Ir. J. Med. Sc. February, 1964, pp. 89-92 Illustrated Printed in the Republic of Ireland

TOTAL EXCISION OF SCAPULA FOR CHONDROSARCOMA COMPLICATING HEREDITARY MULTIPLE EXOSTOSIS

By BERNARD MURPHY, F.R.C.S., and J. F. O'GRADY, M.B., Galway.

T OTAL excision of the scapula is an uncommon procedure. James (1957) described a subtotal subperiosteal excision in a ten year old girl for aneurysmal bone cyst. Cumming removed the scapula and

forequarter in 1808.

CASE REPORT : A farmer, 37 years old, presented with multiple exostesis and a huge expanding lesion of the left scapula (FIG. 1). There was no evidence of involvement of axillary or brachial structures, x-ray of scapula showed a very large calcified mass with a radiolucent area. x-ray of chest revealed no evidence of pulmonary disease.

Biopsy of the scapular swelling showed features of a chondrosarcoma for which total removal of scapula with i ts muscle a t tachments and outer third of clavicle was carried out.

I-I~tology (Prof. 5. D. Kennedy) : Resection specimen (Fza. 2) weighed 7.5 kilograms. Tumour appears well encapsulated and does not show infiltration of the surrounding tissue. I t is lobular in shape. The scapula is destroyed by tumour. The histological structure is tha t of chondrosarcoma.

Post-operative course: Uneventful. Sensation returned to the arm in 24 hours. Wrist and finger movements were normal after one week. Photos 3 and 4 show the hand and forearm excursion after three weeks and eight weeks respectively. Now 12 months post-operative, the pat ient is able to put the hand to his month.

FxG. 1.--Posterior view of tumour. 89

90 IRISH JOURNAL OF MEDICAL SCIENCE

FIG. 2 . - -Resected tumour . Note size in relation to normal forearm.

FIG. 3 . - -Three weeks post-operative. Oedema still present.

TOTAL :EXCISION OF SCAPULA FOR CHONDROSARCOMA 91

Comment

Jaff~ (1943) estimated that the incidence of chondrosarcoma in heredi- tary multiple exostosis (series of 28 cases) was 10 per cent. The signs of malignant change are the onset of pain in a cartilaginous growth and evidence of cortical p erforatio.n.

Liehtenstein states that a cartilage tumour should no longer be regarded as benign if it shows on section:

(i) Many cells with plump nuclei;

(ii) More than one occasional cell with two such nuclei;

(iii) A~y giant cartilage cell with large single or multiple: nuclei or with clumps of chromatin.

Roland Barnes (1958) recommends primary amputation for:

(i) Turnouts of high malignancy;

(ii) Tumom~ of the upper end of humerus invading the scapula;

(iii) Pelvic tumours in which a hindquarter amputation would not be feasible if the tumour recurred locally;

(iv) All large and neglected tumours;

(v) Tumours of the lower limb, where the functional result after local resection would be inferior to an artificial limb. We decided on local ablation in view of the massive tumour without radiological evidence of metastases, the presence of other exostoses and the relative freedom of the axillary structures.

FIG. 4 . - -Eight weeks post-operative.

92 IRISH JOURNAL OF MEDICAL SCIENCE

Summary A case of chondrosarcoma of the scapula complicating hereditary

multiple exostosis is recorded. Total resection of the scapula was carried out. Forearm and hand movements subsequently are photographically recorded.

References

Barnes, R. (1958). Cancer, 4. Jaffd (1943). Arch. Path., 36, 335. J ames (1957). Journal of Bone and Joins Surgery, 39--B. 130. Keevil, J . J . (1949). " Ra lph Cumming and the interscapulo thoracic amputa t ion in

1808." Journal of Bone and Joint Surgery, 31-B, 589. Lichtenstein, L. (1959). Bone Turnouts. 2nd Edition. C. V. Mosby Co.