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Oncology for Postgraduate Orthopaedic Exams (Part 2)
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Oncology for Postgraduate Orthopaedic Exams (Part 2)
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Hello, everybody, welcome again to a joint session with orthopedic UK and FRC mental group, as always, we are very grateful that you are joining us today. We are very lucky to have both prof.
Cost Costco and Mr Dundon Whitwell from Nuffield orthopedic center in terms of introduce Mr. Whitwell in a moment, but just a reminder to everybody. We are aware UK is running a Tuesday foot and ankle Viva session on Tuesday to 20th of October. The FRCS mentor group is also running Viva webinar sessions on the tenth of October, 24th of October and 21st of November. Please do visit the relevant websites and you can register through there.
And of course, we are recording this session today with Mr. Whitwell and will be on the YouTube channel if our mentor, channel 4 and our UK website for your review later on. You will have an opportunity to ask questions and there will also be an issue during this. But today we won't be doing a voiceover session for obvious reasons as we are doing two sessions this week in terms of lectures is once again.
Everybody Welcome and I would like to just say it's a real pleasure to have both Mr. Whitwell and prof. Kostka with us today. Mr Whitwell is a full time NHS consultant specializing in the treatment of orthopedic and oncology disorders and complex hip and knee reconstructive arthroplasty. He is an honorary senior lecturer at Oxford University and holds a consulting post at Nuffield orthopedic center and has a private practice at the Manor hospital in Oxford.
He has been chair of the Oxford sarcoma network and regularly lectures at invited meetings. He has a strong clinical research interest in hip and pelvic oncology and has been awarded the prestigious ABC traveling fellow to Canada and the US and the British Orthopedic Association. In 2012, and speaking personally, I am in awe of both prof. Mccosker and Mr. Whitwell.
Very great pleasure to have you here. Thank you. Thank you very much, Dave. That's called a false start, so I'll go back to the starting line and we'll start. Thanks very much. Great pleasure to be here. Yeah, we really value education as orthopedic oncologists because regrettably, we do see examples where sarcoma maybe hasn't been treated appropriately, and it's largely because it's such a rare cancer.
It's a complicated cancer as well, with over 70 different histological subtypes, we span this benign malignant spectrum, which I'll try and explain to you, but it only makes up 1% of all cancers. And so it's not probably at the front of our brain. Maybe we're not too a busy on-call night, and we see someone who may or may not have a pathological fracture.
Are we thinking that it could be a condron sarcoma? We don't want to take that to fair to a nail. We want to work it up. And my colleague Tom kostka will be talking very much about the workup of these cases tomorrow. I'm going to just concentrate on this range of bone tumors from the benign to malignant spectrum. They have a number of different treatment algorithms. Most involve surgery and another have various degrees of effectiveness with chemotherapy and radiotherapy.
I think the great thing about sarcoma is that it occurs around the body. And so we're mainly hip and knee surgeons who do sarcoma, but we often need to bring in other specialists from other areas. And it was great when we appointed Tom kostka as one of our colleagues at Oxford because he'd done a shoulder fellowship so we could get him really concentrating on upper limb sarcoma.
And I work quite regularly with other surgeons in the bowel, the chest, et cetera, in trying to deal with these difficult cases. Just first, some facts. We see approximately 100 bone tumors a year in Oxford and about 200 to 300 soft tissue sarcomas. Weeks are normal. That rate that the numbers you see is 5 to 1 soft tissues to bone and lovely.
Thank you. Yeah, sorry about that, so yeah, so that's so. So we're here now just talking about the fact that that's a soft tissue sarcoma and the normal sort of relationship between bone and soft tissue is 5 to 1. And there's about 1,500 soft tissue sarcoma in the wells per year and about 350 bone tumors. This is a soft tissue sarcoma here, and this is quite a classic site for a bone tumor.
And I normally ask the question what this is, and most people come up the exam know this is a parasitic osteosarcoma, quite a unique site for that type of tumor and is known by the examiners. So you might see that. The other thing about sarcomas, I said they occur all around the body, but most of them tend to occur in the lower limb, 10% around the pelvic girdle, 40 percent, 6% in the lower limb.
And we do see intra abdominal intrathoracic and the odd head and neck, and about 13% are in the upper limb as well. So yeah, this is where we have to get that site specific expertise sometimes to help us deal with these cases. I'm ready, this is what I just want to highlight why education so important is to try and think always about the potential for not just sakuma, but maybe even metastatic disease when you're seeing sort of unusual presentations of fractures.
And if it doesn't quite seem right, just take your time and your hopefully your radar will get especially attuned as you get more experience to knowing when things is not right. Take your time. You don't need to rush into theater despite maybe the pressure on getting patients on pathways. Try and make a diagnosis if you've got anything unusual.
So this is a case that really. Drove this home to me right at the start of my consultant career in the first year of practice, I got referred this 32-year-old male fit and active who'd been kite surfing in Turkey. He'd fractured his femur and had it nailed and then was flown back. Three months later, the fracture was not healing.
And I think you can see that there is a lytic deposit. And it really wasn't really noticed, even at this stage, three months later, because the patient went for exchange nailing and an exchange nailing. They found. So I'm just trying to make sure I can get take on there and that. And that exchange mailing that they have found renal cell carcinoma, and they also found staph epidermidis, unfortunately.
So we've got this situation where that was a nailing of a metastasis. He also had a they found the primary in one of the kidneys. What do you do? And yeah, ideally we should have before this nailing was put in which that should have been and should have been noted. You can see there's definitely lysis at the bone end and that patient needs to be properly worked up.
Now, metastasis are important. We do see them quite regularly. They're probably they're much more common than actually sarcoma. And these are just some ribbons that people wear to represent the various cancers on fundraising days throughout the year. These are the major metastatic deposits in the bone. So these are the major ostia files, and I just want to mention metastatic disease first because it is so common and it's increasingly becoming more common as a treatment the oncologists give to patients get better.
There's breast, prostate, lung, renal, thyroid. They're the ones that spread to bone. There's actually a difference between a number of these. There's the cancers that really at the moment don't have a lot of oncological treatments, and their survival can be measured as you see here in the lung and the colorectal. And then there's the cancers that actually the survival now is in years breast, prostate, kidney and thyroid.
Many years, in fact. And I've just seen a patient who had kidney cancer 15 years ago who's still alive. And if you look at here about the chance of these fractures healing, you can see that on the whole, if you have a fracture from these metastases, they're not likely to heal. Prostate might, but the rest of them might not.
So that's important when you are faced with patients with pathological fractures of pathological lesions, so you don't want to miss it because it can cause problems. And the other thing is mistaking a primary bone tumor for a secondary, just assuming an elderly patient has got a metastasis if they haven't got any previous history of a primary is wrong. Any solitary lesion in bone is a primary malignant bone tumor until proven otherwise.
The other problems that we see in these is you underestimate patient survival. As I said, you don't realize that some kidney, some patients with kidney cancer can live 10, 15 years now, and so you've got to do the write operation for them. And the other thing is to overestimate the fact that you just nail and you think that radiotherapy is going to kill the cancer and cause bone healing, it won't. Fractures do not heal.
And I just want to emphasize some of the problems we see. This was a beautifully plated distal femoral fracture undertaken in Marseilles. I think that they had a lot of time fitting the screw holes here, and I'm sure the trauma surgeons amongst you would be a little bit critical of the stiffness of this construct. But anyway, at this stage, despite this being a low energy injury, sustained playing tennis, there was no concern about this fracture.
