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Bony Metastasis from Unknown Primary for Orthopaedics Exams
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Bony Metastasis from Unknown Primary for Orthopaedics Exams
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Segment:0 .
Hello, everybody, thank you for coming for today's presentation. Today's topic is metastatic lesion with a non-primary match with a non-primary, so a small disclaimer. These are my opinions and only meant for teaching so many times we come across a scenario like this 50 to 60-year-old gentleman or woman comes with the severe radiating back pain, weakness of both legs and the ethnic causes and say there is a back pain with cauda equina syndrome.
And we all think of a disk prolapse, which has been causing this. And when we have MRI scan done, we see something like this. T2 weighted images shows a lesion in vertebra, destroying it and compressing the tickle sac. And we think of metastasis. Another diagnosis can be infection. However, as this is a preserved, it's more likely to be metastasis.
And that's what we are going to talk about, maybe insidiously or acutely and two or three days since it cannot really work. This weakness of leg, you find localized tenderness, you find object to loss of power. And most of people think that this guy, this might be a problem coming from a disk prolapse. However, if the age is like this 60 65 with no known history of back pain moisture, Fred claw palsy one of the things which you should really suspect can be a metastatic lesion in spine.
You won't be surprised to see a picture something like this, or you can see the T2 scan the destruction of vertebral body, and the mask is actually pressing on the spinal cord, which can cause the loss of power. It's emergency now at this point, I really like to tell you the diagnosis, which you should have in mind, it can be either a malignancy which can be easily metastatic or secondary, or it can be an infection, which is a differential diagnosis.
Welcome to that later. So when you see a metastasis in A or 40 to 60 years age group, usually there are some common sights coming from in men. Carcinoma of lung is very common. The communist state in females is suppressed. Other common sites are kidney, prostate, thyroid. Many times you cannot find where is the primary, and we have to work on the secondary ledger to get the primary.
So sometimes you cannot find a primary lesion, and this is possible in around 10% to 15% of cases. Lymphoma is really a diagnosis, which is not really well, well diagnosed in the elderly population, it's more commonly in middle age, so that can be also a cause of malignancy or a skeletal lesion. So when you see the metastasis, how does this happen?
So you've got a tissue like breast or lungs with a tumor sitting in. So after some part of tumor breaks away from the lesion and goes and does the blood cell. And so the blood vessels and blood vessels carry it to the bone. And sitting the different religion there and causing proliferation of cells and then the metastasis, and then it's equally so.
You can get legions which are still lighting, appearing as radial, isn't it? As you can see, this is a pelvis x-ray, which shows a multiple of 2 lytic lesions or stools. This is a common sequelae of a metastasis because there is a mechanism. However, there's a possibility that the metastasis can be also osteoblasts, which is appearing like a radio dense lesion in the bone.
This is one of the picture to show how it appears it has got differential diagnosis. This type of metastasis is possible with the prosthetic carcinoma. The mechanism is not really well known, but there is a hypothesis that one is responsible for osteoblasts proliferation and two plastic lesions. The isolated deposits in the bone are well-understood.
You got a bone microenvironment here with the trabecular and some of us sitting there and then suddenly the tumor cells come there and it's a great number of chemicals. Importance of this is a related peptide interleukin some tumor necrosis factor. And this work on the osteoblasts and osteoblasts then secrete rankle, which work on the osteoclasts, which causes osteoporosis.
So this is a postulated bone. Religions that took plastic. Are told, is not really poorly. And it's poorly understood. And it's related to a hypothesis in the chemical secreted its endothelium. One so how does the metastatic bone tumor present? Pain is one of the very important characteristics. Being has got various characteristics when it comes to tumor, the type of pain which is described in bony tumors.
It's called deep pain, which is continuous. It can be progressive. It can be sudden increase if there's a fracture, which is severe and unremitting and aggravated by straining that it becomes more when you try to move the limb or suppress it, cetera. And most important is not. Now, one of the very important thing is if the person is getting continuous deep pain and suddenly it increases to a sudden sharp, and then you should suspect that there's a microfracture or there's a collapse of structure.
What are the other features of metastatic lesions when we are going through technological fracture? Also, I mentioned if it is spine, then there can be paralysis, which which is paralysis can be of legs of bladder and et cetera there is often weight loss and generalized axilo. Weight loss is more common axilo because terminal stages.
One of the important thing, which occurs is because of austal lysis that can be hypercalcemia, and it's equally similarly, they can be coagulopathy equally. Right so when you get a. A Legion when you come across allegiance, which looks suspicious. So there are guidelines, which we need to follow, the guidelines are often complicated, but the sense of guideline is important.
So in the initial diagnostic phase, you are in clinic. You take a detailed history. When you say history, you have to ask history, which is onset duration progress of the problem. And the second part is history of risk factors. So if you really squeeze history in to predict this is history, of course, so in. When you say comprehensive history is full of risk factors, it's important to ask is true of any primary cancer and specifically it's got any lumps in the breast, any cough or any jaundice or difficulty in urine in, say, prostate area and then physical examination, physical examination.
We tend to just examine the part, which is presented to us and then really don't do a good systemic examination. But generally we should examine the patient from head to toe if there's a suspicion of malignancy. We're not expert. I an examination of chest and abdomen and prostate or breast, but this is what we need to do in the sense, as a team, if we cannot do it ourselves, we can take help of some of the people then.
Will we have to do X-ray next? I'll come to that nice recommends doing this investigation as a primary thing like full blood count urea, electrolyte plating, liver function tests, bone profile, calcium and lactate dehydrogenase, which is considered the tumor marker. It is a marker of intensity or the severity of malignancy. Once we have an x-ray, done X-ray will show two features of the malignancy, which I'll come to, that we need to do MRI of the part and city of chest and pelvis.
Some other recommendations which can be done as a group. Is this following investigation myeloma screen if you the lesion is multicentric and some tumor markers like PSA see a 1.85 alpha fetoprotein. And if there are some that are suspicious, then ultrasound and biopsy. So what does X-ray really show? So this is a very important X-ray feature of malignancy is unless it's or surrealistic lesion from posted, it shows a radiolucent lesion.
OK, you need to also tell what is the matrix like? There is a fibrous wrong look like or it is a lesion, et cetera but it really loosens. And until 40% of calcium is lost from the bone it stabilizes, this lesion doesn't really appear. So effects appear to convince itself that it has been there for some time and it is spread by the medial margins. The margins are the margins of lesions are merging with the normal, which means the zone of transition is very broad that can be associated microfracture or industrial scale.
So if you see the industrial surfaces of a long bone, we'll see. There's no smooth lines or smooth zones. Sometimes the tumor eats the bone from inside. That is from an industrial side, and that can be and still scalping. So generally, when we got a suspicious lesion, we have to initial phase, all these guidelines tell us to discover three things.
Number one is the origin. They want us to know whether it is a primary or secondary. Now in a. Some two must cancel a characteristic feature, but most tumors in the world 60 or 40 age group can be secondaries, so secondary is focused on more here. Second thing we need to know is the stage of tumor or stage of the disease is what is the spread of the tumor when it is skeletal metastases, which itself tells us that is spread.
