HYPERPLASIA METAPLASIA ANAPLASIAHYPERPLASIA METAPLASIA ANAPLASIA

NEOPLASIA TNM CLASSIFICATION AND ITSNEOPLASIA TNM CLASSIFICATION AND ITS

ORTHOPAEDIC APPLICATIONS SURGICALORTHOPAEDIC APPLICATIONS SURGICAL

CLASSIFICATION HISTOLOGIC CLASSIFICATION HISTOLOGIC

CLASSIFICATION AND PRINCIPLES OF LIMB CLASSIFICATION AND PRINCIPLES OF LIMB

SALVAGE SURGERYSALVAGE SURGERY

Dr Sushil PaudelDr Sushil Paudel

NEOPLASIANEOPLASIA

A neoplasm is an A neoplasm is an abnormal mass of abnormal mass of tissue growth of tissue growth of which exceeds amp is which exceeds amp is uncoordinated with uncoordinated with that of the normal that of the normal tissues tissues

Willis RA The spread of tumours in the human body London Butterworth amp Co 1952

HYPERPLASIAHYPERPLASIA

Increase in the number of cells in an Increase in the number of cells in an organ or tissueorgan or tissue

Physiological hyperplasiaPhysiological hyperplasia

Pathological hyperplasiaPathological hyperplasia

METAPLASIAMETAPLASIA

Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another

Epithelial metaplasiaEpithelial metaplasia

Connective tissue metaplasiaConnective tissue metaplasia

Eg Myositis ossificansEg Myositis ossificans

DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA

Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation

PleomorphismPleomorphism

Altered NC ratioAltered NC ratio

Atypical mitosesAtypical mitoses

Tumor giant cellsTumor giant cells

DYSPLASIA DYSPLASIA

Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual

cells as well as loss in architectural cells as well as loss in architectural orientation orientation

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

NEOPLASIANEOPLASIA

A neoplasm is an A neoplasm is an abnormal mass of abnormal mass of tissue growth of tissue growth of which exceeds amp is which exceeds amp is uncoordinated with uncoordinated with that of the normal that of the normal tissues tissues

Willis RA The spread of tumours in the human body London Butterworth amp Co 1952

HYPERPLASIAHYPERPLASIA

Increase in the number of cells in an Increase in the number of cells in an organ or tissueorgan or tissue

Physiological hyperplasiaPhysiological hyperplasia

Pathological hyperplasiaPathological hyperplasia

METAPLASIAMETAPLASIA

Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another

Epithelial metaplasiaEpithelial metaplasia

Connective tissue metaplasiaConnective tissue metaplasia

Eg Myositis ossificansEg Myositis ossificans

DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA

Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation

PleomorphismPleomorphism

Altered NC ratioAltered NC ratio

Atypical mitosesAtypical mitoses

Tumor giant cellsTumor giant cells

DYSPLASIA DYSPLASIA

Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual

cells as well as loss in architectural cells as well as loss in architectural orientation orientation

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

HYPERPLASIAHYPERPLASIA

Increase in the number of cells in an Increase in the number of cells in an organ or tissueorgan or tissue

Physiological hyperplasiaPhysiological hyperplasia

Pathological hyperplasiaPathological hyperplasia

METAPLASIAMETAPLASIA

Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another

Epithelial metaplasiaEpithelial metaplasia

Connective tissue metaplasiaConnective tissue metaplasia

Eg Myositis ossificansEg Myositis ossificans

DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA

Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation

PleomorphismPleomorphism

Altered NC ratioAltered NC ratio

Atypical mitosesAtypical mitoses

Tumor giant cellsTumor giant cells

DYSPLASIA DYSPLASIA

Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual

cells as well as loss in architectural cells as well as loss in architectural orientation orientation

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

METAPLASIAMETAPLASIA

Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another

Epithelial metaplasiaEpithelial metaplasia

Connective tissue metaplasiaConnective tissue metaplasia

Eg Myositis ossificansEg Myositis ossificans

DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA

Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation

PleomorphismPleomorphism

Altered NC ratioAltered NC ratio

Atypical mitosesAtypical mitoses

Tumor giant cellsTumor giant cells

DYSPLASIA DYSPLASIA

Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual

cells as well as loss in architectural cells as well as loss in architectural orientation orientation

