TUMOR

1. TUMOR DrMohammad.ali Department of Orthopedics

2. PATHOLOGY of NEOPLASM • Abnormal mass of tissue • Growth is autonomous, exceeds normal, & persist after cessation of stimuli • Benign vs. Malignant • Differentiation & Anaplasia • Growth rate • Local invasion • Ability to metastasize

3. HISTOPATHOLOGY • Anaplasia • Hallmark of malignancy • Pleomorphism • Hyperchromatism • Nuclear cytoplasmic ratio of 1:1 • Abundant mitoses • Tumor giant cells

4. BENIGN more common • MALIGNANT (SARCOMAS) are rare • Differentiation of the lesion • Fibrous tissue • Fibrohistiocytic • Adipose tissue • Muscle tissue • Lymph vessels • Synovial tissue • Peripheral nerves • Cartilage and Bone Forming tissue • Pluripotential Mesenchyme • Blood Vessels • Uncertain Histogenesis

7. DIAGNOSTIC CLUES Size • A mass that is small (< 5 cm in its greatest dimension) is unlikely to be malignant, while a mass that is > 5 cm has at least a 20%chance of being a soft tissue sarcoma • Determined by physical examination if the lesion is subcutaneous and easily palpable, or by ultrasound, CT or MRI

8. DIAGNOSTIC CLUES Superficial or deep? • Superficial lesions are more likely to be benign and, when malignant, may have a better prognosis than deep lesions • The depth is best determined by physical exam, ultrasound or MRI • The thigh and buttocks are the 2 most common sites of sarcomas. Any large deep mass in the thigh or buttocks should be considered at high risk for being a malignant lesion

9. DIAGNOSTIC CLUES Cystic or solid • Most cystic lesions are inflammatory or benign lesions, such as ganglion cysts or soft tissue abscesses • If the lesion is solid, it could represent either a benign or malignant neoplasm • Attempt Transillumination • If deep, ultrasound or MR scan will determine this

10. DIAGNOSTIC CLUES Length of symptoms • Rapidly increased in size over 2 months is more likely to be a sarcoma than the lesion that has slowly enlarged over a 20-year period • A mass that increases and decreases in size is usually a cystic lesion • Caution should be taken with masses that have been present for a long time. Soft tissue sarcomas occasionally present with a history of many years duration up to 30 years

11. TUMOUR WORKUP • History (age, sex, site and past history) • Clinical examination • Thyroid • Breasts • Chest • Liver • Kidney • Rectal (prostate & rectal tumors) • Bloods • FBC (leukaemic cells etc) & ESR (often elevated) • Biochemistry (Ca++, PO4, liver enzymes and Alkaline Phosphatase) -> mets • Acid Phosphatase (prostate and increased with metastatic deposits) • Thyroid function tests • PSA • Serum Protein Electrophoresis (Myeloma)

12. TUMOUR WORKUP (cont) • Urinalysis • Urine Bence-Jones (myeloma) • CXR • Abdominal ultrasound • Bone scan -> other sites • MRI -> soft tissue extent and association with nerves and vessels • CT of lesion and chest (-> staging) • Angiography -> tumor blood supply and relationship to major vessels • Biopsy

13. IMAGING OF SOFT TISSUE TUMOR • Plain radiograph • Soft tissue shadow, isodense with muscle • Specific features • Phlebolith within a hemangioma • Cartilaginous juxta-articular masses in synovial osteochondromatosis • Mature peripheral calcification in myositis ossificans • Central calcification in extraosseous osteosarcoma • Amorphous calcium deposit in tumoral calcinosis • Bony involvement

16. IMAGING OF SOFT TISSUE TUMOR • Ultrasound • Rapid inexpensive test • Differentiate solid from cystic • Determine size • Can suggest sarcoma features • As many soft tissue sarcoma present as hypoechoic mass than the echogenic pattern seen in benign lesion, with exception of liposarcoma • Delineate areas of distinctly solid portion of a a mass, a great help for biopsy • Aid in percutaneous needle biopsy • Study of vascular supply by Color Doppler

