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Ok. Hi guys. Welcome to today's session, which is the part of Med's a doctor's guide series. For those that don't know. Medipap is an international non for profit organization which aims to bridge the gap between medical professionals and medical students globally. Um Today's talk, which I mentioned is part of our a doctor's guide series and it features um Cristiana who's an ST six trauma and orthopedic registrar currently based in London, the UCLH rotation. She has special interests which include global trauma and sports medicine, exercise and health and has completed a six month placement in the Sarcoma firm at the Royal National orthopedic Hospital stall. So without further ado, I'm gonna hand things over to Christina who will take us through a wonderful presentation. Thank you. Um So, hi, everyone. I sorry that my camera isn't working, but it's fine. You have to just have my voice instead. Um Thank you for showing up. This shouldn't be a particularly long presentation. Um It's very niche. So I'm talking about orthopedic oncology. I'm not a orthopedic um oncology specialist by any means, but I have spent six months um in the Sarcoma unit. So I will hopefully be able to answer any questions that you have. Um, some of this is um on the job information, um, how to deal with a suspected, um, malignant bone lesion as a new doctor. And then some of it is a bit more advanced, the kind of things that you get asked in your FCS examination. So in your final exams to become an orthopedic consultant. So don't worry if, um, it feels a bit advanced for you, you're not expected to know this level. But if you have a general understanding of this, then all of it will seem a lot easier to you. And if some of you are going to have this in your medical school exams, um then hopefully it's useful revision as well. Um So if we start um go to the next slide, please, um I know there are polls on this, but I don't know if you can unmute yourselves and ask questions, but I'm more than happy for any questions during the talk. So feel free to just um yeah, to interrupt and ask questions. Um So I'm going to be introducing the topic. We're gonna go through um the red flags what to look out for if a patient presents. Um And you're concerned about an um a bone lesion, pacifying bone lesions, how to stage and grade them, how to interpret different x-rays and the principles of biopsy. Next, please. So, orthopedic oncology covers any um malignancy of the bone and soft tissue within the spine and the extremities. So just because we're orthopedic surgeons, bone surgeons doesn't mean that we manage all bones of the body. So um above the head and neck, that will go to a different team, the thorax that will go to a different team. So we're mostly talking about lesions within the arms, the legs, the pelvis and the spine. Um there are primary bone lesions which means that they arise within the bone. And then there are secondary bone lesions which are metastatic. So they're carcinomas or cancers which have spread from other organs into the bone. So it's more common for us to see um in a normal hospital, metastatic lesions in the bone because they're much more um common than primary bone lesions. Next, please. So there are certain risk factors. Um If we just go back. Yeah. Um for someone to present with a primary bone tumor, um which we've already said is very rare. But the risk factors include previous radiotherapy, having a previous primary bone cancer which may have been treated, having Paget's disease of the bone, any cancer in childhood, um genetic abnormalities and then in some cases, benign bone lesions which can transform to malignant lesions. Next, please. So the most common sites for metastases are the lung, liver and the bone is third. So it's a common place for metastases to spread and within um the bone, the most common sites to find metastases is the spine followed by the proximal femur, followed by the humerus. So, the um disadvantage of having mets in the um skeleton is that that's an area of stress and sorry or weakness in the bone um which can lead to pathological fracture. So, a pathological fracture is basically a fracture or a break in the bone um which is through a abnormal section of bone. So that can be if it's cancer or it can be in an osteoporotic or osteopenic bone or any bone, which is abnormal with pathological fractures. 