- Historical Background of the Society
- The First Meeting of the Society
- Co-founders of the MSTS
- The Legacy of C. Howard Hatcher
- The Pivotal Role of Bone Pathologists
Historical Background of the Society
The exact origins of the Musculoskeletal Tumor Society (MSTS) are subject to debate, much like the character of the society itself, which, since its inception, was full of lively conversations and exchange of ideas. Among orthopaedic surgeons, however, these highly specialized conversations on the treatment of musculoskeletal tumors began to emerge only in the early 1970s, when subspecialties in medicine and surgery in the United States began to flourish. At that time, the world of surgery benefited from a remarkable array of new technical advances: among others, surgeons developed expertise in organ transplantation surgery, routine open cardiac surgery, and radical cancer surgery. As a result, many surgeons promoted radical or extensive surgery, such as amputation for bone and soft tissue sarcomas of the extremities. During this brief era, the roots of MSTS as a specialty organization emerged from fruitful exchanges between orthopaedic surgeons and medical oncologists and who collaboratively administered chemotherapy – a recently implemented form of treatment for bone tumors.
Before the MSTS as a group met for the first time in 1977, three figures who worked in medical oncology and orthopaedic surgery in Boston were central to the society’s conception: Norman Jaffe, Hugh Watts, and Henry Mankin. In the mid-70s, Norman Jaffe, who was then a pediatric oncologist at the Boston Children’s Hospital, received a large number of patients with osteosarcoma. For these patients, Jaffe administered chemotherapy, while Hugh G. Watts, a pediatric orthopaedic surgeon at the same hospital, performed amputations and in some patients limb-sparing surgeries. According to Watts, chemotherapy for musculoskeletal tumors became widely known as an effective treatment after one of Senator Ted Kennedy’s children received adjunct chemotherapy for an osteosarcoma of the tibia – a treatment that received widespread publicity in the mass media. Thus, in the late1970s, both chemotherapy and limb-sparing surgery quickly became known as effective treatments, and this knowledge circulated not only among physicians, but also among patients with musculoskeletal tumor and their families.
The successes of musculoskeletal tumor treatments at the Boston Children’s Hospital garnered the attention of Henry Mankin, a prominent orthopaedic surgeon who arrived at the Massachusetts General Hospital in 1972. In the winter of 1976, Mankin compiled a list of self-professed orthopaedic oncologists in the United States, and he asked Hugh Watts to invite them. Out of this list, 17 orthopaedic surgeons attended the first MSTS meeting in 1977, and they subsequently became known as the cofounders of the society.
Nevertheless, there were key omissions from this story – although Mankin’s list contributed to the list of founders found today on the MSTS website, the website as late as 2021, surprisingly, omitted both Norman Jaffe and Hugh Watts—both of whom are key founding figures.
Although Jaffe and Watts were not always listed as founders of the MSTS, they practiced a form of collaboration that was central to the rise of orthopaedic oncology as a specialty in the mid-1970s. As chemotherapy became increasingly effective as a treatment malignant bone tumors, orthopaedic surgeons and medical oncologists had no other choice but to find new ways to collaborate. While Jaffe and Watts worked together at the Boston Children’s Hospital, two physicians also pioneered similar treatments at the Memorial Sloan-Kettering Cancer Center: Ralph C. Marcove, an orthopaedic surgeon and a founding member of the MSTS, worked with Gerald Rosen, a pediatric oncologist. Taken together as a group, these four figures were among the earliest physicians to administer chemotherapy and limb salvage for musculoskeletal tumor patients before surgery. These interdisciplinary efforts gave rise to two triadic forms of collaboration that continue to be central in administering care for patients with musculoskeletal tumors: the diagnostic triad (orthopaedic surgery, radiology, and pathology) is complemented by the addition of the therapeutic triad (medical oncology, pediatric oncology, and radiation oncology).
Although these multi-disciplinary collaborations took place in the 1970s, such forms teamwork continue to be crucial for the MSTS and its members: the multi-disciplinary care regimen for musculoskeletal tumors requires an organizational platform that guarantees a rigorous exchange of ideas and innovations across subspecialties.
Norman Jaffe and the MSTS
After chemotherapy became commonplace in the late 1970s, pediatric oncologists, like Norman Jaffe, became gateways for referrals to orthopaedic oncologists. Nevertheless, many clinicians at that time were skeptical of Jaffe’s interventions in chemotherapy. After the 1976 death of Sidney Farber, a pioneering figure in chemotherapy and an institutional leader at the Boston Children’s Hospital, Jaffe moved to the MD Anderson Cancer Center in Houston, where he established a highly successful career before retiring in 2006. Although Jaffe himself is not an orthopaedic surgeon, Jaffe’s legacy in the field of orthopaedic oncology cannot be underestimated – he pioneered the multi-disciplinary care regime for bone sarcomas in children, regularly contributed to MSTS meetings, and gave a founder’s lecture for the MSTS.