But we are to also see how much is extra skeletal spread of the tumor. Stage is the meaning of stages, meaning how much is spread, which is how much, how much tumor is spread across. Third thing we are to see is grade which, which shows us whether the tumor. How severe is it tomorrow in the sense, what's a great histologically, if you ask the soldiers in Greek means the level to which it which identifies with who its host organ.
So a poorly differentiated is more severe or more serious problem. All right, so next slide will go. Well, as I said, a my is very important because it shows the. Legion and the soft tissue element, sorry for that. And a CT scan is important, no one to get the diagnosis and number two to detect the extra skeletal metastases.
So you might find they might, might ever see a breast and got some lesions in the chest and lungs and in liver, et et cetera. So MRI of Port and city of just thorax, abdomen and pelvis. This is important now. There is always a rule of biopsy. Now, when they're talking about secondary lesions, the biopsy is usually done by oncologist with the help of radiologists or just to summarize for tissue diagnosis.
That is, to establish the first two things, which is the origin of the tumor, as well as the grade of tumor. We can use operative biopsy, needle biopsy, commonly used segregated buses, image assisted getting biopsies like ultrasound guided and scope and do biopsies, and sometimes if people suspect vehicle on the brush biopsies, a number of them. But what we need to mention in the exam, which can give you 6 for sure, is this.
So you should always say I would manage this patient as a multidisciplinary team approach. Now see the multidisciplinary team approach. We got ourselves, we got oncologists, we got pathologists, we got the radiologist, we got nuclear medicine people and all the people sitting together and the patient. The we really actually if you in your routine practice, you don't have to really interact with all of them.
But the most important person or persons you should be really in touch with, which can give you a chance of not missing out things. Are these two people? There is always a MDT coordinator in each and every trust. And if you just call the switchboard and say put to MDT coordinator and most of them are quite cooperative and they allow transferring and they help in transferring images and clinical data to the amputee team, which is located in district hospital and get investigations.
So this is most important to you to talk about the MDT approach and to talk about MDT coordinator and always get hold of patient and details, develop a good rapport with them. And it will solve most of problems. Right so if you really squeeze the management of salty religion, you got a suspicion you do assessment clinical and radiological confirm the diagnosis.
Biopsy or imaging and treatment treatment of malignancy is again multidisciplinary. But what we as a surgeon have to do is to start with the basic level of management and then go further. So first thing is the patient is in pain analgesia, so you give analgesia what analgesia is required. We got a nice letter by the WTO, which I'm quoting you start with.
Lowest and then we go to highest, which is obvious, most of the cancer patients do require opioids, so the most important thing. So just to summarize, I'll tell the leader the lowest level one is a nonopioid like paracetamol and 6 to is with opioid and 3 is. Or strong spirit?
Well, there are some teams in the hospital, which can also do alternative methods of pain management to get in touch with them, which are anesthetic doctors who go with the pain clinic and what they do, different types of blocks and ablation, et cetera. Now, nice recommends using bisphosphonates for postulated lesion and denosumab for a lesion, which is which comes from a solid tumor, the metastases coming from solid tumor, especially if what involvement is there.
This is basically to reduce pain, as well as for the factories and radiotherapy. Again, this comes in. This is given by the uncle Kim, m.d., team. We can give radiotherapy as a. I mean, motility. Now as surgeons, we are not really there is already a team there, which is going to see all of the aspects of diagnosis and what we come across is the legion, what we are going to do with lesion on the limb and coming to link first and then I'll put the spine.
So when you see a suspicious or selective lesion and it's confirmed that you see metastatic. So you ought to know whether it's a lesion. Or it's a fracture if it's a lesion, is there a possibility of the lesion causing fracture, for which we did? So we got some wise people what criteria they call middle criteria, which? Which in which you can quantify the possibility of probiotic fixation.
So you see about site religion and sites and you go to school, if all is more than eight than patient really requires prophylactic fixation. So I'm not going to depth of. The second thing is the patient has come with a fractured skull fracture with the lesion. Then again, he has. He needs a fixation. So you've got religion or religion with impending structural or pathological fracture.
No and 2 and 3. The place of is surgery. Why is surgery a prophylactic surgery better than the surgery done after it fractures? Because the lesser blood loss. You can dissect it better. Your recoveries fast. Your mobility is fast. Faster is a pain relief.
Which is a good one. Now, if one of the really important thing is election to really fix, to avoid the election, to avoid the fracture, you ought to also consider the other aspects like how bad is the cancer? What is the spread of cancer? The most important thing is a life expectancy. People recommend that if it's less than six months easily, no physician or no replacement is done.
So when you say fixation, we do for a long bones or die physical places, we do fixation with kneeling and sometimes inflating. If it's near the joint we do. And do prosthetic replacement like this. This is in shoulder or hip, or sometimes in knee. When we do hinged knee replacement in spine spine, that's got complex variety of implants, which we don't really come across.
But if one word to really describe the spinal operation is decompression and stabilization and it expresses the expresses what we're doing and it also gives us the principle. So we can see the pedicle screw fixation in this case. So if the Legion is in Spain, so it can be either a incidental finding or back pain, the first case, which I showed you came the severe back pain with the weakness of legs, or it can come with a fracture, a compression fracture, which is not political, typical osteoporotic.
So some features or it can come with neurological deficit. These are various ways the thing can present. So what do we do first? First thing is the one which we are told is comprehensive history and examination, a matter of the port and city pier, but also when the region suspicious, you make him better still, be assessing further cervical spine, given the neck collar and providing analgesia and DVT care.
Because because the local very nice recommends a dose of what cost about 10 milligrams if there is cord compression. So it's important in diabetic people you have to monitor the various levels. This those is put 4.5 to 7 days until we got definitive thing coming in by the surgery or radiotherapy.
So when you say surgery for spinal cord maintenance, you've got a lesion in spine, and we wonder whether this will go for it, just analgesia or a sort of radiotherapy for pain relief or it needs surgery. So we got some criteria called nom. So the MDT and the spine surgeon looks at these things. One is neurology bas status.
Most important, if there is neurology, it gives high marks to take him for operation decompression with stabilization, oncological to see great and responsible to radiation. Then we see the stability of the tumor. Cost is sufficient instability and causing collapse of spine. There is a synth score available. I'll put it up for that. But also important thing, which you should mention in the enzyme is to see how is the functional physiological level of patient?
OK, so I put the score, which got a very criterias like location being a type of lesion alignment if it's how much it's called and how much involvement of posterior elements. So this is calculated by spinal surgeons and then consider whether they are going to go for operation. So generally. A decompression stabilization is done only for two things, and I just added the third thing.
So for all the spinal problems, if the lesion or microfracture or a degenerative process is cause it's operated on, it's only because two reasons. One is instability of spine and neurological deficit, which is progressive. This trend for everything severe back pain sometimes is also an indication if this is something like a cut of the spine at this stage where it cannot hold in and we need to stabilize to get rid of pain.
Again, here we have to have a proper life expectancy more than six months. Otherwise, care is just palliative. So what is operative, we got allegiance which you don't want to operate because it's at once, then you just do palliative care, pain management, keep him comfortable, et cetera. One of the things when you calculate or we think about whether they should give non-operated that it is.
