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MUSCULOSKELETAL TUMOR

EKO PERDANA PUTRA

Orthopaedi and Traumatology Departement

Faculty of Medicine

Baiturrahmah University

PADANG
Neoplasia

Hamartoma
CLASSIFICATION OF
MUSCULOSKELETAL TUMOR

BENIGN MALIGNANT

PRIMARY

SECONDARY

METASTASIS
WORK-UP

1. History taking and physical examination


2. Investigation (Laboratory, X-ray, CT Scan, MRI,
Bone Scan)
3. Biopsy
4. Complete Diagnosis
5. Treatment
6. Evaluation
History Taking
• Chief complaint:
– Pain
– Mass
– Pathological fracture
• Age
• History of trauma
• Neurological symptoms
• Asymptomatic
Age Distribution
History
 Pain
• Severity (VAS; 0 – 10)
• Duration (intermittent, continue)
• Associated with injury or ???
 The patient with a bone lesion in general presents in
one of four clinical scenarios:
• Incidentally noted bone lesions
• Painless bony masses
• Painful bone lesions
• Pathologic fractures
 Fever
Physical Examination

1. Look
2. Feel
3. Movement
4. Auscultation
Physical Examination

Look:
• General status
• Lump
• Skin
 Shiny
 Venaectation
 Hyperemia
Feel:
Mass
• Warm
• Tenderness
• Surface
• Fixed / mobile
• Size
INVESTIGATIONS

1. Laboratory
2. Plain photo (X-Ray)
3. CT Scan
4. MRI
5. Bone Scintigraph
6. Biopsi - Patologi
Laboratory

1. Blood Count
2. Liver function
3. Renal function
4. ALP
5. Serum Elektroforesis
6. Bence jones protein
Plain Photo

1.Location
2.Type of destructions
3.Periosteal reactions
4.Border of tumor
5.Matrix
6.Bony expansion and
Soft tissue
extension / mass
7.Multiplicity
Plain Photo - Location
Plain Photo - Type of Destruction

• Lytic

• Blastic

• Mixed
Lytic Lession
Fibrous Dysplasia
Osteoblastoma
Giant Cell Tumor

Metastasis Myeloma
ABC
DD Lytic Lesion Chondroblastoma
Hyperparathytoid
“HOLE IN BONE”
Infection
NOF
Eosinophilic Granuloma
Enchondroma

SBC
Plain Photo
Periosteal Reaction
Plain Photo
Tumor Margin (Transitional Zone)
Narrow or wide
Plain Photo
Type of Matrix
Plain Photo
Extention (bone or soft tissue)
Plain Photo - Multiplicity

Multiple Myeloma Eosinophilic Granuloma


CT Scan
For bone lession
1. Detail destruction
2. Overlap structure
3. 3 dimention
CT Scan (3 Dimension)
MRI

1. Soft tissue tumor


2. Bone tumor
a. Soft tissue
extension
b. Intramedulary
extension
3. To detect skip and
satelit lesion
MRI
Reactive zone: Area, or potential area,
between the tumor and normal tissue;
it may be composed of variable
amounts of pseudocapsule, satellite
tumor lesions, and reactive tissue,
including edema
Satellite lesion: Nodules of isolated
tumor within the reactive zone
Skip lesion: Nodule of isolated tumor
within the same compartment as the
primary tumor but separated by an
interval of normal tissue beyond the
reactive zone
Bone Scintigraphy
Hot spot: increase uptake isotope by increasing osteblast activity
Biopsy
FNAB (closed biopsy) Open biosy

1. Cheaper than open biopsy 1. Invasive procedure


2. Minimally invasive 2. Biopsy is a technically
simple procedure but a
3. Done by surgeon or complex cognitive skill
pathologist
3. Biopsy should be
4. Indication for bone tumor performed by the surgeon
with cortical break who will be doing the
5. Interpretation; by well definitive treatment
trained pathologist 4. Place of biopsy
6. Confirmation by a. Longitudinal
musculoskeletal tumor b. In line with incision for
team definitive surgery
Musculoskeletal Tumor Team
(Clinicopathologist Confrence –CPC)

1. Multidisciplinary team
a. Orthopaedic
b. Radiologic
c. Pathologist
d. Medical and radiation
oncologist
2. Planning for
a. Further diagnostic
b. Diagnosis
c. Treatment
d. Follow up post treatment
APPROACH FOR EVALUATION
Case
Case I
Boy, 8 y.o pain and mass at left thigh
• Location: Left Femur, meta-
diaphysis
• Type of destruction: mixed,
permeative
• Periosteal reaction: codman
triangle, sun burst app
• Border(zone of transition):
wide
• Matrix: osteoblastic
• Soft tissue: soft tissue
swelling (+)
• Multiplicity (-)

Malignant Bone Tumor


Osteosarcoma
Case II
Female, 42 y.o, mass in left
wrist joint
• Location: Left Distal Radius,
metaphysis, central
• Type of destruction: lytic,
geographic, scletoric rim
• Periosteal reaction: -
• Border(zone of transition):
narrow
• Matrix: -
• Soft tissue: soft tissue
swelling (-)
• Multiplicity (-)

Benign Bone Tumor


GCT
Staging
Aims
 To determine surgical margin
 Treatment planning
 Prognosis
 To facilitate interdisciplinary communication
SURGICAL STAGING SYSTEM
(ENNEKING)

Benign tumor

Stage Description Grade Site Metastasis

1 Latent G0 T0 M0

2 Active G0 T0 M0

3 Aggressive G0/G1 T1/T2 M0/M1


SURGICAL STAGING SYSTEM
(ENNEKING)
Malignant tumor
Stage Description Grade Site Metastasis

