Download - Approach to tumors i
![Page 1: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/1.jpg)
How to Investigate a Musculoskeletal Malignancy
Presented by:
Dr.
![Page 2: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/2.jpg)
Introduction• Primary Musculoskeletal
tumors arise from tissue of mesenchymal origin (ie. bone, muscle, connective tissue, adipose.)
• These primary tumors may spread to other sites, usually other bones or lung.
• Secondary bone tumors arise from a host of other tissues and in the appropriate age category must be looked for.
![Page 3: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/3.jpg)
Introduction
• The work-up of any tumor must be thought of in terms of Local disease and Systemic disease.
• By doing so you will have a sensible approach to determining the ultimate pathologic diagnosis and the extent of the disease in the body.
![Page 4: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/4.jpg)
The Problem: A Lump in the Bone
• History• Cause: Age, Age, Age,
smoking, cancer, family history.
• Systemic: sweats, wt loss, fever, cough, hemoptesis, other lumps.
• Local: pain, nerve, lump, time frame.
![Page 5: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/5.jpg)
The Problem: A Lump in the Bone• Physical:
• Systemic: General physical, focus on the Benzene ring and sites of possible Metastases. (lung, breast, bowel, prostate, thyroid, renal).
• Local: Mass size, firmness, tenderness, inflamed, relationship to fascia, nerve, vascular, skin, lymph nodes.
![Page 6: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/6.jpg)
Investigations
• *****Don’t think of your investigations in shotgun form.*****
• Focus your investigations based on the clinical scenario and then think of Local and Systemic investigations.
![Page 7: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/7.jpg)
Local Investigations • X-ray….the most helpful
in focusing our differential and further investigations.
• Cat scan….. Bone architecture, neocorticalization, ?fracture.
• MRI….marrow extent, soft tissue extent, neurovascular involvement, skip lesions.
![Page 8: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/8.jpg)
Investigations
• X-ray of proximal femur lesion
![Page 9: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/9.jpg)
Investigations
• MRI of same lesion 1 day later after a fall.
![Page 10: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/10.jpg)
Systemic Investigations: Radiology
• Total Body Bone Scan…..other lesions.
• Chest Cat scan… fine cut.
• What about CT chest/abdomen/pelvis??? Is there ever a role?
![Page 11: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/11.jpg)
Systemic Investigations: Blood-work
• CBC, calcium, albumin, ESR, C-reactive protein, ALP, LDH. Why do you do these tests?
• Protein electrophoresis, PSA, PtH.
• What about LFT’s, RFT’s, magnesium, Ptt/Pt/INR??? Are they useful tests and if so when?
![Page 12: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/12.jpg)
Other Specialized Investigations
• Bone Marrow Biopsy
• Angiography… when and why?
• Gallium Scan… when and why?
![Page 13: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/13.jpg)
Invasive Investigation
• Biopsy…..the goal is to obtain a piece of tissue adequate to make a pathologic diagnosis.
• Should be done after all other investigations are complete
• Needle, Tru-cut, incisional.
• CT/US guided.
![Page 14: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/14.jpg)
Biopsy
• In the OR…what do you want?
• Principles: “in line with eventual resection incision”…. Homan retractors????…. Tourniquet????….. Hemostasis????…. drain???…. multiple layer closure…. soft tissue mass…. round hole in bone …fixation???? Frozen section
![Page 15: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/15.jpg)
Biopsy
• Frozen section
• Swabs for C+S, and any other things you may be thinking of (ie. Fungus, TB).
• Is it acceptable to proceed on the basis of Frozen section?
![Page 16: Approach to tumors i](https://reader036.vdocuments.us/reader036/viewer/2022070317/556b8a24d8b42a6c7c8b5185/html5/thumbnails/16.jpg)
Incisional Biopsy vs Excisional Biopsy
• Is this practice ever safe???