17. IMAGING OF SOFT TISSUE TUMOR • CT scan • Detecting calcification or ossification within the lesion • Evaluate lung metastases • CT guided needle biopsy • Arteriography • Less frequently used • Mapping of lesions in difficult anatomy location • Identifying normal anatomic variants before surgery • Preoperatively, to embolize hypervascular lesions

18. IMAGING OF SOFT TISSUE TUMOR • Bone scan • Technetium Tc 99m bone scan • Detects area of rapid bone turnover • Sensitive but not very specific, abnormal scan should be further studied with plain radiograph, CT and MRI • Part of staging

19. IMAGING OF SOFT TISSUE TUMOR • MRI • Replace role of CT and arteriography • Advantages • superior soft tissue contrast • multiplanar imaging • no ionizing radiation & the need for iodinated contrast agent • no artifact problem • General Roles • Accurate preoperative staging • Restriction of differential diagnosis • Assistance with biopsy placement • Monitoring response to neoadjuvant chemotherapy or radiotherapy • Identification of residual or recurrent tumor during postoperative period

20. IMAGING OF SOFT TISSUE TUMOR • MRI (cont) • Conventional T1 weighted and T2 weighted • T1 weighted differentiate the hyperintense fatty tissue with hypointense tumor • T2 weighted with or without fat suppression is the most appropriate sequence; tumor will be hyperintense

26. STAGING SYSTEM • Prognostic variables • Histologic grade • Tumor size • Tumor depth • Compartment status • Metastases

27. STAGING SYSTEM • SURGICAL STAGING SYSTEM (SSS) • Enneking staging system • American Joint Committee on Cancer (AJCC) • Cancer Staging Manual 5th Edition • Memorial Sloan Kettering Cancer Center (MSK)

28. STAGING SYSTEM • SURGICAL STAGING SYSTEM (Enneking)

29. Prognostic Factors • Histologic Grade (assessment of biological aggressiveness) • G0    • Histological benign • Well differentiated and low cell to matrix ratio • G1    • Low grade malignant • Few mitoses, moderate differentiation and local spread only • Have low risk of metastases • G2    • High grade malignancy • Frequent mitoses, poorly differentiated • High risk of metastases • Features of aggressive tumors: • Cellular atypia • Frequent mitoses • Extensive necrosis • Significant vascularity • Small amounts of immature matrix

30. Prognostic Factors

31. Prognostic Factors • Site (anatomic setting of the lesion) • T0 Intracapsular  • T1 Intracompartmental (e.g. cortical bone, joint capsule or fascia) • T2 Extracompartmental (spreads beyond 'fascial' plane without longitudinal containment)

32. Prognostic Factors

33. BIOPSY OF TUMORS • Simple ? Low Risk Procedure ? • The planning of the biopsy is technically demanding • All Biopsy carry extreme risk to patient’s limb and potentially to the patient’s life • Poorly planned biopsy can affect diagnostic accuracy and result in delay in diagnosis and treatment

34. BIOPSY OF TUMORS • Planning the biopsy • Basic understanding of diseases/tumors and an ability to generate differential diagnosis • The differential diagnosis determines the indications for biopsy • Knowledge of appropriate placement of limb salvage incisions for resection and reconstruction • Access to experienced musculoskeletal pathologist

35. BIOPSY OF TUMORS • Type of Biopsy • Closed Biopsy (Core Needle) • Open Biopsy • Incisional Biopsy • Excisional Biopsy • Primary Wide Excision

36. BIOPSY OF TUMORS

37. BIOPSY OF TUMORS

38. Biopsy Technique • Incisional Biopsy • Directly cutting into tumor to remove a sample without excising lesion • The entire field is excised en bloc with the major tumor mass at the time of definitive resection • Excisional Biopsy • Removing the entire lesion at the time of biopsy • Marginal excision • Primary Wide Excision • Entire lesion is excised while cutting through normal healthy tissue and leaving a margin of surrounding healthy tissue against the lesion

39. Biopsy TechniqueExcisional Biopsy • Indication • To obtain a large sample size • For benign non aggressive diagnosis, is the treatment of the lesion in single stage • Carry higher risk of extensive soft tissue & important structures contamination • Not for lesion which is suspiciously malignant or at high risk anatomical region

