Lumps & Bumps --When to be concerned--

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1 Lumps & Bumps --When to be concerned-- Eric Silverstein, MD Director of Musculoskeletal Oncology Academic Director of Orthopaedic Surgery Saint Francis Hospital & Cancer Center Trinity Health of New England 33 rd Sports Medicine Symposium March 6, 2018 Disclosure I have nothing to disclose and have no potential conflict of interest with any company or service industry Objectives Identify the red flags of musculoskeletal lesions Case examples of tumors that may emulate sports pathology Understand the basics of musculoskeletal oncologic staging Provide an introduction to the pitfalls of poorly planned and performed biopsies Know when to refer a patient with musculoskeletal lesions

2 Musculoskeletal Oncology Division of orthopaedics focusing on surgical treatment of soft-tissue and bone tumors (and simulators) Requires multi-disciplinary approach Often extensive radiologic imaging Staging / Carefully planned biopsies Vast array of surgical intervention and reconstruction Case #1 30 year old male Chief complaint: Mass in left thigh HPI: Healthy male with slowly enlarging mass in anterior thigh over 6 months. Causing minimal to mild discomfort. ROS: negative X-RAYS: negative Case #1

3 Case #1 In contrast to M eagher, M ic hael H M eagher, M ic hael /5 / YEAR M St Francis Hospita MRI FEMUR RIGHT WITH AND WITHO UT IV CO N t2 _ts e_s a 2 /15/ :54: year old male noticed a mass in the right proximal thigh ~ 6 months ago Has remained the same size Denies any pain or trauma Notices it more with contraction of the quadriceps M eagher, (proximal M ic hael 1/3 rd A of anterior thigh) /5 / A No significant 59 YEAR M PMHx or PSHx St Francis Hospital Skyra MRI FEMUR RIGHT WITH AND WITHO UT IV CO NTRAST t1 _ts e_tra_p2 _ 2 /15/ :04:36 AM LO C : -1 T H K: SP LO C : T H K: SP : FFS N E X: 1 E C : 1 SE FA : R T R: T E : 9 0 A Q M :3 5 8 \5 1 2 P age: 2 5 of 5 0 L F DFO V :4 5 C ompres s I M :2 W Not all masses are Tumors N E X: 1 E C : 1 In contrast to 65 y.o. male with anterior thigh mass for 5 years slowly increasing in size with occasional discomfort

4 MRI

5 Case #2 10 y.o. female Chief complaint: Left knee pain Healthy with no PMHx Was sailing and struck Left leg against the boat during turbulence Had pain but able to walk Pain persisted despite conservative management for the next 4-6 weeks Case #2 Case #2 Sagittal View Coronal View Axial View

6 Case #2 Open biopsy confirms osteosarcoma Proceeded with Neoadjuvant chemotherapy Doxorubicin, Cisplatin, and Methotrexate Current gold standard of treatment Radiation has little to no role Surgery: Knee disarticulation with epiphysiodesis of the distal femoral growth plates Adjuvant Chemotherapy Case #2 Case #3 Healthy 10 year old with LEFT hip pain for nearly 6 months Avid soccer player Does not recall an injury Pain with activity but mostly at night NSAIDs completely relieve the pain but returns as soon as the meds wear off

7 Nathan, Brynn /2/ YEAR F Page: 1 of 2 DELPHI ORTHOPEDIC XR HIP LEFT (2 VIEW) HIP AP 10/9/2014 2:50:52 PM S: 220 Z: 0.51 C: 512 W: 1024 Compressed 32:1 IM: 1001 CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018 Case #3 Case #3 N athan, Brynn /2 / YEAR F A RAH Rad CT HIP LEFT WITHOUT IV CONTRAST 1 1 /2 / H ip 5.0 B s YEAR 5 /28/ :56:00 PM F LO C : T H K: 5 H FS N athan, Brynn H RAH Rad CT HIP LEFT WITHOUT IV CONTRAST C oronal 5 /28/ :55:53 PM T H K: 2 H FS R L R L T ec h c om: RD: T ilt: 0 ma : 4 4 KV p: A c q no: 3 P age: 2 2 of 3 3 P T ec h c om: Z: 1 C : T ilt: 0 W: DFO V :1 4.9 x1 4.9 c m C ompressed 11:1KV p: IM :22 SE :5 A c q no: 3 P age: 3 0 of 5 0 F Z: 1 C : W: DFO V :1 6 x1 6 c m C ompressed 10:1 IM :30 SE :607 Radiolucent Nidus pathognomonic of an Osteoid Osteoma Case #3 Conservative management with daily NSAIDs Although osteoid osteomas are self limiting they often persist on average 3-5 years before burning out Prolonged use of NSAIDs ulcers*, kidney damage, etc. Surgery Radiofrequency ablation Open excision Other modalities (?)

