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Musculoskeletal Tumours for Orthopaedic Exams
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Musculoskeletal Tumours for Orthopaedic Exams
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Language: EN.
Segment:0 .
About bone tumors. I'm not going to talk extensively about bone tumors. I'm going to try and limit it basically a focus of for my experience from the Fox fine allow you to hone in your answers so that you don't go. You don't get too upset or obsessed because it is a vast subject. OK, so the key thing is to remember to relax consumers sounds scary.
But the reality is the person across the other side won't know as much as you probably less than you. Is your knowledge should be fresher and more up to date than theirs. They're going to be heavily reliant on the answers on the answers script they get in front of them. So the key thing is not to over elaborate buy and keep it simple. So the old axiom keep it simple.
Stupid OK, now this is demonstration, but you actually look at the syllabus for musculoskeletal oncology. It consists of three lines, so the presentation of radiological features, pathological features and treatment. Now the common benign and malignant tumors. You just need to know that generally that's not than the principles of management of patients with metastatic bone disease in terms of investigation.
That definitive and fixation pathological fractures, oncological management, you need to know a bit more specifically and broadly. You also need to do presenting features and management and outcome for soft tissue. Soft tissue swelling, including sarcoma, is a little bit more detail, but they're not wanting you to have extensive knowledge because there are very few people who will.
And the reality is, if you're going, you have that knowledge and you're going along that route. You're one of the few, ok? Now, I'm hoping that by keeping it simple, will be safe and you'll do a lovely save like this when this question arises. Ok? now, the most important thing is to have a good systemic approach to when you see a, you see a common question like this, so it might say, tell me about this image, 13-year-old boy back pain relievers, non-steroidal anti-inflammatories and then they might show you this.
This was one of the questions I had in my exam. So, no, it's a spinal problem. You can see a little nydfs there. I'll go back. Apologies you see that little nydfs there says that's consistent with an osteoporosis. OK, no real quick. That is hopefully your introductory question, but they're going to ask you a bit more details.
Ok? or if you are lucky, you might get something a bit like this. So hands up, who thinks this is a bone tumor? Don't worry, I thought I did. But actually, it's a common mistake because this is actually osteomyelitis. Ok? and the bad old days, you might get a question.
He says not trying to draw. Like this, right? You can see that one that's not that's not a pleasant one, but thankfully we don't have any frozen section slides in there. Generally, you want to know about the zone of transitions. When you look at the x ray, have a rough idea of the age of the patient, look for any possible reaction, any cortical destruction.
And think about the location in whether it is in the emphasis metathesis or dialysis. And also the location within that area, whether it is eccentric centrally or just on the edge. Can you also work out whether the matrix in terms of the bone matrix, wherever it is primitive, sclerotic or a ground glass appearance? And again, is it just one lesion or is there multiple lesions back and hopefully help you answer a question like this?
Because reality is you get most of your answers from the X-ray because the morphology of the bone lesion on a plain radiograph will definitely tell you whether it's well defined hostility or ill-defined or sclerotic. It can also generally work out the age of the patient, so you can tell this is a psychologically mature person. It is important, as I said, to stress, that actually the radiograph will tell you a lot more seats memorize only really important and very selected cases.
OK most bone tumors are osteoarthritis in nature, so the most reliable indications tell me whether these lesions are benign is that or malignant is the zonas transition. So can you decide whether it is a lytic feature or ill defined, lytic, well defined or sclerotic and are roughly their age if they're less than 30? And the location where there's long bone axilo at the spinal surgery multiple?
These are the sort of buzz words, you need to be talking about when you're discussing this in vivo. Um, and hopefully you have you can have a rough idea, so this is just a nice schematic, which has seen lots of times on the internet. You can roughly work out from the position of whether it's in a central position or such or such as Ewing's sarcoma or whatever it is on the edge or the metathesis.
