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·PRIMARY TUMORS
OF THE CALVARIA
With Special Consideration of the Clinical Problems
By
FRANKLIN JELSMA MD
fondu Tour (Carl of Sortea) s j srpent Informary
Cowshe Immorterpret Amatuly Papist llasportal
Consoles Torrent St fahory Ilused
Coming Sootagron ha Crispind uldron Hapsel
destinal Professor of
Im Urhesus of Londle School of Voici
Loctaille rainly
CHARLES C THOMAS. PUBLISHER
Sprungfield
IHInous U.S.A
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·PREFACE The literature is decidedly limited on the subject of Pnmary Tumors of the Caliana Except for 2 or 3 series of cares, onc usually finds case reports, and not cry many of these Infor mation concerning these rather rare lcions must be obtained in a precemcal manner by scarching through various text books deal ing with bone tumors roentgenology pathology and widely scattered articles in the literature There is a need for clinical consideration of the subject as a wholc. So it is thought worth while to place under onc cover the vanous clinical aspects of thesc tumors so dat this information will be more readily avail able This monograph contains a classification of calvarial tumors, together with their symptoms diagnosu and treatment Operative and nonoperative viewpoints are discussed A brief discussion of the rocntgenological findings and pertinent laboratory data is given Many case reports with illustrations are included The arrangement, as planned in the classification of tumors in the first chapter has been carned out in order of sequence through out the entire monograph Thc benign tumon are taken up first in the name order as listed in the table, the tumor like lesions are second in order and the malignant tumors are third This applies to the synopsis of cases as well as the arrangement of material case reports and illustrauons throughout the entire work Metastatic tumors of the calvaria, or involvement in a second ary manner, such as, in meningiomas are not mentioned except for reasons of differential diagnosis Tumors of the base of the skull such as, ethmoid groove ostcomas or epidermoid sinus tracts attending to intracranial epidermoid cysts, are not included Encephalocela are not conndered primary skull tumors The material comes from the Author's case records covering a period of over twenty years and includes our experenca in deal ing with more than forty nine case of primary tumors of the calvaria Only four cases of hyperostosis frontalis interna have yu ·been included in this study Many, many more cases are present in our case records Two cases of xanthomatosis were thought sufficient to Ulustrate thus leaon Two more have been found in the office records. The Author wishes to acknowledge the help of Dr Paul Ross who has worked with him on many of the cases, also for his kind nars and that of Drs Gerald Peterson and Harold Gordon in proofreading the manuscript De Sam Black has rendered loval uable and in the classification and histologic study of these cases Our collcagues, thc roentgenologists, Dry Bell, Douglas, Peterson and Blackburn at the office, and Drs Johnson and Maxwell at the hospital, were ever ready and willing to discuss and work out the details of their fields, far beyond the usual call of duty The and gived by our anesthesiologist, Dr J A Buhop and the ever dependable nursing service both in the operating room and on the floor, has beco gready appreciated Me Mary Weber my secretary worked pauently and faithfully in prepanng the manu script and to her I am indeed grateful Mr Lawrence Jelstra was especially helpful in correcting the proofs. I am thankful to my wife for her encouragement and understanding of the time and cffort required to gather together and write this work Mr Jack Haod prepared most of the ullustrations Last, but not least, the Author wishes to express bus sacerC appreciation and thanks to the Publishers for their ever helpful suggestions and guidance in the preparation of this work. Louistelle ky ·CONTENTS Page Preface 3 3 Chapter I GEXERAL COMPLRATION OF CALVARJAL TUYORS Incidence Carification of Tumors of the Calvana General Discusgon of Care Summanes Cranioplasty Bibliography 4 4 9 12 13 13 15 21 25 35 37 II BEXray TUMORS OP TIIE CALVARIA Osteoma Case Reports Hemangiomas Case Reports of Hemangiomas Giant Cell Tumors of the Calvania Intradiploc Epidermoid Cysts Case Reports Traumatic Cyo of the Calvana Case Reports Chondroma Cax Reports Other Beniga Tumori Lipoma Ordfying Fibroma Bibliography 37 40 42 48 48 50 50 52 52 III TUOR LIL LEAOKS OF TILE CALVARIA (DUL TO GENERAL DREASE PROCEAD) 55 ·Pero 55 57 63 66 69 Chaplet Eosinophilic Granuloma Case Reports Xanthomatons Case Reports Fibrous Dysplaga of the Calvania Case Reports Pagets Discase Case Report Leontian Otea Case Reports Hyperostosis Frontalis Interna Case Reports Bibliography 74 75 75 76 79 79 82 84 84 85 90 91 95 IV MALIONANT TUMORS OF THE CALVARLA Osteogenic Sarcoma Case Reports Chrondosarcoma Case Report Fibrosarcoma Ewing - Sarcoma My cloma (Plasma Cell) Case Report Reticulum Cell Sarcoma Case History Hernanglo-Endothelioma (Malignant) Case Report Chloroma Bibliographs 95 96 97 98 98 101 101 104 104 ddddon 107 Iner 111 ·PRIMARI TUMORS OF THE CALVARIA

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·Chapter 1 GENERAL CONSIDERATION OF CALVARIAL TUMORS INCIDENCE PRINARI tumors of the calvaria are rather uncommon Per centagewase tumors seem to occur less frequently in bonc which 19 Ossified in membranc or primiuve connecuve ussue, such as the bones of the calvaria Case reports being scarce, the reports of a group or seria or cases are more difficult to find In one such group of cases, Van denberg and Coley found that benign tumor of the calvana comprised only 2.4% of a total of 1 580 bone tumors occurring in the body Geschichter found thu percentage to be even less in another sends of 500 cases It is quite likely however that these tumors occus more fre quently than the literature would indicate, for various reasons Alany amall osteomas need no care. They are observed indefinitely, and are neither operated nor reported This happens to many small tumors that grow slowly and cause few symptoms Searching through our records, we have found 44 cases of benign and 5 malignant primary tumor of the calvana In most instances they have come to us because of a pain or because of an enlargement somewhere over the head which is often referred to by the patient as a knot The incidence would be hugher than in a bone clinic where the leuon is found coincidentally when the patient is being studied generally or because of a bone tumor disewhere The incidence is higher in the office where the paucnt u referred because of a particular symptom rcferable to the head than would occur as normal percentage per thousand of average populace 3 ·4 Protary Tomas of us Colsona CLASSIFICATION OF TUMORS OF THE CALVARLA In outlining a classification of tumors of the calvania for clinical purposes, we wish to include along with the primary lesions, those tumors produced by general discase processes, if the incidence of the skull manifestation is relatively high in the symptom comple of the disease So this would include some lesions that are not neoplastic in nature 1 GENERAL DISCUSSION OF CASE SUMMARIES Statistically speaking the total number of tumors under con sideration not large enough to permit one to draw definite conclusions in regard to incidence as to age and sex However there may be sufficient evidence to suggest that the benign lemons occur more frequently in the female than in the male. In our group of 43 benign tumors, 72% occurred in the female. ln Van denberg and Coley's' series of 15 cases, 6639% occurred in fe males The average age was 38 years. The reverse is true in malignant cases, there being 80% of our cases in males In Vandenberg and Coley's series of 7 cases, 71% occurred in males The malignant tumors, as one would expect, occurred in the younger individuals It is interesting to note that in our series and in that of Vanden berg and Coley' the vast majonty of tumors occurred in the frontal bone The panctal ranked accond and the occipital a poor third Only 2 tumori affected the temporal bone Tumors of the base of the skull have not been included in the study The benign tumors, as a whole, were usually small Most of them had been discovered some months or years before consulting a physician The tendency for the lauon to grow alowly larger and in some cases to cause pain was the common reason for scel ing help The usual complaint was that they had a koot or bump, which was painful or sore and it was slowly getting larger Head ache was only occasionally mentioned and this especially if the dura was involved or the diploe expanded The malignant tumor were larger more painful and grew mort rapidly The pain was quite severe in some cases Had ache was more common and intracranial signs and symptoms were present depending upon the location and size of the legion ·CLASSIFICATION OF TUMORS I BENIGN TUMORS IIC. MALIGNANT TUMORS IL GENERAL DISEASE PROCESSES WITHI TUMOR LIKE LESIONS Osteoma Heinangroma Cavernous Capillary Giant Cell Tumors Epidermoid Cysts Traumatic Cysts Chondroma Lapoina Osafying Fibroma Eosinophilic Granulomn Lanthomatosis Fibrous Dysplasın Paget's Disensc Leontius Oese? Hyperostosis Frontalis Interna Osteogenic Sarcoma Chondrosarcoma Fibrosarcoma Ewing Tumor Alyclom? (plasına cell) Reticulum Cell Sarcoma Hemangio-cndothelioma Chloroma Gerard Coundation of Calraal TOTS *Cach umor duard in the order listed above un ·SYNOPSIS OF CASES Remarks 4g Sa Lxehtes 26 F Rocc 54 M Lfr 22 FRE GMJ 57 CAL 57 HDS 51 Path Dry 0 0 0 Y40 Die Outcoma Ost. Sier 3 x 3 cm Lump 1 X 2 cm. Koot 2 X 2 CD Koot 3 yrs Hendeche 2 x 3 cm. Mit 2 yn 2 x 1 cm. Koot 3 y 6 X 6 CTO Knot 6 yn 2 3 So No No No Ott 0 Ya AAR 55 BLB. 55 JB 58 25 F Roc. 22 F R.fr 36 F R.fr Osteon Ont. Ost Ost Ya 6 Ya Inner table left tact Inner table lot intact Tumor removed-bone flap Inner table loft intact Inner table left Intact Inner table left intact Ont (2) 7 6 9 10 JJ 43 CEC 57 T.B. 58 PB 58 17 M L 45 F L fr 36 F Lfr 57 TRI 6 x 7 cm. Koot 10 yr. 1 X 1 cm. Koot 18 mon 2 X 2 an hoot 10 YTL 1.5 X 1.3 No symptorna Oft. Ont. Out. Out Out. 2 rernoved Ya Ya No 0 11 NEH 51 42 MR par 15cm X Headache Henang 1957-no removal 2 C Pam 12 Removal tantalum pl ya Primary Times of the Calrania JLS 52 51 MR.fr 2 X 2 an. Headache 13 MW 56 44 FL.fr Cav Hemang Car Hemane Car Hamang Cav Hemang Hemang Hemang 3 x 2 cm. Sortzaa Ya Roentgenotherapy OR and plastic crinoplasty Tantalum anunloplasty 14 HC 52 28 F L par 3 X 2 cm. Headache Louis Gran. 15 JM MCM 50 40 F L par 2 X 2% Headache Hemed an Cav Heming 2 yrs OR and Roentgeno therapy OR and tant aunlopluty ra No 16 17 RB 54 RT 54 71 M Lift 35 F Lir Heming Roontidotherapy 18 MH55 66 F Rocc. 2 X 2 cm. Haduche 8 X 5 co... Headache 2 X 3 cm Throbbing 7x 5 ern. Throbbing pala Heming Cap. Henang Cap. Hem 0 Cap Hemang 19 B.S. 58 19 F Osc. Ligated Eut. car Ya AV Flital Large yucular men removed Skull inrolred ·Sear Au 20 TTB.58 ic 48 Ipar Romeu Tajury 20 yn before 4 X 5 CTO Threache I plu ม pld CE 41 21 27 Sorren MR.fr CML. 3 X 4 cm na I pled 22 FWh 47 23 MR par Sorc mm GIH 54 23 Ileadaches 5-8 prit Sytt Traum cytt ()s (traum ) Traun H Traum cyst 1... 53 OR 55 24 OR and plantle crantoplasty OR and Paul cranioplasty OR and plauk cranboplasty Cut wall and outer lahke retround cry rular 71 33 m. llcadache Tpic TL par MLT 58 OR 58 25 3 X 4cm Tumor 4 FR par ? ATKO hL 50 71 F RDCC 76 6 X 8 cm Chona Crowing Chond Remoral הבום 27 RM 52 21 A1 Roor Hexache Tond lo 16 X 2 am 13 X 2 ст Town Gran Tonin Cran. CIC 52 28 FR par Sormet Colo. Gran Outer cable craded and poft huc invaded Gerriel Considnation of Caltania Tunts 29 Jy 55 24 T R par 2 X 2 an. Sorenc Cogo Gran. Posla. Cran Removal and ant. plate Komor and plastic plate Retroval and plastic cranioplasty Returral Perionioun attached 2 rodn-WBC 17 000 FS 54 35 ARE 1 X 2 on Pain Poun Gran. Foun Cran Trtepukd through perkaranlum 31 J-S B. 54 F Lopar 2 X 2 oth Local pala Extended through both tabki 32 WO 53 21 no M L par 1 X 2 cm Sorens Tin Onn lotin Gran Santho matonta 33 WRO 37 3 M R.par 6 Xin lain fouin Gran Toulot. Gras untha matoals (2) Wantha matasha Fibr dypl Μο Korntgenotherapymultiple lalons Roratrotherapy muldple kuions Ptastic cranioplasty 34 W L 37 2 MI'r k par 4 X 3cm Pun An \unthematosta Fibe Upl 35 JR 58 20 M Fr 4 X 5 on Pain Yo L ·00 Yen BLH 54 try So Lxer 13 FL-par Puh. Dus Fibr dypl Svo 5X 5 cm. Lamp 2 X 3 CIO. Ora 36 O Ya R ir par PJ.H 50 17 FR Out. Ya 4 X 5 cm. Headache 3 x 3 cm dlory MonD Fibe Rorol Cranioplasty Inner ud outer tablo Cipended Cranioplasty Inner and outer tabla expended Circumference in CTC cd . In in dyop! 30 CH 45 Had colarging Paget's db No 39 RH 45 10 y.. Murve Leon Yo 61 M Fr-tomp empecially 55 P Calvarla & bure 16 F L TYmular tetap 55 F Bhd O. 40 SAS 57 Large Tumor 20 y Luce larte Leon O Loon. O. No 41 JBH 39 Headache Hyperar No 42 E.S. 51 57 F Bb Hadache Primary Times of the Calconia S.K. 55 43 P BI-Er Headache SR.M. 50 44 F B. Er Headache Sella enlarged 45 RS. 57 14 MR.Er fr lat Hypero. No [r Int. Hyperos No Erint Hyperor. No fr int Extendre Sart 2) Sarc. (2) Tupoval Outcogs Osteog 2 tima in Birrt. Sarc. 5 O Chandra Chondro. 5 tima in Sarc. 3n Ortoos Ottco Beso Lovolved almo 46 CP 48 14 M Rocc. Par JOT 4 3 X 2 Pala tumor Ate Hondacbc Grape Tumor frolt Laloa 1953 1956 kull & oba bona их Hendacho I go Large Headache 26 at Bliper 2 ORS before we w hlon Afaltkentric chooctrovare Bury and Irradiation Boao marrow podtive BJ pr Deatruction alitun CH.B. 50 75 F Bbpar 19 RP 46 13 A Rocc. PT PLC PIC myelome myeloma ul. hemangio endothe Bomu ·Grand Congdarafton n Calome Twmots 9 Only ilic linusual appcanng onicom is were acctioned for microscopic study Tic soft tissue of all the tumors otherwise was studied in over 75% of the care a tissuc nudy was obtained Forty four operative procedures were performed there being muluple operations in 5 cases The exact diagnosis cannot always be determined befort surgery by the clinical findings and rocntgenographic interpretation Sometimes 1 most exliaustive and delilycratc study ends up with 2 or 3 possibilities Thus the surgcon must dcpend upon his own experience, and dunng surgery utilize the help of a competent pathologist before deciding the type and extent of surgery to be employed He may stop at time with only a biopsy and resort to somc forin of radiotherapy or other nonoperative treatment ample surgical removal may save extensive radiotherapy In some cases tien surgery may not be indicated while in others thic extent of surgery may be in quesuon Expenence, surgical judgment and analysis of results of cases treated by var Tous procedures as noied in scattered cases through the literature, all may point the way But there are many problems of therapy that have not been resolved to date These problems will be discussed with cach particular tumor The problem of cranioplasty is usually decided by the type of tumor the location and the extent of the cranial defect In the benign casa, at the time of the initial surgery we have fitted a cranioplasty when the defect is large enough to requirt dural or cerebral protection or when cosmeuc factor are a matter of con sideration It is easier to get a good fit using the one stage method of acrylic cranioplastic repair in this way the cact thicknats, shape and nze can be obtained by molding the material before it hardens into the cranial defect CRANIOPLASTY Plastic material has been used for many purposes during the Past few yean Orthopedic surgeons have used it for reconstruc tion of bip joints It has beco used by dentists It has now become very weful in repairing skull defects Rictz' reports that Zander in 1940 was first to use methyl methylacrylate for the cranial defect Many neurosurgeons since have reported repair of d ·10 Anmery Timors of the Catania on its use for cranioplasty, and also concerning its favorable tissue reaction Plastic material is strong it is light and it is land to the tigua The speed with which it may be prepared, and the case with which it may be fitted into any shape of cranial defect, has made it especially valuable for this purpose To Oliver and Blainel' and Woringerl should be given the credit of developing the one stage method of acrylic plastic cranioplastics This technique has made it possible at a moment's notice to mold a soug fitting plastic place to fill any sizc defect Therefore, it can be used for repairing skull defects produced at surgery because of any reason or because of previous trauma, such as open depressed fractures or closed depressed fractures of the skull Rietz has routinely used it in traumatic cases at the time of the initial surgery We have used it since 1954 mainly for elective cranioplasties. and for the repair of operative defects produced particularly in the removal of primary benign tumors of the calvaria We have had no complications to date, and we have used it in 21 case We have obtained a more uniform fit and consequently there is no bulge or unevenness at the margin of the plastic plate, like someumo one would have with even the beat fitting tantalum plate This gives a better cosmetic result Furthermore, pneumograms will show normally and will not be obliterated as would occur with a tantalum plate in place Roentgenotherapy for any pur pose can be used without interference by the plastic plate The method we have used has been very satufactory During surgery when the decision has been made that a cranioplasty should be used, the sterile resinous parvder can be placed in a mall mixing bowl and the sterile cranioplastic ampule of liquid can be added The nurse vigorously mixes the two substances, much as in making biscuit dough This mixing is continued for 3 or 4 minutas At this time the powder is thoroughly mixed and a doughy mass results. It is then taken up in the hands and worked pounng some Ringet s solution over the gloved hands to prevent sticking In about 6 or 7 minutes it will begin to feel warm and taka on a workable doughy forma This u then molded into the defect over a piece of cottonoid that has been introduced to pro- ·Grmal Connda whor of Caltansol Tumors 11 F la Showing outer surface of plastic plate molded to fit akull defect. FL1b Showing under surface and flanged margin of place lu contour varias with that of the dull to give a perfect fit tect the dura and a thin fange is allowed to extend out over the periphery of the defcct This will help stabilize the flap and safe guard against outnde pressure forcing the plate inward Soon it will become warmer and before it has become hot, the plate 19 removed from the defect and allowed to cool poumog Ringer s solution over it Gradually it becomes fixed and at this time the finishing touches to secure a good fit are made When it has hardened the margins art trimmed with a rongeur If daired perforations for wire sutures are made at the barglas of the flap This plastic matenal looks like bons, it is about the same weight as bone, it feels like bone and it bites with a rongeur like bonc The cottonoid is now removed from the dura and the plate replaced A tight scalp closure 18 made and a mild pressure bandage u applied over the wound A tendency toward unfavorable tissue reaction in animals has been reported from some laboratories So far as the writer has been able to determine no ruch reaction has been reported in practice and no doubt, many thousands of cranioplastic repairs ·12 Primary Tumors of the Coloana have been used throughout the country It seems likely that the posability of uptoward reactions is very minimal In the malignant cases, a cranioplasty w usually not wed Re moval of the tumor will relieve the pain and headache, even though a cure cannot be affected Sometimes relief of suffanng is sufficient to justify the surgery involved Certainly a cranioplasty is not indicated unless the end results will justify its usage BIBLIOGRAPHY 1 Vandenberg H J Jr Colcy B L Primary tumors of the cranial bond Swy Gyms & Obst 90 602-612, May 1950 2. Goxchickter C.F Primary tumors of cranlal bona. Cancer 20 155. 180 1936 3 Harmon, P H. Methy Lacrylate reans in rurgery with special ref crence to the reconstruction of arthritic joints. Mod Plashes 20 56-57 pp 114-116 1942 4 Rietz, harl A. The one stage metbod of cranioplasty with acrylic plastic. Nextos erg pp 176-182 Mar 1958 5 Gurdjian ES Webster J E Brown J C. Impromuon technique for reconstruction of large zull defects Swrgery 14 876-881 1943 6 Ker A S The use of acrylic reun plate for repair of akull defects. 7 Nacral Psychaal 6 158 1943 7 Small, J M Graham MP Acrylic roin for the closure of hull defect, preliminary report Brt 3 Store U 106-113 1943 8 Woolf J I Walker A E Cranioplasty collective review Irlad Abar Swag 81 1 23 1945 9 Kleinschaidt, O Plexiglas rur Deckung von Schadellucien. Chary 13 273-277 1941 10 Oliver LC Blaloc, G A new one stoge method of cranioplasty with acrylic plastic Med R 220 167 169 1943 11 Woninger E. Schwag B Brogly G Schneider Nouvelle toch pique ultra rapide pour la réfection de bréchos oscuro cran iennes à la réune acrylique. Advantages de la relac Acrylique sur le tantale, Roo ol 85 527 535 1951 ·Chapter II BENIGN TUMORS OF THE CALVARIA We have chosen to include in this group Osteomas hemangiomas, giant cell tumors epidermoid cysts, traumatic cysts, chon dromas lipomas and ossifying tibromas. OSTEOMA We have placed osteomas first because they are the most com mon of all the turnon of the caliana The exact incidence is difficult to determine Many ostcoma go unnoticed, also many are not brought to a physician s attention when nouced It would seem that our figure of approximately 20% would be too low They have a tendency to occur in the frontal region': and decidedly more frequently in femala They do occur in all parts of the skull however including the basal area There are many kinds of bony growths' but the lasons thought to be neoplastic in character are usually considered as being spontancow, or possibly in some cases traumauc in origin In case of the calvaria, osteomas arise from the membranous bone and are very compact and cburnated They may be angle or multiple large or small, but slowly become programively larger It is thought that trauma may cause them to grow faster A rapidly enlarging tumor should be promptly removed The patient u most often a young female but ostcomas may occur in malo and older people. They usually complain of a knot or bump on the head that has slowly enlarged The losion may be smooth and round or irregular and flat The skin is mobile aer the mass and there is wually no reaction of the scalp and no indurauon or discoloration Very few complain of pain ten derness or headache It would seem that if they did not increast in size, very few patients would bother about thu tumor The roentgenograms shovy a well circumscribed dense lesion, that extends outward Only infrequently u the inner table de 13 ·14 Promary Toners of the Caloma pressed or the tumor protruding inwardly Often the toner table may be left intact at the time of removal of the tumor There is no separation of the tablas The diploic markings fade away, as doos the idenuity of the tabla in the arta involved by the tumor Somc large tumors present a spongy appearance Increased vascular markings are not observed There is an outward proliferation of bone and no absorption or erosion of bone. This u an import ant point of differential diagnosis from a meningioma. Menin gromas also produce proliferation of bone, but the proliferation 13 mostly inward Vascular markings are prominent and pressure signs are present. Spiculc formation is common in meningiomas, but rarely found in osteomas Hyperostosis frontalis interna is not difficult to distinguish from osteoma, because these lesions are less circumscribed usually bilateral and extend intracranially They usually occur in older patients Unless the osteoma has already grown to a large azc, or is growing rapidly one need not be in a hurry in deciding upoo removal The fact that they do steadily increase in uze makes their removal degrable, however this may be done at the patients convenience Thar frontal location makes them readily visible on many people Thc protruding nodulc or mas may be quite troublesomc to some patients They may extend into the frontal slous and at times block the outlet or cause other sinus problems. Thus we recommend that astconas be removed The method of remor al depends upon the type of laion and its location The usual sınall circumscribed tumor can be removed by rongeurs and burt leaving the inner table intact A cranioplastic repair usually is not necessary However if it were ad visable to remove the inner table with the tumor a tantaluo button or if larger a plastic plate can be molded into the defect. If the tumor is large, a bone flap is turned about it. The dura and subdural space is inspected carefully for tumor or scar and a plastic repair is made However we have found that in some cases the excessive tumor growth may be removed from the flap and the bone flap boiled for 20 minutes and then replaced in these cases it is better to reflect the pericranium along with the scalp flap so that nothing but the bone is boiled and replaced We have found that this procedure gives a very good end result ·Fig 2 Case 1 R occipital osteoma There is no reaction and a good fitung bone flap replacement is obtained One case, No 6 presented a rather unusual problem becaux of the size of the tumor (Please see later reference) CASE REPORTS In the report of all the cases to follow only the pertinent pos itive findings in the history physical neurological and laboratory cxamination are mentioned This is done to save needless repe tition of negative tests and examinations Case 1 G M J ſeriale, age 31 seen in 1957 because of a lump 1 in. in diameter in the right occipital area. It was first noticed in 1949 and had been growlog slowly since There had been no pain, but headaches of undetermined ongin were present. Roentgenograms showed an area of increased density with Ixonc proliferation extending 4 nm above the surface of the skull. The diploe was les distinct and there was a tendency for the 2 tables to lose their identity Neurologic examination was cnurely nor Inal, to observation was recommended at the tinc So far rc moval has not been necessary ·16 Pristaty Txonors of the Cecama Fig 3 Core 4 R occlpltal osteoma. Case 2. C. A L male, age 54 wus seen in 1957 with com plaint of fatigue, personality change, teasencs, disturbance of memory and concentration. He had no headache, but roentgenograms of the head disclosed a mall osteoma in the left frontal region. Thu was not producing any symptoms and did not enter into the condition cauung this man s troubles. It is being Lept under observation Case 3 HD S female, age 22 was keen in 1951 because of a knot 1/2 cm in diameter in the night frontal arca Thu Hà lycen pobced about a year earlier has not painful or sore, but had grown somewhat larger Headache had been occurring for the past 7 months. There was a history of a car accident 3 years before and of being unconscious for 3 houn Rocntgenogram revealed a dense bone lesion thought to be osteoma Removal was suggested but patent declined She has not been seen doce 1951 Case 4 AA R. (omalc, age 25 wus seen in 1955 because of a knot in the night occipital area It had been noticed first 15 years before, and was slowly getting larger Only recently had it caused pain and was tender on palpation. The scalp was freely movable over it Rocatgenograns showed a dense lesion extend ·17 Bagi Twors of the Colrare Fig 42. Care 6 R frontal osteoma. FT 4b. Cax 6 Same cox, after flap turned and tumor removed. ing outward for about 1 cm. A little over a year later the tumor was removed, using a burr and rongeur. The inner table was left intact. A small nene passed directly over the tip of this lenon. It wus sectioned There have been no further complaints from the patient, and she has beca observed at yearly intervals, Case 5 B. LB female, agc 22, nus seen in 1955 because of lump 2 x 1 cm in the right frontal arca. It had been noticed 3 y can previously and had grown slowly It was not tender and caused no pain Tangenual films showed a protrusion of 6 cm from the skull surface outward A burt was used to grind this tumor down to the loner plate The defect was sucerized a piece of gelfoam placed in it and the scalp closed io layers. There has been no cudence of further trouble from this lalon Case 6 J B., ſemals, age 36 has seen in 1948 because of a bump in the nght frontal area It was nouced Keral yan before and had caused no discomfort, but was gradually becom ing larger At this tune it measured 6 x 6 cm and protruded approdnately 1 cm. from the surface of the skull The under table was slightly depressed A xalp flap wa reflected within the hair lpe, including all of the pericranium, except that oner ·18 Primary Toners of the Cologna the tumor A bone flap was then turned about the tumor With chuel and rongeun the protruding tumor was remooved level with the surface. Then the flap was boiled for 20 minuta. Dur ing this time it was noted that the outer layer of the dura was Lightly involved but the underlying brain was not affected. The bone flap was cooled and replaced and the scalp closed over it. Healing and convalescence were normal and subscquent ob krvations since revealed the fact that the bone flap served as a good osteoplastic repair The bone flap fits perfectly is grong and boiling destroys the tumor cells. We have done this la casa where meningiomas involved the bonc flap to a moderate degrec and there has been no untoward reaction that we know of There have been ſewer complications des clop from the procedure thao from the use of tantalum plates. The procedurc may prove quite useful in certain cases Case 7 J J, male, age 17 was referred to us in 1943 because of a knot in the left frontal aren, attributed to an injury at 7 years of age, and another bump in the midfrontal arce that resulted from a fall out of bed during Infancy Both had been growing steadily Patient complained of headaches. There ww no tenderness and the scalp was freely movable over both Janons. Roentgenograms showed the upper lerion to be denker than the lower onc. It protruded 3 cm. from the surface of the skull, and measured 6 x 7 cm in diameter As Osteomus frequently do the lower losion involved the frontal sous. On 8/21/43 incision was made through cyebrow and the kalp reflected The osteoma was reinoved with burt and rob grur, Icaving the inner table, but including that part involving the outer wall of the frontal unus The membrane of the sinus was not injured On 9/16/43 the larger tumor in the midfrontal area wa renoved The outer portion wu very hard Muldple perfor ator openings were made parallel to the skull surface and the bone between rongeured Away The inner portion was ofter in places, but interpersed were very dense spicules that required 1 double action rongeur to dislodge With this method plus a curet, tbe entre tumor wu removed The inner table of the skull was left latact. lle saw thus pauent again in 1952 He had served in the The skull contour was good and there was no cvidence of recurrence of the tumor Arm 6 years ·19 Bexiga Tumors of the Colome 175 Case 7 Osteoma, L. frontal and midcoronal margin Case 8 C. E. C female age 45 was first seco in Apnl 1958 because of a nodule 1 x 2 croin diameter in the latcral margin of the left supraorbital ridge It extended slightly into the orbital cavity It was not tender The paucot had noticed thu losion for about 18 months and that it had increased rather rapidly in size Roentgenograms showed the arca described above to be of increased density There was no absorption or crosion of bone and no increased vasculanty This is a common ute for Osteomat. In May 1958 this lesion was removed with burr and rongeun. The nodulc protruding into orbital cavity was re moved It consisted of dense eburnated bone No repair of the skull was necessary and the contour of the supraorbital ndge was muntained Had thus tumor teen much larger and destroyed the supraorbital ridge a much more difficult problem of repair would have followed Thus it is well to remove them carly in thu location, before they have attained a large uze and involved the orbital ridge or the orbital cavity to any extent. Case 9 TB Cage 36 ſemalc, was referred to 1958 because of a kpot in the left frontal area It was 2 x 2 cm. in diameter

