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Management of primary bone tumours

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Management of primary bone tumours

  1. 1. MANAGEMENT OF PRIMARY BONE TUMOURS DR TELLA A.O. 23/01/13
  2. 2. OUTLINE • OVERVIEW • CLINICAL EVALUATION - History of the patient - Physical Examination - Investigations - Treatment • FOLLOW-UP • PROGNOSIS • CONCLUSION
  3. 3. OVERVIEW • Bone tumours can be very diverse in morphology and biologic potential • Most bone tumours are benign (˃95% of cases) • Malignant tumours may be primary or secondary - Primary malignant bone tumours are very rare (˂0.2% of all cancers-NCCN)
  4. 4. OVERVIEW • Most primaries occur in long bones • May be quite difficult to diagnose specifically • Morbidity and mortality worse in developing countries • Multimodal approach to management has improved survival
  5. 5. CLINICAL EVALUATION • High index of suspicion is the first step in management • Requires a multidisplinary team • Core Group: - Orthopaedic oncologist - Bone pathologist - Medical/paediatric oncologist - Radiation oncologist - Musculoskeletal radiologist
  6. 6. CLINICAL EVALUATION • Management involves: ○ Meticulous history ○ Thorough physical examination ○ Prebiopsy radiological evaluation ○ Biopsy ○ Other relevant investigations ○ Staging of the tumour ○ Treatment plan
  7. 7. HISTORY OF THE PATIENT ● PRESENTING SYMPTOMS: Pain Mass An abnormal radiographic finding detected during evaluation for other conditions Neurological symptoms Previous radiation exposure Constitutional symptoms History of trauma ● AGE OF THE PATIENT – a very important clue
  8. 8. PHYSICAL EXAMINATION ● Evaluation of patient’s general health ● TUMOR MASS should be measured & its location, shape, consistency, mobility, tenderness noted ● SKIN & SUBCUTANEOUS TISSUE : Small dilated superficial veins overlying the mass are produced by large tumors Café-au-lait spots & subcutaneous neurofibromas indicate Von Recklinghausen’s disease
  9. 9. PHYSICAL EXAMINATION ● REGIONAL LYMPH NODES: sign of metastatic disease ● Atrophy of surrounding musculature ● Neurological deficits ● Peripheral pulses → Adequacy of circulation. ● Other systems e.g chest
  10. 10. RADIOGRAPHIC EVALUATION • Plain X-rays • Bone Scans • Computed Tomography (CT) • Magnetic Resonance Imaging (MRI) • Angiography • PET Scans
  11. 11. PLAIN X-RAYS • Provides most useful diagnostic information in evaluation of bone tumours • Guides the selection of other imaging techniques • Radiographic parameters are different for both benign and malignant bone tumours: - Location and nature of the lesion - Periosteal reaction - Soft tissue changes - Matrix of the tumour - pathological fracture
  12. 12.  Geographic pattern  Ex: Most benign tumours Non-ossifying fibroma Unicameral Bone Cyst
  13. 13.  MOTH-EATEN PATTERN  Ex: Multiple myeloma, Osteosarcoma
  14. 14.  PERMEATIVE PATTERN  Ex: Ewing’s sarcoma
  15. 15. PERIOSTEAL REACTIONS • Benign tumours: - None - Solid • Malignant tumours - Codman’s triangle - Sunburst - Onion skinning or Lamellated
  16. 16.  Codman’s triangle
  17. 17.  Sunburst
  18. 18.  Onion skinning
  19. 19. CartilaginousOsteoblasticNo matrix
  20. 20. EXPANSILE LESIONS OF BONE Enchondroma Fibrous Dysplasia
  21. 21. BONE SCANS • Uses very low radioactive material like technetium to assess spread to other bones - Polyostotic involvement - Skeletal metastases • Isotope Thallium-201 used to assess tumour response to chemotherapy
  22. 22. CT SCANS • CT depicts transverse anatomic relationship of the tumour to surrounding structures • 3-D reconstruction useful in pre-op planning e.g pelvis • Helps in evaluation of pulmonary metastases
  23. 23. MRI • Has better contrast discrimination • Images can be performed in any plane • Useful in detecting neurovascular bundles and skip metastases
  24. 24. ANGIOGRAPHY • Useful in determining relationship of major vessels to the tumour • Pre-op embolization of a highly vascular tumour can be done prior to surgical resection
  25. 25. ADDITIONAL INVESTIGATIONS ►LABORATORY INVESTIGATIONS: • FBC, ESR, E/U/Cr • Serum Cacium & Phosphate • Serum electrophoresis • Urinary Bence Jonce Protein estimation