In other words, end of life pathway depends on the scoring system, which takes various things in consideration for the quality scoring system, which tells us patient is not going to really go very far. So no point in doing much or some lesions can be treated for the radiotherapy. But this and this is Kessler suture, which shows the number of lesions and number of metastases, skeleton and extra skeleton and type of malignancy and what policy it is caused.
You need to know it, but I don't think really, you need to know details about it. And radiotherapy. Radiotherapy is basically done for a stable lesion, which is not causing any instability in either any neurological problem. Radiotherapy also is a if you ask radiotherapy, they say it's quite potent and I'll just stick. Now this I'm just mentioning just for completion, so some very, very enthusiastic people can also do what I stand for.
I'll just put it for completion. But what basically they do is if there is a lot of kyphosis, they inject substance in the canal to build up the height. All right. So if it's fine, you should always talk about rehabilitation of skin to our pleasure, sports nutrition and hydration respiration to prevent any chest infection with help of physiotherapist and look at his bowel and bladder, bowel and bladder is also important.
The one thing which are not really put here is a psychological. You should have psychological assessment of a patient wants one. And I think MBT team has a specialist psychologist. So if you really see one of the thing in question is the like, what's the average survival if a sea Pirates with skeletal metastases nearly 48 months, then prostate for 40 months breast 24 months or the year long is most problematic, which is quite a very short term average survival.
So so rarely we get people who got a legion, you search everywhere, there's no sign of it. So there is a. Primary, which is really unknown, nobody knows about it, so we have to biopsy the lesion of the bone to get the diagnosis, because the biopsy, the lesion has got a primary style. Not really those two plus 2 plus to get the diagnosis.
And this is done. This is what is done by the MDT team if they are unable to find the primary. So these are two guy guidelines you should really use, but you cannot remember each and all point. So most important is somebody somebody is very simple, suspicious religion, code, history and examination, X-ray a matter of what can and NDT approach. And last but not the least, is if there is an impending microfracture or cord compression or mechanical instability of spine surgery.
Well, thank you for your patient listening and. It was really a pleasure talking to. Thank you very much, said. That was very comprehensive. I think you've covered it and then some a bit find some questions here. One question was about the histology slides. Are we expected in the exam to know about the histology features of all these tumors?
Well, I wouldn't say you should know the exact histological features, but basically what you should tell examiners is the if it is the metastatic lesion, the cells will be epithelial. Well, if it is a bone, religion or primary, then it can be nonepithelial or mesodermal. OK and like fibroblast, which is coming from mesodermal or third, it can come from lymphoid.
So the three cells you can say if it's metastatic will get epithelial cells there, or if it is, the bone itself will get a little cells. But I don't think you need to really tell about his exact histological features. I think the question was some people have been presented with histology slides and they are expected to comment on them.
How far do you need to know about these slides, can you? Are you expected to diagnose the tumor just based on these slides? No, no, no. Definitely not. What it is to start in question, OK, you are not histology at all, and you cannot diagnose any of them, but you can tell him this is like, for example, these are, for example, axilo looking at cells with hyperkinetic nuclei and something like this.
So you can say there are certain features. I don't know what it is. And then he will give you the second clue. But I don't think out of 100 only maybe one or two with really wants to will be able to make out some 0.5% because even the astrologists they and they use other modalities like immunohistochemistry to really diagnose it.
I don't think we should diagnose, but we can say this is a killer known killer. That would be thing. I think sometimes it can be said can see there's the plate itself. This can be something like that. Some clue will be there, but I don't think when you don't answer that, they will. You still can't get around it.
Yeah I don't think they will fail you if you don't recognize a particular type of tumor on the histology. It is part of the picture. But I think what they expect you to know is the basics about the histology like hematoxylin eosin. And then that either there is like bony cells and whether there is hematoma, hyper chromatin in the cells, which indicates tumor.
I don't think anything beyond that, sometimes like five fibrous tissues, you can recognize them, sometimes by their fibroblasts, recognizable shape. But other than that, I don't think they will expect you to know more. One of very important people. I want to give to candidates is many times the answer to this is very easy.
Like you say, this is a histology slide, which you don't know anything. So you ask me what you do. Answer is not easy. I lost this to pathologist. OK similarly, if there is a patient who's got and it's a quite good answer, actually, nothing it can. I mean, that's what we would ideally do, isn't it? Yes I think this is or what you like to do.
I'll ask patient and explaining this thing that's also quite a good thing. Now, just there are some other questions, and I encourage people to use the chance to ask any questions about the secondary myths in the bone. Having said that, we have got other series about the bone tumors lined up. So if you have anything about primary bone tumors, either malignant or benign, please hold your horses because there is a series of talks about it.
Now, another question says, what about CD4 T in spine Mets and vertebral plastic indications? I think what they want to know is when each one of them is indicated. I think this is likely beyond this, but this is beyond the really syllabus of first year question. Now, if there is instability, neurological deficit, and then it's definitely not what the group lost, that it means decompression with stabilization.
I think a stable region which causes curvature problem like kyphosis is the lesion, which is treated by vertebral plastic, whether it's metastatic or whether it's osteoporotic. I think the standard answer in this will be, as it said, it's merely decompression and stabilization for blood and vertebral. Glassie is mainly for pain relief, but for efforts is your answer should be decompression and stabilization for the spine.
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And the link to some very useful resources and websites. In addition, to remind you again about the book, which is a summary for the exam, as it says, notes about the FRCS exam. As many of your colleagues have mentioned, it is very useful to revise the last thing before you go to the exam or use it as a base. So that you can cover the syllabus. And it is a project not by us, it is by all of us.
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And as I said, there are some very important links and resources in there. Now going back to the questions about the talk, we Abdul-Jabbar asks how urgent you will operate on a first case presented. I think I think let's summarize, let's separate it because if it's a limp is something, and if it's a spine, it is something else. If it is trapped, it's something.
And if it's not fractured, so how would you address it? So, for example, we'll take the limb first. So is there a first possibility? Is a lesion with impending fracture as a familiar score? OK you can do it on an elective list. OK, but give him immobilization, pain relief and keeping non weight bearing, et cetera. If there is a fracture and again, after you have MDT team approach next trauma list, isn't it?
Now this is about limbs in the spine. If it is causing a cord compression cord compression, then you have to take him immediately to take the role as an urgency. If it is instability, then I think it should go on next trauma list. What do you feel that? Yeah so regarding the limp, I think very important part is to the implant should outlive the patient because this is a very important thing.
A lot of people, they say this is an invented fracture. You need to go and fix it as urgent and you fix it with the nail. While it was like it, you find it out. It turned out to be a primary. It's very, very, very rarely can happen. People have been caught with this to be safe. Yes, you need to say this is an embedded fracture. I need to fix as soon as.
But as Sid was saying, it's very important to get involved with the MDT regarding the spine for the spinal, neurology is the main kind of the main mover for towards the surgery. If there is a neurology, especially on evolving neurology, you need to intervene quite urgently. But some people, there is a lot of debate.
Some people, they say, if it's happened over, like in the middle of the night, you can some people they say you can give. Sometimes you can give a steroid. It's a lot of there is a lot of debate around this. To be safe, you will say I will intervene urgently and that's your answer for the efforts to avoid any controversial topics. About two weeks, the most trust for non-urgent things has got to do with a pathway of investigation.
