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Yes, we're ready, doctor. We can start whenever you're ready. Yeah. Uh good morning, uh good afternoon, good evening from wherever you are joining. Uh And uh I understand that uh it can be difficult uh if you are not able to uh go to your medical school, medical college for your regular lectures. Uh And uh um and I'd like to thank the uh the foundation for organizing this lecture and I hope you will find uh uh the lectures useful and uh you can text in your uh questions on the message chat box and then I'll try to answer them if I can towards the end. Uh So feel free to interrupt. Uh And uh so my name is Chan, I'm an orthopedic consultant from uh Liverpool University Hospital and you can see there is a river called River Mercy, uh which uh sort of joins the Irish uh and Liverpool is the famous for uh uh orthopedic. It's one of the pioneer cities and obviously, you know about uh the football in Liverpool. Uh and the first post graduate orthopedic course was started in a school in 1926. So my topic today would be to talk about soft assurance. Uh So uh and I just want you to know uh if I am not clear if you can't hear me, let me know. So uh can you hear me? We can. Yes, we can hear you doctor. It's just you could raise your voice a little bit better. You could be a bit clearer. Thank you very much. Ok, good. Yes, lovely. Yeah, good. So what you can see there is uh football and I'm sure most uh uh at least number of you would follow football. I would be interested in football. So do you know what is the diameter of a football? And do you know what is the volume of a football? I just think about it? Ok. So the it's useful to know because you see this thing off on the screen now you even play. But um sometimes we don't think about things we see. So the diameter is about 22 centimeters, circumference is about 70 oh uh centimeters and the weight is about nearly half a kilogram. OK. So I think I'll, I'll come back to why I am discussing uh the size and volume uh uh during the lecture and that you look at various other day to day uh things which you see. So for instance, take, take your own time. Ok. So the diameter is roughly about 15 centimeter. It varies. So people vary in size, but on average. Yeah, and then the volume is about say 4 to 5 liters, but this is a rough estimate, OK? And then you look at a little pea, ok. So this is about a 0.5 centimeters in diameter volume may be about two ML. And then we talk about golf ball, but I'm not sure not many, many of you would be interested in golf or playing golf. Uh So the golf ball is about 4.2 centimeters in size and about 41 millimeter in volume. And then I'm sure most of you who have eaten oranges and you like oranges. So roughly about the, the oranges vary in size. Uh So, but if you take uh uh say for a Jaffa or, or something like that, then it could be say 10 centimeter in size or 500 M and then we talked about uh football anyway. Oh, so computers on uh go slow. OK. So bear with me. So the reason why we're talking about uh you know, various objects and volumes, uh soft tissue lumps and bumps are fairly common. Ok. Uh Most of them are benign. Uh Some of them can be malignant. OK. Uh So if you Google this uh uh which we wrote up uh uh some time ago. So it just gives you overview of, you know what I'm trying to talk about. So why we should be aware of uh uh soft tissue lumps and the related problems. Uh And then the other thing I want you to uh uh look into uh would be uh learning module on the British Medical Journal called Lumps Bumps and Sarcomas. So, if you have access to uh the module, uh and then you could uh you know, you could do, you could do the module at your own time. Uh So, uh so these are the uh there's a few resources uh which may be of help to you. So I make a note of it. And if you find time uh uh use this uh module if you can access the uh BMG learning. OK. And so this is just looking at uh a cross section of your uh thigh. OK. So if you look at soft tissue lumps, so they can come from any of the structures, uh any of the structures uh as you see in the cross section. So they could allow soft tissue lump could arise from the skin. It can come from the subcutaneous tissue, it can come from the fascia, it can come from the muscle, it can come from the lining of the mass, blood vessels and bone. So it could come from any of the uh uh structure. So you need to be aware of lymph nodes and lymphatics. Uh So, swellings could arise from there. OK. Uh And then also you have other problems like your infections, hematomas, um soft tissue calcification, bursa, ganglion, cyst, etcetera. Uh uh you know, those are also swellings and then w what you're really worried about is a malignant uh uh uh s uh swelling. It's called sarcoma. So I think we need to be aware, you need to be aware of what is a benign swelling and what is a benign soft tissue swelling? And what is a malignant soft tissue swelling, benign soft tissue swellings by definition. So, uh a a benign soft tissue swelling doesn't spread elsewhere. So, there's a key difference between a benign swelling and a malignant swelling and benign swellings are much more common than