And then, unfortunately, three months later, the plate broke because the fracture wasn't healing, and only at this stage did they diagnose in the fracture that there was a renal cell metastasis and nailing was then undertaken. But really, we're not addressing the issue that renal cell has got a long survival, that it will very rarely heal this fracture. And yet we're asking metal to splint.
This and aim for healing despite maybe some radiotherapy. And so you can imagine what happened. Like, sometimes it happened in my operating theater with some of the instruments that I use. They get metal fatigue and they fracture. And the fact that a lot of these cancers are very radio insensitive, they really don't respond to radiation, whereas breast, prostate partially does.
What we find is that this happened, the nail and the screws failed. What do you do to this patient who's got solitary renal cancer here? And you potentially could live many years. Well, you can't keep doing intra regional surgery in this case, you have to go for an unblocked resection and bring in a tumor type prosthesis. And this patient actually did very well and was walking out of hospital within three days after having what should have been the definitive operation in the first place.
So what do you do with this patient with renal cancer and staph aureus? This is this kite surfer. He only had a kidney cancer. There was no other disease, this is solitary disease, our metastatic disease. You've got to be quite aggressive and this is the patient who now is 15 years after presenting that I still see in my clinic we were very radical.
We did a total femoral section keeping a big soft tissue cuff around the fracture site to make sure we got all the kidney cancer out. We gave him a spacer for six weeks, gave him some antibiotics and then that's a spacer. We make it out of a long nail and old nail that we cover in antibiotic impregnated cement. So there's lots of antibiotic solution into the soft tissues, as well as IV therapy.
And you just jam it into the tibia, you give him a cricket bat splint and they can mobilize, it's actually a reasonably comfortable construct. And then I gave him a total femur replacement really sort of summarizes where I think metastatic is so important because it is a bone tumor. And I think that it is largely poorly served, but you for the exam may well get this case. An 80-year-old male is falling out of bed.
He's got a classic interlock and neck of femur, or maybe even a subtropical naked femur fracture. You've got the scenario that you want to take him to theater or the nieces want to get into theater quickly because the targets are important and they've got to get them done early. What do you do? You've got to be a little bit concerned, haven't you? Just looking at the matrix here that there's something going on, you're going to be concerned that maybe the patient from your history has had some pain previously in the run up to this fall.
And so this patient is to be stopped. It's not to go to theater. You're going to work it up, you're going to work it up with what Tom is going to describe tomorrow. You're going to get an MRI scan. You can maybe get a chest CT abdomen, you're going to try and see what this is. Could this could be a metastatic deposit or as a solitary lesion with this patient having no known history of cancer could be a primary malignant bone tumor.
And so this is really where in the exam they're trying to make sure that you as a consultant on call are safe and that you're going to be of, you know, really just sort of cognizant that there could be other pathologies going on and not letting this go to theater like you could do. And the answer is this was a clear secondary sarcoma. Luckily, it was biopsied. We were then able to take the patient after the biopsy and do this type of operation rather than a neck of femur.
Periostin Moore, that would contaminate the area even further and probably might even necessitate us doing a through hip amputation. So that's what we want you to be sort of thinking about where metastatic disease is a much more common presentation than sarcoma. So this is just in summary of my metastatic talk is don't do this, guys, don't refer to pathologists, refer to your local sarcoma or oncology unit for advice.
All the patients there, if you've got any concerns. So I want you to get an idea on sarcomas, which is quite a big subject that you can actually break it down quite nicely into various different categories. I've already sort of told you that there's bone and soft tissue sarcomas ratio of 5 to one, but also sarcoma as a name because they come from tissue of Mason of mesenchymal origin.
They come from mesoderm tissue and that's cartilage, bow, muscle fat, smooth muscle. And so all these have slightly different types of tumors. As you know, the Latin moniker is given to these the Kondo, the osteo, the Rado lipo and Leia Mayo. I'm sure you can sort of, you know, those and there's this benign malignant spectrum. And I also want you to understand there's a bit of a structure you can do, and then you're further reading will allow you to build up some of the more detail about them.
So there's benign and malignant, the benign tumors tend to be classified into three types of aggressiveness. There's latent like a non falsifying fibromyalgia. There's an active a bit like maybe an ink on and maybe aggressive like a giant cell tumor. Great them down into these major tissue types. Bone cartilage fibrous. Then, unfortunately, because we're not all nice and simple in sarcoma, I've got a fourth group miscellaneous.
And that group, I'm largely going to talk about the cysts. Malignant, your aggressiveness is low intermediate, high grade and gain, you can break them down into these four major categories bone, cartilage and fibrous tissue, and then a miscellaneous in that miscellaneous I tend to put Ewing's around cell tumors because they don't fit really anywhere else. So apart from the miscellaneous category, which is a little bit messy, everything else I'm going to talk to you fits nicely into these categories.
So you can look at these any X-rays and think, is that a bone cartilage or a fibrous tumor? I quickly talked about metastasis. That's probably a subject all on its own. We could have another seminar at some point on that. And occasionally you do get hematologic malignancies as well. Again, we don't have the time really on that. So I'm just going to concentrate on this spectrum of benign to malignant in these categories bone, cartilage, fibrous and miscellaneous.
So you can see that in Bowen, when the matrix is mainly bone forming, the benign lines of these tumors, moving up to the malignant, the obviously the osteosarcoma. And I'll talk about the parallel steel ones, the surface ones, as well as the more classic central osteosarcoma. In cartilage view, these are the benign tumors you should know a little bit about moving over to the Quandre sarcoma. And there's a few different types of condron sarcoma.
I'll touch on as well. Fiber is again, these are the benign fibers, tumors moving onto the slightly more aggressive, malignant version fibrous sarcoma adamantium eight, which actually has changed its name. Now to the polymorphic spindle cell sarcoma. And I'll touch on that later. And then the system, you do see a number of these tests, I think I do need to talk about them.
The giant cell tumour, the ABC unicameral and then the miscellaneous and malignancy is just about the ewings, which we'll touch on at the end. So I really think if you get that sort of structure thinking about whether that's bone, cartilage or whatever, and to get an idea, whether it's benign or malignant, that will help you try and work out what the tumor potentially could be. So the examiners love their X-rays on their computer. You'll sit at the desk, the examiner will turn the computer around to you and you'll have an X-ray on the screen.
They won't want you to touch it. They want you to get your pen out to just touch around what the important features. So this is what the vibe is. Do they get you talking and describing X rays? First thing is to talk about where just want to have some thinking time, so you can just start off just saying what the X-ray shows are. What the X-ray is that's an obviously an X-ray.
And this is a CT scan, and then you can talk a little bit about where there's maybe a lesion. Think about the epithets. Think about the metathesis or the diagnosis. The reason I say that is that the nice thing about sarcoma is even though it's very complex with 70 different types of. Of subtypes, what you find is that there's only a very few that like the epimysium. A few more like the metathesis and then just a few like the deficit, like adamantium renewing.
So this is a really good diagram to commit to memory because it just allows you to see where the lesion is. And it can hopefully trigger, whether it's one of these types of tumors. It's an ability to help. Also, the age you can see whether they're still growth plate. So you can get an idea, whether it's maybe a pediatric problem. And pediatrics would tend to be thinking about Ewing's and osteosarcoma, where it's the growth plates are fully formed.
It's going to be of adult age and then they may be some of the other tumors. So you've got can do this sort of description of the X-ray while you're actually thinking about what it could be. And then why do you think it's a bone matrix, a cartilage matrix, or is it maybe a fibrous matrix? What's the lesion doing to the bone? Is it eroding it or is it just sitting there nicely?
