4/18/2016

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International sarcoma awareness

Mr CR Chandrasekar, MS Orth, M.Ch. Orth.(Liverpool), FRCS Tr.&Orth.Consultant Orthopaedics

Webinar 19/4/2016

No Disclosures

SARCOMA

Sarcomas are cancers that develop from the cells that make up the connective tissue.

Soft tissue sarcomas

Bone sarcomas

GIST [Gastro intestinal stromal tumours]

Sarcoma

Sarcoma (from the Greek 'sarx' meaning "flesh")

Rare tumour -1% of the total burden of malignancy

STS six times more common than bone sarcomas

30 per million population per year

STS -70 Different variants (Liposarcoma, Synovial sarcoma, Leiomyosarcoma, Pleomorphic sarcoma, MPNST etc.)

Sarcomas should be managed by dedicated Multi Disciplinary Teams (MDTs) for integrated care and better outcomes [Surgeon, pathologist, Radiologist, Medical and radiation Oncologist, Specialist nurses, Palliative Care team, Research team, Allied Health professionals]

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Sarcomas

Average size of a sarcoma at diagnosis is 10 cm [breast cancer 2cm]

Late presentations are common [patient factors]

Delayed diagnosis, inappropriate interventions, unplanned excisions Common

Many sarcomas are presumed to be benign and patients falsely reassured

Many sarcoma patients across the world do not have access to facilities that are taken for granted in the West [pathology, surgery, radiology, safe chemotherapy, Radiotherapy, palliative care]

Red Flags!Any swelling which is

More than 5cm in sizeIncreasing in size

Deep to deep fasciaRecurred after previous operation

Painful

Sarcoma ReferralRed Flags = Refer to Regional CentreUsing 2 Week Rule [Urgent Cancer] Referral

Sarcomas can occur in any part of the body, in any age group

15% of all childhood cancers (0-14 years)11% of all cancer diagnoses in young people (15-24 years)

1% of all cancers

Primary Bone Sarcomas

Soft Tissue Sarcomas

Red Flags!Bone painBony swellingNight painAnalgesia resistance

Soft Tissue sarcomas Referral guidelines

Any soft tissue lump that is

larger than 5 cm,

deep to the fascia,

increasing in size

Painful, recurs after surgery

has to be considered malignant until proven otherwise

Refer to sarcoma centre for investigations and treatment

NICE 2015 Any unexplained lump arrange urgent ultrasound scan and refer if the Scan is suggestive of sarcoma

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5cm VS 22 cm

Soft Tissue sarcomas main prognostic factors

Size

Grade

Depth

Diagnosis

Age of the patient

Metastases at diagnosis

only one that can be altered to improve prognosis is size of tumour at diagnosis

Soft Tissue sarcomas Size at presentation and survival

For every 1 cm increase in the size of a

soft-tissue sarcoma at diagnosis there is a 3% to 5% worsening of the chance of cure

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Big tumour more likely to have metastases at presentation

Median survival of metastatic sarcoma is 12 months

Large sarcomas and late presentations are common -3 KG thigh sarcoma

Large sarcomas and late presentations are common - 4 Kilogram tumour

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- 9 KG tumour

Chondrosarcoma 2012 WORKED

AS PAINTER TILL WRIST DROP

Inappropriate friendly advice!

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Groin sarcoma- Patient Delay

Sarcoma of Axilla March 2015

Angiosarcoma June 2014 Inpatient DGH Delay in referral

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Hot water bottle treatment! Fear, isolation/lack of support/pride??

Sarcoma - Sept 2015

Patient/Family Delay Too lateFoot ball size tumour March 2014-Multiple lung metastasis

TOO LATE

MULTIPLE LUNG METS.

PALLIATIVE CARE

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OCT 2012 10 cm [cricket ball] lump, increasing in size,

painful no investigations Day case excision! Leiomyosarcoma!!

[referral 6 weeks after surgery by Registrar-pt.was told that there were abnormal

cells and referred]

Dont presume lumps to be benign and proceed to excision Without any investigations Whoops procedure

Osteosarcoma mistaken formyositis ossificansMale 19 years

3month h/o thigh/knee pain

Ultrasound diagnosis myositis -listed for surgery

Surgery after 6 months Whoops!

X RAY/MRI after surgery!!

Osteosarcoma with lung mets

Delayed diagnosis

Sarcoma presumed to be a haematoma -6 months delay

84 years old active lady could walk 5 miles/day in April 2013.

