Squamous cell carcinoma in chronic osteomyelitis A cilse report
'
1'. L. ~eekr~rons'arlrl C (:. I!. M. Dierickx Dcpartrneiit oiOrlliopacdics (I lcad ol'1)cpt : I .. I)cihitrrcs);irid I)i!p~rliiiriilofHadiology I H w d ofl)epi.: . I . hlylc). Maria hlidclelares IIr~spii.iil.51.-Niklaüs. Brlgiuiii
I
Key words
-
.
- --
Chroiiic osteomyelitis S q u a m o u s cell c a r c i n o m a
Schlüsselwörter
tumotir witti Iiardened bordcrs. pain increased. and there was furthcr bone destructiori. Aritiohiotic nnd NSAl trcatmcnt were uiisucccssful (= a scorc oT 5/; on the scale o i Wagner) (4). Biopsics sliuwed a crumblecl sand-like rnass orwhich thc culture was negative and histology revealed a well dillereiiliated epidnrmoid carcinoiiia. Rndiology revcalcd a largc osteolytic area i r i tlie rnetaphysis of the tibia witti destruction ol'thc cortcx. Further clinical staging was ncgative and a n above-knee airipulation without inguinal lyiripliadenec:toniy was pcrforrned. Heruntergeladen von: NYU. Urheberrechtlich geschützt.
ß!j
C h r o n i s c h e Osteomyelitis Plattenephitelkarzinom
In 1963. Sedlin arid Flerning (1) mcntioned in thcir report that rnaiiy pnticnts with carcinomatous degeneration of chronic ostcomyelitis were war victirns in 1940-1945. Sliot wounds, complcx fractures and aciite tieinatogencous osteomyclitis frequently occurred. Bientans ( 2 ) warned iri 1965 for an incrensc of patients with tliis clinicnl entity to be Seen in the lollowing years, becausc of the established fact that degcncration is likely to appcar after 20 o r 30 yenrs.
Brink (3) also warris with good rcason: after a long period of repeatetl surgical trcatments, bolti patient nnd doclor nre satisficd with "only a sinall listula" that though it is persistent. is easily kept undcr control by the pal.ient. So. mcdical attention is no longer desired. In this paper we warit to drnw attcntion to this pathology because even in thcsc days. patients preseiit tliemsclvcs with mnlignant dcgenerated ctiroiiic osteomyclitis.
Case report In 1965 a man. age 37 presented a t our out-patient dcpartment for the first time. At thc age of severi tie siistained a stiirnp trnurna followed by osteoiriyelitis to thc upper third of Iiis left tibia. Tliis was initially trcated by incisiori arid drainagc. Since 1947 a fistula has been prodiictivc thrce times a year. When we saw Iiim he had a shortening of three cni and a limitcd knee flexiori due to severe degeiierativc joint destruction. For years hc was lielved with orthopaedic shoes and antibiotics. In 1982 the osteitic ceritre was inciscd and a sequestrectoniy perforrncd. l'his was followed by a mtiscle and skin iiap covering. Iri September 1988 thc pain in his lower leg increased (sciatic pain was excluded). A technesiuni aiid galliurn scan showed a possible stnrting infcction and definite signs of osteitis. In January 1989 the siiiiis tract was still closed. Thc Skin becarne warin and shiny. there was a growirig -
..
Fortsehr. Röntgenstr. 154.2 (199 1) 21 5-21 7 O Gcorg'l'hieme Verlag Stiittgart . Ncw York
I r i 'I828 Mnrjolin drccv attcntion on malignani dcgcncrating chronic irritatioii of skiri iirnr iilcern cruris. In 1967 Kotlctslr~nldrew attcntion to degenerating scars. It was i i i 18.33 that Hau:kins rneiitioned Tor thc f rst timc thc occurrence of a carcinoma originating lrom a chroiiic osteomyelitis. Wc found about 190 cases ol'degencratcd chronic osteomyelitis iri world literature.
