Bone Lesion Approach.pptx

orthopaedics

1. What's Hot what's Not Bone lesion approach Dr Wazzan AL Juhani MD FRCSC Dr. M ajed Aalasbali

2. First Task 1- What is the age of the pt ? above 40 yr skeletal mature ( 20-40) Skeletal immature 2- Then Look at the X-ray Feature ? Benign looking Vs more aggressive feature Matrix 3- Location of the lesion . intra-articular epiphysis metaphysis diaphysis Then put in the spectrum . Benign Lesion Metz , vs primary bone tumor ( osteo sarcoma vs chondro , ewing ) Metabolic Bone disease , e.g brown tumor, paget osteomyelitis ( local Tumor )

3. Benign Vs Malignant

4. Immature vs Mature

5. What to read in X-Ray Site Size Matrix Pattern /margins incl. zone of transition Effect of the lesion on bone Reaction of bone to the lesion Soft tissue mass

6. site Which bone is affected (femur, radius,…) Where in the bone Diaphysis , metaphysis , epiphysis , or combination Central, eccentric, intracortical , surface

7. matrix Fibrous Cartilagenous stippled, arcs and rings Osseous cloud-like, dense

8. LESION EFFECT ON BONE Cortical thinning Lower grade, less aggressive Cortical expansion Low or high grade, tumor mimickers Cortical destruction High grade, aggressive

9. EFFECT BONE ON LESION Periosteal reaction Absent Mild – one layer, 1-4 mm thick, adjacent to cortex Major - >5mm, multilayered or lamellated “onion-skinning”, “hair-on-end”, “sunburst”

10. SOFT TISSUE MASS Soft Tissue Mass Absent Present

11. Biopsy Fine Needle Aspiration (FNA)  not typically used for sarcoma Core biopsy ( Tru -cut)    allow for tumor structural examination  cytologic and stromal elements of the tumor frequently used for sarcoma  Incisional biopsy small surgical incision carefully placed to access tumor without contamination of critical structures Excisional biopsy small, superficial soft tissue masses

12. NOT FOR BIOPSY An asymptomatic (latent) or symptomatic bone lesion (active) that appears entirely benign on imaging does not need a biopsy A soft tissue lesion that appears entirely benign on MRI ( lipoma , hemangioma ) does not need a biopsy When in doubt, it is safer to do a biopsy.

13. INDICATIONS FOR BIOPSY 1) Aggressive or malignant appearing bone or soft tissue lesions 2) For soft tissue lesions - >5cm, deep to fascia or overlying bone or neurovascular structures 3) Unclear diagnosis in symptomatic patient 4) Special situation - solitary bone lesion in a patient with a history of carcinoma

14. BEFORE BIOPSY CBC, platelets, coagulation screen Cross-sectional imaging – depicts local anatomy, solid areas of tumour Experienced musculoskeletal pathologist available

15. PRINCIPLES OF BIOPSY SKIN Avoid tenuous skin , Avoid transverse incision DEEP Through muscle , meticulous hemostasis , Avoid NV SAMPLE Ensure adequate diagnostic tissue , FROZEN –SECTION CLOSURE Tight muscle closure , drain at corner , compression dressing Send for C/S

16. For tumours without soft tissue mass , plan biopsy through area of maximal cortical weakening based on CT or MRI . For tumours or with soft tissue mass , biopsy soft tissue rather than creating hole in bone .

17. A- bone forming Tumor Benign lesion Osteoma Enostosis osteod osteoma Osteoblastoma Malignant Tumor Osteosarcoma Soft tissue ( Extraskeletal ) osteosarcoma .

18. B- Cartilage ( chondrogenic Lesion) Benign lesion Enchondroma perisoteal chondroma osteochndroma chondroblastoma chondromyxoid fibroma Malignant Lesion chondrosarcoma

19. Fibrous lesion Benign Lesion Fibrous cortical defect fibrous dysplasia osteofibrous Dysplasia Malignant Tumor MFH

20. Tumor like lesion Benign lesion GCT Simple bone cyst ABC Interosseous lipoma Malignant Tumor Adamantinoma chordoma

21. Intra-articular Tumor PVNS Synovial chondromatosis lipoma Arborescnes Synovial Hmeangioma

22. Above 40 yr DDX ( think of Metz) Metz MM lymphoma May be some thing else ( Sarcoma) Infection vs Brown Tumor

23. Big Five osteophilic Breast prostate Lung Kidney Thyroid Then think of GI , Melanoma

24. Metz some clue to DDX Most common is Breast + prostate Most common with Acral mets Lung Kidney cortical Mets : Lung , Kidney Most common to Bone + soft tissue Lung ,Kidney

