Tumor mega prosthesis

Surgical treatment of tumors in Orthopaedics. Principles of management and operative techniques.

1. Tumor Mega - ProsthesisTumor Mega - Prosthesis
Chairperson – Dr. S. K. SaidapurChairperson – Dr. S. K. Saidapur
Presenter – Dr. Srinath GuptaPresenter – Dr. Srinath Gupta

2. CLASSIFICATION OF BONE
TUMORS

3. HISTORYHISTORY

Dates back to 1920, origin of Bone Sarcoma Dates back to 1920, origin of Bone Sarcoma
Registry by Dr CodmanRegistry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and
Bloodgod drew up in 1922, the first classification Bloodgod drew up in 1922, the first classification
of the Registryof the Registry

Efforts of many pathologists and oncologists has Efforts of many pathologists and oncologists has
given shape to Revised WHO Histologic given shape to Revised WHO Histologic
Classification of Bone tumours in 1993** Classification of Bone tumours in 1993**
**Schajowicz etal,Cancer 1995 Mar

4. Primary tumour (T) TX: primary tumour cannot be assessed
T0: no evidence of primary tumour
T1: tumour ?????? 8 cm in greatest dimension
T2: tumour > 8 cm in greatest dimension
T3: discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: regional lymph node metastasis
Note: Regional node involvement is rare and cases in which nodal status is not
assessed either
clinically or pathologically could be considered N0 instead of NX or pNX.
Distant metastasis (M) MX: distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasis
M1a: lung
M1b: other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION

5. Translation table for ‘three’ and ‘four grade’ to ‘two grade’ (low vs. high grade)
system
TNM two grade system Three grade systems Four grade systems
Low grade Grade 1 Grade 1
Grade 2
High grade Grade 2
Grade 3 Grade 3
Grade 4
Note: Ewing sarcoma is classified as high grade.
Stage IA T1 N0,NX M0 Low grade
Stage IB T2 N0,NX M0 Low grade
Stage IIA T1 N0,NX M0 High grade
Stage IIB T2 N0,NX M0 High grade
Stage III T3 N0,NX M0 Any grade
Stage IVA Any T N0,NX M1a Any grade
Stage IVB Any T N1 Any M Any grade
Any T Any N M1b Any grade
HISTOPATHOLOGICAL GRADINGHISTOPATHOLOGICAL GRADING

6. Benign Benign



LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade, Stage IA-Low grade,
intracompartmentalintracompartmental

Stage IB-Low grade, Stage IB-Low grade,
extracompartmentalextracompartmental

Stage IIA-High grade, Stage IIA-High grade,
intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High
grade,extracompartmentalgrade,extracompartmental

Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING

7. WHO HISTOLOGICAL WHO HISTOLOGICAL
CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours

Cartilage tumoursCartilage tumours

Fibrogenic tumoursFibrogenic tumours

Round cell lesionsRound cell lesions

Giant cell tumour of boneGiant cell tumour of bone

Notochordal tumoursNotochordal tumours

Vascular tumoursVascular tumours

Smooth muscle tumoursSmooth muscle tumours

Lipogenic tumours Lipogenic tumours

Neural tumoursNeural tumours

Miscellaneous tumoursMiscellaneous tumours

Joint lesions Joint lesions
Each class is further divided into benign and malignantEach class is further divided into benign and malignant

8. PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE
SURGERYSURGERY

9. DEFINITIONDEFINITION

** HENRY DEGROOT et al, LIMB SALVAGE FOR EXTREMITY SARCOMAS** HENRY DEGROOT et al, LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish
removal of a malignant tumor and reconstruction of
the limb with an acceptable oncologic, functional, and
cosmetic result**

10. HISTORY AND CHANGING HISTORY AND CHANGING
TRENDTREND

Eiselberg in 1897Eiselberg in 1897

Lexer Lexer  1 1
stst
successful series of 6 patients successful series of 6 patients

Lexer Lexer  concept of using allografts in tumor surgery concept of using allografts in tumor surgery
(1907)(1907)

Major changes since 1970 with the advent of advanced Major changes since 1970 with the advent of advanced
imaging, chemotherapy and radiotherapy, improved imaging, chemotherapy and radiotherapy, improved
surgical techniquessurgical techniques

