appropriate work-up of commonly found lesions how to
TRANSCRIPT
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Appropriate Work-Up of Commonly Found Lesions
How to Decide When to Refer to an Orthopaedic Oncologist
Avoiding Unplanned Resection of Sarcoma/Disease Spread
Jeffrey Krygier, MD
Santa Clara Valley Medical Center
San Jose, CA
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Disclosures / Conflict of Interest
• BOD: Western Orthopaedic Association
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Goals
• Avoiding Missteps:• Metastatic Disease
• Soft Tissue Masses
• Biopsy
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Metastatic Disease
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Metastatic Disease
• Most common malignancy of bone in adults
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54 yr old female8yrs post lumpectomyImpending pathologic fractureFemoral head sent during hemiNo other work up
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Low grade cartilage lesion High grade neoplasm
Dedifferentiated Chondrosarcoma
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Referred to cancer center for further careGross tumor along incision External hemipelvectomySOB post-op, CT with effusionThoracoscopy, biopsy: metastatic diseaseNever extubated from thoracoscopyNo chance to say “good bye” to family
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Metastatic Disease of Bone
• Most common malignancy of bone in adults
• That being said, assuming a lesion is a metastasis can have catastrophic consequences
• “When you assume…”
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#1 What is it? #2 What to do?
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Only Rule
• Do not move onto #2, before you’ve answered #1.
• Example:• “I don’t know what it is, we’ll send the
reamings”
• “Just cut it out and see what the pathologist says”
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Evaluation of Solitary Lytic Lesion
1. Designed to identify primary lesion and extent of disease
2. Includes sampling tissue in case diagnosis and treatment not established otherwise
3. Guide treatment
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History & Physical
Imaging Laboratory Biopsy Diagnosis
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Physical Exam
• Includes “non orthopedic” elements• Thyroid
• Breast
• Rectal for prostate
• Extremity of interest – including lymph node exam
History & Physical
Imaging Laboratory Biopsy Diagnosis
P
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Imaging – Search for a Primary
• CT chest/abdomen/pelvis with contrast
• CHEST• Lung primary
• ABDOMEN/PELVIS• Renal primary
• ALL• Other metastasis• Pelvis to see femoral necks
History & Physical
Imaging Laboratory Biopsy Diagnosis
K
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Imaging – Staging
• Whole body bone scan• Bone formation (blastic and mixed lesions)• May identify
• “Easier” lesion to biopsy• Other areas warranting surgical management
• Skeletal survey• For purely lytic lesions
• Lung• Myeloma• Melanoma
• PET scan• Used for many primaries
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Imaging – Extremity
• Xray of whole bone
• Xray of other areas “hot” on bonescan
• CT of areas difficult to visualize• Scapula
• Pelvis
• MRI• Soft tissue mass
• Neurovascular proximity
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Imaging – Extremity
• Prostate – 90% blastic
• Lung – 90% lytic
• Breast – 50/50 lytic/blastic
• Myeloma – Lytic
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03/08/2009
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04/19/2013
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LaboratoryDiagnosis
• TSH, free T4
• SPEP, UPEP
• PSA
Other tests• CBC w/diff
• Anemia (MM)• WBC (lymphoma)
• Chemistry• Hypercalcemia
• ESR/CRP• ESR (MM)• In case it is infection
• Coags/LFT
History & Physical
Imaging Laboratory Biopsy Diagnosis
P
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Biopsy
• Every solitary lesion is biopsied before treatment
• Labs can establish myeloma diagnosis
History & Physical
Imaging Laboratory Biopsy Diagnosis
P K
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#2 What to do?#1 What is it?