l'he initial osteoiriyelitis is mainly causcd by comniiniitive li~acturcs and deep wounds. also tiaernatogeiious osteomyelitis cari develop in U chronic Icsion. When the chronic ostcomyclitis starts discharging. tliere will be epitholialisation of die siiius trnct. TWOphcnomena increase the chance Tor degeneration (5): - Prolifcrating activity of tlie epitlieliurn incrcascs towards the deptli OS the sinus. - Bottle-neck pheiioiriena within thc sinus tract. which augrnents thc chanccs of deteriuratioii on ttie base oi' - prolonged chronic irritation by pus secretions (tlieory OS Cotiriheim). - continuously disturbed regerieration processes. I.ocal pernianent inflammatory stimuli a r e equally important and Menkin irientions n growth promoting factor iri tlie exiidatc. Malignancy rerriairis a rare complication OS chroriic osteornyelitis. Authors report incidence to he ~ R ~ W R 0.23 and 2.7 % (6). Deterioration appcars slow and with a low innlignancy grade. after 20 to 60 years (2). with a n nvcragc of 3 0 (7. 8).Diagnosed iiiainly in mcn (80 to 100 %) at theage of 40 to 70 (8). Mainly (85 %) the lower lirrib is involved. and for 33 % it is the tibia: feniur. calcaiicus. and cven skull. scapiila. liurneriis and rnctacarpals are possible sites ol'malignancy (8. Y). 'l'he tibia is vulrierable duc to poor circulatiori. easy chronic Iiypoxia and rcduced soft tissue coveriiig. Thrco pcak incidences are kriowii: 20 to 30 ycars after the Franco-Gerrnan war (1870). aftcr thc first and the secoiid world war. Sqiianious ccll carcinoma (SCC) is the rnost frequent type of ncoplasia (9). Due 10 the above-nieiitioncd rcasons. degeneration starts dccp in the sinus tract, from tliere it migrates and invades often iiiiderlying bonc ("Reizthcorie" of Virchoco). Seven irnportant Symptoms niust draw attention to dctcrioration
R ~
216 Forlsclzr. Rörztgcnstr. 154,P
.. . . ~ - - . - ~~
-~
P. 1.. Veekn~uns(rrrd C. C. H. M . Dierickx
.-..--P----.--
Fig. 1 Extensive osteolysisisshown at the lateral side of I he lefi tibia. lrregular small bone fragments Iiewithin inhomogene densecoft Iissue.
----.P-....
Tab. 1
1 - growingmasswith thickened borders 2 - foul odour 3 - increased drainage 4 increased bleediiig 5 - increased pain 6 - recalciirant lesion not improvingon any knownconservative therapy / progressive bony distruction (possiblepathologic fracture) P
-
P
Tab. 2 -
-
basal cell ca adeno-ca fibrosarcoma plasmocytoma reticulum cell sarcorria spindle cell ca parosteal sarcoma
and soft tissue invnsion, which is demonstrnted t» hcttcr ndvnnkige hy C.A.T. scnri estiinirintioii (Fig. 2). Diopsies a t multiple sites and depths nro ncccssüry. Apart from SCC other types a r r clescribrd (Tab. 2).
Accordirig to Jo/znson (8): - ßeiiign sqiiainoiis Iiyperplasia. No invnsinn. no soil. tissiie mnss. histologically definitely benign. - A.P. H. (atypical pscudo-cpithcliornatous hypcrplasia). Invadirig Iayers oisquamous cells. soft tissiie mnss. iio "atypicnl cells". no invasion of blood or lyrnphatics, no rnitosis. It is clinically arid histologically irnpossiblc to tcll if changcs arc bcnign o r maligiiaiit (except with nietastases). Epidcrmoid carcinorna: squarnous ccll Ca. Abnormal mitosis. dyskcratosis, blood nnd lyniphntic iiivnsiori. possible iiictaslases. Accordiiig to (,-iunly niid /.aus (7): - 1"' beiiigii hyperplnstic plinse. - 2"dinvasion. - 3"' definitc SCC. Fig. 2 C. A. T. scan examination shows,moreclearly the bony destruction and soft tissue extention.
