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Bone tumors introduction and general principles

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introduction to bone tumors

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Bone tumors introduction and general principles

  1. 1. BONE TUMORS Dr Barun Kumar Patel APOLLO HOSPITALS BHUBANESWAR
  2. 2. Qns  1. discuss the principles of limb salvage surgery in malignant bone tumor. List the indications and contraindications?  2.describe clinical feature , radiology ,and treatment of non ossifying fibroma ?  3.discuss the anatomy of parathyroid gland, describe the clinical feature , radiological presentation of adenoma of parathyroid gland. What is hungry bone syndroma.
  3. 3.  4. briefly describe methods to cover defects after excision of primary malignant tumors of bone .what is extracorporeal irradiated tumor bone ?  5.discuss the pathology ,clinical features and management of synovial chondromatosis ?  6. write shortnotes on giant cell varients , fibrous dysplacia ?
  4. 4.  7. define giant cell tumor of bone , describe in brief clinical features ,diagnosis and management principles of GCT of upper end of tibia.  8. Indication of limb salvage surgery in malignant bone tumors , describe the techniques of limb salvage in osteosarcoma ?
  5. 5.  9.briefly describe the clinical features and pathology of ewing’s sarcoma . Outline the principles of treatment in a case of ewing sarcoma of upper end of humerus ?  10.discuss the various methods available for treatment of giant cell tumor of proximal tibia in a 30 yr old man ?
  6. 6. INITIAL EVALUATION  Carried out in 4 phases 1 st phase – involves High index of suspicion for tumors Routine X-rays Routine lab facilities Meticulous history Thorough physical examination 2 nd phase -is prebiopsy regional evaluation, to determine size,location and type of tissue involved 3 rd phase – is the actual biopsy. 4 th phase – is undertaken if presumptive clinical & path evidence sugestive of malignancy, search for mets is done, using CT scan of lung & Tc-99 bone scan
  7. 7. PRESENTING SYMPTOMS  Pain  Mass  An abnormal radiographic finding detected during evaluation of unrelated problem  PAIN:- is most frequent symptom -deep constant pain,poorly localised,worse at night -initially controlled by analgesics,later requires narcotics  MASS:- rate of enlargement is important -Fluctuating mass can be cyst,ganglion or hemangioma -Family H/O masses near the joint may be indicator of Ollier’s disease or Maffucci Syndrome
  8. 8. Cont…  NEUROLOGICAL SYMPTOM:- found in few patients such as sacral tumors & with tumors located near the nerve causing compression of nerve,especially common in sciatic notch ,inguinal canal & popliteal fossa  UNEXPLAINED SWELLING OF THE LOWER EXTREMITY :- found in pelvic tumors which are painless & without a palpable mass & cause swelling due to compression of iliac vein
  9. 9. HISTORY OF THE PATIENT  AGE:- most imp information, bcoz of their presentaion in specific age group.  1 st decade- usually ABC ,SBC  2 nd decade- Chondroblastoma,osteosarcoma,Ewings  3 rd decade- GCT  4 th decade- chondrosarcoma  5 th decade- Multiple myeloma  SEX:- less imp than age Some tumors like GCT are more in females
  10. 10. Cont…  RACE:- little imp, Ewings rare in african descent  H/O any exposure to radiation Tt or Carcinogens- bone seeking radionucleotide can cause sarcoma.  Various chemlcal carcinogens- methylcholanthrene,zinc beryllium silicate, beryllium oxide.  Currently the most worrisome & controversial is Nickel which is used in many orthopedic device
  11. 11. PHYSICAL EXAMINATION  Evaluation of patient’s general health  TUMOR MASS should be measured & its location, shape, consistency, mobility, tenderness, local temp & change with position should be noted.  SKIN & SUBCUTANEOUS TISSUE :  Small dilated superficial veins overlying the mass are produced by large tumors  REGIONAL LYMPH NODES: sign of metastatic disease  Atrophy of surrounding musculature should be recorded,also neurological deficits & adequacy of circulation
  12. 12. LABORATORY TEST  Alkaline phosphatase test: Normally, this enzyme is present in high levels when bone-forming cells are very active . High levels of alkaline phosphatase can also be an indicator of bone tumors (when the tumor creates abnormal bone tissues).  PTH test: Lower-than-normal level of parathormone can be an indicator of bone cancer.  Serum phosphorus: Higher than normal levels of phosphorus can be an indicator of bone cancer.  Ionized calcium and serum calcium: Higher than normal levels of calcium can be an indicator of bone cancer.
