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A question because it sounded so correctly. But was there a question? No, perhaps not. Ok. So just to summarize Adema, generally, uh young adulthood up to fifties, anterior tibia, um, they usually, they're technically not a cancer, but they can have a low grade malignancy up to about a quarter of them go on to metastasize. So you need to do your chest surveillance. Uh And if you get a negative margin, they do rarely recur it's very much a surgical treatment for an Amano uh they're not sensitive to chemo, they're not sensitive to radio. And so it is mainly a surgery only procedure, uh, treatment, sorry. Uh So it's a resection and then you're talking about reconstruction with auto or allograft, uh struts and fixation or some form of endoprosthetic, which might be a custom. OK. Any questions about Adema, you're probably not gonna say it in your part two. Not very common in the part two at all, but common in part one. Everyone happy. I'm gonna take the silence is a good thing. All right. Uh So we've kind of done the break already. We'll kind of cut them a bit short. Um OK. So we're gonna kind of end on Bone Mets today predominantly. I think this is mainly cases. So I think if we just carry on chipping in like we have done, if there's anyone that's uh peri exam who wants to um do them just shout out, OK, I can't see who signed in now that I'm in the slideshow. But OK, so bone Mets are common. You guys will see them on call all the time, right? So where do they come from? What kind of tumors? Lung, breast, breast, prostate thyroid, kidney, kidney. Uh So they're your com common breast um Common bone mets, um breast, most common in females prostate, most common in men. Um and then the rest of them made up from the others. So it's the most common reason for a malignant bone lesion in anyone over the age of 40. Ok. Um So sarcoma much less likely. Uh this is frequency of sight. So, spine then pelvis femur and humerus um in terms of frequency of location and does anyone know what an acral metastasis is? So it's a metastasis in the hands and feet? Ok. So you don't see them very often, but they're quite typical of a lung met. So, if you do have a met that's in uh the hand or foot, it's most likely coming from the lung. Ok. A little bit trivia, uh 65% of uh pathological femoral fractures go on to non union uh which is interesting because a lot of the time these get fixed, don't they in kind of peripheral non tumor units? So bear that in mind. Um when you're seeing these patients, when you're on call. So we come back to the osteoblast and osteoclast picture again. And we've got tumor cells here that are producing para para uh I can't speak. Now, parathyroid related peptide, which again triggers the osteoblasts to start producing rank ligand, which switches on your osteoclasts which resorb your bone. And then in the process of doing that, they create uh a signaling pathway that continues to feed back to the tumor cells to continue producing it. So there's more rank ligand, there's more bone resorption and that's how you get a lytic lesion forming in the bone. OK. Um Somebody has been asked in the past to talk through this in part two Fr CS in a basic science station. Is this the same mechanism for uh hypercalcemia as well or? Uh so it would be a reason for why they go on to develop uh hy hypercalcemia because they're leaching the calcium are they? Yeah. Yeah. All right. But it's a positive feedback loop. So it's this continuous cycle that is going on and fueling itself. Um OK. Who would like to go first? Anyone? OK. Who was that to? Was that? OK. Cool. Yeah. So 50 year old, six months of thigh pain, stand up from a chair and then they get sudden pain in their thigh, unable to wait there and they come in to A&E what do you think of the x-rays? So, a graft of the right hip which shows uh an obvious uh pathological fracture of the uh proximal third femur uh femoral shaft, uh which is fractured through a large lipid lesion which is occupying most of the middle canal. Um uh There obviously is the associated pathological fracture. There's a uh white zone of transition. Mhm It doesn't seem to cause any periosteal reaction. Um II can also see that there's some arthritis in the hip joint. Sorry. Are, are you going to investigate this patient? So, basic investigation for blood uh uh local staging, distal staging. So local staging would be MRI scan of the whole bone further x-ray views of the whole bone as well. It and natural and distal staging with CT uh chest of the pelvis, uh bloods, uh FP ce uh infection, tumor marker, infection markers uh and uh bone profile and group uh stuff for getting ready for surgery, like group and safe. Uh What other element of your uh systemic staging is there? So you do a CT chest abdo pelvis. And how are you gonna find out if this is one bone met or if there's multiple? So you can uh further do a bone scan to identify if there's any other good. Uh So nice description. Vish obviously, um you know, lesion is within the