TUMOR

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TUMOR

• Dr Mohammad.ali
• Department of Orthopedics

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PATHOLOGY of NEOPLASM

• Abnormal mass of tissue
• Growth is autonomous, exceeds normal, persist
  after cessation of stimuli
• Benign vs. Malignant
• Differentiation Anaplasia
• Growth rate
• Local invasion
• Ability to metastasize

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HISTOPATHOLOGY

• Anaplasia
• Hallmark of malignancy
• Pleomorphism
• Hyperchromatism
• Nuclear cytoplasmic ratio of 11
• Abundant mitoses
• Tumor giant cells

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• BENIGN more common
• MALIGNANT (SARCOMAS) are rare
• Differentiation of the lesion
• Fibrous tissue
• Fibrohistiocytic
• Adipose tissue
• Muscle tissue
• Lymph vessels
• Synovial tissue
• Peripheral nerves
• Cartilage and Bone Forming tissue
• Pluripotential Mesenchyme
• Blood Vessels
• Uncertain Histogenesis

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DIAGNOSTIC CLUES

• Size
• A mass that is small (lt 5 cm in its greatest
  dimension) is unlikely to be malignant, while a
  mass that is gt 5 cm has at least a 20 chance of
  being a soft tissue sarcoma
• Determined by physical examination if the lesion
  is subcutaneous and easily palpable, or by
  ultrasound, CT or MRI

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DIAGNOSTIC CLUES

• Superficial or deep?
• Superficial lesions are more likely to be benign
  and, when malignant, may have a better prognosis
  than deep lesions
• The depth is best determined by physical exam,
  ultrasound or MRI
• The thigh and buttocks are the 2 most common
  sites of sarcomas. Any large deep mass in the
  thigh or buttocks should be considered at high
  risk for being a malignant lesion

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DIAGNOSTIC CLUES

• Cystic or solid
• Most cystic lesions are inflammatory or benign
  lesions, such as ganglion cysts or soft tissue
  abscesses
• If the lesion is solid, it could represent either
  a benign or malignant neoplasm
• Attempt Transillumination
• If deep, ultrasound or MR scan will determine
  this

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DIAGNOSTIC CLUES

• Length of symptoms
• Rapidly increased in size over 2 months is more
  likely to be a sarcoma than the lesion that has
  slowly enlarged over a 20-year period
• A mass that increases and decreases in size is
  usually a cystic lesion
• Caution should be taken with masses that have
  been present for a long time. Soft tissue
  sarcomas occasionally present with a history of
  many years duration up to 30 years

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TUMOUR WORKUP

• History (age, sex, site and past history)
• Clinical examination
• Thyroid
• Breasts
• Chest
• Liver
• Kidney
• Rectal (prostate rectal tumors)
• Bloods
• FBC (leukaemic cells etc) ESR (often elevated)
• Biochemistry (Ca, PO4, liver enzymes and
  Alkaline Phosphatase) -gt mets
• Acid Phosphatase (prostate and increased with
  metastatic deposits)
• Thyroid function tests
• PSA
• Serum Protein Electrophoresis (Myeloma)

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TUMOUR WORKUP (cont)

• Urinalysis
• Urine Bence-Jones (myeloma)
• CXR
• Abdominal ultrasound
• Bone scan -gt other sites
• MRI -gt soft tissue extent and association with
  nerves and vessels
• CT of lesion and chest (-gt staging)
• Angiography -gt tumor blood supply and
  relationship to major vessels
• Biopsy

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IMAGING OF SOFT TISSUE TUMOR

• Plain radiograph
• Soft tissue shadow, isodense with muscle
• Specific features
• Phlebolith within a hemangioma
• Cartilaginous juxta-articular masses in synovial
  osteochondromatosis
• Mature peripheral calcification in myositis
  ossificans
• Central calcification in extraosseous
  osteosarcoma
• Amorphous calcium deposit in tumoral calcinosis
• Bony involvement

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IMAGING OF SOFT TISSUE TUMOR

