Giant-Cell Tumor of the Lower Femur

Abstract

For 125 years, from 1818 to 1943, low-grade neoplastic processes, now generally designated “giant-cell tumors of bone,” have been mentioned in the medical literature. Cooper and Travers (20) seem to have described them well grossly, with some clinical and therapeutic aspects, in 1818. Lebert (45) is usually given credit for the first description of the giant cells of the medullary tumors in 1845. In 1854, Paget (56) referred to many cases of “myeloid tumor” and discussed in detail the gross, microscopic, clinical, and operative details. He believed these tumors were “not apt to recur after complete removal.” In 1860, Nélaton (54) reported 46 cases in detail, and in 1879 Gross (32) followed with 70 cases of benign giant-cell sarcoma, 5 of which underwent malignant change. Virchow (69) in 1865 raised the question of malignant behavior of myeloid sarcomas. Although most of the cases appeared to be benign, excision or amputation was considered the safe therapeutic procedure for nearly one hundred years. Bloodgood (4) watched Halsted excise the lower forearm and carpal bones for a giant-cell sarcoma in 1893 and performed his own first curettage of the tibia in 1902. Coley (15) in the same year began x-ray therapy in conjunction with surgery and the use of toxins for bone sarcomas. Pfahler (58), in 1906, made roentgenograms and gave roentgen therapy alone to a giant-cell tumor of the upper fibula. Mallory (48), in 1911, and Bloodgood (5), in 1912, appear to be responsible for the change in nomenclature from “giant-cell sarcoma” to “giant-cell tumor.” Favorable mention of roentgen therapy for giant-cell tumor has been made by Pfahler (58), Coley (18), Bloodgood (6), Herendeen (34–36), Kolodony (44), Borak (7), Codman (11–13), Geschickter and Copeland (27–29), Brunschwig (8), Peirce (57), Evans and Leucutia (23), Ewing (24), Meyerding (51), Coley and Miller (14). The quantity and quality of radiation in the earlier years could not be accurately measured. Even in later years dosage has seldom been mentioned. When recorded, it has varied from a fraction of an erythema dose at intervals up to “eight treatments totaling 30,000 r (14,000 r laterally and 16,000 r medially).” This latter dose was given by Coley and Miller (14) to a tumor of the femur (factors: 250 kv., 1.5 mm. copper filtration, 50 cm. target-skin distance; lateral portal 8 × 12 cm., medial, 15 × 12 cm.) Successful dosage of tumors with adequate biopsy (not aspiration), followed for sufficiently long periods of time, has not been found in the medical literature. Sosman (63), Doub, Hartman and Mitchell (21), and Kleinberg (43) have had the courage to report poor results with roentgen therapy.