Small Amounts Of Tumor Tissue Research Articles

IMT-1 PROS AND CONS OF SURGICAL INTERVENTION FOR DIFFUSE MIDLINE GLIOMA AIMED AT DENDRITIC CELL IMMUNOTHERAPY

Abstract Since a diffuse midline glioma (DMG) has no effective therapy, it is an urgent need to develop new therapeutic strategy. We performed immunotherapy using fusions of autologous dendritic cells (DC) with tumor cells in DMG cases in which tumor tissue was collected by surgery aimed at biopsy, and evaluate the effectiveness and examine the pros and cons of surgical intervention against DMG. Among the patients with basal ganglia or brain stem tumors received surgery at our hospital, 5 adult cases of DMG with H3K27M gene mutation were registered. All patients received radiation therapy and temozolomide chemotherapy. 4 cases received bevacizumab chemotherapy when the patients had recurrence or progression of the disease. The tumor-fused DCs (TFDC) were made by DCs induced from autologous peripheral blood mononuclear cells and tumor cells established from surgical specimens. They were injected subcutaneously into the neck 3 ~ 6 times in a 14 ~ 28 day cycle as the immunotherapy. The adverse events, PFS, and OS were evaluated. A transient complication of facial numbness was observed in one case on right after surgery. Although two patients had CR in those therapies, both of them died of disease (OS at 18 and 32 months, respectively). Since the remaining three cases were registered very recently, adverse event or treatment efficacy judgment have not been determined at the time of submission of the abstract. Serious surgical complications have not been observed in the presented cases. Surgery may be acceptable for DMG as long as the surgery is performed by sufficiently experienced surgeon in an appropriate environment. The TFDC immunotherapy, which can be performed only by collecting a small amount of tumor tissue, expects to be a novel treatment for MDG. In this presentation, the pros and cons of surgical intervention aimed at TFDC immunotherapy for DMG will be examined.

The utility of cytology in the diagnosis of adenocarcinoma lung: A tertiary care center study.

Introduction:Pulmonary adenocarcinoma harbors various molecular abnormalities that include epidermal growth factor mutation, anaplastic lymphoma kinase gene re-arrangement, K-RAS mutations. The availability of targeted therapy against these molecular markers has revolutionized personalized medicine. Accurate cytological diagnosis of pulmonary adenocarcinoma will aid in utilising the cytology smears for molecular testing.Objective:The objective of this retrospective study was to evaluate the diagnostic efficacy of various cytology samples in the diagnosis of pulmonary adenocarcinoma.Materials and Methods:The study included a retrospective case series of 50 patients with biopsy proven non small cell lung carcinoma of adenocarcinoma subtype. The corresponding cytology reports of all the 50 cases were analyzed for different samples including broncho-alveolar lavage (BAL), bronchial washings, bronchial brush smears, pleural fluid, sputum and guided fine needle aspiration cytology (FNAC) of lung and metastatic lymph nodes. The overall cyto-diagnosis efficacy as well that of various cytological samples were analyzed.Results:Multiple cytology samples were received in 14 of 50 cases. The overall diagnostic efficacy of the various cytology samples in the diagnosis of malignancy was 78% and 66.6% cases were accurately typed as non small cell lung carcinoma-adenocarcinoma. The best cytological sample for the detection of pulmonary adenocarcinoma was bronchial brush smears which had a detection rate of 70%. In fine needle aspiration cytology samples and bronchial washings the detection rate was 65.5% and 25% respectively.Discussion and Conclusion:In cases where the cytological diagnosis is certain the tissue biopsies can be simultaneously tested for EGRF and ALK gene mutations. Repeat biopsies are often required due to small amount of tumor tissue or necrotic biopsies. Alternate use of cytological specimen for molecular testing can be done when a diagnosis of pulmonary adenocarcinoma is established.