• Ultrasound
• Rapid inexpensive test
• Differentiate solid from cystic
• Determine size
• Can suggest sarcoma features
• As many soft tissue sarcoma present as hypoechoic
  mass than the echogenic pattern seen in benign
  lesion, with exception of liposarcoma
• Delineate areas of distinctly solid portion of a
  a mass, a great help for biopsy
• Aid in percutaneous needle biopsy
• Study of vascular supply by Color Doppler

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IMAGING OF SOFT TISSUE TUMOR

• CT scan
• Detecting calcification or ossification within
  the lesion
• Evaluate lung metastases
• CT guided needle biopsy
• Arteriography
• Less frequently used
• Mapping of lesions in difficult anatomy location
• Identifying normal anatomic variants before
  surgery
• Preoperatively, to embolize hypervascular lesions

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IMAGING OF SOFT TISSUE TUMOR

• Bone scan
• Technetium Tc 99m bone scan
• Detects area of rapid bone turnover
• Sensitive but not very specific, abnormal scan
  should be further studied with plain radiograph,
  CT and MRI
• Part of staging

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IMAGING OF SOFT TISSUE TUMOR

• MRI
• Replace role of CT and arteriography
• Advantages
• superior soft tissue contrast
• multiplanar imaging
• no ionizing radiation the need for iodinated
  contrast agent
• no artifact problem
• General Roles
• Accurate preoperative staging
• Restriction of differential diagnosis
• Assistance with biopsy placement
• Monitoring response to neoadjuvant chemotherapy
  or radiotherapy
• Identification of residual or recurrent tumor
  during postoperative period

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IMAGING OF SOFT TISSUE TUMOR

• MRI (cont)
• Conventional T1 weighted and T2 weighted
• T1 weighted differentiate the hyperintense fatty
  tissue with hypointense tumor
• T2 weighted with or without fat suppression is
  the most appropriate sequence tumor will be
  hyperintense

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STAGING SYSTEM

• Prognostic variables
• Histologic grade
• Tumor size
• Tumor depth
• Compartment status
• Metastases

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STAGING SYSTEM

• SURGICAL STAGING SYSTEM (SSS)
• Enneking staging system
• American Joint Committee on Cancer (AJCC)
• Cancer Staging Manual 5th Edition
• Memorial Sloan Kettering Cancer Center (MSK)

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STAGING SYSTEM

• SURGICAL STAGING SYSTEM (Enneking)

Stage Stage Description Prognostic Factors
IA Low Grade Intracompartmental G1 T1 M0 G1 Low Grade G2 High Grade T1 Intracompartmental T2 Extracompartmental M1 Any regional or systemic metastasis
IB Low Grade Extracompartmental G1 T2 M0 G1 Low Grade G2 High Grade T1 Intracompartmental T2 Extracompartmental M1 Any regional or systemic metastasis
IIA High Grade Intracompartmental G2 T1 M0 G1 Low Grade G2 High Grade T1 Intracompartmental T2 Extracompartmental M1 Any regional or systemic metastasis
IIB High Grade Extracompartmental G2 T2 M0 G1 Low Grade G2 High Grade T1 Intracompartmental T2 Extracompartmental M1 Any regional or systemic metastasis
III Any Metastases Any G, Any T, M1 G1 Low Grade G2 High Grade T1 Intracompartmental T2 Extracompartmental M1 Any regional or systemic metastasis
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Prognostic Factors

• Histologic Grade (assessment of biological
  aggressiveness)
• G0   
• Histological benign
• Well differentiated and low cell to matrix ratio
• G1   
• Low grade malignant
• Few mitoses, moderate differentiation and local
  spread only
• Have low risk of metastases
• G2   
• High grade malignancy
• Frequent mitoses, poorly differentiated
• High risk of metastases
• Features of aggressive tumors
• Cellular atypia
• Frequent mitoses
• Extensive necrosis
• Significant vascularity
• Small amounts of immature matrix