Limb salvage possible in up to 85% cases**. Limb salvage possible in up to 85% cases**.
**Bacci G, Picci 2, Pignatti G,etal **Bacci G, Picci 2, Pignatti G,etal

11. INDICATIONINDICATION

Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage
process based only on the prognosisprocess based only on the prognosis

12. BARRIERS TO LIMB BARRIERS TO LIMB
SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions

Major Neurovascular involvementMajor Neurovascular involvement

Displaced pathologic fractureDisplaced pathologic fracture

Fungating and infected tumorsFungating and infected tumors

Recurrence of malignant tumorsRecurrence of malignant tumors

Inability to afford chemotherapyInability to afford chemotherapy

13. 
Vascular involvement is not an absolute Vascular involvement is not an absolute
contraindication for limb salvage surgery contraindication for limb salvage surgery
as vascular homografts can be used for as vascular homografts can be used for
reconstruction (bypass surgery) **reconstruction (bypass surgery) **

In selected cases limb salvage can be In selected cases limb salvage can be
combined with metastatectomy combined with metastatectomy
**Faenza A et al, Transplant Proc 2005:37(6):2692-3**Faenza A et al, Transplant Proc 2005:37(6):2692-3

14. 
BoneBone

NervesNerves

VesselsVessels

Soft tissue envelopeSoft tissue envelope
If three of these key components are If three of these key components are
involved, the limb salvage is probably involved, the limb salvage is probably
not worth consideringnot worth considering
THREE STRIKE RULE

15. GOALGOAL

Painless limb Painless limb

Functional, tumor free limbFunctional, tumor free limb

Good psychological outcomeGood psychological outcome

16. SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up – MultidisciplinaryWork up – Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction

17. STAGINGSTAGING
Histogenic type of tumor
Local extent
Possibility of metastasis
Radiological stagingSurgical staging

The most important step in formulating a The most important step in formulating a
treatment plantreatment plan

18. RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the lesionDefine the anatomic extent of the lesion

MetastasisMetastasis

19. RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions

Location in boneLocation in bone

Type of destruction Type of destruction

Soft tissue massSoft tissue mass

Matrix of tumourMatrix of tumour

20. CT SCANCT SCAN

Evaluation of cortical penetrationEvaluation of cortical penetration

Osseous detailsOsseous details

Detecting pulmonary metastasisDetecting pulmonary metastasis

21. MRIMRI

Evaluation of the intra-medullary extent of Evaluation of the intra-medullary extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular
structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

22. ANGIOGRAPHYANGIOGRAPHY


Difficult anatomic locationDifficult anatomic location

Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed and neurovascular bundle must be sacrificed and
reconstructedreconstructed

Micro vascular surgery Micro vascular surgery

Intra-arterial chemotherapyIntra-arterial chemotherapy

Pre operative EmbolisationPre operative Embolisation

23. SCINTIGRAPHYSCINTIGRAPHY
Tech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary & metastatic Differentiation of primary & metastatic
lesions, benign & malignant cartilage lesionslesions, benign & malignant cartilage lesions

24. PET SCANPET SCAN

Effect of Effect of
chemotherapy chemotherapy
(Necrosis of tumor (Necrosis of tumor
mass)mass)

Investigation of Investigation of
choice for metastatic choice for metastatic
lesions with unknown lesions with unknown
primary lesionprimary lesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

25. SURGICAL STAGINGSURGICAL STAGING


FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSY
Accurate diagnosisAccurate diagnosis
Histological gradeHistological grade

26. PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tractLongitudinal incision

27. Work through muscle not anatomical plane
Oval window

28. RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP
ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response

¯¯ tumor volumetumor volume

¯¯ in angiographic vascularityin angiographic vascularity

Changes in plain X-ray/CT and/or MRI patterns Changes in plain X-ray/CT and/or MRI patterns
of matrix appearanceof matrix appearance
PET scans are better than MRI & CT for depicting PET scans are better than MRI & CT for depicting
residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

29. PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue & muscle transferSoft tissue & muscle transfer

30. RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS

IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection
(As described by Enneking)

31. 
Exactly what constitutes an adequate Exactly what constitutes an adequate
margin in any particular case remains margin in any particular case remains
controversialcontroversial

For high grade sarcomas, a wide margin is For high grade sarcomas, a wide margin is
considered adequate considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade
tumors where preoperative radiation tumors where preoperative radiation
therapy has been given, a marginal therapy has been given, a marginal
margin may be adequate. margin may be adequate.

32. Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants & curetting

33. SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents
CryosurgeryCryosurgery
Methacrylate augmentationMethacrylate augmentation
Nitrogen mustard, Merthiolate, HypertonicNitrogen mustard, Merthiolate, Hypertonic
salinesaline
Carbolic acidCarbolic acid
High concentration ethanolHigh concentration ethanol
Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

34. 
Chemotherapy – Neoadjuvant or AdjuvantChemotherapy – Neoadjuvant or Adjuvant

RadiotherapyRadiotherapy

Immunotherapy Immunotherapy
Specific – Active and PassiveSpecific – Active and Passive
Nonspecific – IFN and CSF’sNonspecific – IFN and CSF’s

35. RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis

Osteoarticular allograftOsteoarticular allograft

Endoprosthetic replacementEndoprosthetic replacement

Allograft Prosthetic compositeAllograft Prosthetic composite

RotationplastyRotationplasty

Autoclaved tumor bone Autoclaved tumor bone

36. ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS

Large metallic device designed to replace Large metallic device designed to replace
the excised length of bone and the the excised length of bone and the
adjacent jointadjacent joint

Modified hinge designModified hinge design

37. PRE – OPERATIVE WORK-UPPRE – OPERATIVE WORK-UP

39. Proximal femoral prosthesisSaddle prosthesis

40. Proximal humeral
prosthesis
Proximal tibial prosthesis Distal femoral
prosthesis

41. MATERIAL
1.Titanium
2.Cobalt – chromium - molybdeneum

45. TUMORS INVOLVING THE HIP
These patients may need excision of proximal femur and the
pelvis depending on the extent of involvement of the tumor.

51. Tumor involving proximal tibia
Resection of tibia with femur will be needed in these cases.

60. COMPLICATIONS
1.soft-tissue failure (type I),
2.aseptic loosening (type II),
3.structural failure (type III),
4.infection (type IV),
5.and tumor progression (type V)

61. ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC
COMPOSITECOMPOSITE

Allograft provides a Allograft provides a
source of bone stock source of bone stock
& site for tendon & site for tendon
insertions, while the insertions, while the
prosthesis provides a prosthesis provides a
reliable & stable reliable & stable
articulation & some articulation & some
support for allograft support for allograft

63. LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER
EXTREMITYEXTREMITY

HANDHAND

WRIST – Arthrodesis or ReconstructionWRIST – Arthrodesis or Reconstruction

ELBOW – ReconstructionELBOW – Reconstruction

HUMERUS – Arthrodesis or HUMERUS – Arthrodesis or
ReconstructionReconstruction

SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction

64. LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER
EXTREMITYEXTREMITY

ANKLE – Arthrodesis or ReconstructionANKLE – Arthrodesis or Reconstruction

KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction

FEMUR – Arthrodesis or ReconstructionFEMUR – Arthrodesis or Reconstruction

PELVIS – Resection and Arthrodesis or PELVIS – Resection and Arthrodesis or
ReconstructionReconstruction

65. LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty

Tibial turn upTibial turn up
( Turno plasty)( Turno plasty)

Modular Expandable Modular Expandable
prosthesis**prosthesis**
**Michael D Neel etal, Cancer control Aug 2001

66. CONCLUSIONCONCLUSION

Limb salvage has become accepted standard Limb salvage has become accepted standard
care of the patients with malignant bone tumorscare of the patients with malignant bone tumors

Success depends on prompt and early referral Success depends on prompt and early referral
by primary care doctor and on careful and by primary care doctor and on careful and
coordinated sequencing of events.coordinated sequencing of events.

Achieving a surgical margin that will ensure a Achieving a surgical margin that will ensure a
low rate of local recurrence is paramount. low rate of local recurrence is paramount.

Multidisciplinary approach is requiredMultidisciplinary approach is required