proximal third of um the femur mature individual, there is a large lytic lesion occupying the intramedullary canal with endos scalloping of the cortices with an associated pathological fracture, wide zone of transition. And this is most likely in keeping with uh a malignant lesion. This could be primary or a secondary metastatic. My work up would include um local and systemic staging in my local staging. I perform an X ray of the whole bone as well as an MRI. And I'd just take it that next level. Wish rather than just say you're going to get an MRI scan, just say why you're getting it. So you want an MRI scan to look to ascertain um the position of the, of the lesion and the nature of the lesion, any associated skip metastases in the femur and any significant soft tissue component. OK. I'd then proceed onto my systemic staging. This would include a CT chest abdo pelvis. This is to look for any solid organ tumors that could be the source of a bone metastasis or indeed any source of alternative metastases from a primary tumor such as um sarcoma metastasis to the chest. Uh And then my final part of my systemic staging will include a bone scan to look for any um multiple, any signs of multiple metastatic bone disease. OK. I'd also given that it's a lytic lesion, perform a myeloma screen and look for any signs of hypercalcemia. OK. So what we're gonna say is that this lady had breast cancer about 10 years ago. She was treated and she's been discharged. She's no longer under surveillance. So, what do you think that this lesion could be? The lesion is usually gonna be considered to be a Mets unless proven otherwise. Uh Because that's the most likely tumor, especially with the history of breast cancer, she'll have to uh examine the breast for the person as well to try and uh for the lady to see if there's a recurrence of the breast cancer. Obviously, she was discharged previously. Uh it could be an recurrence or it could be a new onset of primary tumor or it can be a new primary which is metastasized. Yeah, good. So some of you in Norwich will have uh met my lovely lady that's back on the ward at the moment who had a history of breast cancer about 15 years ago in the right breast. And then about two years later went on and had a metastasis or another primary, I'm not sure in the left breast. And then she presented um on Christmas Day with a pathological femoral fracture. Um and I worked her up because obviously it's a fair while it passed down uh since the primary diagnosis and her CT chest Abdel vs showed a 20 centimeter renal cancer. So, um that was quite a significant difference for her compared to her previous history. She also had quite a large pleural effusion. So that was aspirated because she was having some breathlessness on the ward afterwards. And actually, that aspirate has come back showing um features of breast um metastasis. So she's got a metastatic, um she's got lung Mets with associated metastatic pleural effusion from breast and the readings have just come back from her nail and suggest that it's breast. So she's really unfortunate. She's got a recurrence of her breast cancer and she's got a new renal primary all at the same time. So, um just, you know, to point out yes, there's a history of breast cancer but don't take it for granted that it's just another breast met. It could be a new primary, it could be a primary bone tumor. Yeah. So don't forget, breast cancers are associated with chondrosarcomas. So if it's been a while down the road and there's an isolated bone met that your nuclear med scan shows that there's no other lesions. Don't forget primary bone tumors in these patients. Ok. The types of people that you want to get involved are the previous breast oncologist that she the patient was under. You might also, if you haven't been able to find a primary on the chest. Um Abdel S CT myeloma screen is negative. Don't forget every hospital has got a cancer of unknown primary team and they'll also help try and investigate and give you suggestions as to what uh you could do to try to find a primary. Ok. So um just to recap. I know today is about a lot of recap but it's trying to drum home like the basic um skill set for on course, but also for the exam. OK. So the MRI scans to exclude skip Mets and soft tissue, look at the soft tissue components. Don't forget your whole skeletal imaging within your systemic staging. It's not just the CT cap. OK? And your diagnostic test. So in isolated bone biopsy in line with you both guidelines, you should be thinking about referral to tumor units for biopsy. Ok. Uh Let's imagine she's come on the Friday morning trauma to take she's had a CT cap, there was no primary identified the MRI scan pending and her skeletal stagings pending. So what, how are you gonna manage her uh at the moment? Vish. So w while we're pending, all the investigations, initial management is gonna be analgesia and uh try to reduce, minimize the movements at the fracture site by putting the patient on some skin traction. Mhm. Um Your colleague suggest