oi' the siniis tract (1. 4. 6. 10) ('l'ab. 1). Biochernistry shows iricreased sediirieiitatioii a r ~ dIeucocyt~sis.Cultures rnay contain cntcrobactcr. bactcroides or streplococciis. biit a r e oflen sterile. Cliiiical signs aiid Iiistopnthological cxarnination togcthcr with imaging techniques will give tlie cliie to diagnoses aiitl exteiision of the proccss. Wc will discuss radiological docurnentsconcerning thiscase report. Iriiaging is very iniportant in the follow-up of chronic osteornyelitis. Our patierit had several staiidard X-ray exnminntions during his follow-up. In Scpternbcr 1988 standard X-rayssliow liealed cliroriic osteoniyelitis. The prosimal third of thc tibia has a n irregular but sclerotic deniarcated osteolytic area: antibiotic bends can bc sccn. Four months later thc irnage is totally different (Fig. 1). Exterisive osteolysis is shown, with irregular unsharp borders. Surrounding soft tissiie is iritiorriogeneoiis deiise arid smnll bone f'ragrncnts a r c sccn within. Uegeneratcd chronic osteomyelitis is diagiiosed becaiise ol' bone dcstruclinn
Mostautliors (2.8)corisider occurrencr of nietastasos to bc low. although (;iunt!j ct al. (7) rcport sccding of maligiiaiitcells in 30 % (populatioii of 1 2 7 cases). liiiietnstasis occurs, it will in less than 18 rnonths after diagnosis. I f patients a r e free froiri rnctastascs for thrcc ycars. long-tcrrn survival irnprovcs. With iiietnstases, niortality attairis up to 3 0 %, within oiie year (1. 9). Sites involved are lungs, kidney;, regional and distant 1irnphnodes (1.10). 'Together with benign squarnous hyperplasia. onc must also trcat thc chronic ostcornyclitis (I It D. scqucstrectorny arid antibiotics). Close follow-up witli iieedle biopsies a t three-rnonthly intervals are indicated (8). As soon a s A . P . H . is dingnosed. arnputation is ncccssary (thc leg is often ni'unctional a t ttiis stage). Wtieii biopsies reveal SCC, regional lyrripli riotle biopsies must be taken: if rnalign. lyrnphadenectorny should be carried out; if benign and palpable lymph nodes do not disappenr 4 weeks after arriputatiori, radical lyrriphadenectomy is iridicated ('1. 8).
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
-
Squarnorrs c r l l curcinonlu iri chronic osleorrtyelilis --
..
Canclusion -. .-
-
L.ong-lerin clironic osteomyelitis. wliich is rarcly complicaic!d by dcgcneration, reinains a scrious conditioii. Coii tinuous. clinical and radiological follo\v-up is nccrssary to keep botli pnticnt and doclor alert. l'his case reporlsliows that dcgcncration caii riipidly Jcopardize yoiii. pntiont's hcalth.
I
.'
