As a result of this survey, the following observations have been made:
1. It is worth while to attempt to separate the more commonly encountered varieties of osteogenic sarcoma (as used in its broadest sense), because the prognosis is distinctly better in some types than in others. The tendency for fibrosarcoma and chondrosarcoma (mainly the low-grade "secondary" chondromyxosarcomata) to metastasize later than "osteogenic sarcoma" is a clinical impression which this study would seem to confirm. The authors believe that the microscopic appearance of tissue taken from the tumor affords the most reliable index of the rapidity of the growth and its tendency to early or late metastasis. Exceptions are, of course, not unusual. This series includes some cases in which a favorable outcome was considered highly unlikely; and, on the other hand, in cases deemed of slow growth with likelihood of survival, the patients have died within five years from pulmonary metastasis.
2. The greatest number of five-year survivals were treated surgically. Of fifty-seven patients with involvement of the long bones, fifty-one had amputation or disarticulation and six had conservative surgery; lesions in five of the six were chondrosarcomata. Two cases of fibrosarcoma were treated by irradiation only. In another case, with chondrosacroma of the rib, the patient received irradiation together with toxins.
3. The part played by irradiation in survival is not easy to estimate. Most of the cases in which it was used were treated in the period prior to 1940, when a high proportion of patients having amputation received preoperative roentgen therapy. However, in the past five years preoperative therapy has virtually been abandoned, and it will soon be possible to make a comparative study of sizable groups treated by amputation, with or without preliminary radiation therapy.
4. Routine postoperative toxin treatment was abandoned several years ago. The senior author became convinced that its use for cases of osteogenic sarcoma could not be justified by any statistical evidence of improvement in the five-year survival rate.
5. There were no five-year survivals in this series of osteogenic sarcoma, including fibrosarcoma and chondrosarcoma, where the lesion was located in the proximal end of the femur.
6. To support the contention that five years is not a sufficiently long period upon which to base end results in this disease, the authors found that five of the fifty-nine patients or 8.5 per cent. died of sarcoma after surviving for five years. Of these, two succumbed after a period of between five and six years, two between six and seven years, and one after fourteen years. Another patient is still ambulatory fifteen years after amputation, but has a large pulmonary metastasis; in this instance the tumor was a low-grade chondrosarcoma of the distal end of the femur. However, one may conclude that, if a patient with osteogenic sarcoma survives for five years, his chances of escaping further evidences of this disease are approximately twelve to one.
7. Lobectomy for pulmonary metastasis, discovered late in the course of the disease, was carried out in two of the cases in this series. One patient died eighteen months after the lobectomy, and sixty-one months after amputation. The other is living and free from evidence of disease, three years after the lobectomy and eight years after amputation. The tumors in these cases were both low-grade chondrosarcomata.
It is hoped that a report of this list of fifty-nine carefully authenticated cases of osteogenic sarcoma in its various forms may help to dispel the attitude, which seems all too prevalent, that this disease is uniformly fatal and that therapy is of so little value as to call for no great effort to reach an early diagnosis and to institute prompt appropriate treatment.