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Pathology for FRCS (Orth)

Soft and Bone Tissue Tumour Descriptives
by

Rej Bhumbra

on 25 September 2014

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Transcript of Pathology for FRCS (Orth)

Rare conditions that warrant management in a Specialist MDT:
Questions from the X-ray:
?
What do you Do?
Refer to my regional bone tumour unit

Management of these conditions is made in a Sarcoma MDT
Pathologists
Radiologists
CNS
Med and Clinical Onco
Orth Onco Surgeons
You are the BTU:
MDT - ?Obtain tissue diagnosis

Stage the disease
Locally
Bone XR/MRI
Distantly
Bone Scan
CT Chest
Cartilage Tumours
Cartilage Rest
Enchondroma
CLUMP
Low Grade Chondrosarcoma
Intermediate CSA
High Grade CSA
De-differentiated CSA
Abnormal Radiograph
1. Metastatic Process

2. Infection

3. Primary Bone Tumour or haematological malignancy
Benign
Latent (non-ossifying fibroma or cartilage rest)
Active (enchondroma/osteoid osteoma)
Aggressive (ABC or GCT)


Malignant
Chondrosarcoma/Osteosarcoma/Ewings
4 presenting complaints
1. Mass – Bony or Soft Tissue

2. Incidentally – minor trauma/x-ray

3. Pain – especially if non-mechanical

4. Fracture
hair on end
lytic fibrous cartilaginous osseous
Summary 2
AGGRESSIVE

Wide Zone of transition

Soft Tissue Mass

Destroyed – grow thru
Non-Aggressive

Narrow ZOT

No mass

Neo-cortex
Codman’s
triangle
sunburst
Summary 1
1. Metastatic Process

2. Infection

3. Primary Bone Tumour or haematological malignancy
Age
Non-aggressive/Aggressive
0 - 10
simple bone cyst
eosinophilic granuloma
Ewing's sarcoma
leukemic involvement
metastatic
neuroblastoma
40 & above osteoma
metastatic tumors
myeloma
leukemic involvement
chondrosarcoma
osteosarcoma (Paget's
associated)
MFH
chordoma
10 - 20
non-ossifying fibroma
fibrous dysplasia
simple bone cyst
aneurysmal bone cyst
osteochondroma (exostosis)
osteoid osteoma
osteoblastoma
chondroblastoma
chondromyxoid fibroma
osteosarcoma,
Ewing's sarcoma,
adamantinoma
Radiology
History
20 - 40
enchondroma
giant cell tumor
chondrosarcoma
matrix
1 Bone Tumours
Orthopaedic Pathology
for FRCS Tr & Orth

1
o
Open physis?
Polyostotic?
2
3
site
doing to the bone?
4
5
soft tissue mass
lytic
fibrous
cartilage
Tissue Origin
(where - micro)
Rej Bhumbra PhD FRCS (Tr & Orth)
Consultant Orthopaedic Surgeon
Barts Health
Newham & the Royal London Hospitals
Miscellaneous Orthopaedic Conditions
Soft Tissue Tumours
Acquired
Congenital
Metabolic
Traumatic
Endocrine
Neurological
Infective
Nutritional
Degenerative
Neoplastic
1
2
3
4
5
Hx and Ex
Pathology
Macro, Micro & Molecular
Radiology
Actually Required?

Biopsy in unit that can perform the procedure (molecular/imprint)

Biopsy path is excised in definitive procedure (if required)

Results interpreted in light of radiology. ie MDT setting

Prompt initiation of Adjunct therapeutic agents (Chemo/XRT)

Medico-legal
Should the Specialist Unit Biopsy?
Treatment aims.
Preserve: Life, Limb, Function
HG osteosarcoma/Ewings.

Without effective chemo =
Can a margin negative resection be completed safely?

Will the distal limb be viable?

Will the limb be functional?


Just because something can be done, should it be done?
Once diagnosis of malignant
bone tumour confirmed.
Staging:
Local:
Whole bone radiograph
Whole bone MR. X1 seq.
Local tumour MR assessing
extent of lesion and relationship
to critical structures

Distant:
Bone Scan.
CT Scan
(PET)
RULES:

1. Start by describing what you can see.

2. What is it coming from and what is it making?

3. Do NOT call something malignant unless
your triple assessment is complete/fits.
There is a lesion....
It is arising from....
It appears to be aggressive/non-aggressive
If concerned, I would refer...
I am aware...
Bone Tumours
Bone Tumours
Pathology
Diagnostic
Triangle
Excisable with further incision

In 1 muscle that can be excised

Avoid T Incisions, Haematomas & NVB

Drains in line with excision
Limb preservation?
zone of transition
2
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