The First Meeting of the MSTS
This first MSTS meeting in 1977 marked an important milestone not only in the history of orthopaedic oncology, but also in the broader history of orthopaedic surgery. It was the first academic conference dedicated for orthopaedic surgeons in the United States who treat patients with musculoskeletal tumors. In the mid-1970s, both surgery and chemotherapy became increasingly effective as treatments for musculoskeletal tumors – new treatments that, when offered in conjunction, offered the possibility of higher survival rates. This first meeting did not only start a conversation among fellow experts in musculoskeletal tumors — it gave birth to a tradition of lively and enthusiastic debates that continue to characterize the society to this day.
After a year of preparation, Mankin and Watts hosted the first meeting of the MSTS in Boston on May 5-6, 1977. The 17 participants in attendance were Edwin Bovill, Michael Bonfiglio, Crawford Campbell, Norman Jaffe, Michael Lewis, John Makley, James McMaster, Henry Mankin, Ralph Marcove, Eugene Mindell, Walid Mnaymneh, John Murray, James Neff, Douglas Pritchard, Franklin Sim, Dempsey Springfield, and Hugh Watts. William F. Enneking, who was by then well-known as an orthopaedic oncologist, was unable to attend, because he had to teach his popular resident courses in pathology at the same time. Thus, two of Enneking’s fellows at that time, James Neff and Dempsey Springfield, attended the first MSTS meeting and became the youngest co-founders of the society.
The program for the first meeting consisted of four half-day sessions: (1) one half day for the discussion of giant cell tumors, (2) the second half day for discussion of Ewing’s sarcoma, (3) the third half day for discussion of osteosarcoma, and (4) the fourth half day for miscellaneous topics, including a discussion of pelvic tumor resections and reconstructions and pathologic fractures.
From the very first discussion on benign giant cell tumors, the character of the society’s lively debates became apparent. Among the 17 participants, there was no single agreement on how to manage these tumors. While at least one individual felt that all giant cell tumors should be resected, others advocated curettage and cancelleous bone graphs and another group discussed the role of resection and reconstruction with allografts or autograph fibula. Ralph Marcove, in particular, called for cryosurgery after curettage and bone graft, although his presentation was constantly interrupted by questions. The constant disruptions during Marcove’s presentation, however, left a mark: Marcove left the meeting frustrated after his talk, and boarded a plane back to New York City at the end of the first day. Although the group did not agree on a single course of treatment for giant cell tumors, the very first day of the meeting reached a valuable conclusion: that care for each case should be decided upon and managed individually.
During the second session of the meeting, the session on Ewing’s sarcoma invited considerable discussion of emerging treatment modalities: chemotherapy, radiation therapy, and surgery. Chemotherapy was also extensively discussed during the third session, which focused on osteosarcoma. Appropriately, this session on osteosarcoma and chemotherapy included a presentation by Norman Jaffe, who was then a pediatric oncologist at the Boston Children’s Hospital. However, orthopaedic oncology as a field was also constrained by the technologies of medical imaging at that time, which did not provide clinicians with axial imaging or high-definition bone scans. As a result, discussions on how to treat osteosarcoma mostly centered on the extent of amputation. Dempsey Springfield, for instance, presented on the difficult choices that orthopaedic surgeons and their patients must make in cases of distal femoral osteosarcoma: disarticulation at the hip joint versus above-knee amputations. Overall, the group as a whole agreed that hip disarticulations were not needed unless skip metastases were evident on either plain films or bone scans. The last half-day sessions, labeled “miscellaneous,” brought out discussions of two complex subjects: pelvic tumor surgery and management of pathologic fractures.
At the end of the meeting, Henry Mankin hosted a dinner for MSTS attendees at the Harvard Club. At this dinner, the group agreed that they should all continue to meet annually, but they would need to wait before committing to a formal organization. This first meeting, however, was remarkable enough to establish a tradition: the vigorous and at times aggressive exchange of ideas, which gave rise to the society’s nickname, “The Piranha Club.” After John Murray came up with the nickname, Franklin Sim contributed to the design of the blue slide with the orange piranha above, which listed William Fisher Enneking – also a well-known competitive fisher – in addition to the 17 participants of the first MSTS meeting. While the term “Piranha Club” was also used in jest, it reflected the spirit of the initial meeting: the intense questioning and debates enabled the free exchange of ideas and innovations that continues to characterize the society today.
- Michael Bonfiglio
- Edwin Bovill
- Crawford Campbell
- William Enneking (not present at the first MSTS meeting)
- Norman Jaffe
- Michael Lewis
- John Makley
- Henry Mankin
- Ralph Marcove
- James McMaster
- Eugene Mindell
- Walid Mnaymneh
- John Murray
- James Neff
- Douglas Pritchard
- Franklin Sim
- Dempsey Springfield
- Hugh Watts
The Legacy of C. Howard Hatcher
In the field of orthopaedic oncology, the legacy of C. Howard Hatcher (1900-82) cannot be underestimated. Hatcher’s legacy is central to the MSTS in two ways: (1) he established pathology as a basic science that informs the study of musculoskeletal diseases; (2) he taught generations of residents who became key educators and institutional leaders in the field of orthopaedic surgery. A quiet figure who kept a low profile throughout his life, Hatcher was a master educator who trained generations of medical students and residents during his time as a faculty member at the University of Chicago (1933-60) and at Stanford University (1960-69). Before Hatcher began his long career as an educator, he followed the footsteps of his mentor in surgery, Dallas Phemister, and, in the early 1930s, studied pathology under Jakob Erdheim in Vienna – a global center for medical research before World War II. Later on, at the University of Chicago’s Department of Surgery, Hatcher developed his signature pedagogy in basic science education, which trained residents to rigorously analyze clinical, radiological and pathological correlations in each case. Through this pedagogy, Hatcher supervised four residents who later became co-founders of the MSTS: William Enneking, Crawford J. Campbell, Eugene Mindell, and Michael Bonfiglio. Owing to Hatcher’s strong emphasis in basic science education, these four figures developed a collective expertise in the bone pathology of tumors as well as in non-tumor conditions of the bone.
