Diagnosis of bone tumors by aspiration

NEW SERIES, VOL. XIII

DIAGNOSIS BRADLEY L. COLEY,

AUGUST,

2

OF BONE TUMORS BY ASPIRATION* M.D.,

GEORGE S. SHARP,

M.D.,

AND EDWARD B. ELLIS

NEW YORK

I

T is a fact we11 recognized by those who have occasion to dea1 with the probIem of the treatment of bone tumors that a correct diagnosis is a matter of supreme importance. The treatment varies so wideIy in the different types of tumor, and in conditions simuIating tumor, that it is essentia1 that it be based on correct interpretation of the underlying pathoIogy. Granting that cIinica1 and roentgenographic evidence together enabIe us to make a correct diagnosis in the majority of instances, we are stiI1 faced with a considerabIe group of cases in which histoIogica1 evidence is essentia1 to avoid error. Up to the present time materia1 from tumors Iying beneath the skin or mucous membrane has generaIIy been obtained onIy by the use of direct surgica1 approach, i.e., by operative biopsy. The advantages and objections to this method have been stressed repeatedIy by various authorities and it is not within the scope of this report to discuss them. Insofar as the operative biopsy is considered in reIation to bone tumors, however, we fee1 that it must be regarded as a procedure not without risk. We do not advise it as routine, reserving it onIy for those few cases where the cIinica1 and roentgenoIogic diagnosis is uncertain and a prompt decision as to the nature of the process is imperative. While admitting that biopsy of bone tumors has, in numerous instances, resuIted badIy, chiefly owing to infection or fungation of tumor tissue through the biopsy wound, we beIieve that these bad resuIts can IargeIy be eIiminated by greater care *From

No.

I 93 I

the Department

and a more thorough understanding of the proper technique, and that its advantages its disadvantages. Another outweigh method of obtaining materia1 for histoIogica1 study wiI1 hereinafter be described. Histologica study of tissue aspirated from a series of cases with tumors has aIready been reported by Martin and EIIis. Their resuIts show that the information gained in this manner has been of unquestionabIe vaIue in estabIishing a diagnosis. The method they describe has certain definite advantages over the forma1 biopsy. Of these may be mentioned the simpIicity of the technique of obtaining the materia1 for study; the fact that it can be carried out in the out-patient or examining department with IittIe inconvenience to the that it permits of immediate patient; operation or radiation therapy without the Iapse of time necessary for wound heaIing, as is the case when a forma1 biopsy is and finaIIy that it obviates performed; hospitaIization and consequent expense to the patient. Certain theoretica disadvantages may be cIaimed for this method. For exampIe, in some cases no tissue is obtained at aspiration; in others, tissue ceIIs are obtained but they cannot be identified as tumor ceIIs. The possibiIity must be kept in mind that viabIe tumor ceIIs may be impIanted aIong the needIe tract; or that in the case of vascuIar tumors intratumora1 hemorrhage may resuIt, affording the opportunity for tumor ceIIs to become disIodged into the bIood stream and cause distant metastasis.

of Bone Tumors, Memo&I Hospital, New York. Read before the Orthopedic Academy of Medicine, April 20, 1931. 215

Section,

216

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et aI.-Bone

We have not seen instances of tumor impIantation aIong the tract of the needIe, or of dissemination of the tumor that could be attributed to the aspiration. Martin suggested that the aspiration method might have a fieId of usefulness in the diagnosis of bone tumors. AccordingIy, the Bone Department undertook this work in a series of cases, the resuIts of which form the basis of this report. ASPIRATION

TECHNIQUE

ADAPTED

TO BONE

TUMORS

We have incIuded the description of the actua1 method of biopsy by aspiration by Martin and EIIis. * There are severa points, however, in which the procedure differs from that used for soft part tumors. The seIection of the proper site for aspiration is more diffIcuIt in deepIy situated tumors than in those on the surface. Aside from the anatomica reIationships, centra1 tumors are frequentIy encountered in which the bony she11 may or may not be stiI1 intact. If radiographs show that it is broken at any point, it is advantageous to aspirate there. This was of particuIar importance in an aspiration of a tumor invoIving the neck of the femur. Radiographs showed that the cortex was broken on the upper side. With the proper position of the Iimb and angIe of the needIe, the procedure was reIativeIy simpIe and a diagnosis of osteogenic sarcoma was obtained from the smear. Novocaine infiItration of the skin and soft tissues is advisabIe before passing through to the deepIy seated bone tumors. Adequate infiItration renders the procedure practicaIIy without pain. A brief gas-oxygen anesthetic can be used if conditions warrant. It may be necessary in young or very nervous subjects. There are severa possibIe expIanations for the faiIure to obtain ceIIs. Some fibrous tumors, such as the osteogenic fibrosarcoma, may, by their texture, present great diff&Ity in aspiration. The * Biopsy by needIe puncture and aspiration. Ann.

