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Okay. Hi, everyone. Um, my name is Caitlyn. I'm from Bombs to Scotland. Thank you for coming to today's event. Um, if you could just pop a wee message in the chat or thumbs up, if you can hear me and you can see the screen and see the presentation. That would be great. Percy Bacon Heroes. We pull them off. Okay. If you can respond on the pool there, that would be great. Thanks. Mhm. Okay, Bob. You got the response there. Okay. So this is our speaker David Skip. See he's from up in Aberdeen and he's kindly come to give us a talk on bone tumor is today. So I hope you enjoy the talk and you'll get your certificates after release the feedback link at the end of the talk. So, yeah, over to David. Great. Thanks Scotland. Um, so, hi, everybody. Uh, my name is David Skips. I'm an S T six register in orthopedics in the north of Scotland. Um, first I want to say thanks to, uh Bump PSA and congratulations for, for setting it up and it's a wonderful idea to have a national organization for medical students. Uh, and it seems to be going from strength to strength. So that's good work. And I especially like to thank Caitlin for and the Scottish bombs, a team for uh running this group of four sessions and thanks for having me alone. Um So I've been asked as one of the boat, a regional representatives to do this talk. And that means, um I represent orthopedic trainees in my own area, which is the north of Scotland and that includes Aberdeen Murray and Highlands and Islands. Um It's a cold but lovely part of the world as you can see from the picture of the walking buddies dog on the way up on the road who's showing off as normal. So please do come and visit. Mhm. Um So I've, I've been asked to teach on, on, on bone tumor and that's, that's based on what the bombs of committee I thought you guys would want to know about and clearly you do if you've tuned in tonight. MSK A tumor's are, are somewhat niche. Uh And I feel the need to point out that that bone tumor is whilst important are perhaps not as high up in the list of obviously things you need to know in orthopedics as, as an undergraduate, which is the sort of uh uh targeted level of this, of this talk. And I'd expect you to obviously know about all the key topics above uh on this slide. Uh But when preparing to this talk, I, I read through the B O A's and suggested undergraduate syllabus. And also the GM sees uh MLA content map which mentions generic malignancy and uh makes reference to bone pain and, and pathological fracture, which we will definitely discuss because that's, that's one of the key points you probably do need to know about it. And so, yeah, basically need to know about metastatic bone disease. And that's, that's the, that's the key take home as, as an underground. Um But you need to check your own curriculum to see uh you know what you need to know because obviously there are some differences between medical schools having said that they are a diagnosis not to miss and as such, they do quite frequently come up in exams. Uh And the main thing is that you consider cancer as a potential diagnosis, which some medical students and some doctors forget to do when it comes to limbs. And that's quite simply because it's not that common and, and I don't want to scare you, but certainly my final exams in 2013 in Glasgow, we had a 10 mark short word answer on osteo. So osteosarcoma, which kind of threw everybody. Um So yes, you need to know a bit, obviously, make sure you know, your acid base balance inside out the ciggies before learning about to inject a tick osteosarcoma. And the less lecture tonight is uh not long enough to cover all msk hmos. So I've tried to give a bit of an overview and a bit of a focus on, on some exam stuff and in particular go into describing x rays because that's really what, what, what the bombs of guys want to talk about. Um at times it'll go slightly beyond your level. But the point is to get the sort of basic principles and one of the take home message is, is, is to get, you know, used to looking x rays rather than um a specific and diagnosis. I'm also not proclaiming to be a bone tumor expert. I've done a diploma in MSK A oncology. So I'd like to think I know a bit more than your average registrar, but not an expert by any means. But I'll try to answer any, any, any questions that you uh that you might have. Uh okay, look, we put the first pulling question. So my whole talk is about 70 minutes long. Um But that includes soft tissue, soft tissue tumors and lumps or that's what the, and bone tumors and x rays and that's about 70 minutes, but I could just talk about just bones. So I just want to know what you would rather do because ultimately sessions up up to you guys. So, um if you could let us know what you want to hear about. Yep. That's the pull up. Now we're getting some responses in. So, yep. So we've got kind of uh eight responses there. There's about, I think most people say yes to the. Yeah. Okay, perfect. We'll just, we'll do that. So, 1st, 1st thing, first I've got a bit of a kind of like a quiz and then go through some X rays. So, um, so first question, so what's more common, primary malignant bone tumors or primary malignant soft tissue shows emphasis on the primary. So we're just gonna flick how many people have what? So give you another couple of seconds. Yeah. So yeah, 2000 year, right? So, yeah, so primary malignant soft tissue tumors are more, are more common than bone tumor. And it's important as we sort of understand that they're aware of that and that's why I want to briefly blast through talking about soft tissues and lumps. Uh First. So yeah, question to what's what's more common primary malignant Boden tumor's or metastatic bone tumors? I suppose we've already mentioned this really haven't we? But yeah. So I think the majority people know that. So, yeah. So uh metastatic bone disease is, is much more common than, than uh tumor's which originate from, from the book. Perfect. Um Next question. So, I mean, this is a classic question. Everyone has to do with this for, for, for the finals. So yeah, what, what five primary cancer is most commonly metastasized to both. Uh we did a poll for that one but if you just never think about it, I give people 20 seconds. Yeah. So yeah, the five most, the five primary cancers which most commonly metastasized to bone are uh prostate breast lung, uh Reno and uh thyroid and, and helpful pneumonic for that is, is led kettle. Um uh So, yes, obviously, uh P B K T L. Um Next question. So I've got to see these X rays. So, is this a, is this normal extra or abnormal X ray? So I give people another 10 seconds for that one. Yeah. So it could be quite difficult, can't it? Um And uh most people I've, I've recognized it's abnormal X ray. Um There's a, you can see within the proximal femur. Can you see my mouse just to check? Uh I can't at the moment. I don't know if you go a little Kristers me. Yeah. Yeah. That's frustrating actually. Okay. Well, yeah. So you can see there's a if you, if you, if you go from the distal end of the femur and work your way up, the cortex is relatively thick and then it, and then it goes uh and then you can see this lytic expansile lesion in the, in, in the proximal femur. So that's, that's abnormal and that's a, that's a big lytic lesion in the proximal femur. And the concern about that would be that, that potentially fracture cause a pathologic fracture. The next one is this abnormal or abnormal actually. And whilst you guys are answering that, I'll see if I can get my cursor to be seen, I give people about 10 more seconds. Yeah. So again, most people, so it's uh I can see, as I can see this is a normal extra. It um there is um some area around about the greater trochanter, it might suggest trochanter bursitis. But certainly I can't see any evidence of, of uh bone tumor, which is talks about is this X ray normal or abnormal and more specifically the bones normal or abnormal. And I appreciate the soft tissue envelope is a bit larger than normal, but the bones normal or abnormal. I give people 10, 10 more seconds. Yeah. So this one, we're getting a bit more subtle, aren't we? So this one's abnormal. Um You can see about halfway down the left humerus. There's a, there's a lytic lesion and there's actually two or three of them isn't there, there's sort of quite small, but there's what we call sort of industrial scalloping. So there's, it looks like there's been a small ice cream ice cream scoop has taken out the uh the cortex of the uh of the bone. Uh So happens this lady had metastatic breast cancer. Um Next one, is this normal or abnormal? We'll give, give people 10 more seconds final call. Uh Yeah. So we're about 50 50 there. So uh this is normal. I couldn't see any, can't see any abnormalities on this. And I've lifted thank you so much to Radio Pedia for this X ray. Uh It's a normal extra as far as I can see. Um uh this one, is it normal or abnormal? So, yeah, I remember when we're looking at a Pelvis X ray, we want to go around the margins