you should just get on a nail at what you're gonna do. II would not be very keen on that idea because obviously we are still waiting for other investigations. Uh The concern is that if this is a primary rather than a uh metastasis, which we're expecting, you can further see the tumor. If this is the only identifiable tumor, then we can resect that and that'll be curative rather than have the risk of further seeding it. Good. Fine. So yeah, don't succumb to peer pressure. Ok. You'll see it often in trauma meetings uh that there's pressure to get on and nail these and it comes as there has been a significant change in the way that we approach these isn't there. So the prognosis of patients with cancer significantly changed from uh if you imagine the more senior consultants in the department now when they would have been coming through training, the treatments that the oncologist had would have been vastly different to what we have now and the survival would have been much different. So getting on and nailing, these was quite common because patients didn't survive to see the effects of nails start failing or that there weren't cancer treatments available to try to improve survival. Ok. So that there is a significant difference in the mindset of um how these are now treated. So you will see that there is some reluctance to wait for investigations. But that's why you guys are having this teaching today to try to make sure that going forward, we're all very mindful of the fact that these patients do survive sometimes longer than, than used to particularly things like more metastatic melanoma because immunotherapy is really good. Now, from that side of things. Ok. So Vish is agreeing, he's waiting for the imaging, but let's now say it's Saturday next day to meeting again, the MRI scans come back. There's no skip lesion, no soft tissue component and there's no other bone lesions. So you're gonna go in and get on it on with it on Saturday. All right. So, sorry, CD chest in primary primary. So, we expecting that this to be a primary lesion because we haven't found any other lesions. Uh This still needs uh uh thi this, this kind of uh procedure would require a resection. Now, that's what we're thinking of to try and resect the tumor and uh do some sort of uh uh reconstruction. So either it could be a proximal femoral replacement or uh yeah, most likely will have to be a proximal femoral replacement for this, this kind of lesion. Uh What do you need to? Sorry. W what do you need to know first? What's the next bit? So you've staged them, haven't you? What else needs to happen? Now, who needs to know about the patient? So, we need to have the uh MDT discussion about it with the oncologist and see uh whether further radiotherapy would be effective or useful in this procedure or chemotherapy prior to surgery would be uh basal. OK. So at the moment, we've got someone with a history of breast cancer with an isolated bone lesion and we don't know if they've got, we can't find a new primary. And so we're kind of at a point where with an isolated bone lesion and no primary where we're having to assume that this is a primary bone tumor until proven otherwise. So how are you gonna find out if it's a primary bone tumor? So further investigated with the biopsy, you need to get it. So in, in your exam, you need to be really clear and very early that you're going to discuss this in a tumor MDT with a tumor center. OK. And you're gonna use the Bose guidelines and for those of you that haven't seen them, the booze guidelines, bo Os uh for Bone Mets, OK. I would say that the booze guidelines, if you look them up on the internet, they're probably in a little bit more detail. The boost one is very much just that kind of typical, a four summary page. But if you go onto the booze guidelines, you do get a little bit more bang for your buck in terms of um the guidelines in that. So they're the things to quote when you're talking about these in the FRC S. But I wouldn't be intervening with this until we've got a biopsy. All right. Um And then the biopsy may come back as a primary, it might come back as it being a metas breast metastases. And you're right. If it does come back that it's a breast metastases, there might be still curative er or survival advantage to having a proximal femur um depending on what the patient's prognosis is. So, we're gonna say on this occasion, the biopsy confirms it's breast and the MDT outcome comes back from the tumor unit saying for local management. OK. So, um it doesn't have to be vish. So we've mentioned proximal femur as one option. Any other options, an inter calorie prosthesis. OK. By the time you've got a resection on it, so you've got a margin, the stem of the inter calories is probably not, is gonna be too long for what you've got left so good thought, but it's probably just on the slightly too high side. So you're kind of looking at a dia lesion for inter calorie, anyone gonna nail it. So, depending on the prognosis that we are expecting, I think that that is an option