90% of those require surgical management and we'll talk about that a bit after um the most common carcinomas that spread to the bone are the breast, lung, thyroid renal and prostate and these spread through the bloodstream. So, hematological spread. So, next, please. So a patient presents to the emergency department and there's a suspicion of a bone lesion. Uh The first thing that you're going to do is take a full history um And that's the answer in your exams and that's the answer for anything. So you wanna take a full history and examination and your history is gonna occlu include any of those risk factors that we've just spoken about. So, any previous history of cancer, um any cancers which run in the family, any previous treatments such as radiotherapy, et cetera, then you're going to examine the patient and you're going to feel the bone, see if there's any tenderness, um feel around the joint, look for any lumps or bumps, any skin changes because uh believe it or not, some patients present late and the tumor is already fungating through the skin. Uh You're going to take appropriate imaging. So that will include x-rays of the bone, which is involved and you want full length view. So if you're suspecting a lesion in the femur, you don't just want a section of the femur, you want to be able to see the hip and the knee as well. Um You're going to take a CT chest abdo pelvis. So you're looking for any either primary lesions. So primary lung lesion which may have metastasized um to your femur, for example, or um to rule out any mets from the primary bone lesion to the um other organs, bone scan can show other lesions within the skeleton. And there are specific blood tests that you can do looking for specific um tumor markers and also um generally looking at the hemoglobin because there are tumors which bleed. Um and there's anemia of chronic disease, looking at um the white cells because one of the differentials is infection, et cetera. Next slide, please. Um OK, so there are red flags and there are symptoms which you're going to look for in the history that you're taking. So pain in the bone or in the joint and specifically night pain, that's a red flag. So if the patient tells you that the pain causes them to wake at night, then you're gonna be more concerned neurological deficit. So, if they've got a metastasis or even a primary tumor, um which is compressing the spinal cord, then that's an emergency hypercalcemia. So, raised calcium, um which is a um known phenomenon in malignancy. And this can um cause confusion, muscle weakness, excessive thirst or excessive urination, feeling sick, vomiting, being very dehydrated, any bony or soft tissue swelling or masses that we've um already discussed. And you're gonna want to really describe the size, the shape, the contour, the overlying skin. Um and all those other features that we use to describe masses, any pathological fractures. So, um if you've got an x-ray showing that there's a fracture through a part of the bone, which doesn't look quite normal. That's a red flag because you're not sure whether it's a metastasis or primary bone lesion. But again, it could be infection, it could be osteopenia, osteoporosis, and then any systemic symptoms such as weight loss, night sweats, fevers, which you would ask about anyway. Um and may signify a malignant process or may signify something like lymphoma, um which is another differential in our list. Next, please. So your differential diagnosis for a patient who presents um with an x-ray or a mass um in a limb, um showing a, a lesion in the limb would be a benign bone lesion such as a Cyst Osteomyelitis or infection in the bone or a stress fracture and a stress fracture is where the bone has become weakened. Um usually by repetitive stresses such as in athletes or um in soldiers who walk for miles. Um Next please. So I've touched on this already. So imaging x-rays will be the first thing that you get. And there are certain features within an x-ray which may point towards um specific type of lesions. So, lytic lesions more common from lung, thyroid and renal metastases, sclerotic lesions. So, that's thickened cortex. Um are more common in breast and prostate uh metastases and then some lesions show mixed patterns. Um You can get a bone scan, skeletal scan, as we said and um most likely it will pick up hot spots where there are other metastases or lesions in the bone. But there are some um diseases which actually show cold lesions and that's myeloma and thyroid cancer. Next, please. So the blood test that you'll order so full blood count, this includes hemoglobin, white cell count and differential. Um And we've already discussed why you might need that. Also, if you're potentially preparing a patient for theater, then you'll need to know their hemoglobin um preop as well. ESRCRP. It is most likely to be raised in a cancerous process anyway, because they're markers of inflammation, but they're also useful um for ruling out infection um and also myeloma LFTs. So, liver function tests again, this can maybe let us know if there's any liver mets or if there's a liver primary. If there's Paget's disease, thyroid function, test, self-explanatory um use an ease again. Um Look at renal function, especially if you're taking a patient to theater bone profile, including calcium. And we've already touched on hypercalcemia psa A marker of prostate cancer, LDH A marker of lymphoma. And then you'll complete your myeloma screen with serum and urine protein electrophoresis. And this is something actually that you need to um perform on any patient where you have um a suspicion of cancer. Next, please. So, in orthopedics, we have