That's what I think the comments is. That vehicle like, suppose you got a suspicion and you want to get urgent MRI. The two week part is to out the investigation and come up with the plan. This is for non-urgent things, and that's what the clarification for the comment. OK, now I may I ask everyone to mute, please, so that we give as much broad width to three, ok?
Three now I was just about to create some stirring and controversy for whatever Sid and I'm said a minute ago. So imagine if you've got the I know I joined a bit late. I know the topic is about unknown primary. So you get a patient with the same query cord compression with metastatic cord compression. What would be mentors for mentors? So would you go into and fix it or decompress and fix it straightaway?
Or would you want to know what the primary is? The reason I'm asking you is if you have a renal medicine, you're going to have a patient who is going to bleed on bleed to death, or if it is a myeloma, you're not going to intervene at all. You're going to stir it with radiotherapy and kill it. So when I mean, whenever I practiced with intensely with spinal surgeons, I've always come with this topic, I personally, unless it is wood, would say for the safety of the patient, there is some situations where you need to be absolutely certain because if you've got a renal limit and if you're going to go and decompress, there's a chance that you could.
The patient could bleed to death on a table. And suppose myeloma, you do not want to decompress myeloma because if you're going to give radiotherapy, you're going to clear myeloma. So there is a bit of ifs and buts here to know the primary before you go and fix it or decompress. That's what I'll give it. I'll give to said, please, can I ask seth?
He's the presenter, ok? I said, what would you answer that? She said, you are on mute, sorry. Can you say that again? Yeah so if the patient has come with the metastasis of the spine and he's got a mechanical instability of spine and a neurological compromise like cord or cord compression? No, I do believe that it needs.
We need to know whether it's coming from kidney or not. Is that the cash question? So we are going to organize the urgent MRI also because this is a serious problem and the TPA, and that should really show the tumor because if there's no tumor and kidney, then I think we cannot say that the renal thing. So these investigations are, I think, are important. Even the middle of the night, you can get them done.
OK Amjad, yeah, so what, I work in a spinal unit. Most of these patients we have actually the answer is the safest way is to say we have the mdc-t. We usually get the mdc-t and the mdc-t involving the oncologist and the radiologists. And in the survey, we will start the MRI whole spine and then we get the CT up, especially if there is unknown primary biopsy is if there is unknown, primary will definitely usually go for a biopsy if there is nothing showed up in this investigation.
So there is no huge rush. Even if there is a neurology, there will be very important, especially if it's the primary suspect. It is a renal cell. You are going to actually lose this patient on table 4 from bleeding. So the safest way is to say I would go for if for four mdc-t, especially if there is renal cell tumor.
I know there are catches there. They try to push you in fat as they try to push you towards you in the middle of the NIPE. And this kind of catastrophic scenarios, I think, try to be safe rather than jumping into the answer. I think I think the neurological symptoms secondary to tumor are slightly different than, well, more than slightly different than acute compression, because of course, the equine is secondary to disk or secondary to trauma.
The reason is there is a reasonable response to steroids. So your first line of management could be steroids to try and reduce the edema, and by reducing the edema, you are reducing the bulk pressure on the cord. And in that case, you buy yourself a little bit of time to investigate. So I think it is very safe to say it is urgent.
However, I would like to exclude a dangerous primary tumor. Hence, I will through the M.D. team meeting urgently, I will arrange for some steroids to try and reduce the edema, and by doing so, I'm reducing the compression on the nerve. And that would recover some of the nerve function and use this valuable time to investigate the primary and do the tumor surgically as soon as we've got more information. The other thing is if the patient has widespread Mets and the prognosis is so poor that the patient will not survive the surgery again, that's I think that you can throw in the mix and make things even more complex.
So the guidelines were not the guidelines. The principles are you be safe, you don't want to kill the patient during the operation. And it is very fair to say I don't want to operate until I know that it's not thyroid and it's not renal. As I said, it's not it's not trauma where you have to intervene.
Immediately, I mean, yeah, this is important. Steroids is a very important point. I think, yes, I think we will have to bring. I mean, I think the guideline is a nice guideline for metastatic cord compression. That's the buzz word to bring in very early. Absolutely absolutely. And I think we've got a summary of it. Sid has mentioned a summary of it and we've got a link to that.
OK, let's move on in the light. Sorry, say again, I'm good. There is another question. Yes, I was going for that. If you have multiple deposits and the one here is unknown, what is the one year? I think it's mean. The survival or the prognosis.
Sorry, primary is known. Do you still have to biopsy or not? Well, if you've got multiple deposits. Yeah, so if there is, if the primary is and you're thinking whether it's either a secondary metastasis or it's something else, you just come. This is again to be discussing the MDT because it's just not like MRI and this thing which you're show, probably most people would like to get a biopsy of the lesion, whether it's not if it's coming from the same metastatic chain or it is something which has come.
No OK, so once you say MDT and I think that was a biopsy of lesion, I think that's quite a reasonable answer. Would you delay the operation to get the biopsy? That's the question. Probably if it's one-year-old and if it's not necessary, it's not one-year-old. That's me misreading the question. Sorry, it's not one-year-old.
Sorry. OK. Yeah so would you delay the operation? Delay the operation until you get a biopsy. You mean, if it's final, is that it's not very clear, actually, it says you've got multiple deposits. Let's assume that it's a limbo, OK, so you've got multiple deposits in limp and muddy and you know, the primary, would you delay the operation until you do a second biopsy?
Well, I don't know is a Frank answer, I would point out to MDT. I'm glad you're working on three hani Mustafa. Any of you? I think three are mutually. Yes, honey. What was that stuff? I think what I heard. If you have if you lose a primary like patient with cancer, breast and chest metastases, but the patient treated from the cancer risk, we don't know, is this from cancer breast more or maybe multiple myeloma?
So even if you have to do a biopsy, there is no pathologist. There is no doing any surgery for any tumor, suspicious for any primary. He has to biopsy whatever, even if the primary. And for the president that said, speak about, I think it's very clear for the examiners there is a lot like buzz words on and you ask, what are the primary tumors to the spine of the wound?
What what is the presentation of the patient? Why it's transferred to the spine before the limbs to speak about Boston venous plexus? They ask you about if you reach to this and for the spine to ask you about Quashie score. It's a prognostic score to tell you about the patient. The survival of the patient is less than 6 months, more than six months, and then you will think about palliative treatment, radiation, then decompression that he will not go through more than this.
This is the buzzword for the future, actually. OK 3. You are going to say something. Now, my question was what was I got you, I mean, I'm almost supposed to answered the same thing because I'm going to say exactly the same. That's fine. Fine good.
OK, guys. Again, you have to take each case as it's presented to. You don't have a rigid answer, like every time you have to delay the management until you get a biopsy because a lot of the time will the MDT will tell you we are sure this is Breast Cancer. Just go ahead and do something about it. And sometimes you can do the biopsy at the same time, for example, you've got a neck of FEMA impeding fracture and there are meds there, and the patient is known to have breast cancer.
