Musculoskeletal Oncology & Therapy

• Deals with musculoskeletal oncology and therapy considerations
• Presented by David Clever, MD, PhD on March 26, 2025

Terms and Conditions

• This content is for learning purposes
• Confusion is common
• Questions are encouraged
• Feedback is welcome

Overview

• Introduction to musculoskeletal oncology
• Gathering patient history
• Conducting a physical exam
• Planning workup and treatment
• Imaging techniques
• Histology analysis
• Surgical principles

Diagnosis Considerations

• "It is never a hazard to have a diagnosis when planning treatment for your patient" - William F. Enneking
• Treatment is determined by diagnosis
• Benign conditions may or may not require surgery
• Includes metastatic carcinoma, lymphoma/Myeloma, and sarcoma
• Options include intralesional treatment and wide resection

Diagnosis Statistics

• 1.7 million new carcinoma cases occur each year in the US
• Over half a million develop metastatic carcinoma to the bone annually
• Approximately 1,600-2,000 bone sarcomas are diagnosed yearly
• Around 14,000 soft tissue sarcomas occur each year

Diagnostic Thinking

• Over 40 years old presenting with malignant bone tumor think metastatic carcinoma, myeloma, lymphoma (but NOT sarcoma)
• Metastatic carcinoma to bone develops more frequently than soft tissue metastasis
• Adult with soft tissue mass consider sarcoma rather than metastatic soft tissue carcinoma

How a Diagnosis is Made

• Gather clinical history includes age, location, and symptom patterns
• Imaging techniques are X-ray, CT, and MRI
• Biopsy can be percutaneous/needle or open

Consequences of Misdiagnosis

• Missed carcinoma diagnosis results in Do not get adequate treatment involving staging, systemic therapy, Radiation
• A missed sarcoma diagnosis may lead to loss of limb/life, negative outcomes

History Gathering and Examination

• Need to obtain history about known cancer diagnosis, how and when it was diagnosed
• Distinguish between clinic vs hospital setting
• Check for preceding pain due to Fracture
• Finding incidental findings vs. symptoms
• Exam should check for other injuries

Imaging

• The process involves X-ray of the whole bone
• Possible use of CT or MRI for tumor of interest
• Use CT for Chest/Abdomen/Pelvis
• Unknown Primary as Primary organ carcinomas, Visceral Mets, Bone mets: Spine, ribs, pelvis, and hips
• Know Primary includes Re-stage, and Rule out second primary tumor

Imaging features

• Focus to Location, Border, Matrix Formation, Periosteal Reaction

Staging Imaging

• Use Nuclear Medicine Bone Scan (T-99)
• Find Asymptomatic mets (wider field of view than CT C/A/P)
• Utilise Skeletal Survey using X-ray vs. CT, for Multiple Myeloma
• PET/CT can be used for whole body staging (difficult for inpatient), using Whole body vs. eyes-to-thighs
• PET/CT Also evaluates for visceral and nodal mets

Benign Bone Tumors

• The spectrum of pathology ranges from indolent to bordering on malignancy

Indolent Observations

• Examples include osteoma (bone island)
• osteochondroma/enchondroma
• Fibroosseous lesions (NOF, fibrous dysplasia)

Benign Bone Tumor Treatment

• Benign Bone Tumor is treated via Excision/Curettage involves
• osteochondroma/ enchondroma
• Osteoid osteoma
• Bone cysts (solitary, ABC)
• Fibroosseous lesions

Benign Aggressive Tumors

• Include chondroblastoma/ CMF
• osteoblastoma
• Giant cell tumor
• Cured using Curettage and bone graft

Malignant Bone Tumors

• Tumors include Osteosarcoma, Ewing’s Sarcoma, Chondrosarcoma, and Metastatic Disease

Operative Treatment Goals for Primary Sarcoma

• Focus is to cure the disease remove the tumor, using wide resection

Operative Treatment Goals

• Also involves Estimating of survival, and Expected response to other treatment
• Local Radiotherapy
• Systemic Chemotherapy
• Hormone therapy, and Immune therapy
• Follow Principles of poly-trauma to mobilize

Operative Treatment of Metastases

• Focus is to relieve pain and restore function, and Stabilise the skeleton, using intralesional surgery (usually)

Overview of Tumor Locations

• Most Common Locations are Axial > Appendicular involving Spine 33%, Pelvis & Sacrum 20%, Ribs, Sternum & Clavicle 17%, Femur 12%, Humerus 5%, Tibia 1%

