E coma are rare tumors, with about 106 cases

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1 EXTRAOSSEOUS OSTEOGENIC SARCOMA FOLLOWING AN INTRAMUSCULAR INJECTION.J. H. LEE, MD,* WILLIAM~J. GRIFFITHS, MD,* AND RICHARD H. BOTTOMLEY, MD' A 29yearold white male with an extraosseous osteogenic sarcoma is reported. He first noted a nodule at the site of eventual tumor development some eight years previously, following an intramuscular penicillin injection. Treatment consisted of wide surgical excision and radiation therapy, and he remains healthy some 8 months later. To our knowledge is represents the first case of extraosseous osteogenic sarcoma occurring at t t e site of a previous intramuscular injection. Cancer 40:309730, 977. XTRAOSSEOUS FORMS OF OSTEOGENIC SAR E coma are rare tumors, with about 06 cases previously reported in the world's literature. Diagnostic criteria for such tumors include the exclusion of bone origin, the production of malignant osteoid and/or bone, and sarcomatous stroma. We are reporting such a tumor which manifested, in addition, certain unusual characteristics, particularly with respect to the possible predisposing cause and the course of the illness. CASE REPORT The patient was a 29yearold otherwise healthy white male who presented with a large painless mass over the right posterolateral thigh and gluteal region. A small nodule had appeared at this site approximately eight years previously, following a penicillin injection. This nodule had, with only the usual daytoday trauma of sitting and working, gradually increased in size. The patient otherwise remained healthy, and did not complain of weight loss, nor was the enlarging mass particularly painful. Physical examination was essentially unremarkable except for the previously mentioned firm 6 X 6 cm mass in the right posterolateral thigh and gluteal region. Laboratory studies including hemogram, chemistries, urinalysis and routine chest x rays were within normal limits. Xray films of the pelvis and femur (Fig. ) revealed a mass containing calcifica tions in the right gluteal region with an otherwise normal bony structure. Tomograms of the tumor showed no communication with the periosteum of the femur, and arteriography demonstrated the mass to be avascular. A Technetium99m diphosphonate bone scan was unremarkable except for an area of increased uptake lateral to the right proximal femur (Fig. 2). Whole lung tomograms were performed, which showed no evidence of pulmonary metastases. The patient was taken to surgery and a wide excision of the mass and capsule was performed. The mass weighed,460 g, was firm in consistency with nodular surface, and the capsule was intact. Microscopically, the tumor was encapsulated and was composed predominantly of a fibrosarcomatous proliferation of spindle cells with a high mitotic index (Fig. 4) and focal areas of immature malignant osteoid production (Fig. 3). The histologic diagnosis was extraosseous' osteogenic sarcoma. The postoperative course was uncomplicated, with the exception of a postoperative hematoma which required evacuation. Adjuvant chemotherapy with cyclophosphamide, vincristine, adriamycin, and DIC, the protocol of the Southwest Oncology Group for primary osteogenic sarcoma, was planned postoperatively, However, because of the patient's refusal to consider chemotherapy, he was given a split course of radiation therapy (total dose of 6,400 rads) to the operative site. At his 8month followup examination, he remains in excellent health with no evidence of recurrence or metastases. * Resident, Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma. + Professor, Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, and Member, Oklahoma Medical Research Foundation. This investigation was supported in part by Grant Number CA6957, awarded by the National Cancer Institute, DHEW. Address for reprints: Richard H. Bottornley, M.D., 825 Northeast 3th Street, Oklahoma City, OK Accepted for publication April 25, DISCUSSION Fine and Stout' in 956 reviewed 46 cases of extraosseous osteogenic sarcoma. In 97, Allen and Soule'expanded these to a total of 94 cases. With subsequent reports, mostly single case reports such as those of Nishimura,22 Lewis,ao Hasson, '' Chambers,' Jacques, '' and Ikeda, l9 the number has risen to 07 (Table ) including the present case. The average age of patients

2 3098 CANCER December 977 Vol. 40 FIG. I. Xray film of the right femur showing the mass with calcification in the right gluteal region. FIG. 2. Whole body bone scan with m T~ Diphosphonate demonstrating a large area of increased uptake at the right posteriorlateral proximal femur.

3 No. 6 EXTRAOSSEOUS OSTEOCENIC SARCOMA Lee et al FIG. 3. Microscopic appearance of the tumor showing the osteoid elements (H & E. X80). FIG. 4. Microscopic appearance of the tumor showing the sarcomatous stroma (H. & E. X80).

