general principles of tumour management

GENERAL PRINCIPLES OF TUMOURS

RAM SUDHAN S

MCH, CALICUT

Ref: campbell’s

Rockwood and green

DIAGNOSTIC EVALUATION : History & physicxal examination: c/c: pain (MC) mass or abnormal x ray

finding. Age: Lymph nodes: ( though rare) seen with, epitheloid sarcoma rhabdomyosarcoma & synovial sarcoma. Radiographic evaluation:PLAIN X RAY:site: epi / meta / dia less vital in soft tissue

tumours: benign or malignant:

BY PLAIN X RAY BENIGN:

MALIGNANT:Zone of transition: - well marginated - less marked( surrounding rim of ( host response

is Reactive bone form’) slower than the

progr’n of

tumour )

Expansile destruction Frank cortical destru

of cortex: ( agg’ benign tion ( without expa

tumour) nsion of cortex)

Periosteal reaction:

( tumour destroys the cortex)

may take the form of: onion skinning

sunburst or codman’s

CT SCAN: ossification, calcification,

integrity of cortex. BEST: to localise the nidus in osteiod

osteoma 3D reconstruction: treatment plan. ANEURISMAL BONE CYST: thin rim of

reactive bone formation. CARTILAGENOUS LESION:

calcification

SUSPECTED CHONDRO SARCOMA: endosteal cortical erosion.

Endosteal erosion in chondrosarcoma:

CT LUNG: Detects pulmonary met.CT WITH CONTRAST: ( if MRI is

prohibited) differentiates cystic lesion from

vascular lesion.

BONE SCAN:( Tc) to determine the activity of the lesion. presence of any other lesion. False negative results ( freq.) - multiple myeloma. - RCC. Normal bone scan is reassuring. NOTE: but increased uptake is not always

malignant.

PET SCAN: 3D visualisation & quantitative

assessment of in vivo physiological & biochemical processess.

Staging and in planning biopsy & response to chemo therapy.

FDG PET: (F^18)-fluro deoxy labelled PET.-useful in detection,staging,management-MECH: FDG – glucose analogue

becomes trapped in malignant cells

( in proportion to the rate of glycolysis)

MRI: ( has replaced CT.)-IS THE STUDY OF CHOICE.-size, extent & anatomic

relationship with soft tissues.-most accurate ( extent of intra

medullary & extrosseus disease )-may also yield specific diagnosis (

lipoma , hemangioma, hematoma & pigmented villonodular synovitis)

- CANNOT DIFFERENTIATE BENIGN AND MALIGNANT LESIONS.

USG:can differentiate cystic and solid

masses

ANGIOGRAPHY:(replaced by MRI)eventhough used in pre operative

embolisation of highly vascular tumours. (esp.RCC & ABC)

LABORATORY TESTS: CBC: r/o infection, leukemia & status. ESR: inc.in infection / metastatic Ca /

small blue cell tumours( EWING, histiocytosis,leukemia ,lymphoma)

S.PROTEIN ELECTROPHORESIS:( multiple myeloma)

S.PSA: S.Ca: mets / hyper parathyroidism / MM ALP: Inc. in metabolic bone disease &

metastatic disease, osteosarcoma,ewings,lymphoma.

PTH: (with Ca) -brown’s tumour( hyper

parathyroidism)- mimic GCT.

BUN & S.Cr:- inc. in renal tumours.

URINARY PYRIDIUM CROSSLINKS:( with ALP)

-paget’s disease.

BIOPSY: PRINCIPLES: 1. done only after clinical,

radiographic, lab tests are completed. 2. biopsy track is always

considered contaminated ( needle/open) with tumour cells

thus biopsy track needs to be excised en bloc with the tumour.

3.the same surgeon who plans the definitive procedure must perform the biopsy.

4.only vertical incisions are made (never transverse – may become impossible to excise the whole track)

5.if tournequet is used , limb may be elevated but not exsanguniated

prevents squeezing of tumour cells

into sys. Circulation. 6.incision should go thro’ a single

muscle compartment ( never thro’ neuro vascular plane/inter muscular plane)

7.if a hole is made in bone, it should be round or oval--- to decrease trhe subsequent fracture.