malignant swellings. Ok. So, if you see one malignant swelling, you probably would see about hundreds of benign soft tissue swellings. And the commonest benign soft tissue swelling would be uh a condition called lipoma. So, a lipoma is a fatty swelling, it commonly seen in subcutaneous tissues. Uh it's soft, uh it is fluctuate, it is mobile, it's nontender. Uh and it is relatively slow growing and most of the time uh it's painless. Ok. And that is the commonest benign soft tissue swelling. It can occur anywhere in the body. Ok. Uh And in any age group. So, lipomas are the commonest uh soft tissue swellings. They are benign. Uh they can occur in any age group, usually painless. They are soft, maybe lob uh lob it just mobile, mostly in subcutaneous tissues, but sometimes it can uh uh it, it can uh uh uh it can occur in uh uh inside the muscles when it is called intramuscular lipoma or inside the abdomen can be a retroperitoneal uh li metas. So, but you have to be aware that it's the commonest uh soft tissue tumor. Ok. Uh And most of them, yeah. You know, if they are small, if they are painless, uh they could be left alone, but if they are symptomatic and there may be a case to remove them. So, key thing to remember is that lipoma is a benign, soft tissue swelling, common. Uh it can occur either uh in one place or it, you can also have multiple lipomas. So multiple lipomas sometimes can run in families. Uh Here is a familial uh lipomatosis. And then you also have a condition called Durkin's disease where uh the lipoma can be painful. Ok. Uh Can you hear me? What's that? Yeah, loud and clear. Doctor, loud and clear, loud and clear. I think basically he's got a frozen screen. Ok. Uh So I don't think I'm uh progressing with the uh uh uh presentation. I'll try to ge get this sorted while I keep talking. Ok. Lovely. Is it still frozen doctor? I'm sorry for the technical issues. We're just facing a couple of technical issues if you can bear with us for a couple more minutes and doctor should join right now. I apologize for the technical issues everyone. So doctors just rejoining right now. Thank you very much. Is right. Good. So, apologies uh about the modern technology. Uh I think I'm just still having a problem opening my power points. So I think I was talking to you about uh benign soft tissue lumps and we talked about lipoma, which is the commonest benign soft tissue tumor. And then we talked about ganglion, we talked about hematoma. Then you have various other conditions. I think you saw the picture. If you look at the cross section of your body, there are a number of uh mhm Good swelling. Uh and I also talked to you about so what is a benign swelling? And what is a Malign? Um, and usually it doesn't spread elsewhere and malignant soft tissue swellings have the potential to spread elsewhere and they are called sarcomas. OK. And again, as I mentioned, uh benign swellings are far more common than malignant swellings and, and they can occur anywhere in the body. So it's quite important to you. Recognize. Hello. Hello. Hello, doctor. Your connection is quite weak. You can you hear me? Yes, we cannot hear you real clear. Your connection is a bit weak. I'm sorry for that. Do you mind? Yeah, I think as I said, I think uh it is uh it, is it any better? Um I think right now is the screen, is it, is it ready to share the powerpoint? The er, not uh uh not yet. Uh So I think I'm still waiting for it to uh open. Uh Can you hear me anyway? So I can open? Yes. Right now, we can hear you. Is it OK? Yes, now we can hear you. Yeah, good. Uh apologies guys. I think II I can understand the frustration from wherever you're trying to join when you have patchy uh internet and the line keeps dropping off. Uh But anyway, so I think we are talking about uh malignant soft tissue tumors. So they're called sarcomas. OK. Uh Sarcomas are malignant soft tissue tumors that can occur anywhere in the body, any age group. Uh and uh uh there is about 100 and 60 types of uh plus types of soft tissue sarcomas. Uh and they can uh occur anywhere in the body. Yeah. Uh usually uh they can occur in new newborn babies, young babies, uh adults, but more common in adults than uh young people. So there are, if you take the terms glaucoma, it is derived from a Greek terminology, uh called sarco means flesh. So it is a tumor arising from the flesh and there are three big subtypes of uh sarcoma. So one is so soft tissue sarcomas which arise from the bone. Second one would be primary bone sarcomas and then third one would be and third one would be what is called a gastrointestinal stromal tumor. So, those are the three big groups of sarcomas and usually the soft tissue sarcomas are more common uh than bones, primary bone sarcomas and gastrointestinal stromal tumors. So, they are relatively uncommon. So in, in meaning in your case, uh we see about say 5000 new soft tissue sarcomas per year out of a population of 66 to 70 million. So we can understand how uncommon it is. So, if you have 100 people with a type of cancer, maybe one will be sarcoma. Ok. Uh And if you have uh 5000 people with all sarcomas, uh you have about 1000 with gastrointestinal stromal tumor and then maybe uh uh