Documente Academic
Documente Profesional
Documente Cultură
Faculty of Medicine
Baiturrahmah University
PADANG
Neoplasia
Hamartoma
CLASSIFICATION OF
MUSCULOSKELETAL TUMOR
BENIGN MALIGNANT
PRIMARY
SECONDARY
METASTASIS
WORK-UP
1. Look
2. Feel
3. Movement
4. Auscultation
Physical Examination
Look:
• General status
• Lump
• Skin
Shiny
Venaectation
Hyperemia
Feel:
Mass
• Warm
• Tenderness
• Surface
• Fixed / mobile
• Size
INVESTIGATIONS
1. Laboratory
2. Plain photo (X-Ray)
3. CT Scan
4. MRI
5. Bone Scintigraph
6. Biopsi - Patologi
Laboratory
1. Blood Count
2. Liver function
3. Renal function
4. ALP
5. Serum Elektroforesis
6. Bence jones protein
Plain Photo
1.Location
2.Type of destructions
3.Periosteal reactions
4.Border of tumor
5.Matrix
6.Bony expansion and
Soft tissue
extension / mass
7.Multiplicity
Plain Photo - Location
Plain Photo - Type of Destruction
• Lytic
• Blastic
• Mixed
Lytic Lession
Fibrous Dysplasia
Osteoblastoma
Giant Cell Tumor
Metastasis Myeloma
ABC
DD Lytic Lesion Chondroblastoma
Hyperparathytoid
“HOLE IN BONE”
Infection
NOF
Eosinophilic Granuloma
Enchondroma
SBC
Plain Photo
Periosteal Reaction
Plain Photo
Tumor Margin (Transitional Zone)
Narrow or wide
Plain Photo
Type of Matrix
Plain Photo
Extention (bone or soft tissue)
Plain Photo - Multiplicity
1. Multidisciplinary team
a. Orthopaedic
b. Radiologic
c. Pathologist
d. Medical and radiation
oncologist
2. Planning for
a. Further diagnostic
b. Diagnosis
c. Treatment
d. Follow up post treatment
APPROACH FOR EVALUATION
Case
Case I
Boy, 8 y.o pain and mass at left thigh
• Location: Left Femur, meta-
diaphysis
• Type of destruction: mixed,
permeative
• Periosteal reaction: codman
triangle, sun burst app
• Border(zone of transition):
wide
• Matrix: osteoblastic
• Soft tissue: soft tissue
swelling (+)
• Multiplicity (-)
Benign tumor
1 Latent G0 T0 M0
2 Active G0 T0 M0
IA Low grade G1 T1 M0
Intracompart
IB Low grade G1 T2 M0
Extracompart
IIA High grade G2 T1 M0
Intracompart
IIB High grade G2 T2 M0
Extracompart
III Any grade G1/G2 T1/T2 M1
TREATMENT
Musculoskeletal Tumor
Chemotherapy Surgery
External Radiation
Internal Radiation
Systemic Controle
Preoperative; neoadjuvant
Objective
a.Downsize of staging
b.Facilitate of surgery (pseudocapsule)
c.Prevent micrometastatic
Posaoperative; adjuvant
SURGICAL MARGINS
TYPE OF PLANE OF RESULT
EXCISION DISSECTION
Various excision types for soft-tissue sarcoma Various excision types for bone sarcoma
Limb Salvage Surgery
1. Wide resection (complete resection of the tumor) must be
attainable.
2. Function of the salvaged limb must be at least as good as
the function of the limb after amputation at the appropriate
level required for complete tumor resection
3. Reconstructed limb must be stable and durable.
4. There must be adequate skin and soft tissue after resection
of the tumor to allow for coverage of the limb/reconstruction.
5. Local rotation of tissues and the use of free tissue transfer
have broadened the indications for limb salvage.
6. Usually major neurovascular bundles must not be involved
or surrounded by tumor
BENIGN MUSCULOSKLETAL
TUMORS
Stage Treatment Reconstruction
1 Observation None
Intralesional excision Local grafting
Stage TREATMENT
IA Marginal/Wide Excision
Reconstruction : Autograf, Allograf, Prosthesis
IB Wide Excision
Reconstruction : Autograf, Allograf, Prosthesis
ANV incorporation : Amputation/Disarticulation
IIA Wide Excision
Reconstruction : Autograf, Allograf, Prosthesis
Chemotherapy / radiation
IIB Wide Excision
Reconstruction : Autograf, Allograf, Prosthesis
Chemotherapy / radiation
ANV incorporation: Amputation/Disarticulation/
Exarticulation
III A/B Palliative & Pain controle
MARGINAL EXCISION
(DERMATOFIBROSARCOMA)
WIDE EXCISION – ARTHRODESIS HIP
(CHONDROSARCOMA)
WIDE EXCISION – INTERCALARY
ALLOGRAFT (FIBROSARCOMA)
WIDE EXCISION – INTERCALARY ALLOGRAFT
(OSTEOSARCOMA)
WIDE EXCISION – AUTOGRAFT
RECONSTRUCTION (JUVARA PROCEDURE)
(OSTEOSARCOMA)
Radical excision – Malignant fibrohystiocytoma
Pathologic Assessment of
Chemotherapy Response
• Clinical significance
• Good response (grade III and IV) is
associated with superior survival
outcomes (as high as 89% at 5 years).
• Grade I and II responders are at
increased risk of relapse.
A grade I response is superior to no
chemotherapy (5-year survival of 50%
versus 17%, respectively).
• Increasing necrosis by prolonging
chemotherapy induction time or dose
intensification does not correlate with
DIAGNOSIS & TREATMENT of MST’s ALGORITHM
MST
Plain x-ray Clin. assessment
FNAB Laboratories
Primary Metastasis