Surg., gz: I6g--ISI, 1930.

Tumors

AUGUST, 1931

technique may be fauIty. It seems certain that practice is necessary in order to obtain a high percentage of positive resuIts. There are several methods of utiIizing the materia1 obtained. If there is but a minute amount of tissue, the smear is the only suitabIe one. In case Iayer pIugs of tissue in cyIindrica1 shape are expeIIed from the needIe, as may happen under idea1 conditions, a portion of the tissue may be hardened in formaIin and paraffin sections made in the usua1 manner. Many bone cases are extremeIy vascuIar and often yieId what appears to be onIy blood. We find that if the blood cIot is hardened and sectioned by the paraffin method tumor ceIIs are frequentIy demonstrable. In the majority of the cases cited two or more of these methods were used as checks on one another. The syringefu1 of bIood may be expeIIed through a few thicknesses of gauze which fIIters out floating particIes of tumor; these may then be transferred to gIass sIides and smeared or, if of sufficient buIk, may be hardened and sectioned. We have incIuded a series of 35 consecutive cases of bone tumors on which aspiration has been performed. In each instance we have tabuIated the cIinicaI diagnosis, the diagnosis from x-ray fiIms, and the report of the pathologist, based on the material aspirated. In addition, a high percentage of cases has been proved by the histologica report from gross materia1 obtained Iater either at operation or autopsy. It wiI1 be at once apparent that the smaI1 fragments secured by aspiration are often sufficient onIy to permit of the report that maIignant tumor ceIIs are present or absent. In other cases the type of tumor can be ascertained. The pathoIogist in many cases has been abIe to classify the tumor with striking accuracy. One of the fieIds of greatest usefuIness of this method Iies in the differentiation between chronic inff ammatory conditions and true tumors; for exampIe, in one instance the report of “fibrin and pus” was the deciding factor in diagnosis in the case of an unusua1 tumor of the phaIanx

NEW SERIES VOL.XIII. No. 2

CoIey, et aI.-Bone

of the thumb, about which we were most uncertain from cIinica1 and roentgenray examinations.

FIG. I. Paraffrn preparation

Tumors

American Journd

217

ure (Case XXIX) occurred when an aspiration diagnosis was made of osteogenic sarcoma and the Iater biopsy showed

of pIug of tissue obtained at aspiration.

Aspiration is adaptabIe to a11 types of bone tumors except those in which the tumor is deepIy situated and surrounded by a zone of norma bone through which the needIe cannot be made to penetrate. FortunateIy, the majority of such tumors are susceptible of diagnosis without biopsy (most frequent exampIes of this type are giant-ceI1 tumor, benign cyst, etc.). In a doubtfu1 case the surgeon may have to resort to an operative biopsy. As shown in TabIe I, of the 35 cases in which aspiration biopsy was performed, the tresuIt was checked by subsequent operative biopsy in 12 and by paraffin sections of formaIin-hardened cIot obtained at aspiration in 3. In Case xxx the aspiration diagnosis was not supported by the findings at a subsequent operative biopsy, the diagnosis at aspiration being osteogenic sarcoma and at operative biopsy metastatic adenocarcinoma. Another faiI-

of Surgery

Osteogenic sarcoma.

Case IV.

neurogenic sarcoma. In one case (XVII), the pathoIogist was unabIe to make a diagnosis. Six cases have been seIected from the series and are outIined briefly beIow in order to furnish a stiII better basis for a judgment of the advantages of this diagnostic procedure. ILLUSTRATIVE

CASES

CASE IV. J. Z. A white maIe of fifty-seven years was admitted to MemoriaI HospitaI November I I, 1929. The history started two months prior to admission with pain and sweIIing in the right shouIder which the patient attributed to a sprain. The swelling over the head of the humerus graduaIIy increased in size. Examination showed a we11 deveIoped and poorIy nourished man appearing chronicaIIy iI with marked Ioss of weight. There was a uniform sweIIing of the upper haIf of the right arm. In comparison with the Ieft arm the

218

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et al.-Bone

CoIey,

of Surgery

Tumors

TABLE Case

No.