·20
Primery Tumors of the Caloana
F 6a Cake 10 Osteoma R. frontal area, lat view
Fig 6b Cake 10 Osteoma R frontal aru, p.2 view
and protruded about 1 cm. out from the surrounding akull It
had been present 10 year, becoming much larger in the past
year or two When a child she was struck in this area with brick
Roentgenograms bowed capannon of the outer table of the left
frontal bone almost to the midline. The inner table was not in
volved No other abnormalities were seen

·Berige Tomors of the Celcare 21 At fungery the periostcuin had not brecn penetrated Bony proliferation extended in mushroom fashion out over the edge of the surrounding skull It was cry hard with burt and curets the entire losion was removed The inner table was not involved and loſt intact. The shull defect was saucerized Case 10 P B age 57 ſemalc, was reſerted in 1958 because of constant headache, which however had been Intermittent before the past 3 weeks Complete phyucal and neurologre examination did not retal any poutive objective findings, except on area of inctcard density 15 cm x 15 cm in the night frontal area A slight claption of the skull was palpated over this louon It was not tender on pressure. The scalp was canly movable and 1 The headache apparently did not onginate from the osteoma Thu lesion will be observed at intervals of 6 months or 1 year Should it cause symptoms or increase in size it should be re moned Unless otherwise stated the symptoms and complaints incident to the tumors in the above cases have been relieved The umple removal of the small ostcoma has been adequate The larger tumors require the removal of a larger part of the calvana and consequently the subsequent repair has been more extensive. The intracranial structura have seldom been involved HEMANGIOMAS These occur less frequently in bones than in soft tissue Ac cording to Wykg, ' of 4 449 ncoplasms of bone, as luted in 3 series of cases, there were only 36 or 0 7% hemangiomata After a thorough search of the literature, he found that henangioma of the skull represented about 02% of bone neoplarms There are 2 primary benign hemangiomas of the calvania, the cavernous and the capillary types The capillary type occun vcry infrequently It u more destructive, may be multiple and may produce symptoms of intracranial involverpent as in the case of Haudousa Holmes and Sweet' think that the cavernous type may result from the confluence of the capillary conglomerates in ther 4 cases the tuber-frontalls was the arca Involved It is also the primary ossification center They thought this to be ugnificant In Toynbce s original case, there was a tumor in cach parietal He also suggested that there may be some antociation bearca ·22 Arnar Tumors of the Caloans Flg 7. Tangential view of bemagroma, showing radiation bode spiculas gh the typical sunburst appearance. Tangential view of meainglords showtog parallel spaculao bony prollferation Fig 7b tween the tumors and the centers of ossification of thc panic bone Considering the findings in the review of the cares avala in the literature, there is little evidence to support thu theory Cavernows hemangiomas constitute the vast majority of the ca reported This is the usual and classical laion found in the calvai Wyke' in 1949 reviewed the literature for the preceding 1 years and found only 39 cases of primary hemangiomas of 1 skull In this group of 39 cases, most occurred in the fourth cade of life and most frequently in the panctal arca For the who are interested all the authors reporting caxs from 1845 1949 are listed in the above paper by Wyke" ·BRICK 7 mors of the Carrera 23 Toynlxe' las lxeen given thc credit for recording the first case of hemangioma of tlic cali na Most of the xulxequcnt reports haic lxccn of single cases. Bucy and Capp' found the skull in volved in 18 cases Geschickteri' reported 5 cases Vandenberg and Colc," reported 6 cases Rowbothin' reported 5 cases Holmes and Sweet reported 4 cases in 1952 In our series there were 8 licmangiomas or alsout 16% of the total nurnlcr of tumors Onc hall occurred in the frontal and one half in tlic panctal arca Two-thirds occurred in fcmalos It was noticed that all complained of licadache It is our thought that the tendency of the licmangioma to develop between the tables of the skull and ballooning of the tables may account for the complaint of headache In ſar advanced cases, the inner table may be croded and thic duro involved causing pain This is rare as they usually grow slowly Thc soft tisuc of the scalp or dura is seldom involved So in palpation very llede tenderness i en countered One can usually feel a slightly raised lesion involving the skuil with thic Kalp freely movable oer it In more advanced cases the outer table is penetrated and in this instance the pen cranium is involved, producing local tenderness and soreness Rocntgenograms talen in the lateral antcroposterior and posteroanterior and tangenual positions are very helpful in the study of the case Coley's mentions the sponge rubber or honeycombed appearance on the direct vicw The tangential films reveal in many cases a sun ray appearance Radiaung trabeculac, like spokes of a wheel extend from a central point, while in menin giomas there is a tendency for the trabeculae to extend in a parallel fashion There is neither shelving of the periphery of the tumor as in cosinophuic granulomas, nor the punched-out appearance How ever the radiolucent area is usually round or oval and is without increased vasculanty of the surrounding bone. There u no hyper togus Spreading of the 2 tables may occur with noticeable Thus u grcater in the outer than in the inner table In far advanced cases the outer tablc may be paforated but this is infrequent The inner table is low frequently penetrated than the outer table, consequently the dura is not likely to be involved The above findings, involving the parietal bone in a female in CTOJOn ·24 Primary Tumors of the Coloana the fourth or fifth decade of life, would strongly suggest a cavernous hemangioma These lesions gradually become larger, cause more headache, and some belicvc may even become malignant" We have no information or evidence which supports this idea However, it would seem that removal of the tumor surgically, offers a utot factory method of handling these cases Roentgenotherapy aloze or after surgery, has been used Surgery presents a definite ding nosis and removal under direct vion after the identity of the tumor us known One also escapes the effect of roentgenotherapy upon the deeper structures A cranioplastic repair an be donc at the sainc setting, thereby obviating a second and later round of surgery When exposed the tumor appears bluish in color with a hard shiny layer of bone forming the outer covering Bencath this outer layer the honeycombed bone is found Using a sucker" one can completely cmpty the small honeycomb compartments and get a good view of its formation Thu part of the tumor is soft and can be removed with a curet or burr down to the inner part of the inner table. Sometimes the tumor has attended between the tables considerably farther than the rocntgenograms would inde cate The texture of the bone, as indicated by the rongeur bite, will help determine the lateral limits of the tumor Usually a burr rongeur and curet will be all that is needed for the removal of the hemangioma Bone wax will control the bleeding placed on the burr while burng through the vascular part. Some choose to remove the lesion by bloc resection In this case a bonc flap is turned about the periphery of the tumor If thus is done, it is well to take into consideration that oftentimes tumor tissue extends far out between the 2 tables away from the raised and honeycombed central part We have used roentgenotherapy in some cases, but more espe, cially the capillary type In these lesions, therapy u repeated at intervals The gross appearance is typical As mentioned before, the honey combed area corresponds to the radiolucent arca seen by direct roentgenographic examination When the pericranium and, if present the thun outer table us removed the lesion can be emptied It can be ·25 Benign 7 Kotors of the Celtmı П; 8а ь External view of hemangioma showing honeycomb appearance (Courtesy B. D lyke Am I Routered and Charkı C Thomas, Publisher ) of blood by suction Then the craters of various size can be casily vigualized They seem to communicatc, because suction in one place readily emptia thc other crateru The blood appears to bc venous It rapidly refills Microscopically the cavernous type consists of lacunae lined with large well de cloped endothelial cells There may be con nective tissuc in places supporting the endothelial lining The bony trabeculac in some arcas may be thickened while in other arcas they may be replaced by fibrous timUC Scheinberg and Ellin' recently called attention to a hemangi oma of the akull associated with an angioma of the brain A casc was reported showing the hemangioma of the occipital bone and an angiogram outlining the intracranial angioma No anatomical connection was demonstrated between the skull lesion and the intracranial angioma It isn t uncommon for hemangiomas to be multiple and to be located in different parts of the body CASE REPORTS OF HEMANGIOMAS Case 1 NE H male age 42 was referred in 1951 because of headache lor 2 ycan and frequent nomentar, dizaines dur ing the preceding 2 months. There was a raised irregular area 15 x 2 cm in the nght panctal arca It wu slightly tcoder Roentgenograms showed a discrete honeycombed lalon. There was no increase in vascular chaonels about it. An encephalo gram did not reveal un attocuted intracranial lauon - ·26 Primary Tumors of the Celtana Tig (l) Heroangioma of occipiul area Fig 96 (Lacert) Samde cox with anglogram showing an angłoma of the brain and no anatomical consecuon with the hemangioma of the occ. bone. (Courtery L Scheinberg, and M Ellis' (the editor Awwwagad publisher Lancet Publications ) The tumor was removed with a burt and rongeur It extended to the dura. A small tantalum plate was fitted Subeequent ob kry auions have recalcd no further trouble Case 2 JLS male, age 51 seca in 1951 because of bead ache and a knot in the nght frontal arca about 2 cm, in diameter Roentgenogrums showed a circumscribed loss of deadty of the home lateral to the frontal anus and communicating with it. The inner table Au not involved There wu po increased at ·27 Benign Tunes of the Calcona Fig 10 Cax 2. Hemangioma In R. frontal arch culanty no hyperostosu. There was a faint honeycombed appaarance in the direct view August 1952 the tumor was removed with burt rongeurs and curet, leaving the inner table. The frontal unus wall was removed leterally but the membrane was not injured The microscopic sections showed the lason to be a typical cavernous hemangioma Postoperative rocntgenotherapy was given because some tumor tispre may have been missed about the onus. Subsequent films showed denty of bonc returning and the defect less prominent Case 3 M VY female, age 44 referred in 1956 because of headache and forener over a growth in the left frontal area for 1 year Three years previously she had been struck in thus region Roentgenograms shorved an arta of decreased density involviog the left orbital ridge and orbital plate There was evidence of bone destruction The direct film showed the honeycombed effect In July 1956 the tunnor was exposed It extended 1 cm above the outer table was very porous and filled with blood A sucher up placed on one part of the tumor emptied the entire loon of ·28 Primary Tumors of the Coloana Fig 112. Cuse 3 Lat view showing radiolucent arca above the left orbrul dye- Fig 11b Same cake, tangential view thowing typical punburst appearance of a hemangiomu. its blood content and one could see the sponge like construction of the tumor It was removed with rongeurs, along with in volved bonc surrounding the main tumor It was necessary to remove part of the ridge and roof of the orbit. After this a plastic plate was fashioned and secured with wire at 3 places. It gave a good cosmetic result The patient was seen as late us May 1958 and was free of symptoms Cass 4 H C femalc, aged 28 was referred in 1952 becaux of headache and a lump in the left panetal area Roentgcto gram showed an area of decreased denunty 3 x 2 cm It wu