of the pelvis, want to think about centonze lines running up the inferior aspect of the, of the femoral neck. Uh And to see if that uh joins onto the superior pubic ramus, um There's your ileo pets Neil line, your ileum issue line. You want to look at the proximal females carefully. Uh There's lots of different things you can look at um give people 10 more seconds for this one. Great. So, yeah. So uh yeah, great. So that's uh I think this is probably one of the harder ones. So I think, I think everyone's done very well. Uh Most people do very well. There, there's uh there's some arthritis in the right hip obviously, but in terms of the bone cancer part of things, there's a, there's a lytic area in the right lesser trochanter. Um And of course, as you all know, if we're looking at, if we're looking at the way X rays are, are projected to the right is obviously on, on the left hand side and there's a little area in the lesser trochanter uh with looks like either it's expansile or there's a lesser uh trochanter avulsion fracture. Uh And that's highly suggestive of uh of a bone cancer. I mean, you can get it in um particularly pediatric cases, you can get avulsion fractures, but particularly an elderly patient as this was, that's highly suggestive of a, of a tumor. Um So, uh we'll change things up with questions wise. So there's just a few more questions or a few X rays to go and then we'll start talking about stuff. So, is this, is this, do you think a benign or malignant tumor? And the truth is you can't tell until, um until you've done a, you know, a biopsy and further work up. But has this actually got features and that would be more in keeping with a benign lesion or uh or a malignant one. So we give people 10 more seconds. So, yes, this is an ap of a left proximal humerus. You can see there's a, a, a large lytic lesion. Um and it looks like it's got malignant features. It's got evidence of um Codman or something called Codman Triangle, which we'll talk about. Um It is, looks very lytic. Um It's quite difficult to delineate where the, where the tumor is also looks like this. This is what's called neocortex formacion. Um And actually, it looks suspicious like there could be a potential pathological fracture, although not definitely on that view. But yes, that looks, that looks more like a malignant tumor and we'll talk about those findings. Um What about this one? Is it, is it benign or malignant do we think? Um So this is obviously a right re X ray and it's a child, isn't it? Because the, uh, you can see that the, uh, their growth plates on there that haven't fused. So it's a, it's a pediatric X ray and the lesion if you're, if you, if you uh perfect just bedrooms responded there yet. So, yeah, absolutely. So, it looks more like, it looks more like a benign lesion, doesn't it? And when we're talking about this, you would say that it's um it's uh specific to the rep if Asus um it's well delineated. It's something called geographic, which means we'll talk about that again, but means you can kind of draw around the uh the margins of the tumor and it doesn't seem to be doing anything else to the bone in particular. There's no massive periosteal reaction. So that's more in keeping with a benign tumor. Yeah. And then what about this one? Is this benign or malignant? Give people 10 more seconds? Great. So, we're 50 50 on that one. Um which is a fair representation, I think of the lesion because it's, it looks aggressive, doesn't, it's uh in the proximal tibia, there is a loss of the cortex, particularly medial aspect. It's in the metaphor, uh Tafa epiphyseal region. Um And um it looks quite sort of destructive, doesn't it? But it's actually uh it's actually a benign lesion, but it's a benign aggressive lesion and it's something called a giant cell tumor. Um having said that I put this up to illustrate the fact that, that just because something's benign doesn't mean just, it doesn't mean it's, uh, it's any, um, uh, just means it can't metastasize, it doesn't necessarily mean that it's not, uh locally aggressive. So just to bear just to bear that in mind. But that's a, that's a difficult one. And the two, and again, the truth is we don't, uh, that would need to be worked up fully. So you wouldn't, you wouldn't make that necessary diagnosis based on just the X ray. So grant. So um uh start talking now about so, yeah. So we, the plan is we, as we talked about a million soft tissue tumors are more common than bone tumors. So we'll briefly talk about assessment of a lump and I'll mention the referral for soft tissue sarcoma. Then we'll talk about different things to look out for on x rays. And then we'll fly through some of the malignant and some of the benign bone tumor's uh and finally, a case of metastatic bone disease to illustrate the need for appropriate uh investigation. So, uh yeah, so lumps. So you all know how to take a history. I'm not going to labor the point on that, but it, but it is very important and, and the key points are, when did the patient first noticed the lump and you need to try and pin them down to a specific timeline. Often it's a relative or a parent has noticed it has the lump changed over time. Um, and in particular has been rapid growth over a number of weeks, um, which would indicate something more malignant. Um, someone lumps can, can wax and wane. Uh, some lumps can get bigger and smaller like ganglion zor hemangiomas. Has the patient had any lumps before? And have they had any surgery for lumps in the past? We need to think about it if the lump is painful and generally pain is a bad sign. Uh And it might indicate malignancy but it's not pathognomonic. So, uh you know, most soft tissue sarcomas are pain less. And so it's a bad sign but it's, it's not, it's not, doesn't mean it's definitely malignant. Uh and some benign tumors are painful because of the mass effect. Uh They can compress nerves and blood vessels uh and stretch the fashion. Have they noticed any change in color? Um Is there any numbness of the limb which might indicate uh nerve involvement? Is there movement affected, is their function affected? So these are all the things we need to ask about. Um And more globally for the patient, we need to ask if they've had any lumps elsewhere and remember that the patient might not initially want to volunteer that information and particularly that's the case in exam settings. Um So you need to have asked that question. Otherwise, the the patient might not volunteer that um we all get taught the red flag features of back pain and many of the same features apply to lump such as unexplained weight loss, fatigue, uh night sweats, fevers, all these things. So you need to ask about those, you need to ask about personal history of cancer. So, uh of course, you need to be slightly careful with the way that that questions asked. Uh and then post graduate exams and probably indeed undergraduate exams, we often use the throwaway phrase that you need to elicit the patient's ideas, concerns and expectations. But what does that mean in practice? So well, in this scenario, if you think you need to know if the patient has what you think is a whopping Great tumor, if they have any insight as to what that is because you do, you surprisingly get patient's that have absolutely no idea. And similarly, you get a patient with a very simple subcutaneous lipoma. It's certainly nothing to worry about, but they've been really worried about it and they, they think it's something nasty, uh particularly they've got family history of anything. Um And finally, it's useful to find out if the lump is bothering them. Um and um in particular, if they are concerned about the appearance because quite often patient's don't necessarily want the lump removed and they just want to know it's not something to worry about. Um So yeah, approach to lumps. So um inspection. So it's all the same stuff isn't it even an orthopedic. So, orthopedics is generally look, feel moved, but I've even added in some percussion and auscultation. Well, not really ostentation but even some uh percussion in here. So, yeah, inspection. So the six S is we need to look at the site, site size, shape, symmetry, uh skin and uh we need to look for scars. So, site. So where is the lesion? Is it anterior, posterior lateral is anterolateral? Where is it on the limb? And remember that we, we usually talk about volar and dorsal when it comes to the hands and the forearm. Uh which limb is it in? And again, remember the anatomically, the leg is the knee down and the thigh is in the up or is it gluteal region? Um uh What are the lumps relations to the surrounding structures? So, things like joints and muscles. Um We need to comment on the size and you'd be surprised at the number of referrals and things that come in with without, you know, very good appreciation of size. So, don't be afraid to measure something. Um It's a good rule in surgery to have a rough idea of what five centimeters is and what 10 centimeters is. And that sounds silly. But then when you're first suturing up your first sort