8 RADIOFREQUENCY ABLATION (RFA) /2 / YEAR F RADIOFREQUENCY ABLATION (RFA) CT RADIOFREQUENCY ABLATION - BONE Biops ysingle B3 0 f 6 /27/2014, 10:19:00 AM LO C : T H K:0.7 5 FFS R L N athan, Brynn /2 / YEAR F B3 0 f RD:2 7 9 T ilt:0 ma :3 6 2 KV p:1 2 0 A cq no:3 P age: 1 of 4 8 A SFH Rad CT RADIOFREQUENCY ABLATION - BONE Biops ysingle B3 0 f 6 /27/2014, 10:37:40 AM P LO C : T H K:0.7 5 FFS Z:1 C :7 1 4 W: DFO V :2 7.9 x2 7.9 c m C ompressed 11:1 IM :1 SE :5 R L B3 0 f RD:2 7 9 T ilt:0 ma :1 9 2 KV p:1 2 0 A cq no:5 P age: 3 6 of 4 8 P Z:1 C :7 1 4 W: DFO V :2 7.9 x2 7.9 c m C ompressed 11:1 IM :36 SE :5 Case #4 37 y.o. female Chief complaint: Shoulder pain w/ mass and swelling 30 weeks pregnant Symptoms present for nearly 7 months Otherwise healthy Went to see sports doc

9 Case #4 Large soft-tissue mass surrounding scapula Case #4 Agreed to x-ray Days before had outside open biopsy done (2.5 oblique incision) Urgent percutaneous biopsy done in my office Consistent with highgrade osteosarcoma (poorly differentiated) Soft-tissue mass with little bony change Case #4 Urgent c-section at 31 weeks Pre-operative clinical photos

10 Case #4 Post-operative follow-up x-rays Red Flags New or old mass with rapid growth Within weeks or months is a concern Night Pain Persistent pain Radicular symptoms Signs of mass effect bowel / bladder issues, DVT, swelling, Systemic symptoms Case #5 42 year old woman with vague pain in right flank with small mass CT showed 3-4 cm mass Felt to be benign or a hematoma Schizo-affective disorder, poor family / social situation Non-compliance issues

11 Case #5 Case #5 Six Months Later Case #5

12 Case #6 15 year old female High school student and volleyball player Long history of bilateral patello-femoral symptoms Otherwise healthy X-ray showed abnormality and sent for evaluation Case #6 Case #6

13 Case #6 Case #6 1. Open biopsy of femur 2. Extensive curettage, high-speed burring, allograft 3. Prophylactic fixation Case #7 64 year old male s/p right THA 2 ½ years ago for OA No history of cancer Fairly healthy and active New onset of severe right hip pain

14 Greater Sciatic Foramen

15 Case #7 Post-Op Case #7 Post-Op Musculoskeletal Oncology Initial evaluation: Comprehensive H&P Mass Pain Fever Systemic symptoms: weight loss, appetite decreased, N/V/D, etc. Incidental finding traumatic event Pathologic fracture

16 Musculoskeletal Oncology Radiologic Work-up: Plain X-Ray CT scan area of interest CT chest / abdomen / pelvis MRI Bone Scan PET Scan Staging Pre-operative planning if necessary Last Words Listen to patients History is critical when you can get it Recognize Red Flags If it doesn t seem normal, it probably isn t Rapid growth, night pain, etc. An injury doesn t mean there can t be another pre-existing or underlying problem Staging helps provide diagnostic information and guides treatment A biopsy is a critical first step in management with potential implications References 1. Biazzo, A, De Paolis, M. Multidisciplinary approach to osteosarcoma. Acta Orthop Belg Dec; 82(4): Zhang, Y, Rosenberg, AE. Bone-Forming Tumors. Surg Pathol Clin Sep;10(3): Huang, AJ. Radiofrequency ablation of Osteoid Osteoma: Difficult-to-reach places. Semin Musculoskelet Radiol Nov;20(5): Terpos, E, et al. Pathogenesis of bone disease in multiple myeloma: from bench to bedside. Blood Cancer J Jan;8(1):7 5. Brown, TS, et al. Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review. Bone Joint J Jan;100-B(1 Supple A):22-30

17 Thank You

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