·kan
Fly 12b
FH 120. Cak 4 Lat view of hemanglama 1952
Same pt. 5 years after operadon-note another ladon developing
posterior to first hemangioma

·30 Primary Toners of the Cdrarna Fig 13 Cax 5 let parietal hemangioma. ance. elevated about 1 cm. above the skull surface and artcoded through both tables of the skull There was no honeycombed appear The roentgenologut favored an cosinophilic granuloma because of the shelf like irregularitia of the tables of the skull. However on April 2 1952 at surgery a typical honeycombed laion was cncountered The frozen sction, and later higopathologic studies, proved thus to be a hemangioma It was removed with burr rongeur and curet Roentgenotherapy was given and later a tantalum plate fitted over the skull defect In 1956 headaches returned Just postcrior to the tantalumn plate patient complained of tendernen, and roentgenogramas showed an arca of decreased deanty One year later in Roverher 1957 it was noted that this area had increased in prominence. There was a margin of normal bone between this lesson and the former defect, now covered in a tantalum plate. Roent genotherapy was given The tantalum plate area was shielded. In the original films, a suspected lexon was noted in the ate of the second tumor Case 5 J M Mc female, age 40 was referred in 1950 be Cause of headache and a lump in the left pancual arca that was ·Fug 14. Caxe 6 Lat view of frontal hemangioma Fly 14h. Care 6 P.A view of frontal hemangioma ·32 Primary Tomors of the Coloana first noticed 2 years previously The headache was quite severe. The lesion was 2 x 2 1/2 cm, in diameter and clevated almog 1 cm aborc the skull surface. The roentgenogramı showed an Ares of decreased denuty but did not reveal the typical hoocy combed cffect found at surgery The denaty of the intervenlog bonc forming the compartments must have been in ufficient to show up in the exposure usedIt was removed with burt rongeurs and curet down to the dura and as far lateralward as accor Lan, to encounter good normal bone A tantalum plate was fashioned and placed over the defact This patient ho been observed at 1 to 2 year intervals and there has been no recur rence of the tumor There have been no complaints referable to her head Case 6 RB male, age 71 was referred in 1954 because of headache that had gradually become morc duurbing There was a slightly raised tender area in the left frontal region. The rocntgenograms showed a small oval radiolucent arta in the left frontal region The tendency toward boncy comb fondation was visible in the postcroantenor vicu This patient was treated with surgery and a plastic cranioplasty following reinoval of the tumor It was a typical cavernou hemangioma He was relieved of the headache. Case 7 R T female, age 35 was referred in 1951 to us be cause of headaches, and at times a feeling of ſaintness for the past 4 jcars. There was a slight discolorauon in the region of the leſt temple and check. 11c were able to locate roentgeno grams taken in 1940 and 1046 The 1946 report noted there was thinning of the left supraorbital ndge and considerable atten sion of the lemon, as compared with the 1940 films. At this time poentgenotherapy was given and at inten als unul 1951 at which time we first sau her Roentgenograms at this time abowed destruction of the lateral margin of the left frontal unus and superior margio of the orbital ridge and orbital roof Enlarged hord vtnous cheoncls could be palpated in the left frontoten poral area Vore roentgcootherapy had been gilta In 1953 end 1954 roentgenograms showed connnued improveicy, and patient improved clinically Whether or not this tumor had unda gone malignant changes cannot be decided Certainly it de furored more bone than the ordinan calernous haangioma and the blood vessels of the local area of the scalp became larger ·33 Remage Tumors of the Calrose IS Increased vaxular Fig 15 Cixe 7 Radiolucent arca 10 let Ripraorbiul area markings. Cap hemangioma and later throrobouc, and in placa calcified Many feature of the cake resembled a capillary hemangioma A section for microxcopic study may yet le secured It is interesting to note that a hemangioma wus removed in the area of the umbilicus when patient was an infant Case 8 A H female, age 66 was referred 13 1955 because of a throbbing sensation in the nght occipital arca It was noted there was a fullness above and antenor to the mastoid Headache was moderate. The general phyucal condition wus not good there being heart, kidacy and gallbladder disturbanca The roentgenograms showed a discrete area of increased vu cular marking just above and entenor to the mastoid There Husno honeycombed effect, no bone proliferation, but definite A thrill could le palpated at tune and pressure oblitet At surgery a branch of the postauricular artery wu TOHOn ated it ·34 Primary tumors of the Calpena Fig 162 (Upper) Case 9 Photograph of lat view of arteriovenous Tacuryan involving akull secondarity F 16b (linkt) Same cake. Fig 16c. (Laos) Tangential roentgenogram showing slight dull cronon. Blore erten Ave Involvement found at rurgery found to be larger than normal and communicated with the lauon The vessel was ligated and sectioned and the local aren in the skull rempared with a burt rongeurs and curct. It wu not necessary to remove the contr table of the skull. Neither was cranioplasts required All symptoms were reliesed The blood ·Remigr Tumors of the Caltania 35 verils of this region wcrc cnlarged and tortuous No evidence of an arteriovenous fretula could be ſound Corel This case is included because it is quite unusual and rarc. It illustrates a point of differentinl diagnosis, 117 a vascular tumor of the realp producing stondary changes in the skull RS. female age 19 was referred lecause of headache and a pulsating man in the occipital area Fiicycan before, she had #truck her head on a loll, while riding a school bus There were no il cffects immediately afterward cxcept some tenderness locally caſt mass gradually appeared over the ute of injury and a headache during the past year caused an incrcayng amount of troulle. The man was comprovable, and as it was compressed the patient complained of pain By gradual compression the mass could Ixe obliterated but when the presturc was released the mass quickly reappeared Apulsation and a high pitched sound Synchronous with the heart beat were easily olyained but der appeared on compresson of the right common carotid artery The suze of the mass also became definitely smaller and again enlarged when the artery was released Roentgenograms revealed some crouon of the skull Soft tissue films showed a mass containing some tortuous elongated densities thought to be distended vascular Etructures At hurgery greatly dilased vascular structures were encountered and removed en masse The outer table of the skull was croded and in places the Irregular surface of the shull was lined with thin endothelial lined structures, surrounded by connderablc argount of fibrous tissue Thc pathologist reported the findings conjutent with changes resulting from an arteriovenous aneuryan Clinical evidence would rupport this diagnosis. GIANT CELL TUMORS OF THE CALVARIA Benign giant cell cunon are commonly found involving the intracartilaginous bones of the body Membranous bona are seldom involved Pancoast, Pendergrass and Schaeffer? found 6 comes in the literature that developed in the bones of the calvana Lichtenstein'' in his bool on Bone Tumors stated that he had never encountered a case originating in the calvana Or 124 casos of giant cell tumort discussed by Coleyli in 1950 nonc were in the calvinia Vandenberg and Coleyli in 1950 reported a case

·36
Primary Thors of the Caloana
Pa
1
3
1----
--
17-
2---
7-
31
5
2
3
2
Fig 17
124
Shoxring location of 124 czta of glant cell tumors (from lows
Beer Courtesy Bradley L. Coky MD author and Paul B Horbo Inc
publisher )

·Rumen Tumors of the Calraria 37 that mostly involied the lasılar arcı, but thic zygoma and portions of the temporal Lonc ucrc invaded Tlus patient wis trcated with high voltage therapy, and 8% ycars later thicre was no cuidcncc of rccurrence of thic tumor McNcrncy's recorded 2 caser, 1 ans ing in tlic temporal bonc and 1 in the basılar arca Surgery and roentgenotherapy scrc lyothi used with good results Trauma'' and subsequent bleeding with reactive changes have been advanced as a possiblc causative mechanism Bone rarc facuon and destruction have been found rocntgenographically Diagnosis is made on histologic sections The prognosis is good in spite of the tendency of thic tumor to recur INTRADIPLOIC EPIDERMOID CYSTS There are 2 kinds of cpidermoid cysts which involve thic head the intradiploic and the intracranial type The introdiploic type u a rarc primary lesion of the shull beginning in the diploic region expanding and croding both tables as it develops It may rupturc through either or both of them and may attain a consider able nze with relatively few symptoms Except for the frontal and basal areas, the expanding tendency of the cyst produces a sclerotic appearance in the bone about the periphery of the lesion Thu losion is not of Infectious ongin and not to be conſwed with the cholesteatoma found about the car It is thought to be congenital in ongin It grows slowly but may become quite large It is soft and yellow in appearance and is composed of tissue de rived from cctoderm According to Ritvo" there are some supporting tissue fatty material cholesterol crystals and massos called wood cells Netry Tolgia and Alexander" recently presented a Unitary Concept of Epidermoid Tumors of the Nervous System They consider all of these tumors to represent embryological rests They were also able to produce a typical epidermoid cyst by closng a portion of scalp bencath the suture line of the skin Treatment is surgical remor al and cranioplasty CASE REPORTS Case 1 CB inalc age 27 was first reen in 1944 Ivecause of a raised place in the right frontoparietal arca It had been ·38 Primary Tumors of the Caloaria Fig 18 Care 1 Showing partial cumnation of bone about margins of an intradiplomc cpidermoid cynt of the ukul growing slowly over a period of several years. There had been some pain and headache during the past year The lenon ex tended about 1 cm above the surface of the stull and was about 2 x 3 1/2 cm in diameter It was firm but not hard The margin of the skull about it could be palpated at one point. Roentgenograms clearly sbowed thus skull defect, which seemed to involve both table. There was slight eburnation of bone about the margin of the lemon The cyst was confined bencath the peru cranium but had destroyed both tables of the skull. It was much larger than the bony defect would indicate Total removal was effected by sharp dissection and curet, uong rongeurs to remove spicules about the margins of the defect. The pathologic report was cp.dermoid cyst. Case 2 CF B femals, age 48 was referred in 1958 because of rightnded headaches that had started in March 1958 At times thev had been accompanied by nausea, watering of the eye and some blurring of vision In 1928 the patient had In jured her head in the left parietal region. The scalp wu lacet ated at the time but she was not rendered unconscious. The general phyncal examination and deurological examination revealed no abnormal objective findings concept in the

·Fig 19 (Upa) Cex 2. Epidermold cyst or alvarla. Jat view
Fly 19b (
Le) Core 2. Pe view

·40 Primary Toas of the Caloaia left panctal region, where one could feel benath the war an irregular defect in the skull Roentgenograms showed a large irregular radiolucent urca 4 x 5 cm in diameter There was definite cburnation of the bony margins There was a slight expansion of both tables about the periphery and a destruction of both tablos in the center of the losion. It was noted at surgery that the cystic tumor had destroyed the external table and was only covered by the percranlum at its central arca It consisted of a soft yellony mushy material, typical of epidermoid cyh. The internal table had been coded completely The tumor was adhered to the dura which re mained intact. The outer and inner tables were apaoded and thun The margins of the akull presented a concave U like" edgs, the inner surface of which was so compressed that it pre sented a hard glutening eburnated appearance. A curet made no impression upon it, except to remove a fine membranous lining The shelves of bone were removed by rongeurs, as well us the eburnated bone. A plastic plate was fitted and the scalp closed in layers The headache on the right ude may have been caused by the tumor but it was thought to be a histamine type cephalgia It was thought also that the injury 20 years before may have resulted in an inclusion of a piece of skin beneath the scalp and subsequently the cyst des cloped On the other hand the lexion quite likely developed from an Intradiplow crabryonic rest and the igjury was noncontributory TRAUMATIC CYSTS OF THE CALVARIA Cysts of the calvaria are most often traumatic in ongin They may involve the outer table, the diploe or the inner table wher ever blood may collect and undergo organization If the injury results in a collection of blood under the pericranium a cyst may develop externally but it would gradually affect the outer table and would show up as an area of decreased density with a soft swelling overlying it should a clot of blood develop and organic within the diploc, there would be a gradual croding and expand ing process that would be difficult to differentiate from an intra diploic epidermoid cyst. This was the diagnosus favored by the roentgenologist in 3 of our cases Epidural collections of blood

·958 3740
-
3
1
Fly 201 Care 2. Epidermold cyt, ahowing tumor tinue redoved.
IT 206. Caxe 2 Epidermold cytt showing kull defect and plantic plate.

·42 Primary Tumors of the Caloonia associated with fracture of the skull or trauma otherwise, which go on to organization may produce changes in the inner table of the skull A leptomeningeal cyst may result from tears in the arachnoid and dura, with flud becoming trapped and pocketed Presumably the pulsation of the brain' causes a bony change of a cystic appearance Loyal Davisº discussed the etiology and reported 3 cases in 1934 The general appearance roentgenologically u that of an area of decreased density with cburdated margins. Sometimes the onginal hematoma is partly calcified, giving a fleched appearance. Evacuation of the cyst is the treatment of choice. Sometimes 2 cranioplasty 18 necessary arca CASE REPORTS Case 1 F Wh. male, age 23 was referred in 1947 because of a headache, a premure feeling dizziness and at uma blurred vision. His symptoms were first noticed about 1 year previoudy In a car accident 7 yean carlier hc had injured his head The head was slightly larger than normal There wu a tender mixed place 3 x 4 cm in the left frontal area The scalp was froely movable over it. The rocntgenograms showed a radiolucent Onc roentgenologist suggested that the lexon lies be tweco the table of the kull and that the inner table was depressed The margins were all cburdated especially the inner table suggering to the roentgenologist an epidermold cyıt of the skull At surgery the pericranium was not attached A bone flap was turned about the tumor The flap measured 4 cm. at its thickat point. The dense inner plate was removed to expok a cystic cavity containing some spongy bone and fibrous tigue. Both the dura and anachnoid were thickened Microscopic Audy showed some chronic fibroblastic proliferation and a few lymphocyto. A tantalum plate was fitted This patient has been observed on several occanons in the past 10 years and has not complained or further symptoms Cou? G H female, age 58 was referred in 1954 because of a tender svollen place 3 x 4 cm. in diameter in the right pareital *A recent very interesting co* antradiplok tretentic cost has been added 106

·Benign 7 mors of the Colcea
43
Fig 212 Case 1
Lat vlew Intradiploic traumadc cysts of the left frontal ures
cortaal markingi diminthed over fr lobe.
F 216
Same cux, p 1 view