of lacerations in any and you come to document you think? Oh goodness. How long was that actually? Yeah. So just bear that mine. Um There are measuring tapes in most orthopedic clinics, but if you don't have one of those, um, most of the dressing packs and, and most NHS hospitals have a tape measure in which is quite handy as do the pens that you get. Um, you want to come out in the shape. So, is it the cecil shape or pedunculated shape you want to comment on, on, on the symmetry? So, is there something similar on the other side? And I have seen a referral of uh bilateral swelling and the dorsal aspect of the arms proximal to the elbow in a 60 year old lady who's who's overweight and the city and the, and the, and the referral referral was quickly sarcoma, you know, urgent, urgent tumor referral and quite clearly that was, that was going to be just unfortunately normal fat. Uh but the patient was worried about it. So we needed to, you know, we need to see an address those concerns, but um just need to have a, have a, have a think about things. Um skin changes. Um So is there any skin changes, overlying things? So, ulcers, punk Tums, color changed, discharge. Erythema is a gouty tophus. Um that's been inflamed previously or is it something like a rheumatoid nodule? So, there's many different causes for lumps scars. Um These are sometimes quite um subtle, especially if the skin is being, is being stretched over a lump over, over a new expanding lump. And of course, the patient may well tell you they've had an operation. But again, in exams, sometimes you just get the opportunity to examine you. So you need to look very closely for scars and you'll find that it's right. Your surgical exams, you need to look carefully for scars because you can easily miss them. Uh palpations. What does the uh lump feel like? Is it smooth? Is it rough? You need to feel the edge and find out if it's irregular or well defined. Um Is it difficult to differentiate from the other tissue or is it quite in filter ship? And then the consistency? So, is, is it hard or soft? And uh and you know why have I got a picture of a nose? Well, it's because uh sometimes it can be difficult to, well, what are you comparing hard and soft against? So classic figures, people say hard as, as the bridge of the nose, the tip of the nose is firm and then ears are the nerves are soft but that's just bye bye. Is it fixed? And that's quite important. So, is it fixed to the skin? In which case, you might not be able to move the skin over the surface of the lump or is it fixed um underlying tissue? And is it deep, do you think it's deep to fascia which is very important? And in particular, is it within the muscle or is it attached to the muscle surface? And how do you tell that. Well, if you get the patient to contract the muscle and the lump becomes more difficult to feel. Uh Well, then it's, it's within the muscle, isn't it? Um But if you ask the patient to contract the muscle and the lump becomes more prominent, then it might be fixed to the surface of the muscle. Uh is the lump fluctuate. So you can do, if you want to formalize it, you could do something called Paget's sign of fluctuations. Um which is where you hold the lump between your, your thumb and your index finger of one hand and you press with the contralateral finger. And if the lump moves uh pushes the other fingers apart, then it's, then it's fluctuating is the lump pulsatile. Uh for example, aneurysm. So, um aneurysms are not only for abdomens, although they are rare in the limbs that do happen. Um And also they'll be expansile. How do you test this expansile? Well, same as the abdomen. You put your fingers side by side against the lump and you can assess whether the lump is pushing your fingers away from each other. You can trans illuminate the lump and ganglion and synovial cysts tend to tend to light up um percussion, you could percuss the lump. Um If it's a nerve tumor tapping over the lump, might elicit a nerve response or tingling or parasthesia. Uh So that's uh something called a positive Tinel site, which is something you might have come across in, in nerve injury or carpal tunnel syndrome. Uh but it could be useful lumps, ostentation, not really a thing in, in, in uh in orthopedic lumps, uh more of a general surgical thing, but you might be able to pump a thrill, I suppose in vascular tumor's. So that's the lump. Then we need to think about the limb in general. So, lymphadenopathy, so you need to get uh you need to examine the draining area. So the inguinal region for the lower limbs or axilla for the upper limbs. And obviously, we need to assess the neuro vascular status and, and as, as as medical students and, and, and F Y S, I think you need to come up with a very quick system for examining the neurovascular status of the liver, particularly if you're going to work in orthopedics. Um and you need to, to do that, you obviously need to have a rough idea of the nerves involved because quite a lot of the F Y S I work with don't no quickly how to examine the new vascular status to fill in, for example, and they should just take a few moments. So for example, for the, for the arm, you can palpate the pulse is so you can quickly do radio on their capillary, refill times less than two seconds. Sensation is quickly first, um dorsal webspace for radial nerve, uh radio aspect of index finger, for median nerve and on the border of little finger for all the nerve. And then you ask the patient to make an okay sign, which is an to intraosseous nervous part of the median nerve. And they can uh do a thumbs up or a gun sign for the radial nerve and they can't get them to cross the fingers and uh make a star for uh for uh the ulnar nerve. Um And then general examination will depend really on the what you find. So you might also examine chest, abdomen and the other joints. So we're getting on to more of the meat and bones now. So um referrals. So there, there are slight differences between the nice guidelines and the Scottish guidelines, but the general just is the same. So um urgent referral for sarcoma. So you refer a patient urgently if they have one or more of the following. So a mass more than five centimeters in diameter and that, that doesn't necessarily mean that uh if the, if the lumps been is bigger than five centimeters, but it's been there for, for 10 years, it might not necessarily need an urgent two weeks can, it might just need investigated with a more routine scan, but five centimeters is concerning. So if you generally see a new presentation of a five centimeter lump, then they need uh an urgent referral. And that's because we know that over five centimeters are suspicious. And we know that if we fact if we catch Sarcoma earlier, we get better survival. Um, back in 2006 now, quite a long time ago now. But Professor Rob Grimmer, who worked in Birmingham just a lot of work, including raising awareness, uh, as he would see a lot of people with late presenting Sarcoma as, uh, as part of that, he sent all gps in the, in the country, a golf ball and this golf ball, well, a golf ball is 4.27, uh centimeters in diameter. Um So any bigger than a golf ball he felt should be investigated if the mass is increasing in size or changing, um, pain, as we said is a bad sign, although most sarcomas remain pain less. So, it's absolutely helpful if the mass is deep to the fascia, uh and if it is uh there's uh an increased likelihood of it being delivered, which makes a lot of sense if you think about it because to notice a lump that's deep to the fascia, it's going to have to be really quite big before somebody before somebody notices it. And, and of course, um if um if the patient's had Olympic size before, even if it's done in a minor surgery department, and they think it was just assist if it's come. If a lumps come back, then that's obviously concerning and that needs to be investigated properly with imaging and, and biopsy, biopsy can include an excision biopsy, but it needs to be done properly. And we need to bear in mind that when lumps or bumps are sent away, they generally all need sent away for histology. Um So that's, that's soft tissue referrals. What about bones? So, well, if you have a normal X ray, that's somewhat reassuring, isn't it? It's not, it's not definite, but it's somewhat reassuring. So you should get an urgent X ray if the patient has unexplained pain or tenderness, particularly if it's persistent, increasing and or not mechanical, which of course means it's not affected by the patient's activities. Um if it's present at, at night or if you have pain at rest. Um and in particular, uh Children with lumps, uh sorry, Children with limps are of concern, which is why they get investigated urgently. Obviously, there's many reasons for a limp, but the tumor is certainly one of them and you shouldn't dismiss a child and with growing pains, particularly if the pain is persistent. Uh So if it's not clear, you bring the patient back in a few days and you see them again if it's still not bothering and if it's still