~

Bone

Aspirated

~ Clinical

SCapUla

1

Diagnosis

Osteogenic

/

X-ray

sarcoma

I II

i

S. S.

~__ 111

I

Diagnosis

~

Malignant primary bone tumor

M. G.

I

I

Ilium

Thyroid carcinoma metastasis

Carcinoma tasis

Mandible

Giant-cell

Epulis

Humerus

Osteogenic

tumor

AUGUST, I 93I

metas-

Aspiration

Diagnosis

IOperative

“Spindle cell sarcomaDeriosteal or medullarv osteogenic sarcoma” “Malignant

“Typical

,

I -.

sarcoma

~ Primary

bone tumor

1

J.Z.

”

Phalanx

Question mation

Metatarsal

Malignant nlor

A. F. “1

L. w.

of in&mor tumor

Giant-cell

bone tu-

tumor

Medullary

malig-

nanttumor

ScapuIa

“II

epulis’

-_I

H.

“Fibrin and tuberculosis”

I “Malignant ’ classitied”

pus;

---

Osteogenic

Ilium

Thyroid carcinoma metastasis

Biopsy confirms aspiration diagnosis of tuberculosis

tumor--un-

No biopsy

sugdefi-

No biopsy

sarcoma

1 Osteogenic

sarcoma

“Tumor ceIIs present-type seen in benign giant-cell tumor unless clinically compatible would make no diagnosis”

No

biops,y

_‘.

D.

Mctastatic noma

carci-

“Looks like carcinoma-no of osteogenic

metastaticfeatures sarcoma”

maxilla

Tumor

of antrum

I Destruction

of bone

-carcinoma

P. v.

No biopsy

__

_I_

Superior

x

Par&n section of aspirated blood clot confirms by aspiration diagnosis (smear)

possibly

.I.

J.

aspiration

--~

Ilium

s.

IX

(from thyroid) conaspiration diagnosis

Biopsy coniirms diagnosis

sarcoma, sarcoma”

“Rare spindle cells. gesting sarcoma-no nite diagnosis”

J. W.

VllI

“Spindle cell i. e., osteogenic

section of blood clot confirms diagnosis bv aspiration (smea;) ”

Biopsy Iirms

N. M. I”

Diagnosis

’ Paralfin

tumor”

giant-cell

Biopsy

“Osteogenic sarcomaspindle cells-not a true bone former”

Biopsy confirms diagnosis

aspiration

_. XI

c

Osteochondrosarcoma

Ilium

Osteochondrosarcoma

Rib

Endothelial loma

mye-

Clavicle

Endothelial loma

mye-

c.

“ Masses of atypical cartilage-unable to tell whether chondrosarcoma or chondroma”

No biopsy

. . XII

1. G.

XlIl

A. Y.

..-

.~ XI”

Femur F. H.

1. Osteogenic coma 3. Myosarcoma

Endothelial Ioma

.i-

Endothelial loma

mye-

“Strongly suggests down endothelial Ioma”

my+

“Fibrin and pus-no mor cells present”

I’

Osteogenic

-!_

circumference was 8 cm. greater. The tumor was hard and not movabIe over the humerus. The arm had only slight motion and that was accompanied by pain. Paget’s disease of the bone was observed in the skuI1, Ieft femur and tibia. X-ray Report: “ FiIms of the skull, left femur, pelvis and tibia reveal characteristic features of Paget’s disease. Stereoscopic views of the Ieft shoulder girdIe revea1 the presence of the same process in the cIavicIe, scapula and humerus. In addition a Iarge area of bone destruction is noted in the upper third of the shaft of the Ieft humerus.” Aspiration Smear: “Osteogenic sarcoma, spindIe-cell type.” This diagnosis was confirmed by a paraffin preparation of the aspirated pIug of tissue obtained from the needle, as shown in the Zustration.

aspidiag-

. .

