lec 18. Malignant Tumors

benign vs malignant

Age Distribution for bone cancer —peaks?

highest between 13 and 18 years

where is bone cancer mostly likely to be found?

central axis or long bones

Sarcoma Cellular Genesis/ Histology

Osteosarcoma Clinical Presentation

what do we see in primary?

what do we see on plain films?

Painful swelling around the knee (and sometime humerus),

• RARE: joint effusion or ROM problems

Night pain and limping

Firm/soft mass fixed to underlying bone

Serum alkaline phosphatase (bone fraction) elevated

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Osteosarcoma Clinical Presentation

secondary usually affects what age group and previous of what disease?

Usually in individuals > 40

Area of previous Paget’s or radiotherapy

Osteosarcoma — PROGNOSIS STATS?

~20% survived 5 years before chemotherapy era

60-70% five-year survival currently

Limb-sparing in 80%+ currently

what are the main Long term morbidities from chemotherapy (3)

1. Heart disease

2. Second cancers

3. Early menopause and infertility

Risk Factors Osteosarcoma

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Osteosarcoma

CASE STUDY: 15 YO MALE, KNEE PAIN 

15-year-old African American male notices pain in his left knee during gym class

Pain is associated with redness, warmth, tenderness and swelling

• Pain is worse at night

• ROM of his knee is normal and not tender

RICE (Rest, Ice, Compression, Elevation) is employed w/ some improvement

Over the next several days he begins to limp and have progressively more pain and swelling

• A mass is palpable in the lateral aspect of the distal femur

He sees the school nurse who recommends he see a physician

His mother had breast cancer at age 33

You order a plain film and MRI

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WHAT DO YOU DO FIRST (after work up)?

DX?

TREATMENT? — long term effects??

refer him immediately to an orthopedic (Ped) oncologist

An orthopedic surgeon trained in removal of tumors and reconstructive surgery

---

tx:

• referred to a pediatric oncologist

  • to begin neoadjuvant (before surgery) chemotherapy {to try and select him into limb sparing}

  • He begins treatment with cisplatin/Adriamycin and high dose methotrexate [Chemotherapy]

• After several weeks limb-sparing surgery is performed

OUTCOME: 5 years later he is doing well without recurrence

CASE STUDY: 15 YO MALE, KNEE PAIN 

15-year-old African American male notices pain in his left knee during gym class

Pain is associated with redness, warmth, tenderness and swelling

• Pain is worse at night

• ROM of his knee is normal and not tender

RICE (Rest, Ice, Compression, Elevation) is employed w/ some improvement

Over the next several days he begins to limp and have progressively more pain and swelling

• A mass is palpable in the lateral aspect of the distal femur

He sees the school nurse who recommends he see a physician

His mother had breast cancer at age 33

---

WHATS YOUR WORKUP?

1. Radiographic studies —> possible osteosarcoma

2. MRI shows neurovascular structures involved – precluding (Limb sparing) surgery

3. CT chest shows no lung metastases

4. Bone scan shows no skip lesions

5. Orthopedic oncology does an open biopsy

labs: Alkaline phosphatase is elevated

Presents similar to osteosarcoma

Pain and constitutional symptoms (mimics osteomyelitis)

Metastatic disease in 25% at presentation —> Lungs, Bone, Bone marrow

Ewing’s Sarcoma

• (more common in white people)

“Onion Skinning”

is seen in?

Plain film Ewing’s Sarcoma

Ewing’s Sarcoma

CASE 2: 19YO F, PAIN IN FOOT

HISTORY:

• 19-year-old  white female college student has pain in her foot presents to student health with small nodule seen over her metatarsal on the plantar side. Diagnosed with plantar fasciitis and given stretching exercises.

• Pain worsens, especially at night

• Develops low grade fevers, malaise and anorexia

• Returns to student health for further evaluation

• Plantar nodule is larger(enlarged quickly) and tender to touch

• No purulence is expressed, nor is there lymphadenitis

• Temperature is normal

workup:

• No recent trauma, No neurologic diseases

• Individuals with neuropathy cannot feel trauma/puncture wounds as well

• Xray's show moth eaten appearance to 2nd metatarsal

• MRI shows possible osteomyelitis

• Referral to orthopedic surgeon is made

imaging:

biopsy:

• Area of radiographic abnormality is curetted

• Wound Culture is negative

• Pathology shows Ewing’s sarcoma

• Serum lactate dehydrogenase (LDH) is high

TREATMENT:

She undergoes radiation to the site

• Pain improves

• F/U films show remission

• Staging CT Chest is negative for metastatic disease

• Bone scan is negative for metastatic disease

OUTCOME:

• She is lost to follow up for 2-3 years

• After graduation she develops dry cough and progressive dyspnea

• She also has progressive back pain

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She presents to urgent care and sees you

What tests would you order?