bothering and get an X ray, um great. So quick, quick definitions. I know, I know you guys probably all know this, but it's important to have firm sort of definitions are in our mind. So, so what's the tumor? Um So tumor is, and I'll just read this is an abnormal growth of tissue which enlarges by cellular proliferation. Uh faster than the surrounding tissue. It continues to enlarge even after the initial stimulus is removed and often doesn't have the organized structure and function of the surrounding tissues. And a tumor, it can be either benign or malignant benign tumors. So, yes, as we know, so, a tumor which may spread locally but does not metastasized distant locations um bear in mind that just because the tumor is, is benign, uh doesn't metastasize, it doesn't mean that it's not potentially destructive as we have already mentioned. Um And that's particularly the case in bones when it comes to growing Children. Uh what's malignant tumors then? So malignant tumors are a tumor which has the ability to metastasize to distant sites and it's generally more aggressive locally as well. Um Grade um is obviously how well differentiated the tissue is on pathological examination. Um So does the tissue just look like a jumble of immature cells which would indicate a higher grade, uh which is usually more aggressive. Uh And to obtain grade, we need to get a tissue uh biopsy and stage as we know is, is how far the cancer spread. And we get most uh the information with, with the help of three D imaging and then M S K tumor's, um they have the same TNM system as they do for most tremors around the body, but they have their own adaptations. Uh And the main question of sarcoma is uh in the limbs is whether they breach there compartment or not. And by that, I mean, there's, there's obviously different compartments within, within the limbs and have they breached their fascial compartments. And that's important because it affects survival. Uh And whether you're gonna be able to try and excise uh the entire compartment and undertake uh so called limb salvage surgery, which is uh secure first and then limb salvage surgery is always the names of, of the, of the tumor surgeons. Um And um this, this is just the staging system. Um that is uh is used you notice when the, the jump is from stage two A two to be is when the tumor spread out with the compartment. And not surprisingly, and the survival rates uh between those two uh falls quite significantly. And then benign bone tumors have their own staging system, which we'll briefly talk about it. It's basically a benign uh later, benign, aggressive, benign, active and benign, aggressive and we'll talk about those. So we'll just briefly talk with soft tissue sarcoma as, as, as, as we said, they're very rare, but they're more common than malignant primary bone tumors by about 5 to 1. Um There's lots of different subtypes. Um And the sarcoma is derived from uh a biological medicine kind uh and their sub classified basically on the, on the tissue that they resemble. So, for example, you get a liposarcoma from fact, a rhabdomyosarcoma from skeletal muscle and a fibrosarcoma from fiber blasts uh and so on and so on. But many of them are actually undifferentiated. So they don't resemble the tissue. And obviously, they're more, they are quite aggressive. So we diagnose these by obviously a full history examination, uh local imaging, which is usually an MRI of the affected body parts. And the, and the MRI scan tells us about the local anatomy and helps uh the tumor surgeons decide where they're gonna stick a needle in for the biopsy. Because at the end of the day, they might want to, when they do the operation, they want to be able to excise, that biopsy tracked as well. And, and the biopsy can quite often be done in clinic just with local anesthetic or it can be done by the radiologist with ultrasound. The patient gets a staging ct and then they're discussed at an MD tea and every everything's done with a multidisciplinary team approach. Treatment is aiming for if aiming for cure is usually a wide local excision and then adjuvant radiotherapy. So operation and then adds radiotherapy. Um but that really depends on the subtype. Um One thing to say is that the spread is usually hematology nus. So it spreads, spreads via the blood stream, which is obviously different to uh most of the other um as we learn about which spread via uh lymphatics, I most adenocarcinomas. And, and finally, the thing to say is that, that in terms of like doctors and surgeons and in particular is that we're trying to avoid removal of the lump, which subsequently turns out to be a sarcoma because then the surgeon has essentially done harm to the patient because they potentially made the situation very difficult to deal with because they may have contaminated the whole local bed of tissue. And then the patient might need a large reception with lots of uh tissue to be removed, to get a cure if it's even possible. So, just to uh to bear that in mind, um X rays. So, yeah, so uh we've now got into bone tumors and x rays, which is what we all want to talk about. And because we generally like looking at x rays if we're interested orthopedics. Um And obviously, before you look at the, actually, you need to check that you have the right patient, the right examination, be amazed at how easy it is to put the wrong X ray. And we need to think about the age of the patient as well. That's very important. So, um some uh tumor's such as primary Mulligan bone tumors are more likely in a younger patient. Whereas an older patient, they're more likely to have something like metastasis or, or or my liver. So yes, once you've looked at the X ray, confirm the right patient, etcetera, you then need to decide uh or you need to look at where the lesion is. So start off by which bone is it in and in particular, which part of the bone is it in? So, if you remember, we split the bones into the shaft or diagnosis, uh the flare, which is the metaphor sis uh before the Fyssas. So the Fyssas is obviously the growth plate which will be fused in an adult and then the area nearer to the joint is called the epiphysis. Um Why is this important? Well, um it's important because the bone involved can give us a clue as to what the tumor might be. For example, um an osteosarcoma commonly most commonly affects the femur and around about the knee and often around the metadata facil area. Uh And then there's a few tumor's that which only affect the up if Asus. So if you're a child with a lesion in the Yep, if Asus, uh then it might point towards something called a condo blastoma. There's a few lesions that cross uh anatomical regions, but many don't and in particular giant cell tumor, the destructive benign aggressive benign tumor we showed in the quiz um can cross epithets iss to metaphysis and, and vice versa. And I'm not saying all these different diagnoses too. Um because I want you to remember them, it's just to have a think about the behavior. So we need to think about the which bones in and whereabouts in the bone. Is it when we're describing the extras? And then some tumor's have a propensity to be either central within the bone or they're completely centric obviously off to one side. So for example, a projection pointing away from the joint is likely to be an osteochondroma. Whereas uh an enchondroma tends to be central in the bone and uh not also flying fibroma tends to be e centric. So this this uh diagram here um sort of illustrates illustrates that quite well. And next is uh this, this slides brilliant. I rub this off radio pedia, sort of thanks to radio pedia, but it's an excellent picture which shows uh you know, a lot of bone tumors look like in one slide which I think I think is brilliant. Again, notice the osteochondroma which is pointing away from the joints, uh chondroblast um when we talked about the kiddies kiddies tumor in the epiphysis and and the the centric no notifying fibroma and osteoid osteoma. So, yeah, just to bear minds, locations, important, location, location, location. Um So what we're doing I should have said at the beginning is we're going through seven questions that orthopedic surgeons tend to think about when they're looking at a bone lesion. And I think it is useful um just to, you know, consider, consider these as a medical student uh when you're trying to describe x rays. So, yeah, secondly, how big is the lesion? And you can quantify this in different ways and in some X rays, you can measure the size using a rule or two. But that needs to be accurate, that needs a calibration um that usually needs to be calibrated um which we really have. Um it's also useful to talk about the percentage or, or ratio or with in terms of width of the bone. And quite often we talk about the percentage destruction of cortical bone, which can be important. Uh is the tumor isolated to one lesion or is there a so called and skip lesions? Uh So that's where there's multiple lesions along the same bone. Um This is the top extra, here is a case of uh distal femoral uh osteosarcoma. But