Lumps & Bumps--When to be concerned--
Eric Silverstein, MDDirector of Musculoskeletal Oncology
Academic Director of Orthopaedic SurgerySaint Francis Hospital & Cancer Center
Trinity Health of New England
33rd Sports Medicine
Symposium
March 6, 2018
Disclosure
I have nothing to disclose and have no potential conflict of interest with any company or service industry
Objectives
Identify the “red flags” of musculoskeletal lesions
Case examples of tumors that may emulate sports pathology
Understand the basics of musculoskeletal oncologic staging
Provide an introduction to the pitfalls of poorly planned and performed biopsies
Know when to refer a patient with musculoskeletal lesions
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Musculoskeletal Oncology
Division of orthopaedics focusing on surgical treatment of soft-tissue and bone tumors (and simulators)
Requires multi-disciplinary approach
Often extensive radiologic imaging
Staging / Carefully planned biopsies
Vast array of surgical intervention and reconstruction
Case #1
30 year old male
Chief complaint: Mass in left thigh
HPI: Healthy male with slowly enlarging mass in anterior thigh over 6 months. Causing minimal to mild discomfort.
ROS: negative
X-RAYS: negative
Case #1
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #1
In contrast to…
59 year old male noticed a mass in the right proximal thigh ~ 6 months ago
Has remained the same size
Denies any pain or trauma
Notices it more with contraction of the quadriceps (proximal 1/3rd of anterior thigh)
No significant PMHx or PSHx
Meagher, M ichaelMeagher, M ichael
37677683767768
7/5/19587/5/1958
59 YEA R59 YEA R
MM
Page: 25 of 50Page: 25 of 50
A Q M:358\512A Q M:358\512
TE: 90TE: 90
TR: 8350TR: 8350
FA : 140FA : 140
SESE
EC : 1EC : 1
NEX: 1NEX: 1
------
St Franc is Hospital Skyra St Franc is Hospital Skyra
MRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA STMRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA ST
t2_tse_sag_rightt2_tse_sag_right
2/15/2018 9:54:38 A M 2/15/2018 9:54:38 A M
52687615268761
------
LO C : -120.61LO C : -120.61
THK: 4 .50SP : 4 .50THK: 4 .50SP : 4 .50
FFSFFS
IM:25 SE:6IM:25 SE:6
C ompressed 7:1C ompressed 7:1
DFO V :45x45cmDFO V :45x45cm
W: 732W: 732
C : 210C : 210
Z: 1Z: 1
AA PP
HH
FF
Meagher, M ichaelMeagher, M ichael
37677683767768
7/5/19587/5/1958
59 YEA R59 YEA R
MM
Page: 53 of 62Page: 53 of 62
A Q M:384\378A Q M:384\378
TE: 12TE: 12
TR: 750TR: 750
FA : 120FA : 120
SESE
EC : 1EC : 1
NEX: 1NEX: 1
------
St Franc is Hospital Skyra St Franc is Hospital Skyra
MRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA STMRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA ST
t1_tse_tra_p2_t1_tse_tra_p2_
2/15/2018 10:04:36 A M 2/15/2018 10:04:36 A M
52687615268761
------
LO C : -72.92LO C : -72.92
THK: 5 .50SP : 5 .50THK: 5 .50SP : 5 .50
FFSFFS
IM:53 SE:7IM:53 SE:7
C ompressed 7:1C ompressed 7:1
DFO V :34.1x34.1cmDFO V :34.1x34.1cm
W: 1308W: 1308
C : 616C : 616
Z: 1 .02Z: 1 .02
RR LL
AA
PP
Not all masses are Tumors…