Right thigh swelling Saw GP presumed muscle tear

Swelling got bigger went to a private hospital Surgeon diagnoses haematoma and wants to drain the haematoma; Anaesthetist finds a heart murmur - referred to local hospital

After 6 months biopsy High grade sarcoma with bilat. pleural effusion -inoperable

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SARCOMA

What the mind does not know The eyes can not seetill it is too late

Public Awareness and Professional Awareness

Sarcoma awareness - Public

Education of the public

Social media, news papers, Television

Involve high profile public figures/celebrities/sports persons

Simple Message

LUMPS CAN BE DANGEROUS

HAVE IT CHECKED

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Awareness/education - Early Diagnosis

Key Points

Sarcomas are cancers arising from the connective tissue that forms the bulk of the human body.

Soft tissue sarcomas can occur any where in the human body, it can occur in any age group.

Presents as painful or painless lump that is increasing in size

STS is treatable and about 60% can be cured

Awareness, early diagnosis and management by a multi disciplinary team can improve survival/cure

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Management of Orthopaedic TumoursSICOT/VUMEDI Webinar 19/1/16

1938 Poster Early cancer can be cured

International Sarcoma Awareness

Remember Red flags

Remember Golf Ball

Early diagnosis and appropriate management - the magic bullet to cure sarcoma

4/12/2016

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Radiology & Diagnosis of Orthopedic

Tumors

Bhavin Jankharia

Bone Tumors

Benign Tumors

Osteoid

Osteoblastoma

Osteoid osteoma

Osteoma

Cartilage

Enchondroma

Chondroblastoma

Chondromyxoid fibroma

Osteochondroma

Cystic

Simple bone cyst

Aneurysmal bone cyst

Fibrous

Fibrous cortical defect

Osteofibrous dysplasia

Fibrous dysplasia

Misc

Giant cell tumor

Lipoma

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Malignant Tumors

Osteoid

Osteosarcoma

Cartilage

Chondrosarcoma

Fibrous

Fibrosarcoma

Malignant fibrous histiocytoma

Misc

Ewings sarcoma

Bone Tumors

Modalities

Plain radiograph

MRI

CT

PET/CT

Bone Tumors

Radiology

Identify the lesion

Differentiate benign from aggressive lesions

Identify benign aggressive lesions

Rule out infection and mimics

Characterize lesions based on location and matrix

Identify leave alone lesions

Stage aggressive lesions

Plan and perform biopsies

Monitor response to treatment

Treat

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metastases

myeloma / plasmacytoma

lymphoma

In any patient above the age of 35, before

considering a primary bone tumor, always think

first of

Identify the Lesion

Osteoid osteoma Unknown

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15-years old boy with pain

Osteoid osteoma

14-years old boy with pain and swelling in the left gluteal region

Ewing sarcoma

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Differentiate Benign from

Aggressive

Benign v/s Aggressive

Zone of transition

Periosteal reaction

Zone of Transition

Narrow

Benign

Wide

Aggressive

Narrow with sclerotic rim

Benign

ABC Chondromyxoid fibroma Ewing sarcoma

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Periosteal Reaction

Thick

buttressing

Benign

Irregular

Aggressive

Sun-ray

Aggressive

OFD Osteosarcoma Osteosarcoma

Identify Benign Aggressive

Lesions

Rule out Infection and Their

Mimics

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Benign Aggressive Lesions

Benign on X-ray with Marrow Edema

Osteoid osteoma

Chondroblastoma

Giant cell tumor

Langerhans cell histiocytosis

Benign tumors with fractures, etc

Chondroblastoma

Langerhans cell histiocytosis

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Ill-defined aggressive lesion with diffuse surrounding

Marrow edema and T1 fat sparing on MRI

Infection

Characterize Lesions

Location & Matrix

Characterize Lesions

Location

Epiphyseal chondroblastoma

Epimetaphyseal up to articular surface GCT

Phalanx enchondroma

Tibia cortical osteofibrous dysplasia

Cortical sclerotic rim fibrous cortical defect

Humerus mid-diaphysis simple bone cyst

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Chondroblastoma Giant cell tumor

Enchondroma Simple bone cyst

Characterize Lesions

Matrix

Fluid-fluid levels

Osteoid

Cartilage

Cystic

Osteoid osteoma

Ground glass

Woven bone

Fibrous

Fat containing / lipoma

Trabeculated expansile

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Aneurysmal bone cyst

F