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA

Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation

PleomorphismPleomorphism

Altered NC ratioAltered NC ratio

Atypical mitosesAtypical mitoses

Tumor giant cellsTumor giant cells

DYSPLASIA DYSPLASIA

Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual

cells as well as loss in architectural cells as well as loss in architectural orientation orientation

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

DYSPLASIA DYSPLASIA

Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual

cells as well as loss in architectural cells as well as loss in architectural orientation orientation

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

HISTORYHISTORY

Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman

Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade

intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade

extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade

intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High

gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS

BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MALIGNANT LESIONSMALIGNANT LESIONS

OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the

neoplastic cellsneoplastic cells

MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION

Takes into account etiology localisationTakes into account etiology localisation

bone specific topography and histologybone specific topography and histology

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA

SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA

EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA

1 INTRAMEDULLARY1 INTRAMEDULLARY

OsteoblasticOsteoblastic

ChondroblasticChondroblastic

FibrogenicFibrogenic

EpithelioidEpithelioid

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

IMAGINGIMAGING

Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

HISTOPATHOLOGYHISTOPATHOLOGY

Markedly pleomorphic tumor cells are separated by lace-like osteoid

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA

3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA

4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA

5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA

Malignant bone aneurysmMalignant bone aneurysm

Aggressive and Aggressive and

poor prognosispoor prognosis

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA

8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA

9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome

Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

SECONDARY OSTEOSARCOMAS

PAGET SARCOMA

FIBROUS DYSPLASIA

BONE INFARCT

POST IRRADIATION

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS

BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

OSTEOCHONDROMAOSTEOCHONDROMA

Multiple hereditary Multiple hereditary

osteochondromataosteochondromata

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

CHONDROBLASTOMACHONDROBLASTOMA

( Codman tumor )( Codman tumor )

Preferred sitendash epiphysisPreferred sitendash epiphysis

CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA

SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA

PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS

CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY

CHONDROSARCOMACHONDROSARCOMA

Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA

MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA

MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA

DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA

PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA

SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA

EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

SECONDARY CHONDROSARCOMAS

ENCHONDROMA

OSTEOCHONDROMA

PAGETIC BONE

SYNOVIAL CHONDROMATOSIS

RADIATION INDUCED

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS

BENIGN LESIONS

FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA

BENIGN FIBROUS HISTIOCYTOMA

PERIOSTEAL DERMOID

FIBROUS DYSPLASIA

MONOSTOTICPOLYOSTOTIC

MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME

OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)

Decided preference for Tibia

DESMOPLASTIC FIBROMA

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA

PRIMARY SECONDARY

Pagets diseaseFibrous dysplasia

Bone infarctChronic sinuses of osteomyelitis

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ROUND CELL LESIONSROUND CELL LESIONS

BENIGN LESIONS

LANGERHANS CELL HISTIOCYTOSIS

Eusinophilic granulomaHand Schullers Christian disease

Letterer Siwe disease

Vertebra plana

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MALIGNANT LESIONSMALIGNANT LESIONS EWINGS SARCOMAEWINGS SARCOMA

Diaphysis of long bonesDiaphysis of long bones

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA

Non hodgkins lymphomaNon hodgkins lymphoma

Hodgkins lymphomaHodgkins lymphoma

permeative bone destruction with an aggressive periosteal reaction

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)

Most common Most common primary primary malignant malignant tumourtumour

TYPES

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

VASCULAR LESIONS VASCULAR LESIONS

BENIGN LESIONS

INTRAOSSEOUS HEMANGIOMA

SYNOVIAL HEMANGIOMA

CYSTIC ANGIOMATOSIS

GLOMUS TUMOUR

LYMPHANGIOMA

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MALIGNANT LESIONS

EPITHELOID HEMANGIOENDOTHELIOMA

ANGIOSARCOMA

HEMANGIOPERICYTOMA

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS

GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN

20-40 yr FgtM20-40 yr FgtM

Epiphyseal region Epiphyseal region of of

long boneslong bones

MALIGNANTMALIGNANT

Radiolucent eccentric expansive absence of reactive sclerosis

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS

BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST

Metaphyseal central lack of periosteal reaction

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST

lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long

bonesbones

SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE

CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma

Radiolucent eccentric expansive butress of periosteal reaction

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MALIGNANT LESIONSMALIGNANT LESIONS