._ sar-

Paraffin section of rated tissue confirms nosis on smear

broken mye-

tu-

No biopsy . .

sarcoma

“Large tumor giant cellssuspect myosarcoma”

No biopsy -

CASE v. A. F. A white maIe of fifteen years was admitted to Memorial HospitaI August 9, 1929. The history started one year prior to admission when the Ieft thumb was sprained whiIe the patient was catching a basebaI1. There was intermittent pain, but not severe enough to cause the patient to favor the hand. However, one week ago abnormal motion was noted and an x-ray showed a pathological fracture of the first phaIanx of the Ieft thumb. Examination showed the Ieft thumb to be diffuseIy swoIIen throughout the middIe and proxima1 phaIanges. This was most marked at the dista1 end of the proximal phaIanx and it was here that abnorma1 painless motion was found. Clinical Diagnosis: Osteitis fibrosa cystica. X-ray Report: “There is a giant-cell tumor

NEW SERIES VOL. XIII,

Coley, et al.-Bone

No. 2

TABLE Case No.

Clinical

Bone Aspirated Superior

XY

maxilla

L. B.

of

an-

X-ray

American

Diagnosis

T

Destructive

tumor

sarcoma

Aspiration

Diagnosis

219

of Surgery

Operative

“Chondrosarcoma”

Biopsy Diagnosis

Biopsy confirms diagnosis

Primary mor

bone

tu-

Osteogenic

Ilium

Primary mar

bone

tu-

Bone -not istic

involvement character-

“Unable to diagnosis”

Clavicle

Primary mar

bone

tu-

Bone -not istic

involvement chuacter-

“Plasma cell my&ma most certain”

K.

Journal

(Continued)

Femur

XYI

s.

Diagnosis

Carcinoma trum

I

Tumors

“Malignant giant mar--relatively sensitive”

cell turadio-

aspiration

No biopsy

.‘_

X”ll

C. R

..

._

xwrr

S. B.

..

._ Sternum

XIX

c.

P.

Osteogenic

sarcoma

Osteogenic

sarcoma

“Chondrosarcoma drama”

Extensive struction

bone de-

“Malignant classified”

._ Rib

Multiple

--__ Femur

Osteogenic

xx

my&ma

P. z. XXI

hI.

G.

s.

-_ Metastatic noma

Skull P

.- __-__--

D. A

.___. Femur

XX,”

A. K

A. P xxvr

B. M. XX”,1

carci-

Endothelial loma

mye-

.-

Osteogenic

Rib

Chondrosarcoma

NO biopsy

Metastatic noma

carci-

“Carcinoma”

No biopsy

Endothelial loma

my*

Osteogenic

sarcoma

of bone

sircoma

“Tumor cells unclassified”

present-

“Cellular neoplastic genie ssrcoms”

osteo-

sarcoma”

“Osteogenic

.-

Sternum

Metastatic carcinoma

Right

Fibrosarcoma

xX,x

Chondrosarcoma

tibia

thyroid

M R.

No biopsy

Biopsy contirms diagnosis

aspiration

Biopsy confirms diagnosis

aspiration

“Chondrosarcoma”

No biopsy

Destruction

of bone

“Carcinoma”

No biopsy

Osteogenic

sarcoma

“Osteogenic

sarcoma”

Neurogenic sarcoma Grade I I. Aspiration failure

Metastatic nom*

carci-

“Osteogenic

sarcoma”

Metastatic adenocarcinoms. Aspiration failure

.Sacwiliac

G. G.

region

Osteogenic

-

I-

OS c&is

Extensive metastases in lungs and ribs

Metastatic carcinoma-primaryundetermined

L. B.

xxx,,

ssxcom&

-_

Rih

xxx,

-_

Sarcoma

._ of tibia ?

J. W.

._

-I-

Mandible

A. L.

Giant cell mandible

“Malignant tumor-most suggestive of metastatic carcinoma. but unwilling to diagnose on aspiration” “Very cellular, highly maIignant tumor-looks like endothelial myeloma”

Endothelial my&ma. opsy confirmation

“Chondrosarcoma”

Biopsy confirms aspiration diagnosis of osteogenic sarcoma (chondromyxosarcoma)

sarcoma

Metastatic sternum

tumor of “Malignant tumor . might be a thyroid tumor, spindle cell variety; some alveolar arrangements”

No biopsy

sacroma

Biopsy confirms diagnosis

._ I. A.

