Extraosseous Sites Research Articles

Myeloma cells exhibit an increase in proteasome activity and an enhanced response to proteasome inhibition in the bone marrow microenvironment in vivo

The proteasome inhibitor bortezomib has a striking clinical benefit in patients with multiple myeloma. It is unknown whether the bone marrow microenvironment directly contributes to the dramatic response of myeloma cells to proteasome inhibition in vivo. We have used the well-characterized 5TGM1 murine model of myeloma to investigate myeloma growth within bone and response to the proteasome inhibitor bortezomib in vivo. Myeloma cells freshly isolated from the bone marrow of myeloma-bearing mice were found to have an increase in proteasome activity and an enhanced response to in vitro proteasome inhibition, as compared with pre-inoculation myeloma cells. Treatment of myeloma-bearing mice with bortezomib resulted in a greater reduction in tumor burden when the myeloma cells were located within the bone marrow when compared with extra-osseous sites. Our results demonstrate that myeloma cells exhibit an increase in proteasome activity and an enhanced response to bortezomib treatment when located within the bone marrow microenvironment in vivo.

Peripheral clear cell variant of calcifying epithelial odontogenic tumor affecting 2 sites: report of a case

A case of clear cell variant of calcifying epithelial odontogenic tumor (CEOT) affecting 2 different extraosseous sites is described. A 43-year-old female patient presented with 2 gingival lesions (1 in the upper premolar and 1 in the lower incisor area), which were clinically diagnosed as inflammatory hyperplasia and surgically removed. Microscopically, both lesions were composed of polyhedral cells (some with clear cytoplasm); hyaline material and areas of calcification were also observed. The diagnostic hypotheses raised were clear cell variant of CEOT, hyalinizing clear cell carcinoma, and renal metastasis. The hyaline material was positive for Congo red, crystal violet, and Lugol's iodine stains, but negative for Coomassie blue; the clear cells showed positively stained granules with PAS stain. Based on these results, the conclusive diagnosis for both lesions was clear cell variant of CEOT. No evidence of recurrence was observed after 1 year of follow-up.

Increasing Wnt signaling in the bone marrow microenvironment inhibits the development of myeloma bone disease and reduces tumor burden in bone in vivo

There is increasing evidence to suggest that the Wnt signaling pathway plays a critical role in the pathogenesis of myeloma bone disease. In the present study, we determined whether increasing Wnt signaling within the bone marrow microenvironment in myeloma counteracts development of osteolytic bone disease. C57BL/KaLwRij mice were inoculated intravenously with murine 5TGM1 myeloma cells, resulting in tumor growth in bone and development of myeloma bone disease. Lithium chloride (LiCl) treatment activated Wnt signaling in osteoblasts, inhibited myeloma bone disease, and decreased tumor burden in bone, but increased tumor growth when 5TGM1 cells were inoculated subcutaneously. Abrogation of beta-catenin activity and disruption of Wnt signaling in 5TGM1 cells by stable overexpression of a dominant-negative TCF4 prevented the LiCl-induced increase in subcutaneous growth but had no effect on LiCl-induced reduction in tumor burden within bone or on osteolysis in myeloma-bearing mice. Together, these data highlight the importance of the local microenvironment in the effect of Wnt signaling on the development of myeloma bone disease and demonstrate that, despite a direct effect to increase tumor growth at extraosseous sites, increasing Wnt signaling in the bone marrow microenvironment can prevent the development of myeloma bone disease and inhibit myeloma growth within bone in vivo.

Cytologic diagnosis of Ewing sarcoma/peripheral neuroectodermal tumor with paired prospective molecular genetic analysis

Ewing sarcoma/peripheral neuroectodermal tumor (EWS/PNET), since its characterization immunophenotypically and cytogenetically, has emerged as one of most common sarcomas of childhood. Currently, it is recognized that EWS/PNET can occur in any number of extraosseous sites and is one of several distinctive tumor types with an EWS translocation. In the past, the pathologic diagnosis of EWS/PNET relied on an open biopsy with the application of various ancillary studies, ranging from periodic acid-Schiff stain to molecular testing, but the tumor increasingly is diagnosed on the basis of cytologic specimens alone. The authors report 3 cases of EWS/PNET in patients aged 11 years to 53 years. These 3 patients had tumors that involved the parotid gland, cervical soft tissue, and pelvis, and were diagnosed by cytologic evaluation of fine-needle aspiration (FNA) biopsy material alone. The FNA materials also were evaluated prospectively by fluorescence in situ hybridization and/or reverse transcriptase-polymerase chain reaction. The results emphasized the diagnostic utility of FNA biopsy material for morphologic and molecular analysis without compromising conventional cytologic and immunocytochemical analysis, and that prospective molecular testing of FNA specimens has utility in routine practice although it is subject to many of the same limitations that impact molecular analysis when applied to conventional tissue biopsy specimens. The current results demonstrated that molecular genetic techniques can provide clinically useful ancillary information for FNA specimens when cytologic features and/or immunophenotype are equivocal on the basis of limited sampling or secondary changes, such as hemorrhage and/or necrosis.