something called the mole score and this um helps inform us when we've got a patient who's got a lesion in the bone um in the arm or the leg or the pelvis. And we're concerned about pathological fracture. So I already said that 90% of pathological fractures require surgery and that's because it's pathological bone. So it's abnormal bone and it's got much less potential for healing itself. Um So it's where some fractures you'd be able to manage um just in a plaster or conservatively in healthy normal bone in um pathological bone. 90% will require surgical intervention. And this is most commonly um an intramedullary nail. So a metal rod which is passed through the bone in order to stabilize it either side. So the mole score, um there's four different criteria and for each criteria, there's a grade of 12 or three and it talks about site um of the lesion So this is looking at x-rays. Um And Morrell himself was a radiologist. So, um site of the lesion, whether it's in the upper limb, the lower limb Perich Perich Ander means around the greater or lesser trochanter, which is um in your sort of elderly ladies where you get your um, hip fractures and it scores the highest because that's an area where you're weight bearing the most. Um So there's a greater risk of fracture there, whether it's painful and how, how the pain is. So, whether it's mild, moderate or functional and functional means with any sort of activity lesion, whether it's blastic or sclerotic, whether it's mixed and whether it's lytic and lytic scores the highest because the cortices are thinned out, um which means the bone is weaker and more likely to fracture and then size. So size is expressed um as a fraction of the cortical thickness. So that can be less than a third, one third to two thirds or over a third and you add up the scores and a score of eight or more suggest that the patient should have prophylactic fixation. If they've scored less than eight, then it's possibly something you can monitor, but that will require an MDT discussion anyway. Um Hope you're all following and I'm not going too fast if you do have any questions or comments, just put them in the um in the message box. Um Next slide. So there are various um management options um for different types of lesions and if we're talking about metastatic bone lesions, um then the options are medical um surgical or palliative. So, medical management includes bisphosphonates and denosumab. And these have been shown to reduce the rates of skeletal events. So, sort of um strengthening the bone radiation, which is mostly for pain and local control of the tumor chemotherapy or hormone therapy. Um and that depends on the um primary bone tumor and its sensitivity to chemo um and hormone therapy because not all cancers are susceptive to this um and surgery. So, I've already mentioned prophylactic na nailing or stabilization that can be um used as part of um further therapy where you also have radiotherapy plus minus embolization um which would be performed by the interventional radiologists in order to reduce bleeding risk in renal cell carcinoma and thyroid cancer. Buzzwords are NDT. So these um patients are always managed by a multidisciplinary team and that includes orthopedic surgeons, um radiologists, specialist nurses, oncologists. Um and depending on where the cancer is from that team specialty and the C team. So that's the cancer of unknown primary. So if the patients presenting with a possible metastasis or a new lesion, and we're not sure if it's a primary bone lesion or a metastasis, every hospital should have a, a cancer of unknown primary team where they oversee all the investigations for that patient. Next, please. So primary bone tumors are very rare. They're less than 1% of all cancer cases, secondary bone tumors are much more common. And in terms of the most common primary bone tumor, that's multiple myeloma, but that's actually a hematological um malignancy and it's not a orthopedic um uh malignancy next, please. So in terms of classifying um primary bone tumors, so we've moved away from metastases. Now, there's the World Health Organization. This isn't something that you need to know, but it helps to kind of understand the different types of lesions that we talk about. Each. Bone tumor is classified based on its similarity to the normal adult tissue. So, in bone, there are various different types of cells and when these become um cancerous, then the way that we classify the tumor or the cancer is based on its original type of cell. So the most recent updated w calcification integrates the biological behavior in each subcategory. So it kind of gives you an indication of how this tumor or cancer is going to behave. Then um the tumors are further subdivided as benign intermediate, whether they're locally aggressive or rarely metastasizing and malignant. And this is important because it helps us understand how long we need to monitor the patients for. Um especially if we've decided not to operate on them because they've got a low grade or a benign um