And emphasis I can osteosarcoma. Or it could be an aneurysm or bone cyst so you can roughly work out from the position and whether it's young or old, roughly whether what type of tumor it might be. OK, so. And here's another sort of a schematic of how you can further define whether there are. It's very easy to go into this in a lot more to talk about this and get lost and go down the garden path.
As I say, if you could describe the X-ray in terms of whether based on the patient's age location, whether it is a solitary lesion, multiple lesion. And what you can tell from the matrix. And whether if there's a zone of transition wherever it is narrow or there's a wide zone transition. And if you can see a tuberosity or reaction or if there's any soft tissue involvement, the reality is that you've answered most of what you've got yourself onto.
Well, safe basis and the examiner's relaxed. And hopefully you can then start scoring more points when they start asking you about steroid level. Well, in terms of position of where it could be. Well, advice for the busy slide. But most of the points you're going to score is when you talk about the principles of the management. OK, but the key thing is you need to show them this you're safe.
This is not something we do on a regular basis. There's the nice sarcomere guidelines from 2015, which you can look at in terms of the British sarcoma group and all hospitals. If you're doing in the UK, all hospitals will have a pathway to a sarcoma MDT. They might ask you a subsequent question what is a sarcoma mater? It typically should include not exclusive to this list.
Specialist sarcoma surgeon who performed sarcoma is on a regular basis as part of the multidisciplinary team of the oncologist, radiologist, oncology nurse and pathologist. It's worthwhile having a rough idea of where your local center is. You're not going to say you're not going to finish it there, but you're all going to talk about understand the principles in terms of treatment. So when you're thinking about you're also thinking in terms of the workup, so if you're the consultant there in the consultant consultation room, you're seeing this patient, you're worried about your making sure you they have atypical pain because you do not want to upset your colleagues at the British glaucoma group.
Do they have neurological symptoms? Those are key things they want to know in your exam, pinpoint any neurovascular issues. You're going to have a clear description of the mass. Any lymph nodes or any other systems, because you can never rule out a metastatic disease in a bone tumor and workup. As we've said, we're going to do a few blood tests. So you're going to do your LDH and alkaline phosphatase because they're very good prognostic indicators and bone tumors.
If it's an older patient, you're going to arrange a myeloma screen. You may also do a urinalysis for some of the weird and wonderful one imaging again key is clean radiograph of the bone a skeletal survey, possibly if you're worried about myeloma, myeloma, a bone scan like slightly going out of fashion because they take too long mRNA staging CT if requested by your local sarcoma unit. OK now, the important thing is the biopsy, so this is where they want to see that you actually understood that there are some guidelines out there and you understand them, there are different types of biopsies.
There's excision, which is what we do on a regular basis when we're taking out a ganglion or like poma. However, they might ask why we not do this? Well, this recurrence with incomplete margins. We don't do percutaneous ones in the UK very much unless you're really got a very good relationship with the MDU. And true biopsies are less common again here. Incisional biopsy is the gold standard, and that's what they want you to talk about.
Typically funding so is performed by the surgeon, hopefully doing the defensive procedure or at least involved that you want to have a pathologist involved because they're going to be there, maybe by your room next door, take the section and to tell you what type of tumor it is and what you need to do. You need to leave a sizeable scar. So avoiding transverse incisions, the approach should not contaminate the muscle compartment, the extra muscle compartments for this reason that over muscle compartments.
You want meticulous hemostasis. If you're using a tourniquet, remember to leave before you close and trying to include as many arteries as possible in any drain should be to go out through the wound. It's like. When we're sampling the specimen, they also want you to say that you're going for.
It soft rather than bone referral rather than necrotic because you're not, the pathologists are not going to give you much information from across the tissue. And the gold standard again is a fresh is a frozen section and you will always send samples for microbiology because invariably you can always get an infection that copies it. OK and typical histology samples as well.