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Prognostic Factors
Low Grade High Grade
Myxoid Liposarcoma Lipoma-like Liposarcoma Angiomatoid Malignant Fibrous Histiocytoma Malignant Fibrous Histiocytoma Pleomorphic Liposarcoma Synovial Sarcoma Rhabdomyosarcoma
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Prognostic Factors

• Site (anatomic setting of the lesion)
• T0 Intracapsular 
• T1 Intracompartmental
• (e.g. cortical bone, joint capsule or fascia)
• T2 Extracompartmental
• (spreads beyond 'fascial' plane without
  longitudinal containment)

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Prognostic Factors
Intracompartment Extracompartment
Intraosseous Intraarticular Intrafascial compartments Ray of Hand or Foot Posterior or Anterior Leg Ant, Med, Post Thigh Buttocks Volar or Dorsal Forearm Ant or Post Arm Pericapsular Soft Tissue Extension Deep Fascial Extension Extrafascial Planes/Spaces (Neurovascular containing spaces) Mid Hind Foot Mid Hand Popliteal Fossa Groin-Femoral Triangle Intra Pelvic Antecubital Fossa Axilla Paraspinal
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BIOPSY OF TUMORS

• Simple ? Low Risk Procedure ?
• The planning of the biopsy is technically
  demanding
• All Biopsy carry extreme risk to patients limb
  and potentially to the patients life
• Poorly planned biopsy can affect diagnostic
  accuracy and result in delay in diagnosis and
  treatment

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BIOPSY OF TUMORS

• Planning the biopsy
• Basic understanding of diseases/tumors and an
  ability to generate differential diagnosis
• The differential diagnosis determines the
  indications for biopsy
• Knowledge of appropriate placement of limb
  salvage incisions for resection and
  reconstruction
• Access to experienced musculoskeletal pathologist

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BIOPSY OF TUMORS

• Type of Biopsy
• Closed Biopsy (Core Needle)
• Open Biopsy
• Incisional Biopsy
• Excisional Biopsy
• Primary Wide Excision

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BIOPSY OF TUMORS
Closed Open
Accuracy of 85 Attributed to small size of biopsy leading to sampling error Insufficient for electron microscopic, immunohistochemical, and molecular genetic testing Non diagnostic needle biopsy results in delay in diagnosis and the need for subsequent formal open biopsy Accuracy of 96 Further minimizes risk of misdirected treatment and its associated morbidity
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BIOPSY OF TUMORS
Closed Open
Less invasive Invasive
Requires only LA outside formal OT Requires Formal Anesthetics Support and OT
Less soft tissue contamination Needle tract contamination Inappropriate incision placement soft tissue contamination that cannot be incorporated into a limb salvage or amputation plan Leading to increase likelihood of the need for soft tissue coverage and a higher risk for amputation
Lower risk of complication Higher risk of perioperative complication infection, haematoma and pathological
Useful in areas of difficult access, like spine and pelvis without risking significant contamination
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Biopsy Technique

• Incisional Biopsy
• Directly cutting into tumor to remove a sample
  without excising lesion
• The entire field is excised en bloc with the
  major tumor mass at the time of definitive
  resection
• Excisional Biopsy
• Removing the entire lesion at the time of biopsy
• Marginal excision
• Primary Wide Excision
• Entire lesion is excised while cutting through
  normal healthy tissue and leaving a margin of
  surrounding healthy tissue against the lesion

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Biopsy TechniqueExcisional Biopsy

• Indication
• To obtain a large sample size
• For benign non aggressive diagnosis, is the
  treatment of the lesion in single stage
• Carry higher risk of extensive soft tissue
  important structures contamination
• Not for lesion which is suspiciously malignant or
  at high risk anatomical region

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Biopsy TechniquePrimary Wide Excision Biopsy

• Indication
• High suspicious of malignancy
• When the risk of contaminating major important
  structures with another form of biopsy outweighs
  the risks and functional and cosmetic deficits of
  excising the lesions primarily