-Humerus

-I

Osteogenic

._ Osteogenic

sarcoma

No biopsy

Osteogenic

tumor

Carcinoma of thyroid with metastases

XXXIY

H. E. M.

No biopsy

.~

xxv,,* N. C.

XXX”

Malignant tumor suggests plasma cell my&ma

“Tumor cells presenttype not determined

._

P. M.

xxx

sarcoma”

No biopsy

carci-

Destruction

sarcoma

Fibula

I-

or chon-

..

osteogenic

Jaw

XX”

al- ’ No biopsy

tumor-w-

“Osteogenic

Biopsy section--“probably osteogenic sarcoma”

.I.

Metastatic n”ms

---

._

involvement character-

any

Metastatic noma

carci--

Skull

XXlll

Bone -not istic

sarcoma

-.

Ixx,,

make

“Ostrogenic

sarcoma”

Ei-

aspiration

-

of the distaI half of the proxima1 phalanx of the Ieft thumb with fracture, which does not invoIve the joint surface.” Aspiration: ApriI 2, 1930, showed fibrin and pus; no tumor.

Biopsy: culosis. CASE

ApriI

III.

was admitted

16, 1930, demonstrated

tuber-

M. A white maIe of seven years to MemoriaI HospitaI November

N.

220

American Journal of Surgery

CoIey, et aI.-Bone

1929. The history started six months 2% prior to admission with a toothache in the Ieft Iower jaw. The first moIar tooth was extracted.

FIG. 2. Smear of aspirated

CASE x. P. V. A white maIe of three years was admitted to MemoriaI HospitaI ApriI 29, 1930. The history started six weeks prior to admission with Iacrimation of the right eye and subsequent sweIIing of the right cheek without pain. Examination showed a moderate exophthalmos to be present without pupiIIary or retina1 changes. The right cheek was swoIIen and particuIarIy prominent over the zygoma where the tumor had bony hardness. The right

AUGUST, 1931

naris was compIeteIL- blocked. The oraI cavity was negative. X-ray Report: “The Ieft antrum is markedIy

materia1 demonstrating

Two months Iater the gum around the empty socket began to enIarge. In August, 1929, the tumor was excised and the wound heaIed quickIy. There was an immediate recurrence. Examination showed the Ieft Iower first moIar, bicuspid and canine to be absent and in their pIace was a Iarge, soft, purpIish tumor. X-ray Report: “We11 defined rarefaction in the Ieft mandibIe, as seen with epuIis.” Aspiration: November 26, 1929, typica giant-ceI1 epuIis, as shown in the accompanying Ilustration. Biopsy performed two weeks Iater confirmed this diagnosis.

Tumors

a typica

giant ceI1 epuIis. Case v.

cIoudy and its walls are irreguIar in outIine. The appearance suggests extensive invoIvement. Diagnosis: carcinoma.” Aspiration smear under gas oxygen showed, “osteogenic sarcoma-spindle ceIIs-not a true bone former.” Biopsy performed ten days Iater confirmed this diagnosis. CASE XII. I. G. A white maIe of twenty-six years was admitted to MemoriaI HospitaI September g, 1929. The history started three weeks prior to admission with a coId. When the physician was examining the chest at that time he noticed a Iump over the right eighth rib anteriorIy. Two weeks Iater a pIeuritic pain appeared in the region of the sweIIing. This pain was reIieved by strapping. On examination an ovoid tumor was found over the anterior end of the right eighth rib. It was approximately 4 cm. in diameter and had a sIightIy spongy texture. X-ray Report: “Extensive destruction of the anterior end of the right eighth rib is noted in this fiIm of the chest.”

NEW SERIES VOL. XIII,

No.z

CoIey,

et aI.-Bone

A spiration Smear: ” StrongIy suggests broken dou rn endotheIia1 myeloma.” A parafin section from the bIood cIot

Tumors

American

Journalof

at

aspiration

confirmed

this diag-

CASE xx. P. Z. A white femaIe of fifty-one years was admitted to MemoriaI HospitaI ApriI 4, 1930. The history started after an attack of inffuenza two years previousIy with pain in the right eIbow which extended up into the shaft of the humerus. Four months before admission pain appeared in the neck and later in the ninth and tenth ribs anteriorIy. Subsequent sweIIings appeared over right zygoma, right cIavicIe and third rib anteriorIy. Examination showed a poorly nourished femaIe in great distress with generaIized pains. There was externa1 evidence of tumors over the areas mentioned in the x-ray report. X-ray Study of Skeleton: “Bone destruction in Ieft fronta and parieta1 bones, dista1 end of right cIavicIe, sixth Ieft rib anteriorIy and right zygoma.” The tumor of the right zygoma was aspirated and a diagnosis of bIood and fibrin was made. Two weeks Iater the sixth Ieft rib was aspirated and a report of maIignant tumor, uncIassified, was made.