to nail, nail it. So if you're expecting the prognosis to be six months or less, then probably the there is a case that can be made for nailing this. Yeah, good. So um this is why that discussion with the oncologist becomes really important. So, in somebody who's got lots of systemic treatment options. So in breast cancer, you've obviously got a lot of hormone um er receptors that they'll test for and they'll obviously have her previous histology available. They would be able to tell you what systemic treatment options they have for her uh and what they might want to escalate to if that say doesn't work. So if somebody's got multiple systemic treatment options, they've got an isolated map. Their chest is ok. Their liver is ok. They haven't got florid metastases elsewhere, the oncologist might say to you, this patient's got, you know, 3 to 5 years. Now, if you put a femoral nail into this lesion, um and it continues to expand because that's obviously the natural process behind a tumor, it's not gonna stay the same as it. Um If you imagine opening out a paper clip and you wiggle each end of the paper clip, what happens? It'll break, it'll break exactly the same principle for your nails. So if this fracture doesn't go on to heal, which we know 6560 ish percent of them don't, um, your nail will break at some point. And generally speaking, in the lower limb that happens around the 6 to 9 month mark, you start seeing failure of the implant, it might not completely fail at that point, but the patient will probably be symptomatic of it. Ok? And then you're into the territories of doing a revision of a nail to a proximal femoral replacement. So, for somebody with an isolated bone lesion, you've got survival advantage of doing a resection and building it up with APF R, you've also got that. If their prognosis is sig significantly longer than 6 to 9 months, then the likelihood is, is that they've got adequate time to recover and rehabilitate from a big operation. But they're also, you're going to try to do that to avoid complications of the metalwork of the nail failing. And then a much bigger revision procedure at a time in their life where they may not be as well as they are. Now just something to factor in. If you are going to nail a pathological fracture or prophylactically nail or something, then you need to think about radiotherapy afterwards to control the local disease. And I've got some pictures later of one that didn't have that. Ok. And again, these are all reasons to have the oncologists involved. Ok. So we're talking about a balance of, is there a survival benefit to having this surgery or is this about function and symptoms or is it about both? Ok. Does that all make sense so far? May I ask with the once you've nailed, let's say you do go on to nail it. Um Is there a time frame when you, before you're allowed to do well before radiotherapy can be done? Yeah, I normally see them in clinic at two weeks for a wound check. And if their wounds healthy, then I let the oncologist know and they usually plan it from about three or four weeks after. Great. Thanks. Any more questions guys, I'm gonna keep going then, um, don't forget fracture beds contaminated. So again, another reason for radiotherapy in the fracture setting to try to reduce contamination. If it was just prophylactic, it's for local control so that your nail doesn't fail. Ok. Um So short prognosis, if it hadn't fractured, you might just talk about radiotherapy and palliation if they think that they've only got days to weeks to live. If they've got less than six months, you'll probably be thinking about fixation and radiotherapy. These are all very much symptom control, aren't they? And more than 6 to 9 months, you're thinking more p fr territory in this kind of situation and that's more, it may not be curative but certainly survival benefit in terms of bringing metastatic disease burden down, but also planning for uh avoiding metalwork complications. Ok. And this is why these things are so important. Ok. So this is the patient, I think uh off the top of my head, they were renal, met, nailed, they survived longer than their nail did. And so then they're in a position of having er P fr and after their nails been removed. Ok. And it's not infrequent that this happens. Um So these are the bo guidelines to read and it's the booze guidelines, the ones other ones that I mentioned. Um So this patient, OK, maybe it was breast milk renal. Uh So this patient had on increasing pain after they'd had their nail three months beforehand and no immediate complications, inflammatory markers uh were all fine, no fevers, but they were becoming progressively unable to weight bear. Ok. And their histology uh came back as a high grade chondrosarcoma. Ok. So what are your thoughts guys? What are you gonna do about it? Um So you should restage it. Absolutely. Yeah. Um So I'd get an X ray of the whole bone. Uh, I'd do a CT chest Abdel vs and A, and a bone scan. Um, I don't think an MRI. Uh I MRI. Yeah. Yeah, an MRI with what, like metal