  13. 13. Cont…  OTHER TESTS Hemoglobin CBC ESR CRP Glucose tolerance test PSA,PAP Electrophoresis & urinary Bence Jones protein
  14. 14. INVESTIGATIONS  X-RAY  CT SCAN  MRI  TECHNETIUM BONE SCAN-This type of scan uses a very low radioactive material (diphosphonate) to see whether or not the cancer has spread to other bones and the damage suffered by the bone.  PET- Positron Emission Tomography uses radioactive glucose to locate cancer. This glucose contains a radioactive atom that is absorbed by the cancerous cells and then detected by a special camera
  15. 15. BIOPSY  The biopsy is the most conclusive as it confirms if the tumor is malignant or benign, the type (primary or secondary ), and stage  According to the tumor size and type and purpose (to remove entire tumor or only a small tissue sample), biopsies can be : needle biopsy , incisional biopsy , excisional biopsy  1. Needle biopsy: a small hole is made in the affected bone and a tissue sample from the tumor is removed. There are two types of needle biopsies: Fine needle aspiration : During this procedure, the tissue sample is removed with a thin needle attached to a syringe Core needle aspiration : a small cylinder of tissue sample is removed from the tumor with a rotating knife like device.  2. Incisional biopsy : During this procedure, the surgeon cuts into the tumor and removes a tissue sample.
  16. 16. Principles of biopsy  Biopsy should be done after clinical, laboratory, and radiographic examinations are complete  biopsy track should be considered contaminated with tumor cells , biopsy track needs to be excised en bloc with the tumor  Transverse incisions avoided because they are difficult to excise with the specimen
  17. 17.  deep incision through a single muscle compartment not to contaminating an intermuscular plane  Major neurovascular structures be avoided  Soft tissue extension of bone lesion should be sampled because leading edge contains most viable tumor for making diagnosis  If tourniquet used,limb elevated before inflation but not to be exsanguinated by compression to prevent “squeezing” the tumors cells into the systemic circulation
  18. 18. Cont…  If a hole is made in bone, should be round or oval to minimize stress concentration and prevent a subsequent fracture, which could preclude limb salvage surgery  The hole be plugged with methacrylate to limit hematoma formation  sample more than just the pseudocapsule surrounding the lesion
  19. 19. Cont…  frozen section should be sent intraoperatively to ensure that diagnostic tissue has been obtained  If drain used, it should exit in line with incision so that the drain track can be easily excised en bloc with tumor  wound should be closed tightly in layers
  20. 20. Cont…
  21. 21. classification Revised WHO Classification – Schajowicz(1994)
  22. 22. STAGING  Staging of benign bone tumours as described by Enneking  stages of benign tumors designated by Arabic numbers, and malignant tumors by Roman numerals  stage 1, latent; stage 2, active; and stage 3, aggressive
  23. 23.  Stage 1 -lesions are intracapsular, usually asymptomatic, and frequently incidental findings  Radiographic features – well-defined margin with thick rim of reactive bone. no cortical destruction or expansion.  not require treatment – not compromise the strength of the bone resolve spontaneously
  24. 24.  Stage 2- intracapsular actively growing cause symptoms or pathological fracture  Radiographs-well- defined margins expand and thin cortex. thin rim of reactive bone  Treatment - extended curettage
  25. 25.  Stage 3 – extracapsular broken through reactive bone and cortex  MRI shows soft tissue mass, and metastases may present in 5% of patients  Treatment -extended curettage marginal or wide resection,  local recurrences are common.
  26. 26.  The staging system for malignant tumors adopted by the Musculoskeletal Tumor Society, and originally developed by Enneking is based on the histological grade, the local extent, and the presence or absence of metastasis  Bone sarcomas are broadly divided as follows:  • Stage I All low-grade sarcomas.  • Stage II Histologically high-grade lesions.  • Stage III Sarcomas which have metastasized
  27. 27.  stage I-lesions are well-differentiated, have few mitoses, and exhibit moderate cytological atypia  risk for metastases is low (<25%)  stage II-poorly differentiated high mitotic rate and high cell-to-matrix ratio  Stage III-lesion that metastasized regardless of size or grade of primary tumor Anatomical compartments are the natural anatomical barriers to tumor growth, such as cortical bone, articular cartilage, fascial septa, or joint capsules
  28. 28. Surgical stages as described by Enneking
  29. 29.  The AJCC staging soft tissue sarcomas based on tumor grade (low or high), size (≤5 cm or >5 cm in greatest dimension), depth (superficial or deep to the fascia), and presence of metastases
  30. 30. PRINCIPLES OF SURGERY AMPUTATION VERSUS LIMB SALVAGE  issues to be considered whenever contemplating limb salvage instead of an amputation 1. Would survival be affected by the treatment choice? 2. How do the short-term and long-term morbidity compare? 3. How would the function of a salvaged limb compare with that of a prosthesis? 4. Are there any psychosocial consequences?
  31. 31.  involvement of neurovascular structures, displaced pathological fracture, complications secondary poorly performed biopsy preclude limb salvage procedures  choice between limb salvage and amputation made on basis of expectations and desires of patient and family  multimodal treatment including surgery and chemotherapy, improved long-term survival for patients.