Primary isolated extramedullary plasmacytoma of colon

BackgroundExtramedullary plasmacytoma is an uncommon entity that most commonly involves nasopharynx or upper respiratory tract. Involvement of the gastrointestinal tract occurs in approximated 10% of cases. Isolated primary plasmacytoma of colon is rare and only 7 well documented cases have been reported in the literature.Case presentationWe present a case of 42 year male who presented with diarrhea. Multiple colonic strictures were found on investigation. Colonoscopic biopsy was not helpful in making any specific diagnosis. Patient underwent subtotal colectomy. Isolated primary colonic plasmacytoma was found on histopathological examination.ConclusionPlasmacytoma is known to occur in extra osseous sites. Primary colonic plasmacytoma, however, is a rare clinical entity. Primary colonic plasmacytoma may have varying clinical presentations including multiple colonic strictures that may mimic colonic tuberculosis or inflammatory bowel disease. Although these cases are rare, treating physician as well as radiologist, and pathologist should be aware of this entity.

Zoledronic Acid Treatment at Home: Safety Data from an Observational Prospective Trial

To prospectively assess feasibility, side effects, and safety of a home treatment with zoledronic acid in patients with bone metastases confined to home. Forty-two patients with bone metastases (15 males and 27 females; mean age, 72 years; range, 48-86), confined to home because of functional impairment or low performance status, were enrolled into the trial. They were included in a comprehensive program of home care, and were treated with zoledronic acid, 4 mg. Primary end point of this observational trial was the safety assessment of the treatment at home; secondary end points were the clinical assessment of the time to treatment discontinuation and the definition of a pattern of patients who could benefit by a home treatment with intravenous bisphosphonates. Nineteen patients had breast cancer; 7, multiple myeloma; 5, non-small-cell lung cancer; 4, renal cancer; 4, prostate cancer; 1, thyroid cancer; 1 non-Hodgkin's lymphoma; and 1 soft tissue sarcoma. On the whole, 220 home treatments were administered in 3 years, with a median of 4 administrations per patient (range, 1-28). Median time to treatment discontinuation was 130 days. The treatment was interrupted for worsening of the performance status in 30 patients (71.4%), length of the treatment greater than 24 months in 2 patients (4.8%), hypocalcemia in 1 patient (2.4%), renal failure in 1 patient (2.4%). No difference in median time to treatment discontinuation was observed among patients with breast cancer, multiple myeloma, or other tumors in univariate analysis. Multivariate analysis showed no prognostic significance for kind of tumor, age at the time of entering the trial, gender, and number of extraosseous sites of disease. No acute major side effects were observed during the treatment, and the treatment had to be interrupted for side effects in 2 patients (4.8%). One patient had jaw osteonecrosis some months after the treatment was stopped. The home treatment with zoledronic acid seems safe. The appropriate use of biphosphonates in such a new setting needs a criterion to identify the subset of patients with bone metastases confined to home who can really benefit by this treatment.

Giant cell tumor of the uterus: case report and response to chemotherapy

BackgroundGiant cell tumor (GCT) is usually a benign but locally aggressive primary bone neoplasm in which monocytic macrophage/osteoclast precursor cells and multinucleated osteoclast-like giant cells infiltrate the tumor. The etiology of GCT is unknown, however the tumor cells of GCT have been reported to produce chemoattractants that can attract osteoclasts and osteoclast precursors. Rarely, GCT can originate at extraosseous sites. More rarely, GCT may exhibit a much more aggressive phenotype. The role of chemotherapy in metastatic GCT is not well defined.Case presentationWe report a case of an aggressive GCT of the uterus with rapidly growing lung metastases, and its response to chemotherapy with pegylated-liposomal doxorubicin, ifosfamide, and bevacizumab, along with a review of the literature.ConclusionAggressive metastasizing GCT may arise in the uterus, and may respond to combination chemotherapy.