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Biopsy Procedure

• Longitudinal Incision
• Limb Salvage or Amputation incision
• Surgical Instrument handling
• Anybody fingers should not be placed directly
  into the wound
• Soiled sponges
• The surgical field should not be in continuity
  with other surgical field
• Tourniquet, no exsanguinations

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Biopsy Procedure (cont)

• Direct approach, contaminating only one
  compartment, not through planes
• Hemostasis
• Vessels, nerves and tendons should not be exposed
• Blunt retractors draping
• Biopsies the peripheral portion with ellipse
  shaped cut
• Cultures
• Volume of 1 to 2 cm3
• Post biopsy hemostasis
• Closure in layers
• Small bite suturing
• Light pressure bandaging
• Immobilization and protection of weight bearing

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OPTION OF DEFINITIVE MANAGEMENT
CLINICAL AND RADIOLOGICAL DIAGNOSIS
BIOPSY
OBSERVE
STAGING STUDIES
ELIMINATION OF PRIMARY TUMOR
NON SURGERY
SURGERY
RADIOTHERAPY
CHEMOTHERAPY
GENETIC IMMUNOLOGIC PROTEIN BASED
COMBINATION OF SURGERY AND NON SURGERY
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PRINCIPLES OF TUMOR SURGERY

• INTRALESIONAL
• Incomplete excisions, either gross or microscopic
  tumor remains ( MARGIN? )
• MARGINAL EXCISION
• Resection at border between the tumor the
  immediate adjacent tissues, leaving no tumor, as
  verified by both gross and microscopic inspection
  ( SATELLITE LESION? )
• WIDE EXCISION
• Excision through normal tissue that is not
  reactive or edematous, as judged by preoperative
  MRI, intraoperative gross inspection and
  microscopic sections ( SKIP LESION? )
• RADICAL EXCISION
• Wide excision based on anatomic barriers to tumor
  infiltration ( METASTATIC
  LESION?)
• ? COMPLETE REMOVAL AND RECURRANCE RATE

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PRINCIPLES OF TUMOR SURGERY

• TUMOR RESECTION STRATEGIES
• COMPLETE RESECTION for CURE
• INCOMPLETE RESECTION with CURE obtained from
  LOCAL ADJUVANT THERAPIES
• PARTIAL RESECTION without the expectation of
  achieving cure (DEBULKING)
• CURE means when no local or distant viable tumor
  cells remain after surgical resection
• Tumor debulking is to eliminate a majority of the
  tumor with minimum of morbidity to prolong
  quality of life and to reduce or eliminate pain

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PRINCIPLES OF TUMOR SURGERY

• Meticulous attention to the isolation of clean
  and contaminated fields, instruments, and
  personnel
• Minimize perioperative exposure to pathogens
• IV antibiotic, antibiotic cement, antibiotic in
  irrigation medium
• Allograft and Prosthetic components

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PRINCIPLES OF TUMOR SURGERY

• HIGH GRADE SARCOMA
• The goal is to remove as much tumor to achieve
  cure while removing the least amount of healthy
  tissue as possible to preserve function
• AMPUTATION versus Limb Salvage Surgery
• No Significant Statistical Advantage in term of
  Local Recurrence
• Following amputation 1 to 3
• Following limb salvage surgery lt8
• Functional loss can be extreme in amputation
  group
• Revision surgery rates for complications and
  revisions are considerably lower for amputation
  group

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PRINCIPLES OF TUMOR SURGERY

• HIGH GRADE SARCOMA
• Superficial sarcoma of the trunk have better
  prognosis than deep axially located tumor
• Deep axially located tumor like around the spine
  and pelvis
• Usually present late and often large by the time
  the diagnosis is made
• Do not routinely permit large volumes of normal
  surrounding tissue to be removed with the tumor

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PRINCIPLES OF TUMOR SURGERY

• HIGH GRADE SARCOMA
• The more inflammatory, fast growing,
  infiltrative the tumor, the wider the margin
  should be, the more strongly preoperative
  radiation or chemotherapy is indicated
• Final consideration is the patients personal
  wishes.