221

The section of the rib removed Iater showe:d considerable productive osteitis. The marro W was fiIIed in pIaces with pIasma ceIIs and wil:h

FIG. 3. Smear of aspirated materiaI from superior maxiIIa showing osteogenic sarcoma.

obtained nosis.

Surgery

the history myeIoma.

the

diagnosis

Case XI.

was pIasma

ceI1

For those who have not read the articIe by Martin and EIIis on Biopsy By NeedIe Puncture and Aspiration, we quote the foIIowing : Technique: The specia1 paraphernaIia required is an ordinary 18-gauge needIe 5 to IO cm. in Iength (which shouId be new and sharp) and a 20 C.C. Record syringe. For the preservation of the specimen glass slides and a specimen bottIe with IO per cent formaIin are needed. The skin at the site of the intended puncture is painted with iodine and a smaI1 area of skin infiItrated with I per cent novocaine. With a bistoury pointed scaIpe1 (No. I I Bard Parker bIade) a stab wound is made through the skin with the instrument heId at right angIes to the skin surface. This puncture of the skin faciIitates insertion of the needIe. An ~&gauge needle attached to a tightIy fitting Record syringe is then inserted and advanced sIowIy through the superficia1 tissues unti1 the point is feIt to enter the suspected neopIastic mass. Guided by

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et aI.-Bone

palpation with the disengaged hand, it is striking how readiIy a difference in consistence of the tissues can be felt as the needle enters a

FIG. 4. Biopsy preparation

showing histological

AUGUST, ,931

wiII be suddenIy drawn and splashed over the interior of the syringe, making its collection diffIcuIt. While the needIe is being advanced

similarity

mass of neopIasm. When the point of the needIe is felt to enter the tumor, the piston of the syringe is partIy withdrawn so as to produce a vacuum and the needIe sIowIy advanced I to 3 cm., depending on the anatomy and size of the tumor. Maintaining the vacuum, the needle is then withdrawn to the same distance and advanced again. This manipuIation may be repeated two or three times at the discretion of the operator, care being taken to maintain the vacuum when the needle is advanced or partIy withdrawn. Aspiration with the needIe at rest is not su&cient to draw tissue into the needIe in most cases. By advancing the needIe and aspirating simultaneously, a pIug of tissue is both forced and drawn into the needIe. Maintaining suction during partia1 withdrawa detaches the pIug of tissue aIready within the needIe. We have found this detail to be very essentia1. Before the needIe is compIeteIy withdrawn from the tissue, the piston must be sIowIy reIeased unti1 the pressure in the needIe is equaIized, or better stiI1, the syringe detached and the needIe withdrawn separateIy, otherwise the aspirated materia1

Tumors

to preparation

and withdrawn quantity G&G

obtained

by aspiration

under negative

of bIood

may enter

mixed

pressure,

with

the syringe,

in the

firmer

masses,

apparentIy remains empty, drawa1, the needIe is usuaIIy a pIug of tissue. After compIete withdrawa the syringe is detached from with air, attached and the needle sIowIy and carefuIIy sIide. A smaI1 fragment

a smaI1

fragments

of

or a soIid cyIin-

drica1 mass of tissue may appear. especiaIIy

method.