Now they I'm not going to go into detail with the ink in staging because that's well covered in most textbooks. It's typically post-recession, but it's a good estimate. Possible preoperatively key things are is it malignant anatomic metastases? Those are the key, so stresses as part of the thinking. So in terms of anatomic, what compartment is it? Is it compartmentalized or within bone or facial compartment extra?
Has it reached the bone or facial compartment and that you can help yourself by doing an MRI scan in this situation, because that's very good for anatomy? So the next question they might be asking, so you've got your staging there, you've got this, you've done your incisional biopsy, you know what type of tumor it is?
So is it limb salvage or amputation? Most sensors feel that from current guidelines that virtually everything is salvageable, but there are some indications for doing an amputation. The main ones being there's a neurovascular infiltration, which means you're going to have to do extensive radical roivant, which might mean the legs not or the limb not salvageable. Again, extensor muscle invasion, so it may involve multiple muscle compartments.
There may be a pathological fracture with widespread dissemination. And again, also you have to think as well because we are pairing doctors, we have to ask what the patient wants as well. And again, they may be asking, so you've decided what you've got, what level of reception is it to talk about?
So they may start going down that way. We'll talk about it regional going through the term itself. This, again again, is not really done nowadays because there's typically 100% The current one time we won't do it is if we're trying to reduce the size of the tumor, the palliative for pain relief. So marginal. So again, this is another option where we're going through what we call the capsule.
This is the reactive zone with inflammatory cells and tumor satellite cells. This is a situation where you want. You're a good working relationship with your pathologist. Tell you that you're still within the margins. However, there's a 50% recurrence. So again, it's not done very commonly, and you often have to do adjuvant therapy with this.
So basically, we will even do a wide margin of resection, which is the most common one used in this country. It's compartmented to really unblock you, taking the whole compartment out with a cuff of normal tissue. Typically, it does have a low recurrence of less than 10 percent, but there still is a recurrence. Again, in this situation, you want to have need your pathologist available to demonstrate that you have got that healthy cuff of tissue around your or resection.
And then the last one is obviously a radical extra compartment dissection resection such as an amputation, for example, that is the most radical we could talk about. And the other thing they might ask you is regards to other therapies. So we again, we're surgeons, we don't know much about this. So we're not going to expect you to go into too much detail but understand some of the principles we talk about neoadjuvant therapy.
This typically means preoperative, and this is to help usually reduce the size of the tumor and help, and you can help restage and plan your surgery around it. And classically, the level of tumor necrosis you want to get, it's up to 90% to improve the prognosis. Then you typically have to wait a little while before you can start operating. Um, why?
How they might ask you, how does it work? So it is typically programmed cell death, apoptosis, so a bit of basic science there. We always have basic science and this they love it. So your classic remain free agents are you are alkylating agents for direct damage to DNA. Your perimeter means depleting the cellular building blocks and obviously the new biologics. I'm not an expert on this.
I would you'd ask your oncologist, which is why you have an MDT. There is some the classic ones. The most sensitive missile are the osteosarcoma is in Ewing's. There is minimal benefit in soft tissue sarcomas, apart from minor sarcoma and soft tissue Ewing's. Radiotherapy is still being used quite a lot, and it's a generation again in terms of the basic science.
It's the generation of free radicals, which create direct DNA damage. The main radiosensitive tumors are Ewing's lymphomas and your metastatic ones. So if they've got a primary cause, such as breast cancer, you can direct the radiotherapy there and it is typically good as an adjunct therapy. So if you have an incomplete marked margin or you're treating metastatic pain, however, it does come with complications, so you have a high risk of posted radiation sarcoma risk of stress fracture burns at the site of radiotherapy wound problems.
Yes, I have seen this where I've done doing spines where we've had radiotherapy on wounds and it breaks down and you end up with horrible, nasty infections. They may also start talking about reconstruction options. So you probably don't. So this is one of the reconstruction options. So basically everyone at the moment is under prostheses, which we seem to be doing a lot. It's generally involving a joint.