Osteosarcoma

Osteosarcoma is the most common primary tumor of bone, yet its absolute incidence among malignant tumors is low. Within its strict histologic definition, osteosarcoma comprises a family of lesions with considerable diversity in histologic features and grade. Its prognosis is dependent not only on these parameters, but also on its anatomic site. It may occur inside the bones (in the intramedullary or intracortical compartment), on the surfaces of bones, and in extraosseous sites. Information of diagnostic or prognostic significance has not been elucidated from studies of its cytogenetics. This review summarizes the anatomic and histologic variations of osteosarcoma and offers a schema for its subclassification.

Osteosarcoma

Osteosarcoma is the most common primary tumor of bone, yet its absolute incidence among malignant tumors is low. Within its strict histologic definition, osteosarcoma comprises a family of lesions with considerable diversity in histologic features and grade. Its prognosis is dependent not only on these parameters but also on its anatomic site. It may occur inside the bones (in the intramedullary or intracortical compartment), on the surfaces of bones, and in extraosseous sites. Information of diagnostic or prognostic significance has not been elucidated from studies of its cytogenetics. This review summarizes the anatomic and histologic variations of osteosarcoma and offers a schema for its subclassification.

Erdheim-Chester Disease of the Breast: A Case Report and Review of the Literature

Erdheim-Chester disease (ECD) is a rare xanthomatous non-Langerhans cell histiocytosis which involves the marrow space of the long bones. Extraosseous sites most commonly affected include the eyes, lungs, pituitary glands, and kidneys. We report the case of a 49-year-old woman who presented with palpable breast nodules, followed by progressive soft tissue and subcutaneous disease, and involvement of the long bones, dysarthria, and dysphagia. The histopathologic features and skeletal radiography findings are consistent with ECD. This case represents an unusual presentation, which led to delayed diagnosis, as ECD of the breast has been rarely reported. ECD should be considered in the differential diagnosis of histiocytoid breast lesions, including fat necrosis and histiocytoid invasive mammary carcinoma.

Extraosseous Ewings Sarcoma of the Tongue Initially Mistaken for Lymphoblastic Lymphoma: Keypoints in Diagnosis

Background. Ewings sarcoma typically presents as a bone tumor and less frequently at extraosseous sites. When presenting at unusual extraosseous sites, these peripheral primitive neuroectodermal tumors may be mistaken for other small round cell tumors.

Complete response of bone-only metastatic breast cancer to skeletal: Targeted radiotherapy with 166HOLMIUM-DOTMP

569 Background: The skeleton is the most common and sometimes the only site of metastatic disease in breast cancer. We tested the feasibility of using 166Ho-DOTMP, which localizes to bone surfaces to deliver targeted high-dose radiation to bone metastases and the adjacent marrow. Patients received autologous stem cell infusions to restore hematopoiesis. Methods: Six women < 65 years old with breast cancer and bone-only disease participated in the study. They had received a median of 2.5 prior chemotherapy or hormonal treatment regimens. Five patients had stable disease and one patient had progressive disease before the high-dose radiation. A 30-mCi test dose of 166Ho-DOTMP was given to assess skeletal uptake; if uptake was adequate, a therapeutic dose estimated to deliver 22 Gy (n=3) or 28 Gy (n=3) was prescribed. Treatment was followed by autologous stem cell transplantation when the ongoing radiation dose to the marrow was < 1 cGy/hour. Results: 870–2065 mCi 166Ho-DOTMP dose was administered.? All subjects showed prompt trilineage hematologic recovery. The most common toxicity was mild nausea. None of the patients experienced grade 3–4 acute toxicity other than the expected myelosuppression. Two patients developed hemorrhagic cystitis 2 years after therapy, which resolved in both patients. One of these patients also had gastrointestinal bleeding and pseudomembranous colitis. One subject develops myelodysplastic syndrome but had trisomy 8 before treatment. Two patients remain progression-free without evidence of disease (complete response) for more than 5 years after study entry; 4 experienced disease relapse (all at extraosseous sites), and died of progressive disease. Median time to progression was 10 months. Conclusions: 166Ho-DOTMP had an acceptable toxicity profile, and two of the six heavily pretreated patients achieved sustained complete response. A phase II study is planned to evaluate the efficacy of this strategy for treatment of bone metastases. No significant financial relationships to disclose.

Targeted Radiotherapy to the Skeleton Using 166Ho-DOTMP with Autologous Stem Cell Transplantation for Patients with Bone-Only Metastatic Breast Cancer.