maybe about say 500 primary bone sarcomas. So it's so in relative terms, primary bone sarcomas like your osteosarcoma or chondrosarcoma, they, they are fairly uncommon uh in relative terms. And so usually sarcoma is present as a soft tissue lump and you have a body called N which is National Ins Institute of Care and excellent. So they came up with some guidelines in the past on diagnosing uh soft tissue uh guidelines how to help uh doctors to diagnose the soft tissue lumps. And prior to 2015, they said any swelling that is bigger than five centimeter that is getting bigger uh or if it does come back after the previous operation, uh or if it is deep to deep fascia and if it is getting bigger or painful, then they should be considered malignant and then they should be referred to a regional center uh for further assessment. And then in 2015, an updated guideline saying that's any unexplained swelling. So if you look at uh you know, if you're a doctor and some uh patient comes to and you uh this is set of short uh duration. You don't, there's no history, there is no past history of lipoma, then you're worried. So what this could be. So what they said was that any unexplained swelling should get a two week full ultrasound, a soft tissue lump would be an ultrasound scan if it is possible. Uh You, you, you can diagnose number of conditions by clinical examination. But if you have a lump, which you don't know where it is identified, uh the soft tissue lung and if you have an ultrasound scan, the ultrasound scan can be, can show benign features. So if you show it's uh you know, it's a benign swelling, a lipoma uh or, or a cyst, benign cyst. So that could be managed uh according to, you know, what needs to be done. But if this, OK. So in that, see if it shows in inter vascularity, if it is heterogenous, it has got show up uh wearing uh the texture, then uh then that, you know, if that situation, it is uh a sarcoma or specialist unit which deals with sarcomas. Uh and uh the, the, the way of cancerous product that is provided varies from country to country. Uh So sometimes you have uh uh sometimes you have uh uh uh especially yeah for sarcomas. So what do, what do you mean by multidisciplinary t to disciplinary, have a group of uh surgeons, you have radiologists, you have, you have oncologists, you have specialist nurses uh and you have varying group of surgeons. So all of them joined together to identify a person's problem. And then try uh and so as I said, if someone has an indeterminate or uh malignant looking swelling, they eu so there are 10 things I would say one should do if anyone, so a clinical examination, uh if someone presents to you with a lump, uh there, see. So look, hm First, I think it's quite important to have a detailed history of how um is it painful or not? Have you had any previous operation in the same area? And have you had any similar lumps anywhere? And then past history of malignancy family, history of similar swelling? So, if you, this conditions like neurofibromatosis, uh uh so uh uh problems like neuro uh c can present as multiple lumps, I'm sure you would have seen people with uh yeah, one, a neurofibromatosis type. Ok. And then you look at the swelling and you so on external examination. So you can see whether the swelling is clearly visible. Is it diffuse or it's got uh altered skin color? Uh Is there any redness or, or any uh other swellings anywhere else? So you inspect the whole of the limb or body just to make sure that you see what you need to say. And once you've seen the swelling, then the next one would be palpation. So history inspection, palpitation. So, palpation, you see if the swelling is soft, ru painful. And uh and you also need to make sure that there isn't any distal neurovascular deficit or regional lymphadenopathy. Uh So we need to check if there is any lymph nodes uh uh uh uh a present. Uh and again, in the history, I think you need to remember that person who's coming to you. Uh doesn't necessarily, you know, they, you have to look at the person as a whole human being who might have multiple other problems. So it's not necessarily the, the current situation with the patient. Mm As well. Uh So what medication they are on and what are they allergic, allergic to whether they had previous operations, whether they had any problems? So you need to get a comprehensive information about the person who to you for a lump. So, but sometimes the lump, one of the many problems and many other problems may be more important than this. So you need, yeah, you take a good history and then you go on to examine uh the lump and then you decide. So you, you, you seen looked, you felt and then, and then there's um sometimes some lumps can po present with the bru the bruit you, you, you uh vascular malformations uh which can uh uh which you know, which you can uh are an aneurysm which can, you can hear pulsation, but they, they, they're uncommon, but you need to bear in mind that you can have swellings coming from the blood vessels like aneurysms, like in your popliteal fossa or in your groin, uh swelling. So you need to be aware and the key. But when you are looking for any swellings is uh the anatomy. So