It has because of your radical dissection of the soft tissues, it typically needs to be quite fairly constrained. And in this case, as you can see for picture, you can see these sort of serrated edges. That's a sign of a growing prosthesis, which can be controlled with magnets. Because a number of these people involved are going to be paediatrics, they're still growing. And we may also do autographs, so typically we use a fibular.
And again, this can also act as a strut graph to augment other procedures of reconstruction methods. And the growth again, less used now, typically mainly because you're using a massive section of dead bone, though it is slow, it's slow to incorporate or has no incorporation, and there's a high risk of infection. Now, soft tissue tumors, they're also quite important in regards to this.
You may be presented with a picture like this part on your vivo table. So the key thing is all malignant soft tissues tend to be sarcomas, their Mason cable tissue origin that usually classified by the tissue of origin, and there's over PAM50 subtypes. But I'm not going to go through all of those. I just want to go for the key principles. Thankfully, they're very uncommon with 7.9 million in this country.
They have a central fetal growth pattern. And important, you approach this as a bone tumor and mdc-t approach. It's very much the same group of people involved. As with your bone tumor. The key thing is, so the clinical presentation, which if you read the nice guidelines, is key. They talk about increasing in size that any lump, any mass, that new soft tissue mass that you see this increasing in size more than 5 centimeters.
And it's painful. You should have a high indication of suspicion that this is a malignant soft tissue, soft tissue sarcoma. OK and that's from the 2015 guidelines that you've recommended urging ultrasound scan, not an MRI scan for an urgent ultrasound scan. And you should be going along the two week cancer pathway. These are key buzz words that you need to be saying in your visor.
Typically, you're going to be the consultant that receive this patient, so hopefully you understand this. And here is an algorithm of from nice the NICE guidelines of what to do. You can mention this as well. A key for getting more points. Then you're going to talk about biopsy it. That's what they want to talk about. So the principles are very similar to bone tumor.
There's some controversy as to with regards to tourniquet. I know some surgeons don't use a tourniquet. However, you do use a tourniquet. It's typically without examination. You can key. As with bone tumors in particular, seem espaces you again, you're going to take good care of the drain. They love this egawa fruit or directly in line with the wound.
You want to be exciting the biopsy tract. And typically, you're going to have quite a radical dissection, so you may need to think of having a free flap reconstruction. But of mdc-t may involve having a plastic surgeon. And again, as we've ever deformed by a tumor unit, it's not something we do on a regular basis. And if you are doing it as the principles of getting a wide excision and again, you're going to have the same conversation with regards to salvage or amputate.
As with bone tumors, as I said, adjuvant therapy again, as I said earlier, chemo has a very limited role in soft tissues. Radiotherapy is very useful. So external beam or brachytherapy, there is no real difference whether you do preoperative or post-operative bone therapy in terms of overall survival. Preoperative there are some benefits.
It seems to develop a thick, fibrous capsule around the lesion, which makes it easier to excise. So some units use that you can use a smaller dose and less of a risk of wound problems. The only thing is you have to wait three weeks before you go. Go in to make sure that you can help. The wound doesn't break down. Post-operatively you do have less wound problems, but there still is that risk of infection.
If you don't go in too soon. OK now they may ask about prognosis with this. So there are well defined normal grounds which are on the nice guidelines, and they are calculated as you can use, for example, such as this Memorial sloan-kettering Cancer Center in New York and not the normal grounds are, the greater the tumor, the size of the tumor, how deep that tumor is, what type of tissue it is, whether there's a synovial sarcoma and the patient age.
Again, in this situation, it's good to be young. So does anyone have any questions you'd like to ask this session? Would this qualify for a hot seat session or is this something I've qualify for at least? OK, so we'll stop the recording. We had 37 participants. It's very good for the house.
This summer with the heat wave and the football. I appreciate everyone skipping the football to come in to see this much more important event to be provided for you. Stop recording here today and we'll continue the hot seat by sessions. Could you please raise your hand?