( hole can be plugged With methacrylate toLimit hematoma Formation) 8.frozen sectionShould be sent intra- opTo ensure that the diagnostic tissue is

obtained. ( if correct- definitive procedure can be done

immedietely,provided it must correlate clinically and radiologically)

9.meticulous hemostasis should be attained before closure.( as hematoma may be contaminated with tumour cells)

10.if drain is used,it should be exited in line with the incision ( drain track can alspo be excised)

six reasons why the biopsy should not be done until the evaluation is complete:

(1) may be a primary sarcoma of bone that may require a biopsy technique that allows for future limb salvage surgery;

(2) another, more accessible lesion may be found;

(3) if renal cell carcinoma is likely, embolization - to avoid excessive

bleeding;

(4) if multiple myeloma is made, unnecessary biopsy can be avoided;

(5) the pathological diagnosis is more accurate if aided by appropriate imaging studies.

(6)the pathologist and surgeon may be more assured of a diagnosis - frozen section – and can plan the definitive procedure immedietly.

INDICATIONS FOR BIOPSY: NEEDLE BIOPSY:

-obese-close proximity to neuro vascular

structures.-remote location( pelvis)

FNAC:-90% accurate in determining

malignancy.-low significance in determining

specific tumours.( as only cells are obtained not tissues)

- done when the suspect is a met / infection / lymph nodes.

CORE NEEDLE BIOPSY:( accuracy- 84-98%)

- uses large bore needle than FNAC.

thus provides tissue with architechture

OPEN BIOPSY:- gold standard- least likely to be ass’ with

samplingerror.

EXCISION BIOPSY:- <3 cm subcutaneous mass

(i.e) unlikely to be malignant. ( if turns malignant – tumour bed

must be re excised)

- should not be done on large soft tissue lesions / lesion deep to facsia UNLESS PROVEN BENIGN.

-relative indication is painful lesion in a EXPENDABLE bone.( prox.fibula/distal ulna)

GENERAL SCHEME OF DIAGNOSIS:

TYPE OF LESION ZONE OF TRANSITION (margins) AGE LOCALISATION

PLAIN X RAY

BASED ON AGE:

BASED ON ZONE OF TRANSITION & AGE

LOCALISATION

WELL DEFINED ALL AGES <30

<30 > 30 >30

>30 ILL DEFINED

<30

>30

PLAIN X RAY

OSTEOLYTIC ANY SCLEROTIC

WELL DEFINED ILL DEFINED

<30 >30SBCABCEosinophilic granulomaNon ossifying fibroma

Osteoblast

Fibrous dysplasia

Chondroblast

CMF

GCTEnchondromaChondro sarcomaHPT (BROWN’S)

Osteoblast

<30 >30

Osteosarcoa

EWING’S

Eosinophilic granuloma

GCT

SCLEROTIC

< 30 YEARS > 30 YEARS

OSTEO SARCOMA

FIBROUS DYSPLASIA

EOSINOPHILIC GRANULOMA

OSTEOID OSTEOMA

OSTEO BLASTOMA

ENCHONDROMA

OSTEOMA

BONE ISLAND

PAR OSTEAL OSTEO SARCOMAHEALED LESIONS - SBC - ABC

INFECTION MYELOMA METASTASIS

ANY

ALL AGES >30 YEARS

METASTASIS OF UNKNOWN PRIMARY: Usual victim >40 years + painful bone

lesion

multiple myeloma metastatic.Ca

screening of: prostate breast lung kidney-RCC.

Thyroid

EVALUATION:-history-physical examination

-involved limb-thyroid –lung –breast – abdomen -prostate

-CBC WITH ESR: -SE-LFT-ALP

-S.ELECTROPHORESIS-S.PSA-X RAY (Involved bone and CXR)-WHOLE BODY BONE SCAN-CT-CHEST,ABDOMEN,PELVIS-mammogram is not routinely

used (met in Ca breast without primary is unusual)

STAGING: Rx BASED ON STAGING: BENIGN:

Stage 1: intracapsular doesn’t req

latent Rx ( resolve

asymptomatic spontaneous)

Stage 2: intracapsular active growing extened symptomatic

curettage. stage 3: extracapsular extended

curettage +

marginal/wide ressection.

