ORTHOPAEDIC TUMOURS DJM FRANTZEN 2012 AUGUST TUMOURS 1

Transcription

1 ORTHOPAEDIC TUMOURS DJM FRANTZEN 2012 AUGUST TUMOURS 1

2 PRINCIPLES STAGING WORKUP RADIOLOGY BIOPSY PROCEDURES CHEMOTHERAPY RADIOTHERAPY 2012 AUGUST TUMOURS 2

3 STAGING ENNEKING'S SURGICAL STAGES (ENNEKING) STAGE GRADE SITE METASTASES 1A Low(G1) Intracompartmental(T1) None(M0) 1B Low(G1) Extracompartmental(T2) None(M0) 2A High(G2) Intracompartmental(T1) None(M0) 2B High(G2) Extracompartmental(T2) None(M0) 3 Low(G1) or High(G2) Intracompartmental(T1) or Extracompartmental(T2) Yes(M1) 2012 AUGUST TUMOURS 3

4 GRADING G0= Histologically benign ( well differentiated and low cell to matrix ratio ) G1= Low grade malignant (few mitoses, moderate differentiation and local spread only ) G3= High grade malignant (frequent mitoses, poorly differentiated, high risk for metastases ) 2012 AUGUST TUMOURS 4

5 Features of aggressive tumours Cellular atypia Frequent mitoses Extensive necroses Significant vascularity Small amounts of immature matrix 2012 AUGUST TUMOURS 5

6 EXAMPLES LOW (G1) Parosteal osteosarcoma Secondary osteosarcoma Myxoid liposarcoma HIGH (G2) Classic osteosarcoma Primary osteosarcoma Pleomorphic liposarcoma 2012 AUGUST TUMOURS 6

7 SITE T1 = INTRA- COMPARTMENTAL T2 = EXTRA- COMPARTMENTAL 2012 AUGUST TUMOURS 7

8 Intracompartmental intraosseous intra-articular Extracompartmental soft tissue extension deep fascial extension Intrafascial compartments: ray of hand or foot posterior or anterior leg ant, med, post thigh buttocks volar or dorsal forearm anterior or posterior arm pericapsular Extrafascial planes/spaces: (neurovascular containing spaces) mid & hind foot / mid hand popliteal fossa groin-femoral triangle intra-pelvic antecubital fossa axilla paraspinal 2012 AUGUST TUMOURS 8

9 METASTASES (Nodal or bloodborn spread) MO = No evidence of regional or distant metastases M1 = Regional or distant metastases present 2012 AUGUST TUMOURS 9

10 TUMOUR WORKUP Clinical examination Bloods Urinalysis CXR Abdominal sonar Bonescan MRI CT (lesion/chest) Angiography Biopsy 2012 AUGUST TUMOURS 10

11 CLINICAL EXAMINATION (age,sex,site,past history) Breasts Thyroid Chest Liver Kidney Rectal 2012 AUGUST TUMOURS 11

12 AGE Probability of OS in yrs vs Mets in > 50 yrs Chondroblastoma vs GCT yrs vs yrs 2012 AUGUST TUMOURS 12

13 ROUND CELL TUMOURS < 6 YRS : Metastatic neuroblastoma 6-15 yrs : Single lesion = Ewing s Multiples = Lymphoma / Leukaemia yrs : Lymphoma / Leukaemia > 35 yrs : Myeloma / Lymphoma / Metastatic melanoma 2012 AUGUST TUMOURS 13

14 HISTORY Presenting complaint Pain and / or swelling Character / duration of symptoms (distinguish benign / malignant clinically) Past and family history Loss of weight Other 2012 AUGUST TUMOURS 14

15 PHYSICAL EXAMINATION General health Anemia, wasting, spleen? Skin lesions Precocious puberty Hypogonadism Optical abnormalities Exophthalmos ( EG, FD ) 2012 AUGUST TUMOURS 15

16 LOCAL EXAMINATION Location ( epi, meta, diaphysis ) Tumor size Consistency ( bone or soft tissue ) Fixed or mobile Solitary or multiple N/V status Lymph nodes? 2012 AUGUST TUMOURS 16