artifact reduction, yep sequencing. Um And, uh, and then I'd plan for, for surgery to remove the nail and do a, um, a proximal femoral replacement. OK. So, uh, in exam setting and you like, obviously, this needs to go back through the tumor MDT. OK. Them because it's a sarcoma. OK. Um You mentioned P fr so we're going to presume that we're in the tumor center because you will be in the FRCS. They'll just keep saying you are the tumor surgeon um is a proximal femoral replacement tom going to be enough to clear this out. No, no, I just thought so that by putting this nail down, we've seeded along the whole length of the femur. So she's going to need total femur replacement. OK. So where's your entry point for your nail, the tip of the GT? OK. So your incisions a few centimeters above that, right. Mhm Yeah. So you kind of go through what to get down to the GT? Oh, I see. So you'd have to excise the um abductors because you, that you'll have seeded it through through there. So, um uh you'd have to excise probably the distal locking screw tract as well. So basically a, a nail is uh there's significant contamination isn't there with a nail. So if you think when you're putting your reamers down the, through the genes, all those reaming are coming back out through that scar uh through your incision, aren't they all within the abductors? And then distally, you've also seeded it all the way down her femur and then you've got distal locking screws as well. So the entire thigh and the gluteal are contaminated in this situation, aren't they? So proximal femoral replacement is not quite enough. So she gets res staged. Co that's correct. Uh high grade chondrosarcomas are bad. Ok. So no other Mets found luckily for this lady. So options, curative intent is probably not up there. Is it because she's got significant contamination and if you were going for curative intent, you're at least looking at disarticulated her hip. Uh So hip disarticulation, uh amputation and debriding those abductors, you may not have adequate cover. So it may even end up going through the MDT for discussion of things like hindquarter or partial pelvic hemi reser resection um to try to get cover of the soft tissues around it. Ok. So these are the reasons, you know, another reason. Yes, metalwork can fail, but don't get caught out of missing a primary bone tumor in somebody just cos they've got this vague history of a metastasis like 10 plus years ago. Ok. Ok. Some more examples of things gone wrong. Ok. So this lady on the left she's got a thyroid met very slow growing. It's already been there for five years. A few years ago, someone decided to do a Prophylactic DHS to prevent this or, you know, from treating this if it went on to fracture. So I think prophylactic fixation is kind of quite a controversial one. There have been a couple of patients in the past that have died on table um in this region having prophylactic fixations and you kind of think to yourself was, well, clearly that wasn't the right decision to make, but difficult to kind of predict these things easy with retrospect, isn't it? But reality is, is that that person got robbed or whatever, not robbed but lost that time that they had with their family. Um And so I generally have conversations with people that are referred to me for prophylactic fixation about, you know, if this fractures, I've got a treatment for you. Um But actually if you're comfortable at the moment, we can try radiotherapy to have local control and symptom control. And actually the risks of having an anesthetic. And what is actually a big operation for someone with metastatic disease uh is trying to find that balance, isn't it? So for me, that's a conversation with the patient and what they would like to do and the risks that they're wanting to take based on the symptoms that they have. Ok. So this lady had this DHS done, I wouldn't do a DHS. From a prophylactic point of view because it's not adequate spanning of the femur and she went on to fracture and now a year and a half down the line, her DHS is failing. So, uh whoever's with me next week, uh we're doing that one. This uh lovely lady is a lady with breast cancer. Um She came in with a pathological fracture. She was nailed and about six months later, I think this had failed. So she had to go on to have a proximal femoral replacement. Ok. She's done remarkably well. This one is a lady who had a soft tissue sarcoma and had most of her anterior compartment excised 20 years ago. And she came in with a pathological fracture. She's 92. OK? And uh no tumor on the MRI scan. But because of her soft tissue sarcoma, 20 years ago, she had really high dose doses of radiotherapy. And so I think she'd actually got radiation changes in her bone. Certainly, when I did her operation, that bone was dead. Ok. And so she fractured through post radiotherapy bone. Um She had a nail in the first sitting under a colleague which at about again, around the 6 to 9 month mark started to fail distally and she was starting to get a lot of pain. She became