‣
- Bloods – FBC, CRP, ESR, ALP (Osteoblastic activity), LDH (osteoclastic activity), Calcium and phosphate, Renal panel
- Local Staging
- MRI with contrast whole bone - 5 things?
- “Avid Contrast enhancement”
- Systemic staging - Chest XR, CT chest, Bone Scan, PET-CT
- Biopsy
‣
- skip lesions
- Joint involvement
- NV involvement
- Reactive zone (plan biopsy)
- Paeds growth plate
‣
‣
- Percutaneous vs Open
- Risk of contamination in open is higher
- Better yield in open (but improving over time)
- Percutaneous needle biopsies - Core vs FNA – histology vs cytology
- CT guided – can avoid necrotic area, avoid danger structures
‣
- Known cancer, but no known mets, presenting with a pathological fracture/ bone lesion
- No known cancer with pathological fracture/ bone lesion
‣
- There is no consensus on the optimal biopsy method for tumors - CT guided percutaneous Core biopsy vs Open Incisional biopsy
- In my institution, we routinely use open incisional biopsy and this is what i will do - divided in to 3 parts…
‣
- Open Biopsy - can be excisional or incisional (usually incisional)
- How to Biopsy?
- Pre- Op:
- MDT with primary MSO Surgeon, Med Onco, Rad Onco
- Ensure all scans completed
- Intra-Op:
- No exanguination of limb but ok with tourniquet
- Extensile incision, thru one compartment (intramuscular plane, not intermuscular ),
- Avoid NV,
- Good Hemostasis,
- No abx
- Biopsy: take sufficient samples, do not take from central necrotic tissue OR reactive zone but plan the biopsy from preop MRI to get live cells,
- Culture all tumors, bone biopsy with circular corer/ drill to prevent stresss riser (as opposed to square with edges) and frozen section before closure
- Post- Op:
- leave drain for 2/52 to avoid hematoma formation
- Close in layers, Drain inline with incision, temporary stabilization
‣
- “Active areas” that are not cystic/ necrotic/ ossified.
‣
- “Aware than Recent studies like
- Pohlig et al. found similar accuracy for bony tumors but better accuracy for soft tissue tumors though not significant.
- Aware that Irene et al. 2017 found that higher biopsy tract seeding rates in open biopsy 32% vs 0.85
- However, recent JAAOS core exhibit paper by Traina et al. reccomend for imaging guided Core biopsy in view of lower complication and lower costs. But for incisional biopsy if it returns to be non diagnostic”
- Pohlig et al. found
- Similar accuracy for bony tumors
- Better accuracy for open biopsy for soft tissue sarcoma
- Recent AAOS Exhibit Selection paper by Traina in 2015 concluded that no consensus however, recommended that in view of low risk of contamination and low cost, core needle biopsy appears to be more suitable than open biopsy in the diagnosis of tumors
- Image guidance is reccomended via US or CT scan
- Recommend that if Core biopsy is non diagnostic, incisional biopsy can be performed.
- Irene Ruiz - Irene et al. 2017 found that higher biopsy tract seeding rates in open biopsy 32% vs 0.85
- https://pubmed.ncbi.nlm.nih.gov/27655183/
pohlig.pdf193.0KB
traina2015.pdf869.4KB
‣
- 1. Neoadjuvant Chemo or Radio
- 2. Surgery
- “Resection” - extended curretage/ wide excision/ intralesional/ wide/ radical
- “Reconstruction or Amputation”
- 3. Adjuvant Chemo or Radio
- 4. Surveillance
‣
- Intralesional
- Marginal – within pseudocapsule/ reactive zone
- Wide = + cuff of normal tissue; outside reactive zone
- Radical
‣
- Tumors grow in centrifugal fashion (inside to out), leads to compression and subsequent atrophy of surrounding tissue ➔ pseudocapsule
- Outside pseudocapsule is the reactive zone.
‣
- “Can I resect with clear margins and still have a useful limb?”
- Joint/ extensive muscle or soft tissue involvement
- NV involvement
- Pathological fracture with hematoma violating compartment boundary
- Severe infection
- Immature skeletal age with significant LLD > 8cm
‣
- Anatomical vs Non Anatomical recon
- Anatomical – Endoprosthesis, Allo-prosthesis, megaprosthesis
- Non anatomical – Rotationoplasty (ankle becomes the knee)