To whom would you refer her?

1st —> imaging

treatment:

top 3 places Distribution Chondrosarcoma

is located at?

pelvis > femur > shoulder

Epidemiology (Chondrosarcoma)

Slight male to female predominance

Children fare worse than adults

Peripheral lesions lower grade than central

5-year survival is ~50%

• Tumor grade has largest impact on survival (stages)

50% of chondrosacarcomas are in what age group?

>40 years

what is this tumor?

Pain is related to location of mass lesion, typically in the shoulder

Previous site of enchondroma

Suspect if tumor involves shoulder/sternum**

Rapid expansion suggests higher grade or de-differentiation(=malignant transformation)

Chondrosarcoma

case 3

history:

image

result:

• You refer him to an orthopedic oncologist

• Needle biopsy (diagnostic) confirms suspected chondrosarcoma

• Humerus is resected and replaced with titanium implant

images Evaluation of Bone Malignancies

x rays are for

Anterior-Posterior and orthogonal views

images Evaluation of Bone Malignancies

CT is used for?

Small cortical lesions

Lung Windows (metastases)

images Evaluation of Bone Malignancies

Angiogram is used for?

Used to image vascular structures

Helps determine resect ability

images Evaluation of Bone Malignancies

Magnetic Resonance (MRI) used for

Gold standard for work up

Soft tissue and bony structures

Neurovascular bundle à “resect ability”

images Evaluation of Bone Malignancies

Bone Scintigraphy (Scan) used for?

“Skip” Metastases

Determines margins

Misses –lytic lesions

gold standard image for bone cancer

MRI

General Treatment Principles for bone cancer

try to save the limb

• Need good margins

• Neoadjuvant chemotherapy +/ -radiation therapy, if primary resection difficult

have a diverse team

• idisciplinary and tertiary/university-based team

• Surgeons, Radiation Oncologists, and Medical Oncologists

• Physical Therapy/Occupational Therapy (PT/OT)

what type of reconstruction is this?

Rotationplasty

what type of reconstruction is this?

Endoprosthesis

what type of reconstruction is this?

Allograft

3 forms of reconstruction are?

treatment

Generally, radio-resistant & Chemo-sensitive

Osteosarcoma

treatment

Radio- and chemo-sensitive

Ewing’s sarcoma

treatment

Radio- and chemo-resistant typically

Chondrosarcoma

Axial (axial skeleton) lesions problematic to resect with __________?

• Intraoperative Radiation Therapy

• Proton beam therapy

good margins

Less than 1% of malignancies involve mesenchymal tissue

Over 50 histopathologic subtypes

75% involve the limbs

Can originate from muscular, vascular, adipocytic (fat), or other connective tissue elements

examples:

• Myosarcoma

• Angiosarcoma

• Liposarcoma

• Rhabdomyosarcoma

Soft Tissue Sarcoma

case 4

history:

PE:

RESULT?

treatment:

case 5

history :

image:

DX?

case 6

history:

work up:

DX?

cancer stages :

stage 0 -?

stage 1- ?

stage 2 -?

stage 3 -?

stage 4 -?

for RMS

Epidemiology:

40% of soft tissue sarcomas in children <5 yo

Clinical presentation/Staging:

May arise in any part of the body, most commonly the extremities and trunk; metastatic spread to lungs, bone, nodes

Prognosis:

depends on tumor type, metastasis, age, extent of resection (Group), tumor size, and grade

Treatment: Surgery, XRT for residual, +/- Chemotherapy

Group I; observe unless grade 3 and > 5 cm, then consider XRT and/or chemotherapy (Dox + Ifos)

Group II; XRT alone unless grade 3 and/or > 5 cm, then consider chemotherapy (Dox + Ifos)

Group III-IV or grade 3 and > 5 cm any group; chemotherapy (Dox + Ifos), RT, delayed surgery

Non-RHABDOMYOSARCOMA SOFT TISSUE SARCOMA (NRSTS)

case 7

history