Court located? And is there a soft tissue mass? Try and get in the habit of describing X-rays. In this sort of sequence. So going back to this X ray, this is an artificial tumour, so already after describing it, you'll know there aren't many eprivacy or tumors, so you'll hopefully come up with eventually and maybe a achondroplasia blast stoma. But I sarcoma research, and it's never, always quite so nice, you've always got to just be careful and say, even though I think it may be a conduire blast tumor will always be getting a tissue diagnosis.
And that's important because very occasionally you can get a clear cell sarcoma in the process that you never want to be caught out on. So there's always a little bit of muddying rather than the rules. This isn't a hypothesis. This is a great decanter. This is a pivotal equivalent. This is again a condo blast, douma.
You can see there's a little bit of sprinkling as though it's a cartilage matrix. It's a relatively walled off tumor. So you don't think that aggressive so that a achondroplasia douma, which is a benign, aggressive tumour, fits in quite nicely. So really, think about that diagram. Think about what part of the bone the tumors are in, and it can often give you a good help to come up with a meaningful differential diagnosis.
And you can see on the MRI scan there was a cartilage matrix. So this X ray, you can say you can describe this a little bit further, it's a metaphysical artificial lesion. It's quite permeate, permeated. There's cortical destruction. Yeah, you don't know where the tumor finishes really do you? It's all like spreading through quite a lot of bones. So this is definitely got an aggressive air to it.
And this actually was a lymphoma, which was destroying the proximal femur. So those sort of few phrases that you can use to describe it are useful for you to come up with a differential. And I would say that you can often use differential tumors, such as different in your differential diagnosis tumors, such as fibrous dysplasia, and you can always often say it could be infection as well infections a big tumor mimic, and that can often be brought into your diagnosis.
So you can see that it's quite disruptive there, and that was an much so. And here now you can see what's this matrix, you can see it's probably bone forming. And you can see there's probably some bone out in the soft tissues here. There's some little bit of Codman triangle there with a dostum's raised up.
It's a mixed lytic picture here. So that's it's also eccentric in the metathesis, so that's hopefully triggering you to come up. This could well be an osteosarcoma, and that's what it was. So, yeah, unfortunately, I can't sort of get you talking, but normally in my talks, I get the delegates to describe these because it just gets people sort of coming up with a vocabulary to describe these X-rays.
And then you've got here. That's quite nice. You can see that we can definitely know where the tumor is. There's not a nice, thin geographic zone around it, and that could either be fibrous dysplasia or a unicameral bone cyst. Maybe infection could be brought in the differential if you as well.
This is an expanse slap lesion distal radius and it's a metathesis sealed tumor going into the epimysium, and we'll see that later in the talk is a giant cell tumor. And these are the sun spit kills, you see an aggressive. And this is actually more in the dialysis than the epimysium than the metathesis. And this actually in a pediatric patient is a Ewing sarcoma.
So let's just carry on straight on to just go through some of the routine tumors, which are the benign bone tumors. This is a patient who had pain at NIPE seemed to be relieved by aspirin. You can see something here in the neck and you can see this on the CT scan. So this is a classic history for an osteosarcoma, which is an osteoblast tumor.
It's a few details here, which you can get from all the textbooks. A lot of these tubers, like the younger patient, most of them tend to have a male predisposition. And as you know, the classic history for Australia is NIPE pain relieved by aspirin and nonsteroidal as it can occur in the back and cause of scoliosis, it can occur near the knee joint. The hip joint and sometimes cause a joint effusion as well.
The treatment is with radiofrequency ablation or potentially cure a charge, a CT scan often nicely shows that there's a lesion in the bone and it's never really bigger than a centimeter. And you occasionally on block size them, but we largely just put a probe in under CT control. That probe heats up to about 90 degrees for about 10 minutes. That completely heats up the tumor. That often causes resolution and bone in filling.
So that's the start of saying, we're really the start of this spectrum of bone tumors from benign to malignant. This is the bigger brother of the. This is again a lesion in here and it's in the metathesis. It's a little bit bigger. It's a bigger than a centimeter. And actually, it can be a little bit more aggressive than Osteria stoma.
And this is called an osteoblast tumor. Again, you can see a little less common than osteosarcoma. Same sort of demographics again still likes going into the spine and seen in the posterior element and about 30% of cases. Again, very similar investigations, MRI and thin sections, CT scan is often hot on bone scan. And it can be mixed up with ABC'S giant cell tumors, even Kundera elastomers sometimes.
And you would tend to want to treat these with on incisions or curettage and bone graft. And you'll see whenever we do curettage these lesions, these benign lesions, we always tend to unfortunately claim about 10% to 20% recurrence rate. So you can always say that in the exam, that seems to be uniform amongst any tumor that we cure at large. Just being always a bit careful, though, even though it looks benign, you can get an osteosarcoma called a 10 10 static osteosarcoma, which I'll show you later, which unfortunately is a very lytic lesion.
And so you always got to make sure that you never really diagnose an osteoblast donor until you've got a tissue diagnosis because you don't want to miss a classic osteosarcoma. Then we're moving on to the cartilage benign tumors. We've got something called Gnostic syndrome, which is that a disorder of the growth plate where rather than the growth plate expanding horizontally, cartilage gets chewed out laterally.
And so that's how you tend to get off to romer's from childhood. Again, very similar demographics that we've seen before. Two types really of plastic and romer's. There can be the sessile flat type or the explosive stalk like often asymptomatic, but can cause some mechanical symptoms on adjacent tendon. The ligaments can be painful if they're not. You really only treat these, though, if they're symptomatic.
However, if after maturity, after you've got skeletal maturity, you're getting increasing growth in one of these Oscar dramas, that is worrying and that does increase the risk of becoming a malignant Conroe sarcoma. Also, if there's a cartilage cap bigger than 2 centimeters that would worry us for changing to a sarcoma. And there the indications for treatment. So we see them around the knee, shoulder and hip.
I'm often the bone scan is relatively cool. But yeah, this is a sessile loss to control here between the tibia and fibula, you can see how long standing it's been there with that long standing erosion of the adjacent fibula. So if you just saw that X ray, you could be a little bit worried that maybe a bone tumor and another type of bone tumor there, but that long standing change in the fibula should reassure you.
That's actually what on cross-sectoral imaging you saw in the human drama, and that cartilage cap is bigger than 2 centimeters. So that would worry us that there may be within this cartilage cap. There is some malignant transformation into a low grade Convery sarcoma. So you're going to get pictures like this, and there is going to say, what is this?
And you know that you've got austere controllers here, but you've got multiple maybe causing sort of gross abnormalities. And so you've got a condition of multiple exhaust doses, multiple and controllers, and it's called hereditary multiplexer stenosis, or previously known as axilo ecclesia autosomal dominant condition variable degrees of penetrance. Number of clinical manifestations, very occasionally malignancy.
Just because you have so many of the consumers they add, they recommend about a very small chance of an interest in each one so that though you do have to be a bit careful and the books vary on what they say is a risk of malignancy. I've seen some textbooks talk about 1% risk of malignancy. I've always known it about 0.2% in every hospital syndrome. So if you've got maybe 100 or so, that might be significant. But we're much more keen on these patients just reporting increased growth after skeletal maturity or increased symptoms like pain.
And then we'll treat them. We don't routinely follow these patients up. So HMD is an important one. Then you've got cartilage tumors within the bone. And these are calls Inc and romer's, and these are very common, and they often do sometimes cause some difficulty when they're seen in other otherwise patients are asymptomatic because of adjacent joint problems.
