The first 10 commandments of - McMaster Faculty of Health...
Transcript of The first 10 commandments of - McMaster Faculty of Health...
The first 10 commandments of Orthopaedic Oncology
Dr. Michelle GhertMcMaster University
Division of Orthopaedic Surgery
Never order an MRI or CT before an xray
12 year-old female with right knee pain
Know the differential for 99% of destructive bone lesions in patients
over 40 and how to find the diagnosis
Mets, myeloma, lymphoma
Work-up
• History and physical• Bone scan• Bloodwork: CBC, lytes, BUN, Cr, LFTs, Ca,
Mg, Phos, Alk Phos, SPEP• UPEP• CT chest/abd/pelvis
65 year-old male with history of lung cancer
Diagnosis?
Metastatic lung cancer
Treatment?
Intramedullary nailing by….
…an Orthopaedic Surgeon!
NOT an Orthopaedic Oncologist
Do not refer patients with benign incidental radiographic findings to
an Orthopaedic Oncologist
Non-ossifying fibroma
Enchondroma
Fibrous Dysplasia
Know the difference between osteoid and chondroid matrix
Osteoid Chondroid
Understand the difference between a benign and malignant periosteal
reaction
Benign Malignant
General Staging Protocol
• Bone: – Local cross-sectional imaging– CT scan chest– TBBS– (Bone marrow aspiration)
•Soft-tissue:–Local cross-sectional imaging–CT scan chest–In some cases, CT scan abd/pelvis
Treatment
• Bone sarcoma: Surgery +/- chemotherapy• Soft-tissue sarcoma: Surgery +/- radiation,
(+/- chemotherapy)
Very controversial!
Understand the difference between a geographic and a non-geographic border and the significance of that
difference
Geographic-benign Non-geographicmalignant
Neocortex = benign aggressive
Do not biopsy a suspicious bone or soft-tissue lesion without speaking to
an Orthopaedic OncologistBut know the principles of biopsy!!
Principles of biopsy: Avoid contamination!
• Incision in line with resection incision• Longitudinal in extremities• Intramuscular if possible (to bury hematoma)• Avoid NV structures and joints• No skin or muscle flaps• Meticulous hemostasis• Tight closure• Approach soft tissue mass or weakened area of bone• Drain if necessary, in line and distal to incision• *never, ever biopsy a fracture!!!!!!*
Know the differential for a benign osteoblastic periosteal response
(classic location tibia)
stress fx osteoid infectionosteoma
Know the differential diagnosis for bubbly lesions in the tibial cortex
Fibrous dysplasia Osteofibrous
dysplasia
AdamantinomaNon-ossifying fibroma
Fibrous-dysplasia
Know what is always on the differential for malignant-looking
bone lesions in children
• Osteosarcoma• Ewing’s sarcoma• Hematologic
malignancy• Infection• EG
Also on the differential for all benign lesions
Questions?