65 y.o. male with anterior thigh massfor 5 years… slowly increasing in sizewith occasional discomfort
In contrast to…
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
MRI
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #2
10 y.o. female
Chief complaint: Left knee pain
Healthy with no PMHx
Was sailing and struck Left leg against
the boat during turbulence
Had pain but able to walk
Pain persisted despite conservative management for the next 4-6 weeks
Case #2
Case #2
Axial ViewSagittal View
Coronal View
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #2
Open biopsy confirms osteosarcoma
Proceeded with Neoadjuvantchemotherapy
Doxorubicin, Cisplatin, and Methotrexate Current gold standard of treatment
Radiation has little to no role
Surgery: Knee disarticulation with epiphysiodesis of the distal femoral growth plates
Adjuvant Chemotherapy
Case #2
Healthy 10 year old with LEFT hip pain for nearly 6 months
Avid soccer player
Does not recall an injury
Pain with activity but mostly at night
NSAIDs completely relieve the pain but returns as soon as the meds wear off
Case #3
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #3Nathan, BrynnNathan, Brynn
60060826006082
11/2/200011/2/2000
13 YEAR13 YEAR
FF
Page: 1 of 2Page: 1 of 2
DELPHI ORTHOPEDIC DELPHI ORTHOPEDIC
XR HIP LEFT (2 VIEW)XR HIP LEFT (2 VIEW)
HIP APHIP AP
10/9/2014 2:50:52 PM 10/9/2014 2:50:52 PM
41395534139553
------
------
------
IM: 1001IM: 1001Compressed 32:1Compressed 32:1
W: 1024W: 1024C: 512C: 512Z: 0.51Z: 0.51S: 220S: 220
Case #3
Nathan, BrynnNathan, Brynn
60060826006082
11/2/200011/2/2000
13 YEA R13 YEA R
FF
Page: 22 of 33Page: 22 of 33
A cq no: 3A cq no: 3
KV p: 130KV p: 130
mA : 44mA : 44
T ilt: 0T ilt: 0
RD: 149RD: 149
Tech com: ---Tech com: ---
RA H Rad RA H Rad
C T HIP LEFT WITHO UT IV C O NTRA STC T HIP LEFT WITHO UT IV C O NTRA ST
Hip 5 .0 B70sHip 5 .0 B70s
5/28/2014 4:56:00 PM 5/28/2014 4:56:00 PM
40446624044662
------
LO C : -1319.90LO C : -1319.90
THK: 5THK: 5
HFSHFS
IM:22 SE:5IM:22 SE:5
C ompressed 11:1C ompressed 11:1
DFO V :14.9x14.9cmDFO V :14.9x14.9cm
W: 2000W: 2000
C : 500C : 500
Z: 1Z: 1
RR LL
AA
PP
Nathan, BrynnNathan, Brynn
60060826006082
11/2/200011/2/2000
13 YEA R13 YEA R
FF
Page: 30 of 50Page: 30 of 50
A cq no: 3A cq no: 3
KV p: 130KV p: 130
------
T ilt: 0T ilt: 0
------
Tech com: ---Tech com: ---
RA H Rad RA H Rad
C T HIP LEFT WITHO UT IV C O NTRA STC T HIP LEFT WITHO UT IV C O NTRA ST
C oronalC oronal
5/28/2014 4:55:53 PM 5/28/2014 4:55:53 PM
40446624044662
------
------
THK: 2THK: 2
HFSHFS
IM:30 SE:607IM:30 SE:607
C ompressed 10:1C ompressed 10:1
DFO V :16x16cmDFO V :16x16cm
W: 1500W: 1500
C : 450C : 450
Z: 1Z: 1
RR LL
HH
FF
Radiolucent Nidus – pathognomonic of
an Osteoid Osteoma
Case #3
Conservative management with daily NSAIDs Although osteoid osteomas are self limiting
they often persist on average 3-5 years before “burning out”
Prolonged use of NSAIDs – ulcers*, kidney damage, etc.
Surgery Radiofrequency ablation
Open excision
Other modalities (?)