So we get a lot of cases just sent up from our knee surgeons who just done the X-rays and they see these cartilage tumors above them. Nine tumor is quite common again, relatively effective in young people, mainly in the long bones, though we do see them in the hands. And just to show these are how these tumors are formed, these are just being chewed out from the growth plate, become X or doses or second romer's, or they remain as remnants of the osteogenesis of the bone formation when kids mature and they became they, they come inside the bone.
And the question is, are they Quandre sarcomas or are they in control? Was that you can watch this is with them in the hands, in the hands. They're often lytic, actually. And you don't often see the cartilage stippling, but tumors in the hand are very often benign. They're very, very rarely malignant. So you can be relatively reassured about having tumors.
So this is how you decide whether you've got a condren sarcoma or an enlightened rohmer, and it can be a little bit tricky. And this is where you useful to get your advice of your local oncologist to or to give you that idea. So you can see here this is a little bit more extensive this stippling in the distal femur here. And there's also intermittent lytic areas and there's also some industrial scalloping here.
And the patient would probably have some pain at rest as well. And this is quite clearly a change. And this is going to become a Quandre sarcoma as compared to, let's just go back to here. There's no industrial scalloping. This is just looking like, yeah, a cartilage tumor, and this is still an ink on Roma. So where how do you sort of tell the difference? That just my little table to try and give you an idea, you tend to just have to weigh up all the evidence, you get a clinical history.
You look at the cross-sectional imaging. You also maybe look at the bone scan and you do have to make a judgment call on how where, how far the evidence forms into became potentially being a low grade sarcoma in consumer low grade contro sarcoma, as you'd want to treat with a charge encontramos. You don't treat, but you probably want to watch them and get another MRI scan in six months just to make sure there's been no change if there has been a change.
They become low grade Conrad sarcomas and you need a treat with a curettage. Radiologists or your local tumor center can often help here. This is a condition of multiple anchor syndrome, a ptosis and again, a nice question that you get asked in the mix. It's called Oliver's disease. It's non hereditary, frequently affects one side of the body, often causes growth disturbance, and the key thing is that this has got a 25% risk of malignancy.
So this is a much more sinister condition and you do need to follow these patients up. So when they've got multiple encke syndrome, is that significant and should be referred to the oncology unit. This is a patient who's had multiple income remittances. He had some changes now in his proximal humerus. We saw that there's significant cartilage here, so this had changed into a condren sarcoma.
And you can see there's cartilage tumor almost all the way down the humerus, very close to the elbow joint. So the only way that we can get a full clearance here was to give him a total humoral replacement. And he's been followed up for some cartilage tumors that has got in his wrist and hand as well, that you can probably see a little bit on his bone scan here. So we're watching him closely. He is part of a regular surveillance.
There's another type of form of multiple income remittances, which also has he meningiomas in the soft tissues. And again, it's nicely favored by examiners. That's called mahfouz's syndrome. And here you've got 100% risk of malignancy in these patients. It's very rare. No genetic background. But yeah, you often have to be quite prophylactic in treating these patients because the risk malignancy is very high.
Then coming on to another X-ray that often gives you almost like a pattern mnemonic clue as to what this tumor is. This is called a shark bite out of the proximal tibia. And if you see this, this is a classic sight for another type of cartilage tumor called a condren mixed Lloyd fried Roma. Which, again, is a slightly more aggressive cartilage tumor, but still benign, similar demographics that we've seen previously, and it's like a shark or rat bite out of the proximal tibia.
So anything in here, it's often classically this and that could look like a tender to osteosarcoma that is where you have to have a differential. It could be a conduit of five braimah, but you would also talk about fibers, dysplasia and infection if you saw an X-ray like this. So this is where you've got to describe the X-ray. Come up with some dark differential diagnosis and but try and rank them in the order of likelihood.
You don't want to go straight in with a.b. five as dysplasia here, you'd want to probably mix five grain with your number one. Treatment is often curettage and again, a similar sort of recurrence rates with curettage. Then you've got the condomless douma, which we talked about right at the start of the talk about the epimysium tumors, and we talked about them being one of the few tumors in this, and the only thing that sometimes can recreate it is a clear cell sarcoma just to be careful.
Again, these benign tumors are often treated with curettage and bone graft. So again, a hypothesis is an activity or equivalent. And so you could have a tumor here in the left. So again, very similar. It would be like to be a secondary blast tumor, and the tolerance bone is also in the pivotal equivalent. And so if you've got a lesion, the tail that's often achondroplasia stoma as well.
Then we're coming onto the fibrous type tumors now we've done bone cartilage fibrous. This is called fibrous dysplasia, and you can see that can actually be used in quite a lot of your differential diagnosis when you have lytic tumors. And this is meant to have this glass is ground glass matrix appearance, but on some of the quality x-ray, that's sometimes difficult to sometimes appreciate that.
So it probably is very common, not hereditary, often seen in the femur of tibia. Can also be seen in the upper limb and can be polycystic when it affects just one side of the body. We only treat it if it's symptomatic, largely it can be left alone. If you just correct for obvious dysplasia, fibrous tissue will come back.
So the only way you can really turn fried with tissue into bone is to do is to do proper bone grafting with structural allograft or structural autographed. And so if you've got a lesion in the neck of the femur, you may want to bring a fibular graft into it to stop it becoming that scaffold deformity that you see. So here we put a fibular graft up that was vascularized, and that does luckily then turned fully to bone.
If you just curettage this and put some more solid bone graft in, that bone graft would be taken away and you get five dysplasia back within a year within a year. So you can only really use structural, adequate graft and proper dysplasia. Again, a nice one for the mic is McKeown Albright syndrome, which is polio orthotic Fryer dysplasia with cafe Au lait spots, precocious puberty accelerated body growth and premature fusion of growth plates.
So so that's an important sort of thing that sometimes you need to speak to know some of the stigmata and some of the signs of this. And then we're now coming on from bone, cartilage, fibrous to the cysts, the miscellaneous group. And again, it's this idea that you can see that could be five of these plays potentially, so you might want to bring that differential. It could be infection, but it's a little lesion at the end of the bone.
It's more metathesis emphasis. So the other option is it could be a giant cell tumor or an aneurysm bone cyst. You get an MRI scan and you nicely see fluid levels, and that gives you a lot of reassurance, this is now an aneurysm or bone cyst. Where the giant cell tumor would be solid. So an annual bonus system system is again relatively rare young patient presents with pain, quite an eccentric lesion and can be expensive.
While we sometimes see ABC'S primarily or we see ABC'S around another Sar coma. So when you look at the MRI scan, you've got to go, you've got to look and make sure there isn't a solid tumor being hidden beneath the aneurysm or bonuses, because that's the bit that near them will need to be biopsied. So it can be an ABC on its own, or it can be secondary to another tumor. Lie, if it's on its own, you would just again treat ABC'S with curettage and bone grafts.
Just a really again, reiterate that you've always got to be thinking, is this a malignancy? And the energetic osteosarcoma, i.e. the osteosarcoma that doesn't produce bone is often a mimic of annuals and bone cyst, and you don't want to treat an annual basis without a biopsy just in case it's this, as this can be obviously a very different treatment. So you've got to be always mindful of that benign malignant spectrum, I'm afraid.
This is a unicameral bone cyst, and the classic thing about this on X-ray is you get the falling leaf sign, which is a freight flake of bone that's within the cystic milieu of this cyst. It sort of works away from the growth plate as the bone enlarges in the upper limb. You can often leave this alone, occasionally fracture. They often heal up, and within a few years they stabilize. And the lower limb, unicameral bone cyst often do need a stabilization because you don't want them to fracture.