lesion. Next, please. Yeah. So we'll talk about some of the specific types of um orthopedic bone tumors, but this is really um, quite advanced and it's not necessarily something you need to know, but it's interesting, it's probably going to come up in some of your medical school exams. Um, and if you're already, um, a doctor, sorry, I don't know what grade you all are. Um, then it's, it's good to be able to make a rough diagnosis even though the diagnosis are all made by the MDT. So chondrosarcoma is actually the most common primary bone cancer in adults. Um So chond means arising from cartilage, sarcoma, um signifies that it's a malignant tumor because you can have osteochondroma, that's a benign um tumor of the cartilage as well. So it's talking about chondrosarcoma. Here most commonly arises in the long bones, the pelvis and the ribs and on x-ray, it's got this popcorn appearance. As you can see its treatment is excision and there's no point um trying to treat this with chemo or radiotherapy because it's not shown to have any benefit. Next slide please. Osteosarcoma is the most common primary malignant bone tumor in Children and young adults. And it's got a biphasic incidence which means it commonly presents um in age groups 15 to 19 and then again, later on in life, 70 to 89. Um that's important to know not only for your um exams because if you have MC Qs or extended matching questions, if they give a particular age, then you can kind of think what's the most common in this age group because common things are common and most likely the right answer will be something that's obvious. But also if you've got a patient presenting to the emergency department of a particular age, you'll be able to think about what's the most common lesion likely to be. Um, this is common along, um, found in long bones and around the knee. And if you can see on the x-ray, it's got this sunray spiculations, um and Codman triangle. So the spiculations shown on the left and the Codman, you can't really see it. It's on the right, but it's basically elevation of the periosteum treatment is surgery and chemotherapy. Next slide, please. Ewing sarcoma. So it's the second most common primary malignant bone tumor in Children and young adults most commonly ages 10 to 20 more often found in caucasians than black or Chinese people commonly found in the long bones, the pelvis, the ribs and the spine on x-ray. There's an onion skin appearance um which you can't really see from the picture here. Um But that is a buzzword for your um exam questions and treatment for. This is chemotherapy surgery and radiotherapy. Next slide, please. So how do you measure the prognosis? So, as an orthopedic surgeon, it's not necessarily something that you're going to be expected to do. But if you're treating these patients, you should know about it. Um oncologists um will be involved in these cases most commonly for the patients which can be treated with chemo and radiotherapy. So there are a number of different variables to take into consideration the overall stage of the disease. And that means the size and the spread, the presence of any metastases. So that spread any skip lesion. So that's when um there's one lesion, for example, proximal and one lesion distal with normal bone in between the histological grade. So the appearance of the cells under the microscope and the actual size of the tumor next days. So in terms of staging, there are two commonly used staging systems. Again, this is not something you necessarily need to know, but it's something of interest, the MST S or aching system, uh which is more useful for orthopedic surgeons. Um and the AJ CC staging system and the stage of the tumor di dictates the extent of the surgical resection and margin. Um So, in the MDT meetings, when we're planning any surgery, um knowing the staging will help us determine um how much tumor we need to remove. So, of course, if we're planning to remove a tumor, we want to remove all of the tumor, but it also tells us how much of a margin we need to leave. So that means how much healthy skin we need to take off around the tumor as a whole. Um Next slide, please. So this is just um a table showing that MST S or um Anna King staging system for malignant tumors. Um And stages are 1 to 3. And um it's based on the grade. So whether it's low grade, high grade or metastatic, so low grade basically means it means a tumor which isn't really changing particularly quickly. Um And is unlikely to metastasize versus a high grade where the cells are really atypical. And it's got much greater potential of metastasizing the size, whether it's within a compartment, outside a compartment and whether there are any metastases next, please. So the MST S tumor grading um is based on the percentage of atypical cells. Um We've already gone through what low grade and high grade means and, but this just shows some examples of those and sometimes there's an intermediate grade. So that means that it doesn't fall into either the um high or low grade category. And it's got