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General principals of musculoskeletal tumors:

General principals of musculoskeletal tumors Sherif El Daw Assistant lecturer Tanta University Hospitals Ortho Dep.

Items of lecture:

Items of lecture Diagnostic evaluation Biopsy Principles of surgery

Diagnostic evaluation :

Diagnostic evaluation History Examination (general -- local) Lab. Investigation Radiology Biopsy and histopathology staging

Personal history:

Personal history Age ( a ge may be the most important information obtained in the history because most benign and malignant musculoskeletal neoplasms occur within specific age ranges .) sex predilection (e.g., female predominance with giant cell tumors Race likewise is of little significance, with the exception that Ewing sarcoma is rare in individuals of African descent.

complaint:

complaint Patients may present to the orthopedic oncologist with pain, a mass, or an abnormal radiographic finding detected during the evaluation of an unrelated problem. Patients with benign bone tumors also may have activity-related pain if the lesion is large enough to weaken the bone, mostly osteoid osteoma may cause night pain . patient with a malignancy of bone often complains of progressive pain Conversely, patients with soft-tissue tumors rarely complain of pain, but more often complain of a mass Exceptions to this rule are patients with nerve sheath tumors who have pain or neurologic signs.

General examination:

General examination general health Vital signs Heart , chest , lung , thyroid . Café au lait spots or cutaneous hemangiomas also may provide diagnostic clues . Potential sites of lymph node metastases should be palpated

Examination of the part in question:

E xamination of the part in question A mass should be measured, and its location, shape, consistency, mobility, tenderness, local temperature, and change with position should be noted. Atrophy of the surrounding musculature should be recorded, as should neurological deficits and adequacy of circulation

Plain Radiographic evaluation:

Plain Radiographic evaluation (1) the site of the lesion many bone tumors have specific site predilections In axial Plane ( centric or eccentric ) In the Longitudinal Plane ( Epiphyseal , Metaphyseal , Diaphyseal ) Site and age relationship An epiphyseal lesion in a skeletally mature patient is likely to be a giant cell tumor, whereas an epiphyseal lesion in a skeletally immature patient is likely to be a chondroblastoma .

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In the Transverse Plane . . .

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Site Age Lesion Epiphyseal 10-25 Chondroblastoma Epiphyseal 20-40 Giant cell tumor Epiphyseal 40-60 chondrosarcoma Diaphyseal 5-25 Ewing sarcoma Diaphyseal 5-30 Fibrous dysplasia Diaphyseal 5-30 Histiocytosis Diaphyseal adult Lymphoma

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Giant cell tumor and Chondroblastoma as example for site and age relation in diagnosis

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Site Age lesion Vertebral Body Younger than 30 Years Histiocytosis Younger than 30 Years Hemangioma Posterior Elements Younger than 30 Years Osteoid osteoma Younger than 30 Years Osteoblastoma Younger than 30 Years Aneurysmal bone cyst Vertebral Body Older than 40 Years Metastases Older than 40 Years Hemiangioma

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(2) the aggressiveness of the lesion whether it is likely to be benign or malignant, usually can be determined by careful evaluation of the plain films Inactive lesions Aggressive lesions well marginated , often with a surrounding rim of reactive bone formation usually have an ill -defined zone of transition between the lesion and the host bone. Cortical expansion can be seen with aggressive benign lesions, but frank cortical destruction usually is a sign of malignancy.

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(3 ) Patterns of Bone Destruction Geographic Moth-eaten Permeative

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Geographic Moth-eaten Permeative Destructive lesion with sharply defined border Implies a less-aggressive, more slow-growing, benign process Narrow transition zone Examples: Non-ossifying fibroma Chondromyxoid fibroma Eosinophilic granuloma Areas of destruction with ragged borders Implies more rapid growth Probably a malignancy Examples: Myeloma Metastases Lymphoma Ewing’s sarcoma Ill-defined lesion with multiple “worm-holes” Spreads through marrow space Wide transition zone Implies an aggressive malignancy Examples: Lymphoma, leukemia Ewing’s Sarcoma Myeloma Osteomyelitis Neuroblastoma

Patterns of Bone Destruction:

Patterns of Bone Destruction Geographic Moth-eaten Permeative Less malignant More malignant

(4) Periosteal Reactions :

(4) Periosteal Reactions Benign No Periosteal Reactions Solid e.g in osteomyelitis Aggressive/malignant onion-peel  Ewing sarcoma Sunburst  Osteo-sarcoma Codman’s triangle  Osteo-sarcoma