Occasionally, they've been treated with steroids, but my recommendation, if you do have upper limb, unique elbows, this is masterly inactivity. Don't touch them, occasionally stabilize the lower limb ones. This has been talked about doing injections of steroids, but we don't bother when we see them in Oxford. The case KGB might need to stabilize a lower limb one. And then the giant cell tumour, which actually is probably a different beast, you've got to be a bit more aggressive with this.
Probably it does have a slightly higher chance of coming back to bite you with recurrences. The classic thing of a giant cell tumor is that it's a metaphysical tumor that goes into the epimysium, so it's never going to be mistaken really for a secondary blast, which is often purely epicondyle. So we ask we do see it in expendable bones. You can do a normal block resection, but largely treat with curettage, and I just want to show you how you correct these lesions because the cure is very important.
You can just window it. But on this case, I'm just going to show you. We take the tumor out with the knife. We do a full Curatola taking anything that we can see out and send it off for histology. This is a curettage spoon. We often get the assistant to have a go as well. Then I inject the cavity with methylene blue and then we come in with a Burr and we take all that methylene blue from without from in the cavity to make sure we burn every single area of the cavity, hopefully doing a good curing and removing any tumor cells.
And then we want to use a adjuvant is to try and kill any tumor cells still, and we use a mixture of fennel or hydrogen peroxide. And finally, we often put cement into the cavity, which heats up and kills tumor cells as well. And that is probably the best way of doing a cure, but still has a 10% to 20% chance of recurrence. And if it recurs, you might need to then think of an unblocked resection.
That's the it's the slides with a giant cell tumor. Luckily, I don't think you see too many tumor slides in the exam, but that's quite a classic, one of a giant cell tumor. This is the expendable bone, the fibula and the giant cell tumor likes to go to the proximal fibula. Here you would actually just probably do an en bloc resection. Being very careful of the nerves as it wraps around the neck here.
So that's a bit of a trawl through the benign. Now we're going finishing under the malignant tumors. These are the three major malignant tumors the osteosarcoma, the bone, the Ewing sarcoma, the miscellaneous and the Quandre sarcoma, the cartilage and the sarcomere. I'll probably just miss out because these are the three commonest ones. And these are their incidences in the population.
Key thing is you osteosarcoma and Ewing's a young people's diseases. Where's a sarcomere affects the middle age and elderly? There's a little peak of osteosarcoma in the elderly where that's due to pageants. So Ewing sarcoma loves the pelvis, marc-andre sarcoma is not the pelvis, osteosarcoma is love the knee, that's what you take home from the incidence of their location.
On that when they present. They tend to ewings likes the diagnosis, osteosarcoma, marc-andre sarcoma as they like the metathesis, so osteosarcoma is a bone forming tumor. Most of called central attente, occasionally 10% of surface. So the interim medullary or classic osteosarcoma is a high grade lesion where some of the surface osteosarcoma is a bit more low grade.
They still need good surgery, but they don't need to have chemotherapy. When you have a classic osteosarcoma, majority of them are a to be presentation, which means they have burst out of the bone, but they haven't got chest metastases. You'll know more about the classifications and staging of sarcoma tomorrow. The key thing to think about when you're dealing with osteosarcoma or ewings is it's a systemic disease with just an orthopedic manifestation at the tumor site.
So neoadjuvant chemotherapy is a key treatment near adequate means. The first thing the patient gets is chemotherapy. They then have about three cycles of quite toxic chemotherapy. Then they get restaged. And then they have the surgery, and after surgery, they have more post-operative chemotherapy up to about 6 to 10 cycles, really, depending on what the kill rate of the tumor is done by assessing the tumor resection that is taken out.
How we do surgery. Tom, we'll talk about this tomorrow. We often do wide margins on malignant tumors, balancing up preservation of limb with risk of local recurrence. We've often some quite complex reconstructions. The essential osteosarcoma do sometimes when you get the out phosphatase raise, they like the distal femur and proximal tibia, and primarily it's a bone producing tumour, which can be permitted because it's very disordered.
So you often have a mixed lytic bone picture. Can you see the x-ray? You don't know where that tumor ends or where it finishes. So the bone is being destroyed here and you've got some lytic areas and some bone forming areas. And that's what you should describe in the it's going from the metathesis into the epidermis. And this is the MRI scan, this needs a tumor prosthesis in the reconstruction.
And the thing about this is you need to reconstruct the extent mechanism and how we do proximal tibial restrictions is we always use a gastronomy is flat, that gastronomy is flat, covers the tuber prosthesis and reduces the infection risk, but also it can help stabilize the extensor mechanism reconstruction. So after about three months of keeping the knee still and stiff, they can then start flexing with no extensive leg.
Bend it. And that's the type of thing you try and do by bringing a gastronomy is to protect your proximal ears. And that's what we hope is a good result. I've mentioned this, this, we Beastie a few times the ecstatic osteosarcoma. It's a bit of a nuisance because it doesn't form bone, it's lytic and you have to be mindful of this when you see other tumors like giant cell tumors and ABCs and even sometimes fibrous dysplasia.
So just remember this it's not a bone forming tumor. It's Oscar lytic blood filled sponge, I'm afraid. Luckily, not a common osteosarcoma, but you can see how you could maybe describe this as a benign tumor like fibrous dysplasia or a big unicameral bone sis, couldn't you? Or but actually, that's why it needed a biopsy and a biopsy would have shown very blood filled lesion with tumor cells within it, and that needed treatment like any osteosarcoma with near adjuvant chemotherapy, surgical resection and post-operative chemotherapy.
Then you have surface osteosarcoma as the period deal and that paper mnemonic x-ray, I showed earlier, the power of steel, both the surface. Tend to be lower grade tumors, so they might not need chemotherapy, but still often need wide local excision in their surgery. So just make your own table up of the differences between the perilous deal and the Paris deal, because there are some differences about where they come from, but really, I'm not really ever seen a parallel still in any other place apart from the distal femur.
So if you get a distal femur, a posterior tumor coming out looking like bone forming, it's probably going to be a pair of steel. And that tends to be low grade, but you still do a distal femoral section to get a wide resection. So that's the power of steel. I don't think I've seen one anywhere else. I've seen perilous deals elsewhere. But paracels, that's a realistic one bone forming surface on the surface of the tumor coming from the parasitism, and that actually was a bit high grade that she was given chemotherapy.
The classic teaching on this is that your chemotherapy is the big difference in your survival, and we're now getting up to about 70% five year survival with chemotherapy when we didn't really appreciate it was systemic disease, we were only getting about 20% With very active, with anyone with pulmonary disease, we respect them, and we've got about eight or nine patients discussed on our tumor board every week or being referred to the cardiac surgeons for pulmonary mastectomies, we are very aggressive and that really does help lift patients with advanced disease.
But the adjuvant treatment is important. I don't think you need to know a lot about chemotherapy, apart from that, it's near adjuvant. It's quite toxic. It affects your fertility. It affects your hair. But it's a key thing to get that five year survival up. If you just operate, they'll have only a 20% five year survival.
So I just move on and just show maybe sort of what chemotherapy can do, this was a Ewing's that had chemotherapy. It shrunk down, but the tumor cells could still be in this tissue around the fibula. So we wouldn't just do a feeble economy here. We will still go and take all the muscle around where the tumor was before, because even though the chemotherapy had been effective, we don't think chemotherapy kills 100% of the tumor cells.
It's a good result when we get up to about 90% So you can see from this graft, over the years, we've had increasing survival with our osteosarcoma and Ewing's largely because we're treating them with chemotherapy, allowing us to do tumor prosthesis and limb salvage, whereas in the old days, we were doing lots of amputations. So I think we are looking more and more at the molecular problems that are occurring in our sarcomas, we're really understanding the molecular disorders that occurs and these were the new biological therapies are being targeted.