For example, you will go ahead and do the stabilization and take the remains and send them as biopsy. Some people, you know, there is an impeding fracture person in our trust. We don't delay the operation for that. We just discuss it in the MDT. Ask them how sure are you that this is breast? And if they say, yes, we are. Then we go ahead and confirm it with the biopsy, because that doesn't change the management in general.
Yeah
Segment:0 .
Hello, everybody, thank you for coming for today's presentation. Today's topic is metastatic lesion with a non-primary match with a non-primary, so a small disclaimer. These are my opinions and only meant for teaching so many times we come across a scenario like this 50 to 60-year-old gentleman or woman comes with the severe radiating back pain, weakness of both legs and the ethnic causes and say there is a back pain with cauda equina syndrome.
And we all think of a disk prolapse, which has been causing this. And when we have MRI scan done, we see something like this. T2 weighted images shows a lesion in vertebra, destroying it and compressing the tickle sac. And we think of metastasis. Another diagnosis can be infection. However, as this is a preserved, it's more likely to be metastasis.
And that's what we are going to talk about, maybe insidiously or acutely and two or three days since it cannot really work. This weakness of leg, you find localized tenderness, you find object to loss of power. And most of people think that this guy, this might be a problem coming from a disk prolapse. However, if the age is like this 60 65 with no known history of back pain moisture, Fred claw palsy one of the things which you should really suspect can be a metastatic lesion in spine.
You won't be surprised to see a picture something like this, or you can see the T2 scan the destruction of vertebral body, and the mask is actually pressing on the spinal cord, which can cause the loss of power. It's emergency now at this point, I really like to tell you the diagnosis, which you should have in mind, it can be either a malignancy which can be easily metastatic or secondary, or it can be an infection, which is a differential diagnosis.
Welcome to that later. So when you see a metastasis in A or 40 to 60 years age group, usually there are some common sights coming from in men. Carcinoma of lung is very common. The communist state in females is suppressed. Other common sites are kidney, prostate, thyroid. Many times you cannot find where is the primary, and we have to work on the secondary ledger to get the primary.
So sometimes you cannot find a primary lesion, and this is possible in around 10% to 15% of cases. Lymphoma is really a diagnosis, which is not really well, well diagnosed in the elderly population, it's more commonly in middle age, so that can be also a cause of malignancy or a skeletal lesion. So when you see the metastasis, how does this happen?
So you've got a tissue like breast or lungs with a tumor sitting in. So after some part of tumor breaks away from the lesion and goes and does the blood cell. And so the blood vessels and blood vessels carry it to the bone. And sitting the different religion there and causing proliferation of cells and then the metastasis, and then it's equally so.
You can get legions which are still lighting, appearing as radial, isn't it? As you can see, this is a pelvis x-ray, which shows a multiple of 2 lytic lesions or stools. This is a common sequelae of a metastasis because there is a mechanism. However, there's a possibility that the metastasis can be also osteoblasts, which is appearing like a radio dense lesion in the bone.
This is one of the picture to show how it appears it has got differential diagnosis. This type of metastasis is possible with the prosthetic carcinoma. The mechanism is not really well known, but there is a hypothesis that one is responsible for osteoblasts proliferation and two plastic lesions. The isolated deposits in the bone are well-understood.
You got a bone microenvironment here with the trabecular and some of us sitting there and then suddenly the tumor cells come there and it's a great number of chemicals. Importance of this is a related peptide interleukin some tumor necrosis factor. And this work on the osteoblasts and osteoblasts then secrete rankle, which work on the osteoclasts, which causes osteoporosis.
So this is a postulated bone. Religions that took plastic. Are told, is not really poorly. And it's poorly understood. And it's related to a hypothesis in the chemical secreted its endothelium. One so how does the metastatic bone tumor present? Pain is one of the very important characteristics. Being has got various characteristics when it comes to tumor, the type of pain which is described in bony tumors.
It's called deep pain, which is continuous. It can be progressive. It can be sudden increase if there's a fracture, which is severe and unremitting and aggravated by straining that it becomes more when you try to move the limb or suppress it, cetera. And most important is not. Now, one of the very important thing is if the person is getting continuous deep pain and suddenly it increases to a sudden sharp, and then you should suspect that there's a microfracture or there's a collapse of structure.
What are the other features of metastatic lesions when we are going through technological fracture? Also, I mentioned if it is spine, then there can be paralysis, which which is paralysis can be of legs of bladder and et cetera there is often weight loss and generalized axilo. Weight loss is more common axilo because terminal stages.
One of the important thing, which occurs is because of austal lysis that can be hypercalcemia, and it's equally similarly, they can be coagulopathy equally. Right so when you get a. A Legion when you come across allegiance, which looks suspicious. So there are guidelines, which we need to follow, the guidelines are often complicated, but the sense of guideline is important.
So in the initial diagnostic phase, you are in clinic. You take a detailed history. When you say history, you have to ask history, which is onset duration progress of the problem. And the second part is history of risk factors. So if you really squeeze history in to predict this is history, of course, so in. When you say comprehensive history is full of risk factors, it's important to ask is true of any primary cancer and specifically it's got any lumps in the breast, any cough or any jaundice or difficulty in urine in, say, prostate area and then physical examination, physical examination.
We tend to just examine the part, which is presented to us and then really don't do a good systemic examination. But generally we should examine the patient from head to toe if there's a suspicion of malignancy. We're not expert. I an examination of chest and abdomen and prostate or breast, but this is what we need to do in the sense, as a team, if we cannot do it ourselves, we can take help of some of the people then.
Will we have to do X-ray next? I'll come to that nice recommends doing this investigation as a primary thing like full blood count urea, electrolyte plating, liver function tests, bone profile, calcium and lactate dehydrogenase, which is considered the tumor marker. It is a marker of intensity or the severity of malignancy. Once we have an x-ray, done X-ray will show two features of the malignancy, which I'll come to, that we need to do MRI of the part and city of chest and pelvis.
Some other recommendations which can be done as a group. Is this following investigation myeloma screen if you the lesion is multicentric and some tumor markers like PSA see a 1.85 alpha fetoprotein. And if there are some that are suspicious, then ultrasound and biopsy. So what does X-ray really show? So this is a very important X-ray feature of malignancy is unless it's or surrealistic lesion from posted, it shows a radiolucent lesion.
OK, you need to also tell what is the matrix like? There is a fibrous wrong look like or it is a lesion, et cetera but it really loosens. And until 40% of calcium is lost from the bone it stabilizes, this lesion doesn't really appear. So effects appear to convince itself that it has been there for some time and it is spread by the medial margins. The margins are the margins of lesions are merging with the normal, which means the zone of transition is very broad that can be associated microfracture or industrial scale.
So if you see the industrial surfaces of a long bone, we'll see. There's no smooth lines or smooth zones. Sometimes the tumor eats the bone from inside. That is from an industrial side, and that can be and still scalping. So generally, when we got a suspicious lesion, we have to initial phase, all these guidelines tell us to discover three things.
Number one is the origin. They want us to know whether it is a primary or secondary. Now in a. Some two must cancel a characteristic feature, but most tumors in the world 60 or 40 age group can be secondaries, so secondary is focused on more here. Second thing we need to know is the stage of tumor or stage of the disease is what is the spread of the tumor when it is skeletal metastases, which itself tells us that is spread.