ADAMANTINOMAADAMANTINOMA

CHORDOMACHORDOMA

LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

rrOSSEOUS METASTASES

SOLITARY MULTIPLE CORTICAL

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients

Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)

Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if

the tumor can be removed with an the tumor can be removed with an

adequate margin and the resulting limb is adequate margin and the resulting limb is

worth savingworth saving No justification for limiting the limb No justification for limiting the limb

salvage process based only on the salvage process based only on the

prognosisprognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

GOALGOAL

Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

SUCCESSSUCCESS

Early Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING

Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

RADIOGRAPHYRADIOGRAPHY

Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical

penetrationpenetration

Osseous detailsOsseous details

Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of

the tumorthe tumor

Soft tissue component Soft tissue component

Relationship to neurovascularRelationship to neurovascular

structuresstructures

Skip lesionsSkip lesions

Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some

neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and

reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP

Estimate the local intramedullary extent Estimate the local intramedullary extent

Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement

TL- 201 and DMSAVTL- 201 and DMSAV

Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage

lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor

Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy

Core biopsyCore biopsy

Incisional biopsyIncisional biopsy

Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis

Histological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Work through muscle not anatomical plane

Drain in the line of incision Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

PRINCIPLESPRINCIPLES

Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

SURGICAL ADJUVANTSSURGICAL ADJUVANTS

Local physical or chemical agentsLocal physical or chemical agents

CryosurgeryCryosurgery

Methacrylate augmentationMethacrylate augmentation

Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic

salinesaline

Carbolic acidCarbolic acid

High concentration ethanolHigh concentration ethanol

Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy

Specific ndash Active and PassiveSpecific ndash Active and Passive

Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting

AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft

FIXATION

INTERNALLong ILNPlating

EXTERNALIlizarov

External fixatorCharnleys clamp

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ALLOGRAFTALLOGRAFT

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Advantages Advantages

Length can be adjustedLength can be adjusted

Biological soft tissue Biological soft tissue

healinghealing

Avoid the risks and Avoid the risks and

complications of complications of

intramedullary fixation intramedullary fixation

of endoprosthesis of endoprosthesis

Direct attachment of Direct attachment of

remaining musculatureremaining musculature

Disadvantages Disadvantages Long healing timeLong healing time

Potential for transfer of Potential for transfer of

disease and infectiondisease and infection

Immune rejectionImmune rejection

Necessity of articular Necessity of articular

surface size matching surface size matching

FractureFracture

Infection Infection

Non-union Non-union

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

AUTOGRAFTAUTOGRAFT

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment

(Irradiated tissue and active infection)(Irradiated tissue and active infection)

Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture

The Journal of Bone and Joint Surgery (American) 20089093-100

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ENDOPROSTHESISENDOPROSTHESIS

MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

ROTATIONPLASTYROTATIONPLASTY

Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or

ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN

RotationplastyRotationplasty Tibial turn upTibial turn up

( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable

prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care

of the patients with malignant bone tumorsof the patients with malignant bone tumors

Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated

sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low

rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87

• Slide 1
• NEOPLASIA
• HYPERPLASIA
• METAPLASIA
• DIFFERENTIATION AND ANAPLASIA
• DYSPLASIA
• Slide 7
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• BONE FORMING (Osteogenic) LESIONS
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• CARTILAGENOUS LESIONS
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONS
• Slide 31
• ROUND CELL LESIONS
• Slide 33
• Slide 34
• VASCULAR LESIONS
• Slide 36
• UNCLASSIFIED LESIONS GIANT CELL TUMOUR
• MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONS
• Slide 39
• Slide 40
• r
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 47
• Slide 48
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 61
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 65
• Slide 66
• SURGICAL ADJUVANTS
• Slide 68
• RECONSTRUCTION
• ARTHRODESIS
• Slide 71
• ALLOGRAFT
• Slide 73
• AUTOGRAFT
• Slide 75
• ENDOPROSTHESIS
• Slide 77
• Slide 78
• AUTOCLAVED AUTOGRAFT
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 81
• ROTATIONPLASTY
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 87