I 0 2 T H E B R I T I S H J O U R N A L O F S U R G E R Y

anastomosis of an aortic bifurcation graft inserted in the treatment of an aneurysm, where extension of the aneurysm into common, internal or external iliac arteries might raise difficulties if end-to-end anastomosis is attempted. However, there is no doubt that the greatest advantage of the method described in this study lies in the preservation of collateral vessels. In segmental occlusion of the main artery of the lower limb, which is secondary to atheroma, the important collateral vessels are the profunda femoris proximally in femoral occlusion, and the vessels at the adductor magnus opening area, which limit distal extension of a femoral thrombosis for a time and proximal extension of a popliteal thrombosis (Mavor, 1955). In fact if arterial resection and graft replacement by end-to-end anastomosis were to be undertaken in all cases of segmental occlusion, one anastomosis would be at the adductor magnus opening site in over 90 per cent of cases (Mavor, 1955). It is apparent then that these collateral vessels are especially vulnerable. Further- more the preparation of the host vessel for end-to-end suture may entail a short endarterectomy or encroach- ment on the lumen of a large collateral such as the profunda femoris, both measures calculated to jeopardize a successful result. It has even been proposed in fact that collateral vessels should not be allowed to limit resection and be sacrificed without hesitation in order to gain a suitable site for end-to- end suture. I t is doubtful whether this is justifiable as it narrows the margin of safety with which all surgery should be concerned. By the use of the shunt method, all collaterals are preserved, and the most suitable sites for the anastomoses as regards exposure and arterial involvement in disease can be selected.

SUMMARY I. A series of 39 dogs in which shunt arterial

homografts were inserted is presented. The im- mediate results show a 79 per cent incidence of patency at the third post-operative week.

2. In g dogs, there was no late thrombosis up to six months post-operatively.

3. If the shunt graft passes deep to the inguinal ligament, a higher incidence of immediate post- operative thrombosis is to be expected, due possibly to the constricting effect of the inguinal tunnel. This may not be of clinical significance.

4. The technique of anastomosis is described, and the technical advantages of end-to-side anasto- mosis discussed.

5. The clinical benefits of such a method of arterial reconstitution are noted.

The facilities for this work were provided at the University of Rochester Medical School, Rochester, New York. I wish to thank Dr. W. J. M. Scott and Dr. IZarle B. Mahoney for their interest and encouragement. My gratitude is also due to Mrs. M. Metzler for her skilful operative assistance and her expert care of the experimental animals.

REFERENCES FONTAINE, R., and HUBINOT, J. (I950), Acta chir. belg.,

49, 580. -- RIVEAUX, R., KIM, M., and KIEY, R. (1952), Froc.

Congr., European Cardio-vascular Surgical Society, p. 227.

HUFNAGEL, C. A. (1955), Surgery, 37, 165. -- and EASTCOTT, H. H. G. (1950), Proc. Surg.

Forum, Clin. Congr. Amer. Coll. Surgeons. Philadelphia : W. B. Saunders Co.

---- (1951), Bull. Georgetown Univ. med. Center, 4, 119.

---- (1952), Lancet, I, 531. JULIAN, 0. C., GROVE, W. J., DYE, W. S., OLWIN,

J. H., and JORDON, P. H. (I952), Ann. Surg., 136, 459.

LINTON, R. R. (rg55), American Surgical Society, Philadelphia.

MAVOR, G. E. (1955)~ Brit .J. Surg., 43, 352. ROB, C. G., and EASTCOTT, H. H. G. (1953), British

Surgical Progress, I, I. London : Butterworth & Co., Ltd.

SHORT NOTES OF RARE OR OBSCURE CASES

CHONDROSARCOMA OF THE PUBIC BONE BY DONALD YOUNG, O.B.E., T.D.

CONSULTANT SURGEON, WARRINGTON INPIRMARY

THE infrequency of excision of the pubic bone for chondrosarcoma has encouraged the publication of the following case.

CASE REPORT HISToRY.-The patient, a man of 34 years, was first

seen a t Surgical Out-patients in July, 1952. He had noticed a mass in his right groin for a fortnight. The mass felt hard and appeared to be separating his adductor muscles. Pain was referred to the right hip and right

knee-joint. A diagnosis of psoas abscess or obstructed obturator hernia was suggested and radiographs of the spine and pelvis were ordered. The radiograph showed no evidence of pathological bone changes in the dorsal spine, but a calcified shadow was seen superimposed on the right 0s pubis and there appeared to be some peri- osteal thickening of the pectoneal line (Fig. I 19).

At operation on July 18, 1952, the lesion was found to be a chondromatous mass and a biopsy specimen was taken. This was reported as a chondrosarcoma. A radiograph of the chest showed no lung pathology and a

C H O N D R O S A R C O M A O F T H E P U B I C B O N E 103

further film of the pelvic brim did not show any sign of erosion in the pubic region.

Hindquarter amputation was suggested but the patient preferred to keep his leg. The small tumour was in no way incommoding him and he could walk or run without difficulty.

By December, 1952, the mass had increased in size and he was having pain in the right thigh and knee. A further operation removed a large tumour mass and the obturator nerve was cut.

bone and ischium had been cleared of their attachments and sawn across, the turnour was removed en bloc (Fig. 120). The large gap in the right groin was closed with interrupted thread suture of fascia and muscle. The skin was closed and a small drain left in the thigh wound because of the looseness of the skin there. A hip spica of 6-in. domette bandage over the dressings completed the operation.

On examination three days after operation it was found that he had developed a scrota1 hrematoma on the

YOUNG 1954

FIG. 119.-Radiograph of pelvis showing tumour as a calcified shadow superimposed on the right 0s pubis.