Detection of Common Chromosomal Translocations in Small Round Blue Cell Pediatric Tumors

Recurrent and specific chromosomal translocations have been described in four pediatric sarcomas belonging to the small round blue cell (SRBC) group of tumors. Identification of mRNA chimeras using RT-PCR discriminates among alveolar rhabdomyosarcoma (ARMS), Ewing's sarcoma (ES/pPNET), synovial sarcoma (SS) and desmoplastic small round cell tumor (DSRCT); however, frequencies of these translocations are variable. We present a retrospective study comparing histological examination and occurrence of major chromosomal translocations to validate the diagnosis and to assess the frequency of these molecular markers in a group of 92 small round blue cell (SRBC) tumor samples from Hospital Infantil de Mexico. We tested a panel of RT-PCR assays to each RNA tumor sample from formalin-fixed, paraffin-embedded tumors to detect specific mRNA chimeras in 47 ES/pPNET, 19 ARMS, four SS, three DSRCT, and 19 other SRBC tumors. After excluding poor RNA quality samples, we found translocations in 17/31 ES/pPNET (54.8%), 10/19 ARMS (52.6%), 4/4 SS (100%) and 4/4 DSRCT (100%). We found disagreement in only three samples: one ES/pPNET and one embryonal rhabdomyosarcoma harbor a PAX3-FOXO1 translocation (for ARMS), and one neuroepithelioma harboring a EWS-WT1 (for DSRCT). Unsuitable RNA was found in 20/92 samples (21.7%) and was related to necrosis, small amount of tumor tissue, and use of nitric acid in bone biopsies, but was not related to age of the block. We found a significantly lower occurrence of chromosomal translocations in ES/pPNET compared to reports from other groups. Differences may exist in the frequencies of these molecular markers among different populations.

Systemic antitumor immune response following reconstruction using frozen autografts for total en bloc spondylectomy

Background contextTotal en bloc spondylectomy (TES) is a surgery designed to achieve complete resection of a malignant spinal tumor, such as spinal metastasis. Although this procedure decreases the rate of local recurrence, it is questionable whether local control prolongs a patient's survival. In cryosurgery, antitumor immunity is activated after percutaneous cryoablation of tumors. We applied this tumor-induced cryoimmunology to TES surgery and developed a “second-generation TES” that brings about TES enhancing antitumor immunity to prolong a patient's survival. PurposeTo present a second-generation TES applied tumor-induced cryoimmunology and assess the immunity-enhancing effect after implementing this surgery. Study designThis is a retrospective review of prospectively collected data. Patient sampleThe sample consisted of 65 consecutive patients who underwent second-generation TES. Outcome measuresInterferon gamma (IFN-γ) and interleukin-12 (IL-12) before surgery and at both 1 and 3 months after surgery was used to assess the immunity-enhancing effect. MethodsIn second-generation TES, instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from TES are frozen using liquid nitrogen and used as grafted bone for spinal reconstruction. In the most recent 33 of the 65 cases, in addition to the TES procedure, a small amount of the tumor tissue from the resected tumor-bearing vertebra was also placed into liquid nitrogen. This small amount of tumor tissue was then implanted subcutaneously on one side of the axilla at the end of the TES surgery. In 60 of 65 cases, measurement of IFN-γ and IL-12 was performed. ResultsIFN-γ increased after surgery in 45 (75%) of 60 cases. The mean IFN-γ relative concentrations at both 1 and 3 months after surgery, as compared with before surgery, were significantly higher (284%±596% and 275%±354%: p<.05). IL-12 increased after surgery in 44 (73.3%) of 60 cases. The mean IL-12 relative concentrations at both 1 and 3 months after surgery, as compared with before surgery, were significantly higher (277%±385% and 486%±1032%: p>.05 and p<.01) at 3 months. At final follow-up, 13 of the 65 patients died due to progression of metastases (mean 12.6 months after TES), 15 remained free from disease, and 36 patients were alive with disease. ConclusionsThe second-generation TES using frozen tumor-bearing autograft inside a cage affords three benefits: (1) no pain at the bone harvest site, (2) shortening of operation time, and (3) decrease of blood loss. Moreover, our results show that second-generation TES provides not only a local radical cure but also a systemic immunological enhancement.

Detection of BRAF V600 Mutations in Metastatic Melanoma: Comparison of the Cobas 4800 and Sanger Sequencing Assays

Detection of BRAF V600 Mutations in Metastatic Melanoma: Comparison of the Cobas 4800 and Sanger Sequencing Assays

Increase of IL-12 following Reconstruction for Total En Bloc Spondylectomy Using Frozen Autografts Treated with Liquid Nitrogen