  32. 32.  patients with a local recurrence despite wide margins represent aggressive or chemotherapy-resistant disease , has poor outcomes regardless of surgical procedure  most important aspect of surgical procedure is attainment of a wide margin regardless of achieved by amputation or local resection
  33. 33.  Amputation often requires nonstandard flaps for closure or bone graft augmentation for a more functional residual limb  Complications - infection, wound dehiscence, chronically painful limb, phantom limb pain, and bone overgrowth requiring revision surgery  Limb salvage is associated with greater perioperative and long- term morbidity  Complications- greater risks of infection, wound dehiscence, flap necrosis, blood loss, and dvt  long term complications like periprosthetic fractures, prosthetic loosening or dislocation, nonunion of the graft-host junction, allograft fracture, leg-length discrepancy, and late infection  more likely to need multiple future operations for treatment of complications including
  34. 34.  regard to function, location of tumor is most important issue  Resection of upper extremity lesion with limb salvage, even sacrificing one or two major nerves, provides better function than amputation and prosthetic fitting  resection of a proximal femoral or pelvic lesion with local reconstruction provides better function than after hip disarticulation or hemipelvectomy
  35. 35.  Around ankle and foot, large sarcomas treated with amputation and prosthetic fitting  osteosarcoma around the knee treated with wide resection with prosthetic knee replacement or transfemoral amputation  osteoarticular allograft reconstruction, allograft arthrodesis, and rotationplasty are less prefered
  36. 36.  patients with amputations had difficulty walking on steep, rough, or slippery surfaces but active and least worried about damaging limb  Patients with arthrodesis performed most of physical work but had difficulty with sitting, especially in back seats of cars, theaters  Patients with arthroplasty led more sedentary lives , protective of limb but had less difficulty with activities of daily living
  37. 37.  probability of limb survival after resection depends on type of reconstruction and location of tumor(most imp issue).  proximal reconstructions outlasting distal reconstructions. ( inverse of the prognosis for patient survival, with distal sarcomas better prognosis than proximal ones.)
  38. 38.  No study has shown significant difference between amputation and limb salvage with regard to psychological outcome or quality of life in long-term survivors of sarcoma.  patient ultimately make the final decision in light of long-term goals and lifestyle decisions.
  39. 39. MARGINS  In oncological surgical procedure, the surgical margin must be appropriately defined  orthopaedic oncology, surgical margin described by one of four : intralesional, marginal, wide, or radical
  40. 40.  intralesional margin- plane of surgical dissection is within the tumor  appropriate for symptomatic benign lesions when the surgical alternative would be to sacrifice important anatomical structures , or as a palliative procedure in case of metastatic disease
  41. 41.  marginal margin -plane of dissection passes through pseudocapsule(surroundi ng reactive tissue referred as pseudocapsule)  treat most benign lesions and some low-grade malignancies.  marginal resection leaves microscopic disease leading to local recurrence in high grade malignancies  marginal resection preferable if alternative is more mutilating procedure
  42. 42. Cont..  Wide margins -plane of dissection is in normal tissue  no specific distance , entire tumor remains completely surrounded by rim of normal tissue  quality of margin is more important than the quantity (thickness) of the margin  wide margins are goal of most procedures for high-grade
  43. 43.  Radical margins -all compartments containing tumor removed en bloc  previously the procedures of choice for most high-grade neoplasms  amputations defined further by any of the four margins
  44. 44. CURETTAGE  Many benign bone tumors treated by curettage  curettage is associated with higher rate of local recurrence than resection, but allows a better functional result PRINCIPLES OF CURETTAGE  done by first making large cortical window
  45. 45.  Next, cavity is enlarged to normal host bone in each direction with a power burr  Finally, cavity and wound TO be copiously irrigated to remove any debris and tumor cells  Extended” curettage - use of adjuvants, such as liquid nitrogen, phenol, polymethyl methacrylate, or thermal cautery to extend destruction of tumor cells
  46. 46. filling the cavity  -through autogenous bone graft, allograft, demineralized bone matrix, artificial bone graft substitutes, or bone cement  Autogenous bone graft must be harvested using different set of instruments to prevent contamination of the donor site
  47. 47.  Autogenous bone graft provides most rapid and most reliable healing rate as it is osteogenic, osteoinductive, and osteoconductive  But is associated with morbidity harvest site, may not available in sufficient quantity to fill a large cavity  cancellous allograft (only osteoinductive)incorporated easily, available in large quantities and not involve further operative morbidity
  48. 48.  demineralized bone matrix used as filling agent after curettage of benign bone tumors  is osteoconductive and osteoinductive  Artificial bone graft substitutes ( calcium sulfate, calcium phosphate) are osteoconductive, easy to use, and readily available  used alone or in combination with autogenous bone graft, bone marrow aspirates, or demineralized bone matrix
  49. 49.  bone cement is also used as a filling agent  has the advantage of providing immediate stability, makes rehabilitation easier and lessens risk of pathological fracture  another advantage of bone cement is detection of local recurrence  recurrent tumor recognized as an expanding lucency adjacent to bone

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