  26. 26. DIFFERENTIAL DIAGNOSES
  27. 27. DIFFERENTIALS
  28. 28. BIOPSY • Tissue sampling for pathological evaluation • The planning and technique is important - Error may have negative impact on survival • Biopsy of bone tumours can be done open or closed - Needle biopsy to be done with image guidance • Patient should be well prepared
  29. 29. BIOPSY • The smallest longitudinal incision compatible with obtaining adequate sample should be employed • Knife and bone curette should be used to avoid crushing the specimen • Small circular holes minimise stress risers on the bone • Meticulous haemostasis must be maintained - Careful use of tourniquet • Exposure should violate one compartment • Drain to pass through incision wound • All biopsies must be cultured and vice versa
  30. 30. BIOPSY
  31. 31.  Enneking surgical staging system
  32. 32. TREATMENT • INITIAL RESUSCITATION - Anaemia to be corrected - Pain control - Antibiotics • Palliative treatment for metastatic disease
  33. 33. CURETTAGE OF BONE TUMOURS • Used for benign active tumours e.g unicameral bone cyst, aneurysmal bone cyst, giant cell tumour • The technique involves creating a window and ‟scooping” out the tumour • The bony defect created can then be reconstructed using bone graft, PMMA or biologic fillers • Cryosurgery (use of liquid Nitrogen) is often used to kill remaining tumour cells
  34. 34. AMPUTATION • Involves the removal of the entire bone and soft tissues at a safe proximal level to the tumour • Often indicated in complex tumours with neurovascular compromise and tumours complicated with infection and severe soft tissue compromise • Requires careful planning : - patient’s goal and expectations - Oncologic and functional outcome • May entail intralesional, marginal , wide or radical excision
  35. 35. LIMB-SPARING PROCEDURE • Currently being employed due to advances in imaging modalities and availability of tumour prosthesis • Requires patient preparation, staging studies, adequate biopsy, pre-op and post-op chemotherapy • Phases of operation: ○ Tumour resection ○ Skeletal reconstruction ○ Soft tissue reconstruction
  36. 36. REQUIREMENTS • No major neurovascular involvement • Wide resection of affected bone and cuff of normal tissues • Resection of bone 3-4cm beyond abnormal uptake on bone scan • Complete soft tissue coverage • Contraindications: 1. Major neurovascular involvement 2. Pathologic fractures 3. Inadequate biopsy 4. Tumour complications e.g infection, muscle necrosis 5. Skeletal immaturity
  37. 37. METHODS OF SKELETAL RECONSTRUCTION • Autograft (vascularised) • Allograft (Osteoarticular) • Modular endoprosthesis • Allograft-prosthetic composites • Expandable prosthesis • Rotationplasty • Arthrodesis • Limb lenghtening
  38. 38. LIMB-SPARING VS AMPUTATION • Survival of the patient • Functional outcome • Complications • Psychological factors • Cost
  39. 39. CHEMOTHERAPY • Effective multiagent chemotherapy has improved overall survival of patients • Could be given as Noeadjuvant or Adjuvant therapy • Neoadjuvant chemotherapy avoids tumour progression and decreases tumour spread at time of surgery • Not very useful in cartilaginous and low-grade tumours • Patient must be well prepared • Response to chemotherapy needs to be measured
  40. 40. RADIOTHERAPY • Most primary malignant bone tumours are relatively radioresistant • Useful in multiple myeloma, Ewing’s sarcoma, spinal tumour • Brachytherapy or EBRT employed
  41. 41. FOLLOW-UP CARE • Aim is to detect local recurrence or metastatic disease • Patients are seen at regular intervals after completion of initial treatment • Entails adequate assessment of the patients - Physical examination - Lab investigations - Imaging studies • Long term complications of treatment also evaluated
  42. 42. CONCLUSION • Treatment of MSS tumours still expanding • Results better with dedicated centres - Multidisplinary team - Research oriented - Tumour registry • Early detection and appropriate treatment remains the key in reducing morbidity and mortality

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