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PRINCIPLES OF TUMOR SURGERY

• LOW GRADE SARCOMA
• Generally treated similar to the high grade
• Margins are typically smaller as they show
• Smaller or absent reactive zone of inflammation
• Limited infiltration
• However a wider margin of excision might be
  preferable it if would eliminate the need for
  radiation therapy
• Cure is achieved through a carefully planned
  surgical excision without adjuvant therapy

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• The second part of surgical resection
• Planned preoperatively
• Liaison with plastic surgeon
• Principles for Pure Soft Tissue Defect Recon
• Preserve Limb Viability
• Restore Function
• Achieve Skin Closure

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• Principles of Wound Closure
• To have the most rapid biologic reconstitution of
  a viable skin barrier, between the deep tissue
  and outside world
• Minimize dead space in the deep tissue layer
  which can harbor bacterial inoculum
• Radiation and Chemotherapy impair wound healing

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• Dynamic Reconstruction
• Space Filling Reconstruction
• Skin Barrier Reconstruction

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• Dynamic Reconstruction
• Dynamic function include stability, power, blood
  transport or nerve conduction
• Refers to the implant or transfer of tissues
• Ligaments deficit in knee replaced with
  autograft, allograft or artificial replacement
• Vessels Reconstruction to restore blood flow
• Nerve Grafting for protective sensation and motor
  function
• Tendon or Muscle Transfer restore lost motor power

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• Space Filling Reconstruction
• To fills defects created by surgery
• Not to restore function but to relieve tension on
  the wound, obliterate dead space and place
  healthy tissue in areas that will promote rapid
  healing and reduce infection risk
• Muscle or Myocutaneous Local, Free and
  Vascularized Flap

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• Skin Barrier Reconstruction
• Precise wound closure is critical
• Wound breakdown can result in deep infection
  subsequent limb loss, might prevent or delay the
  use of chemotherapy or local radiation therapy
• Skin and subcutaneous fascial layer should be
  closed in layers, with precise matching of the
  anatomic layers
• Non braided suture short tail to minimize
  foreign body
• Small skin staplers with Antibiotic Ointment
  applied
• Early often changing of dressing
• If skin closure with minimal tension cannot be
  achieved
• SSG of flap

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PRINCIPLES OF TUMOR SURGERY

• DEFECT RECONSTRUCTION
• Surgical drains
• Eliminate dead space-preventing accumulating of
  fluid pockets
• Divert drainage from the skin incision
• Prevent formation and spread of haematoma along
  fascial planes-might carry tumor cells
• Drain tracks
• Should not traversed uninvolved anatomic areas
• Should exit the skin in line with the incision
• Critical drains can be sutured to skin but keep
  the suture sites close by for easy excision with
  drain track if needed

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PRINCIPLES OF TUMOR SURGERY

• INTRAOPERATIVE ADJUVANT THERAPIES
• Tumor killing potential
• H2O2 - tumoricidal ability
• Thermal kill
• Tissue Heating with diathermy, heat gun,
  cryosurgery using liquid nitrogen
• Produce necrosis of 1 to 10mm
• Lasers
• Intraoperative Radiation
• Advantage Precise Direct to tumor bed, not
  associated with wound healing difficulty seen
  with preop, high dose radiation therapy
• Brachytherapy
• Deliver local radiation through catheters
  implanted surgically after tumor excision

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PRINCIPLES OF TUMOR SURGERY

• THE YOUNG CHILD
• Remarkable adaptive capabilities to anatomic loss
  either by tumor itself or amputation
• Preserving epiphyses through very closed
  resection margins a few mm away from metaphyseal
  tumor
• If the child survive from the sarcoma, the
  extremely long life span ahead raises the
  lifetime risk of developing
• Secondary radiation induced sarcomas and other
  radiation associated morbidities
• Secondary chemotherapy induced cancers