as you move approximately, you can see the arrows pointing to skip lesions all way up the female. Um And obviously, it might affect what kind of operation you do and what, what, what level you can do the reception at. Um So you do, it's important that you have X rays of the whole bone. Um This extra in the bottom is something called fibrous dysplasia, which comes in monostotic and polish ptotic forms. Uh meaning effects more than one bone. Uh And it can be quite locally destructive with growth abnormalities but is generally watched unless it causes a particular issues or there's there's fractures in which case, we can be operations and sometimes patient's gets phosphorus, but the specifics are not really the point of this talk. So, um question number three is what is the lesion doing to the bone? Um And by that, we're talking about something called the, the zone of transition. So, is there a narrow zone of transition, which is where the lesion is very well defined? Uh So that's also termed geographic, which is where you can uh you know, you can almost easily take a pen and uh draw around the lesion. Uh Like you like, you would, if you were looking at an island on a map, you could easily see that, see the island and draw around the island if you can do that with the, with the lesion, and then it has a narrow zone of transition. And that suggests that lesion is growing slowly. And as a consequence that the lesion's walled off, you can also get expansion of the bone, but a narrow zone of transition uh would be more suggestive of a, of a benign lesion. In contrast, a wide zone of transition is where the border is uh ill defined. The lesion is, is permeated. I've within the bone, there's poorly demarcated border and you see this in aggressive lesions which are rapidly growing and they're much more likely to be malignant. Um So for these two X rays here, if you've got your imaginary pence already, uh and you can see in the lesion in the, in the distal femur at the bottom, you can easily draw around that. It's got a sclerotic margin. Um The lesion looks well walled off which is s a benign lesion. And um in this case, it is something called a non notifying fibroma. Again, I don't want to get too bogged down in the specifics. Just mainly talk about the malignant or benign features. The X ray in the top has a more permeated appearance. Um You couldn't easily draw around it, meaning it's, it's not geographic and this is a more aggressive looking tumor. And in this case, it's an osteosarcoma. I don't know why it's got uh the writing on it. So sorry about that image of an extra um then what is the bone doing in response? So, as we said, if the lesion is a slow growing, you get a walled off appearance. But if the lesion is aggressive and growing fast, you get some uh fairly unique radiographic signs which happened in the periosteum. Uh Well, sorry, which happened uh due to the periosteum, basically really reacting to the lesion and the main things, uh the main ones you hear about our common strangle. So common strangle is uh is uh there's actually a common strangle, I think in three of these. Um So the one on the right at the top and the two at the bottom. Um But that's where you get a triangle of reactive bone that's lifted off at the edge of a tumor. And that's highly suggestive of uh of an aggressive lesion. I wish I could show you in my point of view. I don't think you see the point of uh sun rays speculation. Um So that's on the top left, excuse me. So that's a speculated um periosteal reaction which indicates rapid bone growth under a raised periosteum where the basically the tumor is growing so rapidly that the bones not, not had time to grow normally and it's not had time to calcify. Uh And then the other classic uh bone response is onion skinning. Um So that is the one on the bottom, right where you get multiple layers of new bone forms. And uh this can happen is as basically the tumor goes through different phases of growth. And you can see those different layers and almost look like the skin of an onion in that, in that bottom, right um image. And this is fairly classical to uh one of the primary malignant tumor is called Ewing's tour. Question five. Is, is there a matrix? So um when we say bone tumor's, we mean tumor is affecting the bone, but the tumor can originate from different cells within the bone or in the bones. So they can be from the cartilage of the bone fibrous tissue. Um You can get more sclerotic lesion which obviously look whiter on X ray or you can get lytic lesions as in a hole in the bone. Um We've got examples uh here. So, and the second one along is, is, is uh fibrous matrix. Um and that's so called ground glass matrix. And that's um the classic thing about uh description of that is, is, it almost looks as if the normal trajectory of the bone, you've taken your thumb and you've, you've, you've, you've smudged them out. So that's a classic fibrous uh matrix. The one, the one uh second from uh 3rd, 3rd, 1 along, sorry is popcorn calcifications. So that's the cartilage matrix. So you get these punctate or, or ring like calcifications, um which is seen in, in cartilage tumor such as chondrosarcoma enchondroma as uh bone forming matrix or bone bony matrix. That's the one on the, on the, on the far left. Uh And that's characteristic of uh tumor is like osteosarcoma. So um often the new bone is what confused me when I started looking at them is is it's not just pure bone. Obviously, there's there's there's bone being formed, but then there's also potentially lytic areas around it, which kind of look a bit confusing and then you get uh lytic areas. Is this on the far right? This proximal femur has a, has a big lytic lesion in it. Um bear in mind that lytic lesions don't necessarily have to have a specific matrix. Um And often there's no way of knowing um if, if this, you know, single lesion is isolated, metastases are not without further imaging and biopsies. So, um whilst a lot of metastases tend to be lytic, you can also get sclerotic uh metastasis. Uh for example, um uh prostate and breast uh metastasis are much more likely to be blastic or sclerotic while lung thyroids and and, and reno tend to be more lytic. So we're nearly there with the questions we'll keep going. Um, is the cortex eroded? So, is there a deer disappearing cortex? Um, is there a scalloping of the cortex? And is the cortex? Yeah, disappearing, which would suggest a more malignant tumor. And finally, is there a soft tissue mass? So remember actually is a good for looking at soft tissues. But you can also sorry, actually, they're not in particularly good looking at soft tissues, but you can see them and they can give you little clues. And so for this uh distal femoral osteosarcoma, you can see that there's you can see the uh the new bone formation permitted appearances. But also you just get the impression that is quite a big soft tissue mass all the way around it too. And this this kind of um ability to look at soft tissue mass is, is obviously helpful in other X rays as well. So for example, if you're seeing a difficult kiddies X ray, kiddies ankle X ray, and you can't really quite work out if there's a fracture or not. Well, if you've got a great big soft tissue swelling, and then obviously, that would be a bit more concerning and you, you might have a have a have a closer look. Um Let's quickly blast our way through benign board tumor's. We don't have time to talk about all of them. So I've just picked a few to illustrate their behavior of latent, active and aggressive tumors. Uh uh We've seen some of them before. So, uh latent benign tumor. So, latent tumor's are those with a narrow zone of transition. They have no periosteal reaction. They don't have a soft tissue mass. Uh They usually is symptomatic and so often they're just diagnosed incidentally and usually no treatment is required. Um So it's often, you know, a patient whose twisted their ankle and they've got, they've got this lesion on a, on an X ray, but use the on call orthopedic S H O has often been asked to um comment on it which often you'll then take away to your boss to confirm. So, yeah, enchondroma. So these are cartilage based um tumor's and as a consequence, they have this sort of stippled calcification or popcorn calcification we were talking about and they can look quite different in the long bones uh in comparison with the hands. But pathologically, they're the same um in the hands, they look like uh sort of lucent lesions within the uh within the uh method, uh metatarsal region of the phalanges often. Um But in long bones, they look like these central intern medullary lesion's uh and they have a more classic cartilage appearance. Um Inka dramas are the most common tumor of the hand. Um and they can very rarely undergo malignant transformation. Uh and their cartilage tumor. So if you think about it, what will they undergo malignant transformation to will probably be the cartilage malignant tumor which would be chondrosarcoma. So if there's industrial scalloping and then that