Musculoskeletal tumors

1. Musculoskeletal tumors Prepared by Dr Fadel Naim Orthopedic Surgeon IUG

2. Early detection, proper techniques of diagnosis and treatment can dramatically improve the chances of achieving functional limb salvage.

3. Classification of Bone tumors • Origin: - • Primary • secondary: 95%, breast, lung, prostate, kidney and thyroid • cell type: Bone • Osteoma, osteosarcoma Cartilage • Chondroma, Chondrosarcoma Marrow • Hemangioma, angiosarcoma Fibrous tissue • Fibroma, fibrosarcoma • Tumor type: Benign: Osteoma, osteochondroma Malignant:: Osteosarcoma, chondrosarcoma

4. Metastatic neoplasms • Metastatic neoplasms primary origin can be in descending frequency : • Prostate • Breast. • Lung. • GIT. • Kidney. • Thyroid.

5. Symptoms and Signs • It may be asymptomatic and discovered accidentally. • Pain: may worsen at night and awakes patient, caused by tumor compression on surrounding tissue, hemorrhage in the tumor, pathological fractures also cause pain • Swelling. • Increase in size : • Bleeding, malignant change • Local tenderness.

6. Warmth • Pathological fracture: • may be the first sign. • With any diaphyseal fracture in the elderly, malignancy should be ruled out . • General: fatigue, fever, wt. loss • Amasscan be felt at the tumor site. • Loss of function • Neurovascular involvement • Deformity

7. Malignant vs. Benign Tumors “Rapid growth, warmth, tenderness, and ill defined edges are suggestive of malignancy.”

8. Benign vs. Malignant

9. investigations • History and examination • Imaging • Biopsy • Labs • Calcium:Greater than normal levels may indicate metastasis. • Serum phosphorus: Greater than normal levels may indicate bone metastasis. • PTH: Lower than normal levels may indicate bone metastasis. • ALP isoenzyme: Higher than normal ALP levels may indicate Paget's disease, osteoblastic bone cancers, osteomalacia and rickets. • LDH: High values indicate poor prognosis

10. Plain x-ray Most useful Could see: • A lump • Bone destruction • Cortical thickening+ periosteal reaction • Cysts Important to notice: • site • properties • Number (monostotic or polyostotic) • Effect and reaction (aggressive / non aggressive )

11. Four questions of Enneking • Where is the lesion? • What is the lesion doing to the bone ? • What is the bone doing (endosteally and periosteally) ? • What is in the lesion?

12. Four questions of Enneking 1. Where is the lesion? • Medullary centric • Medullary eccentric • Cortical • Juxtacortical • Diaphyseal • Metaphyseal • Epiphyseal

15. Four questions of Enneking 2. What is the lesion doing to the bone ? • Usually causes 30-40% bone destruction before detection • destructive and ill-defined • circumscribed and localized

16. Less malignant Moremalignant Patterns of Bone Destruction • Moth-eaten Permeative Geographic

17. Benign lesions with aggressive features • Giant cell tumour • Chondroblastoma • Aneurysmal bone cyst • Unicameral bone cysts Aggressive GCT

18. Four questions of Enneking 3. What is the bone doing (endosteally and periosteally ) ? Clue to the biologic activity • Smooth periosteum, benign process • Onion-skin ( ewing’s sarcoma ) • Sunburst reaction ( osteosarcoma ) • Codman’s triangle

19. Midshaftperiosteal reaction with smooth + thick edges: this is a benign osteoma.

20. Codman triangle • a triangle of reactive bone formation found at the proximal and distal extremes of the elevated periosteum. • “Onion skin” layersof reactive bone formation • represent a more competent response; successive waves of tumor expansion create layers of reactive bone formation.

23. sunburst reactionCodman’s triangle

24. Onion-skin

25. Less malignant More malignant Periosteal Reactions Solid • Sunburst • onion-peel • Codman’s • triangle

27. Four questions of Enneking 4.What is in the lesion? • Neo-bone formation • Osteoid forming process • Stippled calcification • Cartilaginous

28. Cartilaginous Expansile Lesions Osteoblastic

29. Lytic Blastic

30. Number

31. Leukemia MultipleMyeloma

32. CT and MRI • Asses the extent of the tumor • Relation to surrounding structures • Radionuclide scanning: • Helpful in revealing site of a small tumor • Skip lesions • Silent secondary deposits

33. Multiple hotspotsseen: lung cancer which has metastasized to vertebrae.

34. Angiography • Diagnostic : • Feeding vessels identified as well as the tumor proximity to major vessels • Therapeutic : • Embolisation of vascular tumors prior to surgery , Intra-arterial chemotherapy

35. Biopsy of Bone Tumors • Should know probable diagnosis and stage of tumor before biopsy • Performed by the surgeon who will perform the definitive surgery • do not biopsy what you are not equipped to treat. • Meticulous haemostasis to avoid tracking haematomas • Send samples for microbiological analysis • Longitudinal incision. • sharp dissection through the muscle. • Uninvolved compartments should not be exposed • Windows in bone should be oval and small

36. Biopsy • A biopsy is performed after appropriate staging studies • Alternatives include • Fine needle aspiration (FNA) • A simple procedure that can be done using local anesthesia. • Most helpful in diagnosing soft tissue tumors and bony tumors with homogenous cell types • Obtains the least amount of material. • Core needle biopsy • May be aided by ultrasonography, fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI). • The surgeon obtains a core of tissue that measures 10 mm by 2 mm. • open biopsy or incisional, biopsy • A surgical procedure that provides the largest amount and the best sampling of tissue for pathologic identification.

38. CT guided FNA confirmed…

39. MANAGEMENT PRINCIPLES AIMS: safe margins, minimum recurrence, minimum morbidity

40. Surgical Margins : 1. Intra-lesional through the tumour , leaves macroscopic tumour ,,not therapeutic . 100% recurrence For benign lesions or for debulking

41. 2. Marginal Through pseudo-capsule of tumour / reactive zone controls non-invasive benign tumours recurrence of malignant tumours = 25-50%

42. 3. Wide around reactive zone, leaving a cuff of normal tissue skip lesions left recurrence of malignant tumours = < 10%

43. 4. Radical removal of entire compartment or compartments distant metastases left

44. 5. Amputation should be thought of as a form of reconstruction where surgical control of the tumor precludes useful function.

45. Limb Salvage • • Criteria for limb salvage: • 1. local control of the lesion must be at least equal to amputation ( no skip lesions ) • 2. the saved limb must be functional

46. Limb Salvage versus Amputation • The surgeon must determine whether a limb salvage operation or an amputation will provide the best outcome in terms of postoperative function and local control. • Amputation usually provides better postoperative function and reduced risk of recurrence for tumors located in the distal leg • Limb salvage surgery should be considered for treatment of tumorsin the more proximal aspect of an extremity, because an amputation at this level would be very disabling.

48. Rotationplasty is a new solution to disfiguring surgical resections of lower limb sarcomas:

49. Benign Bone Tumors • Osteoid Osteoma • Osteoblastoma • Osteochondroma • Enchondroma • Nonossifying Fibroma • Fibrous Dysplasia • Langerhans Cell Histiocytosis • Giant Cell Tumor of Bone • Solitary Bone Cyst • Aneurysmal Bone Cyst

50. Osteoid Osteoma • a unique and relatively common benign bone tumor • The typical age at presentation is 5 to 25 years, with peak incidence in the second decade. • M:F is 3:1 • Radiographs show a radiolucent zone (the nidus) surrounded by a halo of increased density( a sclerotic zone ).