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PRINCIPLES OF TUMOR SURGERY

• THE VERY OLD
• Most common malignant fibrous histiocytoma
• Problem less cardiac reserve and overall poorer
  physiologic function
• Adjuvant chemotherapy and high dose radiation
  therapy will cause more risk than benefit
• More radical resection with much wider margin
• Senile and Demented Patients, Medical disease
  which complicate wound healing
• Aim for NO TREATMENT or PALLIATIVE

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PRINCIPLES OF TUMOR SURGERY

• METASTATIC SARCOMA AT PRESENTATION
• Poor prognosis
• Survival depends on removal of primary tumor
  eradication of metastatic disease through either
  surgical or chemotherapeutic modalities or
  combination of both
• CHEMOTHERAPY IS ESSENTIAL to eliminate the
  micrometastases
• Any surgical complication that can delay or
  prevent perioperative chemotherapy must be
  avoided
• Limb salvage has NO ROLE

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PRINCIPLES OF TUMOR SURGERY

• UNRESECTABLE TUMOR
• Tumor involves major vessels, nerves or other
  critical structures
• Means unacceptable morbidity
• Truly unresectable situation is death as result.
• In cases with unacceptable morbidity like
  resection of tumor including the sciatic nerve,
  producing insensate lower limb
• Amputation is better choice OR
• Limb Salvage surgery with the idea of tiring and
  skill demanding nerve grafting or reconstruction,
  in mind OR if complication arises, amputation at
  a very high level is unavoidable
• Excellent candidate for preoperative
  chemotherapy, radiation therapy or more
  aggressive techniques like isolated limb
  perfusion to gain tumor size regression.

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PRINCIPLES OF CHEMOTHERAPY

• Action of Chemo Agents
• Damage DNA
• Alkylating agents, platinum compounds,
  anthracyclines, epipodophyllotoxins
• Deplete the cellular building blocks required for
  replication
• Antifolates, 5-fluoropyrimidines, cytidine
  analogs
• Interfere with microtubule function required for
  mitosis
• Vinca alkaloids, taxanes

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PRINCIPLES OF CHEMOTHERAPY

• Chemo Agents are cytotoxic to tumor cells through
  induction of apoptosis
• Selectivity is due to the fact that rapidly
  dividing tumor did not have sufficient time to
  repair the chemotherapy induced damage
• Combination chemotherapy
• Antitumor effect will be cumulative whereas the
  toxicity will not
• Avoid resistant
• Effective for different phases of cell cycle

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PRINCIPLES OF CHEMOTHERAPY

• Indication
• Induction chemotherapy (Neoadjuvant or
  Preoperative)
• Decrease tumor size
• In tumor that are capable of metastases
• (Standard of care for osteosarcoma and Ewings
  sarcoma)
• Malignant musculoskeletal tumor with systemic
  metastases
• Chemosensitive neoplasm
• Osteosarcoma
• Ewings sarcoma
• Rhabdomyosarcoma
• Synovial sarcoma
• Malignant Fibrous Histiocytoma
• For chemosensitive benign tumors which is
  multiply recurrent or impinge on vital structures

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PRINCIPLES OF CHEMOTHERAPY

• Chemoresistant tumors
• Gastrointestinal stromal tumors
• Chondrosarcoma
• Alveolar soft part sarcoma

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PRINCIPLES OF CHEMOTHERAPY

• Side Effects
• Stunting of growth
• Osteoporosis
• AVN
• Cisplatinum -gt Nephrotoxicity and hearing loss
• Adriamycin -gt Cardiotoxicity
• Vincristine -gt Neurotoxicity
• Chemotherapeutic induced malignancy usually blood
  forming eg leukaemias but also may -gt Ca bladder
  or skin (particularly associated with
  cyclophosphamide)

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PRINCIPLES OF RADIOTHERAPY

• Radioactive focused local treatment
• Using high energy photon beam produced by a
  linear accelerator
• Others gamma rays, electron beams, radiation
  from brachytherapy, beams from heavy particle
  like protons and neutrons
• Mechanism of action
• Oxygenation of water molecules within the cells,
  producing free radicals that interact with DNA to
  cause strand break, eventually results in cell
  death