Segment:0 .
About bone tumors. I'm not going to talk extensively about bone tumors. I'm going to try and limit it basically a focus of for my experience from the Fox fine allow you to hone in your answers so that you don't go. You don't get too upset or obsessed because it is a vast subject. OK, so the key thing is to remember to relax consumers sounds scary.
But the reality is the person across the other side won't know as much as you probably less than you. Is your knowledge should be fresher and more up to date than theirs. They're going to be heavily reliant on the answers on the answers script they get in front of them. So the key thing is not to over elaborate buy and keep it simple. So the old axiom keep it simple.
Stupid OK, now this is demonstration, but you actually look at the syllabus for musculoskeletal oncology. It consists of three lines, so the presentation of radiological features, pathological features and treatment. Now the common benign and malignant tumors. You just need to know that generally that's not than the principles of management of patients with metastatic bone disease in terms of investigation.
That definitive and fixation pathological fractures, oncological management, you need to know a bit more specifically and broadly. You also need to do presenting features and management and outcome for soft tissue. Soft tissue swelling, including sarcoma, is a little bit more detail, but they're not wanting you to have extensive knowledge because there are very few people who will.
And the reality is, if you're going, you have that knowledge and you're going along that route. You're one of the few, ok? Now, I'm hoping that by keeping it simple, will be safe and you'll do a lovely save like this when this question arises. Ok? now, the most important thing is to have a good systemic approach to when you see a, you see a common question like this, so it might say, tell me about this image, 13-year-old boy back pain relievers, non-steroidal anti-inflammatories and then they might show you this.
This was one of the questions I had in my exam. So, no, it's a spinal problem. You can see a little nydfs there. I'll go back. Apologies you see that little nydfs there says that's consistent with an osteoporosis. OK, no real quick. That is hopefully your introductory question, but they're going to ask you a bit more details.
Ok? or if you are lucky, you might get something a bit like this. So hands up, who thinks this is a bone tumor? Don't worry, I thought I did. But actually, it's a common mistake because this is actually osteomyelitis. Ok? and the bad old days, you might get a question.
He says not trying to draw. Like this, right? You can see that one that's not that's not a pleasant one, but thankfully we don't have any frozen section slides in there. Generally, you want to know about the zone of transitions. When you look at the x ray, have a rough idea of the age of the patient, look for any possible reaction, any cortical destruction.
And think about the location in whether it is in the emphasis metathesis or dialysis. And also the location within that area, whether it is eccentric centrally or just on the edge. Can you also work out whether the matrix in terms of the bone matrix, wherever it is primitive, sclerotic or a ground glass appearance? And again, is it just one lesion or is there multiple lesions back and hopefully help you answer a question like this?
Because reality is you get most of your answers from the X-ray because the morphology of the bone lesion on a plain radiograph will definitely tell you whether it's well defined hostility or ill-defined or sclerotic. It can also generally work out the age of the patient, so you can tell this is a psychologically mature person. It is important, as I said, to stress, that actually the radiograph will tell you a lot more seats memorize only really important and very selected cases.
OK most bone tumors are osteoarthritis in nature, so the most reliable indications tell me whether these lesions are benign is that or malignant is the zonas transition. So can you decide whether it is a lytic feature or ill defined, lytic, well defined or sclerotic and are roughly their age if they're less than 30? And the location where there's long bone axilo at the spinal surgery multiple?
These are the sort of buzz words, you need to be talking about when you're discussing this in vivo. Um, and hopefully you have you can have a rough idea, so this is just a nice schematic, which has seen lots of times on the internet. You can roughly work out from the position of whether it's in a central position or such or such as Ewing's sarcoma or whatever it is on the edge or the metathesis.
