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

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Pitfalls

• H&P• Assumptions• Distracters

• Imaging• Under utilization• Under reviewed• Inaccurate reports• Non-specific

• Management• Biopsy technique• Inadvertent excision

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“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

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“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

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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