general principles of tumour management
DESCRIPTION
a generaL review of evaluation, diagnosis and management.TRANSCRIPT
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GENERAL PRINCIPLES OF TUMOURS
RAM SUDHAN S
MCH, CALICUT
Ref: campbell’s
Rockwood and green
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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:
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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)
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Periosteal reaction:
( tumour destroys the cortex)
may take the form of: onion skinning
sunburst or codman’s
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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.
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Endosteal erosion in chondrosarcoma:
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CT LUNG: Detects pulmonary met.CT WITH CONTRAST: ( if MRI is
prohibited) differentiates cystic lesion from
vascular lesion.
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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.
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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)
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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.
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USG:can differentiate cystic and solid
masses
ANGIOGRAPHY:(replaced by MRI)eventhough used in pre operative
embolisation of highly vascular tumours. (esp.RCC & ABC)
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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.
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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.
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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.
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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)
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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)
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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)
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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;
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(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.
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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.
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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.
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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)
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GENERAL SCHEME OF DIAGNOSIS:
TYPE OF LESION ZONE OF TRANSITION (margins) AGE LOCALISATION
PLAIN X RAY
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BASED ON AGE:
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BASED ON ZONE OF TRANSITION & AGE
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LOCALISATION
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WELL DEFINED ALL AGES <30
<30 > 30 >30
>30 ILL DEFINED
<30
>30
PLAIN X RAY
OSTEOLYTIC ANY SCLEROTIC
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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
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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
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INFECTION MYELOMA METASTASIS
ANY
ALL AGES >30 YEARS
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METASTASIS OF UNKNOWN PRIMARY: Usual victim >40 years + painful bone
lesion
multiple myeloma metastatic.Ca
screening of: prostate breast lung kidney-RCC.
Thyroid
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EVALUATION:-history-physical examination
-involved limb-thyroid –lung –breast – abdomen -prostate
-CBC WITH ESR: -SE-LFT-ALP
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-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)
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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.
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NO DISTINCTION IS MADE BETWEEN LYMPH NODE STATUS/ DISTANT MET – BOTH HAVE
EQUAL PROGNOSIS.
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AMERICAN JOINT COMMITTEE ON CANCER SYSTEM ( AJCC ) :
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ADJUVANT TREATMENT: GOALS:
if primary malignancy: making disease
free. if metastatic Ca: minimise pain
and to preserve
function.
Optimal Rx:radiation therapychemotherapysurgery.
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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)
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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.
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- 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.
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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)
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IN CHILDREN:-scoliosis/kyphosis-chestwall deformities- hypoplasia of ilium- LLD.
NEW Rx: BRACHYTHERAPY
radiation is delivered in close proximity.
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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)
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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
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IN REGARD TO PT’ SURVIVAL, most vital technical aspect is attainment of WIDE MARGIN regardless of whether it is achieved by AMPUTATION/LOCAL RESSECTION.
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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.
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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.
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Enneking classification of
local procedures.
Enneking classification of
amputations
Radicalamputation ordisarticulation
Wideamputation
Intralesionalamputation(debulking)
Marginalamputation
Radical resection
Wide resection
Intralesionalresection(debulking)
Marginal resection
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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
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Curettage and extended curettage
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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
)
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Thanks…