown to have a high sensitivity and specificity for the identification of infection at the time of revision arthroplasty; however, the usefulness of this test at the time of reoperation after resection arthroplasty and treatment with antibiotics is, to our knowledge, unknown. METHODS: The medical records of sixty-four consecutive patients who had had a resection arthroplasty of either the knee (thirty-three patients) or the hip (thirty-one patients) and had had intraoperative analysis of frozen sections of periprosthetic tissue obtained at the time of a second-stage operation were reviewed. The mean interval between the resection arthroplasty and the attempted reimplantation was nineteen weeks. The results of the intraoperative analysis of the frozen sections were compared with those of analysis of permanent histological sections of the same tissues and with those of intraoperative cultures of specimens obtained from within the joint. The findings of the analyses of the frozen sections and the permanent histological sections were considered to be consistent with acute inflammation and infection if a mean of ten polymorphonuclear leukocytes or more per high-power field (forty times magnification) were seen in the five most cellular areas. RESULTS: The intraoperative frozen sections of the specimens from two patients (one of whom was considered to have a persistent infection) met the criteria for acute inflammation. Four patients were considered to have a persistent infection on the basis of positive intraoperative cultures or permanent histological sections. Overall, intraoperative analysis of frozen sections at the time of reimplantation after resection arthroplasty had a sensitivity of 25 percent (detection of one of four persistent infections), a specificity of 98 percent, a positive predictive value of 50 percent (one of two), a negative predictive value of 95 percent, and an accuracy of 94 percent. CONCLUSIONS: A negative finding on intraoperative analysis of frozen sections has a high predictive value with regard to ruling out the presence of infection; however, the sensitivity of the test for the detection of persistent infection is poor

OBJECTIVE: To demonstrate the radiologic and pathologic manifestations of osteoid osteoma arising beneath the periosteum, on the surface of the bone. DESIGN: One hundred and sixty osteoid osteomas were seen over a 30-year period. The radiologic, pathologic and operative findings of those that were subperiosteal were reviewed. PATIENTS: Eleven patients with subperiosteal osteoid osteoma were reviewed. The patients ranged in age from 13 to 36 years with a mean of 24 years. Eight were male and three were female. RESULTS AND CONCLUSION: Eleven subperiosteal lesions were studied. The reactive periostitis of four lesions was atypical and misleading. Four lesions had features similar to the more common intracortical variety. Three lesions occurring within the joint like other intra-articular lesions were barely seen on plain radiographs. Bone scan and CT scan were virtually diagnostic. The histopathology of these lesions was also atypical though not misleading. In conclusion, subperiosteal osteoid osteoma is a rare lesion with atypical radiographic and histopathologic features. The unusual reactive periostitis seen in several extra-articular cases may suggest other diagnoses

BACKGROUND: The main reinforcing effect of cocaine happens by altering dopaminergic neurotransmission in the brain reward systems. Dopamine is found in high concentrations in the retina in which it plays an important role in color vision. Therefore, we investigated whether cocaine-dependent patients might have impaired color vision. METHODS: We compared patients recently withdrawn from cocaine (n = 31) with matched normal controls (n = 31) on 2 color vision tests. RESULTS: Cocaine-withdrawn patients had significantly higher error scores than matched controls on the Farnsworth-Munsell 100-hue and Lanthony desaturated D-15 color vision tests. Also, 23 of the 31 cocaine-withdrawn patients had blue-yellow color vision losses on the Farnsworth-Munsell 100-hue test compared with 3 controls (P < .001, chi 2 test) and 15 had blue-yellow color vision loss on the Lanthony desaturated D-15 test compared with 2 controls (P < .001, chi 2 test). CONCLUSIONS: These significantly higher test error scores and blue-yellow color vision losses suggest that color vision is impaired in cocaine-withdrawn patients. Color vision testing may be useful in future studies of cocaine-dependent patients

Epiphyseal extension of a unicameral bone cyst is rare. We report a case of a 13-year-old boy with three pathological fractures through a unicameral bone cyst with epiphyseal involvement in the proximal humerus. These lesions initially tends to expand the humeral epiphysis laterally and progress medially. They also commonly cause a slip of the epiphysis in a medical direction. They also have a greater association with growth retardation and lesser degree of recurrence than their metaphyseal counterpart.