The trouble about a number of our sarcomas is that some of the genetic abnormalities are quite extensive. Osteosarcoma has multiple genetic abnormalities, and so it's not at the moment very sensitive to biological treatments. But this is where the future of treating sarcoma is being undertaken. So I'm just going to move on a little bit to just finishing on with Cassandra sarcomere.
Condesa coma is malignant, cartilaginous differentiation. It's that cartilage that if calcified matrix. You've got various different grades of chondrocyte coma from one, two and three low grade intermediate grade, high grade and even within a tumour, you can have different types of grade. All of them can only really be treated with surgery and the fortunately, as you get more aggressive, the chance of you actually dying from the disease becomes higher.
So low grade has got a 90% five year survival a high grade 29% but differentiated, which is a very aggressive type of cartilage tumor, has got less than 10% chance. Just to come, just to highlight that a primary conduit sarcoma, a rise in normal bone, but secondary Quandre sarcoma is arise from those benign tumors that I've talked about earlier, such as an ink syndrome or an nastier consumer.
And I just sort of show that calmly stippling here, this is a pelvic tumor. And you can see that popcorn type appearances. This isn't a bone forming tumor. This has got calcification in it, little rings and arcs and this is cartilage, and this was enormous cartilage tumor arising from the ideal blade in a '41 year old male. Here we have to do a very joint preserving osteotomy resection through the side joint, and that allowed us to get this out.
And these are just the various types of pelvic resection you sometimes have to do. Type one is just taking out the ileum type 2s, taking out the sake, the Alex tableland type 3s, taking out the pelvis or eskin. Obviously, this is the one that's a challenge to reconstruct big tumor. We brought all the abductor muscles down, and that's the tumor here that we're going to do in osteotomy just above the hip joint.
The only way this patient can be treated with surgery. So we've got to get the margin. So this margin is absolutely imperative that it doesn't go through tumor. Luckily, we did. We kept a bit of the hip joint. We were able to span the gap between the sacrum and the hip joint with a free fibula graft, which the plastic surgeons raised for us.
They plumb that in. We put that in to give the gait the guy, his pelvic ring back. And you can see after taking all that out, that fibular graft nicely high feet up over the next year and gave him intact pelvic ring. He was a bit weak with his abductors, but his tumor free and didn't get any recurrence. So I'm just going to just sort of finish off if I can, just talking about Ewing's.
So ewings is the final one, it's that miscellaneous one. It's a small round cell tumor of unknown origin. It's a little bit distinguish that, yeah, it doesn't quite fit into anyone's classification, but it's often present systemically. It's got a diaper seal location often. And it managed with osteosarcoma, with chemotherapy. If you do have expendable bones, they can be excised if it's like a pelvic bone.
You sometimes just treat with chemotherapy and radiotherapy. Um, the treatment survivor with chemotherapy is similar to osteosarcoma, about 60% to 70% And if you don't give chemotherapy, the outcome is very poor. So this is a poor girl who had this little lesion in the femur that looks maybe could be fibrous dysplasia, it could be infection, looks a bit irregular for a cyst. But if you get the MRI scan, you can see there's tumor permeating all the way down the femur.
She had systemic symptoms, if I remember this was a ewings, she ended up with a total femoral replacement because these tumors often occur in the young, the children you maybe have to think about. Can this tumor grow to allow the leg to maintain the same side as the other leg? And so we often use things called extendable prosthesis. This is where the implant can actually grow as a child grows in the old days used to just have to come into theater and put a screwdriver in to yank out the implant.
There was a high infection rate with that. So now in tumor surgery, we now use non-invasive growing implants. This is a magnet that the patient goes in every month and every month. They can be lengthened just a few millimeters by going into this electromagnetic field, which means you don't have to come into. You don't have any risk of infection.
And because Ewing's is the predominant pediatric condition we treat, we're often treating them with noninvasive growing implants. So I'm conscious, I've just slightly gone over my time. I'm happy to stay on and do the mdc's, so this is where I'm going to stop. I've tried to give you a flavor of the classification to try and give a framework on which you can get a bit more detail into.
Bone tumors are common, but there's a spectrum, and just using that description of the X-ray can often give you that stepwise assessment. Think about age, site and matrix. What's a tumor doing to bone or what's the bone doing to the tumor and always consult your local tumor center and always be ready to talk about that in the exam, I think. I mean, in general, sarcoma is a rare it's early detection.
Referral treatment requires an extensive MDT, lots of different types, subtypes, lots of specific surgery required. Oncological and reconstruction are the Twin surgical aims, and your adjuvant treatment is dependent on the type and grade of the tumor. So I just asked you, even in your not just your exam, in your clinical practice, be alert. Always assess your patients.
No shortcuts here in sakuma, work them up like as Tom will describe tomorrow. And when you do see these patients always have the right tools for the job. And we're always here for advice. Thank you very much. Thank you very much, Mr. Well, that's excellent talk and quite an important topic for these folks. There's always going to be one religion on the FRC exam, on the Bible section, and we'll move straight on to the mix.
And then from there, we'll answer any questions after that, if you could kindly share the poll. Thank you very much. OK, so the poll started, guys, if you don't mind to answer, it's completely anonymous. We won't know who's answered what, but it gives us an idea of how you guys are doing and what areas of knowledge we're imparting on you. And if it's working or not.
Mr Whitwell will go through the questions at the end. In the meantime, just a reminder to everybody, or UK is a charity organization involved in research and education for orthopedic conditions, including arthritis and other conditions. Their website is our UK dot org.
They have quite a number of educational activities going on. The most recent one is going to be on the 20th of October Tuesday evening. Five a practice session for foot and ankle the FRCS mentor site is FRC assessment or code. Again, it's another charity of orthopedic surgeons who passed the exam and passionate about teaching. Again, we have a number of vyver courses.
Please do take advantage of going to that site to register for those courses, as well as our usual webinars every Wednesday and everything. All lectures are recorded and put on to our YouTube channel, as well as on our UK website. We also published a book that you can see just over my shoulder. Concise orthopedics notes. It is a we believe is a good solution for preparing for the revision notes for the FRCS, but we want to remind you that all proceeds go to maintaining the Zoom channel and on their website.
Essentially, everything's plowed back into making sure that we can provide a better service each time. OK, we're up to two minutes, I think, on 77% The quicker you guys can answer that would be great, so we can maximize the answer. We'll close the polls in a minute. Nikki, I know you've been taking notes of all the questions for later.
Thank you. And thank you to all our mentors today who are supporting without their help and administration today. These sessions are very difficult to run and I apologize today. We are just not. We don't have enough hours in our week to be able to provide the mentors for a revival session today.
OK, we're up to 80 percent, I think we should close the polls soon. OK which can you see the results of the poll? Yeah, yeah, thank you very much, everyone. I think, yeah, just quickly looking. It looks like most people were listening, which is good, and probably most people knew these because I try to highlight what I know the examiners like.
Yeah and I think the first one is, which of the following is the most commonly placed patient at risk of malignancy. I largely talked about all these. I think I didn't talk about neurofibromatosis. And that really is quite low. That that doesn't really does have some risk, but very low. And I did emphasize quite strongly the 100% from the Fauci. That's multiple income drummer.
Ptosis with human genome is very rare, but that's rare in clinical practice, a bit more common in the exam. Mcewan, Albright that's got a small risk. We talk about that. Ollie is 25 percent, the future up to 100% HMG the exam. The other said the books change about 0.2% for every yardstick and Roma. So look at question number two, what current chemotherapy regimens, again, I try to give you a bit of a structure.