In other cases, the

sgringe

but after withfound to contain of the apparatus, the needle, fiIIed contents of the

expeIIed on a gIass

of tissue shouId be Ieft

on the sIide for smearing, and the remainder placed in the specimen bottIe for fixation and staining by reguIar methods. If the needIe is empty, smaI1 masses of tissue can aImost always be found mixed with bIood in the syringe, and these shouId, if necessary, be very carefuIIy searched for. One or two of these smaI1 masses can readiIy be fished out upon a gIass sIide for smearing and immediate staining. In any case where the syringe contains bIood or any tissue, formalin from the specimen bottIe

CoIey,

NEW SERIES VOL. XIII. No. 2

is poured agitated bottle.

into the open barrei and returned to

et aI.-Bone

of the syringe, the specimen

FIG. 3. Smear of aspirated material demonstrating LABORATORY

TECHNIQUE

In the preparation of the specimen for study we have foIIowed the technique described by Martin and EIIis and quote in fuI1 as foIIows: Preparation of the Specimen. In the average case, we have examined the material obtained by two methods: The shorter (a technique devised by one of us (E) has the advantage of a reading in six to eight minutes and the longer, the advantage of a fixed and cIeared preparation. The Immediate Method. The fresh tissue fragment on the gIass sIide is smeared by very firm ffat pressure by another slide drawn once across. The smeared &de is fixed by heating gently over a gas ffame until warm and dry, and is then prepared according to the foIIowing technique : I. AIcohoI (95 per cent)-one minute. minute. 2. Water-one minute. 3. Haematoxylin-one minute. 1. Water-one minute. 5. Eosin-one minute. 6. AIcohoI (95 per cent)-one-half minute. 7. CarboIxyIoI-one-haIf

Tumors

American

8. Mount with Canada gIass. Longer Method. The

Journal

balsam

and

remainder

broken down endotheIia1 myebma.

223

of Surgery

cover of

the

Case XII.

specimen is treated as any smaI1 biopsy, being carried through the stages of aIcoho1 fixation and embedding in paraffin, great care being taken to collect and mass every minute particIe of tissue, since a positive diagnosis may often be obtained from the smaIIest fragment. AbsoIuteIy fresh 42’ - 56”~. paraffin shouId be used for embedding, and a11 particles massed together on the bIook and cooIed immediateIy on ice. Every section cut from the bIock should be examined for fear that in deaIing with such small particles, one might lose the opportunity of making a positive diagnosis. We usuaIIy cut six to eight sections and place them on a singIe slide. These are carefuIIy exammed and further sections cut rf the first are negative and more materra remains on the bIock. In case a reading is desired earIier than by our routine Iaboratory technique, we use the foIIowing method of preparation which requires about three hours: The quick paraflin method: I. FormaIin IO per cent--ten minutes. 2. AIcohoI 95 per cent-two changes, ten minutes each. 3. XyloI--two changes, one-half hour each.

224

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CoIey,

et aI.-Bone

Tumors

AUGLW. 1931

changes, one-half 4. Paraffin 54’c.-two haulr each. (First three steps in incubator 37’c.) 5. Cut and stain.

operation or biopsy was the origina aspiration diagnosis found to be in error. This method is described with due appre-

FIG. fj. Aspiration

uncIassified.

smear reported

as maIignant

tumor,

Subsequent

biopsy was simiIarIg

reported.

Case XXII.

ciation of the dangers that may be inherent in its genera1 adoption. The possibiIities Biopsy by the aspiration method is of error, the necessity for seIection of of vaIue in estabIishing the diagnosis of cases for its use, and the unusua1 demands bone tumors. It has advantages over the pIaced upon the pathoIogist is reaching operative biopsy, but in our opinion wiI1 concIusions from a study of such a smaI1 never compIeteIy dispIace it. In those amount of tissue shouId be borne in mind. cases in which the diagnosis cannot be The Iatter consideration is the one which made, even after severa attempts, by is most IikeIy to Iimit its fieId of usefuIness. FinaIIy, the writers wish to express their the aspiration method, recourse can aIways be had to an operative biopsy. In those appreciation of the assistance given by cases in which the pathoIogist is unabIe the PathoIogicaI Department, Dr. Jamts Ewing, Director, and by Dr. Fred Steware, to differentiate the exact type of tumor present, it is of advantage to know whether upon whom devoIved the diffIcuIt task the condition is neopIastic or inff ammatory, of making most of the diagnoses from maIignant or benign. In onIy I case out aspirated materia1; and to acknowIedge of the 35 was the pathoIogist unabIe to their indebtedness to Dr. Martin at whose make a diagnosis and in onIy 2 cases out suggestion this work was commenced and who was personaIIy responsibIe for of 16 which were subsequentIy checked by paraffin sections of tissue removed at a number of the aspirations. CONCLUSIONS