BackgroundTotal en bloc spondylectomy (TES) is a surgery designed to achieve complete resection of a malignant spinal tumor such as spinal metastasis. Although this procedure decreases the rate of local recurrence, it is questionable whether local control prolongs patient’s survival. We developed a “second-generation TES” that brings about TES enhancing antitumor immunity to prolong patient’s survival. Our purpose is to present a second-generation TES applied tumor-induced cryoimmunology and assess the immunity-enhancing effect after implementing this surgery.MethodsWe performed a retrospective review of prospectively collected data in second-generation TES as carried out in 56 cases. In second-generation TES, instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from TES are frozen using liquid nitrogen and used as grafted bone for spinal reconstruction. In recent 26 of the 56 cases, in addition to the TES procedure, a small amount of the tumor tissue from the resected tumor-bearing vertebra was also placed into liquid nitrogen. This small amount of tumor tissue was then implanted subcutaneously on one side of the axilla. In 52 of 56 cases, measurement of interleukin 12 (IL-12) was performed before surgery and at both 1 and 3 months after surgery.ResultsIL-12 increased after TES surgery in 38 of 52 cases (73.1%). The mean IL-12 relative concentrations at both 1 and 3 months after surgery, as compared to before surgery, were significantly higher (121±89 and 149±111%: P<0.05 and P<0.01).ConclusionsOur results show that second-generation TES may provide not only a local radical cure but also a systemic immunological enhancement. Further prolonged survival in patients with a malignant spinal tumor is promising by second-generation TES.

Cationic Liposomes as Non-viral Vector for RNA Delivery in Cancer Immunotherapy

This review presents the current status in the use of liposomes as non-viral vector for nucleic acid delivery in cancer immunotherapy. Currently, cancer treatment uses surgery, radiotherapy and/or chemotherapy. The search for new strategies to improve the efficiency of conventional treatments is a challenge, and biological therapy has emerged as a promising technique. Immunotherapy is a branch of biological therapy that uses the body's immune system to detect and destroy cancer cells. One immunotherapy approach is the activation of T lymphocytes from cancer patients by dendritic cells (DCs) loaded with tumor antigens. Among different antigens, mRNA coding the tumor antigens is advantageous due to its capability to be amplified from small amounts of tumor tissue, its safety because it is easily degraded without integrating into the host genome, and it does not need to cross the nuclear barrier to exert its biological activity. Nanotechnology is an approach to deliver tumor antigens into DCs. Specially; we review the use of nanoliposomes in the field of cancer therapy because cationic liposomes can be used as non-viral vectors for mRNA delivery. Aside from the promise of liposomes, the development of scalable processes and facilities to the use this individualized therapy is still a challenge. Thus, we also present the recent techniques used for liposome production. In this context, the integration between technological knowledge in the production of cationic liposomes and immunotherapy using mRNA may contribute to the development of new strategies for cancer therapy.

Abstract 802: Development and validation of a microRNA-based diagnostic assay for the classification of renal cell tumors.

Abstract Background: Renal cancers account for more than 3% of adult malignancies and result in more than 13,000 deaths per year in the US alone. The four most common types of kidney tumors include the malignant renal cell carcinomas: clear cell, papillary and chromophobe, as well as the benign oncocytoma. These histological subtypes vary in their clinical course and their prognosis, and different clinical strategies have been developed for their management. The differential diagnosis between the subtypes of kidney tumors based on morphology alone can be challenging, and is subjected to inter- and intra-observer variability. Even when utilizing immunohistochemistry (IHC) markers, the ability to differentiate between sub-types can be difficult, especially in the setting of uncommon morphology and biopsy sample with small amounts of tumor tissue. We present the development and validation of a microRNA-based test for classifying primary kidney tumors. Methods: 181 Formalin Fixed Paraffin Embedded (FFPE) samples from primary kidney tumors were collected and reviewed by pathologists from different institutes according to morphology and available IHC labeling data. High-quality total RNA, including the well-preserved microRNA fraction, was extracted from the FFPE samples using a proprietary protocol. Expression levels of hundreds of microRNAs were profiled using a custom microarray platform. Technical validation of the array results was performed using qRT-PCR. A diagnostic assay was developed using a K-nearest neighbor algorithm that searches for the 5 samples in the training database (181 samples used for assay development) that are most similar to the tested sample. The result for the tested sample is defined by a majority vote of the pre-determined subtypes of these 5 closest neighbors. A validation set of 201 independent samples was classified using the assay and analyzed blindly. Results: A set of 24 differentially expressed microRNAs were found to separate the four kidney tumor subtypes and were chosen as classifiers in the KNN algorithm. Clinical validation was performed using an independent, blinded sample set. The test was able to produce results for 92% of the validation set of 201 samples with accuracy of 95%. Conclusions: Expression levels of 24 microRNAs measured on a microarray platform were found to accurately differentiate the four main types of primary kidney tumors. These findings were the basis for the development and validation of a standardized diagnostic assay for the classification of renal cell tumors in FFPE samples from resections or biopsies. This assay can serve as a reliable diagnostic tool to aid physicians with the growing unmet need for kidney tumor classification. Citation Format: Robert Wassman, Brianna St. Cyr, Eddie Fridman, Iris Barshack, Yajue Huang, Sofia Zilber, Mats Sanden, Hila Benjamin, Noga Yerushalmi, Yael Spector. Development and validation of a microRNA-based diagnostic assay for the classification of renal cell tumors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 802. doi:10.1158/1538-7445.AM2013-802

