PULSATING ANGIO-ENDOTHELIOMA OF THE INNOMINATE BONE TREATED BY HINDQUARTER AMPUTATION

Abstract

The infrequency of pulsating angio-endothelioma of bone appears to merit the publication of an individual case in a short note rather than its inclusion in a list of thirtythree personal interinnomino-abdominal (hindquarter) amputations wherein the case might more readily be overlooked. An appeal to the classical work of Ewing (l94 ) vouchsafes the information that the growth of endotheliomata tends to be slow but progressive, and thus they are comparatively benign. More particularly, by comparison with the carcinomata and sarcomata which they may resemble histologically, the course of endotheliomata is relatively favourable. When undisturbed by the knife the growth capacity of some of these tunlours seems to be confined within certain limits which do not apply to carcinoma and sarcoma. It is saiti that endotheliomata spread by local infiltration, principally along existing channels such as lymph vessels and spaces, while extension to neighbouring lymph nodes, if it occurs at all, is late. Such infiltration accounts for the difficulty of thorough extirpation and for the frequency of persistent local recurrence, each recurrence being apt to show an increasing capacity for growth. This fact encourages the belief that the appropriate treatment is complete removal of the organ involved anti not merely local extirpation of the tumour. Endothelioma of bone tends to replace pre-existing tissues with little or no increase in the size of the bone, but with perforations. Three types of bone endothelioma were distinguished by Ewing: 1) solitary, bulky telangiectatic angio-endothelioma; 2) multiple endothelioma of bone ; 3) diffuse endothelioma of bone. The solitary angio-endothelioma of bone, which is the type of tumour present in the patient now reported, affects adults and principally involves the long bones. It grows steadily, perforates and invades the soft tissues and may, as a late feature, metastasize to the lungs; it may pulsate and produce a bruit. Considerable variation in size may be observed ; it is usually painful and sometimes causes pathological fracture. The tumour consists of masses of large cuboidal cells in cords or pseudoalveoli enclosing freely circulating blood. Ewing also reminds us that a somewhat similar clinical and histological picture may be given by metastatic carcinoma of renal or adrenal origin, and that such a primary tumour must always be excluded in formulating the diagnosis. Other pulsatile osteolvtic tumours may occur in bone, such as telangiectatic osteogenic sarcoma and giant-cell tumour. Telangiectatic osteogenic sarcoma usually affects children and is characterised by exceedingly rapid growth anti early pulmonary metastases. Giant-cell tumour of bone, when vascular and pulsatile, may cause great difficulty in differential diagnosis, its growth being slow like the angio-endothelioma ; but usually the periosteum lays down a bony capsule which gives rise to characteristic radiographic appearances. Case Report-E. B., female, 42 years of age, was admitted to hospital on April 15, 1949, with a history that five months earlier she had noticed pain in the right hip, rather posteriorly, which persisted for a month. The pain was a dull ache, with an occasional sharper element, gradually spreatiing down the front of the thigh to the knee and from there to the front of the shirt and the toes. In the lower leg it tended to be a shooting pain, rather sharp like a knife. It came on particularly in the morning and was eased by rest. Lying on the right side Cause(i discomfort in the limb which prevented her from getting to sleep, but did not awaken her when she was once asleep. The pain made her limp. On exanzi,zation-There was a mass in the right iliac fossa exhibiting marked expansile pulsation which could be obliterated by compression of the aorta. A to-and-fro murmur