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(4) Periosteal Reactions Solid onion-peel Sunburst Codman’s triangle Less malignant More malignant

CT scan:

CT scan assessing ossification and calcification and in evaluating the integrity of the cortex. It also is the best imaging study to localize the nidus of an osteoid osteoma to detect a thin rim of reactive bone around an aneurysmal bone cyst to evaluate calcification in a suspected cartilaginous lesion, and to evaluate endosteal cortical erosion in a suspected chondrosarcoma

Ultrasonography :

Ultrasonography cystic from solid soft-tissue lesions

Technetium bone scans:

Technetium bone scans determine the activity of a lesion determine the presence of multiple lesions or skeletal metastases A normal bone scan is reassuring; however, the converse statement is not true because benign active lesions of bone also show increased uptake.

MRI:

MRI size, extent, and anatomical relationships of bone and soft-tissue tumors specific diagnosis with tumors such as lipoma , hemangioma , hematoma, or pigmented villonodular synovitis , all of which have characteristic appearances

Staging:

Staging Enneking System for Staging Benign Musculoskeletal Tumours (1) latent (2) active (3) aggressive

Staging Enneking System for Staging Malignant Musculoskeletal Tumors:

Staging Enneking System for Staging Malignant Musculoskeletal Tumors Stage Grade Site Metastases IA Low Intracompartmental None IB Low Extracompartmental None IIA High Intracompartmental None IIB High Extracompartmental None III Any Any Regional or distant metastases

Staging:

Staging American Joint Committee on Cancer System for Staging Bone Sarcomas Stage Grade Size Metastases I-A Low ≤8 cm None I-B Low >8 cm None II-A High ≤8 cm None II-B High >8 cm None III Any Any Skip metastasis IV-A Any Any Pulmonary metastases IV-B Any Any Nonpulmonary metastases

Biopsy:

Biopsy

series of recommendations:

series of recommendations completion of the evaluation before biopsy aids in planning the placement of the biopsy incision the biopsy track should be considered contaminated with tumor cells . If a tourniquet is used, the limb may be elevated before inflation but should not be exsanguinated by compression.

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4) Transverse incisions should be avoided because they are extremely difficult or impossible to excise with the specimen . 5) The deep incision should go through a single muscle compartment rather than contaminating an intermuscular plane 6) Soft-tissue extension of a bone lesion should be sampled, if possible . 7) If a hole must be made in the bone, it should be round or oval to minimize stress concentration and prevent a subsequent fracture

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8) The periphery of a lesion usually contains the most viable tissue and is the best tissue on which to base a diagnosis 9) If a tourniquet has been used, it should be deflated and meticulous hemostasis ensured before closure 10) If a drain is used, it should exit in line with the incision so that the drain track also can be easily excised en bloc with the tumor . 11) The wound should be closed tightly in layers. Wide retention sutures should not be used.

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PRINCIPLES OF SURGERY

Amputation versus Limb Salvage:

Amputation versus Limb Salvage Would survival be affected by the treatment choice How do the short-term and long-term morbidity compare How would the function of a salvaged limb compare with that of a prosthesis Are there any psychosocial consequences Finally treatment with long-term survival , short-term morbidity, good function , psychosocial satisfaction is needed.

Margins:

Margins

intralesional margin:

intralesional margin described as “ debulking appropriate for symptomatic benign lesions, also may be appropriate as a palliative procedure in the setting of metastatic disease

marginal margin:

marginal margin As musculoskeletal tumors grow, they compress the surrounding tissues and appear to become encapsulated. This surrounding reactive tissue often is referred to as the pseudocapsule A marginal margin is achieved when the closest plane of dissection passes through the pseudocapsule . This type of margin usually is adequate to treat most benign lesions and some low-grade malignancies

Wide margins:

Wide margins achieved when the plane of dissection is in normal tissue in all directions wide margins are the goal of most procedures for high-grade malignancies

Radical margins:

Radical margins when all the compartments that contain tumor are removed en bloc . Radical operations were previously the procedures of choice for most high-grade neoplasms; H owever , with improvements in imaging studies, radical procedures now are rarely performed because equivalent oncological results usually can be obtained with wide margins

Curettage:

Curettage

Curettage:

