Musculoskeletal Tumors (Bone Tumors) - PDF

Musculoskeletal Tumors (Bone Tumors) General Features Dr. Evrim Şirin Marmara University Dep. Of Orthopaedics & Traumatology 3/25/2021 1 MUSCULOSKELETAL TUMORS BONE TUMORS - Primary Bone Tumors (Benign, Malignant) - Metastatic Bone Tumors SOFT TİSSUE TUMORS General Features of Bone Tumors Clinical F...

Musculoskeletal Tumors (Bone Tumors) General Features Dr. Evrim Şirin Marmara University Dep. Of Orthopaedics & Traumatology 3/25/2021 1 MUSCULOSKELETAL TUMORS BONE TUMORS - Primary Bone Tumors (Benign, Malignant) - Metastatic Bone Tumors SOFT TİSSUE TUMORS General Features of Bone Tumors Clinical Findings Radiographic Features Staging Treatment EVALUATION Clinical Examination - Physical Examination - History Imaging (Plain X-ray, BT, MRI, Bone scan) Laboratory Biopsy Clinical Findings * common presenting symptoms of musculoskeletal tumors pain swelling (mass) pathological fracture incidental radiographic finding 5 Clinical Findings * pain → (usually) first and most common finding (duration, localization, severity, character) usually nonmechanical (not related with motion) Clinical Findings * swelling (mass) (duration, size, consistency, mobility) Clinical Findings * pathological fracture → microfracture/displaced fracture (previous findings, fracture mechanism) (nondisplaced) microfracture displaced fracture Clinical Findings * incidental radiographic finding (asymptomatic lesions can be detected in x-rays taken for other reasons) Systemic Findings/Laboratory * systemic findings (fever, leukocytosis, ↑ ESR) → in rare tms eosinophilic granuloma Ewing‘s sarcoma Imaging Studies plain radiography → most important study MRI bone scan CT Imaging Studies / X-rays * plain radiographs → mainstay of differential diagnosis at least in two views (AP-LAT) Imaging Studies / X-rays Questions to make a differential diagnosis; 1) Where is the lesion located in the bone ? 2) What is the lesion doing to the bone ? 3) What is the bone doing to the lesion ? What is the periosteal response ? 4) Are there any radiographic peculiarities of the lesion that give a hint as to its tissue type? Imaging Studies / X-rays 1) Where is the lesion located in the bone ? anatomical location, place of origin metaphyseal diaphyseal epiphyseal Imaging Studies / X-rays 2) What is the lesion doing to the bone ? malignant bone tm grow rapidly → permeative/motheaten dest. transitional zone (-) Imaging Studies / X-rays 3) What is the bone doing to the lesion ? benign bone tm have well-defined margins surrounding the lesion sclerotic ring expansion + cortical thinning 16 Imaging Studies / X-rays 3) What is the bone doing to the lesion ? * malignant bone tm have ill-defined margins; host bone cannot limit the lesion (cortical barrier is lost) …. Imaging Studies / X-rays 3) What is the bone doing to the lesion ? periosteal reaction → (usually) a feature of malignant bone tm Imaging Studies / X-rays 3) What is the bone doing to the lesion ? periosteal reaction → (usually) a feature of malignant bone tm Imaging Studies / X-rays 4) spesific characteristic features ? sometimes points out a specific tm prox. femoral deformity (fibrous dysplasia) vertebra plana (eosinophilic granuloma) osseous protrusion (osteochondroma) Imaging Studies / CT Scan complex location (axial skeleton) evaluation of cortical continuity Imaging Studies / MRI MRI → produces images in three planes * Best study to define the extent of many tumors coronal sagital axial Imaging Studies / MRI MRI → can show the whole bone in which the tm is located intra / extraosseous extension anatomic relationship btw tm and surrounding tissues Imaging Studies / Bone Scan bone scan usually hot in both bening and malignant tumors localises the primary lesion searchs the entire skeleton (poliostotic lesions, metastasis) 24 Laboratory Studies often nonspecific (but can be helpful) elevated WBC and ESR is common OGS (in some forms) → elevated ALP multipl myeloma → serum/urine protein electrophoresis (SPEP/UPEP) or immunoelectrophoresis (IEP) Histopathology / Biopsy CLOSED BIOPSY TECHNIQUES - fine needle aspiration - tru-cut (soft tissue tm) - trochar, Jam-Shidi OPEN BIOPSY TECHNIQUES - incisional - excisional (benign tm) Histopathology / Biopsy * Closed biopsy has ~ %70-80 diagnostic accuracy in bone tm Staging Enneking (GTM) system (benign/malignant bone tm) grade → G0, G1, G2 local extension of the tm → T0, T1, T2 metastasis → M0, M1 SARCOMAS-BIOLOGICAL BEHAVIOUR intra-compart. spread may progres can be limited late stage extra-compart. Staging-Metastasis metastasis M0 → metastasis (-) M1 → metastasis (+) metastatic spread to the lung → ~ %10 distant nonpulmonary metastasis → rare Treatment Surgical Excision * * * * Intralesional resection Marginal resection Wide resection Radical resection Intralesional Margin (Resection) * Curettage of benign bone tumors enchondroma Marginal Margin (Resection) compartment reactive zone tumor dissection plane goes through the (possibly contaminated) reactive zone just peripheric to the tumor leaves (possibly) microscopic tm behind Wide Margin (Resection) dissection plane goes through noncontaminated tissue distant to the tm can leave skip lesion behind Wide Margin (Resection) * Gold standart for malignant bone tumors Wide Margin (Resection) * Gold standart for malignant bone tumors Radical Margin (Resection) compartment reactive zone tumor dissection plane goes through extra-compart. region (resection of entire bone) no residual tm behind Amputation (for wide or radical margins) H-G (G2) chondrosarcoma Reconstruction of Bony Defects (Endoprosthetic Reconstruction) Reconstruction of Bony Defects (Biological Reconstruction) EWS initial after chemotherapy THANK YOU