💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
Bone tumours and principles of limb salvage surgery
1. HYPERPLASIA, METAPLASIA, ANAPLASIAHYPERPLASIA, METAPLASIA, ANAPLASIA
NEOPLASIA, TNM CLASSIFICATION AND ITSNEOPLASIA, TNM CLASSIFICATION AND ITS
ORTHOPAEDIC APPLICATIONS, SURGICALORTHOPAEDIC APPLICATIONS, SURGICAL
CLASSIFICATION, HISTOLOGICCLASSIFICATION, HISTOLOGIC
CLASSIFICATION AND PRINCIPLES OF LIMBCLASSIFICATION AND PRINCIPLES OF LIMB
SALVAGE SURGERYSALVAGE SURGERY
Dr. Sushil PaudelDr. Sushil Paudel
2. NEOPLASIANEOPLASIA
A neoplasm is anA neoplasm is an
abnormal mass ofabnormal mass of
tissue, growth oftissue, growth of
which exceeds & iswhich exceeds & is
uncoordinated withuncoordinated with
that of the normalthat of the normal
tissues **tissues **
**Willis RA; The spread of tumours in the human body.
London, Butterworth & Co, 1952
3. HYPERPLASIAHYPERPLASIA
Increase in the number of cells in an organIncrease in the number of cells in an organ
or tissueor tissue
Physiological hyperplasiaPhysiological hyperplasia
Pathological hyperplasiaPathological hyperplasia
4. METAPLASIAMETAPLASIA
Reversible change in which one cell typeReversible change in which one cell type
(epithelial or mesenchymal) is replaced by(epithelial or mesenchymal) is replaced by
anotheranother
Epithelial metaplasiaEpithelial metaplasia
Connective tissue metaplasiaConnective tissue metaplasia
Eg; Myositis ossificansEg; Myositis ossificans
5. DIFFERENTIATION ANDDIFFERENTIATION AND
ANAPLASIAANAPLASIA
Anaplasia is loss of DifferentiationAnaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered N:C ratioAltered N:C ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells
6. DYSPLASIADYSPLASIA
Disordered growthDisordered growth
Loss in the uniformity of individual cells asLoss in the uniformity of individual cells as
well as loss in architectural orientationwell as loss in architectural orientation
8. HISTORYHISTORY
Dates back to 1920, origin of Bone SarcomaDates back to 1920, origin of Bone Sarcoma
Registry by Dr CodmanRegistry by Dr Codman
Dr Codman along with James Ewing andDr Codman along with James Ewing and
Bloodgod drew up in 1922, the first classificationBloodgod drew up in 1922, the first classification
of the Registryof the Registry
Efforts of many pathologists and oncologists hasEfforts of many pathologists and oncologists has
given shape to Revised WHO Histologicgiven shape to Revised WHO Histologic
Classification of Bone tumours in 1993**Classification of Bone tumours in 1993**
**Schajowicz etal,Cancer 1995 Mar
9. 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
10. 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
14. MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS
share the ability to form osteoid from theshare the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology, localisation,Takes into account etiology, localisation,
bone specific topography and histologybone specific topography and histology
18. IMAGINGIMAGING
Medullary and cortical bone destruction , aggressive periosteal reaction of the velvet
and sunburst types, soft tissue mass contains tumor bone.