wheelchair bound, uh which she had never been. And so we decided together that she, she would go ahead and have a proximal femoral replacement she had had it discussed with her at the time of the initial fracture, but she opted understandably at 92 to try the nail first, but she's ended up with a proximal femur. So she again, she's doing quite well. OK. Uh And this one is an unfortunate tale of woes. So this lady had um a small renal met here. It was just about visible on plain X ray, but more visible on MRI scan. And she had a prophylactic nail and COVID. OK. And no postoperative radiotherapy was done. And so over the 18 months after this nail, her local tumor obviously continued to grow co she not had any treatment. So she's started to have femur missing. OK. So that's painful. OK. She's getting obviously some movement around the nail. But actually, what you can see is that they also seeded it down her femur. OK. So she wanted a proximal femoral replacement, but because her lesion down here needed to be resected as well. My resection level was around this level because I'm past the isthmus. She has to have a custom made implant. So she had to wait eight weeks for it to be made. And she ended up in uh the palliative care unit and really deconditioned during that time. But actually, she had an isolated bone at this stage. She could have had a relatively straightforward proximal femoral replacement and been up and about walking in that 18 months. And she, she had really, she's lost out on about the last 18 months now, uh following her surgery as well as the pain that she had from this side of things and all that time in the palliative care unit while she's waiting for her implant to be made. So these are really quite big decisions for these patients and people often want some kind of uh algorithm that they can follow if it's this, do that. But actually, you have to really look at these patients as a whole and what their expectations and what it is that they're wanting to achieve. So in the exam, I would, especially if it was happened to be a longer case, put quite a big emphasis on their expectations and what they want to achieve and have a holistic approach to that patient rather than it being very much like an algorithm driven cancer treatment. OK. Any questions about any of these ones that the first one with the D, the failing DHS, what are you planning to do for that in terms of the tumor itself? Are you planning to resect that or this lady's got a metastasis in her spine and a metastasis in her pelvis uh on the other side. So she's already multimetastatic, she's got a systemic treatment option available, but this is a really slow growing thyroid tumor. So they expect that her life uh that her prognosis is still around the um they gave her a prognosis around 10 years. That was about four or five years ago. So there's still, they still think that she's got about five years at least. Um, so what I'm gonna try and do for her is that these broken screws need to come out. And so we're going to take the metal work out over ream her and, um, I'm going to do a really low neck cut and we're just going to curettage this out because she's multimetastatic. The surgery here is not with curative intent. Um, and she's had this lesion there for a fair while now. So I'm just going to curette it out, try and minimize any contamination of the field. So there will be lots of um, damp swabs in to catch anything so that we don't contaminate anywhere else. Uh And then I'm going to hopefully just do a long bipolar for a bipolar hemi for her, but I've got a proximal femoral replacement available. If these cause me any problems, it would be much easier to just go in and take this out as one piece and not risk any contamination. And I would do that if it was her only met, right? But it's not. So, uh I think for her, I can keep her own uh tissue and she'll get up mobilizing a lot quicker. This lady is still working in a factory and she wants to be able to get back as soon as possible. So, we've had that conversation of P fr versus uh hemiarthroplasty. Thank you. No worries do with this. Um This was a disaster. Um Again, so if you're gonna fix something, it needs to be followed up until union and you need to think about radiotherapy to stop that local progression. Ok? So if you fix something long term, follow up to union, you'll often see in the units that that's not happening. So raise it and mention the both guidelines, audit it, audit your departments. OK? If a fixation becomes painful, that patient needs an X ray. OK? To check, they haven't got a complication of their metalwork failing. And if their fixation fails, it is to be discussed with the tumor unit before repeat fixation is taken on and that's in the both guidelines. OK? So again, if you're getting that coming up in your exam, you need to be quoting the both guidelines and going back through the tumor MDT. OK. Um I think this is the final case. This is a 30 year old chap he's had, he's got bowel cancer, active bowel cancer and this is picked