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Treatment – Fracture prevention
Score 1 2 3
Site Upper limb Lower limb Pertrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Size <1/3 1/3-2/3 >2/3
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ClinOrthop Relat Res. 1989;249:256–264
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Treatment – Fracture
• Intramedullary nails• Protect whole bone
• Weight sharing, early mobilization, weight bearing
• Often protect femoral neck
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Humerus – Plating
• Biomechanical studies with superiority to nailing
1/10/2014 6/4/2014
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Treatment – Peri-articular
• Arthroplasty options
• Cemented implants
• Tumor prostheses
• Evidence that LONG stems no longer needed for pathologic femoral neck fractures
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Slide from Valerae Lewis, MD
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Additional Treatment(s)
• Radiation• Bisphosphonates• Curettage of solitary and large lesions• En bloc resections in some situations
• Radiation resistant lesions• Longer suspected patient survival
• PMMA to reinforce• Avoid bone graft
• Emphasis on durable constructs to outlive patient• Early mobilization• Chemotherapy
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Demonstrative Case
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Pathologic Fracture
• 48 yr old healthy male
• 2-3 mo aching thigh pain
• Audible crack and brought to ED with worsening pain
• No significant medical or family history
• + Smoking history
• Review of systems underwhelming
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No other lesions in this femur
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Special Situations
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Acral Metastasis
• Hand• Often delayed diagnosis
• Treated as infection
• Most often lung
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Highly Vascular Metastases
• Renal
• Myeloma
• Thyroid
• Pre-operative embolization
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Cortical Metastasis
• Lung
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Renal Metastasis
• Vascular
• Locally aggressive
• Radiation resistant
• Long survival
• More aggressive local treatment
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09-05-0812-09-03XRT
10-28-15
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Metastatic Disease – Summary
• Follow the steps to evaluate a lytic lesion in an adult• More work-up rarely the wrong test answer
• Do not nail/broach/ream a sarcoma
• Prevent pathologic fractures• Assess risk
• Surgery to allow early weight bearing/rehabilitation
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Don’t Forget the Cautionary Tale
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Soft tissue masses
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Soft Tissue Tumors
•Incidence incalculable•Never to MD attention•General practitioner•Orthopaedics•General surgery•Plastic surgery•Dermatology
http://alpha-business.blogspot.com/2011/03/tip-of-iceberg.html
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Soft Tissue Tumors
•Benign lesions•Far outnumber malignant
•Non-neoplastic lesions•Infection
•Post-traumatic
•Inflammatory
•Malignant lesions•Sarcoma & others
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Responsible Decision Making
• How to avoid doing harm in a patient with a soft tissue malignancy?• Delayed diagnosis• Procedure compromising definitive intervention• Iatrogenic tumor spread
• Is it responsible to MRI/biopsy every:• Baker’s cyst• Wrist ganglion• Gouty tophus• Small subcutaneous lump• Etc…
http://newwavesystemsinc.com/attachments/Image/cost_benefit_risk_white_dice.png
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Pitfalls
• H&P• Assumptions• Distracters
• Imaging• Under utilization• Under reviewed• Inaccurate reports• Non-specific
• Management• Biopsy technique• Inadvertent excision
http://www.atariage.com/2600/screenshots/s_Pitfall_2.png
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Pitfalls
• H&P• Assumptions• Distracters
• Imaging• Under utilization• Under reviewed• Inaccurate reports• Non-specific
• Management• Biopsy technique• Inadvertent excision
http://www.atariage.com/2600/screenshots/s_Pitfall_2.png
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“Baker’s Cyst”
• 79yr old female• On schedule at
outside hospital for TKA
• Presents to county ER hoping to get TKA faster there
• Per pt: told there is large cyst in back of knee – will take care of at time of TKA
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“Baker’s Cyst”
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“Baker’s Cyst”
• Large, firm posterior thigh mass
• US in ED to r/o DVT; CT
• Contrast MRI
• Biopsy: HG spindle cell sarcoma
• Management: AKA
• DOD 2yrs post-op
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“Baker’s Cyst”
SARCOMA• Deep – along femur
• Firm
• Proximal
BAKER’S CYST• Superficial
• Compressible
• Rarely progresses proximally
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Trauma
• Many patients will present after trauma• Patients believe it to be
etiology of mass
• More relatistically 1st
time mass noticed
• May be late sequela of trauma
Calcific Myonoecrosis
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Trauma
• 18yr old
• 6mo leg swelling
• 1st noticed after falling from bicycle
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Trauma
Synovial Cell Sarcoma
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Trauma
• Most likely to bring lesion to attention
• May develop reactive lesion
• May develop neoplasm
• Patient looking for a “reason”
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Pitfalls
• H&P• Assumptions• Distracters
• Imaging• Under utilization• Under reviewed• Inaccurate reports• Non-specific
• Management• Biopsy technique• Inadvertent excision
http://www.atariage.com/2600/screenshots/s_Pitfall_2.png
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“Its just a…”
• 38 yo diagnosed with “fatty tumor” by PMD on H&P alone.