27. MALIGNANT TUMOURSMALIGNANT TUMOURS
CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with
annular and comma shaped calcifications and
periosteal new bone formation
30. FIBROGENIC, FIBROOSSEOUS ANDFIBROGENIC, FIBROOSSEOUS AND
FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECT
AND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTIC
POLYOSTOTIC
MC CUNE ALBRIGHT SYNDROME
MAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA
(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
31. FIBROSARCOMA AND
MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets disease
Fibrous dysplasia
Bone infarct
Chronic sinuses of osteomyelitis
32. ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL
HISTIOCYTOSIS
Eusinophilic granuloma
Hand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
33. MALIGNANT LESIONSMALIGNANT LESIONS
EWINGS SARCOMAEWINGS SARCOMA
Diaphysis of long bonesDiaphysis of long bones
MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA
Non hodgkins lymphomaNon hodgkins lymphoma
Hodgkins lymphomaHodgkins lymphoma
permeative bone destruction
with an aggressive periosteal reaction
37. UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOUR
BENIGNBENIGN
20-40 yr, F>M20-40 yr, F>M
Epiphyseal region ofEpiphyseal region of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent, eccentric, expansive,
absence of reactive sclerosis
38. MISCELLANEOUS TUMORS ANDMISCELLANEOUS TUMORS AND
TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN
SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal, central, lack of periosteal reaction
39. ANEURYSMAL BONEANEURYSMAL BONE
CYSTCYST
<20 yr, F>M<20 yr, F>M
Metaphysis of long bonesMetaphysis of long bones
SOLID VARIANT OFSOLID VARIANT OF
ANEURSYMAL BONEANEURSYMAL BONE
CYSTCYST
Giant cell reparativeGiant cell reparative
granulomagranuloma
Radiolucent, eccentric, expansive,
butress of periosteal reaction
43. 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**
44. HISTORY AND CHANGINGHISTORY AND CHANGING
TRENDTREND
Eiselberg in 1897Eiselberg in 1897
LexerLexer 11stst
successful series of 6 patientssuccessful series of 6 patients
LexerLexer concept of using allografts in tumor surgeryconcept of using allografts in tumor surgery
(1907)(1907)
Major changes since 1970 with the advent of advancedMajor changes since 1970 with the advent of advanced
imaging, chemotherapy and radiotherapy, improvedimaging, 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
45. INDICATIONINDICATION
Every patient with tumor of the extremityEvery patient with tumor of the extremity
should be considered for limb salvage ifshould be considered for limb salvage if
the tumor can be removed with anthe tumor can be removed with an
adequate margin and the resulting limb isadequate margin and the resulting limb is
worth savingworth saving
No justification for limiting the limb salvageNo justification for limiting the limb salvage
process based only on the prognosisprocess based only on the prognosis
46. BARRIERS TO LIMBBARRIERS 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
47. Vascular involvement is not an absoluteVascular involvement is not an absolute
contraindication for limb salvage surgerycontraindication for limb salvage surgery
as vascular homografts can be used foras vascular homografts can be used for
reconstruction (bypass surgery) **reconstruction (bypass surgery) **
In selected cases limb salvage can beIn selected cases limb salvage can be
combined with metastatectomycombined with metastatectomy
**Faenza A et al, Transplant Proc 2005:37(6):2692-3**Faenza A et al, Transplant Proc 2005:37(6):2692-3
48. BoneBone
NervesNerves
VesselsVessels
Soft tissue envelopeSoft tissue envelope
If three of these key components areIf three of these key components are
involved, the limb salvage is probablyinvolved, the limb salvage is probably
not worth consideringnot worth considering
THREE STRIKE RULE
50. SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up – MultidisciplinaryWork up – Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
51. STAGINGSTAGING
Histogenic type of tumor
Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in formulating aThe most important step in formulating a
treatment plantreatment plan
52. RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the lesionDefine the anatomic extent of the lesion
MetastasisMetastasis
53. RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions
Location in boneLocation in bone
Type of destructionType of destruction
Soft tissue massSoft tissue mass
Matrix of tumourMatrix of tumour
55. MRIMRI
Evaluation of the intra-medullary extent ofEvaluation of the intra-medullary extent of
the tumorthe tumor
Soft tissue componentSoft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
56. ANGIOGRAPHYANGIOGRAPHY
Difficult anatomic locationDifficult anatomic location
Limb salvage surgery where someLimb salvage surgery where some
neurovascular bundle must be sacrificed andneurovascular bundle must be sacrificed and
reconstructedreconstructed
Micro vascular surgeryMicro vascular surgery
Intra-arterial chemotherapyIntra-arterial chemotherapy
Pre operative EmbolisationPre operative Embolisation
57. SCINTIGRAPHYSCINTIGRAPHY
Tech 99m MDPTech 99m MDP
Estimate the local intramedullary extentEstimate the local intramedullary extent
Screen for other skeletal areas ofScreen for other skeletal areas of
involvementinvolvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary & metastaticDifferentiation of primary & metastatic
lesions, benign & malignant cartilage lesionslesions, benign & malignant cartilage lesions
58. PET SCANPET SCAN
Effect ofEffect of
chemotherapychemotherapy
(Necrosis of tumor(Necrosis of tumor
mass)mass)
Investigation ofInvestigation of
choice for metastaticchoice for metastatic
lesions with unknownlesions with unknown
primary lesionprimary lesion
Residual tumorResidual tumor
Recurrence of tumorRecurrence of tumor
61. Work through muscle not anatomical plane
Drain in the line of incision
Oval window
62. RESTAGING AFTER PRE OPRESTAGING 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 patternsChanges in plain X-ray/CT and/or MRI patterns
of matrix appearanceof matrix appearance
PET scans are better than MRI & CT for depictingPET scans are better than MRI & CT for depicting
residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
63. PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue & muscle transferSoft tissue & muscle transfer
65. Exactly what constitutes an adequateExactly what constitutes an adequate
margin in any particular case remainsmargin in any particular case remains
controversialcontroversial
For high grade sarcomas, a wide margin isFor high grade sarcomas, a wide margin is
considered adequateconsidered adequate
In low grade tumors or in high gradeIn low grade tumors or in high grade
tumors where preoperative radiationtumors where preoperative radiation
therapy has been given, a marginaltherapy has been given, a marginal
margin may be adequate.margin may be adequate.
66. Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants & curetting
67. 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 boneBisphosphonates in Giant cell tumor of bone
68. Chemotherapy – Neoadjuvant or AdjuvantChemotherapy – Neoadjuvant or Adjuvant
RadiotherapyRadiotherapy
ImmunotherapyImmunotherapy
Specific – Active and PassiveSpecific – Active and Passive
Nonspecific – IFN and CSF’sNonspecific – IFN and CSF’s
70. ARTHRODESISARTHRODESIS
With acute docking and shorteningWith acute docking and shortening
With bone graftingWith bone grafting
AllograftAllograft
Autograft (fibula,iliac crest,ribs)Autograft (fibula,iliac crest,ribs)
Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNAL
Long ILN
Plating
EXTERNAL
Ilizarov
External fixator
Charnleys clamp
73. Advantages:Advantages:
Length can be adjustedLength can be adjusted
Biological soft tissueBiological soft tissue
healinghealing
Avoid the risks andAvoid the risks and
complications ofcomplications of
intramedullary fixation ofintramedullary fixation of
endoprosthesis.endoprosthesis.
Direct attachment ofDirect attachment of
remaining musculature.remaining musculature.
Disadvantages:Disadvantages:
Long healing timeLong healing time
Potential for transfer ofPotential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular surfaceNecessity of articular surface
size matchingsize matching
FractureFracture
InfectionInfection
Non-unionNon-union
75. VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT
Can heal in hostile environment (IrradiatedCan heal in hostile environment (Irradiated
tissue and active infection)tissue and active infection)
Addresses the complications such as hostAddresses the complications such as host
allograft nonunion and allograft fracture**allograft nonunion and allograft fracture**
**The Journal of Bone and Joint Surgery (American). 2008;90:93-100.
80. ALLOGRAFT PROSTHETICALLOGRAFT PROSTHETIC
COMPOSITECOMPOSITE
Allograft provides aAllograft provides a
source of bone stocksource of bone stock
& site for tendon& site for tendon
insertions, while theinsertions, while the
prosthesis provides aprosthesis provides a
reliable & stablereliable & stable
articulation & somearticulation & some
support for allograftsupport for allograft
81.
82. ROTATIONPLASTYROTATIONPLASTY
Amputation of the legAmputation of the leg
above the knee, lowerabove the knee, lower
leg and foot are rotatedleg and foot are rotated
180 degrees, tibia is180 degrees, tibia is
then fused to thethen fused to the
proximal femur. Theproximal femur. The
ankle now functions inankle now functions in
place of the knee jointplace of the knee joint
83. LIMB SALVAGE IN UPPERLIMB SALVAGE IN UPPER
EXTREMITYEXTREMITY
HANDHAND
WRIST – Arthrodesis or ReconstructionWRIST – Arthrodesis or Reconstruction
ELBOW – ReconstructionELBOW – Reconstruction
HUMERUS – Arthrodesis orHUMERUS – Arthrodesis or
ReconstructionReconstruction
SCAPULA - Scapulectomy orSCAPULA - Scapulectomy or
ReconstructionReconstruction
84. LIMB SALVAGE IN LOWERLIMB 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 orPELVIS – Resection and Arthrodesis or
ReconstructionReconstruction
85. LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty
Tibial turn upTibial turn up
( Turno plasty)( Turno plasty)
Modular ExpandableModular Expandable
prosthesis**prosthesis**
**Michael D Neel etal, Cancer control Aug 2001
86. CONCLUSIONCONCLUSION
Limb salvage has become accepted standardLimb 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 referralSuccess depends on prompt and early referral
by primary care doctor and on careful andby primary care doctor and on careful and
coordinated sequencing of events.coordinated sequencing of events.
Achieving a surgical margin that will ensure aAchieving 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