Post on 11-Dec-2021
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
Disclosures / Conflict of Interest
• BOD: Western Orthopaedic Association
Goals
• Avoiding Missteps:• Metastatic Disease
• Soft Tissue Masses
• Biopsy
Metastatic Disease
Metastatic Disease
• Most common malignancy of bone in adults
54 yr old female8yrs post lumpectomyImpending pathologic fractureFemoral head sent during hemiNo other work up
Low grade cartilage lesion High grade neoplasm
Dedifferentiated Chondrosarcoma
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
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…”
#1 What is it? #2 What to do?
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”
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
History & Physical
Imaging Laboratory Biopsy Diagnosis
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
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
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
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
Imaging – Extremity
• Prostate – 90% blastic
• Lung – 90% lytic
• Breast – 50/50 lytic/blastic
• Myeloma – Lytic
03/08/2009
04/19/2013
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
Biopsy
• Every solitary lesion is biopsied before treatment
• Labs can establish myeloma diagnosis
History & Physical
Imaging Laboratory Biopsy Diagnosis
P K
#2 What to do?#1 What is it?
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
ClinOrthop Relat Res. 1989;249:256–264
Treatment – Fracture
• Intramedullary nails• Protect whole bone
• Weight sharing, early mobilization, weight bearing
• Often protect femoral neck
Humerus – Plating
• Biomechanical studies with superiority to nailing
1/10/2014 6/4/2014
Treatment – Peri-articular
• Arthroplasty options
• Cemented implants
• Tumor prostheses
• Evidence that LONG stems no longer needed for pathologic femoral neck fractures
Slide from Valerae Lewis, MD
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
Demonstrative Case
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
No other lesions in this femur
Special Situations
Acral Metastasis
• Hand• Often delayed diagnosis
• Treated as infection
• Most often lung
Highly Vascular Metastases
• Renal
• Myeloma
• Thyroid
• Pre-operative embolization
Cortical Metastasis
• Lung
Renal Metastasis
• Vascular
• Locally aggressive
• Radiation resistant
• Long survival
• More aggressive local treatment
09-05-0812-09-03XRT
10-28-15
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
Don’t Forget the Cautionary Tale
Soft tissue masses
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
Soft Tissue Tumors
•Benign lesions•Far outnumber malignant
•Non-neoplastic lesions•Infection
•Post-traumatic
•Inflammatory
•Malignant lesions•Sarcoma & others
http://4.bp.blogspot.com/-_BV0WsmMpaY/Tg27eysz2eI/AAAAAAAAD5U/-0qOjKe3R2U/s1600/ZebraHorse.jpg
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
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
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
“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
“Baker’s Cyst”
“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
“Baker’s Cyst”
SARCOMA• Deep – along femur
• Firm
• Proximal
BAKER’S CYST• Superficial
• Compressible
• Rarely progresses proximally
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
Trauma
• 18yr old
• 6mo leg swelling
• 1st noticed after falling from bicycle
Trauma
Synovial Cell Sarcoma
Trauma
• Most likely to bring lesion to attention
• May develop reactive lesion
• May develop neoplasm
• Patient looking for a “reason”
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
“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.
Leiomyosarcoma
• Refer to tumor specialist
• Management• Stage
• Resect & reconstruct
• XRT
• Surveillance
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
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.
Operative Narrative
• Findings: Right hand tumor, appears to be lipoma
Spindle cell component
Epithelial component
Biphasic synovial sarcoma
“Just a lipoma…”
• Lipoma will match signal intensity of fat on all MRI sequences
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
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
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
Leg Mass
• Longitudinal excision over lesion
• Attempted en bloc excision
• Comment on NOT violating periosteum or fascia
• Pathology: poorly differentiated liposarcoma
• Positive margin
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)
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
Biopsy
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
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