Book Review

Bone Tumors

N Engl J Med 1998; 339:1088-1089October 8, 1998

Article

Bone Tumors
By Howard D. Dorfman and Bogdan Czerniak. 1261 pp., illustrated. St. Louis, Mosby, 1998. $225. ISBN: 0-8151-2746-4

Bone tumors, one of the least common neoplasms, account for less than 0.2 percent of all cancers. The clinical, radiographic, and pathological understanding and classification of these rare tumors has slowly developed over the past several decades. Henry Jaffe's descriptions of the pathology of bone tumors and his system of classification, recorded in Tumors and Tumorous Conditions of the Bones and Joints (Philadelphia: Lea and Febiger, 1958), is the basis for our current understanding of these neoplasms. Howard Dorfman, the senior author of Bone Tumors, was for many years Jaffe's protégé at the Hospital for Joint Diseases in New York, and with his coauthor, Bogdan Czerniak, he has written an excellent book.

Bone Tumors is based largely on 5872 cases from the files of the senior author. In addition, two other data bases were used: data on 2627 malignant bone tumors from the National Cancer Institute's Surveillance, Epidemiology, and End Results program, and 4904 cases from the M.D. Anderson Cancer Center. This collection of 13,403 cases represents the world's largest combined experience with bone tumors. It has traditionally been taught that radiographic features, demographic and clinical characteristics (age, sex, site, and symptoms), and pathological findings are all essential for the correct diagnosis — pathologists must correlate their interpretation with the radiographic and clinical data to establish the diagnosis. Any deviation from this tripartite approach could, and in fact has, led to erroneous diagnoses. This concept is the basis for the organization of Bone Tumors.

The book has 24 chapters, with the title of each chapter and subsection in red. The first page of each chapter outlines the sections and subsections. This format is very useful as an overview and for quick reference to the chapter's contents. The first three chapters cover general information, special techniques, and molecular biology. Chapters 4 through 18 describe various types of bone tumors. The organization of these chapters follows the traditional classification and approach to bone tumors described by Jaffe, and later by Dahlin, at the Mayo Clinic. Specifically, bone tumors are classified according to the component of bone from which they apparently arise. Thus, chapters 4 through 18 discuss tumors that arise from osteoid, cartilage, fibrous tissue, bone marrow, and immunohematopoietic, vascular, and neurogenic structures. Each component gives rise to benign and malignant tumors. Chapters 19 through 24 discuss tumors that do not arise in bone but might involve it, as well as metabolic diseases that affect the bone — for example, metastatic tumors, synovial lesions, osteomalacia, and conditions that simulate bony neoplasms. The final chapter discusses precancerous conditions.

The key to the success of this book is its simple but effective organization, with an emphasis on the combination of radiographic, pathological, and clinical data for each entity. About 80 percent of the book consists of radiographs, photographs, photomicrographs, schematic drawings, and graphs. For example, the section on classic osteosarcoma (the most common primary bone cancer) contains 48 radiographs, 9 drawings, 20 photographs of gross specimens, and 60 photomicrographs.

The book, although apparently intended to cover all aspects of bone tumors, discusses treatment only in general terms. A chapter on orthopedic oncology would have been appropriate at the beginning of the book. Specifically, surgical and chemotherapeutic treatment and guidelines for limb-sparing surgery should have been discussed. There is only minimal discussion of the evaluation of resected bone for the killing effect of chemotherapy. This has become an important contribution of the pathologist in the management of malignant bone tumors. Since approximately 90 percent of malignant bone tumors are now treated by limb-sparing surgery rather than amputation, it is essential that radiologists and pathologists understand the surgical techniques and staging concepts.

Another omission is a discussion of the role of the pathologist in establishing the initial diagnosis of a bone neoplasm and the techniques and special considerations involved in the biopsy of bony tumors. This is a very important first step, enhanced by the rapidly growing use of needle biopsies, which greatly reduce local contamination.

This book should be the standard textbook for the new generation of pathologists, radiologists, and surgeons. It should have a place next to Soft Tissue Tumors (Franz M. Enzinger and Sharon W. Weiss. St. Louis: Mosby, 1994) on the bookshelves of physicians taking care of patients with musculoskeletal neoplasms.

Martin M. Malawer, M.D.
Washington Cancer Institute, Washington, DC 20010