General principles of tumour management.
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Transcript of General principles of tumour management.
GENERAL PRINCIPLES OF TUMOURS
RAM SUDHAN S
MCH, CALICUT
Ref: campbell’s
Rockwood and green
DIAGNOSTIC EVALUATION : History & physicxal examination: c/c: pain (MC) mass or abnormal x ray
finding. Age: Lymph nodes: ( though rare) seen with, epitheloid sarcoma rhabdomyosarcoma & synovial sarcoma. Radiographic evaluation:PLAIN X RAY:site: epi / meta / dia less vital in soft tissue
tumours: benign or malignant:
BY PLAIN X RAY BENIGN:
MALIGNANT:Zone of transition: - well marginated - less marked( surrounding rim of ( host response
is Reactive bone form’) slower than the
progr’n of
tumour )
Expansile destruction Frank cortical destru
of cortex: ( agg’ benign tion ( without expa
tumour) nsion of cortex)
Periosteal reaction:
( tumour destroys the cortex)
may take the form of: onion skinning
sunburst or codman’s
CT SCAN: ossification, calcification,
integrity of cortex. BEST: to localise the nidus in osteiod
osteoma 3D reconstruction: treatment plan. ANEURISMAL BONE CYST: thin rim of
reactive bone formation. CARTILAGENOUS LESION:
calcification
SUSPECTED CHONDRO SARCOMA: endosteal cortical erosion.
Endosteal erosion in chondrosarcoma:
CT LUNG: Detects pulmonary met.CT WITH CONTRAST: ( if MRI is
prohibited) differentiates cystic lesion from
vascular lesion.
BONE SCAN:( Tc) to determine the activity of the lesion. presence of any other lesion. False negative results ( freq.) - multiple myeloma. - RCC. Normal bone scan is reassuring. NOTE: but increased uptake is not always
malignant.
PET SCAN: 3D visualisation & quantitative
assessment of in vivo physiological & biochemical processess.
Staging and in planning biopsy & response to chemo therapy.
FDG PET: (F^18)-fluro deoxy labelled PET.-useful in detection,staging,management-MECH: FDG – glucose analogue
becomes trapped in malignant cells
( in proportion to the rate of glycolysis)
MRI: ( has replaced CT.)-IS THE STUDY OF CHOICE.-size, extent & anatomic
relationship with soft tissues.-most accurate ( extent of intra
medullary & extrosseus disease )-may also yield specific diagnosis (
lipoma , hemangioma, hematoma & pigmented villonodular synovitis)
- CANNOT DIFFERENTIATE BENIGN AND MALIGNANT LESIONS.
USG:can differentiate cystic and solid
masses
ANGIOGRAPHY:(replaced by MRI)eventhough used in pre operative
embolisation of highly vascular tumours. (esp.RCC & ABC)
LABORATORY TESTS: CBC: r/o infection, leukemia & status. ESR: inc.in infection / metastatic Ca /
small blue cell tumours( EWING, histiocytosis,leukemia ,lymphoma)
S.PROTEIN ELECTROPHORESIS:( multiple myeloma)
S.PSA: S.Ca: mets / hyper parathyroidism / MM ALP: Inc. in metabolic bone disease &
metastatic disease, osteosarcoma,ewings,lymphoma.
PTH: (with Ca) -brown’s tumour( hyper
parathyroidism)- mimic GCT.
BUN & S.Cr:- inc. in renal tumours.
URINARY PYRIDIUM CROSSLINKS:( with ALP)
-paget’s disease.
BIOPSY: PRINCIPLES: 1. done only after clinical,
radiographic, lab tests are completed. 2. biopsy track is always
considered contaminated ( needle/open) with tumour cells
thus biopsy track needs to be excised en bloc with the tumour.
3.the same surgeon who plans the definitive procedure must perform the biopsy.
4.only vertical incisions are made (never transverse – may become impossible to excise the whole track)
5.if tournequet is used , limb may be elevated but not exsanguniated
prevents squeezing of tumour cells
into sys. Circulation. 6.incision should go thro’ a single
muscle compartment ( never thro’ neuro vascular plane/inter muscular plane)
7.if a hole is made in bone, it should be round or oval--- to decrease trhe subsequent fracture.