The skeleton is the most frequent site of metastatic disease in breast cancer, involving cortical and trabecular bone with or without extension into adjacent bone marrow. A subset of breast cancer patients develop bone dominant disease without metastases to other organs over a prolonged period of time. An attractive strategy is to utilize bone targeted radiotherapy to address this site of disease with minimal systemic toxicity. This study was designed to determine the safety and preliminary efficacy of 166Ho-DOTMP, which localizes to bone providing radiation to adjacent marrow and malignant cells. The limiting toxicity is myelosuppression, which can be overcome by autologous stem cell transplantation. We studied this strategy in subjects with breast cancer metastatic to confined to the bone.Treatment occurred between 1997 and 1999. Subjects were eligible if they were <65 years of age, had bone only disease, had an estrogen receptor negative tumor or had failed hormonal therapy. A 30 mCi tracer dose was administered to assess targeting and to allow the therapeutic dose to be calculated.If uptake was adequate, a therapeutic dose was to be administered in one of 2 dose levels, receiving 22 Gy (n=3) or 28 Gy (n=3). Treatment was followed by autologous stem cell transplantation when the ongoing radiation dose to marrow was <1 cGy/hour. The 6 subjects received a median of 1548 mCi (range 870 2065 mCi) of 166Ho DOTMP. There was selective uptake in the bone, particularly in sites of osteoblastic metastases, with unbound drug cleared into the urine. The most common toxicities seen during active treatment were mild nausea and vomiting. None of the patients experienced grade >3 acute toxicity aside from the expected profound myelosuppression. All subjects treated in the trial had prompt trilineage hematologic recovery post transplant. Two patients developed hemorrhagic cystitis at approximately two years following therapy which resolved in both patients. One of these patients also had GI bleeding and pseudomembranous colitis unrelated to the 166Ho DOTMP treatment. One subject developed MDS, but was found to have a pre-existing trisomy 8 by FISH analysis from the peripheral blood stem cell product collected prior to treatment on this study. Two patients achieved complete remission and remain progression-free over 5 years following study entry. Four relapsed and died of progressive disease; all recurred in extraosseous sites with two also having disease in the bone marrow. Median time to progression was 10 months.Conclusions: Treatment with 166Ho DOTMP delivers targeted radiotherapy to the skeleton with an acceptable toxicity profile. Two of 6 patients with bone-only metastases achieved sustained complete responses. Further studies are warranted to evaluate this strategy for treatment of bone metastases.

Spectrum of imaging findings in abdominal extraosseous myeloma.

Extraosseous multiple myeloma is rare (< 5%) and has not been systematically documented in the abdomen. Our aim is to catalogue and describe the manifestations of multiple myeloma affecting abdominal organs. Extraosseous myeloma may involve multiple abdominal organs and may mimic other malignancies. Clinicians and radiologists should be aware of the potential for myeloma to involve extraosseous sites to avoid unnecessary interventions when this occurs.

Grafting RGD containing peptides onto hydroxyapatite to promote osteoblastic cells adhesion.

Ceramics possess osteoconductive properties but exhibit no intrinsic osteoinductive capacity. Consequently, they are unable to induce new bone formation in extra osseous sites. In order to develop bone substitutes with osteogenic properties, one promising approach consists of creating hybrid materials by associating in vitro biomaterials with osteoprogenitor cells. With this aim, we have developed a novel strategy of biomimetic modification to enhance osseointegration of hydroxyapatite (HA) implants. RGD-containing peptides displaying different conformations (linear GRGDSPC and cyclo-DfKRG) were grafted onto HA surface by means of a three-step reaction procedure: silanisation with APTES, cross-linking with N-succinimidyl-3-maleimidopropionate and finally immobilisation of peptides thanks to thiol bonding. Whole process was performed in anhydrous conditions to ensure the reproducibility of the chemical functionalisation. The three-step reaction procedure was characterised by high resolution X-ray photoelectron spectroscopy. Efficiency of this biomimetic modification was finally demonstrated by measuring the adhesion of osteoprogenitor cells isolated from HBMSC onto HA surface.

Soft tissue uptake on 99mTc methylene diphosphonate bone scan imaging: pictorial review.

99mTechnetium methylene diphosphonate (MDP) bone isotope may accumulate in many extra-osseous sites due to a variety of both benign and malignant conditions. This finding on a bone scan can be crucial to the diagnosis and may not be apparent in other imaging or the clinical evaluation of the patient. We present a pictorial review sampling some of the many causes of extra-osseous 99mTc MDP accumulation.

Metastatic pattern and DNA ploidy in stage IV breast cancer at initial diagnosis. Relation to response and survival.