an unpredictable biological behavior. If you remember how rare orthopedic um tumors or bone tumors are, sometimes there's just not enough evidence um for us to be able to say um what the grade is or how a particular tumor will behave. And that's more reason to continue to monitor next, please. So this is the other staging system. It's the AJC C. Um And this says the American Joint Committee for Cancer. Um and this is stage 1 to 4 and the grade again can be low or high grade. They talk about sizes of the tumor. So less than eight centimeters or more than eight centimeters. And they also describe any skipped lesions, how deep the tumor has invaded, whether it's superficial, so above the fascia or deep to the fascia, whether there's any nodal involvement, whether there's any metastases. And it also gives us an idea of five year survival. So, for example, stage one, a low grade tumor which is smaller than eight centimeters with no nodes or mets. Um And they predict a 98% 5 year survival. In contrast, the four b um where there's metastasis, which have gone anywhere else other than the lung and there are nodes present automatically, that's 30% 5 year survival. Next, please. So, in terms of prognosis, um again, I've already touched on that. Um So we can go to the next slide. So when you're interpreting an x-ray for a bone lesion, you want to have a systematic approach and that's like any x-ray that you'll interpret, for example, chest x-ray abso x-ray. So you want to look at the age of the patient, we're going to describe the zone of transition and I'll explain that next, any periosteal reaction. So um the layer on top of the cortex, the periosteum, whether that's involved or reacting cortical destruction, um whether the lesion has breached the cortex and it started to eat away at it and the location, whether it's in the epiphysis, the metastasis or the diaphysis, whether it's in the center or on the outside of the bone, what type of matrix it is So whether it's formed from um cartilage or bone and whether there are other lesions, whether it's polyostotic. Next, please. So, again, important determinants. Um The of what we're looking for on x-ray, the morphology of the bone lesion, whether it's well defined, whether it's cutting into the bone or whether it's sclerotic, the age of the patient and in patients who are over 40 mets and multiple myeloma are the most common tumors. So, common things are common suspect that first. Next, please. Um I'm not talking about benign lesions in this talk. Um But these are some benign lesions and these are their abbreviations because they come up um in some of the diagrams in the later slides and I believe you have access to these slides. Um So it's more for your information next slide, please. So, systematic approach to X x-ray interpretation. Got your x-ray in front of you. You can see a lesion in the bone. Is it tic? So it could be well defined or ill defined or is it sclerotic? How old are they? This um chart says less than 30 or over 30 but that's just sort of a rush, a rough age group and the location in the bone and um which area of the body it is, whether there's periosteal reaction or cortical destruction. Next. Um Again, this is more for your um information and so you can look back at it, but this diagram shows the most common lesions, what they look like um in age groups, less than 30 or over 30. Um and where you can expect to find them, the epiphysis or the metastasis or the diaphysis. Um whether it's um centric or acentric um et cetera. Next slide. This is just another table giving us a differential diagnosis of various different types of cancers in different age groups and whether they're well defined, ill defined or sclerotic and to remember that in all ages, infection is a differential diagnosis. Next, please. So, um I mentioned zone of transition. So these three x-rays are showing a narrow zone of transition and that basically means the area from normal healthy bone to the pathological bone. Is that obvious? Is it well defined? And if the answer is yes, then that's a narrow zone of transition or is it a bit fuzzy? Is it unclear where the normal bone is and where the abnormal bone and that's a wide zone of transition? So these um three x-rays, number one shows a non ossifying fibroma which is an a benign bone lesion. And you can quite clearly see um where the normal versus the abnormal area is. Um The number two shows a simple bone cyst. Again, that's another benign lesion. And again, you can see quite clearly the transition between normal and abnormal bone and three is an aneurysm or bone cyst. Again, this is a benign lesion, but just because it's benign, doesn't mean that it's um not destructive. So, aneurysmal bone cysts are known to expand and break through the cortex. So they still need um surgical management and surgical input and monitoring. Um But it's not a cancer which will necessarily metastasize. Um But again, this talk um doesn't cover benign bone lesions. So we'll leave that there. Next slide, please. So if there are ill