( hole can be plugged With methacrylate toLimit hematoma Formation) 8.frozen sectionShould be sent intra- opTo ensure that the diagnostic tissue is
obtained. ( if correct- definitive procedure can be done
immedietely,provided it must correlate clinically and radiologically)
9.meticulous hemostasis should be attained before closure.( as hematoma may be contaminated with tumour cells)
10.if drain is used,it should be exited in line with the incision ( drain track can alspo be excised)
six reasons why the biopsy should not be done until the evaluation is complete:
(1) may be a primary sarcoma of bone that may require a biopsy technique that allows for future limb salvage surgery;
(2) another, more accessible lesion may be found;
(3) if renal cell carcinoma is likely, embolization - to avoid excessive
bleeding;
(4) if multiple myeloma is made, unnecessary biopsy can be avoided;
(5) the pathological diagnosis is more accurate if aided by appropriate imaging studies.
(6)the pathologist and surgeon may be more assured of a diagnosis - frozen section – and can plan the definitive procedure immedietly.
INDICATIONS FOR BIOPSY: NEEDLE BIOPSY:
-obese-close proximity to neuro vascular
structures.-remote location( pelvis)
FNAC:-90% accurate in determining
malignancy.-low significance in determining
specific tumours.( as only cells are obtained not tissues)
- done when the suspect is a met / infection / lymph nodes.
CORE NEEDLE BIOPSY:( accuracy- 84-98%)
- uses large bore needle than FNAC.
thus provides tissue with architechture
OPEN BIOPSY:- gold standard- least likely to be ass’ with
samplingerror.
EXCISION BIOPSY:- <3 cm subcutaneous mass
(i.e) unlikely to be malignant. ( if turns malignant – tumour bed
must be re excised)
- should not be done on large soft tissue lesions / lesion deep to facsia UNLESS PROVEN BENIGN.
-relative indication is painful lesion in a EXPENDABLE bone.( prox.fibula/distal ulna)
GENERAL SCHEME OF DIAGNOSIS:
TYPE OF LESION ZONE OF TRANSITION (margins) AGE LOCALISATION
PLAIN X RAY
BASED ON AGE:
BASED ON ZONE OF TRANSITION & AGE
LOCALISATION
WELL DEFINED ALL AGES <30
<30 > 30 >30
>30 ILL DEFINED
<30
>30
PLAIN X RAY
OSTEOLYTIC ANY SCLEROTIC
WELL DEFINED ILL DEFINED
<30 >30SBCABCEosinophilic granulomaNon ossifying fibroma
Osteoblast
Fibrous dysplasia
Chondroblast
CMF
GCTEnchondromaChondro sarcomaHPT (BROWN’S)
Osteoblast
<30 >30
Osteosarcoa
EWING’S
Eosinophilic granuloma
GCT
SCLEROTIC
< 30 YEARS > 30 YEARS
OSTEO SARCOMA
FIBROUS DYSPLASIA
EOSINOPHILIC GRANULOMA
OSTEOID OSTEOMA
OSTEO BLASTOMA
ENCHONDROMA
OSTEOMA
BONE ISLAND
PAR OSTEAL OSTEO SARCOMAHEALED LESIONS - SBC - ABC
INFECTION MYELOMA METASTASIS
ANY
ALL AGES >30 YEARS
METASTASIS OF UNKNOWN PRIMARY: Usual victim >40 years + painful bone
lesion
multiple myeloma metastatic.Ca
screening of: prostate breast lung kidney-RCC.
Thyroid
EVALUATION:-history-physical examination
-involved limb-thyroid –lung –breast – abdomen -prostate
-CBC WITH ESR: -SE-LFT-ALP
-S.ELECTROPHORESIS-S.PSA-X RAY (Involved bone and CXR)-WHOLE BODY BONE SCAN-CT-CHEST,ABDOMEN,PELVIS-mammogram is not routinely
used (met in Ca breast without primary is unusual)
STAGING: Rx BASED ON STAGING: BENIGN:
Stage 1: intracapsular doesn’t req
latent Rx ( resolve
asymptomatic spontaneous)
Stage 2: intracapsular active growing extened symptomatic
curettage. stage 3: extracapsular extended
curettage +
marginal/wide ressection.