would be a concerning feature which might uh might work a biopsy. Most of these don't require treatment unless they become symptomatic. In which case, they get curettage and grafting. So, basically scoop them out and we can fill them with bone graft. And there are syndromes associated with this, with this condition that I think, I don't think we've got time to go into and it's maybe a bit over the top, but just bear in mind that if you have multiple lesions, then you're more likely to have the potential for malignant transformation quickly, non Acidifying fibroma. So they're very common. Um I think roughly if you exit all kids and young adults just over a third of people would our kids would have one. Um They're usually a symptomatic. So they're often found incidentally as we were saying. So uh one of these kids just had an ankle sprain, had this X ray and uh come in on the X ray. Um But if they get very big, they can cause pathological fracture. So that's something to bear in mind. They have a classic appearance. So it's sort of narrow zone of transition. They're very geographic, you could very much draw around them. Um They usually the centric, you see how they're off to one side and they usually metaphyseal. Remember in the flare of the board uh lesions, sclerotic and our white all the way around the lesion. And you get this soap bubble appearance and most of these resolved spontaneously in adulthood. And so there's no treatment needed aside from observation, unless they get very big and develop pain and pathological fracture. But that's rare osteochondroma. Um These are, these are want to know about if you're interested orthopedics because you'll probably see them relatively frequently. So they're um these, these lesions are different beasts in adults and in Children. So, despite being a benign latent lesion in adults, um in the growing skeleton, they're considered active. And that's because um if you think about the combination of the lesion with the growth that can be much more destructive and they're a combination of a bony outgrowth. Um And they've got a cartilage cap on them and they generally appear in the second decade. So, yeah, like 10 to 10 to 19 and they tend to stop growing at skeletal maturity on X ray and they look like these sort of bony outgrowth, uh point away from the joint and most commonly there around the knee. So in the distal femur or proximal tibia, they can be um cecil or they can be productive, weighted in shape. And a key is that the cortex of the osteochondroma is continuous with the cortex of, of the femur. And as is the as is the medullary cavity and that's important because um if it's new, not that it's more likely to be a sort of bone forming tumor and more likely a malignant tumor or potential for malignant chewer. So, um in general, you leave these alone unless they cause any issues. And if there are causing issues, you try to wait until skeletal maturity, to skeletal, maturity, to excise them, which you do through the base, they have a low rate of malignant transformation. Again. Um It's two chondrosarcoma because it was a Siboney, a outgrowth, it's bony and cartilage. Um And the main thing to know about this is is it's in relation to the cartilage cap. So if the cartilage cap on top of the bony outgrowth is more than two centimeters, then that's highly suspicious for uh transformation. And there's specific syndromes that are again out with the scope of this top. But I thought I put it in cause I thought was interesting is this family has multiple hereditary exostosis. And as you can see, they've got uh fairly characteristic features. So uh that's latent tumor's active, active benign bone tumor. So, these are, are generally, well, these are symptomatic benign tumor's. They are uh they might have some well ordered periosteal reaction, but they generally have a, have a narrow zone of transition and we treat them if they're symptomatic uh osteo chondroma uh impedes. So, yes, this is different. So, as I was saying, so, um we were just looking osteochondroma. But in a kid, um osteochondromas can be more significant and that's because of the potential for growth abnormalities. Um If you think about it, that's because they're, they're next to the joint there in the growing skeleton. And so in that case, they might require surgical intervention. Although if we can wait till skeletal maturity, then we do. Uh this one you'll see in trauma meetings quite a lot. It appears now and again. So this is a simple bone cyst or a unicameral bone cyst. Um They are usually solitary legion's, they are cystic there in the metatarsal region. So, uh the flare and they are most commonly in the proximal humerus about 50% of the time. Um They've got a narrow zone of transition, they're very geographic. So, remember we were talking about you could, you could draw around them and they've got a sclerotic rib. Um These occur in Children and adolescents and again, resolved by skeletal maturity. Uh They usually present with pain, uh can undergo pathological fracture because they can, they can get quite big. And in general and you leave them alone. If they fracture, particularly proximal proximal humerus, they can usually managed conservatively. Uh And some people think that's actually a good, not, not necessarily the worst thing in the world when they fracture because often that stimulates some bone healing and can get the cyst to fill in a bit. And they're quite controversial surgically. And there's no consensus on what you should do and most people just leave them alone. Um, uh, some people inject steroids in them when they're symptomatic. But that's of, of, of little proven benefit. And if it's a real problem, you can do an operation where you do a curettage and graft. So, again, scrape it out and fill it with a bone graft and, but the main indication for surgery for these, it comes if you have a lower limb fracture, which you obviously need to fix to then get the patient out walking again. Um Osteo, I'd osteoma and osteoblastoma. So these are essentially the same but are different sizes. So, um osteoid osteoma is, are, are painful little tremors and they develop in the diagnosis. So the shaft of bones uh but the central night uh uh of an osteoid osteoma and osteoblastoma is different sizes. So you get this central nidus that's less than a centimeter in an osteoid osteoma and more than a centimeter in an osteoblastoma. The pain is usually worse at night. It's eased by nonsteroidals and it usually appears in, in, in somebody's twenties. Um The nidus can be very difficult to see and because of that, there can be a misdiagnosis or often pain is put down to another cause they usually resolve with time. But if they don't, you can get radio ablation, which is basically where you, you stick a probe in with uh and it heats up. Uh osteoblastoma are a bit of a different beast because they're bigger and they actually quite often occur in the spine. Uh And as you can imagine, a benign lesion of the spine is often treated as if it were a malignant lesion. Uh And that's because that part of the body doesn't tolerate deformity very well. And so even though it's benign lesion, you might treat uh with the on block reception because you want to ensure that the lesion doesn't cause any deformity, which could obviously have significant consequences. Okey dokey. So, yeah, we're getting there. Uh We just have another set of benign bone tumors to rattle through and then um malignant tumors and then quickly talk about metastatic disease. So, um benign aggressive. So these are symptomatic. Uh they can be either geographic or more per me acttive. They tend to form a neocortex and, and so have a periosteal reaction. Uh and they will usually have some cortical destruction. So a couple of examples of this. So that's an aneurysm of bone cyst. Uh These things are usually solitary. Um uh but they're sort of expansile, multi loculated cystic, um and they present with pain and swelling and it's usually in the patient's childhood are up to the twenties and the X rays often show this trabeculated expansile lesion. And the main thing to know is that these can be secondary to another bony lesion. So you need to bear that mind. Uh They kind of put this in partly because they have quite cool imaging um so that the they have fluid levels in them. And so that's what the horizontal lines are there. So the MRI scan shows the shows the fluid levels which you can see is obviously based on, on gravity. So the image on the far right is a calcaneus. Um and and the calcaneus obvious images have also been spun round. So the lines horizontal to gravity um treatment is usually curettage and grafting, but they quite often come back. So they can be a bit of a bother from that perspective. G C T cells, giant cell tubers. So that's the one we showed you a picture of before that we said was quite difficult to work out and you could well be forgiven for thinking that this is a malignant condition. Uh It's uh it's solitary and locally aggressive uh usually in the uh metaphase iss or epithelial