40. Biopsy TechniquePrimary Wide Excision Biopsy • Indication • High suspicious of malignancy • When the risk of contaminating major important structures with another form of biopsy outweighs the risks and functional and cosmetic deficits of excising the lesions primarily

41. Biopsy Procedure • Longitudinal Incision • Limb Salvage or Amputation incision • Surgical Instrument handling • Anybody fingers should not be placed directly into the wound • Soiled sponges • The surgical field should not be in continuity with other surgical field • Tourniquet, no exsanguinations

43. Biopsy Procedure (cont) • Direct approach, contaminating only one compartment, not through planes • Hemostasis • Vessels, nerves and tendons should not be exposed • Blunt retractors draping • Biopsies the peripheral portion with ellipse shaped cut • Cultures • Volume of 1 to 2 cm3 • Post biopsy hemostasis • Closure in layers • Small bite suturing • Light pressure bandaging • Immobilization and protection of weight bearing

44. OPTION OF DEFINITIVE MANAGEMENT CLINICAL AND RADIOLOGICAL DIAGNOSIS BIOPSY OBSERVE STAGING STUDIES ELIMINATION OF PRIMARY TUMOR NON SURGERY SURGERY RADIOTHERAPY CHEMOTHERAPY GENETIC IMMUNOLOGIC PROTEIN BASED COMBINATION OF SURGERY AND NON SURGERY

45. PRINCIPLES OF TUMOR SURGERY • INTRALESIONAL • Incomplete excisions, either gross or microscopic tumor remains ( MARGIN? ) • MARGINAL EXCISION • Resection at border between the tumor & the immediate adjacent tissues, leaving no tumor, as verified by both gross and microscopic inspection ( SATELLITE LESION? ) • WIDE EXCISION • Excision through normal tissue that is not reactive or edematous, as judged by preoperative MRI, intraoperative gross inspection and microscopic sections ( SKIP LESION? ) • RADICAL EXCISION • Wide excision based on anatomic barriers to tumor infiltration ( METASTATIC LESION?) ? COMPLETE REMOVAL AND RECURRANCE RATE

46. PRINCIPLES OF TUMOR SURGERY • TUMOR RESECTION STRATEGIES • COMPLETE RESECTION for CURE • INCOMPLETE RESECTION with CURE obtained from LOCAL ADJUVANT THERAPIES • PARTIAL RESECTION without the expectation of achieving cure (DEBULKING) • CURE means when no local or distant viable tumor cells remain after surgical resection • Tumor debulking is to eliminate a majority of the tumor with minimum of morbidity to prolong quality of life and to reduce or eliminate pain

47. PRINCIPLES OF TUMOR SURGERY • Meticulous attention to the isolation of clean and contaminated fields, instruments, and personnel • Minimize perioperative exposure to pathogens • IV antibiotic, antibiotic cement, antibiotic in irrigation medium • Allograft and Prosthetic components

48. PRINCIPLES OF TUMOR SURGERY • HIGH GRADE SARCOMA • The goal is to remove as much tumor to achieve cure while removing the least amount of healthy tissue as possible to preserve function • AMPUTATION versus Limb Salvage Surgery • No Significant Statistical Advantage in term of Local Recurrence • Following amputation 1 to 3% • Following limb salvage surgery <8% • Functional loss can be extreme in amputation group • Revision surgery rates for complications and revisions are considerably lower for amputation group

49. PRINCIPLES OF TUMOR SURGERY • HIGH GRADE SARCOMA • Superficial sarcoma of the trunk have better prognosis than deep axially located tumor • Deep axially located tumor like around the spine and pelvis • Usually present late and often large by the time the diagnosis is made • Do not routinely permit large volumes of normal surrounding tissue to be removed with the tumor

50. PRINCIPLES OF TUMOR SURGERY • HIGH GRADE SARCOMA • The more inflammatory, fast growing, & infiltrative the tumor, the wider the margin should be, & the more strongly preoperative radiation or chemotherapy is indicated • Final consideration is the patient’s personal wishes.