up as an isolated Met. So anyone wants to take it, the oncologist want to know whether you want to do a prophylactic nail. So there's a apian lateral radiograph of uh the femur um of a skeletally mature individual. Most obvious abnormality is a uh di diaphyseal tumor that appears to be causing a, a smaller cortical reaction. Um It doesn't look well uh, well circumscribed, uh, and there is a wide zone of transition as well. Uh, the first steps I want to do is take a history. See, Chris, make sure it's not infection. I'd also want to, after doing that, uh, um, history of any pain, any night sweats be symptoms. Any, um, we know that they've had a previous cancer, how it was treated, who treated it and what their follow up has been. Um After that, I'd want to take bloods such as a full blood count bone profile, ensure he's not hypercalcemic. I'd want to um get uh alongside that tumor markers as well. A FP I think is also involved in bowel cancer. So I'd want to get that. Um and then MRI scan uh as well as X rays, MRI scans of the femur and then CTC er for staging as well. After that point, I would follow both guidelines um to decide if, if I need to refer this to a tumor center before proceeding. Ok. Fine. So, um he's on this met has been picked up uh at the time of his staging for his bowel cancer, which is active. So he is referred into the tumor unit for possibility of a resection, given that it's an isolated bone met. So how could you go about resecting it? What kind of reconstruction options are there guys? Tom's favorite, the intramedullary one. Yeah. So it's called inter calorie. All right. So, um you resect the diaphysis and, uh, they have a diaphyseal replacement. Ok. So you can see that here. This is the part that's been resected stems go up top and bottom. Ok. So that's what he went on to have. And then after about four months, he starts to develop thigh pain. So he has some repeat x rays in clinic. And what do you think of those if this one hand? Mm. Uh, so basically clear the diaphyseal um prosthesis in place. Um thigh pain. I I'm suspecting a fracture of some sort. Uh some what fracture could be something, what else might have happened? What do you think this is, could have been a reoccurrence of the, of the cancer that we haven't got yet. So either recurrence or there weren't clear margins. Ok. So, and therefore local progression. So this guy unfortunately has an early recurrence and ends up having his uh inter calorie converted to a proximal femoral replacement. OK. And then another four months go past and he starts to develop thigh pain and he comes with this X ray. So now there appears to be progression distally uh with uh well, it there is definitely a cortical reaction with that kind of sunburst appearance and it also seems to be have now progressed maybe through the joint fluid to the proximal tibia as well of the spec of that, which is not good news for the guy. So he's got this really aggressive uh bowel cancer. And what would you do at this stage? Because the options are now, isn't it total femur proximal tibial replacement? It's in his fibula? Not really a reconstruction option. Is there so? Well, I would want to know what his functional capability is like you said, treatment treatments. Yeah, a whole holistically where his wishes are, what he wants to actually go back to doing what his prognosis is. Probably talked with the bowel surgeons as well as well as the uh tumor MDT and identify if arthro arthroplasty is a viable option or if there are any other. Yeah, it depends on his prognosis. If we're going down the more palliative route if we've gone through this extent of procedures. Yeah. So I think uh you're right in the sense of, you know, what are the expectations and having that kind of MDT discussion around what systemic treatment options there are the reality here is that even if you wanted to do an arthroplasty, I'm not too sure what you could do. This went about halfway down his tibia. So if it stopped at his femur, you could talk about total femur uh which includes obviously the hinge and the tibial platform, but actually having a total femur and a proximal tibial replacement would be pretty grim. Um and he'd become multi metastatic elsewhere at this point. So even if you were to talk about hip disarticulation, um getting rid of this, he's, he's got spinal Mets at this point. So, not curative uh amputation either from a me metastasis point of view. So, uh at this point, it becomes a conversation about radiotherapy for local symptom control and uh palliation. All right, it's really difficult sometimes as orthopedic surgeons to sometimes uh call that because it's not conversation that we often have from a tumor point of view. Uh on a day to day basis, we occasionally have it with hip fractures, don't we? Um But it's not quite the same, you know, having these conversations with somebody in their thirties. Is it? So, um you might not get very much experience in sarcoma and tumors in the east of England cos we obviously don't have a tumor