And emphasis I can osteosarcoma. Or it could be an aneurysm or bone cyst so you can roughly work out from the position and whether it's young or old, roughly whether what type of tumor it might be. OK, so. And here's another sort of a schematic of how you can further define whether there are. It's very easy to go into this in a lot more to talk about this and get lost and go down the garden path.
As I say, if you could describe the X-ray in terms of whether based on the patient's age location, whether it is a solitary lesion, multiple lesion. And what you can tell from the matrix. And whether if there's a zone of transition wherever it is narrow or there's a wide zone transition. And if you can see a tuberosity or reaction or if there's any soft tissue involvement, the reality is that you've answered most of what you've got yourself onto.
Well, safe basis and the examiner's relaxed. And hopefully you can then start scoring more points when they start asking you about steroid level. Well, in terms of position of where it could be. Well, advice for the busy slide. But most of the points you're going to score is when you talk about the principles of the management. OK, but the key thing is you need to show them this you're safe.
This is not something we do on a regular basis. There's the nice sarcomere guidelines from 2015, which you can look at in terms of the British sarcoma group and all hospitals. If you're doing in the UK, all hospitals will have a pathway to a sarcoma MDT. They might ask you a subsequent question what is a sarcoma mater? It typically should include not exclusive to this list.
Specialist sarcoma surgeon who performed sarcoma is on a regular basis as part of the multidisciplinary team of the oncologist, radiologist, oncology nurse and pathologist. It's worthwhile having a rough idea of where your local center is. You're not going to say you're not going to finish it there, but you're all going to talk about understand the principles in terms of treatment. So when you're thinking about you're also thinking in terms of the workup, so if you're the consultant there in the consultant consultation room, you're seeing this patient, you're worried about your making sure you they have atypical pain because you do not want to upset your colleagues at the British glaucoma group.
Do they have neurological symptoms? Those are key things they want to know in your exam, pinpoint any neurovascular issues. You're going to have a clear description of the mass. Any lymph nodes or any other systems, because you can never rule out a metastatic disease in a bone tumor and workup. As we've said, we're going to do a few blood tests. So you're going to do your LDH and alkaline phosphatase because they're very good prognostic indicators and bone tumors.
If it's an older patient, you're going to arrange a myeloma screen. You may also do a urinalysis for some of the weird and wonderful one imaging again key is clean radiograph of the bone a skeletal survey, possibly if you're worried about myeloma, myeloma, a bone scan like slightly going out of fashion because they take too long mRNA staging CT if requested by your local sarcoma unit. OK now, the important thing is the biopsy, so this is where they want to see that you actually understood that there are some guidelines out there and you understand them, there are different types of biopsies.
There's excision, which is what we do on a regular basis when we're taking out a ganglion or like poma. However, they might ask why we not do this? Well, this recurrence with incomplete margins. We don't do percutaneous ones in the UK very much unless you're really got a very good relationship with the MDU. And true biopsies are less common again here. Incisional biopsy is the gold standard, and that's what they want you to talk about.
Typically funding so is performed by the surgeon, hopefully doing the defensive procedure or at least involved that you want to have a pathologist involved because they're going to be there, maybe by your room next door, take the section and to tell you what type of tumor it is and what you need to do. You need to leave a sizeable scar. So avoiding transverse incisions, the approach should not contaminate the muscle compartment, the extra muscle compartments for this reason that over muscle compartments.
You want meticulous hemostasis. If you're using a tourniquet, remember to leave before you close and trying to include as many arteries as possible in any drain should be to go out through the wound. It's like. When we're sampling the specimen, they also want you to say that you're going for.
It soft rather than bone referral rather than necrotic because you're not, the pathologists are not going to give you much information from across the tissue. And the gold standard again is a fresh is a frozen section and you will always send samples for microbiology because invariably you can always get an infection that copies it. OK and typical histology samples as well.
Now they I'm not going to go into detail with the ink in staging because that's well covered in most textbooks. It's typically post-recession, but it's a good estimate. Possible preoperatively key things are is it malignant anatomic metastases? Those are the key, so stresses as part of the thinking. So in terms of anatomic, what compartment is it? Is it compartmentalized or within bone or facial compartment extra?
