Silent but deadly – how to spot a sarcoma Craig Gerrand Consultant Orthopaedic Surgeon Freeman...
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Transcript of Silent but deadly – how to spot a sarcoma Craig Gerrand Consultant Orthopaedic Surgeon Freeman...
Silent but deadly – how to spot a sarcoma
Craig Gerrand
Consultant Orthopaedic SurgeonFreeman Hospital, Newcastle
Introduction
• What is a sarcoma, and why does it matter?
• Who gets sarcomas?• What is the best treatment for a
sarcoma?• How can I tell a sarcoma from a
ganglion?
What is a lipoma?
Benign tumour of mature adipose tissue
What is a ganglion?
A simple fluid filled cyst usually arising from a joint or tendon.
What is a sarcoma?
Bone and soft tissue sarcomas
• Are rare malignant tumours arising from connective tissues
• Heterogenous in type and location
• Most are mesenchymal in origin
How rare is rare?
• Soft tissue masses are common (many hundreds in a GP lifetime)
• Malignant soft tissue sarcomas are uncommon (1 or 2 in a GP lifetime)
• England and Wales- 400 primary bone tumours per annum- 1500 soft tissue sarcomas per annum
How malignant 1?
• Survival of all patients with bone sarcomas
How malignant 3?
• Survival of all patients with soft tissue sarcomas
Primary bone tumoursMorphological classification
• Over 30 variants
Histological type Benign Malignant
Haemopoetic Myeloma Lymphoma
Chondrogenic Osteochondroma Chondroblastoma Chondromyxoid fibroma
Chondrosarcoma
Osteogenic Osteoid osteoma Osteosarcoma
Unknown Giant cell tumour Ewing’s tumour
Fibrogenic Benign fibrous histiocytoma
Malignant fibrous histiocytoma
Notochordal Chordoma
Soft tissue sarcoma Morphological classification
• Over 100 variants
Mesenchymal differentiation
Other differentiation, consistent pattern
No specific differentation, variable
pattern
Liposarcoma Leiomyosarcoma Rhabdomyosarcoma Angiosarcoma MPNST Osteosarcoma Chondrosarcoma Fibrosarcoma
Synovial sarcoma Epithelioid sarcoma Clear cell sarcoma Ewing sarcoma/PNET Alveolar soft parts sarcoma
MFH Sarcoma NOS
Aetiology
• Most are sporadic• Predisposing factors
- inherited predisposition- immunosuppression- irradiation- specific chemicals
• Genetic changes within cells lead to tumours
Age distribution of primary bone tumours
Age distribution of soft tissue sarcomas
Soft Tissue SarcomaDistribution
• 55% extremities• 35% retroperitoneum and
viscera• 10% head and neck
What is the best treatment for sarcomas?
Best treatment
• Early detection and referral• Multidisciplinary team
management
Why refer early?
• Delays in diagnosis are common• Risk of metastasis relates to size
of tumour
Where do delays occur?
• Patient (7 months)• GP (7 months)• Hospital
Biopsy of sarcomas
Sarcomas are implantable
Therefore
Careful planning is mandatory
The Whoops! procedure
• Excision without regard to principles of tumour surgery and usually without imaging
• ie tumour “shelled out” without considering the possibility of malignancy
• Further treatment complicated
Principles of biopsy
• Image first• Careful planning with regard to definitive
surgery• If in doubt, discuss!• Excise the biopsy track during definitive
surgery• Extensile incisions• Avoid neurovascular structures • Good haemostasis• Drain through or close to the wound
Treatment of sarcomas
• Multidisciplinary team • Combined approach with
radiotherapy, surgery and chemotherapy
• Specialist centre
Patient perspective
• Rare tumour• Often incorrectly reassured• May have to travel for treatment
Low grade fatty tumours
• Low risk of local recurrence• Low risk of metastatic disease• Treatment by planned marginal
excision
Indications for amputation
• Adequate margins not possible with limb salvage
• Major complications of radiotherapy would follow
• A below knee amputation may be more serviceable than a salvaged distal extremity
• Some cases of local recurrence may not be treatable by standard surgery and radiotherapy
The future
• Changes in administrative structure (NICE, NSCAG, NCRI)
• Better identification of risk groups
• Better chemotherapy• Better radiotherapy• Tissue engineering• Gene therapy• New imaging modalities
Who to refer 1?
• Soft tissue masses- Size >5cm- Painful- Increasing in size- Deep to fascia- Recurring after previous excision
Who to refer 2?
• Undiagnosed bone pain needs an x-ray!
• Bone abnormalities on X-ray- Bone destruction- New bone formation- Associated soft tissue swelling- Periosteal elevation
North of England Bone and Soft Tissue Tumour Service
• Orthopaedics- Shona Murray- Craig Gerrand- Mike Gibson
• Plastic Surgery- Rick Milner
• General Surgery- Derek Manus- Paul Hainsworth
• Thoracic surgery- Sion Barnard
• Clinical Oncology- Helen Lucraft- Charles Kelly
• Medical Oncology- Mark Verrill- Ruth Plummer
• Paediatric Oncology- Juliet Hale- Quentin Campbell
Hewson- Alan Craft
• Radiology- Geoff Hide- Chris
Baudoin
• Pathology- Petra Dildey
• Macmillan nurse- Joy Dowd
Thank you