Extent of Disease and Tumor Type

• Breast and myeloma, >2-3 years
• Prostate and renal, 1-2 years
• Lung 6 months
• Surgery may be warranted even with only 2-3 months of survival

Metastatic Disease Mnemonic

• PT Barnum Likes Kids
• BLT with a Kosher Pickle
• Lead Kettle (Pb KTL)

Metastatic Tumor Statistics

• Tumors metastatic to bone consist of %80 involves Breast, Prostate, and Lung
• Tumors can include Breast 184,000, Prostate 180,400, Lung 164,100, Renal 31,200, and Thyroid 18,400

Goal of Surgery

• Treat or prevent fracture and Pain Relief
• Improve Quality of life
• Minimize disruption to systemic therapy/chemo
• Facilitate Immediate fixation and local control, and Construct to tolerate post-op radiation

Surgery Considerations

• Metal + cement = immediate fixation!
• The surgeon must Describe the lesion and find Treatment

Surgical Choice Stabilization vs Replacement

• Depends on disease type, extent, and responsiveness

Primary Malignant Bone Tumors

• Surgery is almost always part of the treatment
• With the use of "Wide" Excision, and Limb salvage vs Amputation

Surgical Alternatives

• Amputation:
  • Better tumor control
  • Fewer complications
  • Functional deficit
• Limb Salvage
  • Increased potential for local recurrence
  • Extensive surgery with more complications
  • Better functional result

Amputation

• Can provide better tumor control with fewer complications, but has a functional deficit.

Limb Salvage

• Has an increased potential for local recurrence and requires more extensive surgery with more complications, but offers better functional result

Key Symptoms

• Pain: constant, present at night, worsening. Differentiate this from the painless soft tissue sarcoma
• Mass: enlarging, tender
• Possible traumatic onset

Viable Amputation Alternative

• When Comparable tumor control enables Functional result superior to amputation and prosthetic fitting
• Using arthrodesis, arthroplasty, segmental reconstruction

Soft Tissue Sarcoma Considerations

• Look for any new soft tissue mass in an adult
• Note if Growing and Painful (often they aren't)

Therapy following Soft Tissue Sarcoma Resection

• Consider what tissue is resected involving Bone Muscle, and Capsule
• The surgeon needs to decide on What tissue is reconstructed, where Not all things need reconstruction

Post-operative Care

• Focus is on Post Operative Motion and Weight Bearing with Optimal Timing
• Monitor for Muscle Healing, Capsule Healing, and Bone Healing
• If using Allograft Bone, Autograft Bone or Vascularized Bone
• Metal involving cemented or ingrowth surface
• Assess Upper or lower extremity
• Monitor how can monitor healing

Soft Tissue Sarcoma Treatment

• Includes Surgery and Radiation
• Chemo/Immunotherapies are more experimental

Osseointegration

• Allows Direct bony ingrowth or ongrowth to metallic implant which protrudes through skin
• Allowing for direct connection of implant to prosthesis using Variety of implant styles and vendors
• Applied to variety of amputation sites
• Prosthesis can be traditional or myoelectric

Problems with Socket Prostheses

• Include Not suitable for short residual limbs, causes Skin breakdown,
• Difficulty donning/doffing, Limited range of motion and Rotational control, which causes Weight gain/loss

Osseointegration History

• 1962 Switzerland Titanium integration to bone while studying microcirculation in the bone of animal models
• Early human applications included Dental Implants, Anchored hearing aids and Maxofacial reconstruction

Orthopedic Development

• 1990s Rickard Branemark - expanded father’s work aiming to aid amputees
• Refined surgical procedures and implants
• OPRATM Implant System – FDA Approved spindle

OPRATM Osseointegrated Prosthesis

• Has Modular Design, Fixture Anchoring element inside bone, Abutment, Skin penetrating connection, and Axor II TM
• The Connection is between abutment and prosthesis, and then the Prosthesis

Limb Salvage Complications

• 26 y Male
• Synovial Sarcoma
• Limb Salvage Local Recurrence AKA
• Sciatic Neuroma and Skin blistering despite prosthetic modification
• The Patient is a college student is Not wearing prosthetic, and harder to get to class and work

Amputation Process

• Shape and thin muscle, Purse-string suture to femur, Prepare skin flap, and Transcutaneous opening for abutment
• Placement abutment. Bolster dressing
• Wait for skin healing before loading prosthesis