Expression of cyclooxygenase-2 (COX-2) in an advanced metastasized hypopharyngeal carcinoma and cultured tumor cells

The inducible enzyme cyclooxygenase-2 (COX-2) catalyzes PGE(2) production and plays an important role in the progression of many solid cancers. However, the role of COX-2 expression in cervical lymph node metastases of head and neck cancer has not been clarified yet. We comment on a male patient aged 53 who was admitted to an ENT-department with acute bleeding from an advanced hypopharyngeal carcinoma and a frontotemporal mass. Prior to palliative intended radiotherapy, the metastasis was resected. During the procedure, a small amount of tumor tissue was harvested for primary tumor cell culture. COX-2 overexpression was demonstrated in the primary tumor tissue, the metastasis, in the cultured tumor cells by standard immunohistochemistry, as well as cytochemistry. A simultaneous expression of COX-2 in head and neck carcinoma was presented for the first time. Besides the prognostic impact in oral carcinogenesis, this COX-2 role of biomarker for aggressive head and neck squamous cell carcinomas should be further evaluated. Additionally, treatment of hypopharyngeal carcinomas with selective COX-2 inhibitors could be beneficial when administered in combination with radiochemotherapy.

Detection of EGFR mutations in samples with few cancer cells in non-small cell lung cancer (NSCLC) patients (p) and distribution of exon 20 mutations

8073 Background: Detection of EGFR mutations in advanced NSCLC p is very often limited by the small amount of tumor tissue. We developed a protocol to determine EGFR mutations in tumor samples containing less than 150 cancer cells. We also studied the distribution of EGFR mutations throughout tumor samples in p progressing after erlotinib treatment. Methods: Cancer cells were microdissected directly into PCR buffer and amplified by a nested PCR. This preliminary microdissection ensures that only cancer cells are collected. Exon 19 del were subsequently detected by sequencing and Genescan, and exon 20 (T790M) and exon 21 (L858R) mutations by sequencing and TaqMan assay. Results: We examined 268 samples of primary NSCLC having less than 150 cancer cells. EGFR gene status was assessable in 213 samples (79%); 45/45 fresh cytological specimens - pleural effusions, fine-needle aspirates, broncoalveolar lavages, sputum - and 168/223 paraffin-embedded samples. Samples having as little as 8 cancer cells were successfully amplified. Overall, 11.7% of p had exon 19 del and 5.6% exon 21 mutations. The presence of either mutation was predictive of the response to erlotinib. In p progressing to erlotinib, exon 20 mutation was detected in 6/15 p (40%) and was found more frequently in p harboring exon 19 del (5/9) than those with the L858R mutation (1/6). In the 6 p harboring the exon 20 mutation, the original mutation was homogenously present. However, in two cases, the exon 20 mutation could not be detected in some groups of cells or areas within the tumor. Conclusions: The protocol presented allows for detection of EGFR mutations in samples containing few cancer cells, thus widening the range of NSCLC p that can be analyzed. In addition, the distribution of the exon 20 mutation is frequently heterogeneous in mutated tumors from p progressing to erlotinib, suggesting that microdissection of several groups of cancer cells might be the most appropriate way to test for this mutation. E20 wt E20 T790M Primary mutation Del Exon 19 4 5 L858R 5 1 No significant financial relationships to disclose.

Fine-needle biopsy as a diagnostic technique for metastatic melanoma

Fine-needle biopsy (FNB) is a rapid, minimally invasive technique, widely used for the investigation and diagnosis of lesions in a variety of body sites. It is a procedure with high diagnostic accuracy for metastatic melanoma, with a sensitivity of 92.1% and a specificity of 99.2% in a recent large study. Although at present FNB has virtually no role in the initial diagnosis of pigmented primary cutaneous tumors, recent evidence suggests that it should be the first-line diagnostic modality for confirmation of clinically and/or radiologically suspected metastases in melanoma patients. As the specimen procured by FNB can be examined within minutes of performing the procedure, an on-demand FNB service with rapid communication of results to the patient's treating clinician enables a more efficient and cost effective approach to the multidisciplinary management of melanoma patients. In the future, it is likely that molecular analysis of very small amounts of tumor tissue obtained by FNB will provide an accurate estimate of prognosis and will facilitate selection of patients who may benefit from targeted molecular therapies.