Curettage benign bone tumors only . Compared with resection, curettage is associated with a higher rate of local recurrence; however allows for a better functional result . the surgeon should adhere strictly to several principles to avoid an unacceptably high rate of local recurrence, especially with more aggressive benign tumors . Types are (Simple or extended)

minimal requirements for a “simple” curettage:

minimal requirements for a “simple” curettage done by first making a large cortical window over the lesion This window must be at least as large as the lesion itself . If the window is smaller than the lesion, the surgeon inevitably leaves residual tumor on the undersurface of the near cortex

minimal requirements for a “simple” curettage:

minimal requirements for a “simple” curettage The bulk of the tumor is scooped out with large curets the cavity is enlarged by 1 to 2 cm in each direction with a power burr . the cavity and the wound should be copiously irrigated to remove any debris and tumor cells

Extended” curettage:

Extended” curettage use of adjuvants, such as liquid nitrogen, phenol, polymethyl methacrylate, or thermal cautery to extend destruction of tumor cells . Multiple authors have reported greatly reduced recurrence rates of aggressive tumors with the use of adjuvants

Types of adjuvant in Extended” curettage:

Types of adjuvant in Extended ” curettage Cryosurgery with liquid nitrogen Phenol polymethyl methacrylate bone cement T hermal cautery

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liquid nitrogen Phenol polymethyl methacrylate bone cement Thermal cautery effective at extending the tumor kill. Studies have shown it to be superior to phenol and methacrylate at creating a rim of necrotic bone (≤14 mm) around experimental cavities in animal and cadaver models. Liquid nitrogen usually is applied by the “direct pour” technique and may be associated with greater complications, including pathological fracture and nerve injury has relatively poor penetration into bone (<1 mm). Although it is relatively easy to use, serious complications have been reported when phenol was inadvertently applied to the surrounding normal tissues act as an adjuvant through its heat of polymerization or through direct toxicity of the monomer. It is easily applied and can be used as a filling agent in conjunction with other adjuvants such as with an argon beam coagulator. Studies have shown the depth of necrosis in cancellous bone treated with argon beam coagulation to be approximately 4 mm. We have extensive experience with the use of argon beam coagulation and have noted no complications that can be attributed directly to its use

filling the cavity left after curettage:

filling the cavity left after curettage autogenous bone graft. allograft. demineralized bone matrix. artificial bone graft substitutes. bone cement .

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autogenous bone graft. allograft. artificial bone graft substitutes. bone cement . osteogenic , osteoinductive , and osteoconductive additional morbidity at the harvest site it may not be available in sufficient quantity to fill a large cavity associated with the theoretical risk of disease transmission (e.g., calcium sulfate, calcium phosphate) osteoconductive , are easy to use, and are readily available They may be used alone or in combination with autogenous bone graft, bone marrow aspirates, or demineralized bone matrix providing immediate stability makes rehabilitation easier and lessens the risk of pathological fracture Another advantage of bone cement is associated with the detection of local recurrence which is easily recognized as an expanding lucency adjacent to bone cement.

Resection and Reconstruction:

Resection and Reconstruction

Options of reconstructions:

Options of reconstructions Osteoarticular allografts Allograft-prosthesis composites Endoprosthetic reconstruction

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Osteoarticular allografts Allograft-prosthesis composites Endoprosthetic reconstruction high rates of complications, including nonunion at the graft-host junction, fatigue fracture, articular collapse, dislocation, degenerative joint disease, and failure of ligament and tendon attachments temporary measure to preserve an adjacent physis in an immature patient when the alternatives include amputation or sacrifice of both physes converted later to an endoprosthetic reconstruction when it becomes necessary avoid the complications of degenerative joint disease and articular collapse associated, however, with fatigue fracture, infection, and nonunion at the graft-host junction main indication for an allograft-prosthesis composite is an inadequate length of remaining host bone to secure the stem of an endoprosthesis the advantage of predictable immediate stability that allows for quicker rehabilitation with immediate full weight bearing. Fatigue fracture at the base of the intramedullary stem where it attaches to the body of the prosthesis is more problematic

Considerations for Pediatric Patients:

Considerations for Pediatric Patients future limb-length inequality must be considered epiphysiodesis of the contralateral limb can be done at the appropriate age to preserve limb-length equality use of expandable prostheses currently is gaining support.

Repiphysis Expandable Prosthesis:

Repiphysis Expandable Prosthesis

Thank You Good Luck:

Thank You Good Luck