Srdlin. 1: D., J. L. 1;lenting. i'pidcrmoid carciiioniii arisiiig in chronic ostroiiiyclitic foci. J. Uoiie .loiiit Surg. (Am.) 45 (1963) 827- 838 ßieniriris. R. G. M.: Osteoiriyelitis chionica en plaveiselspitheclcarcinoorri. Ned 'l'ijdschr. Geneeskd. 1 0 9 (1965) '1150- 1 153 llrink, I'. I{. G., W. \.I. Molcr~aar:De chronische osteocutane fistel, geen onschuldig bezii. Ned Tijdschr. Geneeskd. 132 119881 1225-1227 M'ccgner, H. F., D. .I. Grnrzde: Pseudoepii.heliomatous hyperplasia vs. squamous cell carcinoma arising froiri clironic osteomyelitis of thc humeriis. J. Dermatol. Surg. Oncol. 12 ('1986) 6 June. 632-635 ßraurr, W., H. Krumme lind ~Miturb.:1:istelkarzinoni als Komplikation der chronischen Osleoniyel~tis. Münch. rrietl. Wochcnschr 125 (1 383) 8 2 9 821
"
"
"'
A~lcArzall~~. A. h'., NI. ß. Dokcrl!~: Carcinorna drvelol)iiig iii c:lironic draining cutaneoiis siiiiises nnd fistulas. Surg. Cynecol. Obstt!l.. 44 (1949) 87- Y6 (;iulr/. A.. (M.I.«cls: Malignant turnours i n chroriic osiroiiiynlitis. Ital. .I. Orthop. 'I'ratiniatol. 4 (1974) 171- I 8 2 Johnson. L. L.. H . L.. Kentpsorr: El)iderinoid carcinoma i n chronic osit!«myclitis: diagnostic problems arid iriaiingiliii(:nt. .J. Bonc Joint Surg. (,4iri.) 47 (1065) L : < : < 1 4 5 Filzgcrnld, I?.H., N. S. Brrrrirr. 0. C. ß a l ~ l i r i Squarnous-ccll : carcinoma cuiriplicating chronic osteomyrliiis. .I. Iloiie .loiiil. Sui'g. (Am.) 58(1976)1146- 1148 ßt~rcston,1;. .Y.. (.'. Ne!/: Sqiialrioiis (:eil carcinorna arising i n a chroiiic osi.si,inyclitir. sinus tract w i t h iiic!Laslasis. Arcli. Suig. 43 (1941) 2 j 7 - 2 6 8
Varia nvliddelarcs Hospitals Hospitaalslraat 1 7 0-2700 St. Niklaas Heruntergeladen von: NYU. Urheberrechtlich geschützt.
. -.-
'
1'. L. ~eekr~rons'arlrl C (:. I!. M. Dierickx Dcpartrneiit oiOrlliopacdics (I lcad ol'1)cpt : I .. I)cihitrrcs);irid I)i!p~rliiiriilofHadiology I H w d ofl)epi.: . I . hlylc). Maria hlidclelares IIr~spii.iil.51.-Niklaüs. Brlgiuiii
I
Key words
-
.
- --
Chroiiic osteomyelitis S q u a m o u s cell c a r c i n o m a
Schlüsselwörter
tumotir witti Iiardened bordcrs. pain increased. and there was furthcr bone destructiori. Aritiohiotic nnd NSAl trcatmcnt were uiisucccssful (= a scorc oT 5/; on the scale o i Wagner) (4). Biopsics sliuwed a crumblecl sand-like rnass orwhich thc culture was negative and histology revealed a well dillereiiliated epidnrmoid carcinoiiia. Rndiology revcalcd a largc osteolytic area i r i tlie rnetaphysis of the tibia witti destruction ol'thc cortcx. Further clinical staging was ncgative and a n above-knee airipulation without inguinal lyiripliadenec:toniy was pcrforrned. Heruntergeladen von: NYU. Urheberrechtlich geschützt.
ß!j
C h r o n i s c h e Osteomyelitis Plattenephitelkarzinom
In 1963. Sedlin arid Flerning (1) mcntioned in thcir report that rnaiiy pnticnts with carcinomatous degeneration of chronic ostcomyelitis were war victirns in 1940-1945. Sliot wounds, complcx fractures and aciite tieinatogencous osteomyclitis frequently occurred. Bientans ( 2 ) warned iri 1965 for an incrensc of patients with tliis clinicnl entity to be Seen in the lollowing years, becausc of the established fact that degcncration is likely to appcar after 20 o r 30 yenrs.