The three major malignant bone tumors, Ewing's osteosarcoma, they're treated with neoadjuvant chemotherapy. You then do the surgery. You look at the histological kill rate and then you put them back on chemotherapy for another 6 to 10 cycles. After that Convery sarcoma only surgery. Really, no sensitivity to radiation or chemotherapy. So, yeah, it quite clearly that I think you've got that right, that it's Andre sarcoma that.
So sorry. So I'm actually looking at question three, so I apologize. I'm talking about chemotherapy and improve survival for all of the following malignancies, except on question number three, it's condron sarcoma, and I think I emphasize osteosarcoma, Ewing's lymphoma. I didn't mention those last two, but chemotherapy is vital. And then just going back to question number two, like axilo, I'm sorry, I'm not.
I've got all the I haven't got all the screen. I think that's the one where we talked about with current chemotherapy regimens. What are the typical five year survival rate? I think if you didn't do chemotherapy, it's 20% I think you do well. If you get up to 70% with your chemotherapy and osteosarcoma, and that's for patients with non metastatic disease, it obviously goes down significantly if you do have a meritocracy.
So everyone, most people got that answer right as well. So Thanks very much. Thank you very much. Well, we have had 220 participants on our session today and quite a few questions. Excellent talk. And obviously by the questions it's coming up. It's been it's a topic, which is burning hot in the minds of the guys who are preparing for the exam.
Nikki, do you want to go ahead? So the first question is from Mohammed egawa test. It's a bit of a staged question. What if we know before nailing the FEMA that it was a pathological fracture as a result of a renal deposit, would that change the decision? And then what after if we nail it, if it then went on to a nonunion, is it indicated to radically excise and replace?
Yeah, I think an hour to cover metastatic disease in all its depth as well as sarcoma is a tall order, but it needs to be talked about because it does overlap and it is so important. And I think it's changing. It really is. With these new biological therapies and the elderly population, we are facing a big onslaught of metastatic disease.
Kidney cancer does not respond very well to radiation. It's got a number of new biological therapies. And actually, there is a feeling that you can maybe cure solitary renal cancer to bone. So if we had known that was a pathological fracture second to renal cancer and it was his only deposit in the skeleton, absolutely he would have had a wide resection. But in that case, it probably would have been a proximal femoral replacement.
Why it had to become a total femur was that the nail had pushed all the tumor down into the distal femur. It was all infected and so that's why we had to be aggressive with a distal femur. So that's my. So I think we should have not nailed it. It should have been biopsied. It should have been kept in traction.
There should have been an MRI scan, a bone scan, a CT chest, Abdo pelvis, and then it would have been clear what the problem was and we would have recommended a proximal femur and then a secondary nephrectomy once. What a few weeks after the proximal femur replacement. Thank you. The next question is from masood Khan. If there's a past history of cancer, but no Mets and the cancer is known to be in remission, but the patient presents with a long bone fracture, which looks suspicious should we do local and systemic staging first before attempting to fix?
Absolutely Well picked up. I think you've got it because you're in a busy trauma meeting and maybe some corners are being cut. But when you're coming to the exam, you're not in a busy trauma meeting. You're trying to do best practice to show you're a safe and considered consultant. So if there's any idea that this maybe could be a malignant bone tumour, you have to do all the appropriate staging.
Keep the patient interaction if necessary. MRI scan workup for metastatic disease I would only go straight to theater if the patient had known metastatic skeletal disease. So if you've got someone who's got a good history or has got an MRI scan with multiple metastatic disease, then you probably could go straight to theater. But if you don't have that, it's a primary malignant bone tumor until proven otherwise, and it's beholden on you to keep the patient in bed or whatever and do the investigations, and you can get the investigation done reasonably quickly on the whole.
And so definitely for the exam, if there's any question you do that. So it's important if there is no need to metastasis from a cancer, then you can go straight to the FDA unless you've got that. Which I think is your scenario of a previous cancer, that is to me that still could be a prime target bone tumor. Does that make sense? Yep, Yep.
Oh, that's great that to your question. So the next question is from motel's al-masri. How can I differentiate between non-roma and bone island? It's a very logical thing, it's yeah, if your matrix really, I think that once you get an MRI scan, you'll clearly see that the ink on has got a cartilage matrix of bone island won't. It will be.
And the radiologist can easily tell you the difference on an X-ray. Yeah, it might be a bit harder for you to tell, but an MRI scan will be the key. The key investigation. Thank you. We've got a question from Ali Abdul Hamid. What are the worrisome signs of encontramos? Yeah, again, it does take quite a lot of explaining and it's that spectrum, isn't it, between income drummers and low grade Andre sarcomas?
And it's not an easy one. There's not an exact answer. As I tried to explain, you've got to just look at all the evidence and largely be talking to your local oncology unit. Yeah, come down. Where I get worried about income and rumors is they've expanded. So sequential imaging has shown a change. Looking at the matrix, there's a bit more lysis around the cartilage component than normal.
There's industrial scalping. The patient actually experiences pain in the area. And the bone scan is maybe a bit is very active rather than just being a little bit lukewarm, the ink syndrome is tend to and you tend to balance all that evidence up to decide whether you should do a cure or charge. But if you think it's an end controller, I would still recommend that you get sequential imaging and you recommend that another scan is done in six months time, just so you can make sure that there's no change.
Thank you. And the next question, two people have asked the same question I've got AJ Eurasia and Mohammed Hamid Hamdi Abdul Hamid of both asked, what's the difference between a warm and a hot scan? I think just how it's reported, I think when you do a PET scan, which is the time will tell to you tomorrow, which is our major investigation now for systemic staging, the PET scan will actually give you an SUV, which is the activity of the tumor.
The amount of sort of glucose radiated glucose that's deposited and that gives you actual value. Yeah, I'm afraid it's much more subjective with bone scans, and it largely is dependent on the radiology reporting. There isn't a scale that they can really assess. It's a bit gray rather than Black on the scan, et cetera. But they'll talk about lukewarm, tepid. We'll give you an idea whether it's bright or whether it is that again, that really doesn't help me that much.
It gives a bit of evidence when you look at encontramos and no great contrast comas, but it's not the essential evidence. But PET scans are much better now at giving us an actual figure. Thank you. We've got Imran Ali who said his moral score of pathological fractures valid for pediatric cases, or do we have another similar scoring system to guide a treatment decision?
That's an interesting question. I must admit miralles, yeah, it probably is the 1 to use for the exam. I think it is still quite valid. Yeah again, Merrill's is largely due to metastatic disease, isn't it? And that's very uncommon in pediatrics. So I don't know a pediatric specific one, to be quite honest.
I think if you do have a pathological fracture, I think you do need to often get a biopsy or you need to look at the imaging very closely. But no, there isn't. The answer to your question is there isn't a specific pediatric one that I know of. I don't think that minerals is more for disease, as you said. I don't believe there is anything pediatric at all. So we do use miralles to a degree, but yeah, it does help.
So I think that's still very valid for the exam to have an understanding of miralles, which again, I haven't had time to describe, but it's quite easy to understand if you read the books. OK, thank you. We've got Cameron hafeez, who's asked our monastic fibrous dysplasia and non-islamic Vibram of the same. No, no, they are, they are different and not answering five Roma is really is the very on aggressive tumor.
We'd almost call it late and it doesn't do anything at all. It very rarely causes pain. It's got a big, coordinated margin around it. So you know that the boat is really warded off and it's very different from private dysplasia, which is this ground glass appearance without the bone doesn't show any evidence that it's warded off. So there are different pathologies, probably dysplasia, not promover, but you'd largely just observe anyway.