defined margins, cortical destruction and periosteal reaction, um And as you can see sort of a wide zone of transition, so there's quite a large area of bone where you can't really tell if it's normal or abnormal. This is a wider zone of transition. It means a process which has been ongoing probably for a bit of a longer time as well. Um Number one, that's an osteosarcoma. Number two is actually osteomyelitis. So this just highlights the fact that infection in the bone can still mimic or look like a malignant bone process because you've still got cysts within the bone and sclerotic areas and cortical destruction and eosinophilic granuloma again. Um That's actually a benign lesion. Um But it's showing sort of um destructive processes next please. Periosteal reaction. Um So there are different ways to describe this. Um It can be in benign or aggressive tumors um and it can also be in trauma and infection. So, um if it's a sort of a solid periosteal reaction, that's more likely to be benign and then you've got um aggressive features in laminated. So sort of onion, skin periosteal reactions or spiculated like the sun ray appearance in osteosarcoma. And then in Codman, um again, in osteosarcoma, the triangle where you can see elevation of the periosteum shows a very aggressive process. Next, please. Again, this just shows um elevation of the periosteum. Um Figure one is osteosarcoma and two is ewing sarcoma. Nice please. And again, cortical um destruction, as I said, doesn't have to necessarily be a malignant um tumor. So one is a chondroid fibroma. That's a benign bone lesion, but it's still causing cortical destruction. So, potentially you would need um surgery where you would curettage out the lesion. So that's making an incision, scooping out um the cyst or the fibroma and possibly um reinforcing it with bone graft or cement, bone cement. And the same with um figure two, that's a giant cell tumor, which is a benign bone lesion but still causing a lot of destruction in the bone. Next, please. So again, this is just for your reference, it shows the most common tumors in various parts of the skeleton. Um And we've already mentioned around the knee, any um tumor can present there, but osteosarcoma is commonly present around the knee. Next, please, again, location within the bone, whether it's in the diaphysis metaphysis or epiphysis. Um And there are some examples there um for you to refer back to next, please. Um Same again. Next, please. Um So these show some images of, oh yeah, various locations in the bone. So um one is central Diapy, so Diapy in the shaft um and central within the cent central part of the bone, that's a simple bone cyst. Number two is acentric meta so, metaphysis is the area um just above the physis. Um and that's a non ossifying fibroma. Three is another simple bone cyst four is something called an osteoid osteoma and it's within the actual cortex of the bone. Number five is a subchondral cyst. So that's something that is found in arthritis. Um And six is the aneurysmal bone cyst we saw from before and you describe that as centric diap. Next, please. So there are two types of matrix mineralization. So, chondroid matrix that's in cartilaginous tumors. So, for example, enchondroma, that's a benign bone tumor and chondrosarcoma. That's one of the malignant bone tumors formed from cartilage. Um You describe calcifications in chondroid chondroid tumors um and various ways to describe them a popcorn appearance or focal stippled and then you have osteoid matrix. So this is in bone or osseous tumors, for example, osteoid osteomas and osteosarcoma. And you can describe the mineralization as um cloud like ill defined trabecular ossification. Um You can also find sclerosis um which is reactive, for example, in Ewing sarcoma or lymphoma. Next, please. So, tumors which are found um are cartilage forming. Um So chondroid matrix number one shows an enchondroma and this is the type of tumor most commonly found. Um in the fingers. Two is a chondrosarcoma um which is actually arising from an osteochondroma. So, osteochondroma is also known as an exostosis and it's a benign bone lesion. Um but there is a low percentage risk of transformation to a malignant osteochondroma. And number three shows a chondrosarcoma of the rib in a CT scan. Next please. So, osteoid matrix um tumors which are arising in bone forming cells. Uh On the left hand side, we've got cloudlike bone formation in an osteosarcoma. And on the right side is an osteoid osteoma. Um in with trabecular ossification. Next slide. And then there are some um syndromes or diseases where you'll find polyostotic or multiple lesions. And in these patients, there is a much higher risk of transformation to malignant lesion. So, um for example, when an osteochondroma which is solitary or just one osteochondroma on its own is found in the body that's got a very low risk of transition to cancer. But if it's found um in a um disease like mh multiple hereditary exostosis, then there's a much higher risk of this lesion becoming malignant. So