Beyond the students and residents whom Hatcher himself taught, many of Hatcher’s former residents also became influential educators in their careers as orthopaedic surgeons. William Enneking, for instance, became the first chair of the Department of Orthopaedic Surgery at the University of Florida, and supervised three fellows who became the younger founding members of the MSTS: Dempsey Springfield, James Neff, and John Makley. Henry Mankin, who was a key figure in the founding of the MSTS, did not pursue residency under Hatcher’s mentorship, but he was indirectly influenced by Hatcher during his internship at the University of Chicago’s Department of Internal Medicine. Subsequently, Hatcher’s influence shaped Mankin’s career pathway as a leading educator and researcher in the field of orthopaedic surgery.
Although almost four decades have passed since Hatcher’s death in 1982, the MSTS continues to preserve Hatcher’s educational legacy through an academic fellowship. In 1986, the Howard Hatcher Travelling Fellowship was initiated under the auspices of the American Orthopaedic Association (AOA) by William Enneking, Michael Bonfiglio, and Eugene Mindell – all of whom were accomplished academics who completed their residency under Hatcher. Beginning in 2007, the AOA transferred the administration of the Hatcher fellowship to the MSTS. Through its financial endowment and its global scope, the Howard Hatcher Fellowship continues to enrich the educational experiences of aspiring leaders in the field of orthopaedic oncology.
The Pivotal Role of Bone Pathologists
Contemporary research in musculoskeletal tumors and their treatments would not be possible without innovations in bone pathology. As early as the 1860s, Rudolph Virchow, an eminent figure in modern medicine, documented cases of bone tumors: he noted that they were rare but still posed a major problem for patients.[i] At that time, pathologists obtained a lot of knowledge from cadavers that they dissected for scientific study. As a result, Central Europe, particularly Vienna, became a global center for medical training, including in pathological anatomy – a prominence that lasted until World War II. Vienna’s public hospitals treated patients from an ethnically and socioeconomically diverse populace, and, in exchange for free healthcare, the numerous bodies of deceased poor patients were given to doctors, who would perform autopsies for the purposes of teaching and research in medicine.[ii] This unparalleled access to cadavers was conducive for the development of bone pathology, which benefited from the work of pioneering figures such as Jakob Erdheim, who directed the Institute of Pathology at Vienna’s Municipal Hospital.[iii] In this thriving environment for research, surgeons from across the world, including the United States, came to study under Jakob Erdheim’s mentorship. Among others, Dallas Phemister and Howard Hatcher went to Vienna for postgraduate training under Erdheim, and they became key figures in the development of oncology as a specialty for orthopaedic surgeons in the US. Other eminent bone pathologists also studied in Vienna before developing their careers in the United States: Henry Jaffe, Fritz Schajowicz, Ernst Freund, and Fuller Albright all trained under Jakob Erdheim’s supervision.
In the middle of the 20th century, bone pathology remained one of the more challenging subfields of surgical pathology, because of, among others, limitations in medical imaging. Before CT scans and MRIs became commonplace in the 1970s, orthopaedic surgeons diagnosed rare bone diseases by analyzing correlations between X-rays and a tissue samples, which are mounted on a glass slide. Furthermore, surgeons had to do their own pathology: they obtained tissue samples during surgeries (or autopsies) and wrote their own pathology assessment in surgical reports. At the University of Chicago, for instance, all the surgical divisions signed out and wrote their own reports until 1960 – a practice that was extensively implemented by both Dallas Phemister and Howard Hatcher, who was chief of orthopaedic surgery. Such an extensive exposure to pathology undoubtedly shaped the careers of Hatcher’s former residents: William Enneking, Eugene Mindell, and Michael Bonfiglio all developed large collection of macrosections that became central to research and teaching in bone pathology. Their collections of slides, for instance, were a major component of board exams for orthopaedic surgeons for decades.
Beginning in the 1950s, surgical pathology began to be institutionalized as a subspecialty of pathology, and, as a result, surgeons started to delegate the responsibility of writing pathological assessments to specialists in pathology. Although surgeons and pathologists now follow different pathways in their education and research, the science of pathology continues to provide key contributions to the successes of orthopaedic oncology as a field and, more importantly, to the care of patients with musculoskeletal tumors.
Michael A. Simon