to know to me particularly and then thematic coming from doctor is coming in and the black we roll it. What is the, the possibility? And then you come to a clinical diagnosis. So you, so from the history and the examination, say for instance, someone who's had a swelling for a long time and the swelling is painless. It is subcutaneous, it's lo related, it's mobile, it's non tender. The diagnosis would be a lipoma. Clinical diagnosis would be a lipoma. Sorry doctor. We could, the connection is caught off you again. Yeah. Can you hear me now? Yeah. Now we can hear it's continuously kind cutting off. Hey, kids. Ok. It would it be possible maybe connecting to an hot spot or maybe to an alternative alternative um wifi connection if it's possible? Ok. Uh Sure. So if you uh give me say uh five minutes, I'll try to join again. OK. So, so actually you have a, a five minute break. Is it OK? Ok. All right. OK. Thanks. All right. Will allow me to share the screen. Um Just OK, I've given you permission. Maybe you can try right now. Uh Good. So. Ok. Yeah, me on the uh zoom. I think I was talking about uh uh you know, how to uh you know, clinical examination and then followed by uh uh I think once a patient presents to you. So you get a good history. Uh and uh uh and then you need to uh the next thing you need to do is to arrange for appropriate investigation. So I think we said uh should uh come with the uh uh should have an ultrasound scan as a screening tool. And if the spelling is deep or it is bigger, uh and then maybe there's a case to uh have an MRI scan or a CT scan. So the MRI scan is very good uh and uh to show the anatomy and pathology better. And then the next thing if you think a lump is malignant, uh and then you need to arrange for what's called uh uh biopsy. Uh So we need to take a small sample uh from the tumor. Uh And usually what we recommend uh would be what's called uh uh ultrasound guided co needle biopsy. Uh So we take a small sample using the ultrasound scan uh and then send it to be seen under the microscope by a pathologist and the pathologist, most of the time would be able to give a diagnosis. And if the diagnosis comes back as a sarcoma, uh and then what we need to do is to do what's called staging studies. OK. So just to see whether the tumor is localized or whether it spread elsewhere. Sarcomas as a rule, they tend to spread mostly to lungs. There are certain cancers which go to lymph node, uh and certain cancers which go to liver. Uh but sarcomas by and large, they metastasize to uh to lung. There are all sarcomas which can go to uh uh liver and lymph nodes, but most of them metas uh I mean, so what we normally do would be take, get just a and uh the chest abdomen and pelvis. So you get a CT scan. So this will give us any information whether, whether the stuff glaucoma is locally to the limb or uh as per cause. What is the best possible uh way of treating sarcomas. If someone's got metastatic disease, then, so usually about say 10 to 20% of people would present with uh soft tissue dis comma and about say 80 to 90% would have localized disease. So if you have a s it turned out to be a sarcoma and if it is localized, if it does not spread elsewhere, then the options of treatment, they will give you preoperative radio. Do you uh uh certain types of tumors? Main idea would be to remove it completely. Ok. So you don't want to remove any uh residual tumor behind and also you want to make sure that you preserve function of the limb. Uh So as most of the sarcomas or soft tissue and circle in the extremities. So the main he is to remove the tumor completely and then preserve function. OK. How from your? OK. Uh you need to have, so you need to have good uh support in theater, you need to have uh a good postoperative. And so the infection is just need to make sure that there isn't any uh infection, the wound has uh healed completely and then you have uh managed to uh restore as much function as possible. Uh So you, you could uh you know, you need to ensure that the patient is fully recovered. And then if and then, you know, the tumor that's been resected would be sent to be assessed again by the pathologist. And this could turn and depending on what type of tumor it is and what grade of tumor and what is the margin? There may be a role for postoperative radiotherapy. And the idea of postoperative radiotherapy is to improve local control. So, the idea of the postoperative radiotherapy is to stop the tumor coming back in the same area and it reduces uh the risk of the tumor coming back by about 50%. So there is a role for postoperative radiotherapy after re of sarcomas. And if someone has had preoperative radiotherapy, then there is obviously no need for postoperative radiotherapy. And then the next thing we want to discuss is that if someone has got a soft tissue sarcoma. So what is the prognosis? So if you have 100 people with sarcoma today, OK, about 50 to 60% would be alive in five years time. In other words, about 40 to uh 50% may not survive more than five years. So this is uh in, in, in grand scheme of cancers. So this is uh it's sort of in the middle ground. So if, hm, OK, uh things like pancreatic cancer or lung