IA Low grade G1 T1 M0
Intracompart
IB Low grade G1 T2 M0
Extracompart
IIA High grade G2 T1 M0
Intracompart
IIB High grade G2 T2 M0
Extracompart
III Any grade G1/G2 T1/T2 M1
TREATMENT

Musculoskeletal Tumor

Systemic Control Locale Control

Chemotherapy Surgery
External Radiation
Internal Radiation
Systemic Controle
Preoperative; neoadjuvant
Objective
a.Downsize of staging
b.Facilitate of surgery (pseudocapsule)
c.Prevent micrometastatic
Posaoperative; adjuvant
SURGICAL MARGINS
TYPE OF PLANE OF RESULT
EXCISION DISSECTION

Intralesional Curettage or debulking Leaves


macroscopic tumor

Marginal Pericapsular reactive Likely to leave


zone microscopic tumor

Wide Normal cuff of tissue May leave skip or


(intracompartment) satellite tumor

Radical Whole bone & muscle No residual


outside compartement
Various Excision Types

Various excision types for soft-tissue sarcoma Various excision types for bone sarcoma
Limb Salvage Surgery
1. Wide resection (complete resection of the tumor) must be
attainable.
2. Function of the salvaged limb must be at least as good as
the function of the limb after amputation at the appropriate
level required for complete tumor resection
3. Reconstructed limb must be stable and durable.
4. There must be adequate skin and soft tissue after resection
of the tumor to allow for coverage of the limb/reconstruction.
5. Local rotation of tissues and the use of free tissue transfer
have broadened the indications for limb salvage.
6. Usually major neurovascular bundles must not be involved
or surrounded by tumor
BENIGN MUSCULOSKLETAL
TUMORS
Stage Treatment Reconstruction

1 Observation None
Intralesional excision Local grafting

2 Intralesional excision Local grafting


Cementation

3 Marginal or en bloc Structural grafting


excision Endoprosthesis
Allograft
Composite
INTRALESIONAL EXCISION – CEMENTATION
( GIANT CELL TUMOR)
INTALESIONAL EXCISION – MIX ALLO-BOVINE
BONE GRAFT (SIMPLE BONE CYST)
MARGINAL EXCISION (NEUROLIMMOMA)
MARGINAL EXCISION (OSTEOCHONDROMA)
MARGINAL EXCISION – HEMICONDYLE ALLOGRAFT
(GIANT CELL TUMOR RECURRENT)
EN BLOC EXCISION – FIBULA AUTOGRAFT
RECONSTRUCTION (GIANT CELL TUMOR)
EN BLOC EXCISION – OSTEOCHONDRAL ALLOGRAFT
(ANEURYSMAL BONE CYST RECURRENT)
EN BLOC EXSICION - MASSIVE OSTEOCHONDRAL
ALLOGRAFT (GIANT CELL TUMOR)
MALIGNANT MUSCULOSKELETAL
TUMORS

Stage TREATMENT
IA  Marginal/Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
IB  Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
 ANV incorporation : Amputation/Disarticulation
IIA  Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
 Chemotherapy / radiation
IIB  Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
 Chemotherapy / radiation
 ANV incorporation: Amputation/Disarticulation/
Exarticulation
III A/B  Palliative & Pain controle
MARGINAL EXCISION
(DERMATOFIBROSARCOMA)
WIDE EXCISION – ARTHRODESIS HIP
(CHONDROSARCOMA)
WIDE EXCISION – INTERCALARY
ALLOGRAFT (FIBROSARCOMA)
WIDE EXCISION – INTERCALARY ALLOGRAFT
(OSTEOSARCOMA)
WIDE EXCISION – AUTOGRAFT
RECONSTRUCTION (JUVARA PROCEDURE)
(OSTEOSARCOMA)
Radical excision – Malignant fibrohystiocytoma
Pathologic Assessment of
Chemotherapy Response

• Aside from the presence of metastatic disease at


presentation, histologic necrosis following induction
chemotherapy is the most powerful predictor of
disease-free survival available.
• Synonyms: Huvos grading system
• Prognostic value has been established for both
osteogenic sarcoma and Ewing sarcoma.
• Calculated by quantifying tumor viability on grid
constructed from cut sections of the tumor
Pathologic Assessment of Chemotherapy
Response
Pathologic Assessment of
Chemotherapy Response
• Theoretically, the amount of necrosis reflects the
effectiveness of the therapy.
• Consists of a four-tiered grading system
a. Grade I (0% to 50% necrosis)
b. Grade II (51% to 90% necrosis)
c. Grade III (91% to 99% necrosis)
d. Grade IV (100% necrosis)
Pathologic Assessment of
Chemotherapy Response

• Clinical significance
• Good response (grade III and IV) is
associated with superior survival
outcomes (as high as 89% at 5 years).
• Grade I and II responders are at
increased risk of relapse.
A grade I response is superior to no
chemotherapy (5-year survival of 50%
versus 17%, respectively).
• Increasing necrosis by prolonging
chemotherapy induction time or dose
intensification does not correlate with
DIAGNOSIS & TREATMENT of MST’s ALGORITHM
MST
Plain x-ray Clin. assessment
FNAB Laboratories

Non Neoplasm Benign In Doubt Malignant

Open Biopsi -Thorax PA/LAT & CT


-Scintigraphy
Observation Surgery

Primary Metastasis

Stage I & II Stage III


• MRI regional
• CT regional Palliative - MST
• Angiography Score

SURGERY - CHEMOTx - RADIATION


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