General principles of tumour management.

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a generaL review of evaluation, diagnosis and management.

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General principles of tumour management.

  1. 1. RAM SUDHAN S MCH, CALICUT Ref: campbell’s Rockwood and green
  2. 2. DIAGNOSTIC EVALUATION :  History & physicxal examination: c/c: pain (MC) mass or abnormal x ray finding.  Age:  Lymph nodes: ( though rare) seen with, epitheloid sarcoma rhabdomyosarcoma & synovial sarcoma.  Radiographic evaluation: PLAIN X RAY:site: epi / meta / dia less vital in soft tissue tumours: benign or malignant:
  3. 3. BY PLAIN X RAY BENIGN: MALIGNANT: 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)
  4. 4. Periosteal reaction: ( tumour destroys the cortex) may take the form of: onion skinning sunburst or codman’s
  5. 5. CT SCAN: ossification, calcification, integrity of cortex.  BEST: to localise the nidus in osteiod osteoma  3D reconstruction: treatment plan.  ANEURISMAL BONE CYST: thin rim of reactive bone formation.  CARTILAGENOUS LESION: calcification  SUSPECTED CHONDRO SARCOMA: endosteal cortical erosion.
  6. 6. Endosteal erosion in chondrosarcoma:
  7. 7. CT LUNG: Detects pulmonary met. CT WITH CONTRAST: ( if MRI is prohibited) differentiates cystic lesion from vascular lesion.
  8. 8. BONE SCAN:( Tc)  to determine the activity of the lesion.  presence of any other lesion.  False negative results ( freq.) - multiple myeloma. - RCC.  Normal bone scan is reassuring.  NOTE: but increased uptake is not always malignant.
  9. 9. PET SCAN:  3D visualisation & quantitative assessment of in vivo physiological & biochemical processess.  Staging and in planning biopsy & response to chemo therapy. 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)
  10. 10. 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 MALIGNANT LESIONS.
  11. 11. USG: can differentiate cystic and solid masses ANGIOGRAPHY:(replaced by MRI) eventhough used in pre operative embolisation of highly vascular tumours. (esp.RCC & ABC)
  12. 12. LABORATORY TESTS:  CBC: r/o infection, leukemia & status.  ESR: inc.in infection / metastatic Ca / small blue cell tumours( EWING, histiocytosis,leukemia ,lymphoma)  S.PROTEIN ELECTROPHORESIS:( multiple myeloma)  S.PSA:  S.Ca: mets / hyper parathyroidism / MM  ALP: Inc. in metabolic bone disease & metastatic disease, osteosarcoma,ewings,lymphoma.
  13. 13.  PTH: (with Ca) -brown’s tumour( hyper parathyroidism) - mimic GCT.  BUN & S.Cr: - inc. in renal tumours.  URINARY PYRIDIUM CROSSLINKS:( with ALP) -paget’s disease.
  14. 14. PRINCIPLES: 1. done only after clinical, radiographic, lab tests are completed. 2. biopsy track is always considered contaminated ( needle/open) with tumour cells thus biopsy track needs to be excised en bloc with the tumour. 3.the same surgeon who plans the definitive procedure must perform the biopsy.
  15. 15. 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 sys. Circulation. 6.incision should go thro’ a single muscle compartment ( never thro’ neuro vascular plane/inter muscular plane)
  16. 16. 7.if a hole is made in bone, it should be round or oval--- to decrease trhe subsequent fracture. ( hole can be plugged With methacrylate to Limit hematoma Formation) 8.frozen section 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 and radiologically)
  17. 17. 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 be excised)
  18. 18.  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 found; (3) if renal cell carcinoma is likely, embolization - to avoid excessive bleeding;
  19. 19. (4) if multiple myeloma is made, unnecessary biopsy can be avoided; (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 immedietly.
  20. 20. INDICATIONS FOR BIOPSY:  NEEDLE BIOPSY: -obese -close proximity to neuro vascular structures. -remote location( pelvis)  FNAC: -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.
  21. 21.  CORE NEEDLE BIOPSY:( accuracy- 84-98%) - uses large bore needle than FNAC. thus provides tissue with architechture  OPEN BIOPSY: - gold standard - least likely to be ass’ with sampling error.
  22. 22.  EXCISION BIOPSY: - <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 ulna)
  23. 23. GENERAL SCHEME OF DIAGNOSIS:  TYPE OF LESION  ZONE OF TRANSITION (margins)  AGE  LOCALISATION PLAIN X RAY
  24. 24. BASED ON AGE:
  25. 25. BASED ON ZONE OF TRANSITION & AGE
  26. 26. LOCALISATION
  27. 27.  WELL DEFINED ALL AGES <30 <30 > 30 >30 >30  ILL DEFINED <30 >30 PLAIN X RAY OSTEOLYTIC ANY SCLEROTIC
