Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Musculoskeletal Tumours and X-ray T eaching BOMSA Teaching Event 23.5.23 David SkipseyTrauma and Orthopaedics • Top undergraduate topics • Open fractures • Compartment syndrome • Cauda equina syndrome • Hot swollen joint • Metastatic cord compression • Limping child (Septic hip, SUFE, DDH, Perthes) • Physiological response to trauma (Haemorrhagic shock) • GALS, REMS (Spine, shoulder, elbow, hand/wrist, hip, knee and foot/ankle) • Back pain • Hip/knee OA • Simple fractures (Hip, wrist, ankle) • Elective hands (Carpal tunnel, trigger finger, Dupuytrens) • MLA Map • Bone pain • Pathalogical fractureQuestion 1 • What is more common? • Primary malignant bone tumours • Primary malignant soft tissue tumoursAnswer 1 • What is more common? • Primary malignant bone tumours • Primary malignant soft tissue tumoursQuestion 2 • What is more common? • Primary malignant bone tumours • Metastatic bone diseaseAnswer 2 • What is more common? • Primary malignant bone tumours • Metastatic bone diseaseQuestion 3 • What 5 primary cancers most commonly metastasize to bone?Answer 3 • What 5 primary cancers most commonly metastasize to bone? • Prostate • Breast • Lung • Renal • Thyroid • Lead Kettle (Pb KTL) • P = Prostate • B = Breast • K = Kidney • T = Thyroid • L = LungQ5. Normal or Abnormal?Q 6. Normal or abnormal?Q 7. Normal or abnormal?Q 8. Normal or abnormal?Q 9. Normal or abnormal?Q 10. Benign or Malignant?Q 11. Benign or Malignant?Q 12. Benign or Malignant?Learning Objectives • Lump Assessment • X-ray assessment • Primary bone tumours • Benign • Malignant • Metastatic bone disease caseLump Assessment and Soft Tissue SarcomaApproach to Lumps-History Lump Patient • What, why, when where? • Lumps elsewhere • Pain • Red flags • Function • PMH cancer • Timing • Have they thought what it could be? • Change in size • Concern regarding appearance • Previous lumpsApproach to Lumps- Examination • Inspection • Site • Size • Shape • Symmetry • Skin • Scars • Palpation • Percussion • ?Auscultation/tranilumination • Lymphadenopathy • Neurovascular status • General examination-nearby jointsReferral for Suspected Sarcoma • Referral for urgent USS/Suspected sarcoma pathway • > 5cm • Increasing in size • Painful • Deep to fascia • Recurrent (Previous lump excised from same area) • Referral for urgent x-ray for suspected bone tumour • Unexplained bone pain or tenderness which is: • Persistent • Increasing • Not mechanical • Nocturnal or at rest • `Definitions • Tumour • Benign • Malignant • Grade • Low, intermediate or high • Stage • Malignant • Benign • Latent • Active • Aggressive Rare Many subtypes Late presentation and prognosis Diagnosis Soft Tissue CT CAP, MRI of lump, biopsy, MDT Sarcoma Treatment- Wide local excision and radiotherapy Haematogenous spread (Lung Mets) Whoops procedureX-ray interpretation • Which bone? 1. Where is the • Which part of bone? (Epiphysis, metaphysis or diaphysis) lesion? • Central or eccentric2. How extensive is the lesion? • How large? (Quantify) • Solitary or multiple • ?Skip lesions3. What is the lesion doing to the bone? • Zone of transition • Narrow • Wide • Geographic4. What is the bone doing in response? • Periosteal reactions • Codman’s triangle • Onion skinningtion • Bone forming • Fibrous-ground glass 5. Is there a matrix? • Cartilage-popcorn calcification • No specific matrix-lysis6. Is the cortex eroded? • Is there a disappearing cortex? • Endosteal scalloping7. Is there a soft tissue mass?Benign Bony Lesions Latent Active Aggressive • Enchondroma • Osteochondroma (Paeds) • Aneurysmal • Non-ossifying • Unicameral bone bone cyst fibroma cyst • Giant Cell • Osteochondroma tumour (Adult) • Osteoid osteoma • Fibrous dysplasia • Chondroblastoma • Eosinophillic • Osteoblastoma granuloma Narrow zone of transition Benign No periosteal reaction/soft Bone tissue mass Tumours- Latent diagnosed incidentallyoften Usually no treatment requiredEnchondroma • Derives from cartilage • Central/intramedullary, solitary • Long bones • Stippled calcification • Hands-most common • Lytic lesion • Rarely undergo malignant transformation to chondrosarcoma • Often incidental • Concerning features = endosteal scalloping • Symptom triggered Rx • Intralesional curettage +/- bone graft • Syndromes Non-ossifying fibroma • Very common in children • Asymptomatic • Eccentric metaphyseal lesion • margin and ”Soap bubblelerotic appearance” • Can cause pathological fracture • Rx = observation unless fracture or > 50%Osteochondroma (Adult) • Osteocartilagenous exostosis • Appear 2 decade • Stops growing at skeletal maturity • X-ray Appearances • Sessile • Pedunculated • Cortex of lesion is continuous with medullary cavity • Grow away from joints • Most common = Near Knee • Asymptomatic = Leave along • Symptomatic = Excision (Ideally after skeletal maturity) • Malignant transformation (Cartilage cap >2cm) • Multiple hereditary exostosis Benign Bone Active TumoursOsteochondroma (Paeds) • Consider active lesion in children • Potential for growth abnormalitiesUnicameral bone cyst • Solitary, cystic lesion • Metaphyseal • Narrow zone of transition, geographic, sclerotic rim • “Fallen leaf sign” • Children/adolescents • 50% prox humerus and 25% prox femur • S/S = pain or pathological fracture • Rcurettage and grafting.injections, • LL-?fixOsteoid osteoma/Osteoblastoma • Painful solitary diaphyseal lesions rd • 3 decade • Pain worse at night, eased with NSAIDs • XR/CT shows central nidus within sclerotic cortex (<1cm) • Usually resolve with time • Rx- radiofrequency ablation • Osteoblasmtoma- • Same but larger >1cm • Spine- need different RxBenign Bone Tumours Aggressive • Solitary, expansile, multiloculated cystic lesion • S/S = pain and swelling • Before 3 decade Aneurysmal bone cyst • XR- trabeculated, expansile lesion • Can be 2ndry to other lesion (Telangiectatic osteosarcoma) • Curettage and grafting • High recurrence rate (25-50%)Giant Cell T umour • Solitary locally aggressive lesion long bonesphysis/metaphysis of • XR- aggressive lytic lesion which complete cortical destructionimes and neo-cortex formation • Denosumab • Rx- Curretage and graft • Rarely metastasizeQuestion 13 • What is the most common primary malignant bone tumour? • Osteosarcoma • Chondrosarcoma • Myeloma • Ewing’s sarcoma • OsteochondromaAnswer 13 • What is the most common primary malignant bone tumour? • Osteosarcoma • Chondrosarcoma • Myeloma • Ewing’s sarcoma • OsteochondromaMalignant Bone Tumours Osteosarcoma Chondrosarcoma nd Ewing’s Sarcoma • 2 most common primary • Older people malignant bone tumour • Malignant tumour • Malignant small round blue • 20% of all primary bone tumors producing cartilaginous cell tumour children/adolescentsurs of matrix • Metadiaphyseal lesion • 2 peaks: • Phumerusfemur and • Most common bone tumour < • 10-19 10 and 2 most common 10- • 50-60 (Paget’s/Radiation) • Lucency in meta- 19 • Around knee 55% diaphyseal region • Chondroid lesions difficult • S/S = swelling and pain but • 70% no mets at presentation to assess on histology anaemia, feverand • Intramedullary/conventional leukocytosis mean infection 95%, periosteal and parosteal • Large variation grade 1-3 can be a mimic lower grade • Rx-only surgery • Ix- Raised ALP and LDH • XR- moth eaten lytic lesion • Rx- neoadjuvant chemotherapy with sheets of laminated and surgery periosteal bone (Onion skinning) • Ix inc bone scan and bone marrow biopsy to assess its involvement • Rx = Chemotherapy and surgery +/- radiotherapy • Limb salvage vs amputation Malignant Bone • Megaprosthesis/endoprosthesis Tumour Surgical • Big surgery, big complications Management • Children- expanding prosthesisCase • 68F retired nurse with 3- month history of increasing left hip pain • Managing to walk with stick and pain • Attended for X-ray • Any thoughts on X-rayCase-Question Is the x-ray normal or abnormal?Case-Answer • Abnormal but very subtle • Left femoral neck lesion] • ?left ilium lesionCase Contd • 3 days later, couldn’t get out of bed • Brought in by ambulance • What next?Case • History • Examination • Mechanism-fall or atraumatic • Leg is short and externally rotated • Timeline • PT/DP pulses intact • Preceeding pain and function • Sciatic and femoral nerves intact • PMH inc Cancer/steroids • Breast cancer 6 years ago-mastectomy and • CVS • Medications and allergies • RESP • SH • Abdo • Job • Neuro • Hobbies • Mobility aids/carers • Neck • Smoking hx • Alcohol hx • Breast • Illicit drug use • ?PR • SE • Weight loss • Fevers, sweats, rigors • Lumps • Full systemsInvestigation of Metastatic Lesion • History • Examination • Full length x-rays of bone • Bloods: • Myeloma screen • Tumour markers- PSA, CEA, CA125, TFTs • FBC, U&E, LFTs, CRP, Coag and bone profile • CT Chest/Abdo/Pelvis • ?MRI of affected bone • ?Bone scan • ?Biopsy • Common Metastatic • Pb KTL (Prostate, Breast, Renal, Thyroid and Lung) • Orthopaedics do see first presentation of cancer in pathological Bone Disease fractures • Never assume an isolated lesion is a metastasis • MDT approach • Biopsy where uncertain • Note- solitary renal mets can be cured • Site-spine most common • Surgical management • Assume the fracture won’t heal • Allow for immediate weight bearing • Durable treatment • Understand epidemiology of bone tumours • Aware of how to assess a soft tissue lump and referral of possible soft tissue tumour Conclusion • Able to appreciate benign versus malignant features on x-ray • Aware of investigation of a patient with potential metastatic bone diseaseQuestions?