But we are to also see how much is extra skeletal spread of the tumor. Stage is the meaning of stages, meaning how much is spread, which is how much, how much tumor is spread across. Third thing we are to see is grade which, which shows us whether the tumor. How severe is it tomorrow in the sense, what's a great histologically, if you ask the soldiers in Greek means the level to which it which identifies with who its host organ.
So a poorly differentiated is more severe or more serious problem. All right, so next slide will go. Well, as I said, a my is very important because it shows the. Legion and the soft tissue element, sorry for that. And a CT scan is important, no one to get the diagnosis and number two to detect the extra skeletal metastases.
So you might find they might, might ever see a breast and got some lesions in the chest and lungs and in liver, et et cetera. So MRI of Port and city of just thorax, abdomen and pelvis. This is important now. There is always a rule of biopsy. Now, when they're talking about secondary lesions, the biopsy is usually done by oncologist with the help of radiologists or just to summarize for tissue diagnosis.
That is, to establish the first two things, which is the origin of the tumor, as well as the grade of tumor. We can use operative biopsy, needle biopsy, commonly used segregated buses, image assisted getting biopsies like ultrasound guided and scope and do biopsies, and sometimes if people suspect vehicle on the brush biopsies, a number of them. But what we need to mention in the exam, which can give you 6 for sure, is this.
So you should always say I would manage this patient as a multidisciplinary team approach. Now see the multidisciplinary team approach. We got ourselves, we got oncologists, we got pathologists, we got the radiologist, we got nuclear medicine people and all the people sitting together and the patient. The we really actually if you in your routine practice, you don't have to really interact with all of them.
But the most important person or persons you should be really in touch with, which can give you a chance of not missing out things. Are these two people? There is always a MDT coordinator in each and every trust. And if you just call the switchboard and say put to MDT coordinator and most of them are quite cooperative and they allow transferring and they help in transferring images and clinical data to the amputee team, which is located in district hospital and get investigations.
So this is most important to you to talk about the MDT approach and to talk about MDT coordinator and always get hold of patient and details, develop a good rapport with them. And it will solve most of problems. Right so if you really squeeze the management of salty religion, you got a suspicion you do assessment clinical and radiological confirm the diagnosis.
Biopsy or imaging and treatment treatment of malignancy is again multidisciplinary. But what we as a surgeon have to do is to start with the basic level of management and then go further. So first thing is the patient is in pain analgesia, so you give analgesia what analgesia is required. We got a nice letter by the WTO, which I'm quoting you start with.
Lowest and then we go to highest, which is obvious, most of the cancer patients do require opioids, so the most important thing. So just to summarize, I'll tell the leader the lowest level one is a nonopioid like paracetamol and 6 to is with opioid and 3 is. Or strong spirit?
Well, there are some teams in the hospital, which can also do alternative methods of pain management to get in touch with them, which are anesthetic doctors who go with the pain clinic and what they do, different types of blocks and ablation, et cetera. Now, nice recommends using bisphosphonates for postulated lesion and denosumab for a lesion, which is which comes from a solid tumor, the metastases coming from solid tumor, especially if what involvement is there.
This is basically to reduce pain, as well as for the factories and radiotherapy. Again, this comes in. This is given by the uncle Kim, m.d., team. We can give radiotherapy as a. I mean, motility. Now as surgeons, we are not really there is already a team there, which is going to see all of the aspects of diagnosis and what we come across is the legion, what we are going to do with lesion on the limb and coming to link first and then I'll put the spine.
So when you see a suspicious or selective lesion and it's confirmed that you see metastatic. So you ought to know whether it's a lesion. Or it's a fracture if it's a lesion, is there a possibility of the lesion causing fracture, for which we did? So we got some wise people what criteria they call middle criteria, which? Which in which you can quantify the possibility of probiotic fixation.
So you see about site religion and sites and you go to school, if all is more than eight than patient really requires prophylactic fixation. So I'm not going to depth of. The second thing is the patient has come with a fractured skull fracture with the lesion. Then again, he has. He needs a fixation. So you've got religion or religion with impending structural or pathological fracture.
No and 2 and 3. The place of is surgery. Why is surgery a prophylactic surgery better than the surgery done after it fractures? Because the lesser blood loss. You can dissect it better. Your recoveries fast. Your mobility is fast. Faster is a pain relief.
Which is a good one. Now, if one of the really important thing is election to really fix, to avoid the election, to avoid the fracture, you ought to also consider the other aspects like how bad is the cancer? What is the spread of cancer? The most important thing is a life expectancy. People recommend that if it's less than six months easily, no physician or no replacement is done.
So when you say fixation, we do for a long bones or die physical places, we do fixation with kneeling and sometimes inflating. If it's near the joint we do. And do prosthetic replacement like this. This is in shoulder or hip, or sometimes in knee. When we do hinged knee replacement in spine spine, that's got complex variety of implants, which we don't really come across.
But if one word to really describe the spinal operation is decompression and stabilization and it expresses the expresses what we're doing and it also gives us the principle. So we can see the pedicle screw fixation in this case. So if the Legion is in Spain, so it can be either a incidental finding or back pain, the first case, which I showed you came the severe back pain with the weakness of legs, or it can come with a fracture, a compression fracture, which is not political, typical osteoporotic.
So some features or it can come with neurological deficit. These are various ways the thing can present. So what do we do first? First thing is the one which we are told is comprehensive history and examination, a matter of the port and city pier, but also when the region suspicious, you make him better still, be assessing further cervical spine, given the neck collar and providing analgesia and DVT care.
Because because the local very nice recommends a dose of what cost about 10 milligrams if there is cord compression. So it's important in diabetic people you have to monitor the various levels. This those is put 4.5 to 7 days until we got definitive thing coming in by the surgery or radiotherapy.
So when you say surgery for spinal cord maintenance, you've got a lesion in spine, and we wonder whether this will go for it, just analgesia or a sort of radiotherapy for pain relief or it needs surgery. So we got some criteria called nom. So the MDT and the spine surgeon looks at these things. One is neurology bas status.
Most important, if there is neurology, it gives high marks to take him for operation decompression with stabilization, oncological to see great and responsible to radiation. Then we see the stability of the tumor. Cost is sufficient instability and causing collapse of spine. There is a synth score available. I'll put it up for that. But also important thing, which you should mention in the enzyme is to see how is the functional physiological level of patient?
OK, so I put the score, which got a very criterias like location being a type of lesion alignment if it's how much it's called and how much involvement of posterior elements. So this is calculated by spinal surgeons and then consider whether they are going to go for operation. So generally. A decompression stabilization is done only for two things, and I just added the third thing.
So for all the spinal problems, if the lesion or microfracture or a degenerative process is cause it's operated on, it's only because two reasons. One is instability of spine and neurological deficit, which is progressive. This trend for everything severe back pain sometimes is also an indication if this is something like a cut of the spine at this stage where it cannot hold in and we need to stabilize to get rid of pain.
Again, here we have to have a proper life expectancy more than six months. Otherwise, care is just palliative. So what is operative, we got allegiance which you don't want to operate because it's at once, then you just do palliative care, pain management, keep him comfortable, et cetera. One of the things when you calculate or we think about whether they should give non-operated that it is.
