Trauma in malignant tumors of bone

TRAUMA

IN MALIGNANT

TUMORS OF BONE

BRADLEY L. COLEY, NEW

YORK,

NEW

M.D.*

YORK

A

REVIEW of the voluminous literature dealing with the question of injury as a causative factor in the development of malignant tumors in general and of bone tumors in particular Ieaves the reader convinced that from the mass of conflicting opinions and theories expressed it is difficult if not almost impossible to reach an unbiased conclusion. We are not concerned here with any of the so-called chronic irritations of occupation, such as chimney sweep cancer or mule spinner’s cancer. We are interested only in the reIationship of direct trauma as a theoretical causal factor in the deveIopment of sarcoma of the muscuIoskeIeta1 system. The question of whether a mahgnant bone tumor which deveIoped or was first recognized after an injury to the part was caused by said injury, is one that has been argued pro and con for many years. While in earlier times this was a matter mereIy of academic interest, with the advent of Workmen’s Compensation legislation and liability insurance the whole question has taken on great medicolega1 importance. Unquestionably the majority of those of the medica profession who conceded a causal relationship of injury to bone sarcoma have been cIinicians while the opponents of this view have, almost without exception, been pathoIogists. The trend of opinion in recent years has been to doubt the importance of a single trauma; those who still accept it are in the minority. After many years of experience in the field of bone tumors, the author must confess to an uncertainty of opinion and to a feeIing that the final answer has not as yet been provided. He does not hoId that a single injury cannot ever be a factor of etioIogic significance. He feels that a study of the histories of a large group of cases of bone sarcoma leaves one with the inescapable impression that in a high percentage of cases, 30 per cent in some types of tumors, recent local injury antedated the demonstrable appearance of the tumor. Does this have significance-was it merely a coincidence---or did the injury call the patient’s attention to a pre-existing tumor, i. e., traumatic determination (Ewing)? * Attending

Surgeon, Bone Tumor

Department,

300

hlemorial

Hospital.

COLEY--BONE

TUhlORS

301

ObviousIy it is human nature for the layman to ascribe a malignant tumor to an antecedent IocaI injury even though there may be no material gain or selfish interest at stake. On the other hand, everyone during the course of life sustains injuries some of which are of even greater severity than those cited as being responsible for a bone tumor. Therefore, injury cannot be regarded as the sole causative factor. The exceeding rarity of late sarcomatous development following so serious an injury as a major Iong bone fracture is an argument that has often been advanced by the opponents of the traumatic theory. We know of no case of bone sarcoma in the MemoriaI HospitaI records in which there is cIear evidence that it originated at the site of a simpIe fracture. In 1907, at the French Congress of Surgeons, Segond outlined certain conditions which he feIt must be fulfilled for the establishment of a causal reIationship between an antecedent IocaI injury and a subsequentIy deveIoping mahgnant tumor. They imply the folIowing: (I ) That there was a verified trauma, (2) that it was of sufficient severity, (3) that reasonable evidence existed of the integrity of the part prior to the injury, (4) that the site of the injury corresponded to that of the tumor, (3) that the tumor appeared at a date not too remote from the time of the accident to be reasonabIy associated with it, and (6) that the diagnosis was confirmed by clinical, roentgenographic and whenever possible, microscopic examination. These criteria have been wideIy accepted both in Europe and in America as a basis for adjudication of disputed cIaims. In actual practice, however, they are very seIdom verified and the fact that they exist is an incentive to a clever Iawyer or doctor who is IinanciaIIy interested in the case to “trump up” stories and manufacture evidence to conform to these criteria. Commentingspecificahy on criterium 2, i.e., sufficient severity of the trauma, this, we regard as most vague. Apparently no one knows how severe or trivia1 an injury must be to be regarded as the theoretical cause of a cancer. One aImost has to adopt as a working hypothetical possibiIity the theory that any trauma of any sort and of any degree of severity may cause any sort of cancer in any Iocation. In other words, there seems no clear w-ay to quantitate the amount of trauma that is necessary to cause cancer. It is worthy of note that in the majority of cIaims hled in the Compensation Courts of New York the injury to which the tumor was ascribed has been triviaI; seldom has there been any evidence of a major alteration of the part concerned.

COLEY-BONE

302

The injury

author

feels that

as a determining

decisions

have

been

evidence.

It is believed

TUMORS

in many factor

medicolegal

cases

in the past,

has been over-emphasized

rendered

on a flimsy

that the system

structure

and that of scientific

in vogue at present

whereby

medica expert testimony is given, is shocking in several particuIars and is rendered Iess vaIuabIe by the undeniabIe fact that the expert wouId not have been cahed by his side had his views not been known in advance

and his opinion

anticipated

as being

favorable.

Until

the present set-up is revised and a11 experts are cahed, empIoyed and recompensed by the Court rather than by the plaintiff or the defendant,

rea1 experts

of the present

In the interest to avoid shouId of

will shun

day wilI continue

of fair play, to assure

important

blanks

be the invioIate

a patient

medicoIega1

with

in the

ruIe that

a suspected

records certain pertinent facts. to what he attributes his tumor

cases

and the

evils

unabated. a complete

sequence whoever

sarcoma

clinical

of a given takes

history,

the initia1

shouId

set

record,

forth

it

history in the

First of a11 he should ask the patient and if the Iatter describes an injury,

he shouId then be asked whether the cause has been suggested to him by others. Proceeding with the history it shouId contain the foIIowing facts: (I) Date of injury, (2) nature and mechanism of injury, (3) site of injury, (4) subsequent manifestations of injury, e.g., ecchymosis, injury

sweIIing, tenderness,

in which these symptoms

subsidence of symptoms

of symptoms

disabiIity,

persisted,

(5) period foIIowing

and (6) interva1

and signs of injury

and

between

first recognition

or signs of tumor.