region and it can cross those regions. And so that's we turn that juxtacortical er so it's around the joint. Uh and there's often um complete cortical destruction and neocortex formation and treatment is again, curettage and grafting. Um And that's, that's what we call intralesional. So you go into the tumor and scrape it away, but because it's a difficult thing to get rid of is quite often done in a quite a specific way. So you, you, you go in, you make a window in the bone um and then you scrape away as much of the tumor as you can. Uh, and then you use something like methylene blue, so die to coat the inside of the body cavity. And then you can use a high speed burr just to get rid of all the dye. And then that shows that you've, you've got rid of all the, uh, all that bit of bone. And then you can put in something called feno, which is sort of alcohol to kill the tumor further. And then finally, you can fill the defect with cement, which provides some structural support, but it also kills the tumor via heat. So there's uh difficult to get rid of. But there's very specific things that people do to make uh you know, to surgically uh to try and get rid of it. So it's sort of, yeah, surgically interesting. And there's a drug called Denosumab, which is a rank ligand inhibitor, which you can give and it, it seems to work well and it uh it shrinks G CT. But the problem is that once you stop it and it just comes back and that can make surgical management more difficult. So there are certain times you would use it and then uh perfect. Right. So, yeah, we're back to a question. So you can see, you can see if we've still got people. So, um what's the most common primary malignant bonjour? So we give people 10 more seconds or so, Yeah. So this one split the room, hasn't it? So it's actually myeloma. Um, so from an orthopedic perspective, obviously, we think of it as osteosarcoma, but because that's the sort of primary bone tumor that we have to deal with, but overall, myeloma is actually actually more common just to bear that in mind. Um, so quickly we'll talk about the malignant bone tumors and I apologize for this, this busy slide, but I wanted to have all three of them up there. So you had the ability to compare them. Uh But the ones, the ones to have heard of our osteosarcoma. So osteo bone chondrosarcoma. So, Chondrosarcoma College and ewing sarcoma, which is its own special thing. Um So osteosarcoma, so that's the second most common primary militant bunch tumor. The first being myeloma, um which is obviously managed by the hematologist and oncologist. And, but osteosarcoma is the big one from the orthopedic perspective. I mean, whilst it's 20% of bone tumors, I think it's, I think it's something like 55% of the bone tumor of kids and adolescents. So it's the, it's, you know, it's the one that uh we're more aware of. It's still very rare, but it's one of the more rare and it has two peaks. So it happens in your sort of teens or 10 to 19 year olds and it has a second peak in, in a patient patient's fifties to sixties. And this spike later on is, is thought to be related to osteosarcoma because of Paget's disease and also radiation induced osteosarcoma, which is rare, but it does happen. Um most commonly um uh osteosarcoma happens around the knee, whether it's the distal femur or proximal tibia, but it can occur elsewhere. Uh Most patient's don't actually have metastases that we can find on presentation. Um So most patient's undergo an attempted curative treatment. Um and that involves neo adjuvant treatment with chemotherapy, um followed by surgical excision and the biggest improvement to um the care of osteosarcoma in the last 40 years has, has is still the better chemotherapy that was discovered in the, in the, in the eighties and nineties. And they've only been modest improvements since. So, outcomes really are quite dependent on the patient's response to chemotherapy. Um And you need to consider osteosarcoma as a sort of systemic disease because you can get these micro metastases, uh which we're all trying, we're trying to kill with the chemotherapy and the surgery is important. So you need to get what's called a clear margin. So you want a normal cup of tissue around about the around about the tumor. But much as I was saying, a lot of the success is down to the oncologist. Most osteosarcoma Czar Intramedullary, which is called a conventional and again, don't worry about this too much. But there's other types which are surface osteosarcoma as which tend to be a slightly lower grade. Also bear in mind that their blood tests and that you can do which might indicate a poor prognosis. So those are LP so outlined phosphate ease and LDH um chondrosarcoma and so chondrosarcoma meaning malignant tumor from the cartilage. Uh This, this is generally an older people. Um and it typically affects, typically affects the pelvis, uh the femur and the humerus and, and because it often affects the pelvis, it's quite a deep structure and that often means that they don't actually present until quite late. Um You often get a lucency in the, in the metastasis or the diagnosis. And the other thing to say is that there's quite a range of cartilage, uh cartilage lesions or so called what we called chondroid lesion's. And these can be really difficult to evaluate to decide if they're uh you know, how aggressive they are. And that can be quite difficult for the pathologists as well as the radiologists. And then that makes it difficult for the surgeons and which makes planning difficult. Obviously, um the thing to know about chondrosarcoma is that unfortunately, um it's uh not chemo sensitive or radio sensitive, which means that you only are relying on your operation to get a cure, which means that can be very challenging and particularly around about the Pelvis ewing sarcoma. That's the sort of of strange heritage. It's a small round blue cell tumor. Um It occurs in the metadata facil region and it's the most common bone tumor of million bone tumor of 0 to 10 year olds. Uh, and, and second behind osteosarcoma from 10 to 19 year olds, it's usually presents with pain and swelling. Um, but you need to be aware that often infection can mimic uh sorry Ewing's can mimic infection because patient's can get a fever anemia and leukocytosis. Um, x rays show a moth eaten lytic lesion with sheets of laminated periosteal bone, which is that classic thing I showed you before of onion skinning. So, the investigations includes also include bone scan and a bone marrow biopsy because you need to assess the bone marrow involvement as that's a poor prognostic indicator. The treatment for Ewing's is usually chemotherapy and surgery and sometimes we add on radio therapy right when you were there. Um So I'll briefly talk. So when it comes to surgical management of bone tumor's, the excision is, is very important. Surgeons are aiming for a clear margin around the tumor. So they've excised the whole tumor along with any little micro metastases that might have ceded along near the tumor. And then the surgeon has to decide if they're going to undertake limb salvage, which is, you know, obviously trying to, trying to keep the limb. Um and then they need to decide about reconstruction and, and the benefit of that is obviously that you, you keep the patient's leg and hopefully improve function, but that's uh not that needs to be traded off with the cost of survival. And it's interesting. Most a lot of surgeons in the western world tend to use large bits of metal such as uh they may end up using things like replacing the whole femur distal femur. Um And uh you know, for interest sake and there's because of lots of these patients are skeletally mature, they might require what's called the growing prosthesis, uh where the prosthesis grows with time and you can change the length of the prosthesis via magnets, which is quite cool. Uh Whereas in the developing world, they have less access to all these expensive metal work. So they quite often use a lot of allograft which is basically bone from a dead bone. So, you know, bone from a cadaver and in rare cases, they do uh crazy things like this on the right, which is a van Ness rotational plasty, which is basically where the tumor has been excised from around about the knee. Um And the nerves and blood vessels have been kept intact and the legs then been turned around 100 and 80 degrees um shortened down and then the ankle joint uh and the legs been joined again and the ankle essentially has become the knee joint. Um And this is not very well except in the West, but they have good results and particularly in places like India. So it's not common. Um I haven't seen one but I just put it here for interest sake just because we want to see, you know, some of the surgical side of the, of the MSG in college and the main challenge to orthopedic oncologist, just you're aware is, is survival and longevity of implants and they have real problems with infection. Because if you think about your average hip replacement last 10 to 20 years in a sort of elderly