  28. 28. WELL DEFINED ILL DEFINED <30 >30 SBC ABC Eosinophilic granuloma Non ossifying fibroma Osteoblast Fibrous dysplasia Chondroblast CMF GCT Enchondroma Chondro sarcoma HPT (BROWN’S) Osteoblast <30 >30 Osteosarcoa EWING’S Eosinophilic granuloma GCT
  29. 29. SCLEROTIC < 30 YEARS > 30 YEARS OSTEO SARCOMA FIBROUS DYSPLASIA EOSINOPHILIC GRANULOMA OSTEOID OSTEOMA OSTEO BLASTOMA ENCHONDROMA OSTEOMA BONE ISLAND PAR OSTEAL OSTEO SARCOMA HEALED LESIONS - SBC - ABC
  30. 30. INFECTION MYELOMA METASTASIS ANY ALL AGES >30 YEARS
  31. 31.  Usual victim >40 years + painful bone lesion multiple myeloma metastatic.Ca screening of: prostate breast lung kidney-RCC. Thyroid
  32. 32. EVALUATION: -history -physical examination -involved limb -thyroid –lung –breast – abdomen -prostate -CBC WITH ESR: -SE -LFT -ALP
  33. 33. -S.ELECTROPHORESIS -S.PSA -X RAY (Involved bone and CXR) -WHOLE BODY BONE SCAN -CT-CHEST,ABDOMEN,PELVIS -mammogram is not routinely used (met in Ca breast without primary is unusual)
  34. 34.  Rx BASED ON STAGING:  BENIGN: Stage 1: intracapsular doesn’t req latent Rx ( resolve asymptomatic spontaneous) Stage 2: intracapsular active growing extened symptomatic curettage. stage 3: extracapsular extended curettage + marginal/wide ressection.
  35. 35.  NO DISTINCTION IS MADE BETWEEN LYMPH NODE STATUS/ DISTANT MET – BOTH HAVE EQUAL PROGNOSIS.
  36. 36. AMERICAN JOINT COMMITTEE ON CANCER SYSTEM ( AJCC ) :
  37. 37.  GOALS: if primary malignancy: making disease free. if metastatic Ca: minimise pain and to preserve function.  Optimal Rx: radiation therapy chemotherapy surgery.
  38. 38. RADIATION THERAPY: - Causes cell death- by forming free radicals inside cells DNA damage. - sensitivity depends on: 1. cells position in cell cycle; ( active mitotic cells are more sensitive) 2.tissue oygenation,(hypoxia – tissue protective)
  39. 39. 3. cells ability to repair DNA damage. 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.
  40. 40. - 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.
  41. 41.  Pre operatively used – In reducing the bulk  Post operatively used – in prevention of recurrence.  COMPLICATION: - Skin irritation - desquamation - AVN -pathological # - radiation sarcoma( lag time 10 y)
  42. 42.  IN CHILDREN: -scoliosis/kyphosis -chestwall deformities - hypoplasia of ilium - LLD.  NEW Rx: BRACHYTHERAPY radiation is delivered in close proximity.
  43. 43. CHEMOTHERAPY: -IN GENERAL: not useful for cartilagenous tumours & low grade malignancy. -ADJUVANT CHEMO: post op chemo for persumed micro mets. -NEO ADJUVANT CHEMO: before surgical ressection ( dec’ bulk & dec’ the spread of tumour during surgery)
  44. 44. PRINCIPLES OF SURGERY: (AMPUTATION Vs LIMBSALVAGE) While prefering salvage, always keep in mind SIMON’S 4 ISSUES: 1. would the survival affected by treatment choice. 2.how do the short term & long term morbidity compare? 3.how would the function of a salvaged limb with that of the prosthesis. 4. are there any psychosocial consequences
  45. 45.  IN REGARD TO PT’ SURVIVAL, most vital technical aspect is attainment of WIDE MARGIN regardless of whether it is achieved by AMPUTATION/LOCAL RESSECTION.
  46. 46. MARGINS: ( suits for amputation / ressection ) 1.INTRA LESIONAL: -plane of surgical dissection is within the tumour. -Symptomatic benign lesion. -palliative in metastatic disease. 2.MARGINAL: -plane of dissection passes thro’ the pseudocapsule formed by the tumour. -most benign lesion & low grade malignancies.
  47. 47. 3.WIDE: -plane of dissection is thro’ normal tissue. -no specific distance is defined. -quality of the margin is more important than the quantity. - hiogh grade malignancy. 4. RADICAL: - 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 involved muscle.
  48. 48. Enneking classification of local procedures. Enneking classification of amputations Radical amputation or disarticulation Wide amputation Intralesional amputation (debulking) Marginal amputation Radical resection Wide resection Intralesional resection (debulking) Marginal resection
  49. 49. CURETTAGE: - higher rate of local recurrence than ressection. PROCEDURE: ( simple curettage) large cortical window ( in the size of the lesion) bulk of the tumour is scooped out. the cavity is enlarged back to normal host bone well irrigated
  50. 50. Curettage and extended curettage
  51. 51. EXTENED CURETTAGE: - use of adjuvants, ( liq N2 , phenol , methacrylate, thermal cautery) recurrence rate can be reduced FILLING THE CAVITY: -autogenous bone graft -allograft -demineralised bone matrix -artificial bone graft substitute -bone cement ( immediete stability )
  52. 52. Thanks…

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