you're much more likely to continue to follow up these patients, some other um um sort of diseases where you'll find multiple lesions um include Ole's disease and Maci syndrome. Next, please. Next. So, in order to have a definitive diagnosis of what a bone lesion is, it needs to be biopsied um prerequisites for a biopsy. Um as mentioned earlier, you need to perform FBC platelets, coag on all of your patients and particularly if you're working them up for surgery. But for a biopsy as well, you need to know the risk of bleeding. They need cross sectional imaging. And this helps determine how the lesion is going to be biopsied from which angle. Um and the center performing the biopsy must be capable of the full management um diagnosis and treatment of the patient. And that's actually a standard um in the UK. So, if a patient presents to um a district General Hospital and that hospital is unable to safely biopsy and treat the patient, then the patient will be transferred to a hospital who has the capability of doing that. Next, please. So, indications for biopsy include an aggressive bone or soft tissue lesion, a soft tissue lesion which is more than five centimeters and is deep to fascia, um overlying bone or neurovascular structures. If there's an unclear diagnosis in a patient who's symptomatic. So if they've got pain on neurology, a solitary bone lesion in a patient who's got a history of cancer and a biopsy is not indicated in patients who are asymptomatic or symptomatic, but their lesions appear benign on imaging. And that's after discussion with the MDT um with the radiologist and the surgeons and soft tissue lesions um which appear completely benign on MRI. So, um sarcomas can be within the bone or they can be in the soft tissue so you can have soft tissue sarcomas as well and they're managed by the orthopedic team. Next, please, various types of biopsy. Um FNA so fine needle aspirate is not performed by orthopedic surgeons. Um, but it is used to obtain cellular specimens in carcinoma core biopsy, um can be performed by the radiologist. So it's a type of biopsy to look at the cytologic and stromal elements in particularly soft tissue sarcomas with an accuracy of up to 95%. An incisional biopsy um is when there's a large lesion. Um and you don't know yet what it is or if it needs to be completely removed, but you do need to know what the diagnosis is. So, a um small sample is taken through a small incision and sent to the lab. Um You need to plan the incision very carefully to avoid contamination. So for example, if this lesion is in the thigh, um and it's in the anterior thigh, um and maybe it spreads to the lateral part, you want to find the area where you can safely incise it in order to um traverse as few um structures as possible when removing the sample. Because potentially anywhere that you take a sample from, if it turns out to be cancer, then that area is contaminated. So, if a patient has had an incisional biopsy and the um lab tells us actually, it is sarcoma. Um and we go back to excise the whole tumor then we also excise the tract where the biopsy was taken from because that's presumed to be um contaminated. And then there's excisional biopsy. So this is where you have small lesions um which are too small to biopsy. So the idea is you take it all out and you send it off to the lab. And this is common um for example, lesions in the hands. Next key um when performing an open biopsy, um there are certain principles to abide by the incisional, uh the incision should be longitudinal and it should allow for um extension if definitive management is chosen. So you want to make an incision where if the operating surgeon needs to go back and take out the whole lesion, you've put your scar or your um surgical incision in a place that makes sense so that you can access the whole area approach, do not expose any neurovascular structures. So, in sarcoma surgery, you're not planning to carefully dissect out all of the nerves and vessels because once you expose these, once you take them um out of any healthy tissue that they're surrounded by, then you have to consider that they're contaminated. And of course, if you've got a a contaminated blood vessel or nerve, then that can travel down all the way through the leg or the arm or wherever it is, um meticulous hemostasis is necessary. So if there's bleeding, then that needs to be controlled with diathermy. Um If after the operation, a pool of blood collects or hematoma, then all the cells in that hematoma are presumed to be contaminated with tumor. Mhm. The biopsy should be um performed through the involved compartment. And if there is a um bony component and a soft tissue component, then it's it is fine to take the biopsy of just the soft tissue component. And if you're closing a wound um and you're using a drain to avoid a hematoma collecting, then you should bring the drain out in line with the incision. Next, please. So, um that's the end of the presentation. The take home messages are bone tumors can be benign or malignant. Um