·14 Primary Tumors of the Coloana Fig 22a. Care 2. Traumatic leptomcaingeal cytt, lat view PA VICH Ame ex F 226 arta uma. She remembered striking her head in this area several At one ume she was unconscious for several dayz She had seen aware of a slow growing swelling during the past 4 ycan The neurological and physical aaminations did not reveal anything abnormal Hosvever the roentgenograms showed ·Hermign 7 w of the Celana an area of decreixel density 3 x 4 cm in diameter raised 2 cm abunt the hull curiace Tlic churnnted margins gave the op. pearance of an mpanding process Deineen the 2 tables of the Lull Again, the radiologic diagnoli #7s that of an epidermold Cut At surge When the pericranium was removed from the tumor the lon; shell appeared a reddish brown The texture Hay porous and by actual cuunt 20 drops per minute (crocodile tan") of spinal furd cruded through the tiny openings of the hard outer plate of brunc The removal of this plate unconered a cavy filled with cerebral spinal fluid and a small piece of pedunculated cerebral tissue which extended through the inner table and dura The long floor of the cavity was removed alout the protruding cerebral trasue and the dura opened the brain trauc mas normal Ixoncath and extending from the surface was this pedunculated piccc of normal appearing brain at out 1 cm. in its greatest duameter The pedicle was secuoned Microscopic sections showed it to represent highly vascular cerebral cortex The dura was cloed tightly and the cavity filled with gelloam and a plastic plate molded and secured in place with wire suture. The patient has been olxeritd on several occasions since and has had no complainus The skull contour is good There has been some thought alsout thus louon being of congen Ital ongin, rather than of traumatic ongin the Case 3 L Page 68 was referred in 1955 because of a con stant headache for several yean and a cranial defect in the left pariet: area alxout the size of a hall dollar She had in the past 3 years consulted many physcians and tried vanous med icines and procedures to obtain relief of the headache. Roentgen ograns taken 1 and 2 ycan previouds were compared with the the ones taken in 1955 There was definite enlargement of the area of decreased density The radiologist reported that area of dextuction, 3 x 3 cm in diameter lying in the leſt post parietal region 2 incha from the midling, appears to involve predominanty the diploic portion of the bone. There is more involvement of the inner table than the outer table. There u some sclerons of bonc about the periphery suggesting that it may have been prexent for an appreciable length of time He then fuggented a diagnosis of an epidermold c# She had suffered a rather severe injury to the head in 1941 ·46 Primary Tumors of the Callane At surgery we found a leptomeningeal cyst. The thin outer shell of hard bone was removed exposing a cavity filled with cerebrospinal flud The inner table was absent. There was a dural opening about 1 cm, in diameter attending into the pub arachnold space, and through which some Large blood tasels protruded Cerebrospinal flurd ebbed and flowed with orch pulsation The blood vessels were replaced beneath the anach noid and the dura was repared unng a flap from the outer layer A piece of gelfoam was placed in the cavity and a plastic plate molded to fit the skull defect In the past 3 year she had done very well The old headache has gone and she has resumed her usual household functions. Case MF age 4 months first seen August 5 1958 because of a lump on the back of the head It was noted immediately after birth, at which time it was soft. Slace, it bad gradualh become maller hard and fixed. It was 4 x 3 cm in diameter and protruded about 1 cm abond the surface of the skull in the nght parietal area. It was not tender and the scalp was readily movable over it. Roentgenograms showed a bony projecuon in the nght par Ictal arca, which seemed to bave developed over the outer table of the calvana It was 3 x 4 cm. in dlameter and extended above the outer table 1 cm. The outer table was distinct and was not depressed There was an area of decreased density between the outer table and the dense outer layer of the tumor which was thicker than the skull and appeared almost as dense. The layer of decreased deosity between represented part of the betruktora that had not yet become calcified and may well in the future have become cystic and develop into a typical traumatic subpericranlal cyst. the perkranium wu reflected from the tumor There was a blue discoloration of the entire tumor The hard glistening outer layer was completely removed with rongeurs Each bite produced fresh brisk bleeding Bone wax was used after cach bite to control bleeding This blue vocular bony outer Layer wus removed exponing a normal under layer of bone. A cranioplasty was not necessary The pathologut reported that the findings were indicative of a traumatic cyıt of the skull At purget) ·Fig 232. Case 4 Lat view of R. perteul sabperioranlal cyat (traumatic) Fly 235 Tangential view of cyst, Ame can ·48 Primary Tumors of the Coloane CHONDROMA I have been unable to find a report of a chondroma of the calvaria although I am certain that some must have been re corded in our records we have found 1 case involving the occapital bonc, also a slowly growing intradural chondroma, extending from lumbar 1 to sacral 2 arca It had completely entangled the cauda cquina from the conus medullaris to the sacrum. Apparently from the history given its development had extended over a period of 25 years Copeland' stata that chondromas are seldom multiple, and are usually found in the small bones of the hands and fect, the sternum spine and ribs, and occasionally in the long bonos Coley sl: diagram shows the distribution of 24 casas They grow slowly but may become quite large in time Thae is little discomfort or pain On examination the lesion may seem much harder than when exposed at surgery There may be a tendency to gain the impression from palpation that the tumor might be an osteoma Also there is a tendency for the chaician to group these lesions with benign osteochondromas I have en countered the latter in the parasellar region of the head They tend to develop in the basılar areas Chrondromas are benign but invasive, and definitely retur after incomplete removal Some may undergo malignant changes. Complete study of the specimen removed should be made befort ruling out malignancy Roentgenologically they produce a radiolucent effect, and many tima a cystic appearance If sizable, there will be a soft tissue shadow outlining the tumor lo the case reported below there was both an area of decreased density of the skull and a large raft tissue shadow Lichtenstein" stresses the importance of spotty calcification or a calcific stippling within the translucent art.. CASE REPORTS KL ſemale, 71 scan of age, wu referred to us in 1950 becaure of a large tumor in the nght postauricular region. She reported that approximately 30 19 and 11 years previously . cartilaginou tumor had been removed from the same place It was noted in the last hospital record that the surgeon made ·Penice Tus of the Celrona 42 H- 2 2--- 4--- 2- 24 Fir 24 Showing distribution of 24 Cure of central chondroma, (from pilons of Beers Courtesy Bradley L. Coley M.D author and Paul B Hoeber Inc., publisher) ·50 Primary Toners of the Carans At surgery a propumpuve diagnosis of an osteoma but his surgical note indicated the tumor was much after than he had expected. and changed the postoperative diagnosis to a chroodroma The man was about the size of a hen i egg The patient wa concerned mainly because of the size of the tumor It was not teoder and was not movable. It was encapsulated with turue moving freely over it The rocntgenograms showed a hazy area of decreased denuty with some areas of spotty calafication Tangential films showed a large tissue shadow representing the protruding tumor There was no increased vascularity e had been fonnerly noted the laon was firm but not hard It was an encapsulated nodular pearly while tumor about 6 x 7 cm in its greatest diameter It was removed with a sharp chisel after which a burt was used to remove the involved bone, which we thought to be the panctomastoid region. Part of the parietal bone and a portion of the posterior margin of the mastold bone was involved It was not necessary to re move the inner table The microscopic secuons showed closely packed cells, with ome rounded nuclei, definitely distinct cartilage cells. In mome urcas the cells were more carcc and the intercellular substance appeared collagenous. The pathologist Lindly checked the alldas of 1939 and found the appearance to be crentially the same, except the latter was a little more anaplastic. Both were benigol To date the lenon has not recurred OTHER BENIGN TUMORS In this category we have choseo to place primary lipoma and ostcogenic fibroma These tumors occur very infrequently in the skull but should be mentioned nevertheless LIPOMA Lipomas may develop anywhere that one can find fatty tisuc They may occur within the head along the brain stem the hypothalamus the corpus callosum and inside the ventricles We have renoved them from within the dura in the lower lumbar arta They infrequently occur within the medullary canal of long bona Smith and Feinberg's recently reported a case of intrucoscow Lipoma of the fibula and stated that only 1 other intraoscous upoma lad been reported in this country

·Benign tumors of the Colore
51
Fug 25b
Fh 25a
Lat view of a primary lipoma of the skull
P.A view (hamc ax) (Courtery Dr Loyal Davis and Lea & Febiger
publisher) from care record of Dr Davis
As a primary tumor of the calvana we know of but one case,
that reported by Loyal Davis" Through the kindness of the
abonc author who kindls sent the entire case record we have

·52 Primary Tumors of the Caloana been permitted to use this rare and remarkable case of primary lipoma of the calvara This patient ſemals, age 42 was first seen by Dr Davis in 1935 A man had first been noted in the leſt frontal urca in 1915 In 1921 it was removed but gradually grew back, until in 1935 it measured 6 5 cm in diameter and protruded 15 cm. from the skull surface. It was firm throughout, acept the vertas, where there was a soft irregular area possibly the former oper ative defect. There was no evidence of increased intracranial pressure, or focal ugns of cerebral dysfunction The roentgeno grams showed a large area of increased density sotne bone proliferation and some bone datruction At operation it was found that the tumor had growo through the skull at the soft spot over the tumor vertex Burr bolos were placed about the periphery of the tumor Here the skull was almost an inch thick and quite vascular The bone and tumor were removed The dura was intact The bruin »eneath was not involved. The tumor was encapsulated yellow but not lobulated The operator mentioned in the operative note that it resembled fat, although he did not know at the time it was a fatty tumor Macroscopic studies showed thus tumor to be a typical lipoma OSSIFYING FIBROMA Osafying fibroma is mentioned by Copeland! We have never encountered one. He thinks they are quite re, occur at times in the calvana and are benign Excision is recommended 1 BIBLIOGRAPHY Copeland M M Benign tumon of bone Sorg Gmer & Obst, 90 697 712 June, 1950 2 Young B R Roentgen findlogi 10 tumors of the skull Radiology 55 321 326 Sept. 1950 3 Meredith, J M Osteomas of the craolal and base 3 cases illus trating 2 vanetia South Surg 16 785-795 Aug 1950 Rand CW Ortcome of the skull report of 2 casa 1 lxctog associated with a large intacteniel endothelioma trck Sos 6 573-587 1923 5 like, BD Primon) hemangioma of the skuli a rare cranial 4 7 Roraig P302, March, 1943 tumor ·Ilmigu Tumes of Ihr Calrarie 53 6 Hlaudoniet AS Multiple capillan hemangioma of the akull donat Int J Surg 31 326 Jan 1947 7 Holmes, TV Sweet Hct nl Hemangiomas of the frontal Lone fan Olol Rhinod o Lar no! 01 45 March, 1952 8 Toynlxce J An account of 2 vncular tumors des cloped in sul stance of lone Lancet 2676 1945 155-180 1936 9 Bucy P C Copp, CS Primary hemangioma or lone with special reference to mentgenologic diagnosis. Am J Rorulgraal 33 1 33 1930 10 Geschickter Cr Priman tumors of cranial bones, Conca 26 155-180 1936 11 Vandenlxerg H J- Jr Colcy BL Pnmary tumors of the cranial Bona Sur Grace Ob# 90 602 12, May 1950 12 Rowbotham, G F Hemangiomata arising in bones of the shull, Brl Sure 3D 1-8 1942. 13 Cole, Bradley L. Troplasms of Bone Hocler New York, 1949 P 423 14 Abbott D Angioma of the skull. Ann Surg 106 1100-1105 Dec. 1937 15 Ritvo Max Rolgonographic Dragnosis of Diseases of the Stall New York, Hochver p 353 16 Scheinlxerg L Elkin, M Hemangioma of the shull associated with intracranial angiomata Ancology Aug 1958 p 051 (fig 2 and 3) 17 Pancoast, H I Pendergran, E. P Schaeffer J P The Hood and Veck in Rornige Diagnons Springfield Thomas, 1940 p 247 18 Lichtenstein L Jaffc, H L Fibrous dysplaua of bone. Arch Palk 33 777 1942. 19 Meeracy J C. Giant cell tumors of bona of the skull 7 Noro- ANT 6 169 1949 20 Copeland M M Geschichter C G Tumors of the Bona and Joints Chapt 28 pp 1121 1145 21 Alpes, BJ Harmony R Cholesteatoma originating in the skull Lones, causing smptoms of Intracranial pressure. Am J Surg 18 51 57 October 1932 22 Neteky Tolgra and Alexander Personal communication. 23 Davis, Loyal Chorixosby, J Cyst formations of the stull Swag Gra Obs! 58 12 31 January 1934

·54
Primary Tumors of the Celsone
24 Smith, W E, Fienberg R Intraosseous lipoms of bone Corsi
10 1151 1152, 1957
25 Dickson, A B Mason, MWV Noller " R Lupoma of bone of
Osteous origin 7 Bone & Jourt Surg 3A 257 259 1951
26 Davis, Loyal Toological Surgery Philadelphia, La & Febeger
1936
P
193 Also personal communication

·Chapter III TUMOR LIKE LISIONS OF THE CALVARIA (DUE TO GENERAL DISEASE PROCESSES) llchait chosen to place in this category those tumors produced by general discasc processes of the incidence of the skull maniſestauons is relatively high in the symptom compler of the docase. In tlus group we have included cosinophilic granulomas, Xanthomatosus, fibrous dysplasia Pagets discase, leontianus ossca and hyperostosus frontalis interna Ilso, onc could include craniolabos of Ricketts, cranial changes in Gaucher s disease, osteopor osus circumscripta osteius fibrosa cystica, and syphilitic skull in volvement. The latter group does not represent as much a local camal problem as a general systemic problem which w usually more compelling than the incidental cranial lauon Also thc cranial manilatation of these diseases needs no particular local form of treatment years or matosus EOSINOPHILIC GRANULOMA In 1940 Otani and Ehrlich' first applied the term cosinophilic granuloma to the lesion involving the skull It is characterized by a single or multiple punched-out arcas of lesser density usually ID females below 30 age The cause is unknown but several wnters: associate this lesion more or less with xantho- Clinically the 2 diseases present an entirely different symptom complex The symptoms, age, incidence and the skull pattern of the 2 respective lesions are enurely different except for an occasional casc, such as reported by Swaine and Williams - The course of the 2 diseases is different as one can note from compani son of the casos luted below Knighton and Fox' thought it to be a prunary disease of the reticuloendothelial system Shuster and Flynn' inclined toward the infectious ongin 55 ·56 Primary Tumors of the Coloana plain of The patient is usually a female In our cases, 50% were female The majority of the patients are in carly adult life. They corn pain and sortness over a local area, most often the panctal region This is due to the fact that there is a tendency for this lesion to grow outwardly and involve the percranium and even the muscles, or at times the dura' inwardly We have noticed on increase in the eosinophils in the blood count. In our cases, the patient has not been ill and has not presented systemic or general complaints as in cases of xanthomatosis Roentgenologically, the lesion presents an irregular punched out area of decreased density, with no increased calcification or eburation about the borders It may suggest a metastatic lesion, especially if there are multiple arcas Other bones of the body may be involved There is no sunburst appearance on tangentul views, as in the case of a hemangioma These lesions are usually smaller than hemangiomas, when first seen It may be that they cause pain earlier A soft tissue shadow may be seen if the lesion has extended beyond the outer table They are much dufferent from the large multiple map-like configurations of Schuler-Chnt tian , Ducase The late Clyde McNeil' noted a double shadow which he thought characteristic of the disease. This he attributed to different degree of involvement of the 2 tables of the skull At surgery one finds a granulomatous laion confined beneath the pericranium or perhaps growing through into the soft trores. We have seen it invade the temporal muscle qute extenuvely Also it may involve the dura or extend through the dura and producc adhesions or direct cerebral involvement.' The gross specimen may be cystic in places and may have hemorrhagic arcas, but u soft and does not have the honcycombed sponge-rubber cffect of the hemangioma It is less vascular Microscopically the diagnosu u not difficult. There are foamy appeanog large mononuclear cells with cosinophils xattered or in clumps There may be some plasma cells and lymphocytes. Later connective tissue and new bone formation may be seen We feel that a diagnosis cannot at times be made without a biopsy Also there us dural and intracranial involvement at times. Consequently surgical removal of these tumor is advuable. Co ·The 1s510ns of the Calrarse 57 tainly remor al and plastic rcpur will clicct a curc Somc advise doing nothing Some suggest nadiotherapy The surgical plan wc cmploy is to rcmort tic losion with a curct and sharp dissection, including any of the scalp uiat is in volved Thic dura is saved, if porubic, but the tumor issue is remored Additional bone is removed with rongeurs if necessary, and a plastic repair of the skull is fitted in place In this study of cases, tliere were 6 patients with cosinophilic granuloma or about 12% of the total The lesion occurred most frequently in the panctal arca There were no multiplc lesions In 3 of the 6 cases the losion had invaded the soft tissue of the scalp and the dura in 2 casos Pain was more prominent and more severe in these cases, probably because the tumor more frequently involved the scalp and dura Elevated cosinophil count was noted in most of the cases lo other systemic changes were noted CASE REPORTS Case 1 RM W male, age 21 was referred in 1942 because of headache for 6 months and becaux of a knot 162 cm in the nght occipital arca The mass was tender on prexure. Roent gcaograms revealed an area of decreased dendty with shelf like margins. The outer table of the skull was destroyed We do not know what Ixecame of this patient. Case 2. CA C female, age 29 was ten by us in 1952 kc cause of pain in the right parietal area There wu a very tender palpable nodule that the patient had nouced for 5 wechs. The blood Kahn was posure, but the spinal fluid was normal in all respects Rocotgenograms showed an area of destruction near the night lambdoldal future involving both tables. It wa 15 x 2 cm in dunncter TheTC WAS One small flcck of bone in the central portion of the dcfect that had not been completely absorbed The roentgenologut thought it was characteristic of an conn ophilic granuloma There were 2 cosinophils and the redumenuation rate was 20 Ribs, heart and lungs were normal At purgery the tumor was encountered out in the galan. It was repoved with sharp dissection and curet down to the dura A tantalum button was fitted in the defect The pathologic report was that of an coanophilic granuloma A yearly follow up since has revealed no further complalat:

·58
ProRay Tomors of the Coldaria
72
854
Flg 261 Care 4 Eodnophilic granuloma R. (rontal.
Case 3
I feinale, age 24 was referred in 1951 because of
pain for kitral months in the night ade of the head gradually
getting work. Palpation revealed an extremely tender man
2 x 2 cm. in the nght panctal area The roentgenograms abowned
e sharply demarcated defect in both tables of the skull, thought
to be an counophilic granuloma The cognophil count wu9
and the sedimentation rate was 7
At surgery the tumor bad extruded through the outer table.
It was removed by sharp dlarection, curet and rongeurs The
dura wus involved but not penetrated A tantalum button wu
placed in the skull defect. The microscopic sections showed it
to be cominophilic granuloma
Rocatgenograms of the stull
talen in 1958 did not reveal any new lenons and the patient
had no complaints

·Tumorile lssons of the Calraria
52
TE
FK 266
Fi 26c.
Same caktow powth
Same CLK high powo

·60 Prona) Tremors of the Coloane Case 4 ES, male, age 35 was referred in 1954 because of sharp pains for 2 months in the nght frontal area A tender nodule could be palpated The roentgenograms showed a de fect in the skull lavolving both tables and thought to be an counophilic granuloma The connophu count was 1 It was removed with curet and rongeurs down to the dun Part of the involved dura was included The external portion of the tumor had penetrated the percranium and a large por tion was located in the muscle. A plastic button was placed in the defect of the akull Microscopic sections revealed a typical cosinophilic granuloma There have been no further complaints when last seen In 1957 Case 5 ISB ſemnale, age 41 was seen in 1955 because of ICVETO pain in the left panctal region This had been present for 6 months but had gradually increased Rocatgenograms rt vealed an area of decreased denuty 2 x 2 cm in diameter It was less sharply defined than usual but considered as an codinophilic granuloma At purgery the tumor had involved the soft tissue of the scalp and dura It was completely removed and the defect repaired with a plastic plate. The study of the microscopic sections disclosed the time to be that of a typical codnophilic granuloma Cars 6 W O male, age 21 was first scen in 1953 with mayo clonic seizura as his chief complaint. These had occurred since he was 8 years of age. There were no objective or focal signs at this time When seen again in 1958 the roentgenograms aboved a local area of decreased density 1 x 2 cm in diameter in the left parietal region A central area of increased density was also noted Both tables were croded A raised tender lesion was palpated in the area involved It is believed from the hlatory of the seizura, that they are not associated with the local lenon Horvever a pneumococeph alogram an electroencephalogram and other studies are planned Surgery u to be evaluated according to the findings. This com is listed as a probable condophilic granuloma Postoperative checks have been made on the above patients, and addıuonal roentgenograms have been made of the skull as well but no additional troubles have developed and they remain symptom free

·Tmortile Irgons of the Calcaria
61
FTR 27 Cax 5 Eosinophilic granuloma of panicul area.
Fug 26 Cax 6 Eodnophille granuloma of parietal area.