cancer, we can be quite low, maybe 10% 20% 30%. Uh On the other hand, if you look at things like breast cancer, uh uh lymphoma, uh uh et cetera, you, they can have very high uh survival rates. The main reason why uh sarcoma not that great prognosis is that the average size at presentation is about 10 centimeters. So if you remember, I talked about football, golf ball, et cetera. So it's like a big orange. So that's the average size in the United Kingdom. I'm sure uh in, you know, countries around the world, soft tissue swelling can be huge. OK. And the prognosis depends on the size of the tumor and every one centimeter increase in size, it reduces the survival by about 2%. So bigger the swelling was the prognosis. So that's size. And then the next one would be depth of the tumor. So if you have superficial tumors and you have deep tumors, if you have deep tumor uh that has got worse prognosis compared to superficial tumors, purely because superficial tumors can be seen easily. Uh And they're diagnosed yearly, deep tumors can take a while before they're picked up. Ok. And the third prognostic fracture uh factor would be the grade of the tumor. So you have high grade tumors, you have intermediate grade tumors and you have low grade tumors. So if the tumor is high grade tumor and then the prognosis is not great. Ok. And then the next factor is metastatic disease at diagnosis. So, if you have metastatic disease at diagnosis, then that is not great. Ok. So the survival drops down to about say uh 20% 5 year survival if you have metastatic disease at diagnosis, and then the next prognostic factor is the actual tumor it there. Uh and if, if you that there are various types, sub types of sarcoma. So if you have something like undifferentiated sarcoma or rhabdomyosarcoma or pre morph sarcoma or epithelioid sarcoma. So these are sort of really uh the the the the the prognosis is bad compared to something like uh common tumors like say a liposarcoma which are relatively slow growing. So that is about uh the prognostic factor. And then once you treated someone with a sarcoma, what happens. So what normally happens is that we tend to follow them every three months, every three months, they come for a clinical assessment to see if there is any local recurrence or if they've got metastatic disease, and we would do that by using a chest x-ray. So chest x-ray to diagnose metastatic disease is a relatively crude tool. By the time you see something on a chest x-ray, uh then obviously there is bigger volume of tumor in an ideal world. A CT scan, low dose CT scan would be a good screening tool. But then you have to look at the cost implication of having a CT scan uh and also the potential radiation dose. So we sort of judiciously use a staging scan. Uh sorry, a CT scan in the follow up setting. Uh If someone has got a high grade tumor who's got high risk of developing metastatic disease, then probably we would get a CT scan in a year's time, two years, time, et cetera. But most people would get a three month chest x-ray and clinical assessment and we do that for up to two years. Hello, white. Two. Yes. People who tend to have problem look like a look. This is the OK and be in the two years. So we just set up. Can you hear us? Uh Can you hear me now? Yeah. Can you hear me now? I can hear you? OK. Connection was cutting out a little bit too much right now and we've got five minutes left until the Yeah, I'm finishing anyway. So I think I'm coming to the end. So, yeah, I think we're talking about prognosis. And yes. And if, if, if they don't develop any metastatic disease or local records, then they could be discharged from uh the clinic. Ok. So, in essence, I think I talked to a comma if you get a chance uh try to do that. And the key thing to remember is that uh the 10 Commandments. So a good history, physical examination that the swelling could be a sarcoma, the right thing to do would be to refer uh the patient to an expert or a specialist center there who deal with this problem often because uh sarcomas are uncommon and people who treat it more often have the expertise to deal with the problem better than someone doing it once in a while, an important thing to know awareness of soft tissue lumps and burns and some of them could be malignant. You need an ultrasound scan assessment if it is is a history of sarcoma, send it to an expert who can deal with it. So, and as I said, science is an important program comma bigger the swelling worse the prognosis. I I hope that uh the I have pictures this better a bit sequel those. But uh unfortunately, I couldn't do it today. I think what I will try to do uh talk to your coordinators and then try to reschedule the swelling. Uh internet connection is better. Uh So thank you very much for your patient hearing and I wish you and uh, uh and I'm sure you will become excellent doctors uh in the future. Uh, is it ok, Mose, have you finished? Yes, thank you. Thank you very much again. Is there any, any questions or anything on the chart? I can unfortunately, no, there are no questions in the chat but, um, I'm sure, I'm sure if there's gonna be a next lecture where we can cover all of the questions and everything for.