They can be primary or secondary so they can be arising from the bone or they can be metastatic from other parts of the body. Every single patient with a suspected bone tumor requires history, examination, appropriate imaging and biopsy. If they satisfy the indications for biopsy, every single patient should be managed by the MDT. So that's your multidisciplinary team um which consists of orthopedic surgeons, radiologists, o oncologists, special nurses, plastic surgeons if that's required. Um et cetera and management doesn't always have to be surgical. It can be medical, can be chemotherapy, radiotherapy or palliative. So, an MDT decides with the patient as well, the best interest of the patient, their prognosis, chance of survival and whether a big surgery would um be of any benefit or if it would just harm the patient, then if you decide palliative management is optimal, you just want to keep the patient comfortable. Um So that's the end of that. Please feel free to ask any questions. I know that someone posted a question um before. So I'm just gonna read that out. So how would you manage a fracture? Um Should this occur at the critical site of a primary osteosarcoma or fractures at the size of a secondary bone met? Um So hopefully, having gone through this talk, you can understand that we manage primary bone tumors and metastases slightly differently and it really depends on what the primary is. Um But essentially, if you've got a metastasis, which is proven as a metastasis, that means you know that the patient has a primary diagnosis, diagnosis of a specific cancer. This is a metastasis. You're already treating them for their cancer. And for example, they're um they've already fractured. So it's a pathological fracture and you plan to um stabilize this. Most likely you're gonna use an intramedullary nail and this stabilizes the whole of the bone in a fracture of a primary osteosarcoma. The last thing you want to do is to stick a um rod through the bone where the sarcoma is, there's risk of seeding. So there's risk of um pushing the tumor further down the bone and contaminating more bone. Um and there's risk of bleeding because you don't know what kind of cells that um tumor is made of until you've got proper diagnosis and patients can bleed to death if you're not careful. So I didn't go too much into the management of different types of um tumors. But essentially in primary bone tumors, the surgical management would include um limb sparing or amputation. So, if there's a section of the bone where you can resect or take out the cancerous part and have a margin of healthy tissue, so you can be sure that you've removed all of the um malignant part, then the area that you've taken out it, the defect can be um filled with either graft. So, bone graft. So we've got things called struck graft, which means um it's taken um from another part of the body, for example, fibula and it's used to support the bone or um prostheses. So, metal work um and in sarcoma, we use um huge endoprosthesis. So you can do a total femur replacement. So you can take out the whole of the femur and replace it. Um with a metal femur, you can do proximal femoral replacement, distal femoral replacement. So it really depends on the patient if depending on the level of the tumor and the contamination of the soft tissues and the skin. Um the vessels is the leg or the limb viable. The patient may require an amputation. So, um management of these tumors really depends on what type of tumor it is, the prognosis and, and all the things that we've discussed today. So I hope that answers your question. Um But if not, please just um send another message and I'll try and clarify it. Um Any other questions? Thank you for your comment, Nadine. Um If there are no other questions, that's fine. I'm happy to take any questions by email. I already said I'm not an expert on this, but I can try to answer. Um I know a lot of you are um foreign trainees and if you're interested to know about what it's like working in the UK and the NHS, um then I'm happy for my email address to be passed on for anyone to contact me. Ok, thank you very much Christina for very captivating and coherent um talk. I think if anyone didn't have an interest in orthopedics, they certainly do. Now. Um I'd just like to proudly announce that um and thank our sponsor, which is MD. Um and also notify people that this is a CPD approved um talk by the Royal College of Surgeons of Edinburgh. And all attendees will be awarded one CPD hour. And in order to gain um the certificate you'll have, you'll be sent a feedback form and if you could kindly just fill that, fill that in and send it back to us, your certificate will then be um issued. So, thank you everyone and thank you Christina once again for such a lovely talk. Pleasure. Thank you all for turning up. So, thank you, everyone. Look forward to seeing you um in the talk next week. So just stay tuned on our Instagram for further announcements as the series continues. Thank you and everyone have a good night.