·62 Primary Tumors of the Coloana XANTHOMATOSIS In 1893 Hand!* first described xanthomatosu but cronicowy associated it with tuberculosis In 1915 Schuller and in 1919 Chrutian" reported some cases of this disturbance but asociated it with pituitary dysfunction Rowland" in 1928 was first to di cover the true nature of the disease, that is, a disturbance of lipad metabolumn Epstein and Lorenz! and Cowie and Mageel re ported more details of metabolic changes. Sosman'' and Dan son't suggested that trauma or infection may be causative agents in stimulating local lipoid deposits It is characteristic of this disease to occur in early chudhood and most often in males Exophthalmos, diabetes insipidus and changes in the skull represent the classical symptom triad of the disease. Other bones of the body may be involved The involve ment of the retrobulbar arca and the hypothalamic area produces the exophthalmus and the water imbalance These changes are reversible however, because after minimal dores of roentgeno therapy normal water balance returns and the сус recedes The prognosu is good if the ravages of the disease can be held in check unul puberty while the reverse is true in those cases starting after puberty or in adult life Usually both tables of the calvana are completely eroded The scalp over the defect is clevated but the margins of the body defect can be canly palpated There is some tenderness The mic of the defects vary from a few millimeters to several centimeten in diameter The irregulanty of the large lesions accounts for the map-like configuration that is characteristic of this type skull erosion vascular spaces The microscopic findings are easily recognized and diagnoos not difficult Histiocytes loaded with fat are found in the pen New connective tissue invasion occurs, with fibrous and foreign body grant cell reaction Foam cells are found in the marrow spaces of the bone Atrophy and degeneration of the invaded bonc develops because of the massive accumulations of foam cells in the marrow spaces It has been thought that fat cells would not invade the bonc tisue Weedrnand and Freeman't considered nerve tissue as being re fractory in lipoid invasion kyrkland'' and Henschen?' found ·Twinske Issions the Calraria 63 + ។ Tig 29 Cas1 Lanthomatisk showing proptouts. lipoid changes in thic hypothalamus. Dectrich" found lipoid tumor masses above the optic nervos Davison't found deposit of fat cells in the reparatic processes in the cerebrum and cerebellum lic haic found 4 cases of lantliomatosis among out records For illustratie purposes, 2 will be included in this study Both were under puberty Small amounts of roentgenotherapy were used over the shull lesions, and on er the hypothalamus if exoph thalmos and diabetes insipidus were prosent It was remarkable how much improvement occurred when a minimal dose was used at intervals CASE REPORTS Case 1 URO age 3 male, was first seen on November 12, 1937 Seven months before, 10 April the patient had bumped his head with considerablc force, so that when a tumor mas was first nouced a few weeks later it was thought that it was a partial detachment of scalp with a hematorga bencath. In July 1937 3 months later protrusion of the left eye was first noted The se gradually became more prominent A polydipsia and poly una bowly developed to where the child would drink about 3 times the amount he formerly drank dunng the day and about 4 or 5 glasses cach night, with nocturla 3 to 4 time. In October It was observed that the nght leg was weak and there was tenderaas on deep pressure over the lower part of the femur Hc also protected hu nght upper extremity becaux of pain in his shoulder ·64 Primary Tours of the Cdoara 9173 R Tig 301. Care 1 Lanthomaton, showing map-like configuration of skull defect Fig 30b Same car thowing kapular Lovolvement The neurologic hustory was negative, except for the develop ment of the tumor in the nght parietal region, limitation of motion of the nght upper and lower extremitia and the uni lateral left cxophthalmos. Examination revealed a definite left crophthalmos, a large soft, nonpulating mas 4 x 6 cm. In the nght perletal area and a small bony dcfect 1 x 1 cm in the right frontal region By careſul palpation a discrete bony defect could be made out bencath the tumor mass. Point tenderness wus present over the right scapula and over the right femur at the juncton of the lower and middle thirds. Roentgenographic cxamination showed defects in the skull in the place mentioned also bony defects in the nght femur and the right scapula The blood and urinalysis were negative. The blood hahn was negative The blood cholesterol was 287 mg per 100 cc of stum The patient was placed on a low fat diet and rocntgenotherapy given in mall dores, unog 200 h. V 20 me at 50 skin focal distance with filters of 0 5 copper + 1 aluminum In 2 year, 1 350 r were given in 5 series to the left frontotemporal area 900 r in 5 applications to the nght ſeiner and 500 r in 3 tumas to the nght kapula He made a spectacular improvement The large right parietal mass had disappeared 2 months after ·Tumorske lestart of the Celrona 65 350 r had been given and a winhen cranial delect could be palpated in its place. The right upper and lower extremities ccased to cause pain 2 months after 300 r had lreen given In 2 scars the sinaller skull defect was hardly palpable and a large one was less than hall the original ic and fairly well filled in sy fibrous thac There was no longer a pulsation present Roentgenologically the night scapula and ſemur appeared nor mal The left ac was not so prominent as when first seen, but the mother stated that if the patient became excited or had love sleep the cyc protruded more The polydipsia and polvuna were relieved within 4 months alter the first treatment was administered A total of 2 050 5 was given to the left icinporofrontal and right frontoparietal megrons the pituitary and neighborhood area being in direct line or some, it was undoubtedly irradlated sufficiently to produce rerulla He has grown and de cloped normally and at present he has graduated from the univeaty is married and has 2 nornal children. Case 2. 1 Lage 9 was first seen in 1936 In November 1935 4 months previously the pauent first notxed a frequency and a gradually increased nocturia which had mounted to 20 umo the first night at the hospral He was very thirsty He complained of a dull nght frontal headache, and at timo a bitcraporal headache He had programvely grown weaker during the pax 4 months and weighed only 51 pounds on ad mission. Since December 1935 3 months lefore admision, there had been blurring of vigon The child was sluggish and apathetic. The parents stated that he had lxecome mentally dull On examination the blood premure was 90/70 The pulse was 70 the temperature normal Thc lips, hands and feet pre sented dusky huc, as if patient were cyanou. Respirations were normal. The cranlal neria were negative, except for a papilledema of the nght dush The pupils were widdy dilated and reacted slugguhly to light. There were no other glinornul neurologic finding A1 x 2 cm defect could be palpated in the occipital region, also 1 3 x 5 cm defect in the right parietal region. The specific graszty of the urine was never above 1005 The red blood cells were 4 730 000 nod the white cells 10,200 with polymorphonuclars 65% lymphocytos 32% cosinophils 2% ·60 Prime Timors of the Coloane monocytes 2% The test for Bence Jona protein was negative. The Wasserman was negative. The sugar tolerance test gave fasting blood sugar of 115 in a half hour it was 220 1 hour 229 2 hours 133 The blood plasma bicarbonate was 40 valames per cent on February 11 1936 and 50 volumo per cent on March 14 1936 Blood cholesterol was 315 mg per 100 cc of sarum Vaxopremrn was given to control the insipidus. The patient voided between 5 000 and 6 000 cc. in 24 hours. The intake was proportionally large With vasopresen the intake and out put could be controlled very readily Roentgenotherapy for a period of 4 days, beginning March 19 1936 407 5 were given directly orer the leshan in the ngbt parietal arca The pituitary area was protected May 1 to May 5 1936 another 444 r were given directly to the pituitary arca Two hundred and ninety-fir Wete given over the canal dcfects. April 24 1937 270 r were given over the same area. It u interesting to note that the diabetes iosp dus was not changed in any way after the administration of the roentgenotherapy over the akull defects and that it was necesary to continue with vasopreno However with an application of 444 r or approximately 70% of an erythema dose, directly over the pituitary region, the polyuria with polydipua gradually duminished and the flud intake and output returned to normal It has remained normal ance, which has been 23 jcars For hustorical review of the subject, the reader is referred to the reports of Sosman, Davison?' and Chiar" a FIBROUS DYSPLASIA OF THE CALVARIA Fibrous dysplasia 18 a disease of young people, seen most often from childhood through the third decade of Ufe. Females are affected more frequently than males Coley" suggested that it is akeletal developmental anomaly characterized by angle or multple areas of fibrous tissue in bone Schlumberger thinks that the single leon may represent a response to injury to the bonc In his report of 67 cases, he noted that the nbs were the most often affected The skull was involved in only 8% of his cares Lichtenstein" noted that the average duration of symptoms in his cases was 20 усал This would indicate that the symptoms are not revere and that the lemon is usually not discovered carly ·Timor-toke lestons of the Celoos 67 in the course of the discase Perhaps in those cases affecting the skull the local cnlargement or nodulc is noticed more readily than when located on a nil) or other well coi cred bones of the body There may be a single lesion called a monostotic tumor, or muluple lesions called polyostotic fibrous dysplasia, if more than one boncus involved The former is more common The latter is often associated with otlier systemic changes, such as skin pig mentation and precocious sex development In 1937 Albright" and associates were first to describe as an cnuty tlic disturbance now known as 'Albaghts Brown-spot Syn drome, or disseminated fibrous dysplasia with cutancous mani festation and sexual precocity The skull is often involved in this type of casc, and presents a problem secondary to systemic in volvement elsen here We will not further claborate on thu type of disturbance In some cases of polyostoric types, and in most cases of mon ostotic types, and particularly where the skull alone is involved there may be 1 or morc lesions but there is not an associated systemic disturbance with skin discoloration or sexual precocity There may be 2 or more laions in the same bone and still be a monostouc lesion A polyostotic loon refers to lesions involving more than 1 bonc The lesions may be of variable size, depend ing on how carly it is discovered Some sorenes us present over the raised arca and there is tenderness on pressure. Roentgenograms show a rarefied well demarcated radiolucent lauon associated with thickening and sclerosis in places, while at other arcas, erosion may be noted A multilocular appearance, an cystic, is often seen and at time it u difficult to differentiate it from a cystic tumor If the sclerotic changes predominate, it is sometimes difficult to rule out a bony tumor A biopsy may be required in some of the solitary lauons in order to make a diag nosis We think that at this time, if the frozen secuon proves the laion to be fibrows dy plana, that one should be prepared to remove the entire lesion and mold a plastic plate into the defect. According to Coley " there is a likelihood of transformation to a sarcoma Notwithstanding the tendency for a progrekuve en largement associated with pain, would support the wisdom od removal ·68 Primary Tumors of the Coloana 2 Fig 311 (Upper lA) Typial appearance of fibrous dysplasia of calvaru Fig 31b (Upper nyk) Same core, p.a. vlev Fhg 31c. (Laos Lt) Samc care operative defect. Flug 31d (Lacey ngh) Same Cox, photomicrograph low power The microscopic findings of the lesion without, and with the associated skin and endocrine changes, differ considerably So much so that trauma us suspected as the ongin of the former and a congenital ongin for the latter Schlumberger" was unable to find islands of cartilage in the primary tissue of any of the 67 cases of monostouc fibrous dysplasia that he had studied He supported the theory of injury as a causative factor The fibrous tusue cells were uniforin and well differentiated with small spicules of bone interspersed throughout the field At surgery it is best to plan the removal of the entre lason by curet and rongeurs Sometimes this enlarges the orginal bony defect conuderably but this removal must be extended to good bone about the entire margin of the lesion Some places the

·Tumorekih lessons of the Caliana
69
Fig 316
Same cax, photomicrograph, high povret
usue may
bc
quite soſt
It is very vascular A plastic repair of
the skull permits the use of any size or shape needed and lends
Itself well to these cases
CASE REPORTS
We have only encountered 3 cases of fibrous dysplasia of the skull
Cas 1 BH was a female, age 17 Whom we saw in 1954
because of 2 knots, 1 in each frontal area The 1 in the left frontal
urca was tender and was about 4 x 5 cmn. in diameter The
rightnded lesion was approximately 2 x 3 cm in diameter
This was a questionable monostotic type because of the light
atennon of the leftsided leaon back into the parietal lone
However it seerns to have onginated in the frontal bonc bilater
ally thereby qualifying for a monostouc type Belda, roentgco
ograms of the entire slcletal sitem did not reveal any other
lowons.