25. Mets Most common site thoracolumbar spine sacrum PF pelvis ribs ,sternum PH

26. Approach Known Hx of cancer ? No Metastatic Work Up + Biopsy f/u MSK biopsy Principle . Yes solitary Lesion Metastatic Work up + Biopsy . Yes Multi focal Bone or Visceral Metz . Biopsy if not Proven before proven Metz treat accordingly .

27. Metz workup HX + E Breast , prostate & thyroid exam abdomen for organomegaly Lab ( Blood work) ,urine anaylsis Cbc anemia , thrombo - Ca ,Ph ,ALP ESR CRP infection ,MM - serum /urine EP INR , ptt coagulopathy - PSA Liver enzyme , - TSH

28. systemic work up Bone scan skeletal survey CT chest ,abdomen ,pelvis Bone marrow aspirate . Eg MM ,Lymphoma ,Ewing sarcoma ( by the medical oncolgist ) Local full length x-ray CT VS MRI

29. Goal of treatment Pain relief . Immediate mobilization . Immediate Rigid fixation durable fixation protect the entire Bone when feasible Radio therapy Reduce need for subsequent surgery . improve post-op Function Bisphosphonate

30. Case

31. Case 2

32. Brown Tumor pt looking well /bone scan Ca , ph , ALP PTH high Radiograph - osteopeina shoulder - sub periosteal ,sub chondral , Bone Hand resorpation spine sof tissue and chondral calcification skull

33. Multiple lesion

34. subperiosteal resorpation Mainly Radial aspect of the middle Phalanx

35. Soft tissue calcification subperiosteal resorpation Mainly Radial aspect of the middle Phalanx

36. Tunneling of cortices

37. Rugger jersey spine

38. Salt and Pepper Skull

39. Resorpation of the clavicle

40. Less than 40 more Of Benign Lesion Skeletal Immature ( Location ) UBC osteoid osteoma / osteoblastoma ABC non ossifying fibroma EG Osteomyelitis Fibrous dysplasia Skeletal Mature GCT Enchndroma infection ABC

41. Classification of Benign Bone Tumours Bone Cartilage Fibrous tissue Unknown tissue Cysts

42. Classification of Benign Bone Tumours Benign latent (enchondroma) Benign active (Fibrous dysplasia) Benign aggressive (GCT)

43. Presentation Incidental finding Mass- Painless or Painful Pain without mass Pathological Fracture

44. Based on Location and Characteristics First identify location- surface, peri-articular, epiphyseal, epiphyseal-metaphyseal, metaphyseal or diaphyseal then fit on spectrum

45. Surface

46. Surface

47. Surface

48. Surface

49. Epiphyseal

50. Epiphyseal

51. Apophyseal

52. Epiphyseal lesions Chondroblastoma Clear cell chondrosarcoma Osteomyelitis (occasionally)

53. Epiphyseal-Metaphyseal

54. Epiphyseal-Metaphyseal

55. Epiphyseal-Metaphyseal Benign aggressive lesions GCT ABC osteoblastoma

56. Metaphyseal

57. Metaphyseal

58. Metaphyseal

59. Metaphyseal lesions Enchondroma UBC NOF/fibrous cortical defect Chondromyxoid fibroma Osteosarcoma Chondrosarcoma

60. Diaphyseal

61. Diaphyseal

62. Diaphyseal

63. Diaphyseal

64. Diaphyseal lesions Osteoid osteoma Fibrous dysplasia Osteofibrous dysplasia Adamantinoma Ewing’s sarcoma

65. Treatment Observe /asymptomatic Radio frequency ablation curettage and Bone graft /cement extensive Curettage Resection and replace

66. Case

67. Case

68. curettage and Bone graft /cement

69. extensive Curettage

70. Resection and replace

71. And always remember infection

72. Sarcoma treatment Bone sarcoma Chemo + wide margin + chemo Except : low grade sarcoma E.g paraosteal OS Chondrosarcoma Soft tissue sarcoma Radiotherapy + wide margin