Has it reached the bone or facial compartment and that you can help yourself by doing an MRI scan in this situation, because that's very good for anatomy? So the next question they might be asking, so you've got your staging there, you've got this, you've done your incisional biopsy, you know what type of tumor it is?
So is it limb salvage or amputation? Most sensors feel that from current guidelines that virtually everything is salvageable, but there are some indications for doing an amputation. The main ones being there's a neurovascular infiltration, which means you're going to have to do extensive radical roivant, which might mean the legs not or the limb not salvageable. Again, extensor muscle invasion, so it may involve multiple muscle compartments.
There may be a pathological fracture with widespread dissemination. And again, also you have to think as well because we are pairing doctors, we have to ask what the patient wants as well. And again, they may be asking, so you've decided what you've got, what level of reception is it to talk about?
So they may start going down that way. We'll talk about it regional going through the term itself. This, again again, is not really done nowadays because there's typically 100% The current one time we won't do it is if we're trying to reduce the size of the tumor, the palliative for pain relief. So marginal. So again, this is another option where we're going through what we call the capsule.
This is the reactive zone with inflammatory cells and tumor satellite cells. This is a situation where you want. You're a good working relationship with your pathologist. Tell you that you're still within the margins. However, there's a 50% recurrence. So again, it's not done very commonly, and you often have to do adjuvant therapy with this.
So basically, we will even do a wide margin of resection, which is the most common one used in this country. It's compartmented to really unblock you, taking the whole compartment out with a cuff of normal tissue. Typically, it does have a low recurrence of less than 10 percent, but there still is a recurrence. Again, in this situation, you want to have need your pathologist available to demonstrate that you have got that healthy cuff of tissue around your or resection.
And then the last one is obviously a radical extra compartment dissection resection such as an amputation, for example, that is the most radical we could talk about. And the other thing they might ask you is regards to other therapies. So we again, we're surgeons, we don't know much about this. So we're not going to expect you to go into too much detail but understand some of the principles we talk about neoadjuvant therapy.
This typically means preoperative, and this is to help usually reduce the size of the tumor and help, and you can help restage and plan your surgery around it. And classically, the level of tumor necrosis you want to get, it's up to 90% to improve the prognosis. Then you typically have to wait a little while before you can start operating. Um, why?
How they might ask you, how does it work? So it is typically programmed cell death, apoptosis, so a bit of basic science there. We always have basic science and this they love it. So your classic remain free agents are you are alkylating agents for direct damage to DNA. Your perimeter means depleting the cellular building blocks and obviously the new biologics. I'm not an expert on this.
I would you'd ask your oncologist, which is why you have an MDT. There is some the classic ones. The most sensitive missile are the osteosarcoma is in Ewing's. There is minimal benefit in soft tissue sarcomas, apart from minor sarcoma and soft tissue Ewing's. Radiotherapy is still being used quite a lot, and it's a generation again in terms of the basic science.
It's the generation of free radicals, which create direct DNA damage. The main radiosensitive tumors are Ewing's lymphomas and your metastatic ones. So if they've got a primary cause, such as breast cancer, you can direct the radiotherapy there and it is typically good as an adjunct therapy. So if you have an incomplete marked margin or you're treating metastatic pain, however, it does come with complications, so you have a high risk of posted radiation sarcoma risk of stress fracture burns at the site of radiotherapy wound problems.
Yes, I have seen this where I've done doing spines where we've had radiotherapy on wounds and it breaks down and you end up with horrible, nasty infections. They may also start talking about reconstruction options. So you probably don't. So this is one of the reconstruction options. So basically everyone at the moment is under prostheses, which we seem to be doing a lot. It's generally involving a joint.