Brink (3) also warris with good rcason: after a long period of repeatetl surgical trcatments, bolti patient nnd doclor nre satisficd with "only a sinall listula" that though it is persistent. is easily kept undcr control by the pal.ient. So. mcdical attention is no longer desired. In this paper we warit to drnw attcntion to this pathology because even in thcsc days. patients preseiit tliemsclvcs with mnlignant dcgenerated ctiroiiic osteomyclitis.
Case report In 1965 a man. age 37 presented a t our out-patient dcpartment for the first time. At thc age of severi tie siistained a stiirnp trnurna followed by osteoiriyelitis to thc upper third of Iiis left tibia. Tliis was initially trcated by incisiori arid drainagc. Since 1947 a fistula has been prodiictivc thrce times a year. When we saw Iiim he had a shortening of three cni and a limitcd knee flexiori due to severe degeiierativc joint destruction. For years hc was lielved with orthopaedic shoes and antibiotics. In 1982 the osteitic ceritre was inciscd and a sequestrectoniy perforrncd. l'his was followed by a mtiscle and skin iiap covering. Iri September 1988 thc pain in his lower leg increased (sciatic pain was excluded). A technesiuni aiid galliurn scan showed a possible stnrting infcction and definite signs of osteitis. In January 1989 the siiiiis tract was still closed. Thc Skin becarne warin and shiny. there was a growirig -
..
Fortsehr. Röntgenstr. 154.2 (199 1) 21 5-21 7 O Gcorg'l'hieme Verlag Stiittgart . Ncw York
I r i 'I828 Mnrjolin drccv attcntion on malignani dcgcncrating chronic irritatioii of skiri iirnr iilcern cruris. In 1967 Kotlctslr~nldrew attcntion to degenerating scars. It was i i i 18.33 that Hau:kins rneiitioned Tor thc f rst timc thc occurrence of a carcinoma originating lrom a chroiiic osteomyelitis. Wc found about 190 cases ol'degencratcd chronic osteomyelitis iri world literature.
l'he initial osteoiriyelitis is mainly causcd by comniiniitive li~acturcs and deep wounds. also tiaernatogeiious osteomyelitis cari develop in U chronic Icsion. When the chronic ostcomyclitis starts discharging. tliere will be epitholialisation of die siiius trnct. TWOphcnomena increase the chance Tor degeneration (5): - Prolifcrating activity of tlie epitlieliurn incrcascs towards the deptli OS the sinus. - Bottle-neck pheiioiriena within thc sinus tract. which augrnents thc chanccs of deteriuratioii on ttie base oi' - prolonged chronic irritation by pus secretions (tlieory OS Cotiriheim). - continuously disturbed regerieration processes. I.ocal pernianent inflammatory stimuli a r e equally important and Menkin irientions n growth promoting factor iri tlie exiidatc. Malignancy rerriairis a rare complication OS chroriic osteornyelitis. Authors report incidence to he ~ R ~ W R 0.23 and 2.7 % (6). Deterioration appcars slow and with a low innlignancy grade. after 20 to 60 years (2). with a n nvcragc of 3 0 (7. 8).Diagnosed iiiainly in mcn (80 to 100 %) at theage of 40 to 70 (8). Mainly (85 %) the lower lirrib is involved. and for 33 % it is the tibia: feniur. calcaiicus. and cven skull. scapiila. liurneriis and rnctacarpals are possible sites ol'malignancy (8. Y). 'l'he tibia is vulrierable duc to poor circulatiori. easy chronic Iiypoxia and rcduced soft tissue coveriiig. Thrco pcak incidences are kriowii: 20 to 30 ycars after the Franco-Gerrnan war (1870). aftcr thc first and the secoiid world war. Sqiianious ccll carcinoma (SCC) is the rnost frequent type of ncoplasia (9). Due 10 the above-nieiitioncd rcasons. degeneration starts dccp in the sinus tract, from tliere it migrates and invades often iiiiderlying bonc ("Reizthcorie" of Virchoco). Seven irnportant Symptoms niust draw attention to dctcrioration
R ~
216 Forlsclzr. Rörztgcnstr. 154,P
.. . . ~ - - . - ~~
-~
P. 1.. Veekn~uns(rrrd C. C. H. M . Dierickx
.-..--P----.--
Fig. 1 Extensive osteolysisisshown at the lateral side of I he lefi tibia. lrregular small bone fragments Iiewithin inhomogene densecoft Iissue.
