RAM SUDHAN S
Rockwood and green
DIAGNOSTIC EVALUATION :
History & physicxal examination:
c/c: pain (MC)
mass or abnormal x ray finding.
Lymph nodes: ( though rare)
seen with, epitheloid sarcoma
& synovial sarcoma.
PLAIN X RAY:site: epi / meta / dia
less vital in soft tissue tumours:
benign or malignant:
BY PLAIN X RAY
Zone of transition:
- well marginated - less marked
( surrounding rim of ( host response is
Reactive bone form’) slower than the
progr’n of tumour )
Expansile destruction Frank cortical destru
of cortex: ( agg’ benign tion ( without expa
tumour) nsion of cortex)
( tumour destroys the
may take the form
of: onion skinning
sunburst or codman’s
ossification, calcification, integrity of
BEST: to localise the nidus in osteiod
3D reconstruction: treatment plan.
ANEURISMAL BONE CYST: thin rim of reactive
CARTILAGENOUS LESION: calcification
SUSPECTED CHONDRO SARCOMA: endosteal
CT LUNG: Detects pulmonary met.
CT WITH CONTRAST: ( if MRI is prohibited)
differentiates cystic lesion from vascular
BONE SCAN:( Tc)
to determine the activity of the lesion.
presence of any other lesion.
False negative results ( freq.)
- multiple myeloma.
Normal bone scan is reassuring.
but increased uptake is not always
3D visualisation & quantitative assessment
of in vivo physiological & biochemical
Staging and in planning biopsy & response to
FDG PET: (F^18)
-fluro deoxy labelled PET.
-useful in detection,staging,management
-MECH: FDG – glucose analogue
becomes trapped in malignant cells
( in proportion to the rate of glycolysis)
MRI: ( has replaced CT.)
-IS THE STUDY OF CHOICE.
-size, extent & anatomic relationship
with soft tissues.
-most accurate ( extent of intra
medullary & extrosseus disease )
-may also yield specific diagnosis (
lipoma , hemangioma, hematoma &
pigmented villonodular synovitis)
- CANNOT DIFFERENTIATE BENIGN AND
can differentiate cystic and solid masses
ANGIOGRAPHY:(replaced by MRI)
eventhough used in pre operative
embolisation of highly vascular tumours.
(esp.RCC & ABC)
CBC: r/o infection, leukemia & status.
ESR: inc.in infection / metastatic Ca / small
blue cell tumours( EWING,
S.PROTEIN ELECTROPHORESIS:( multiple
S.Ca: mets / hyper parathyroidism / MM
ALP: Inc. in metabolic bone disease &
PTH: (with Ca)
-brown’s tumour( hyper parathyroidism)
- mimic GCT.
BUN & S.Cr:
- inc. in renal tumours.
URINARY PYRIDIUM CROSSLINKS:( with ALP)
1. done only after
clinical, radiographic, lab tests are
2. biopsy track is always considered
contaminated ( needle/open) with tumour
thus biopsy track needs to be excised
en bloc with the tumour.
3.the same surgeon who plans the
definitive procedure must perform the
4.only vertical incisions are made
(never transverse – may become impossible
to excise the whole track)
5.if tournequet is used , limb may be
elevated but not exsanguniated
prevents squeezing of tumour cells into
6.incision should go thro’ a single
muscle compartment ( never thro’ neuro
vascular plane/inter muscular plane)
7.if a hole is made in bone, it should be
round or oval--- to decrease trhe subsequent
( hole can be plugged
With methacrylate to
Should be sent intra- op
To ensure that the diagnostic tissue is obtained.
( if correct- definitive procedure can be done
immedietely,provided it must correlate clinically
9.meticulous hemostasis should be
attained before closure.( as hematoma may
be contaminated with tumour cells)
10.if drain is used,it should be exited in
line with the incision ( drain track can alspo
six reasons why the biopsy should not be
done until the evaluation is complete:
(1) may be a primary sarcoma of bone that
may require a biopsy technique that
allows for future limb salvage surgery;
(2) another, more accessible lesion may be
(3) if renal cell carcinoma is likely,
embolization - to avoid excessive
(4) if multiple myeloma is
made, unnecessary biopsy can be
(5) the pathological diagnosis is more accurate
if aided by appropriate imaging studies.
