Bone Cutter
Diagnostic strategy in MSK tumor
Sunday, November 28, 2010 2:52 AM | 0 SAID SOMETHING

1. Presentation:
  • Pain- pain at rest / night pain
  • Palpable mass
  • Altered functions
  • LOW
  • LOA
  • Pathological fracture
          - fever not prominent
  • Clinical evaluation

Age
  • 50 – mets (destructive bone lesions)
  • 10 – Histiocytosis

sex
  • Osteosarcoma- male
  • GCT – female


2. Risk factors:
  • smoking
  • certain jobs
  • previous irradiation


3. Progression

4. Complications – mets/pathological #
  • Physical Examination:
  • General examination :

         -cachexia
         -pale
  • Secondary:

         -LN
         -lungs
         -liver
         -spine
  • Primary:

        -thyroid
        -breast
        -lungs
        -prostate
        -kidney

Investigations:
Blood :
  • FBC

-anemia/thrombocytopenia – suggest bone marrow infiltration.
-TRO infection
-BUSE (calcium) – hypercalcemia in bone mets – can be fatal
-LFT (ALP, Albumin) – liver secondaries
-Specific (PSA,CEA, TFT, Bence Jones protein)
-Radiology

  • Plain radiograph

-to see bony lesions
-‘personality’

  • Bone scan

-very sensitive to detect secondaries
-CT scan
-CT chest – to detect lung secondaries
-CT of the affected bone – delineate cortical involvement in details

  • MRI

-delineate soft tissue involvement
-blood vessel – possibility of resection of the affected vessel & anastomosis with
graft
-nerve – if it is involved, limb salvage may not be feasible
-marrow extension - determine the extent of bone resection/skip lesion.
-muscle involvement etc.

  • Angiogram

-define vascularity of the tumor – very vascular tumor may require pre-op
radiotherapy/embolization
-vascular involvent of the tumor

  • Tumor staging (Enneking)

-radiological –intracompartmental/extracompartmental/distant mets.
-done BEFORE biopsy
-histological – biopsy
-low grade/high grade tumor
-proper diagnosis.


Treatment
Curative – patient is free from the disease.
Palliative - patient is not free from the disease but to ease the suffer eg, pain relief,
eradication of smelly/infected tumor.

Modes:
  • Surgical resection

-for respectable tumor/ accessible umor
Chemotherapy
-for chemosensitive tumor, syatemic spread tumor
Radiotherapy.
-for inaccessible localized tumor for surgical resection
-inadequate surgical margin following resection.
Most aggressive tumor require combination of these treatment modes.
Radiotherapy is contraindicated for benign tumor!

  • Plain Radiograph:

Site :long bones

  • Epiphysis

-open growth plate(GP)
-respect GP – ABC,solitary cyst,chondramyxoid fibroma
-breach GP - Chondroblastoma
-closed growth plate – GCT , chondrosarcoma

  • Diaphysis – Round cell tumors (Histiocytosis, leukemia,lymphoma, Ewing,

Myeloma, secondaries, neuroblastoma)

  • Metaphysis

-mineralization
-calcification – cartilage forming tumor(chondrosarcoma,
enchondroma, chondroblastoma )
-secondaries : bladder, prostate, bronchus.
-ossification – bone forming tumor (osteosarcoma, osteoid osteoma, osteoblastoma)
-without mineralization (soft tissue tumor )
-fibrous tissue (non ossifying fibroma)
-fat (liposarcoma)
-muscle (rhabdo myosarcoma)

Aggressiveness.
-cortical destruction
-massive soft tissue swelling
-wide zone of transition
-irregular margin
-signs of distant metastasis
-certain lytic pattern (geographical, moth eaten)

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