NO DISTINCTION IS MADE BETWEEN LYMPH NODE STATUS/ DISTANT MET – BOTH HAVE
EQUAL PROGNOSIS.
AMERICAN JOINT COMMITTEE ON CANCER SYSTEM ( AJCC ) :
ADJUVANT TREATMENT: GOALS:
if primary malignancy: making disease
free. if metastatic Ca: minimise pain
and to preserve
function.
Optimal Rx:radiation therapychemotherapysurgery.
RADIATION THERAPY:- Causes cell death- by forming
free radicals
inside cells
DNA damage.
- sensitivity depends on: 1. cells position in cell
cycle; ( active mitotic cells are more
sensitive) 2.tissue oygenation,
(hypoxia – tissue protective)
3. cells ability to repair DNA damage.
DOSE OF RADIATION: ( GRAY ) 1 GRAY = 1 JOULE energy absorbed
per Kg 1 Rad = 1 centi gray
GOAL: deliver highest possible dose of radiation to tumour cells, while minimising toxicity to normal cells.
- delivered by linear accelerators.
- Most protocols deliver 150-200 cGy / day
- Myeloma = 30-40 Gy- Sarcoma = 60 Gy.
Most primary bone malignancy are RADIORESISTANT (.except small blue cell tumour , myeloma, lymphoma, ewing)
Carcinoma except RCC are sensitive.
Pre operatively used – In reducing the bulk
Post operatively used – in prevention of recurrence.
COMPLICATION: - Skin irritation
- desquamation- AVN-pathological #- radiation sarcoma( lag time
10 y)
IN CHILDREN:-scoliosis/kyphosis-chestwall deformities- hypoplasia of ilium- LLD.
NEW Rx: BRACHYTHERAPY
radiation is delivered in close proximity.
CHEMOTHERAPY:-IN GENERAL:
not useful for cartilagenous tumours & low grade malignancy.
-ADJUVANT CHEMO:post op chemo for persumed
micro mets.-NEO ADJUVANT CHEMO:
before surgical ressection ( dec’ bulk & dec’ the spread of tumour during surgery)
PRINCIPLES OF SURGERY:(AMPUTATION Vs LIMBSALVAGE)
While prefering salvage, always keep in mind
SIMON’S 4 ISSUES: 1. would the survival affected by treatment choice.2.how do the short term & long term morbidity compare?3.how would the function of a salvaged limb with that of the prosthesis.4. are there any psychosocial consequences
IN REGARD TO PT’ SURVIVAL, most vital technical aspect is attainment of WIDE MARGIN regardless of whether it is achieved by AMPUTATION/LOCAL RESSECTION.
BENIGNMARGINS:
( suits for amputation / ressection )
1.INTRA LESIONAL:-plane of surgical dissection is within
the tumour. -Symptomatic benign lesion.-palliative in metastatic disease.
2.MARGINAL:-plane of dissection passes thro’ the
pseudocapsule formed by the tumour.-most benign lesion & low grade
malignancies.
3.WIDE:-plane of dissection is thro’ normal
tissue.-no specific distance is defined.-quality of the margin is more
important than the quantity. - hiogh grade malignancy.
4. RADICAL:- All compartments containing tumour
are removed en bloc-deep soft tissue tumours- In case of bone tumour: removing
entire bone and the compartments of any involved muscle.
Enneking classification of
local procedures.
Enneking classification of
amputations
Radicalamputation ordisarticulation
Wideamputation
Intralesionalamputation(debulking)
Marginalamputation
Radical resection
Wide resection
Intralesionalresection(debulking)
Marginal resection
CURETTAGE:- higher rate of local recurrence than ressection.
PROCEDURE: ( simple curettage)large cortical window ( in the size
of the lesion) bulk of the tumour is scooped out.
the cavity is enlarged back to normal host bone
well irrigated
Curettage and extended curettage
EXTENED CURETTAGE:- use of adjuvants, ( liq N2 ,
phenol , methacrylate, thermal cautery)
recurrence rate can be reduced
FILLING THE CAVITY:-autogenous bone graft-allograft-demineralised bone matrix-artificial bone graft substitute-bone cement ( immediete stability
)
Thanks…