• 4mo later to ED for worsening size & pain of mass.
• Bedside I&D for “hematoma” – 15cc blood returned.
• No anticoagulants, bleeding disorder, recent trauma or travel; no drug use; no signs of sepsis.
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Leiomyosarcoma
• Refer to tumor specialist
• Management• Stage
• Resect & reconstruct
• XRT
• Surveillance
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Hand Mass
•44yr old male
•Growing Rt hand mass
•Uses jackhammer at work
•Multiple ED visits
•Minimal pain
•No signs of infection or penetrating wound
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T1 axialT2 axial
T1 FS +gad sag
Report:Differential diagnosis includes peripheral nerve sheath tumor, soft tissue sarcoma (MFH, synovial sheath sarcoma, etc.), and hemangioma. Other benign and soft tissues tumors not excluded.
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Operative Narrative
• Findings: Right hand tumor, appears to be lipoma
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Spindle cell component
Epithelial component
Biphasic synovial sarcoma
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“Just a lipoma…”
• Lipoma will match signal intensity of fat on all MRI sequences
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Huh?
REPORT• Couple of small bones
adjacent to posterior margin of the humerus
• The arm is unusually muscular
• Pt had been to several depts/providers/ED
• MRI: large heterogenous mass
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Pitfalls
• H&P• Assumptions• Distracters
• Imaging• Under utilization• Under reviewed• Inaccurate reports• Non-specific
• Management• Biopsy technique• Inadvertent excision
http://www.atariage.com/2600/screenshots/s_Pitfall_2.png
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Leg Mass
•51yr old healthy female
•Lt leg mass/shin pain with running 8/2011
•Aspirate: 1.5cc blood
•Dx stress fracture
•RICE, therapy →persistent pain
•MRI – 10/31•Medial tibial stress syndrome•Ganglion cyst
•Persistent pain•Excision of periosteal ganglion 4/2012
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Leg Mass
• Longitudinal excision over lesion
• Attempted en bloc excision
• Comment on NOT violating periosteum or fascia
• Pathology: poorly differentiated liposarcoma
• Positive margin
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Leg Mass
GOOD• Longitudinal incision
• Minimal undermining
• No distant drain site
• No violation of bone or muscle compartments
• Timely referral to tumor specialist
LESS GOOD• B/L whole leg MRI has
minimal cuts of lesion/detail
• Positive margin: whole field contaminated
• Time from MRI to excision (6mo)
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Soft Tissue Masses – Summary
• Far many more benign and non-neoplasticlesions
• Many more horses than zebras
• Be aware of things that aren’t quite right• Atraumatic, non-resolving
“hematoma”• Spontaneous sizeable
“lipoma”
• Follow-up on imaging ordered
• Be aware of squamousCA in chronic draining wound
• Very tough to make diagnoses on visualization alone
• Refer early if any question
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Biopsy
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Biopsy
• Best performed by treating physician
• Longitudinal incision
• Avoid major neurovascular structures
• Through muscle/avoid contaminating internervous planes
• In line with resection
• Minimal dissecting/flaps
• Meticulous hemostasis
• Drain if needed; in line & close to incision edge
• Needle/less invasive methods proving beneficial• Requires pathology experience/comfort also
• Refer before biopsy
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Closing Remarks
• Refer early
• Though its probably a metastasis – it still needs to be worked up – it may not be
• “Its just a lipoma…”
• “Its just a hematoma…”
• Biopsy done poorly can do great harm
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