·70 Primary Tumors of the Caloane Fig 32. Caxe 2. Moportotic fibrous dysplada In January 1954 through a coronal Incision, both lexions were removed completely and a plastic plate molded into the defects. The scalp and dun were not involved The microscopic studies revealed mature fibrous tissue proliferation with spicula of hone intenpersed No cartilage was found There was no evidence of mallgnancy Subscquently in 1956 and 1957 roentgenograms showed no change in the skull or skull margins about the 2 cruoroplastic repain The plastic plate permits good visualization of the skull margin. There were no other complaints Cas 2 PH a female, age 17 was referred in 1950 because of a lump on the night side of the head, and a dull ache over the entire head About 3 year before, when she first noticed the lesion, it was about the aze of a dimc. When cumined 10 the nght panctal arca there was en uree, 4 x 5 cm of decreased denety also there was some bony proliferation The defect was Irregular and lavolved both wbles and reported us a fibrows ·Tomo-like Issions of the Carona 71 dyplasia Roentgenograms of the pelvis, cxtremities and chat with nibe, utre negative. At surgery a squarc lonc llop 45 cm each way was turned down alxerit the lesion The center of the Map Contemponding to the fumar meared 2 cm in thickness A tantalum plate was fitted nnd secured with 3 screws The higologic sections shou cel conuderalslc filsrous rcplacc ment and proliferation in the canccllous portion of the lone Dr Black reported further that there were mini thich bony trabeculac running through this cry thick fibrous tissuc. There Mete a number of multinucleated giont cello present and many of these appeared as the cpulis type giant cell His diagnosis H2 "fibrous dysplaga of Ixonc. This pauent has been olkened at early interval. There have been no other troubles Recheck of the skeletal stem remained negative. She has since married Case 3 J F R male age 20 was seen in 1958 because of tumor over the left eye first noticed after being struck with a bnch 12 years previously It had slowly grown larger until now there was noticed a bulging area in the loſt frontal region, Axtending from the lateral margin of the frontal sinus to the lateral confines of the skull and apparently into the tempor ozygomatic lona A sodule about the rize of the end of his index finger protruded from the lateral margin of the orbital ndge, displacing the left eye slightly mesalward He had had headaches on the left ide, and had had some dizziness, nausea and vormting There had been no report of double vision up to date. Roentgenograms showed an area of increased density with altered texture in the bone forming the lateral margin of the left orbit The zygomatic proces and orbital plate wert alvo involved A tangential view showed , localized bulge in the frontal bonc, which was evidently due to an overgrowth of rather thinly trabeculated bone. In the area of the bulge the tabla were thin. The outer table was expanded and the diploic space was widened with an altered texture. Medially the disturbance extended to the margin of the frontal sinw. The superior orbital nm was flattened and there was alight downward encroachment upon the space of the orbit. There was increased prominence of the lateral margin of the base of the zygomatic process. The roentgenologist's diagnosis was that of a vanant fibrow dysplana At surgery the left frontotemporal bone wus exposed with a flap turned at the base over the supraorbital ridge The fupra ·72 Primary Tumors of the Caloonia اللہ تا Fig 33a. (Upper left) Caxe 3 Photo showing fibrous dyrplada of left poprobital ure Fig 33b (Upper nykt) Same cax, thowing lateral encroachment upon left orbit. Fig 33c (Lacrer left) Same Cax, rocnigenogram showing uovotremot auprto orbital area. Fig 33d (Laos nght) Same can roentgenograma showing lat View orbital ridge was ctposed A definite bulge and thrchening of the bone was visible. Three burt bola were placed in the superior lateral margin of the expoure at the penpher of the tumor after which rongeun were used to remove the bon tumur In places the tumor was 3 cmt in thicknes. The 2 tablos of the hone were obliterated by the intervening tumor Hege, ·7 Wonder lason of thr (alona 73 14 33c. Same ase showing postoperative akull defect (pa vw) and nues securing plate in place which remed to have grown into and through them The tumor was rather soft, considering that it was bony and could be removed casily with rongeurs without much force. It was more vascular than normal lonc The entire tumor was removed to good bone around the periphery This necessitated removal of part of the frontal bonc Outer two-thirds of the supraorbital ridgs, the orbital plate part of the zygoma and part of the temporal Ironc There was no soft tumor tinue encountered A plastic plate was molded and fitted in place and scured with 3 sainless steel wire stures. It was possible to mold a new supraorbital ridge and to cover Oer the orbital cavity ·74 Promary Tumors of the Celoord The specimen was decalcified and sectioned The microscop sections revealed the tumor to be a fibrou dysplena of the cal varra. This is the largest lesion of this kind that we have et countered It was totally removed He should have no more trouble from this ladion PAGET'S DISEASE Osteitis deformans was first described by Paget" in 1877, as a form of chronic inflammation of bone. Inflammation is still can sidered a likely cause by many Endocrine dysfunction as also supported as an etiologic factor Actually, a proven cause has not been definitely established The cuiology 1 unknown It us most always mulucentric, affecting most bancs of the body, except rarely the hands and feet It involves males in an over whelming majority and the skull in a high percentage of casca Bird" estimated that Paget's Descase occurred in 1 3000 patients admitted to the hospital This number may be high Certainly the akull involvement is considerably less frequent The onset is so inadious as to be imperceptible, and when first noticed Inay have been quictly developing for years At thus stage, and it is usually in a male past middle life one finds a rather limited area or arcas of decreased density of ostcalytic type involv ing the outer table of the calvaria Ritvo" emphanzes the pret cnce of a narrow band of slightly increased radlance at the peri pheral margins of the diffuse rarefaction, as a diagnostic feature of early Paget's Ducase At thu time the bone is soft and show no sclerosis. Later a poor quality of new bone is formed involv ing the outer table and diploe first then the inner table as the lesion advanca. It becomes hard and takes on a' cotton tuft appearance The skull becomes enlarged asymmetrically The featura arc dutorted There may be pain of moderate degree. No temperature elevation is present Serum phosphatase may be cicvated Burdo found that 11% of cases studied, developed ostcogenic sarcoma Other authon report sunular findings. The microscopic findings vary somewhat, depending on the stage of the disease Early the tigue u poft vaxular and fibrotic Osteoclasts are present Huge deposits of bone tuuc develop with unregularly placed trabeculac. Osteoblasts are more numerow in this stage ·Tom helson of it Calcone 72 Surgery is not indicaled Thic foramini arc not cncroached upon, cauung little involucment of the neat and blood vessels of the area involved Rorntgenotherapy has been used for palli auon of pain Continued olxem ntion is casential to apprchcnd the daclopment of accoscnic sarcom? Symptomatic treatment Otlictise indicated CASE REPORT lic have cncountered only I case involving the shull It may be that this losion is readily recognized by the proſession and is not referred laccausc surgery is not indicated and treatment is limited lotwithstanding in the thousands of shull films obtained for other reasons during the past 27 years we have not inad vertently discovered morc cases of Pagets Discase of the shull CIL male ose 61 was referred in 1945 with a diagnosis of Pagets Disease with a request of his family physician for any suggestions that may prolons the patients acuve career He only recently discontinued work as a plumixer because of con ſuton some headache and difficulis in getung about Ten vcars belore he had fallen lle had humped his head but was not unconscious. The slzc of his hat had focreased from 74 to 8% in the past 10 ycars There was no increased intracroial provare and no focal sgos found Aside from muld confusion and headache, ncu rologic studies gave normal response Extcnave laboratory in Verigation abowed well developed Paget s Dusease, with typical roentgenographic findings The patient was treated symptomatically and expectantly by his family physician LEONTLASIS OSSEA There o considerable difference of opinion concerning this dis case. Ritvo"' thinks it is not an entity but that vanow typos are caused by different ctiological facton Leontlasts is a descriptive term that has been used for centures applied to vanous condı tronu. Virchow : however in 1865 used it to darcnbe a disturb ance of a body type involving the face. Leontians ossea is a rare condition beginning around puberty and confined to the bond of the head According to Reix, n the ·76 Pamary Tmors of in Calgaria bones of the upper part of the face and the frontotemporal area are more frequently involved It is slowly progressive Gradually the physognomy takes on the appearance of a lion The foramina and canalı of the skull arc often obliterated, resulting in auditory visual lacrimal and nasal duturbances of varying degrees, depeod ing upon the stage of the disease Sometimes the encroachment upon the orbital fora may producc proptou and upon the optic forarına, blindness The proliferaaon of bone may be quite extensive, at times be coming several cenumeters in thickness The rocntgenograms reveal the involvement of the upper bones of the face and the frontotemporopanctal arca mainly There may be mamive production of denie bone with a loss of definition of the skull tabla There is a periosteal production of sclerotic bone with overproducaon af osteoblasts No definite ctiologic factor has been discovered Treatment is mostly symptomatic lo one of our cases with marked prolifera tion of bone and pressure symptoms involving the frontal arca ind producing proptogus surgery was used to obtain mechanical hencfits and to relieve the effects of pressure CASE REPORTS Car 1 RH ſeinale, age 55 was referred in 1945 because of the enlargement of the face and skull in the frontal area furt noticed about 25 cans previoudy Protruson of left cc had been developing for 5 years The furrowed features were typical or lcontian Ossen. Also the masove enlargement of the frontotemporopanetal bond with associated involvement of upper facial bona and a left proptosis indicated a far advanced cute lo places the bone growth was over 5 cm in thckaca Hard ache and vijual disturlunce (hlurring) were becoming store troublesome After a connderable amount of planning surgery was advised with the idea of reducing the blood supply to the area fovolved and decompremng the left cze Februry 28 1946 under basal local anerthens the left posterior margin of the tumor was posed Because of the vasculanty and dural adhesions, « guide could not be used Instead a rongeur was used to remove a secuon of bone at the periphery extending from butt hole to ·ni 11 (alat lar hole thine hat in lyer quantitie 170ml 10 control Blonding horfend ciglu un na not weiniai an clerite rulan uk Ircing camall not be controlled 11- factonk wit na luncenel lien a trip of lone 23 cm had leen maal me placed intalum fenl Drencen the margina and cloud ihr walp tigliks oirt 10 meure bomlage warned Saimday latct the proxelure #1 continued. This small frontal Snus was unconered and the membrane perle anai uninjured Then, with multiple luir lle derrcial through the limet frun ul lote anul donnn and the thickened Lull nas penetrated into boxh the frontal fing and original funct With ronscurs it has ponable to enlarge the lurt openings so that the thickened orbical rool could le roikned as well as a nullyin of lons tumor ex teading into the reso-orbital pace The retro-orhilal ſat proinded into the decompresyon With rongeuri and lurt the trench alyou the llimor was continued alout its entire circumference connecting on both sides with that made the previous woch This left only a bridge of Lomy connection from the tumor mass by nas of the left malar area to the leaset Hing of the sphenold A good bit of this bridge was removed but not all of it llou ever the vascular connec tton was otherwise completch sesered The dura mas divided all around acept for the sagittal sinus. The middle meningeal antenes were ligated At this point it was decided that the tumor and involved calyama could not be safely removed Thinking that the blood supplı wa matenalls reduced and the ac decompressed we proceeded to remove the external mass of the tumor by making muluple perforator and burt openinga parallel to the inner table and removing the inter cung leone with rongeurs This gave a good commetic result Subsequently the ese receded from its place of prominence, headaches were reliested and the skull enlargement was lo prom Inent In the time that has elapsed approximately 12 years, there has been no apparent evidence of growth, recurrent propios OT headache Cart 2 S AS femals, age 16 referred to 1957 because of unsteadinen of galt and myoclonic seizures. It was noticed that the left maxillo and zygomatic area was considerably enlarged but when inquiry about this was made, the family indicated that thus had been present once early childhood and although it was becoming slowly larger they were concerned about the seizures ·78 Primary Twors of the Celsona Fig 34 Loontinis ose, showing thickening of the marillary zygomatx and temporal bones and un cadines. The seizure began 6 years before and lately some unsteadices and personality changes were noticed Ande from the history and appearance of the face, we could find no abnormal objective findings on complete physical and neurologic Hudy The roentgenograms teken in 1957 showed some increased denuty and thickening of the temporo-zygomatic malar area es compared with some taken in 1953 Pacumoencephalogramu showed no displacement or impingement upon the ventricla. The cortical markings weTC DOTID:al Spinal Aud studies were normal It was poruble to control ber seizures by changing ber medi cation and with this her personality and unstadiners uaproved ·Tomi Tront of the Calt atia 79 frontals interna HIPCROSTOSIS PROSTALIS INTERVA In 1936, Voore'' described 7 liy peronto is frontılıs intema in a paper on metabolic craniopatlıs Since it is often lxccn rc ferred to as Sherwood Voore » Dicci«c Its cauce is unknown The discas is not uncommon Thic ly pcrostosis is associated with or without smploms. Usually it occurs in females between the age of 35 to 45 lihat the connection may lxc lxctween the bypetostoris, a dull headache personality changes, obesity and other mild metabolic changes 1176 not been determined Many cases have no symptoms associated with the lyperosiosis The roentgenogrims show a bilrietal symmetrical dens, ir regular wavy proliferation of lonc involving the inner table only and projecting inwardly The diploc is not involved There is somnc calcification of the file and at times along the walls of the sagittal sinus Surgical treatment is not indicated but symptomauc treatment may be lielpful lic have on record a large number of cases of hyperostosis Tic findings and symptoms conform so closely that it seems unnecessary to relate the cave record on all so uc have chosen at random 4 cases for bricf presentation CASE REPORTS Case 1 J BH age 55 referred in 1949 because of a dull aching and compression feeling in the vertex of the head. There was nonne insomnia and tcosion problems. She nos moderately obene Complete physical and neurologic studios revealed no Organic changes of abnormal character Rocntgenograms showed rather marked internal hyperostosis buatcrally in the frontal arta Her headaches gradually sulxided on er a period of years, and although there is some discomfort, she understands her condition and has learned to live with it. Case 2 E. S female, age 57 referred in 1951 because of a headache and a feeling of fullness beginning in her earl 40s. The only objective finding on physical and neurologic examina toon, was a right nere deafness. Encephalogram showed normal ventricles and subarachnoid space Spinal llud findings uere all Rocotgenograms revealed an advanced hyperostosus normal internal auditory meat and petrous radger She made a good adjustment to her problems, after she was reasured that she had notbing to fear Dormal frontalls interna

·80
Primary Tutors of the Caloria
Fig 354. Case 3 Hypero toda frontalle interna lat view
F 356 Same am pe View towing caldation of fun

·7 w Irunas n tl Coloma 81 ist Mig 36 Cox Hyperostoris frontalia Interna Case 3 Sh female, age 46 was referred in 1955 liccause of frontal headaches, and some feeling of unsteadines. These varted after a car accident 3 months previously There was a scor in the right fupraorbital area where she had been struck but not ren dered unconscious. Roentgenograms showed a typical picture of hyperostosis frontalis interna with bilateral bony proliferation and calcium deposits in the folk It was thought from her him tory that this louon was asymptomatic and that her headacho onginated from the head injury Suliscquently her hendaches left her Case SR female, age 44 was referred in 1950 because of a continuous headache and a feeling of weakness. The neurologic examination did not reveal increased intracranial pres aire or local wgns or symptom. The sella was slightly enlarged There were no neighborhood ymptoms Vigual fields were normal Glucose tolerance test was normal There was also a ·82 Primary Tonks of the Caloonia bilateral hyperostosis frontalys interna and a calcification of the falı Thu patient has been treated symptomatically and kept under observation Headaches have ribaded 1 BIBLIOGRAPHY Otani G Ehrlich J C. Solitary grouloma of bone dimulating primary neoplasmn Am Path 16 479-490 July 1940 2. Groen W T Farber S Eosinophilic or solitary granulome of bonc. J Bone and Joint Surg 24 499 526 1942 3 Thaunhaux S J Eonnophilic granuloma of bone 7 A 1.A 134 1437 1438 1947 4 Swain G Williams, J M Eoupophilic granuloma of bone 3 Norony, 10 185 1953 5 koighton, RS for J del Diagnosis and creatment of counophilic granuloma of kull JAMA, 162 1294-1297 December 1956 6 Shuster B H Flynn, T F Eosinophillc granuloma of Crootal bona report of case. Arch. Olalams 60 501 504 Octoher 1954 7 Raaf J Eosinophilic granuloma of the skull West J Surg p 53 Jan 1945 8 McNeil, Clyde Personal communication. 9 Beker GS Fisher RG founophilic granuloma of the skull report of 4 cases with 5 yar follow up N.S N.D 10 Hand A General tuberculos Trans Path Sac Philadelphia, 12 282 284 1893 11 Schuller A. Ueber ergenartige Schadeldefekte un Jungendolter Forsch u. Geb Ronigonstrahlm, 23 12 18 1915 12 Christian, H A Defects in membranous bonas, crophthalmos and diabetes inupidus An unusual syndrome of dvypituitarium a clin ical study in Corel Mied & Bior Research Vol 1 pp 391-401 New York, Hoeber 1919 13 Rowland RS Exanthomatons and reticulo-endothelial system Correlation of unidentified groups of casos described us defect in membranoui bones, Exophthalmoon and duabeta Indipidus (Chrit tuan i syndrome) Arch Ini Med 12.611-674 1928 14 Epstan Emil Lorenz, karl Zlochu Physiol Ch 192 145 1930 15 Covic, D Magee, M C. Lipoids and lipoid dixuxes Disease (Yanthomatous) and review of the literature on the lipold com tent in human tigue Arck Int tot 53 391 March, 1934 16 Sermon M Xanthomatosis. J AAA 48 110 Januan 1932 ·TWO- La Stors of the Calcais 83 17 Davron C lanthumatosis and the Central Nervous System fick Irrol & Pachat 30 75 July 1931 18 didman F Tretman 11 Santhoma Tutxerorum dich Damat & Sinh 9 149 rcloruary 1924 19 hyllund R Beitrag zu anem selienen Symptom-homplex Lesch hendah JI 56 1926 20 Henschen F Fall von \anthomatose mit hnochenveranderungen und gronzelliget Sphenomegalic intral bl ally Poth., 51 44 1930 21 Dietrich A I mchorr's Irch Paik Inal 212 119 1913 22 Chian, H Die generaliserte Santhomatose von Typus Schuller Christian Eugeba allo Path 24 396 1931 23 Colc, BL Troplasma of Hone New Jork Hoclxer 1949 24 Schlumberger H G Fibrous dysplasia of single bones (monostoric fibrous displasia) Viol Sangeon 99 504 1946 25 Lichtenstein, L. Jafſc H I. Fibrous dysplaua of lone. Arch Palk 33 777 1942. 26 Albngh, F Butler A M Hampton, A OSmith, P Syndrome charactenzed by Ostcius fibrosa disseminata areas of pigmenta 0100 and endocrine dysfunction, with precocious puberty in females report of 5 cases. A Eng 3 lid 216 727 746 April 29 1937 27 Paget, Sir J On a form of chronic inflammation of bona (ostcitis deformans) T. Roy Vied Chur So London, 60 37 65 225 1877 and 1882 28 Bırd, C. E. Sarcoma complicatiog Paget s ducase of bone report of 9 cases, 5 with patholigic venfication Arch Surg 14 1187 1927 29 Rıtvo Max Roentgenographic Diagnosis of Diseases of the Skull New York, Hoebner 1949 30 Virchow R. Arck Path dual 1865 31 Reuz M Leontiasis ossea. Arck 17 Clur 184 320 1936 32. Moore, Sherwood Metabolk craniopathy Am J Rornigeror 35 30-39 1936 ·Chapter IV MALIGNANT TUMORS OF THE CALVARIA We have included in this group 8 tumors definitely malignant and which have a tendency to develop as primary tumors of the caliana (sce Tumor Classification p 3) There are other thal may be included such as, Hodgkins disease and lymphosarcoma but have been left out, either because they are encountered 30 infrequently in the calvana or their presence in the skull dou nou constitute a part of a symptom complex of that particular general ducase or the customary primary ate of ongin OSTEOGENIC SARCOMA Colcyl found only 7 cases involving the skull in the files of the Memorial Hospital over a period of 20 years Three were in the panctal bons, the others in the basilar bona of the skull Ga chikter and Copeland also found the calvana to be quite rarely involved by osteogenic sarcomas Except for the associated de velopment in Pagets discase, they tend to occur in the younger individuals The patient complains of pain and a nvelling of the head Both rapidly progress Early metastases to the lungo roon aux additional symptoms of a systemic character Roentgenograms show marked bonc destruction with new bonc formation The growth extends from the skull both internally and externally Fortunately however it seems to develop out wardly more rapidly los extengon through the pericranium into the Kalp product at ting a sizable tumor and conuderablc pain There u not a comparable inward extension, and, although the dura may be involved and compressed inwardly it is not Ilkely to be penetrated At surgery & varying degree of vasculanty is found in different parts or the tumor 4150 a varying degree of asufication u found B4 ·Valigneal 7 mars of the Celiona 85 Some areas may require rongeurs for removal, while a curet will do quite well in other places in onc patient clicrc vcrc 2 dutinct xeparatc cleared 1015 in the frontal Ironc thint represented tumor tsue that was densely owsified wilc anticriorly whicre it extended onto the orbital plate and lesser wing of the splicnoid bone, the tumor tissue was oftet ind could be casily scraped out with a curct It was perhapx 1 10 1 1/2 inches in thickness and quite vascular These patients do not Inc long Surgery may help prolong life and certainly can reduce suffering Cade applies rocntgenother apy to the losion and olxcn as them for 2 or 3 months after which he operatas only those in whom no metastases have been found They seem to get some relicf alicr the tumor lias been removed As an additional lclpful measure we recommend that at surgery a plan also be made to section the posterior root of thc 5th nerve on the same ude, of the lesion is frontal and basılar The removal of the tumor relieves the pain incident to the invasion of the pericranium and tic scalp as well as that caused by pressure from expansion, while the posterior root section will anesthetize the arca supplied by the 5th nerve. It 18 helpful in time, other pain relieving desica and medication may be needed Eventually and not too long afterwards they succumb with metastases to the lungs and other bones of the body CASE REPORTS Case 1 RS male age 15 year, was referred in November 1957 Because of a proptosis of the nght cys mas in the right frontal irca and headache. These symptoms had begun about 3 months previously at which time he had fallen off a bicycle injuring this area BP 150/100 At 15 years he was 6 feet 2 inches tall and weighed 182 pound.. General physical examination showed an al normally large box and rather olxex, with normal findings except for those factors relative to the nght frontal area Thatc was no increased pressure or local neurologic signs. The cyc was proptosed and displaced mewlward and upward There were 2 distinct and xparate masses, alvout the size of a lime in the right frontal area ·86 Primary Toons of the Coloana Roentgenogram showed the 2 arcas to be somewhat doner than the surrounding dull Both were elevated above the outer table. There were some regions of decreased denuty There was thichening and increased dennity of the zygoma, the orbital roof and the lower wing of the sphenaid It was evident that we were dealing with a angle tumor presenting varying degree of dennty bone proluferation and destruction At gurgery the involved frontal bonc and elevated mases were removed with rongeurs. Then the orbital plate, parts of the Zygoma temporal bone and part of the laster wing of the spberrond bone were removed with rongeun and curct. Some of this foruc was quite soft and some quite hard Bleeding vaned connderably throughout verious areas of the tumor The pathological report indicated there were about 70 gm of tumor sent to the laboratory Large areas of the tumor were composed of fibrous type tissue. The aucla were ungular vary iog moderately in uze and staining properties. A modaatc amount of mitosis was observed. There were many areas in which the tumor was ostcold and bone was present which had the appearance of being tumor bone. Cartilage cells were also prexent in some portions of the tumor Other areas showed flbroblastic turuc, which appeared to be directly producog ostead Diagnout was osteogeak arcoma Subsequently the patient continued in school. His cye had returned to its normal position He was contented nod felt well. In April, about 4 months later pain became a matter of concern. It was mostly in the maullandistribution At this point we wished that a posterior root section had been done at the time of the tumor surgery because it would have saved him another operation. Thu prin became * acute that the patient readly agreed to have the posterior root of the 5th nerve sectioned. Thu again gave him relief for 4 more months. The rubsequent rection of the posterior root has certainly been worthwhile, even though a bilateral mosul frontal lobe section has since been necessary to control an apprehensive and emotional state An cnlargement of the right side of the face was quite pouceable when last seen, and it is evident that the tumor has continued its growth in the base of the skull and lace. The zygomatic proces, the qurmous portion of the temporal bone, and the malar bone have recently become involved Pretpure over the balar cnlargeonent does not aux prin. There has been no noticeable ·Malignant Thonors of the Celtarja 87 F1 37a Core 1 Oncogenic urcoma lovolving frontal bone zygoma orbital plite and sphenoid bonc Same care thowing postoperative deſece in skull Fig 376 After enlargement or evidence of recurrence of the tumor along the outling of the shull defect The cranicctomy opening has been a little sunken and soft and has shown no sgns of intncranial pressure to date (September 1958)

·88
Primo Tomors of the Coloana
$57. 1933
ya
Fig 37c. Seme care, pecimen showing dette omfied time to left and rolet
time to right
Fi 372
Same aux, photomicrographs of osteogenic sarcoma, bowing tumor
bonc formation
Case 2 CP malc, age 14 yean, was referred lo May 1948
because of a large tumor on the right side of the lead postenorly
Duning the past 5 months thc laion had been operated twice la

