18. Imaging
Detection (X-rays, bone scan, MRI for soft tissue tumor)
Characterization (X-rays, CT scan)
Local staging (MRI)
Evaluation for regional and distant metastases (CT
chest, bone scan, PET scan)
19. What to read in X-Ray
1. Site
2. Size
3. Matrix
4. Pattern/margins incl. zone of transition
5. Effect of the lesion on bone
6. Reaction of bone to the lesion
7. Soft tissue mass
20. site
• Which bone is affected (femur, radius,…)
• Where in the bone
Diaphysis, metaphysis, epiphysis, or combination
Central, eccentric, intracortical, surface
23. LESION EFFECT ON BONE
• Cortical thinning
Lower grade, less aggressive
• Cortical expansion
Low or high grade, tumor mimickers
• Cortical destruction
High grade, aggressive
24. EFFECT BONE ON LESION
Periosteal reaction
Absent
Mild – one layer, 1-4 mm thick, adjacent to cortex
Major - >5mm, multilayered or lamellated
“onion-skinning”, “hair-on-end”, “sunburst”
35. Enneking system—Enneking and associates developed a staging
system for benign and malignant musculoskeletal tumors.
American Joint Commission for Cancer (AJCC) classification system
STAGING
36. benign lesions
1 latent lesion
e.g. NOF,enchondroma
2 active lesion
e.g. ABC, UBC
3 aggressive lesion
e.g. giant cell tumor of bone
38. Biopsy
Fine Needle Aspiration (FNA)
not typically used for sarcoma
Core biopsy (Tru-cut)
allow for tumor structural examination
cytologic and stromal elements of the tumor
frequently used for sarcoma
Incisional biopsy
small surgical incision carefully placed to access tumor without
contamination of critical structures
Excisional biopsy
small, superficial soft tissue masses
39. NOT FOR BIOPSY
An asymptomatic (latent) or symptomatic bone lesion
(active) that appears entirely benign on imaging does
not need a biopsy
A soft tissue lesion that appears entirely benign on
MRI (lipoma, hemangioma) does not need a biopsy
When in doubt, it is safer to do a biopsy.
40. INDICATIONS FOR BIOPSY
1) Aggressive or malignant appearing bone or soft tissue
lesions
2) For soft tissue lesions - >5cm, deep to fascia or
overlying bone or neurovascular structures
3) Unclear diagnosis in symptomatic patient
4) Special situation - solitary bone lesion in a patient
with a history of carcinoma
41. BEFORE BIOPSY
CBC, platelets, coagulation screen
Cross-sectional imaging – depicts local anatomy, solid
areas of tumour
Experienced musculoskeletal pathologist available
42. PRINCIPLES OF BIOPSY
SKIN
Avoid tenuous skin , Avoid transverse incision
DEEP
Through muscle , meticulous hemostasis , Avoid NV
SAMPLE
Ensure adequate diagnostic tissue , FROZEN –SECTION
CLOSURE
Tight muscle closure , drain at corner , compression dressing
Send for C/S
43. For tumours without soft
tissue mass, plan biopsy
through area of maximal
cortical weakening based on
CT or MRI .
For tumours or with soft
tissue mass, biopsy soft
tissue rather than creating
hole in bone .
44. Chemotherapy
induces apoptosis
eliminates micrometastasis in lungs
>98% necrosis with chemotherapy is good prognostic sign
Multi-drug resistance (MDR) gene (poor prognosis )
cells can pump chemotherapy out of cell
present in 25% of primary lesions and 50% of metastatic lesions
45. Radiation therapy
Two mechanisms of action
production of free radicals
direct genetic damage
46. Indications of External beam
irradiation
Definitive control (primary malignant bone tumors)
Ewing sarcoma , primary lymphoma of bone
Adjuvant to surgical excision
soft tissue sarcomas
Palliative care and after impending fracture
fixation
needed after fixation of impending/pathologic fractures to
reduce overall tumor burden
47. Complications of Radiation
therapy
Radiation effects on normal tissue
early effects
delayed wound healing , infection
late effects
fibrosis , joint stiffness
Post-radiation sarcoma
incidence is ~13% , poor prognosis
Post-radiation fractures
48. Impending fracture
prophylactic fixation
Harrington's criteria
Life expectancy greater than 1 - 2 months
Continued pain after radiotherapy
Lesion greater than 2.5 cm diameter in metaphysis (50 - 75 %
destruction)
Destruction of 50% or more of the diaphyseal cortex of a long bone
Adequate bone quality
Procedure would enhance mobilisation and independence