It has because of your radical dissection of the soft tissues, it typically needs to be quite fairly constrained. And in this case, as you can see for picture, you can see these sort of serrated edges. That's a sign of a growing prosthesis, which can be controlled with magnets. Because a number of these people involved are going to be paediatrics, they're still growing. And we may also do autographs, so typically we use a fibular.
And again, this can also act as a strut graph to augment other procedures of reconstruction methods. And the growth again, less used now, typically mainly because you're using a massive section of dead bone, though it is slow, it's slow to incorporate or has no incorporation, and there's a high risk of infection. Now, soft tissue tumors, they're also quite important in regards to this.
You may be presented with a picture like this part on your vivo table. So the key thing is all malignant soft tissues tend to be sarcomas, their Mason cable tissue origin that usually classified by the tissue of origin, and there's over PAM50 subtypes. But I'm not going to go through all of those. I just want to go for the key principles. Thankfully, they're very uncommon with 7.9 million in this country.
They have a central fetal growth pattern. And important, you approach this as a bone tumor and mdc-t approach. It's very much the same group of people involved. As with your bone tumor. The key thing is, so the clinical presentation, which if you read the nice guidelines, is key. They talk about increasing in size that any lump, any mass, that new soft tissue mass that you see this increasing in size more than 5 centimeters.
And it's painful. You should have a high indication of suspicion that this is a malignant soft tissue, soft tissue sarcoma. OK and that's from the 2015 guidelines that you've recommended urging ultrasound scan, not an MRI scan for an urgent ultrasound scan. And you should be going along the two week cancer pathway. These are key buzz words that you need to be saying in your visor.
Typically, you're going to be the consultant that receive this patient, so hopefully you understand this. And here is an algorithm of from nice the NICE guidelines of what to do. You can mention this as well. A key for getting more points. Then you're going to talk about biopsy it. That's what they want to talk about. So the principles are very similar to bone tumor.
There's some controversy as to with regards to tourniquet. I know some surgeons don't use a tourniquet. However, you do use a tourniquet. It's typically without examination. You can key. As with bone tumors in particular, seem espaces you again, you're going to take good care of the drain. They love this egawa fruit or directly in line with the wound.
You want to be exciting the biopsy tract. And typically, you're going to have quite a radical dissection, so you may need to think of having a free flap reconstruction. But of mdc-t may involve having a plastic surgeon. And again, as we've ever deformed by a tumor unit, it's not something we do on a regular basis. And if you are doing it as the principles of getting a wide excision and again, you're going to have the same conversation with regards to salvage or amputate.
As with bone tumors, as I said, adjuvant therapy again, as I said earlier, chemo has a very limited role in soft tissues. Radiotherapy is very useful. So external beam or brachytherapy, there is no real difference whether you do preoperative or post-operative bone therapy in terms of overall survival. Preoperative there are some benefits.
It seems to develop a thick, fibrous capsule around the lesion, which makes it easier to excise. So some units use that you can use a smaller dose and less of a risk of wound problems. The only thing is you have to wait three weeks before you go. Go in to make sure that you can help. The wound doesn't break down. Post-operatively you do have less wound problems, but there still is that risk of infection.
If you don't go in too soon. OK now they may ask about prognosis with this. So there are well defined normal grounds which are on the nice guidelines, and they are calculated as you can use, for example, such as this Memorial sloan-kettering Cancer Center in New York and not the normal grounds are, the greater the tumor, the size of the tumor, how deep that tumor is, what type of tissue it is, whether there's a synovial sarcoma and the patient age.
Again, in this situation, it's good to be young. So does anyone have any questions you'd like to ask this session? Would this qualify for a hot seat session or is this something I've qualify for at least? OK, so we'll stop the recording. We had 37 participants. It's very good for the house.
This summer with the heat wave and the football. I appreciate everyone skipping the football to come in to see this much more important event to be provided for you. Stop recording here today and we'll continue the hot seat by sessions. Could you please raise your hand?
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