Musculoskeletal Tumor Management

Clinical

Radiologic Exam. Staging Hystopathologic Exam.

Planning

Surgical tx Radio tx Chemo. tx

Staging
 Surgical Procedure
 There are four basic types of excisions; each is based on the
relationship of the dissection plane to the tumor and its
pseudocapsule:
 intralesional excision
performed within the tumor mass and results in removal of only a portion
of it; the pseudocapsule an macroscopic tumor are left behind.
 Marginal excision
the dissection plane passes through the pseudocapsule of the tumor. Such
a resection may leave microscopic disease.
 Wide (en-bloc) excision
removal of the tumor, its pseudocapsule, and a cuff of normal tissue
peripheral to the tumor in all directions.
 Radical
excision involves removal of the tumor and the entire anatomical
compartment within which it is located
 Role of Chemotherapy
 Initially used only in the treatment of metastatic
disease,
 later used as a part of combined-modality therapy
in the adjuvant (postoperative) setting,
 then as preoperative (neoadjuvant, induction)
therapy in an attempt to preserve limb function
and/or increase long-term survival.
 The routes of chemotherapy administration have
included intravenous (IV) bolus, continuous IV
infusion, and local (regional) drug delivery
directly to the tumor via a feeding artery
Role of Chemotherapy (the benefit)
 Role of Radiotherapy
 Radiotherapy is currently accepted as a standard adjuvant
for most soft-tissue sarcomas of high grade, while the
routine use of adjuvant radiotherapy for low-grade
sarcomas is controversial.
Chemo/Radio sensitive
 Planning after staging
Benign tumors
 Stage 1 tumors: Intracapsular excision (or

curettage) is adequate.
 Stage 2 tumors: Extracapsular excision passing

through the reactive zone is needed.

 Stage 3 tumors: Wide margins of resection are required

in stage 3 or aggressive benign lesions.

In areas not amenable to wide excision,
marginal excision together with adjuvant
treatment (eg, radiation therapy) may be
acceptable.
 Planning after staging
Malignant tumors

 Stage 1A: Tumors are treated with wide excision and usually are
amenable to limb salvage procedures.
 Stage 1B: Tumors may be treated with wide excision but the choice
between amputation and limb salvage depends on the
estimated amount of residual tumor left behind after a limb
salvage procedure.
 Stage 2: Tumors are high grade and usually are extracompartmental
and have a significant risk for skip metastases. They usually are
not amenable to limb salvage operations and require radical amputation or
disarticulation in most patients. However, bone tumors responsive to
chemotherapy may be treated successfully using wide excision and
adjuvant therapy.
 Stage 3: Tumors are responsive to chemotherapy and may be treated
with aggressive resection. Tumors not responsive to adjuvant therapy
should be treated with palliative resection.
Survival by Enneking’s surgical stage
 Conclusion
 Staging is needed to plan the treatment and
estimate the prognosis
 Classification (Aegerter,1975)
I.Reactive Bone II.Hamartomas III.True Neoplasms of
Lesion Affecting Bone Bone
A. Osteogenic
A. Oteogenic 1. Osteosarcoma
A.Osteogenic 1. Osteoma 2. Parosteal sarc
1. Osteoid osteoma 2. Osteochondroma B. Chondrgenic
2. Osteoblastoma 1. Benignchondrobl
B. Chondrgenic astoma
1. Enchondroma 2. Chondromyxoid
fobroma
B.Collagenic
3. Chondrosarcoma
1. Subperiosteal C. Collagenic
cortical defect C. Collagenic
1. Angioma
2. Non-osteogenic 2. Aneurysmal 1. Fibrosarcoma
fibroma bone cyst 2. Angiosarcoma
D. Myelogenic
1. Ewing’s tumor
2. Reticulum cell
sarc
3. Hodgkin’s
disease
E. Osteoclastoma
(GCT)
SURGICAL STAGES

Stage G1, T1, M0 Low grade, intracompartmental lesion,

IA without metastasis
Stage G1, T2, M0 Low grade, extracompartmental lesion,
IB without metastasis
Stage G2, T1, M0 High-grade, intracompartmental lesion,
IIA without metastasis
Stage G2, T2, M0 High-grade, extracompartmental lesion,
IIB without metastasis
Stage G1 or G2, Intracompartmental lesion with metastasis
IIIA T1, M1
Stage G1 or G2, Extracompartmental lesion with metastasis
IIIB T2, M2
SurgicalStaging System (SSS)
William F. Enneking
Stage I: (G1,T1,Mo)
Low-grade, intracompartmental,
metastase (-)
Stage IB:(G1,T2,Mo)
low-grade, extracompartmental, metastase
(-)
Stage IIA:(G2,T1,Mo)
High-grade,intracompartement. Metastase
(-)
Stage IIB:(G2,T2,Mo)
High-grade,extracompartment. Metastase
(-)
Stage IIIA: (G1 or G2,T1,M1)
Intracompartment, metastase (+)
Stage IIIB:(G1 or G2,T2,M2)
Extracompartment, metastase(+)
Principles of Treatment
Accurate diagnosis
Benign neoplasms and non-
malignant lesion: surgically
(excision, curettement, bone
grafting)

Malignant primary
neoplasms: surgical ablation,
eradication, with or without
radiotherapy and adjuvant
chemotherapy

Enneking’s staging system