4 300 CANCER December 977 Val. 40 TABLE. Summary of Reported Cases of Extraosseous Osteogenic Sarcoma No. of Cases Authors Age Range Survival Time 46' 9 9' 26' 2 Fine and Stout' Das Gupta et al.' Wurlitzer'' Allen and Soule' Case Records of Massachusetts General Hospital' Salm'' Kauffman and Stout De Boer el al.' Jussawalla and Desai" Lowry and Haynes" Gupta and Aga" Boyer and Navin' Rachman and Di MassaZa Hoffman el al. '' Khoo and Balachandran'' Shanoff el al." Sheikh and Koten'",Jarvi et al. '' Tkeda" Lewis'" Nishimura" Jacques" Chambers' Hasson" Lee et al. 8 to 80 3 to to to and mas. to 0 yrs. 2 mas. to 2 yrs.5 26 days to 29 mas." 9 mas. to 4 yrsq 8 mos. 9 mas. yrs. 9 mos. mas. 0 and 3 mos. 5 days 2 M yrs. 5 mas. 5 yrs. (alive at time of report) 0 yrs. 3 mas. 9 mos. 2 yrs. (alive) 8 mos. (alive) * One case was excluded. due to similarity to pseudomalignant tumor. ' One case was previously reported by Fine and Stout. ' One case was included in the series of Fine and Stout. #Three of the cases were alive at the time of the report. " One of the cases was alive at the time of the report. Five of the cases were alive at the time of the report. with extraosseous osteogenic sarcoma is over 40 years. *8928 This is in contradistinction to the early age (0 to 20 years) of most patients with intraosseous osteogenic sarcoma. 28 Although patients with extraosseous tumors as young as 8 years old have been reported,' our patient was relatively young at 29 years. Predisposing causes, such as contrast media extravasation, irradiation, and trauma' have been reported in only a few cases of extraosseous osteogenic sarcoma. This case represents, to the authors' knowledge, the first possible association with an intramuscular injection, in this case penicillin. Such an association must be an exceedingly rare event since we were unable to find any other reports in the literature describing development of a malignant tumor following penicillin injection. Although the duration of symptoms before diagnosis varies considerably, in one of the larger series' the range was week to 3 years, with an average of 6.5 months. Our patient was most unusual in manifesting a mass at the site of eventual development of his tumor for a period of 8 years. This prolonged course might suggest malignant transformation from a benign lesion such as a hematoma or myositis ossificans following the penicillin injection. Fine and Stout' suggested that the rapidly progressive cases might be malignant at the beginning, and that slowly progressive cases could represent malignant transformation of some benign lesion. Myositis ossificans was suspected to be one of the underlying benign conditions. Although there was no myositis ossificans found in our case, preexistence of this condition cannot be completely excluded. This case certainly emphasizes that all slow growing masses are not necessarily benign, and may, as in this case, harbor a highly malignant tumor. The treatment of choice for extraosseous osteogenic sarcoma is surgery, with either wide excision or hemipelvectomy. 2o Chemotherapy has been generally disappointing in extraosseous forms of osteogenic sarcoma. *8~20 Recently, however, the use of adjuvant chemotherapy for intraosseous forms of osteogenic sarcoma has been more encouraging. Adriamycin, cyclo

5 No. 6 EXTRAOSSEOUS OSTEOCENIC SARCOMA Lee et al. 30 phosphamide, phenylalanine mustard, high dose methotrexate with citrovorum factor rescue, vincristine and DTIC, a0ne~*'~ and in combinati~n'.'~ have been reported to improve survival in patients with these tumors. Whether these regimens will have the same favorable results in patients with extraosseous forms requires further evaluation. In the case of our patient, adjuvant chemotherapy was planned in addition to surgery and irradiation, but was refused by the patient. The prognosis of extraosseous osteogenic sarcoma is poor. Cures occur in only 8 to lo%, although survival for as long as 4 years with possible recurrence has been reported. '@ The majority of patients succumb to local recurrence or systemic metastases. ~8,20 With the poor prognosis evident from the reported cases, it would appear that an aggressive multimodality approach is indicated in the therapy of patients with extraosseous osteogenic sarcomas in an attempt to improve survival in this rare condition. I. Allen, C.,J., and Soule, E. H.: Osteogenic sarcoma of the somatic soft tissue. Clinicopathologic study of 26 cases and review of literature. Cancer 27:233, Boyer, C. W.,.Jr., and Navin, J. J.: Extraskeletal osteogenic sarcoma: A late complication of radiation therapy. Cancer 8:628633, Case records of the Massachusetts General Hospital (Case 44 2). New Engl. 3. Med. 258:554558, Chambers, A,, and Carson, R.: Primary osteogenic sarcoma of the kidney. Br. J. Radiol. 48:3637, Cortes, E. P., Holland, J. F., Wang,,J. J., Sinks, L. F., Blom,,J., Senn, H., Bank, A,, and Glidewell, 0.: Amputation and adriamycin in primary osteosarcoma. N. Engl. 3. 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