tumor n.
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  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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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)

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

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

  18. 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)


  20. 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

  21. Prognostic Factors

  22. 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)

  23. Prognostic Factors

  24. 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

  25. 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

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



  29. 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

  30. 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

  31. 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

  32. 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

  33. 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


  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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.