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
RADIOFREQUENCY ABLATION (RFA)
RADIOFREQUENCY ABLATION (RFA)
PP
RR LL
AA
Page: 36 of 48Page: 36 of 48
A cq no:5A cq no:5
KV p:120KV p:120
mA :192mA :192
T ilt:0T ilt:0
RD:279RD:279
B30fB30f
------
------
IM:36 SE:5IM:36 SE:5
C ompressed 11:1C ompressed 11:1
DFO V :27.9x27.9cmDFO V :27.9x27.9cm
W:3128W:3128
C :714C :714
Z:1Z:1
Nathan, BrynnNathan, Brynn
60060826006082
11/2/200011/2/2000
13 YEA R13 YEA R
FF
------
SFH RadSFH Rad
C T RA DIO FREQ UENC Y A BLA T IO N - BO NEC T RA DIO FREQ UENC Y A BLA T IO N - BO NE
BiopsySingle 0 .75 B30fBiopsySingle 0 .75 B30f
6/27/2014, 10:37:40 A M6/27/2014, 10:37:40 A M
40471984047198
------
LO C :442.10LO C :442.10
THK:0.75 ---THK:0.75 ---
FFSFFS
PP
RR LL
AA
Page: 1 of 48Page: 1 of 48
A cq no:3A cq no:3
KV p:120KV p:120
mA :362mA :362
T ilt:0T ilt:0
RD:279RD:279
B30fB30f
------
------
IM:1 SE:5IM:1 SE:5
C ompressed 11:1C ompressed 11:1
DFO V :27.9x27.9cmDFO V :27.9x27.9cm
W:3128W:3128
C :714C :714
Z:1Z:1
Nathan, BrynnNathan, Brynn
60060826006082
11/2/200011/2/2000
13 YEA R13 YEA R
FF
------
SFH RadSFH Rad
C T RA DIO FREQ UENC Y A BLA T IO N - BO NEC T RA DIO FREQ UENC Y A BLA T IO N - BO NE
BiopsySingle 0 .75 B30fBiopsySingle 0 .75 B30f
6/27/2014, 10:19:00 A M6/27/2014, 10:19:00 A M
40471984047198
------
LO C :445.40LO C :445.40
THK:0.75 ---THK:0.75 ---
FFSFFS
Case #4
37 y.o. female
Chief complaint: Shoulder pain w/ mass
and swelling
30 weeks pregnant
Symptoms present for nearly 7 months
Otherwise healthy
Went to see sports doc
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #4
Large soft-tissue mass surrounding scapula
Agreed to x-ray
Days before had outside open biopsy done (2.5” oblique incision)
Urgent percutaneousbiopsy done in my office
Consistent with high-grade osteosarcoma(poorly differentiated)
Case #4
Soft-tissue mass with little bony change
Case #4
Urgent c-section at 31 weeks
Pre-operative clinical photos
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #4
Post-operative follow-up x-rays
“Red Flags”
New or old mass with rapid growth
Within weeks or months is a concern
Night Pain
Persistent pain
Radicular symptoms
Signs of mass effect – bowel / bladder issues, DVT, swelling, …
Systemic symptoms
Case #5
42 year old woman with vague pain in right flank with small mass
CT showed 3-4 cm mass
Felt to be benign or a hematoma
Schizo-affective disorder, poor family / social situation
Non-compliance issues
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #5
Case #5
Six Months Later…
Case #5
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #6
15 year old female
High school student and volleyball player
Long history of bilateral patello-femoral symptoms
Otherwise healthy
X-ray showed abnormality and sent for evaluation
Case #6
Case #6
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #6
Case #6
1. Open biopsy of femur
2. Extensive curettage,
high-speed burring,
allograft
3. Prophylactic fixation
Case #7
64 year old male s/p right THA 2 ½ years ago for OA
No history of cancer
Fairly healthy and
active
New onset of severe right hip pain
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Greater Sciatic
Foramen
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Case #7Post-Op
Case #7Post-Op
Musculoskeletal Oncology
Initial evaluation:
Comprehensive H&P
Mass
Pain
Fever
Systemic symptoms: weight loss, appetite decreased, N/V/D, etc.
Incidental finding – traumatic event
Pathologic fracture
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Musculoskeletal Oncology
Radiologic Work-up: Plain X-Ray
CT scan area of interest CT chest / abdomen / pelvis
MRI
Bone Scan
PET Scan
Staging
Pre-operative planning if necessary
Last Words
Listen to patients History is critical when you can get it
Recognize “Red Flags” If it doesn’t seem normal, it probably isn’t
Rapid growth, night pain, etc.
An injury doesn’t mean there can’t be another pre-existing or underlying problem
Staging helps provide diagnostic information and guides treatment
A biopsy is a critical first step in management with potential implications
References
1. Biazzo, A, De Paolis, M. Multidisciplinary approach to osteosarcoma. Acta Orthop Belg. 2016 Dec; 82(4):690-698
2. Zhang, Y, Rosenberg, AE. Bone-Forming Tumors. Surg Pathol Clin. 2017 Sep;10(3):513-535
3. Huang, AJ. Radiofrequency ablation of Osteoid Osteoma: Difficult-to-reach places. Semin Musculoskelet Radiol. 2016 Nov;20(5):486-495
4. Terpos, E, et al. Pathogenesis of bone disease in multiple myeloma: from bench to bedside. Blood Cancer J. 2018 Jan;8(1):7
5. Brown, TS, et al. Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review. Bone Joint J. 2018 Jan;100-B(1 Supple A):22-30
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
Thank You
CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018
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