Giant Cell Tumours of Bone.

NZMJ, 1926

By W. R. Stowe, M.R.C.S. and P. P. Lynch, M.B.

The urgent necessity for discrimination between benign and malignant neoplasms is stimulating research to a marked degree. It is impossible, in the present state of our knowledge, to draw a hard and fast line between the two. The following experience is illuminating in a small way:—

A.M., 31 years, presented himself for treatment of a protruding granulomatous mass based on the right pre-maxilla. The clinical and skiagraph evidence gave rise to the suspicion that the mass was not of a benign character. A skiagraph of the pre-maxillary region displayed the following features:—(1) A well-defined circumscribed mass of low density, the size and shape of a broad bean, on the right side. (2) On the left, an area of the same size in the malar bone, showing an entirely abnormal condition, of the osteitis fibrosa type. An osteoclastic process in the past had given place to the type of repair usual in such cases. The mandible, as far as the angle of the jaw, on each side showed the same degenerate quality of repair after a similar process of destruction. The rami are now attenuated, irregular in contour, and somewhat cystic in appearance.

At this stage the patient stated that all the teeth were removed from the lower jaw when he was nine years old (22 years ago), and that fifteen years ago the jaw was “X-rayed.” Fortunately the negative was still in existence. It shows loss of detail in the bone and a “furry” margin, such as was then considered typical of sarcoma of a lethal type. The tibia (left) was skiagraphed at the same time. I have a clear recollection of a uniformly thickened shaft of columnar type appearance, with ill-defined margins. The whole shaft was involved in a gross degenerative change, an active hyper-plastic condition.

To-day there is no sign of activity. Repair, of a very irregular nature, appears to be complete. Further investigation revealed a similar condition in the other tibia, both femora and pelvis.  The cranium and shoulder girdle are normal in appearance. The pelvic brim is deformed. The sacro-iliac region on both sides shows very gross changes.

In 1910 four other children of the same family were treated in a local hospital for neoplastic condition in the tooth-bearing area. In each case the clinical and pathological conclusion was “myeloid sarcoma.” Then it came to light on the husband’s statement that the mother, who died of pleurisy and pneumonia, had submitted to an operation for some pathological condition of the jaw. The following notes are copied from the hospital records:—

Donald M., aged 8 years; 15^th June, 1910.—Sarcoma of the lower jaw anterior master attachment. Bone soft and crackling. Glands of neck involved. Same both jaws. Glands removed. Bony growth cut out. Nuclei of new teeth found embedded in large cavities of bone.

Kathleen M., aged 10 years; May, 1910.—Epulis first molar, right lower jaw. Two teeth removed. Cut out edge of bone. Pathologist’s report:—“Myeloid sarcoma.”

Hugh M., aged 12 years; 28th July, 1910.—Hypertrophy and gingivitis. Removed carious right lower molar, left lower molar, and group of three teeth matted together in a cell nest over the site of the right lower canine. Bone round these teeth was very thickened, and, in view of family history, probably sarcomatous.

William M., aged 15 years; May, 1910.— Epulis pre-maxilla, sloughing. Teeth not carious. One carious stump, left lower jaw, removed with wedge of bone. Pathological report:—“Myeloid sarcoma.” Returned two months later with large sarcoma, right lower jaw—removed—very soft—and carious. Chiselled out, etc. Gland in sub-maxillary triangle removed (sarcomatous). Returned October, 1910. Area cut away from lower jaw on right side. This was myeloid sarcoma.

The family consists of eight boys and two girls. The five eldest, four boys and one girl, have never shown any sign of disease (father’s statement).

The other five were born, with one exception, at two-year intervals, approximately, and were all affected as described. All the ten are in average good health and able to perform such duties as rural life demands. The father has marked kyphosis. His health is good and his history has no apparent connection with the condition of the affected five. An endeavour to investigate the condition of the other children been unsuccessful. It is difficult to offer any acceptable explanation of this remarkable sequence of neoplasms in the tooth-bearing area in the same family. The evidence as a whole supports the hypothesis that there is an hereditary factor in all neoplastic conditions, that biological degeneration is to be expected in moribund strains.