17 LABORATORY Blood / urine samples seldom helpful Multiple myeloma Metastatic disease Pagets Infection 2012 AUGUST TUMOURS 17

18 LABORATORY examinations FBC ESR Biochemistry Acid-phosphatase PSA Thyroid function test Serum protein electrophoresis 2012 AUGUST TUMOURS 18

19 ALKALINE PHOSPHATASE ELEVATED IN ANY ENTITY WITH OSTEOBLASTIC ACTIVITY BONEFORMING OS BLASTIC METS PAGETS ETC 2012 AUGUST TUMOURS 19

20 NEUTROPHILIA Osteomyelitis, sometimes Ewing s sarcoma 2012 AUGUST TUMOURS 20

21 ESR ELEVATED IN : INFECTION EOSINOPHILIC GRANULOMA MYELOMA 2012 AUGUST TUMOURS 21

22 ANEMIA LYMPHOMA / LEUKEMIA CHRONIC DISEASE EWINGS ETC 2012 AUGUST TUMOURS 22

23 PROTEIN ELECTROPHORESIS MYELOMA 2012 AUGUST TUMOURS 23

24 Tc 99 CT-scans Angiography MRI RADIOLOGICAL EXAMINATIONS 2012 AUGUST TUMOURS 24

25 RADIOGRAPHIC INTERPRETATION X-RAYS IN 2 PLANES CT : BONE FORMATION, CALCIFIED LESIONS INTEGRETY CORTEX LUNG METS 2012 AUGUST TUMOURS 25

26 Tc- BONESCAN : - Detects skeletal mets - presence of multiple lesions, enchondromas, osteochondromas,etc. May be false negative in multiple myeloma 2012 AUGUST TUMOURS 26

27 MRI STUDY of choice to determine anatomical setting of both bone and soft tissue tumors Tumour relationship to vital structures like blood vessels and nerves Evaluation of lesion on Tc scan, not yet visible on X-rays 2012 AUGUST TUMOURS 27

28 ULTRASOUND FOR SYSTIC LESIONS / SOFT TISSUE MASS 2012 AUGUST TUMOURS 28

29 ARTERIOGRAPHY SELDOM USED EMBOLIZATION OF APPROPRIATE LESIONS 2012 AUGUST TUMOURS 29

30 RADIOGRAPHIC FEATURES TUMORS AND TUMOR- LIKE LESIONS OF BONE 2012 AUGUST TUMOURS 30

31 SITE Epiphysis : GCT, Chondroblastoma Metaphysis : Osteosarcoma, osteoblastoma, Chondromyxoid fibroma, NOF osteochondroma Diaphysis : Metastatic carcinoma,ewing s, Chondrosarcoma 2012 AUGUST TUMOURS 31

32 RADIOGRAPHIC FEATURES BORDERS - SLOW GROWING.. BENIGN - AGGRESSIVE.. MALIGNANT 2012 AUGUST TUMOURS 32

33 TYPE OF BONY DESTRUCTION RADIOGRAPHIC FEATURES 2012 AUGUST TUMOURS 33

34 CARTILAGE VS BONE 2012 AUGUST TUMOURS 34

35 PERIOSTEAL REACTION 2012 AUGUST TUMOURS 35

36 PERIOSTEAL REACTIONS Codman : Triangular cuff of reactive periosteal bone at the edge of a lesion. ( OS, osteomyelitis, ABC, infection) Onion-skinning : Due to episodic or pulsatile tumour growth ( Ewing s, Infection, OS of shaft ) Sunburst : Rapid continuous periosteal lifting and stretching ( bone next to Sharpy fibres ) 2012 AUGUST TUMOURS 36

37 SOFT TISSUE INVOLVEMENT PRIMARY SOFT TISSUE TUMOUR VS PRIMARY BONE TUMOUR 2012 AUGUST TUMOURS 37

38 RADIOGRAPHIC FEATURES BENIGN VS MALIGNANT 2012 AUGUST TUMOURS 38

39 BIOPSY OF BONE TUMOURS? Diagnosis,? Stage Same surgeon as final procedure Biopsy tract location important Meticulous haemostasis Samples for micro & histo 2012 AUGUST TUMOURS 39