·Valignant Tumors of the Celtala 89 5 FT. 38 Core 2. Rapidly growing osteogenic sarcoma different ciues. It had again attained the size of a flattened grape fruit. This was estimated to be about 10 uma larger than the original tumor removed 5 months before and 4 times larger than the tumor removed 2 months previous to our contact with the patient. The patient was emaciated cacheuc and showed evidence of a chronic illnes. There was a secondary anemia Rocatgcnoframs of the chest did not rei cal a metastasis and on general a amination none was found clsew here The lesion did not sem to produce intracranial pressure and there were no focal peu rologie ogas. Roentgenograms of the head showed a large radiopaque man in the right parleto-occipital Area The protruding tumor con tuned a large amount of Osscous ussue with radiating spicula etlending perpendicular to the skull The shull was involved brut the tumor did not appear to extend loto the cranial cavity There ·90 Primar Tumors of the Coloana was a trangular defect in the tumor mars, which appeared to be due to previous surgical removal of bone At this time, 2,200 r were given through each of 2 portals. For 2 months be improved. In July 1 week before he died hc had difficulty swallowing and vomited frequently which may have been due to his cachetic state, or a terrainal development of intercranial pressure. Excerpts of postmortem findings There is evidence of marked cachexia, emaciation and dehydration. A max 15 cm, 10 duam cter protruded from the right paneto-occipital arca There art no lymph gland enlargements noticeable. No flud in pentoncal or pleural cavities. Pericardial cavity normal Gros camina ton reveals many calcified larons near the periphery in both lungi. They range up to 1 cm in diameter Liver weghu 800 gm. The heart, ladncyı, GI trace, pancreas and adrenals did not show gross or microscopic evidence of metastas. Mediastinum andre troperitoncal spaces were searched and no lymph node enlarge ment found Permission was not granted for a head craniannon Microscopic camination of the nodes and vixccra did not reveal metastases anywhere, except the lung. It was nccemary to decalcify the lesions in the lung before sectioning They pre sented Acoplastic time consisting of many uregular cells with vaned shaped hypochromatic nucle These, in many instances, produced definite osteoid tissue CHONDROSARCOMA Chondrosarcoma of the skull is a very rare tumor It occurs more frequently in the basal area, and almost never in the cal varia as a primary tumor Secondarily it may complicate Paget: discake, or arise from a chrondroma, which in the vault, occurs very infrequently (sce p 26 Chondromas) This lonon tends to occur in adults, grows more slowly as a whole, than ostcogenic sarcoma Yet it is almost invariably fatal Sometima surgery will prolong life Irradiation is used separately or with surgery Both give little more than tenporary relief In Krantas CAK both were wed and the patient died 20 months later because of masuve intracranial extension of the tumor Ordipanly metastases or spread occurs by extension along croded venous channels, or by the blood stream. The heart and lungs are the most common uto of metastases ·Halignant 7 wes of the Calratia 91 The experiences we lid with the case reported lxlow scre quite unique The consensus or opinion 75 that thic tumor nasa chron dorsarcomı yet thus opinion w7s not unanimous in any means In this case thic minner of insolvement of thic vanous arcas afected was quite difficult to explain satisfactorily The idea of multiceninc development w76 adminced but the matter is sull open to question CASE REPORT lic have lad only 1 onion hat dehatable case of chondrus urcoma of the calana The cave hi ton roentgenograms and Licauc sections were circulated in D: Black pathologist among several cincnt nuthorities on lonc tumors, and it was the consensus of opinion that the tumor was a chondrosarcoma of multi centrx ongin The patient was a male 26 years of aço He was first son in March 1954 because of constant aching during the previous 6 months, lo the left axılları region. Complete studies by an interaust gave normal findings including chest films, electrocardio grams, pyclograms, tum phosphatase, etc There was no focal central neruusistem involvemens, and no evidence of peripheral motor or sensory changes, except the subjective symptoms of pain When again examined on July 1 1954 slight motor utalnom was found in the left lower extremity There was an indefinite level of hypalgesia at T 7 on the right. There was an asociated temperature loss, also Deep reflexa were slighth increased in the left lower extremity Balinsh, Gordon and Oppenheim were absent. Lamioagraphs showed a tumor in the postenor medias finum and slightly to the left The 5th intervertebral foramen was mlarged and there was evidence of destruction of bone tueue On July 9 1954 in association with a thoracic surgeon, the chest was opened on the left side l» removal of thc 5th nb and atending the inctuon ſar posteriorly A tumor nodule the size of a lime, was found at the 5th inter ertebral foramen, and another the size of a hazelnut Lxneath The transverse processes, the pedicles and portion of the laminac of the 5th and 6th vertebrae were remoed The lone was invaded in the tumor In place it was soft and quite vascular After exposure was completed the tumors were removed The dura had not been invaded All abnormal looking soft and bonc it ·92 Primor Thors of the Calvara tissue was removed Thus finally included part of the posterior and Lateral portions of the body of the 5th thoracic vertebn Symptomatically the patient did well. He was frec of pain, the motor and sensory functions returned to normal. He continued to work and had few complaints. Repeat roentgenograms of the thorace spune 6 months later showed hone regencratico in r 5 and T-6 vertebrae. Subsequently roentgenograms were taken of the entire skeletal system. Poorly defined irregular areas of decreased dennt were found in midpanctal and right paneto-occipital region A radiolucent datructive process involved the manubrium. There was a vague, poorly defined area of decreased density in the right side of the RCUIT The cervical, thoracic and lumbar spine were aegative, atcept for the precious finding of bone regencrados at site of the removal of the tumor at T 5 and T-6 The lungs were not involved The 5th rib had partly regenerated. The long bones were negative. In April 1955 the 2 lesions of the akull were exposed. solt tumor time was found under the pericranium and extended through the skull to the dura, where it spread out between the dura and skull The involved akull and tumor tigue were rcmoned Again, the tumor was very vascular The pain and headache were relieved after the removal of the tumors of the skull, and did not return throughout the re mainder of his diseax, although before he opired, a little over a year later the cranial tumors had reappeared In October 1955 teodernow was noted over the right croiluc region, and roentgenograms shon ed a mall area of deutruction in the right sacroiliac area A few weeks later stoptom of cord 15volverneut at T4 level developed Tumor has removed from the right sectoillac region and through a laminectomy an extra dural mox removed at T-4 level Agun, the tumor HU VETV vascular and again the mucroscopic findings were all similar to the tumor responed before. The original tumor tissue was thoroughly studied as well as the subsequent specimcot It was after considerable pathologic Consultadon, and after a change of clinical recorde, roentgeno grants, as well as sections, that a final diagnosus of a multicentie choodrosarcoma was made lle are dreply indebted to the patholog, department for their labors and helpful information

·Velichani 7m3 nf the Cell 0757
93
S54 2423
S
Fig. 392 Unusual muldcentric chondrosarcoma, Ar tumor from intraplural
crtendon s atradural portion of tumor
FH 39b Same cake sharing tumor aindlage.

·94 Primary Tomors of the Calpena Det F 39. Sume cax, showing pattern of differentiated neoplann with arcu of tumor curtuage The tumor was ſnable aod pinkish gray in color A oumber of fragments of bone were scattered the port turare. The pathologist further describes other portions of the tumor * being quite firma and contalong tieue, which us ather canilage or very dense collageous thac containing some mall fragmenta of bone. Aſicroscopically the report on the skull tumors was in part as follows The tumor cells range from rather unnature fibrow rucuc type cells up to cells that have the appeanace of mature cartilage. The cells are invading bone and some spicula of degencrated bone are present within the tumor maska commented further The nicoplann in the car is unique and tome, who have studied the histologic sections, art uncertain u to the proper clasification. At first the tumor removed at TS area was thought to be probably benign, but it is now obvious that the tumor u malignant. Secuons roentgenograms and clin ical data have been submitted to various pathologists and crain He ·Valicoonl / wmons n the Calma 95 ent authontics on Ixone pathology Uncla ficd tumor, malig nant, and chondmarcoms of multicentric origin in the skeleton reconed the most consider ition licet a long and arduous cffort to identify the tumor Roentgenoll tap 174 med osct the local clinor arcas later when recurrcncc occured It gave some rellef of pain This patient remained actiic for almost another sear Dunng the last 3 to 4 weeks he stayed indoors and in led not of the time There HA na cr endence of pulnionin or other usccral in ok cment He viccumxed to the effects of the tumor October 1956 FIBROSARCOVA According to Pancoast, Pendergrass and Schacffer, fibrosar comas do involve the cranium Tus supports the concept of Geschickter that they anse ſrom the outer layer of the per osteum or from the surrounding soft parts Lichtenstein' men tons a type of fibrosarcoma that originates centrally mary in the medullary region The aborc autiors do not report a case involving the calvania and I have been unable to find reſcrcncc of a case hirschbaum in 1943 reported a case associated with Pagets disease of the skull primary fibroma of the calvana was reported by Dandy. It is pri EWING S SARCOMA Coley states that Lucke in 1866 was first to recognize thu turnor It has been hnown as round cell sarcoma In 1921 Ewingle described in detail the vanous aspects of this lesion, and unce, it has been referred to as Ewing : tumor Next to ostcogenic sarcoma Ewing s tumor is the most common primary tumor of bone Yet it is almost never found as a primary tumor of the It may metastasize to the shull If one is found here a primary losion elsewhere is most certainly to exist. Since it does occur wo frequently it is thought best to menuon it, in spite of iu tendency to almost always develop in other places than in It develops most frequently in male children, in the shaft of somnc long bone Although it is very sensitive to roentgenother apy the prognosis w not good It is considered advisable to secure the calvaria ·96 Prnny Troms of the Caleena a biopsy before roentgenotherapy is used, so as to allow a microscopic study of more nearly natural tumor tigue Again if found in the calvaria it is most likely metastatic occur MYELOMA (PLASMA CELL) Myeloma is a disease of later ufc affecting males more fre quently It is generally accepted that it originates from the blood forming elements. There is some varianon of opinion as to whether It should be classified as a ncoplastic discasc Certainly, myeloma tusuc develops in the marrow spaces all over the body yet it may develop as a solitary Javon 11 A solitary plasma cell myelom of the skull apparently does Willus'? thought they could be so classified if no Bence Jones proteinura or no other lesion appeared in 1 ycar Vanden berg and Colcyl reported 2 cases that were apparently cured with high voltage rocotgenotherapy A needle biopsy helps to rule out other lesions, such as, metastatic cancer hemangioma, cosinophuic granuloma or carly primary malignant bone tumon In case of multiple myelomas involving the calvana the myeloma tissue may destroy the diploic structures and fill the space. There also appear thipping of the tables in discrete punched out arcas In these areas the tables are seldom penetrated Vru ally when the skull is involved by the process, many of these areas, varying 10 size from a pin head to several centroeters 10 diameter will be found by roentgenographic study, depending upon the stage of the disease In the far advanced cases, mony bonds will be involved and the skull ddecu may be larger Pain is the most common symptom Weakness and anemia are quite common. A leukocytosis with plasme cells predominating may occur batu rart, and more apt to be found in patients under 50 than those above that age Bence Joncs protanuna, sometime in the course of the disease, can be found in over 50% of cases An increase of serum globulin occur in some cases Hyperproteinemia? with aboormal beta and gamma globulins may ruggat the diagnosis in sorte cosa The uk of elec papar trophoresis to pick up the presence of abnormal globullas'' provides a very valuable diagnostic and Serum phospbatasc a Bot ·Valignant 7 omnes of the Caliana 97 altered A bone marrow study is one of the best means of establahing 1 diagnosis Therapeutically rocntgenotierapy will often relicve pain and may prolong liſc Tic course of this discrs can seldom be pre dicted making it difficult to tell just how much therapeutic agents benefit the patient Radioactive pliopliorus stillaamıdınc and pentamıdıne Irrve lacn used, with varying degrees of success Surgery is indicated for relicuing rocal arcas of pressure, as in cord compression Oilienuse it can be of little help Since the tumor tituc in the radiolucent punchied-out arcs seldom penc trates the inner table of the skull and there is no tendency to penetrate the dura surgery for focal cerebral compression u not necessary CASE REPORT CH B., ſemalc age 75 scars, has referred in 1950 because of pain in the lower cervical and midthoracic area She also complained of pain in the left arm and land These symptoms were first noted alxout 6 months previously It was Icarned that she had lost considerable waght and strength. It was noted that she was rather pale with a tendency towards cachexia There was tendernes over C-7 Some hy pesthena was cliated over the ulnar distribution on the left There were 2 540 000 red blood cells, color index of 86 11 BC was 5 700 with lymphocytas 46 and neutrophils 54 Hematocht was 24 cc pached cells/100 cc blood Sedimentation rate was 30 in 10 minutes. There was a trace of albumin. Serum albumin was 3 35 kerum globulin 5 53 and setun protein 8 88 The roentgenograms rascaled almost complete destruction of the body of C-7 T-8 and T 12 and the first ab on the left. There was increased density in the left aper There were numerous punched-out areas in the skull particularly in the panetal regions, Bone marrow amean showed a predominance of plastna cells. Roentgenotherapy was given at intervals a palliative measure. Abo ethyl carbamate was given for tolerance and maintenance dosage Some temporary relief was obtained Blood transfusons for a while improved the tired feeling The cachexia gradually Increaxed, and she expired about 6 months later ·98 Primary Tumors of the Caloana RETICULUM CELL SARCOMA Reticulum cell sarcoma was first descnbed in 1939 by Parker and Jackson " It occurs in preadult, as well as later yean of life Coleyl tabulated the findings and results in 23 cases In these, the age ran from 8 to 63 years. It is interaung to note that in 12 of this group the disease had been cradicated in 5 treatment was in progrets, and in 5 the patient had died of the discase Thc prognosis is much better than in Emng's tumor with which it is so often confused Also it may be noted that in ponc of the above cases did thc laion occur in the calvarua. Ivias and Dahlin' found 49 reticulum cell sarcomas in 2,000 cases of primary bonc tumors There was 1 among these 49 cases that was located in the left parietal region They noted that the prognosis was better than most of the other primary bone tumors Only recently Ullrich and Bucyll reported the third care of reticulum cell sarcoma of the akull to be recorded Through the Lindness of the abovc authors parts of this casc record are here reported We are also grateful to Charla C Thomas, publuher and the Editor of the American Journal of Rornigmology, Radom Therapy and Nuclear Mediane for permission to reproduce portions of this work CASE HISTORY The patient w a 53 year old white female, whom they first saw in August 1952 complaining of pains in her head for 8 months. There were tender lanonu 8 x 9 cm. In the left frontal and 5 x 5 cm in the left occipital arcas Roentgenograms shared progresive bonc destruction, which, In view of the history of and extenuve treatnent for pulmonary tuberculous, wu diagnosed tuberculow osteomyelitus of the skull In August 1952 a left frontal craniectomy was performed A mog of granulation timpue 2 3 cm was first removed and then the soft coded hone was rongeured away until normal bone was encountered A defect in the ukull 8 x 9 cm wu produced They reported that the dura was not involved Alks, but aller lenon in the left occipital area wu treated in the same manner 5 days later The microscopic examination u reported by the authors, was as follows The cells were imperfectly subdivided by trabeculac ·alignant 7 WINS of the Collare 99 F 40a. Reticulum cell arcoma of the alvorla (from Ulrich and Bucy) a CAD and snall blood vessels, which were accompanied collagenous groma Thus loose stroma was reinforced by the char acteristic network or fine reuculin fibers, which were well dem onurated by impregnation with alier The cells of the tumor ranged from ordinary marcophage like and fibrocite like cells to large cells with obulared or multiple nuclei In some the nuclei were quite large Mitotic figures were numerous. They were found in all stages. Many of there were bizarre. The bone marrow had disappeared from the region of the tumor The few small dark cella present were lymphocytes and plasmocytes. Bone perdixed focaly especially near the margins as eroded trabec ulac or necrouc fragments Occasonally bits of reactive new The histopathologic diagnosis was typical hlghly malignant reticulum cell carcoma. This patient was studied at intervals for a period of 5 Cars. Roentgenotherapy was given postoperatively (3 500 r to 4 000 bone wercken

·100
Anary Times of the Caloonia
FL 400
Same cake, showing postoperative whull defect.
Fig 40c
Same car, showing low power
Ftg 40d. Same car, abowno dentely packed pleomorphic cells with DUMTOW
mitotic figures
to each area) Repeated roentgenograms of the skull failed to
reveal further datruction of bone, and the patient has remained
well us far as the tunor was concerned
Since there is information available in the literature concern
ing only 4 cases of primary reticulum cell sarcoma of the akull

·I{alignant 7 mms of the Caltania 101 no definite conclusons inay 1xc made in regard to trcitment Tuo cores of Strange and clonmies!! received only 1,000, and 1 800 r., respectively, and remained free of symptoms after many years Bucy concluded that roentgenotherapy, after a biopa diag DOX, 15 probably tlic xest treatment Thic surgical removal of the lason, followed by a plastic crinioplasty seems simpler and obazates the usage of large dosage of roentgenmys over the brain HIEMANGIO-CADOTTILIOVA (MALIGNANT) There is considerable control cry concerning the classification of the lesion as an entity Somc yuthorities have shown preference for another term or the inclusion of this losion within another group of tumors It luas bccn suggested that only those tumon in which microscopic aidence of malignant tumor with vasoformation, should be included in tius group This is a rare tumor Pancoast Prendergrass and Schaeffer have mentioned the involvement of the skull stating that a dilated vascular channel may be the only roentgenographic evidence until late in the disease Although we have no microscopic evi dence to verify the tumor forming blood vessels, clinically in the case reported below there were multiple cnlarged vascular chan nek, bruits and eventually destruction of bone and pulsation Even in spite of multiple ligauon of the primary arteries to the head blood supply remained amplc probably suggesting new blood channel formation CASE REPORT R P., Male, age 13 years, was refcrted in 1948 because of headache, progresively increasing duning the past 2 mooths. It was generalized It would awaken him frequently dunng the night. There were no ugos of increased intracranial premure and no focal algas. The positive physical findings were confined to the skull The right ude of the skull was larger than the left. Abo, numerous enlarged vascular channels were noted in the scalp and in the skull on the right ude. Some nght occipital and Ruboccipital tenderness was elicated Pneumoencephalograns dit closed a lightly enlarged right lateral ventricles with the weptum COD fo

·102
Printay Tomors of the Catrand
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1 -
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1
2
1
24
20
12
10
11
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1
4
3
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149
Flg 41
Lucation of primary tumor in 149 care of endothelioms (from
Hanns f Barthe Courtesy Bradley L. Coles MD, author and Paul & Hocbet
loc publisher)