FIG. ~zr.-Drawing showing mass of tumour and bone removed at operation.

By February, 1954, there was a swelling as large as a newborn baby’s head in the right groin, growing down the thigh. A mass could also be felt in the abdomen in the right iliac fossa. The patient agreed to local removal of the tumour and operation was performed on Feb. 23.

AT OPERATION.-A T-shaped incision was made in the right groin with the vertical incision carried down the thigh in the line of the femoral vessels. The pubic bone and ramus were exposed and the latter was cut through with a saw. The retroperitoneal mass arising from the obturator foramen was peeled off the peritoneum. The mass in the thigh was freed from the adductor muscles and dissected off the femoral vessels. After the pubic

\ I

FIG. 120.-Diagram showing position of tumour, and area. of hone excised.

FIG. 122.-Radiograph taken post-operatively, of hone excised.

showing area

right side. His haemoglobin was 56 per cent. A blood transfusion was advised but firmly refused by the patient because of religious beliefs; he is a Jehovah Witness. In spite of his low haemoglobin he made an uneventful recovery.

THE SPECIMEN.-The tumour and bone removed weighed 4 lb. 13 02. (2192 g.) (Fig. 121). It was a pear- shaped mass which measured 16 x 18 x 10 an. in the thigh and 8 x I I x 7 cm. in its retroperitoneal extension. The pathologist reported as follows : “ It consists of very numerous lobules of hyaline cartilage. The larger ones have become cystic and the smaller ones are at the peri- phery of the mass. Microscopically it is similar to the earlier biopsy specimen.”

PROGRESS.-h two weeks the patient was weight- bearing, using crutches. An X-ray report on March 9, 1954, stated : “ The pubic bone on the right side has been removed. There is no evidence of further bony change.” (Fig. 122.)

I04 T H E B R I T I S H J O U R N A L O F S U R G E R Y

When seen in Out-patients on April 30, his general condition was satisfactory. He said he was feeling very well and could walk, sit, and lie down in comfort. There was no pain now, but he was still wearing the hip spica as a support. On July 20 the right groin had healed firmly. There was some thickening along the inguinal ligament but no evidence of a hernia.

On routine examination in December, 1954, a definite nodule of a recurrence of the tumour was felt above the

STEWART I906

FIG. 1z3.-Diagram of case described by Stewart (1906). Showing position of tumour and area of bone excised.

inguinal incision. The man was very agile and his general condition was satisfactory. He was advised to come in for removal of the nodule.

At operation on Jan. LO, 1955, four nodules of second- ary tumour growth were found-one in the retroperi- toneal space, lateral to the external iliac artery, one in the rectus muscle, and two in the external oblique muscles. The histological picture of these recurrent tumours was similar to that of the earlier specimens. One of the tumours, that from the retroperitoneal space, was re- ported on as follows : “ This fragment looks more malignant than any specimens hitherto seen from this patient. Here and there, ill-formed vascular spaces can be found with very thin walls. Mitotic figures, which have hitherto been infrequent, can now be found without difficulty. There is also considerable pleomorphism.”

COMIMENT Muir (1951) and Strange (1954) have shown that

removal of one pubic bone causes no great disability, Stewart (1906) removed parts of both pubic bones (Fig. 123) in the excision of a spindle-cell sarcoma arising from the periosteum on the back of the pubic ramus. King had suggested in 1931 that local removal rather than the more radical methods of treatment would save unnecessary mutilation in the comparatively benign cases. This case confirms the possibility of conserving the leg and the hip-joint

when excising sarcoma of the pubic bone. Although on the conclusion of the excision a gap is left through which you may pass your fist, it is interesting to note that in this, and the previously recorded cases, a hernia did not develop at the operation site.

Pathology.-Evans (1956) states that chondro- sarcomata may appear as large smooth or lobulated tumours covered by a layer of expanded periosteum j they project into the adjacent soft tissues and pro- ceed to infiltrate. The microscopical appearances of a chondrosarcomatous lesion may resemble those of a benign chondroma so closely that the tumours are histologically indistinguishable. On other occasions the chondrosarcomatous nature of the neoplasm is histologically obvious. In between these two types of structure there are transition forms in which features of malignancy are more or less apparent. Phemister (1930) stated that chon- drosarcomata may grow more rapidly than osteogenic sarcomata, producing more bulky neoplasms and giving rise to metastases at a late phase in their evolution and development. Lichtenstein (1952) observed that untreated chondrosarcomata are likely to remain only locally invasive for years. If the tumour had not been completely excised at the initial surgical operation, local recurrence of the lesion in even bulkier form is almost the rule. This case would appear to show that once local recurrence has commenced the tumour spreads rapidly and grows quickly. Lichtenstein agrees that the only form of therapy which offers any prospect of cure in cases of chondrosarcoma is surgery.

SUMMARY A case of excision of the pubic bone for chondro-

sarcoma is reported. I. I n spite of late excision by local removal the

patient had ten months of normal life before second- ary tumours appeared.

2. Removal of one pubic bone does not make the pelvis unstable and hernia following the operation is unlikely.

REFERENCES EVANS, R. W. (1956), Histological Appearances of Turnours.

KING, E. S . J. (1g31), Brit. J . Surg., 19, 330. LICHTENSTEIN, L. (1952), Bone Turnours. London :

MUIR, E. G. (IgSI), Brit .J. Surg., 38,527. PHEMISTER, D. B. (Ig30), Surg. Gynec. Obstet., 50, 216. STEWART, F. T. (1906), Ann. Surg., 44, 946. STRANGE, F. G. St. C. (I954), Brit .J. Surg., 41, 377.

Edinburgh : Livingstone.

Kimpton.