MANAGEMENT OF EXTREMITY TUMORS

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MANAGEMENT OF EXTREMITY TUMORS
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PRESENTING FEATURES

• PAIN
• SWELLING
• DIFFICULTY IN MOVEMENT
• NEUROVASCULAR DEFICIT

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DIFFERENTIAL DIAGNOSIS

• Bone Tumor

• Soft Tissue Tumor

• Ewings Sarcoma
• Osteo Sarcoma
• Metastatic Neuroblastoma

• Rhabdomyo Sarcoma
• Non RMS Soft tissue Sarcoma

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Osteosarcoma Clinical Presentation

• Pain and Swelling
• Common site
• Distal Femur
• Proximal tibia
• Proximal Humerus
• Age- 2nd decade

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Osteosarcoma Radiograph

• Metaphysis of bone
• Permeative Destruction
• Intense new bone formation
• Codman triangle
• Sunray Spicules
• Soft tissue mass

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Radiograph of Ewings Sarcoma

• Diaphysis
• Poorly marginated
• destructive leison
• Erosion of cortex
• Soft tissue extension
• Multilaminated Periosteal reaction
• (Onion peel)

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Rhabdomyosarcoma and Soft Tissue Sarcoma

• Swelling in extremity
• with or without lymphnode
  enlargement
• Xray no bony involvement
• CT Scan/MRI
• Standard Imaging Modality

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STAGING

• BONE TUMOUR

• -Non Metastatic/
• Localized and
• -Metastatic
• -Clinical group
• TNM Staging

• SOFT TISSUE SARCOMA

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Metastatic Work - Up

• CXR
• CT Scan Chart

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Metastatic Work -Up

• Bone marrow Biopsy
• Bone Scan

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Osteosarcoma CTScan/MRI

• Local Tumor
• Extent before
• Surgery

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Ewings Sarcoma CTScan/MRI

• Local Staging
• Intramedullary / Extra Medullary extent
• Relationship with adjacent physis, muscle , joint
  and neurovascular compartment

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Tissue Diagnosis

• Properly planned biopsy
• Multiple core or Open Biopsies
• Sample Sent for Immuno
• histochemistry Cytogenetics,
• Electron
• microscropy RTPCR

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Histopathology

• Osteosarcoma
• Spindle shaped Cells
• -Highly Malignant
• -Large Irregular nucleus
• Tumour Osteoid

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Histopathology

• Ewings Sarcoma
• Sheets of small round cells, Scanty Cytoplasm,
• round smooth nucleus

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Histopathology

• Rhabdomyo
• sarcoma
• Round cell tumour
• -Cross Striations
• -Air Spaces - Alveolar

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ImmunohistoChemistry Cytogenetics
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Treatment of Non Metastatic Osteo Sarcoma

• NeoAdjuvant Chemotherapy 3-4 Cycles -gt
• Surgery Amputation/
• Limbsalvage -gt
• Adjuvant Chemotherapy 3-2 Cycles

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Treatment of Localized Ewings Sarcoma

• NeoAdjuvant
• Chemotherapy
• 12-15 weeks-gt
• Local Treatment
• RadioTherapy/
• Surgery-gt
• Chemotherapy upto 4 8 weeks

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Teatment of Rhabdomyosarcoma NonMetastatic

• Initial surgical Resection
• Radiotherapy in residual leison
• Unresectable regionRadiotherapy
• Combination Systemic Chemotherapy for 52 weeks

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Other Non Metastatic Soft Tissue Sarcoma

• Surgery is the key role
• Irradiation in residual tumor
• Role of Chemo therapy not well defined

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Conclusion

• Clinical Suspicion
• Properly planned Biopsy
• HPE,immunohistochemistry,
• Cytogenetic,RT-PCRStudies
• Refer to Oncology Centre
• Multimodal Approach
• Chemo/Radio/Surgery
• Avoidence of late toxicities

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