Sixty-nine patients with metastatic breast cancer (MBC) at initial diagnosis were analyzed to verify if metastatic pattern and clinical outcome are related to DNA ploidy determined by flow cytometry (FCM). Characteristics of 55 fully evaluable patients were as follows: median age: 61 years; postmenopausal: 75%; bone-only metastases (BM): 60%; extraosseous-only metastases (EM): 40%. Overall response rates (CR + PR) obtained with different chemotherapies and/or hormonal therapies were 58% and 68% for patients with BM and EM, respectively. Sixty percent of specimens resulted aneuploid, and the mean coefficient of variation of the complete series was 5.1%. In the whole group of patients DNA ploidy of primary tumor did not predict the metastatic pattern and had no influence upon response to treatment, duration of response, time to progression, and overall survival. When analyses were carried out according to metastatic pattern, those patients with BM showed similar results. However, within the group with EM, those with diploid tumors presented a significantly better survival (median 18 vs 13 months, p = .04). FCM-DNA analysis seems to identify a subgroup of patients with poor prognosis constituted by those who had aneuploid primary tumors and metastases to extraosseous sites.

Effect of demineralized bone powder on osteoblast-like cells in culture: A potential rapid quality control assay

Demineralized bone powder (DBP) has been shown to induce osteogenesis in a variety of bone defects and extra-osseous sites. Previous investigations have been carried out in animal models which are time-consuming and expensive. We studied the effect of DBP on well-established populations of osteoblast and non-osteoblast-like cells in culture to establish an inexpensive, efficient and reliable assay for bone induction. DBP and BP (non-demineralized powder), of particle size 38–53 μm, were prepared from rat long bones. ROS (rat osteosarcoma) 17/2.8 and ROS 24/1 cell lines were subcultured weekly. For both 17/2.8 (well differentiated) and 24/1 (poorly differentiated) cells, proliferation, i.e. cell count, was significantly greater in DBP enriched medium when compared with control or medium with BP. Cell counts for wells with BP were no different from controls. The increased cell count in DBP-enriched medium was significant on days 2–5 (peak effect 2–3 days). Alkaline phosphatase production reached peak levels after day 3 when proliferation was beginning to taper off. In this study a consistent increase in osteoblast proliferation and alkaline phosphatase production under the influence of DBP was demonstrated. The tissue culture assay for proliferation must now be correlated with bone induction in vivo, In future, the method may be useful for investigating the mechanism of bone induction.

Growth of bone marrow cells on porous ceramics in vitro.

Following the transplantation of bone marrow cells to extra-osseous sites, bone formation occurs in those sites. This osteogenic potential of bone marrow cells might be utilized for filling defects in bone if they could be transported on porous ceramic materials. Before such an approach becomes feasible, it is important to know what happens to the cells in the presence of the ceramics that might be used. In order to investigate the interaction between bone marrow cells and ceramics, in vitro, a system for culturing bone marrow cells on ceramic materials has been developed. Bone marrow cells adhered well to the surface of calcium hydroxyapatite and tricalcium phosphate ceramics, and this was followed by the formation of fibrous tissue on and within the ceramics. These ceramics were compatible with bone marrow cells even in culture conditions in which there was a large surface area of ceramic interfacing with cells. The results support the proposal that calcium hydroxyapatite and tricalcium phosphate are appropriate as bone replacement materials. In contrast, calcium aluminate had an adverse effect on bone marrow cells when there was a high proportion of ceramic to culture medium. However, this effect was not present if the proportion of ceramic to culture medium was low. Therefore, a large amount of biodegradable porous calcium aluminate ceramic should not be used as an alternative to autogeneous bone grafting.

Bone deficit in ovariectomized rats. Functional contribution of the marrow stromal cell population and the effect of oral dihydrotachysterol treatment.

This study investigates the proliferative and osteogenic role of marrow stromal/osteoprogenitor cells in the development of the cortical bone deficit in ovariectomized (OVX) female rats. In vitro, clonal growth of marrow stromal cells from OVX rats was significantly impaired (vs. sham-operated controls). Yet in vivo, cells from sham-operated and OVX rats had equal osteogenic potential in several in vivo experimental situations, such as in intraperitoneally implanted millipore diffusion chambers and in intramuscular implants of marrow plus osteoinductive bone matrix (composite grafts). Long-term (6 mo) dihydrotachysterol (DHT) treatment of OVX rats enhanced their in vitro proliferative potential and clonal growth, as well as their osteogenic expression in composite grafts. The observation that the in vivo osteogenic performance of OVX rat marrow stromal cells was normal at extraosseous sites suggests that the mechanisms leading to osteopenia may involve an abnormality in cell-matrix interactions.