A diagnostic tool for monitoring multidrug resistance expression in human tumor tissues

Studies on multidrug resistance (MDR) require a sensitive and quantitative assay of mRNA expression in clinical tumor samples. Based on the small size, heterogenity, and the possibility of partial degradation of clinical specimens, unambiguous data are often difficult to obtain. The aim of the present study was to develop a multiplex polymerase chain reaction (PCR) in combination with nested PCR for quantitative analyses of mRNA expression of MDR1, MRP (multidrug resistance protein), and DNA topoisomerase IIα in small amounts of tumor tissue. RNA samples extracted from the human cell line RPMI 8226 and its MDR sublines 8226/Dox6 and DOXint40c, that overexpress MDR1 and MRP, respectively, were used as model substrates. In the first step, cDNAs of the three genes as well as of the housekeeping gene β-actin were simultaneously amplified in single tubes using 20 cycles of PCR after random-primed reverse transcription. When necessary, a second amplification step of the preamplified PCR products was employed using nested primer pairs. Primer competition was evaluated by analyses of serially diluted amounts of cDNA and at different numbers of PCR cycles. Based on the results obtained, this multiplex/nested PCR approach may provide a base for quantitative analyses of MDR1, MRP, and topoisomerase IIα mRNA expression in clinical tumor biopsies.

Prognostic factors of prostatic carcinoma

The histological classification or typing of prostate carcinoma combined with histological grading according to Gleason or WHO with nucleolar subgrading are the most important prognostic factors in carcinoma of the prostate. Prostatic cancer is the most common malignancy in adult males and is the second-most-common cause of cancer death in the USA. The histological Gleason grade may be reduced if only a small amount of tumor tissue is present in the core needle biopsy, in contrast to the combined histological and cytological grading according to WHO with nucleolar subgrading. When there is sufficient carcinomatous tissue in the core needle biopsy, there is no difference from that in radical prostatectomy tissue, because most cases of prostatic carcinoma are highly malignant. DNA cytometry, immunohistochemical analysis with Ki67/Mib1 or molecular pathological studies with the tumor suppressor gene p53 or apoptosis suppressing oncoprotein bcl2 and the density of blood capillaries may be helpful as additional prognostic factors, but only together with the results of the primary histological section. For comparison of grading results with the international literature both grading systems should be used according to Gleason and WHO with nucleolar subgrading.

Genomic semi-automated cycle sequencing as a sensitive screening technique for p53 mutations in frozen tumor samples.

Single-strand conformational polymorphism (SSCP) is the most widely used method for p53 gene mutation screening. Nucleotide sequence analysis is considered more sensitive for detection of mutations. We established a genomic semi-automated cycle sequencing protocol suitable for p53 gene mutation screening. The technique was applied to 44 SSCP-negative frozen ovarian cancer samples: Eleven mutations (11/44, 25%) were found, 6 point missense mutations, 3 silent point mutations, 1 nonsense mutation and 1 single-base deletion. Heterozygous mutations were readily detectable. Genomic semi-automated cycle sequencing is a sensitive, time-effective screening method requiring only small amounts of tumor tissue.

Gastric cancer

Gastric cancer remains one of the most common causes of cancer mortality worldwide, despite a decline in incidence in Western countries. An important recent finding has been the recognition of an association between Helicobacter pylori and gastric cancer. The mechanisms, however, by which H. pylori infection and other environmental factors influence gastric tumorigenesis remain to be elucidated. The recent identification of growth factors and their receptors has provided insights into the regulation of cell growth, proliferation, and differentiation. Furthermore, studies of the effects and interactions of growth factors, oncogenes, and tumor suppressor genes on biological behavior of human gastric cancers are in progress and may aid in therapeutic decision-making. Fortuitously, molecular analysis requires small amounts of tumor tissue, which can be obtained from endoscopic biopsies. Regarding the treatment of gastric cancer, promising data on the use of neoadjuvant chemotherapy to increase surgical resectability have been obtained. However, locoregional failure continues to be the major obstacle and the addition of adjuvant intraperitoneal chemotherapy is specifically aimed at this problem. Novel therapeutic approaches are clearly needed in the management of advanced disease in view of the relatively poor results thus far with available compounds. Current Opinion in Gastroenterology 1993, 9:930-937

A review of cancer cachexia and abnormal glucose metabolism in humans with cancer.