(6)the pathologist and surgeon may be more
assured of a diagnosis - frozen section – and
can plan the definitive procedure
INDICATIONS FOR BIOPSY:
-close proximity to neuro vascular
-remote location( pelvis)
-90% accurate in determining malignancy.
-low significance in determining specific
tumours.( as only cells are obtained not tissues)
- done when the suspect is a met / infection
/ lymph nodes.
CORE NEEDLE BIOPSY:( accuracy- 84-98%)
- uses large bore needle than FNAC.
thus provides tissue with
- gold standard
- least likely to be ass’ with sampling
- <3 cm subcutaneous mass (i.e)
unlikely to be malignant.
( if turns malignant – tumour bed must
be re excised)
- should not be done on large soft
tissue lesions / lesion deep to facsia
UNLESS PROVEN BENIGN.
-relative indication is painful lesion in
a EXPENDABLE bone.( prox.fibula/distal
GENERAL SCHEME OF DIAGNOSIS:
TYPE OF LESION
ZONE OF TRANSITION (margins)
PLAIN X RAY
NO DISTINCTION IS MADE BETWEEN LYMPH
NODE STATUS/ DISTANT MET – BOTH HAVE
AMERICAN JOINT COMMITTEE ON CANCER
SYSTEM ( AJCC ) :
if primary malignancy: making disease
if metastatic Ca: minimise pain and to
- Causes cell death- by forming free
radicals inside cells
- sensitivity depends on:
1. cells position in cell cycle;
( active mitotic cells are more
2.tissue oygenation,(hypoxia –
3. cells ability to repair DNA
DOSE OF RADIATION: ( GRAY )
1 GRAY = 1 JOULE energy absorbed per Kg
1 Rad = 1 centi gray
GOAL: deliver highest possible dose of
radiation to tumour cells, while minimising
toxicity to normal cells.
- delivered by linear accelerators.
- Most protocols deliver 150-200 cGy / day
- Myeloma = 30-40 Gy
- Sarcoma = 60 Gy.
Most primary bone malignancy are
RADIORESISTANT (.except small blue cell
tumour , myeloma, lymphoma, ewing)
Carcinoma except RCC are sensitive.
Pre operatively used – In reducing the bulk
Post operatively used – in prevention of
- Skin irritation
- radiation sarcoma( lag time 10 y)
- hypoplasia of ilium
NEW Rx: BRACHYTHERAPY
radiation is delivered in close
not useful for cartilagenous
tumours & low grade malignancy.
post op chemo for persumed
-NEO ADJUVANT CHEMO:
before surgical ressection ( dec’
bulk & dec’ the spread of tumour during
PRINCIPLES OF SURGERY:
(AMPUTATION Vs LIMBSALVAGE)
While prefering salvage, always keep in
SIMON’S 4 ISSUES:
1. would the survival affected by
2.how do the short term & long term
3.how would the function of a salvaged
limb with that of the prosthesis.
4. are there any psychosocial
IN REGARD TO PT’ SURVIVAL, most vital
technical aspect is attainment of WIDE
MARGIN regardless of whether it is achieved
by AMPUTATION/LOCAL RESSECTION.
( suits for amputation / ressection )
-plane of surgical dissection is within
-Symptomatic benign lesion.
-palliative in metastatic disease.
-plane of dissection passes thro’ the
pseudocapsule formed by the tumour.
-most benign lesion & low grade
-plane of dissection is thro’ normal
-no specific distance is defined.
-quality of the margin is more important
than the quantity.
- hiogh grade malignancy.
- All compartments containing tumour
are removed en bloc
-deep soft tissue tumours
- In case of bone tumour: removing
entire bone and the compartments of any
of local procedures.
- higher rate of local recurrence than
PROCEDURE: ( simple curettage)
large cortical window ( in the size of the
bulk of the tumour is scooped out.
the cavity is enlarged back to normal