NO DISTINCTION IS MADE BETWEEN LYMPH NODE STATUS/ DISTANT MET – BOTH HAVE

EQUAL PROGNOSIS.

AMERICAN JOINT COMMITTEE ON CANCER SYSTEM ( AJCC ) :

ADJUVANT TREATMENT: GOALS:

if primary malignancy: making disease

free. if metastatic Ca: minimise pain

and to preserve

function.

Optimal Rx:radiation therapychemotherapysurgery.

RADIATION THERAPY:- Causes cell death- by forming

free radicals

inside cells

DNA damage.

- sensitivity depends on: 1. cells position in cell

cycle; ( active mitotic cells are more

sensitive) 2.tissue oygenation,

(hypoxia – tissue protective)

3. cells ability to repair DNA damage.

DOSE OF RADIATION: ( GRAY ) 1 GRAY = 1 JOULE energy absorbed

per Kg 1 Rad = 1 centi gray

GOAL: deliver highest possible dose of radiation to tumour cells, while minimising toxicity to normal cells.

- delivered by linear accelerators.

- Most protocols deliver 150-200 cGy / day

- Myeloma = 30-40 Gy- Sarcoma = 60 Gy.

Most primary bone malignancy are RADIORESISTANT (.except small blue cell tumour , myeloma, lymphoma, ewing)

Carcinoma except RCC are sensitive.

Pre operatively used – In reducing the bulk

Post operatively used – in prevention of recurrence.

COMPLICATION: - Skin irritation

- desquamation- AVN-pathological #- radiation sarcoma( lag time

10 y)

IN CHILDREN:-scoliosis/kyphosis-chestwall deformities- hypoplasia of ilium- LLD.

NEW Rx: BRACHYTHERAPY

radiation is delivered in close proximity.

CHEMOTHERAPY:-IN GENERAL:

not useful for cartilagenous tumours & low grade malignancy.

-ADJUVANT CHEMO:post op chemo for persumed

micro mets.-NEO ADJUVANT CHEMO:

before surgical ressection ( dec’ bulk & dec’ the spread of tumour during surgery)

PRINCIPLES OF SURGERY:(AMPUTATION Vs LIMBSALVAGE)

While prefering salvage, always keep in mind

SIMON’S 4 ISSUES: 1. would the survival affected by treatment choice.2.how do the short term & long term morbidity compare?3.how would the function of a salvaged limb with that of the prosthesis.4. are there any psychosocial consequences

IN REGARD TO PT’ SURVIVAL, most vital technical aspect is attainment of WIDE MARGIN regardless of whether it is achieved by AMPUTATION/LOCAL RESSECTION.

BENIGNMARGINS:

( suits for amputation / ressection )

1.INTRA LESIONAL:-plane of surgical dissection is within

the tumour. -Symptomatic benign lesion.-palliative in metastatic disease.

2.MARGINAL:-plane of dissection passes thro’ the

pseudocapsule formed by the tumour.-most benign lesion & low grade

malignancies.

3.WIDE:-plane of dissection is thro’ normal

tissue.-no specific distance is defined.-quality of the margin is more

important than the quantity. - hiogh grade malignancy.

4. RADICAL:- All compartments containing tumour

are removed en bloc-deep soft tissue tumours- In case of bone tumour: removing

entire bone and the compartments of any involved muscle.

Enneking classification of

local procedures.

Enneking classification of

amputations

Radicalamputation ordisarticulation

Wideamputation

Intralesionalamputation(debulking)

Marginalamputation

Radical resection

Wide resection

Intralesionalresection(debulking)

Marginal resection

CURETTAGE:- higher rate of local recurrence than ressection.

PROCEDURE: ( simple curettage)large cortical window ( in the size

of the lesion) bulk of the tumour is scooped out.

the cavity is enlarged back to normal host bone

well irrigated

Curettage and extended curettage

EXTENED CURETTAGE:- use of adjuvants, ( liq N2 ,

phenol , methacrylate, thermal cautery)

recurrence rate can be reduced

FILLING THE CAVITY:-autogenous bone graft-allograft-demineralised bone matrix-artificial bone graft substitute-bone cement ( immediete stability

)

Thanks…