In 1919, glucose intolerance became the earliest recognized metabolic abnormality in cancer patients. Prior to the development of severe malnutrition, colon, gastric, sarcoma, endometrial, prostate, localized head, neck, and lung cancer patients had many of the metabolic abnormalities of type II (noninsulin dependent) diabetes mellitus. These metabolic abnormalities include glucose intolerance, an increase in both hepatic glucose production (HGP) and glucose recycling, and insulin resistance. In a study of over 600 cancer patients, a diabetic pattern of glucose tolerance test was noted in over one-third of the patients. An increased rate of HGP, commonly seen in diabetics, has been noted in almost all types of cancer patients studied to date. Etiology of the increased glucose production in the cancer patient is not known, but abnormalities in the counter regulatory hormones, especially growth hormone, may contribute to the development of abnormal glucose metabolism. A second possible stimulus for the increase in HGP could be the glucose needs of the tumor. Abnormally high glucose utilization rates in small amounts of tumor tissue have recently been described. This suggests that small tumors may have large needs for glucose calories. An increase in anaerobic glycolysis in the tumor tissue can increase lactate production in the tumor-bearing human, thus supplying substrate to the liver to increase glucose production rates. In this paper, the nature of abnormal glucose metabolism in cancer patients is described.

A simple cell-suspension method for transplantation of V2 carcinoma.

A simple and rapid method for the preparation of an essentially monodispersed cell suspension from the rabbit V2 carcinoma, suitable for either large or small amounts of tumor tissue, did not require specialized equipment and yielded relatively large numbers of viable cells. Cell suspensions prepared by this method could be used to approximate a dose-response curve relating the percentage of tumor takes to the number of cells inoculated and could allow quantitative correlations not possible when macroscopic tumor fragments are used for implantation. The method, or slight modifications of it, should prove suitable for most tissues with a significant connective tissue component.

A Case of Recurrent Giant-cell Tumor of the Lower Right Radius

The patient whose case is reported, Miss L. Y., aged 37 years, stenographer, first consulted me on April 13, 1928. Her family history was negative for malignancy. The patient's general health had been good except for two fairly severe attacks of influenza, and paratyphoid about 1924. She had been extremely nervous and had had three or four “nervous breakdowns.” She had gained weight during the past year. Wassermann tests were consistently negative, and other laboratory examinations were negative. She had noticed a tumor at the lower end of the right radius for at least two years before I first saw her (Figs. 1, 2, and 3). The growth had been treated with X-rays and finally was operated upon elsewhere about the first of April, 1927, the growth being thoroughly curetted. Roentgenologic examination on October 21, 1927, seemed to show a recurrence (Fig. 4). When I saw her there was a tumor of the lower end of the right radius, appearing chiefly on the palmar surface (Figs. 5 and 6). The skin over it was stretched rather tightly and seemed to be quite vascular, though it was not definitely adherent to the growth. No axillary lymph nodes were palpable. On April 25, 1928, I operated, under local anesthesia, resecting the lower end of the right radius, with the immediately surrounding soft tissue, doing all of the dissection with the endotherm knife except that the bone was divided with bone forceps. The block dissection included the adjacent tendons around the lower end of the radius. After removing this mass there appeared to be a small amount of tumor tissue between the tendons. This was dissected away with the endotherm knife. The head of the metacarpal bone of the thumb was removed with forceps. The bone after division was immediately cauterized with the coagulation current. Histologic examination showed a typical giant-cell bone tumor. There were many giant cells and a stroma of spindle cells and connective tissue. The tumor was rather cellular. There were no mitotic figures (Fig. 7). The patient made a satisfactory recovery, the wound healing without infection. Roentgenologic examination May 15, 1929, showed no evidence of recurrence (Fig. 8). On May 16, 1929, I operated upon her again for reconstruction of the right wrist, the operation being done under ethylene anesthesia. The stump of the radius was exposed, and the tip of it cut off with bone forceps. The lower ulna was exposed for about four inches, and divided with bone forceps about one and one-half inches from its end. With the electric drill the distal end was hollowed out, and the proximal end of the radius was drilled. A bone peg was cut with the electric saw from the ulna and made to fit into the distal fragment of the ulna and the proximal end of the radius as a medullary graft.