----.P-....
Tab. 1
1 - growingmasswith thickened borders 2 - foul odour 3 - increased drainage 4 increased bleediiig 5 - increased pain 6 - recalciirant lesion not improvingon any knownconservative therapy / progressive bony distruction (possiblepathologic fracture) P
-
P
Tab. 2 -
-
basal cell ca adeno-ca fibrosarcoma plasmocytoma reticulum cell sarcorria spindle cell ca parosteal sarcoma
and soft tissue invnsion, which is demonstrnted t» hcttcr ndvnnkige hy C.A.T. scnri estiinirintioii (Fig. 2). Diopsies a t multiple sites and depths nro ncccssüry. Apart from SCC other types a r r clescribrd (Tab. 2).
Accordirig to Jo/znson (8): - ßeiiign sqiiainoiis Iiyperplasia. No invnsinn. no soil. tissiie mnss. histologically definitely benign. - A.P. H. (atypical pscudo-cpithcliornatous hypcrplasia). Invadirig Iayers oisquamous cells. soft tissiie mnss. iio "atypicnl cells". no invasion of blood or lyrnphatics, no rnitosis. It is clinically arid histologically irnpossiblc to tcll if changcs arc bcnign o r maligiiaiit (except with nietastases). Epidcrmoid carcinorna: squarnous ccll Ca. Abnormal mitosis. dyskcratosis, blood nnd lyniphntic iiivnsiori. possible iiictaslases. Accordiiig to (,-iunly niid /.aus (7): - 1"' beiiigii hyperplnstic plinse. - 2"dinvasion. - 3"' definitc SCC. Fig. 2 C. A. T. scan examination shows,moreclearly the bony destruction and soft tissue extention.
oi' the siniis tract (1. 4. 6. 10) ('l'ab. 1). Biochernistry shows iricreased sediirieiitatioii a r ~ dIeucocyt~sis.Cultures rnay contain cntcrobactcr. bactcroides or streplococciis. biit a r e oflen sterile. Cliiiical signs aiid Iiistopnthological cxarnination togcthcr with imaging techniques will give tlie cliie to diagnoses aiitl exteiision of the proccss. Wc will discuss radiological docurnentsconcerning thiscase report. Iriiaging is very iniportant in the follow-up of chronic osteornyelitis. Our patierit had several staiidard X-ray exnminntions during his follow-up. In Scpternbcr 1988 standard X-rayssliow liealed cliroriic osteoniyelitis. The prosimal third of thc tibia has a n irregular but sclerotic deniarcated osteolytic area: antibiotic bends can bc sccn. Four months later thc irnage is totally different (Fig. 1). Exterisive osteolysis is shown, with irregular unsharp borders. Surrounding soft tissiie is iritiorriogeneoiis deiise arid smnll bone f'ragrncnts a r c sccn within. Uegeneratcd chronic osteomyelitis is diagiiosed becaiise ol' bone dcstruclinn
Mostautliors (2.8)corisider occurrencr of nietastasos to bc low. although (;iunt!j ct al. (7) rcport sccding of maligiiaiitcells in 30 % (populatioii of 1 2 7 cases). liiiietnstasis occurs, it will in less than 18 rnonths after diagnosis. I f patients a r e free froiri rnctastascs for thrcc ycars. long-tcrrn survival irnprovcs. With iiietnstases, niortality attairis up to 3 0 %, within oiie year (1. 9). Sites involved are lungs, kidney;, regional and distant 1irnphnodes (1.10). 'Together with benign squarnous hyperplasia. onc must also trcat thc chronic ostcornyclitis (I It D. scqucstrectorny arid antibiotics). Close follow-up witli iieedle biopsies a t three-rnonthly intervals are indicated (8). As soon a s A . P . H . is dingnosed. arnputation is ncccssary (thc leg is often ni'unctional a t ttiis stage). Wtieii biopsies reveal SCC, regional lyrripli riotle biopsies must be taken: if rnalign. lyrnphadenectorny should be carried out; if benign and palpable lymph nodes do not disappenr 4 weeks after arriputatiori, radical lyrriphadenectomy is iridicated ('1. 8).