In addition a compIete clinica record should incIude roentgenograms of the part concerned taken as soon as possibIe after the injury as we11 as others taken subsequentIy. Aggravation. Th e provisions of the Workmen’s Compensation Iaws of many states presume that an injury is compensibIe which can

be construed

as having

aggravated

a pre-existing

mahgnant

tumor. Therefore, cIaims of aggravation are often made, and this, introduces a much more controversial issue. From what is known of the dissemination of maIignant ceIIs it is probabIe that direct trauma to the primary Iesion might be conducive to metastasis. However, the onIy experimental evidence on singIe trauma in tumors of known dissemination rate faiIs to support this view point, and the fact remains that malignant tumors do metastasize with or without IocaI trauma. It has seemed to the author that in a given case one wouId have to show that the cIinica1 course

of the

disease

had

COLEY-BONE

TUMORS

been

affected

adversely

303

by the

that it ran a much more rapid course than the average case.

Even

then

one

must

reaIize

that

there

is a great

variation

in the rapidity

of spread

and tota

tumors.

It wouId appear

therefore

that

if a sarcoma

to injury

the

circumstances

as having

existed

thereafter

wouId have to be exceptiona

prior

assume aggravation. Decisions in these accident or to the injured individua1

to the injured the

pIaintiff

or his famiIy.

medica

party

duration

testimony

which

natural

of maIignant were accepted of its course

entai1 severe

to the workman hardship

In an effort to avoid any possibIe

the doctor

i e.,

before one could justifiabIy

cases that are adverse

frequentIy

trauma,

untraumatized

to the injustice

is apt to Iet his sympathies he offers.

This

motive

color

seems

aIso

to influence the referee, the jury and sometimes even the judge. Yet as Steward has pointed out, this is no excuse for making awards in the face of incompetent medicine

to further

Stewart

evidence

his Notion

iIIustrates

or of using “supposedIy

of proper

the faulty

reasoning

scientific

socia1 behavior.” of the “supposed

expert”

as foIIows : “The same surgeon who wiI1 do a11 sorts of orthopedic jobs invoIving chiseIing into bone or insertion of such objects as ice tongs or pins or screws signs has caused his surgery severest

may

testify

that

an osteogenic

a bIow which

sarcoma,

aIthough

wiI1 do so nor has he ever warned

form

for a possibIe

of bone

trauma-a

sarcoma.”

are hard to refute. There are certain

Such

fracture-to arguments

bone processes

has Ieft no rea1 he never

a patient

with the

be on the bear

and benign

much

thinks Iookout

weight

and

Iesions in which the

roIe of trauma seems more difflcuIt to deny. Of these the most conspicuous is benign giant ceI1 tumor of bone. Considerable authoritative monIy

caused

opinion

uphoIds

by the effects

the theory of trauma.

that Many

this tumor patients

is com-

with giant

ceI1 tumor have been awarded compensation, and we beIieve rightIy so. On the other hand, it should be pointed out that pathoIogists who have had considerable experience in bone neopIasms are unconvinced that even in giant ceI1 tumor trauma is an important etioIogic factor. On rare occasions we find an osteogenic sarcoma associated with a previousIy incurred ossifying hematoma and in such instances it is diffIcuIt to dissociate the origin of the sarcoma from the injury which caused the ossifying hematoma, and yet the

304

COLEY-BONE

TUMORS

periostea1 hemorrhages of scurvy are apparently never the precursor of sarcoma. Certain cases of osteochondroma or chondromyxoma have been studied where injury has seemed to initiate a change in the type of tumor to that of chondrosarcoma and occasionaIIy unsuccessful extirpation of such a benign tumor has been folIowed by recurrence and a transition to fully malignant chondrosarcoma. Therefore we believe that injury may play an important part in such transition and as a preventive measure we advocate removal of these tumors when they occur in a location which renders them liable to external injury. It must be admitted however that on a number of occasions we have seen such malignant degeneration occur in cases of osteochondroma in which there was no history of injury. To summarize briefly, it wouId seem that the r&Ie of single injury in the deveIopment of bone sarcoma has been overemphasized. A critical evaluation of each case and a decision based upon a scientific appraisal of a11 the known facts has not been the rule. LittIe support of the traumatic theory has been afforded by the pathologist; no Iaboratory experience seems to favor it. Considering the universarity of injuries on a par with those aIIeged to be the cause of sarcoma of bone it is diffIcuIt to explain why so few of them are followed by the deveIopment of sarcoma. So-caIIed expert testimony on matters involving the alleged relationship of injury to malignant disease is not at present Iikely to appeaI to the disinterested observer as worthy of credence; it is colored by the profit motive. UntiI quaIified authorities are summoned by the court and not by the pIaintiff or the insurance carrier to pass upon the merits of each case in a judicia1 and scientific manner, medica expert testimony wiI1 continue to be of doubtful vaIue and will not enhance the doctor’s reputation.