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PRINCIPLES OF RADIOTHERAPY

• Radiation units
• Grays (Gy), a unit of absorbed dose (1Gy1J/kg)
• In the past rads
• 1 rad 1 centigray (cGy) or 1/100 of a Gy
• Radiotherapy is delivered in small doses or
  fractions over many days
• Allows a large total dose of radiation to be
  delivered without exceeding the tolerance levels
  of surrounding normal tissue
• Standard fractionation 180 to 200 cGy daily, 5
  days per week

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PRINCIPLES OF RADIOTHERAPY

• Indication in soft tissue sarcoma
• Radiosensitive sarcoma, theoretically, well
  oxygenated tumors
• Rhabdomyosarcoma
• PNET (extraosseous Ewings sarcoma)
• (definitive primary radiotherapy local control
  rate for the above type of tumor is 80)
• (mandatory treatment for all patient)
• Other unresectable soft tissue tumor local
  control rate is in the range of 25 to 30
• Current standard for high grade resectable
  extremity soft tissue sarcomas is limb salvage
  surgery, when possible, in conjunction with
  radiotherapy

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PRINCIPLES OF RADIOTHERAPY

• Indication in soft tissue sarcoma
• Postoperative radiotherapy
• Decrease risk of local relapse for both high
  grade and certain high risk low grade sarcoma.
• For low grade sarcoma, consider if having
  microscopic positive margin or of large tumor
  size (gt5cm)
• Preoperative radiotherapy
• Shrink tumor size
• Decrease risk of tumor contamination
• Intact well oxygenated tumor respond better than
  hypoxic tumor bed
• Disadvantages
• Delay in surgery
• Possible wound healing complication
• Less information on tumor extent and pathology

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PRINCIPLES OF RADIOTHERAPY

• Indication in soft tissue sarcoma
• Brachytherapy
• Insertion of radiation sources into tissues after
  tumor resection before closure
• Radioactive source (usually cesium or iodine)
  placed inside the catheters on post op D5
• Excellent postoperative treatment for extremity
  soft tissue sarcoma (adjuvant brachytherapy local
  control rate for high grade lesion is 89)
• Intraoperative Radiotherapy
• Electron or orthovoltage beam
• 74 local control rate for primary
  retroperitoneal sarcomas when combined with
  external beam radiotherapy

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PRINCIPLES OF RADIOTHERAPY

• Timing of radiotherapy
• Definitive radiotherapy for rhabdomyosarcoma and
  Ewings sarcoma is generally integrated into the
  middle of a chemotherapy program
• Postoperatively, as soon as adequate wound
  healing is achieved, usually 3 to 6 weeks

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PRINCIPLES OF RADIOTHERAPY

• Side Effects
• Acute side effects depend on the total dose of
  radiation and overall treatment time
• Late side effects depend on fraction size

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PRINCIPLES OF RADIOTHERAPY

• Acute Side Effects
• begins after first 2 weeks and increase as the
  treatment continues
• Most common is fatigue
• Majority develop erythema, and temporary
  desquamation
• Uncommon wound dehiscence, suppresses blood
  counts and other complications pertaining to
  anatomic site involved
• At least one clinic visit per week to see
  radiation oncologist to assess and manage
  potential side effects

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PRINCIPLES OF RADIOTHERAPY

• Late Side Effects
• Months to years after receiving radiotherapy
• Muscle fibrosis stretching exercise
• Weaken Bones and cause Joint Dysfunction
• Edema distal to irradiated site full
  circumference of limb should never be treated to
  a high dose
• More then 20 years after radiation
• Secondary malignancy esp. in children
• Rate of secondary bone cancer after radiation
  treatment for all childhood cancers was less than
  1
• For those treated for Ewings sarcoma, the risk
  was 5.4
• Others bone growth arrest and iatrogenic
  scoliosis in children

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THANK YOU