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
-
Squarnorrs c r l l curcinonlu iri chronic osleorrtyelilis --
..
Canclusion -. .-
-
L.ong-lerin clironic osteomyelitis. wliich is rarcly complicaic!d by dcgcneration, reinains a scrious conditioii. Coii tinuous. clinical and radiological follo\v-up is nccrssary to keep botli pnticnt and doclor alert. l'his case reporlsliows that dcgcncration caii riipidly Jcopardize yoiii. pntiont's hcalth.
I
.'
Srdlin. 1: D., J. L. 1;lenting. i'pidcrmoid carciiioniii arisiiig in chronic ostroiiiyclitic foci. J. Uoiie .loiiit Surg. (Am.) 45 (1963) 827- 838 ßieniriris. R. G. M.: Osteoiriyelitis chionica en plaveiselspitheclcarcinoorri. Ned 'l'ijdschr. Geneeskd. 1 0 9 (1965) '1150- 1 153 llrink, I'. I{. G., W. \.I. Molcr~aar:De chronische osteocutane fistel, geen onschuldig bezii. Ned Tijdschr. Geneeskd. 132 119881 1225-1227 M'ccgner, H. F., D. .I. Grnrzde: Pseudoepii.heliomatous hyperplasia vs. squamous cell carcinoma arising froiri clironic osteomyelitis of thc humeriis. J. Dermatol. Surg. Oncol. 12 ('1986) 6 June. 632-635 ßraurr, W., H. Krumme lind ~Miturb.:1:istelkarzinoni als Komplikation der chronischen Osleoniyel~tis. Münch. rrietl. Wochcnschr 125 (1 383) 8 2 9 821
"
"
"'
A~lcArzall~~. A. h'., NI. ß. Dokcrl!~: Carcinorna drvelol)iiig iii c:lironic draining cutaneoiis siiiiises nnd fistulas. Surg. Cynecol. Obstt!l.. 44 (1949) 87- Y6 (;iulr/. A.. (M.I.«cls: Malignant turnours i n chroriic osiroiiiynlitis. Ital. .I. Orthop. 'I'ratiniatol. 4 (1974) 171- I 8 2 Johnson. L. L.. H . L.. Kentpsorr: El)iderinoid carcinoma i n chronic osit!«myclitis: diagnostic problems arid iriaiingiliii(:nt. .J. Bonc Joint Surg. (,4iri.) 47 (1065) L : < : < 1 4 5 Filzgcrnld, I?.H., N. S. Brrrrirr. 0. C. ß a l ~ l i r i Squarnous-ccll : carcinoma cuiriplicating chronic osteomyrliiis. .I. Iloiie .loiiil. Sui'g. (Am.) 58(1976)1146- 1148 ßt~rcston,1;. .Y.. (.'. Ne!/: Sqiialrioiis (:eil carcinorna arising i n a chroiiic osi.si,inyclitir. sinus tract w i t h iiic!Laslasis. Arcli. Suig. 43 (1941) 2 j 7 - 2 6 8
Varia nvliddelarcs Hospitals Hospitaalslraat 1 7 0-2700 St. Niklaas Heruntergeladen von: NYU. Urheberrechtlich geschützt.
. -.-