40 OPEN BIOPSY EXCISIONAL : When possible in benign lesions INCISIONAL : Preferable in malignant lesions 2012 AUGUST TUMOURS 40

41 PRINCIPLES Longitudinal incision Sharp dissection Limited anatomic exposure Avoid neurovascular exposure Sample reactive tissue, pseudo capsule, capsule, tumour Small bone window if necessary 2012 AUGUST TUMOURS 41

42 PRINCIPLES (CONT) Haemostasis Subcutaneous stitch Drain in line with incision If procedure follows biopsy new instruments and drapes 2012 AUGUST TUMOURS 42

43 NEEDLE BIOPSY As for open biopsy Biopsy tract where can be excised Fine needle biopsy Core needle biopsy Disadvantage = tissue biopsy possibility being non-representative (eg. Necrosis or reactive) 2012 AUGUST TUMOURS 43

44 FROZEN SECTION Determine if specimen adequate or reactive Lesion inflammatory/ needs mcs? Need for further investigations? Immediate diagnosis possible 2012 AUGUST TUMOURS 44

45 SURGICAL PROCEDURES GOAL REMOVE LESION WITH MINIMAL RISK OF LOCAL RECURRENCE 2012 AUGUST TUMOURS 45

46 LIMB SALVAGE CRITERIA : 1. Local control = amputation 2. Saved limb must be functional 2012 AUGUST TUMOURS 46

47 LIMB SALVAGE VARIOUS METHODS: 1. Endoprosthesis 2. Allograft 3. Composite 4. Arthrodesis 2012 AUGUST TUMOURS 47

48 Contra indications: LIMB SALVAGE 1. Pathological fractures 2. Skeletal immaturity 3. Anatomical site Distant metastases is not a Contra-indication 2012 AUGUST TUMOURS 48

49 SURGICAL MARGINS 1. INTRA-LESIONAL 2. MARGINAL 3. WIDE 4. RADICAL 5. AMPUTATION 2012 AUGUST TUMOURS 49

50 INTRA-LESIONAL Dissection passes through the tumour Leaves macroscopic tumour Not therapeutic 2012 AUGUST TUMOURS 50

51 MARGINAL Through pseudo-capsule of tumour / reactive zone Controls non-invasive benign tumours Recurrence in malignant lesions = 25-50% 2012 AUGUST TUMOURS 51

52 WIDE Dissection entirely through normal tissue at a distance from the lesion Skip lesions / microscopic satellites may be left Recurrence of malignant lesions = < 10% 2012 AUGUST TUMOURS 52

53 RADICAL Removal of entire compartment Distant metastases left 2012 AUGUST TUMOURS 53

54 AMPUTATION Intra-capsular Marginal Wide Radical 2012 AUGUST TUMOURS 54

55 ADJUVANT CHEMOTHERAPY Reduces mass and vascularity of tumour Time for operative planning Want 90% kill rate Localized disease = 60-70% long-term disease free survival 2012 AUGUST TUMOURS 55

56 COMPLICATIONS Stunting of growth Osteoporosis AVN Cisplatinum nephro & oto toxicity Adriamycin Cardiotoxic Vincristine Neurotoxicity Chemotherapeutic induced malignancy usually blood forming, eg Leukaemias 2012 AUGUST TUMOURS 56

57 RADIOTHERAPY Absorption by complex molecules rupture of chemical bonds Indirect DNA changes stop cell reproduction & specific cell Fx Destruction of small blood vessels Radiosensitivity = mitotic activity x= degree differentiation 2012 AUGUST TUMOURS 57

58 ADVERSE EFFECTS Joint stiffness / function loss Subcutaneous fibrosis Premature growthplate closure Irradiation induced sarcoma Enteritis, diarrhoea, obstruction and bleeding Cystitis and hepatitis 2012 AUGUST TUMOURS 58

59 ADVERSE EFFECTS Muscle atrophy and fibrosis Erythema and hyperpigmentation Hair loss and skin flaking Lymphoedema 2012 AUGUST TUMOURS 59

60 DEFINITIONS Rad (radiation absorbed dose) =Energy imparted to matter by ionising radiation per unit mass Grays (Gr) = 1 Joule of energy absorbed by a mass of 1 kg 2012 AUGUST TUMOURS 60