center, tertiary tumor center. Um But if it's something, an element of it that you enjoy, we can certainly arrange for you to go down to Stanmore and experience a Sarcoma unit or even the sarcoma MDT S. Um And it might be an element of a subspeciality that you personally might enjoy. So, just bear it in mind that although we don't have it in this region, it doesn't mean that it's a subspeciality that you may not be interested in later. Um So if anyone ever wants to talk about Sarcoma Fellowships, things like that, just let me know. I'm always happy to have a chat with you, right? Um So final pieces because I think we're hitting five o'clock. Um Things to think about in terms of tumors in bone met side of things is one you think you might say in, in the FRC S and to patients about prophylactic fixation. Ok, fixation versus endoprosthetic. And when you're going to do which again in the exam and which patients you're going to pick out of the on call and be like, actually, I don't know, should they be being fixed? Should they, should we be discussing this before an endoprosthetic? Thinking about survival benefit, not just management of the fracture and remembering adjuvant treatment to try to make your implant last longer or for symptom control, local, local control of tumors. All right. Anyone have any questions? Uh, I had a question about, um, when primary bone tumors are nailed, uh, without the appropriate investigations and there's a, like a national data or something like that. That is that something that we need to know about? Um, I don't know that that would come up in the exam, but, you know, yes, they are. So, um, the ops are investigated, I think they call it a now. Um, and, um, the tumor units will initiate that happening. So if, um, you inadvertently nail or operate on a sarcoma, it will get flagged obviously when you refer it to at unit because otherwise they won't know about it. Thank you. Thanks. You're welcome. Any other questions? Anyone? Anything in the group chat? No, I wanted to ask you, um, MS space for that patient that, that had a resection for the diaphyseal re um lesion and was treated with intra prosthesis. If we have a patient who is elderly and uh osteoporotic, using that type of prosthesis does not cause biomechanically stress risers in the area on the neck. No, that's a good question, George. So, um they're cemented and you can get different length stems and you can get custom stems. So it will very much depend on what bone you've got left to work with. Um which of those implants you choose. But again, in an osteoporotic patient, I would use a fed implant. The risk would be quite low of um a femoral neck associated femoral neck fracture. The alternative would be to do say a, a custom made long um proximal femoral replacement if you were really concerned about an elderly patient with osteoporosis. OK. And another question. So sorry for bothering you. Uh that patient, that patient with the renal cell metastasis that you mentioned was treated with um a long uh I inhaling preoperatively. Uh Do we arrange for any embolization to be done to reduce the risk of bleeding? So, my personal preference is that if somebody's got a renal tumor and they have a soft tissue component on their MRI scan, I personally embolize them because I do find it much drier. When I do a proximal femoral replacement, they still bleed quite a bit. Um But it's much less than if you don't embolize them. If there's not a soft tissue component and it's purely bony metastasis, then I may not embolize them for that. There are some centers that now say you don't need to embolize them. Um And so there is controversy there. Um but there's very low complication rate of an embolization. So why would you risk not in my eye? Ok. They're also very miserable to do it and they've not been embed. You definitely save a lot of time in theater. OK? OK. Any more questions from anyone? If you think of any questions, feel free to drop me an email, we'll do something similar uh next time, but we're gonna focus on kind of the benign bone and soft tissue lesions and then we'll focus a bit on sarcomas. I'm not gonna be able to cover every single type of tumor with you, but it's very much about the principles and spot diagnosis that might come up in the exam. Ok? Anything anyone particularly wants me to cover next time anyone coming up to the exam that wants anything covered next time, I think we're going through pretty much everything. So you're happy. Nothing yet. Yeah, happy with that. Thank you. OK. All right. And then those of you coming to the workshop this term, we've got Mr Per coming up from ST, so he's going to be there. He'll do distal femoral replacements and we've got the kit coming in to play with and I'll go through proximal femurs and then we'll spend some time doing some Bible practice or case discussions depending on how keen you guys are. Ok. Great. Well done guys. Thank you for helping and being interactive. I'll see you soon. Thank you. Bye guys. Bye. Thank you very much pleasure. Thank you. Bye.