How to Investigate a Musculoskeletal Malignancy

Presented by:

Dr.

Introduction• Primary Musculoskeletal

tumors arise from tissue of mesenchymal origin (ie. bone, muscle, connective tissue, adipose.)

• These primary tumors may spread to other sites, usually other bones or lung.

• Secondary bone tumors arise from a host of other tissues and in the appropriate age category must be looked for.

Introduction

• The work-up of any tumor must be thought of in terms of Local disease and Systemic disease.

• By doing so you will have a sensible approach to determining the ultimate pathologic diagnosis and the extent of the disease in the body.

The Problem: A Lump in the Bone

• History• Cause: Age, Age, Age,

smoking, cancer, family history.

• Systemic: sweats, wt loss, fever, cough, hemoptesis, other lumps.

• Local: pain, nerve, lump, time frame.

The Problem: A Lump in the Bone• Physical:

• Systemic: General physical, focus on the Benzene ring and sites of possible Metastases. (lung, breast, bowel, prostate, thyroid, renal).

• Local: Mass size, firmness, tenderness, inflamed, relationship to fascia, nerve, vascular, skin, lymph nodes.

Investigations

• *****Don’t think of your investigations in shotgun form.*****

• Focus your investigations based on the clinical scenario and then think of Local and Systemic investigations.

Local Investigations • X-ray….the most helpful

in focusing our differential and further investigations.

• Cat scan….. Bone architecture, neocorticalization, ?fracture.

• MRI….marrow extent, soft tissue extent, neurovascular involvement, skip lesions.

Investigations

• X-ray of proximal femur lesion

Investigations

• MRI of same lesion 1 day later after a fall.

Systemic Investigations: Radiology

• Total Body Bone Scan…..other lesions.

• Chest Cat scan… fine cut.

• What about CT chest/abdomen/pelvis??? Is there ever a role?

Systemic Investigations: Blood-work

• CBC, calcium, albumin, ESR, C-reactive protein, ALP, LDH. Why do you do these tests?

• Protein electrophoresis, PSA, PtH.

• What about LFT’s, RFT’s, magnesium, Ptt/Pt/INR??? Are they useful tests and if so when?

Other Specialized Investigations

• Bone Marrow Biopsy

• Angiography… when and why?

• Gallium Scan… when and why?

Invasive Investigation

• Biopsy…..the goal is to obtain a piece of tissue adequate to make a pathologic diagnosis.

• Should be done after all other investigations are complete

• Needle, Tru-cut, incisional.

• CT/US guided.

Biopsy

• In the OR…what do you want?

• Principles: “in line with eventual resection incision”…. Homan retractors????…. Tourniquet????….. Hemostasis????…. drain???…. multiple layer closure…. soft tissue mass…. round hole in bone …fixation???? Frozen section

Biopsy

• Frozen section

• Swabs for C+S, and any other things you may be thinking of (ie. Fungus, TB).

• Is it acceptable to proceed on the basis of Frozen section?

Incisional Biopsy vs Excisional Biopsy

• Is this practice ever safe???