patient, well, in a young patient who's higher demand that will obviously potentially be a bit shorter, these are obviously much bigger hip and knee replacements. And that means that a patient who's 18 to have an osteosarcoma removed, might end up having multiple operations um in their lifetime. And the biggest worry aside from occurrence of cancer is infection, which is very difficult to deal with. Right. So we're on to our last bit. Thanks for being with us. So yeah, I wanted to finish with a quick case. So this is the lady we actually last week. Uh I've changed some of the details just to make it anonymous. But uh she's a 68 year old retired nurse who had a three month history of uh increasing left groin pain and she had pain at night. Um and it was worse when she was walking. She been taking some painkillers but wasn't really helping and she was starting to struggle. She went to her GP to get an X ray, um have a look and see what you think. Um And see if there's any abnormalities I think you could be forgiven for, uh, not seeing anything particularly obvious. Um, if you look at the left ileum, it doesn't look quite right. And her femoral neck, there's a bit of a bit of a lucency there. So it's abnormal. Um, so this is her just a few days later. So, yeah, unfortunately, her actually hadn't been reported. She'd gone home and then three days later she couldn't get to bed. Her husband phoned an ambulance and she comes in. Um and it actually shows an inter capsule and echo femur fracture. So, what happens next? Well, you're the S H O on call. Uh just uh depending on what you are. Just a couple years time times that flies by you is the admitting S H O are all important, your vital member of the team and to recognize that this uh is a potentially pathological fracture. So you're a good S H O U, take a full history examination and you pick up that she's had previous breast cancer. Um although it was treated with mastectomy 10 years ago and her last mammogram earlier this year and showed no evidence of recurrence, but you do ask her specifically about weight loss. She shrugs the question off initially, but then she said, well, actually, my clothes haven't been fitting quite so well recently and I might have lost a bit of weight. And so obviously, in this scenario, you need to have your spidey senses on you and you need to switch and change tact and recognize that you're dealing with a potentially pathological fracture. And that needs to be investigated before we can go ahead and do an operation. And why? Why is that? Well, that's because if this, if this pathological fracture, so pathologic fracture is a fracture through abnormal bone. Um If, if that turns to, to be because of a primary bone tumor, then if you do a standard treatment for this, which would be a hemiarthroplasty or a total hip replacement for an inter capsule fracture, you could contaminate the entire field with tumor and then, you know, you can affect the patients' outcome. So, um mets. So um it's important so to investigate any suspicious bone lesion, including METS that we need a full history and examination and the examination um needs to include a breast exam and the neck exam. And that's because remember, breast cancer, thyroid cancer, you need to get x rays of the whole bone, uh the full length of the bone. And that's because as we were talking about, you need to check whether the patient's got these skip lesions, excuse me, blood's. Um So we need standard blood, so full blood count using these LFTs CRP. Um but you also wants obviously a calcium because if they've got metastatic bone disease, they could well have hypercalcemia. And uh we also want to go searching for uh tumor's. So, consider, you know, do a P S A in men uh for prostate cancer, see a 125, which is, of course, the tumor marker for ovarian cancer, see a which might indicate Bell cancer and TFTs, which can be deranged in, in thyroid cancer. And of course, we want to do a myeloma screen and, and if you remember my lower screens got two bits too, hasn't it? So it's got the blood test and the urine test, the blood test is serum electrophoresis and the urine test is your In Revenge Jones protein. And then imaging. Um So this patient can't go straight to theaters were just talking about the need to be worked up. Uh They need a ct chest Abdul pelvis. Um And in her case, unfortunately showed that she had liver mets and she had Mets throughout her pelvis. And this was not to be related to her breast cancer. Um If this lady hadn't had widespread Mets, then she would then have gone, gone on to get an MRI scan and that would have been to see if there's evidence of a primary tumor. I want to say MRI scan, I mean, MRI is kind of the of the femur and then the, if we're still not sure the patient would have had a biopsy. And the difficulty is that the bone biopsy can sometimes take quite a long time to come back. But if, if we manage the patient surgically before finding out if it's a primary bone see whether we can get into, into difficulties and you'd be doing a patient a disservice because you could compromise that overall survive. And so our lady got a total hip replacement for fracture, accepting that she had widespread metastatic disease. So we weren't going to and negatively affect the outcome. So, yeah, metastatic bone disease is common. Most units see this every week or two, unfortunately. And as we talked about, you need to know the big five primaries. Um And we as orthopedic surgeons are often seen as, you know, we we don't really get involved in cancer and that's true to some extent unless you're a tumor surgeon. Um but we do often, we do relatively often see a first presentation of cancer in pathological fracture. Um for pathological fractures, there's no particular rush. You need to do an M D T approach. You might need to do a biopsy. And one thing I found out recently, which uh in the last few years, which I thought was interesting is that if you've got a patient with metastatic kidney cancer renal cancer and they have an isolated metastasis, just one met, then that can still be potentially cured via excision. Uh which is interesting. Um So you've got to be a bit careful and ask for advice. Basically is the thing. So I have a high index of suspicion and then ask for advice. Um Mets of course, are most common to the spine followed by the proximal femur. So please know about metastatic core compression. We don't time to talk about that tonight. Have gone on long enough and, and it's a separate topic but bear that mind. So, orthopedically, if you have a patient with a pathological fracture, um you need to assume that the fracture won't heal because the biology is poor. You need to ensure the patient will be able to immediately weight then afterwards. And because of that, we might do a different operations. So we want, we want to, to do an operation that's, that's durable and is robust and will outlast the patient. And that means that sometimes we do quite big joint replacements over our normal intra medullary nails, which can potentially fail if the fracture doesn't heal. And the other thing to be in mind is that even if a patient has metastatic cancer, they can actually live for for quite a long time. Um So one of my relatives has metastatic renal cancer and she's still with us eight years later. So, yeah, um so in conclusion, we talked about a bit about soft tissue tumor is being more common than, than, than bone tumor's. We talked about how to assess a lump and when they need referred urgently, um we had a quick blast through the radiographic features of million versus benign tumor's. And then we talked a bit about metastatic bone disease. Okey dokey. So, yeah, that's uh thanks very much for being with us. And uh has anyone got any questions? Okay. Well, hang fire on the questions. They're um thank you very much, David. That was really useful. Um, especially the case at the end. It's definitely something I've seen on placement before. Um, patients coming in and, and a really brief overview of all the tumor's and what to look out for is really helpful. Um I've just popped the feedback form in the chat there for everyone to ning in. And so if you could fill that in, that would be great. Um And we'll hang around for another five minutes or so if anyone has any questions. Um But yeah, uh anyone thinks of any questions afterwards to give me an email. That's not a problem as well. Uh Yeah. Would you like me just, I can pop your email on the chat if you, are you okay with that or would you rather? Uh Yeah, I can, I can do that too. Ok. Cheers. As long as that doesn't go out in the record, I'll go out in the record of it. You can catch, I'll crop, it doesn't uh grant well, nobody's, if you get, if nobody's got any questions, I'll leave you to uh well done for, uh sticking through what was actually in the end? Nearly uh, 12 minutes. Uh Yeah. Okay. Yep. I'll just see if, oh, hang up on us there. So, yeah, thank you very much and have a good evening. Everyone. See you later. Thanks guys. Thanks for me. Welcome. Bye bye.