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Transcript of Tumor mega prosthesis
Tumor Mega - ProsthesisTumor Mega - Prosthesis
Chairperson ndash Dr S K SaidapurChairperson ndash Dr S K SaidapurPresenter ndash Dr Srinath GuptaPresenter ndash Dr Srinath Gupta
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone
Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman Dr Codman along with James Ewing and Dr Codman along with James Ewing and
Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign LatentLatent
ActiveActive
AggressiveAggressive
MalignantMalignant
Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental
Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental
Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental
Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone
Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman Dr Codman along with James Ewing and Dr Codman along with James Ewing and
Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign LatentLatent
ActiveActive
AggressiveAggressive
MalignantMalignant
Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental
Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental
Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental
Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
HISTORYHISTORY Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone
Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman Dr Codman along with James Ewing and Dr Codman along with James Ewing and
Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign LatentLatent
ActiveActive
AggressiveAggressive
MalignantMalignant
Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental
Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental
Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental
Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign LatentLatent
ActiveActive
AggressiveAggressive
MalignantMalignant
Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental
Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental
Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental
Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign LatentLatent
ActiveActive
AggressiveAggressive
MalignantMalignant
Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental
Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental
Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental
Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Benign Benign LatentLatent
ActiveActive
AggressiveAggressive
MalignantMalignant
Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental
Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental
Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental
Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION
Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
DEFINITIONDEFINITION
HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of
advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving
No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE
Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
GOALGOAL Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical penetrationpenetration
Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed
and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Work through muscle not anatomical plane
Oval window
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response tumor volumetumor volume
in angiographic vascularityin angiographic vascularity
Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
PRINCIPLESPRINCIPLES Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
MATERIAL1 Titanium
2 Cobalt ndash chromium - molybdeneum
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of
the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-
- Tumor Mega - Prosthesis
- PowerPoint Presentation
- HISTORY
- TNM CLASSIFICATION
- HISTOPATHOLOGICAL GRADING
- ENNEKING STAGING
- WHO HISTOLOGICAL CLASSIFICATION
- PRINCIPLES OF LIMB SALVAGE SURGERY
- DEFINITION
- HISTORY AND CHANGING TREND
- INDICATION
- BARRIERS TO LIMB SALVAGE
- Slide 13
- Slide 14
- GOAL
- SUCCESS
- STAGING
- RADIOLOGICAL STAGING
- RADIOGRAPHY
- CT SCAN
- MRI
- ANGIOGRAPHY
- SCINTIGRAPHY
- PET SCAN
- SURGICAL STAGING
- PRINCIPLES OF BIOPSY
- Slide 27
- RESTAGING AFTER PRE OP ADJUVANT THERAPY
- PRINCIPLES
- RESECTION
- Slide 31
- Slide 32
- SURGICAL ADJUVANTS
- Slide 34
- RECONSTRUCTION
- ENDOPROSTHESIS
- PRE ndash OPERATIVE WORK-UP
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- ALLOGRAFT PROSTHETIC COMPOSITE
- Slide 62
- LIMB SALVAGE IN UPPER EXTREMITY
- LIMB SALVAGE IN LOWER EXTREMITY
- LIMB SALVAGE IN CHIDREN
- CONCLUSION
- Slide 67
-