In other words, end of life pathway depends on the scoring system, which takes various things in consideration for the quality scoring system, which tells us patient is not going to really go very far. So no point in doing much or some lesions can be treated for the radiotherapy. But this and this is Kessler suture, which shows the number of lesions and number of metastases, skeleton and extra skeleton and type of malignancy and what policy it is caused.
You need to know it, but I don't think really, you need to know details about it. And radiotherapy. Radiotherapy is basically done for a stable lesion, which is not causing any instability in either any neurological problem. Radiotherapy also is a if you ask radiotherapy, they say it's quite potent and I'll just stick. Now this I'm just mentioning just for completion, so some very, very enthusiastic people can also do what I stand for.
I'll just put it for completion. But what basically they do is if there is a lot of kyphosis, they inject substance in the canal to build up the height. All right. So if it's fine, you should always talk about rehabilitation of skin to our pleasure, sports nutrition and hydration respiration to prevent any chest infection with help of physiotherapist and look at his bowel and bladder, bowel and bladder is also important.
The one thing which are not really put here is a psychological. You should have psychological assessment of a patient wants one. And I think MBT team has a specialist psychologist. So if you really see one of the thing in question is the like, what's the average survival if a sea Pirates with skeletal metastases nearly 48 months, then prostate for 40 months breast 24 months or the year long is most problematic, which is quite a very short term average survival.
So so rarely we get people who got a legion, you search everywhere, there's no sign of it. So there is a. Primary, which is really unknown, nobody knows about it, so we have to biopsy the lesion of the bone to get the diagnosis, because the biopsy, the lesion has got a primary style. Not really those two plus 2 plus to get the diagnosis.
And this is done. This is what is done by the MDT team if they are unable to find the primary. So these are two guy guidelines you should really use, but you cannot remember each and all point. So most important is somebody somebody is very simple, suspicious religion, code, history and examination, X-ray a matter of what can and NDT approach. And last but not the least, is if there is an impending microfracture or cord compression or mechanical instability of spine surgery.
Well, thank you for your patient listening and. It was really a pleasure talking to. Thank you very much, said. That was very comprehensive. I think you've covered it and then some a bit find some questions here. One question was about the histology slides. Are we expected in the exam to know about the histology features of all these tumors?
Well, I wouldn't say you should know the exact histological features, but basically what you should tell examiners is the if it is the metastatic lesion, the cells will be epithelial. Well, if it is a bone, religion or primary, then it can be nonepithelial or mesodermal. OK and like fibroblast, which is coming from mesodermal or third, it can come from lymphoid.
So the three cells you can say if it's metastatic will get epithelial cells there, or if it is, the bone itself will get a little cells. But I don't think you need to really tell about his exact histological features. I think the question was some people have been presented with histology slides and they are expected to comment on them.
How far do you need to know about these slides, can you? Are you expected to diagnose the tumor just based on these slides? No, no, no. Definitely not. What it is to start in question, OK, you are not histology at all, and you cannot diagnose any of them, but you can tell him this is like, for example, these are, for example, axilo looking at cells with hyperkinetic nuclei and something like this.
So you can say there are certain features. I don't know what it is. And then he will give you the second clue. But I don't think out of 100 only maybe one or two with really wants to will be able to make out some 0.5% because even the astrologists they and they use other modalities like immunohistochemistry to really diagnose it.
I don't think we should diagnose, but we can say this is a killer known killer. That would be thing. I think sometimes it can be said can see there's the plate itself. This can be something like that. Some clue will be there, but I don't think when you don't answer that, they will. You still can't get around it.
Yeah I don't think they will fail you if you don't recognize a particular type of tumor on the histology. It is part of the picture. But I think what they expect you to know is the basics about the histology like hematoxylin eosin. And then that either there is like bony cells and whether there is hematoma, hyper chromatin in the cells, which indicates tumor.
I don't think anything beyond that, sometimes like five fibrous tissues, you can recognize them, sometimes by their fibroblasts, recognizable shape. But other than that, I don't think they will expect you to know more. One of very important people. I want to give to candidates is many times the answer to this is very easy.
Like you say, this is a histology slide, which you don't know anything. So you ask me what you do. Answer is not easy. I lost this to pathologist. OK similarly, if there is a patient who's got and it's a quite good answer, actually, nothing it can. I mean, that's what we would ideally do, isn't it? Yes I think this is or what you like to do.
I'll ask patient and explaining this thing that's also quite a good thing. Now, just there are some other questions, and I encourage people to use the chance to ask any questions about the secondary myths in the bone. Having said that, we have got other series about the bone tumors lined up. So if you have anything about primary bone tumors, either malignant or benign, please hold your horses because there is a series of talks about it.
Now, another question says, what about CD4 T in spine Mets and vertebral plastic indications? I think what they want to know is when each one of them is indicated. I think this is likely beyond this, but this is beyond the really syllabus of first year question. Now, if there is instability, neurological deficit, and then it's definitely not what the group lost, that it means decompression with stabilization.
I think a stable region which causes curvature problem like kyphosis is the lesion, which is treated by vertebral plastic, whether it's metastatic or whether it's osteoporotic. I think the standard answer in this will be, as it said, it's merely decompression and stabilization for blood and vertebral. Glassie is mainly for pain relief, but for efforts is your answer should be decompression and stabilization for the spine.
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And as I said, there are some very important links and resources in there. Now going back to the questions about the talk, we Abdul-Jabbar asks how urgent you will operate on a first case presented. I think I think let's summarize, let's separate it because if it's a limp is something, and if it's a spine, it is something else. If it is trapped, it's something.
And if it's not fractured, so how would you address it? So, for example, we'll take the limb first. So is there a first possibility? Is a lesion with impending fracture as a familiar score? OK you can do it on an elective list. OK, but give him immobilization, pain relief and keeping non weight bearing, et cetera. If there is a fracture and again, after you have MDT team approach next trauma list, isn't it?
Now this is about limbs in the spine. If it is causing a cord compression cord compression, then you have to take him immediately to take the role as an urgency. If it is instability, then I think it should go on next trauma list. What do you feel that? Yeah so regarding the limp, I think very important part is to the implant should outlive the patient because this is a very important thing.
A lot of people, they say this is an invented fracture. You need to go and fix it as urgent and you fix it with the nail. While it was like it, you find it out. It turned out to be a primary. It's very, very, very rarely can happen. People have been caught with this to be safe. Yes, you need to say this is an embedded fracture. I need to fix as soon as.
But as Sid was saying, it's very important to get involved with the MDT regarding the spine for the spinal, neurology is the main kind of the main mover for towards the surgery. If there is a neurology, especially on evolving neurology, you need to intervene quite urgently. But some people, there is a lot of debate.
Some people, they say, if it's happened over, like in the middle of the night, you can some people they say you can give. Sometimes you can give a steroid. It's a lot of there is a lot of debate around this. To be safe, you will say I will intervene urgently and that's your answer for the efforts to avoid any controversial topics. About two weeks, the most trust for non-urgent things has got to do with a pathway of investigation.