·Valignant Tms of the Calcoria 103 shuted to the left An noslogram (carould) rocaled a Saint ac cumulation of contrast medu in the nght occipital arca bencath Trur hole that had been previous placed for a ventriculo gram. (Bleeding from the skull and dura has so lyrisk at that time that introduction of origen into the right ventricle had been aliandoned) Section of bone token from this area did not reveal any audence of neoplasm The headaches continued to be his chief complaint Tender new and corines in the ncht occipital arca Increased A large arra or decreased density gradually became more prominent, and in June 1950 bonc destruction was noted by palpation and rocntgenogram. A bruit was audible and later a pulation was palpabile At that time a panlol Icft homonomous hemlanopsia was present Compression of the nght carotid artery stopped both the bruit and the pulution The nght common carotid and vertebral arteries were ligated in August 1950 Roentgenotherapy was given and svmptoms abated almost completely The bruit ceased and the bulging at the skull defect receded (School, basketball and hunting were cogaged in along with other normal acuvioa da loy of 15) Early in 1952, prominence of scalp vesels was again noted Another area of decreased deonty in the skull was noted this uime in the right panctal area A bruit could be heard over this region Compresson of the left carotid artery relieved it. In July 1952 the left common carotid artery was ligated The brut and pulsation rulmuded The bulging at the cranial defect receded No untoward effects from the occlusion of the carotid were noted He left the hospital in less than a week, feeling much improved Up to this time, cerebral ſunction remained unimpaired Rocat genograms of the chat did not reveal evidence of metartans There were no symptoms directed to any other part of the body bocpt the head and all complaints continued to be reſortable to the cranial problem He continued to be an A student was active in lasketball and also H work to within a few months of his death In September 1952 little over 4 yars after the fint symptoms developed this patient succumbed to what seemed to be a respir atory fallure. He was bone at the tune and uolortunately a portuoortem cxamination was not kcured It seerna most likely that priman, yaxular changos accounted ·104 Primary Tears of the Caloare for the marked vascularity in the bone and dura in 1948, when a ventriculogram was attempted and for the later destruction of the skull in 2 different arcan. A bruit was heard, a pulution felt and large vaxular channels noted in the kalp and by roent genograms. There wu a pooling of contrast medu before the ligation of the carotid It would seen that new vascular channels were responable for progresive changes associated with bruit, puluadon and bone destruction Then also, there was an expan son of the hull on the nght ude. An expansion of the shaft of long bones occurs quite commonly when involved by endotbeliomu. The reader u referred to the recent work of Carter and Dicker con who have furnuhed a good review of the literature and rcpored 1 more care. CHLOROMA Chloroma is a disease that onginate from the lymphatic or myeloid cells of the bone marrow Tumor inhitration may uvolve most any tigue of the body The calvana is affected in a high percentage of cases It occurs in younger individuals, but at umes may be found in later adult life. It is characterized by A tumor like growth that varies in ute, depending upon the stage of the disease, but may become quite largs, forming a large tumorous mass The skull may be penetrated or it may even ettend intracranially The dura is seldom penetrated the faint greenuh color lends the tumor its name Growth us raped and death en gues in 1 to 2 years. 1 BIBLIOGRAPHY Coley Bradley L Noplan of Bake New York Hocber 1949 2 Geschickter F Copeland M M Tumors of Bone (ed 2) 4m 7 Cox 1936 P 669 3 Cade, Sir S Otcogenic sarcoma, a Hudy of 133 patients, 3 Roy Coll Swt, Edinburgh 1 79 111 December 1955 4 Krantz S Gay B. B Jr Primary chondrourcons of the accipital bone. Am 3 Roxtgenol A 598-604 April, 1953 • Pancoast, H h. Pendergras, E P Schaeffer J PTK Hond and dock in Romegria Draguas Springfield, Thoras, 1940 p 251 6 Geschickter CF So-called fibrosarcoma of bone bone involve ment by Barcoma of neighboring soft parts. Arch Stars 2231 1932 ·Malignant Tumors of the Caltare 105 7 Lichtenstein, I Roter Timers St Louis, Mody 1952, p 180 8 Dands WI.. Dron Laus Practice of Surgery Hagerstown Pror 1932, lol VII 9 hinhbaum J D Fibrocircoma of the skull in Pages disease. Arch Path 34 74 79 July 1943 10 Ening J Diffuse endothelioma of Ixonc Mori Palk for 21 7 1921 11 Schuart C. Solitary my cloma of the frontal lone 4 3 Rorngrad 53 573-574 June 1945 12. WILS, R. A Solitary plasmacytoma of lone 7 Pall & Baci 53 77 1941 13 Vandenlxrg H J Jr Coley B I. Primary tumors of the cranial bone. Sog Gonne Obst 90 602-612, May 1950 14 Wintrolx, MM Ruel M V Hyperprotcincmia associated with muluplc my cloma with report of a case in which an extraordinary hyperproteinemia was associated with thrombosis of retical veins and symptoms ruggoning Raynauds descase Bull Johan lloplins llosp, 52. 156 1933 15 Volpe, Robt Bruce-Rolertson Alan, Fletcher Almon, Charla, Bruce Essential cyto globulus, reizen of literature and report of a case treated with ACTH and cortisode 1m 7 Med 20 533 January June 1956 16 Parker F Jr Jackson H Jr Primary reticulum cell sarcoma of bone. Sme Gym & Obst 28 45 1939 17 luzas, JC Dahila, D C. Reticulum cell urcoma of bone 7 Bone & Joint Sox 35 A 835-842 October 1953 18 Uunch, D P Bucy P Am y Rorriganol Red Therapy & Nuclear 11ed., 79 4 Apn! 1953 19 Strange, V M DeLonmier A A Reticulum cell sarcome primary in skull report of 3 cases. Am J Roerigrad! Rad Therapy & Nuclear Med 71 40-50 1954 20 Hauser H Angiosarcoma of bone. 4m Rornigraol 12.656 1939 21 Carter J H Dickerson R et al Anglosarcoma of bone A re VICH of the literature and presentation of a car. Ir. Sure 144 107 117 July 1956

·No text on this page.

·ADDENDUM This recent case of intradiploic imumauc cyst in an 8 weeks old infant, has just becn seen and has been added because it is a classical representation of this type of lesion MA 11., 8 wechs of age first seen in June 1959 because of a lump on the right side of the head noticed immediately after birth It had not changed in sızc, and now was very firm yet for a short ume after birth there was somc fluid directly overlying the mass. Roentgenograms showed an area of increased density measunng 5 x 5 cm and extending outward from the normal contour of the skull approximately 142 cm. The tangential view revealed a dense outer plate, while the remainder of this mas appeared cystic, with a few radiopaque areas interspersed The inner table was intact. At operation the outer table was removed cxposing a grayish/ yellow soft fibrous mass which could be curetted away from the inner table. The outer table was removed complctely the inner tablc was left intact The sections of this soft material revealed well-organized fibrous tissue, and scattered throughout thu tissue werc areas of hemosiderin pigment It was considered an organized intradiploic hematoma 107

·108
Pronary Tumors of the Caloonia
V
Fig 1 Intradiplolc traumatic cynt, lat. view

·som
102
Rig 2. Intradiploic traumatic cyat apgual vter

·110
Primary Thors of the Colomnt
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11
12
Lilit
13 It 16
117
.
JIB'19 20
FL 3
R bone
Same --L fibrous throue men removed from goulc vacity
retroved-outo table.

·INDE А Abbott, W D., 54 Alan 105 Atribe, F., 67 43 Abbracht. Browanpox Syndrome 69 Verndt 38 54 Aloom, 105 Alper, A. J 54 Angioma, latrmania, 16 27 rachnoid, 41 43 46 Wtorom incunan 35 37 Artery carodd 103 B Dakar GS, 82 Bence Jooca proteinuria, % Bird, CE, 74 83 Bebop. J A, vlil Mac, S., IA, 70 91 Kalnc, 10 12 Bloc-fonction 25 Boor cburgation of 38 39 41 map, 14 16 25 marrow 104 humor. 3 WE, 25 48 Brain, pubadoa o, 41 brogly G 12 Brown, JC 12 Bruce-Robertoo, 105 Bocy P C, 22,53 % % 101 105 Boell, AL V, 105 Bart 14 25 Batler A, 83 drophalk granuloma, 55-61 Tihom dyplans a 66-72 hyperostori frontalo fateraa, 79-82 Frogtuatu ostea, 75-78 Tarct disc am 74-75 Lanthomatosis, 62-66 tumor or benim 4 5 13-54 chrondroma, 48-51 females and 4 klant cell 37 38 hemangiom,, 22 37 Incidence of 3 latradipotic spidermold cpus, 38-41 Il porne, 51 53 arilying fibromy, 53 atoma, 13-22 symptoms of 4 traumath cym, 41-48 dodfication of 4 58 facral consideradom of, 3-12 cole rummaries, 49 Incidence 3 te ud, 4 Kund, 4 malignant, 3 4 84-105 chlorona, 104 chondrouutoca, 90-95 Fwing's sarcom, 95-96 fibrourcoma, 95 beruanglo-codotheliocoa (mallgount) 101 104 Un and, 4 myeloma (ploma cell) 96-97 antracok ura, 84-89 reticulur cell Artoma, 98-101 symptoms of 4 radiotherapy in, 9 Purgay la, 9 typopaba oca, 6-8 Capa CS. 22, 53 Carter J H, 104 105 с Cadde, 6 85 104 Calefcation, 50 Carra bond of 3 tunar-ne ledom of, 55-83 111 ·112 Princ, Toptors of the Coloria Cauda equins, 18 Cabello, 63 Cerebrum, 63 Charla, WB, 105 Chieri, H. 66 53 Chloroca, 5 104 Chalatatoos, 18 Cooadromu, 5 48-51 90 Cae report of, 50-51 distribution of, 49 50 Entradunal, 48 Chondroprrcoma, 5 7 8 90-95 God reports of, 91 95 focidence of 90 mulaceatrlc, 91 93 94 Charboull, J., 54 Chlon, H A, 42, 42 Calcy B L, 12, 22, 24 34 36 37 49 50, 54 66 67 83 84 95, 96 98, 102, 104 105 Coow medullarts, 48 Copeland, M, M., 46, 53 54 84 104 Cowrie, D., 62, 82 Craoloplety & 9-12, 14 43 cpildomold cya aod, 38 to maligamat tardor, 12 plauk, 67 68, 71 yl, 10-11 rocthod of, 10-11 tantalug, 67 10 Cranlouba a Rocketts, 55 Craniam, 95 Суль epideripotd, 7 42, 43 Intracranial, vii, 39 atradiptak 18-11 cike report of, 38-41 keptopeningeal, 41 trutubs, 7 41-48 CUC report of, 43-48 Intrudiplolc, 44 Leptomeningeal, 45 46 parietal abperiental 47 Durbon, C., 62, 63 66 62 Deetrict, 63 DeLormar 101 105 Diabetes indplag, on 63 66 Dictaton, Ry 104 105 Dlcio A B., 54 Dietrich, Ay 83 Diploe, 4 15 41 71 74 79 Durt, 4 14 18 23 24 27 41 43 4 51 56 57 60, 77 84 92, 97 98 Dyrplade, sbroon, 5 7 6 66-74 e In, 65 can report of, 68-74 aux, 68 dingous , 67 dhaminated, 67 tochdeace of, os Doportoth, 67 68 70 polyartots, 67 rocotgenogram to, 67 nery lo, 67 68 typical yppetrance of 69 E Eberlict, J C, 55 82 ETKO, M., 26, 17 54 Eocephalocele, vil Eodothelial celb 26 Endothctions, locution of primary tu in 102 Fontaophib, 56 57 65 Epidermold onus tracts, vil Epotein, E., 62 Ethradd groote ortcom. Sce Outcore Ethyl carbamate, 97 Ewidy J 95 105 Ewing tumori, 5 Ewig's pancom See Sartome Ecophtbulma, 62, 64 F Fab, calefcatono, 79 81 82 Farba S. &2 Fat cel, 62, 63 Fdaberg, 51 54 Fibromy, 95 14 5 33 Fibromarcoma, 5 95 Fibroces, 62 D Dahln, DC, 9, 105 Dody IY E 95 105 Darh, L. 41 51 44 ·Inder 11. Faber R G. 62 Freteba 103 Fyan TT., 55 82 Foam celk, 62 For, J dell, 55 82 Freeman, W. 62, 83 Frontal bone, tumori and, 4 G Gulez, 57 Grocher 1 dica SS Gry BB, Jr., 104 Geocral dizze proconch tumor-like ledoms of alvarla and, 45 55-83 Cerchichter CF 3 12, 22, 54 B4 95 105 Glent cell epula, 70 tumori, S 37 38 location of, 36 Gardon, H., VII Graham, MP, 12 Granuloma, coulnophilke, 5 6 7 24 55-61 care reports of, 57-61 Chor of, 55 diaris o 56 females and, 56 madence of 55 radiotherapy in 57 rentgenogram of, 56 TTguy h 56 57 ymptom of, 56 Green, W T, 32 Gurdjun, E. S, 12 calcpOUL 5 6 22 24 26 27 33 honeycomb appearance in 24-25 27 3. locidence of 22, 23 mulüple 27 roentgenograma lo 24 mentresotherapy In 24 25 27 runburnt appearance of, 29 surgery in 24-25 rymoptoms of 23-24 Hematoma 43 48 Hemlanopola, 103 Henchen F., 62, 83 Hadocytos, 62 Hodgkin dincare 84 Holme, L. AL 22, 53 Hyperortos frontalla fatero, vil, 5 8 14 79.12 care reports of 79-82 incidence of, 79 Hyperproteinemla, %6 Hypothalamus, 62 63 I Ivin, JC 98 105 J Jackoo H., Jr., 98 105 Jale, H L 54 83 H Hamptoo, A 0., 83 Hand A., 62, 62 Hamboa, P H., 12 How R 54 Haudoise, AS 22.53 HAT H 105 Herdache, 23 45 Hanamglo-cordothelioma, 5 ! malignant, 101 104 reports of 101 104 Hercun plomes, 22-37 ollar 567,25 34 * roporti , 77 37 K het AS 12 Kinchbaum, J D., % 105 Klemchmidt, O., 12 Knighton R S 55 62 hranta, S 90 104 hyrkland, 62 Kyrklund, 83 L Leontial mea, 5 75-78 C report of, 76-78 furgery la 76 rymptom of, 75-76 Lichtenstein L. 37 50 54 66,83 95 104 Jipold metabolism, 62 Lipoma, 5 51-63 development of, 51 Lorenz, h, 62, 82 Lucks 95 Lymphoprcoms, 84 ·114 Primary Tumors of the Celsanie M Ortcoporon's creampta, 55 Otant, G, 55 82 Mace ML C., 62, 82 Malar bone, 86 MUO M. WY 54 McNal, C 56 32 AlcNeney J C., 37 84 Meningloma, v 14 18 23 24 Meredith, J M., 53 Matustarle umor See Tuman Micthyl-methylacrylate, 9 Afitof, 86 Voore, S. 79-83 Myeloma (plome cell) 5 8 %-27 cortport of, 97 dummode of, 96-97 Incidence of, 96 rocaigtooberapy is, 96 97 tytupton of 96 P Paget, J, 74 83 Peret's doen, 5 , 74-75 84 90 95 e reports of, 75 doo, 74 etiology of, 74 Inddence of, 74 symptoors of, 74 Pain in alyaris tumors, 4 Pacou, H K., 37 54 95 101 104 Parictal bona, 22, 23 24 61, 84 103 tumors und, 4 Putar F, Jry 98 105 Peridone, C. P. 37 54 95 104 Pentamidine, 97 Perkenanlum, 14 18, 24 25 38 39 41 43 45 40 56 84 90 92 Palostrum, 21 95 Peterman G, IT Prendergro, 101 Pbosphorus, radotctive, 97 Planta, te of, 9 10 Polydipole, 63 65 66 Patyuria, 63 65 66 Proptoob, 62, 76 85 N Narve Bfth, section , 85 86 opeke 63 Narty 38 54 Noller " R., 54 0 Occipial area, 48 101 103 tumon and, Oliver L C. 10 12 Orbital plate, 71 85 86, 87 salec, 29 71 roof, 86 Ontett deformans, 74 Abrou cyta, 55 Osteochondrocos, 50 Qacand, 86 89 Ostcomm, 356 89 13-22 50 e, and, 13 care report of, 15-22 ctbmotd Toone, vil Indoce of, 13 remonil of, 14 rocntgenoten in 13-14 Od 13 optom, 13-14 R Real, J 82 Radiotherapy in alveral tumor, I Rand, CW, 53 Reks, M 75 83 Rita, K. A., 9 10 12 Ritro, ML 38 44 74 75 33 Rou, P vili Rowbothan, GF 22.54 Howland, RS 62, 82 S Sacrum, 48 Sorong, 67 Ewing's, 95-96 Loodance of 95 Outtogik, 5 $ 74 75 84-39 99 cole report of, 85-89 Loader of 84 noentrepognon, 84 ·Inder 115 Swalne 55 Sweet 11, 22 53 т Tantalum brutton 57 36 plate 29 31 69 Temporal boce, 37 73 78 8 tumod und 4 Thauphaurer S J 82 Tolgla, 38 54 Toynbee, J 22 53 Trruma, Klant cell tumors and 37 Tuber-frontalis, 22 Tuman benign. See Calvurie, tumors of aalarial. See Calvaris, tumor of metastatic vii U Uurich, D P, 98 99 105 purgery in, 84 85 Torpiogu of 44 reticulum cell, 5 98-101 coe hbtory of, 98-101 Inchcoce 0,98 proportin 98 treatment of 101 round cc11, 95 Saatp fap 18 Schader J P., 37 54 95 101 104 Scheinberx L 26 27 54 Schlumberger Il G. 66 68 83 Schocicker J, 12 Schuler-Christian dhe 56 Schuller A, 62, 62 Schwut, C. W. 105 Schrweta B 12 Sella, 81 Septum,101 Sherwood Moores dhcmc Sre Hyper antora frontalb interna, 79 Shurter BH, 55 82 SOONCI, octcornas und, 14 Skull beco, tumors of, vu deprancd fractura of 10 reticulum cell Larcoma of, 98 nyphilltic Im alrement of, 55 uables of, 23 38 41 43 67 71 96 destruction a, 38 39 Inner 14 17 19 20 21 23 24 25 41 43 45 74 79 outer 21 24 25 41 45 48 56 57 58 74 spreading of, 24 Soul, J A 12 Smith, P., 83 Smith, W E, 51 54 Scanso M 62, 66 82 Sphesond bone, 77 85 86 87 Spmal fluid, cerebral, 45 Salam dune, 97 Strings, V M 101 105 Suburachnod space, 45 Subdural pece, 14 Suprkortutal ridys, 21 73 SuTuy In calyarial tudom, Sram, G 82 V Vandkabery H J Jr., 34 12 22, 37 54 96, 105 Vascular chanpek, 101 Voropreno 66 Virchow R., 75 63 Volpe R, 105 Walker AE, 12 Water imbalance 62 Hebater J E 12 Seadmedd, 62 Idman 1,83 Illuar, JM, 55 62 WI, RA, 96, 105 WYIntrobe MM 105 Wood celu Wooll, J I 12 Worloger E 10 12 Wyke B, D, 22, 25 53 х Xanthomatar, nil, 5 7 55 62-66

·116
Primary Tumors of the Colonia
Y
Yoxo B R., 53
auto report of, 63-66
dle posle of, 62
Incidence of 62
prognoda ta, 62
roentgenotherapy in 63 64 65 66
symptor oL, 62
z
Zander 9
Zygomy, 37 73 78 86 67
Zygomatke proces. 71

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