That's what I think the comments is. That vehicle like, suppose you got a suspicion and you want to get urgent MRI. The two week part is to out the investigation and come up with the plan. This is for non-urgent things, and that's what the clarification for the comment. OK, now I may I ask everyone to mute, please, so that we give as much broad width to three, ok?
Three now I was just about to create some stirring and controversy for whatever Sid and I'm said a minute ago. So imagine if you've got the I know I joined a bit late. I know the topic is about unknown primary. So you get a patient with the same query cord compression with metastatic cord compression. What would be mentors for mentors? So would you go into and fix it or decompress and fix it straightaway?
Or would you want to know what the primary is? The reason I'm asking you is if you have a renal medicine, you're going to have a patient who is going to bleed on bleed to death, or if it is a myeloma, you're not going to intervene at all. You're going to stir it with radiotherapy and kill it. So when I mean, whenever I practiced with intensely with spinal surgeons, I've always come with this topic, I personally, unless it is wood, would say for the safety of the patient, there is some situations where you need to be absolutely certain because if you've got a renal limit and if you're going to go and decompress, there's a chance that you could.
The patient could bleed to death on a table. And suppose myeloma, you do not want to decompress myeloma because if you're going to give radiotherapy, you're going to clear myeloma. So there is a bit of ifs and buts here to know the primary before you go and fix it or decompress. That's what I'll give it. I'll give to said, please, can I ask seth?
He's the presenter, ok? I said, what would you answer that? She said, you are on mute, sorry. Can you say that again? Yeah so if the patient has come with the metastasis of the spine and he's got a mechanical instability of spine and a neurological compromise like cord or cord compression? No, I do believe that it needs.
We need to know whether it's coming from kidney or not. Is that the cash question? So we are going to organize the urgent MRI also because this is a serious problem and the TPA, and that should really show the tumor because if there's no tumor and kidney, then I think we cannot say that the renal thing. So these investigations are, I think, are important. Even the middle of the night, you can get them done.
OK Amjad, yeah, so what, I work in a spinal unit. Most of these patients we have actually the answer is the safest way is to say we have the mdc-t. We usually get the mdc-t and the mdc-t involving the oncologist and the radiologists. And in the survey, we will start the MRI whole spine and then we get the CT up, especially if there is unknown primary biopsy is if there is unknown, primary will definitely usually go for a biopsy if there is nothing showed up in this investigation.
So there is no huge rush. Even if there is a neurology, there will be very important, especially if it's the primary suspect. It is a renal cell. You are going to actually lose this patient on table 4 from bleeding. So the safest way is to say I would go for if for four mdc-t, especially if there is renal cell tumor.
I know there are catches there. They try to push you in fat as they try to push you towards you in the middle of the NIPE. And this kind of catastrophic scenarios, I think, try to be safe rather than jumping into the answer. I think I think the neurological symptoms secondary to tumor are slightly different than, well, more than slightly different than acute compression, because of course, the equine is secondary to disk or secondary to trauma.
The reason is there is a reasonable response to steroids. So your first line of management could be steroids to try and reduce the edema, and by reducing the edema, you are reducing the bulk pressure on the cord. And in that case, you buy yourself a little bit of time to investigate. So I think it is very safe to say it is urgent.
However, I would like to exclude a dangerous primary tumor. Hence, I will through the M.D. team meeting urgently, I will arrange for some steroids to try and reduce the edema, and by doing so, I'm reducing the compression on the nerve. And that would recover some of the nerve function and use this valuable time to investigate the primary and do the tumor surgically as soon as we've got more information. The other thing is if the patient has widespread Mets and the prognosis is so poor that the patient will not survive the surgery again, that's I think that you can throw in the mix and make things even more complex.
So the guidelines were not the guidelines. The principles are you be safe, you don't want to kill the patient during the operation. And it is very fair to say I don't want to operate until I know that it's not thyroid and it's not renal. As I said, it's not it's not trauma where you have to intervene.
Immediately, I mean, yeah, this is important. Steroids is a very important point. I think, yes, I think we will have to bring. I mean, I think the guideline is a nice guideline for metastatic cord compression. That's the buzz word to bring in very early. Absolutely absolutely. And I think we've got a summary of it. Sid has mentioned a summary of it and we've got a link to that.
OK, let's move on in the light. Sorry, say again, I'm good. There is another question. Yes, I was going for that. If you have multiple deposits and the one here is unknown, what is the one year? I think it's mean. The survival or the prognosis.
Sorry, primary is known. Do you still have to biopsy or not? Well, if you've got multiple deposits. Yeah, so if there is, if the primary is and you're thinking whether it's either a secondary metastasis or it's something else, you just come. This is again to be discussing the MDT because it's just not like MRI and this thing which you're show, probably most people would like to get a biopsy of the lesion, whether it's not if it's coming from the same metastatic chain or it is something which has come.
No OK, so once you say MDT and I think that was a biopsy of lesion, I think that's quite a reasonable answer. Would you delay the operation to get the biopsy? That's the question. Probably if it's one-year-old and if it's not necessary, it's not one-year-old. That's me misreading the question. Sorry, it's not one-year-old.
Sorry. OK. Yeah so would you delay the operation? Delay the operation until you get a biopsy. You mean, if it's final, is that it's not very clear, actually, it says you've got multiple deposits. Let's assume that it's a limbo, OK, so you've got multiple deposits in limp and muddy and you know, the primary, would you delay the operation until you do a second biopsy?
Well, I don't know is a Frank answer, I would point out to MDT. I'm glad you're working on three hani Mustafa. Any of you? I think three are mutually. Yes, honey. What was that stuff? I think what I heard. If you have if you lose a primary like patient with cancer, breast and chest metastases, but the patient treated from the cancer risk, we don't know, is this from cancer breast more or maybe multiple myeloma?
So even if you have to do a biopsy, there is no pathologist. There is no doing any surgery for any tumor, suspicious for any primary. He has to biopsy whatever, even if the primary. And for the president that said, speak about, I think it's very clear for the examiners there is a lot like buzz words on and you ask, what are the primary tumors to the spine of the wound?
What what is the presentation of the patient? Why it's transferred to the spine before the limbs to speak about Boston venous plexus? They ask you about if you reach to this and for the spine to ask you about Quashie score. It's a prognostic score to tell you about the patient. The survival of the patient is less than 6 months, more than six months, and then you will think about palliative treatment, radiation, then decompression that he will not go through more than this.
This is the buzzword for the future, actually. OK 3. You are going to say something. Now, my question was what was I got you, I mean, I'm almost supposed to answered the same thing because I'm going to say exactly the same. That's fine. Fine good.
OK, guys. Again, you have to take each case as it's presented to. You don't have a rigid answer, like every time you have to delay the management until you get a biopsy because a lot of the time will the MDT will tell you we are sure this is Breast Cancer. Just go ahead and do something about it. And sometimes you can do the biopsy at the same time, for example, you've got a neck of FEMA impeding fracture and there are meds there, and the patient is known to have breast cancer.
For example, you will go ahead and do the stabilization and take the remains and send them as biopsy. Some people, you know, there is an impeding fracture person in our trust. We don't delay the operation for that. We just discuss it in the MDT. Ask them how sure are you that this is breast? And if they say, yes, we are. Then we go ahead and confirm it with the biopsy, because that doesn't change the management in general.
Yeah
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