You wouldn't actually treat. OK, thank you. We've got ours, Sheikh, who's asked, do you use the bench on traject, even at a young patient? Very good question. I think that's a little controversial area. I like cement. I think it's a very good adjuvant. It heats up.
It gives structure and that heating up really does belies any remaining tumor cells. So but still, we get 10% to 20% risk of recurrence. I think a pediatric patient is obviously got some bone growth still to do. Yeah, that could potentially affect it. So yeah, we do in pediatric cases do largely just put bone graft in. Thanks we've got amre Abdullah, how do we differentiate traject osteosarcoma from mimicking benign tumors?
How do you do that is to educate all orthopedic surgeons, to be mindful about it and to make sure that they work the patients up properly with the scans and they get a biopsy and you've got to have it at the front of your cortex and not have it at the back of your cortex and you don't think about it. So yeah, the biopsy, unfortunately, is so vital. So we see benign tumors and we're saying we think they're benign.
But we'll probably get a biopsy, just to be sure. And that really can only happen in a tumor unit, so these cases get referred up. So think about that because you can always get caught out and we see examples of that happening, unfortunately quite regularly. So it's not just hoping to scare you. It still happens regularly. But osteosarcoma is a missed, I'm afraid, with will with any radiological investigations, including bone scans and/or MRI in these situations, and not particularly bone scans, could still be quite active.
An MRI scan would we know you might see a bit more primitive than MRI scan than an x-ray, but the biopsy is the critical thing there. OK, I think we just got two more so. Harry Benjamin Lang has said for isolated renal cell metastases, how soon after ablation can you operate and what is the window? Oh, Yeah. Good question, so renal cell again, is the subject all on its own because kidney cancers are very vascular and we've had some frightening days in theater treating kidney cancers intra regionally.
And so yeah, you tend to well, you always have to recommend that if you're going to go into a lesion into a kidney metastasis, you've got to embellish it. First of all, and how we analyze it is with our interventional radiologists. And we tend to try and do that within three days of the operation. So, yeah, 72 hours is the recommendation. Yeah, I probably if the worst comes to the worst and and we and we've missed that, I would be happy to go up to about a week.
But after about a week, new vessels will be growing into that tumor. And so it could be a bit more vascular than you'd like it. Still, be prepared when you're treating a renal cell. The classic teaching the classic example is in the pelvis. It's eroded the hip joint you're trying to put a hip replacement in. The classic thing is that it could still bleed a lot. So even though you've embolism it, it could still be a bit challenging.
So I get lots of adrenaline soaked gauze swabs. And if it does bleed, just pack it with adrenaline so-called swabs. And that can often staunch the blood flow quite significantly, allowing you to carry on. So that's a little tip if you do ever encounter quite brisk bleeding from some of these metastasis. Thank you. Then we've got Suleiman Yunus, he said, in a case of you in Tacoma, or maybe it's in your case of the Ewing sarcoma islet wing, would you recommend chemotherapy after resection and pasteurization?
Yeah, that's a really nice point. So you know, what's interesting about treating sarcoma is if you go around the world, there are lots of different ways of doing it. Some people use liquid nitrogen inside lesions which get curative, et cetera, and there's some funny sort of treatments out there. What that question is alluding to is the fact that you can take bone, which is affected by tumor away at the time of surgery, and you can take it out of the body.
And you can go and treat that cancer with some other type of adjuvant. And then in the same operation, you can put it back in and you just basically plate it back in and then hopefully with creeping substitution that the fracture will heal and you'll have the tumor treated. But the patient's own bone back in and the pelvis is a classic situation for this. I've had experience of radiation, so it's called extracorporeal irradiation, where the pelvis is taken out.
It's given high dose radiation that otherwise could not be given to the patient with the bone in because it would be too toxic to the running tissues. The tumors killed and then you put that bone back in like a bone graft. Another option is pasteurization, which you can put it into liquid nitrogen or things like that. So there are those techniques around. I don't do it.
And often at the moment, because it's quite logistically challenging to do. But yeah, it is well recognized as treatments for these conditions. So yeah, it does talk about some ways that some units do treat and their Ewing's sarcoma. OK, thank you. Mohammed nail, this is like an exam question, would you advise to do a biopsy in A or better by a tumor unit?
The class, I think again, Tom, we'll talk about this tomorrow because there is Catholic teaching on how you do a biopsy. The key thing about a biopsy that should be excised, that definitive surgery, the biopsy track should be excised could potentially the needle or the operation has led some tumor seeding along that biopsy track. So if you're not going to do the definitive surgery, how do you know where the biopsy will be?
So we do recommend that any tumor gets biopsied in the tumor unit and then we can direct our radiologists or we can do the surgery with a biopsy tract in mind for our definitive surgery. So any tumor specimen we take out often has to biopsy tract attached to it. OK, I know this. This is a really hot topic. I really know that a lot of people are got a lot of questions, but to be honest with you, a lot of these questions are now getting to the high level.
And I know Mr Whitwell has gone way over the time that he had allocated to us, and we really appreciate it. Thank you so much for the time you've given us, Mr Whitlow. Those the questions, the rest of those questions are pretty much beyond the scope of the parks exam. In fact, some of those questions were already beyond. Thank you very much for answering them. I'm thank you for your patience. Really amazing talk.
Once again, thank you very much. Well over 220 participants. Watch this and I'm sure we'll get a lot more hits on the different platforms that we're going to be putting this up on once again, guys tomorrow. Prof prof. Costco will be here to discuss how to investigate and manage these patients in the special metastatic disease as well to everyone.
Thank you so much for attending. We are, as always here every Wednesday except tomorrow, which will be Thursday and look forward to seeing you again. Thank you. Thank you very much. Best of luck, everyone. Thank you. Thank you.
OK, if we can stop recording now. And
Segment:0 .
Hello, everybody, welcome again to a joint session with orthopedic UK and FRC mental group, as always, we are very grateful that you are joining us today. We are very lucky to have both prof.
Cost Costco and Mr Dundon Whitwell from Nuffield orthopedic center in terms of introduce Mr. Whitwell in a moment, but just a reminder to everybody. We are aware UK is running a Tuesday foot and ankle Viva session on Tuesday to 20th of October. The FRCS mentor group is also running Viva webinar sessions on the tenth of October, 24th of October and 21st of November. Please do visit the relevant websites and you can register through there.
And of course, we are recording this session today with Mr. Whitwell and will be on the YouTube channel if our mentor, channel 4 and our UK website for your review later on. You will have an opportunity to ask questions and there will also be an issue during this. But today we won't be doing a voiceover session for obvious reasons as we are doing two sessions this week in terms of lectures is once again.
Everybody Welcome and I would like to just say it's a real pleasure to have both Mr. Whitwell and prof. Kostka with us today. Mr Whitwell is a full time NHS consultant specializing in the treatment of orthopedic and oncology disorders and complex hip and knee reconstructive arthroplasty. He is an honorary senior lecturer at Oxford University and holds a consulting post at Nuffield orthopedic center and has a private practice at the Manor hospital in Oxford.
He has been chair of the Oxford sarcoma network and regularly lectures at invited meetings. He has a strong clinical research interest in hip and pelvic oncology and has been awarded the prestigious ABC traveling fellow to Canada and the US and the British Orthopedic Association. In 2012, and speaking personally, I am in awe of both prof. Mccosker and Mr. Whitwell.
Very great pleasure to have you here. Thank you. Thank you very much, Dave. That's called a false start, so I'll go back to the starting line and we'll start. Thanks very much. Great pleasure to be here. Yeah, we really value education as orthopedic oncologists because regrettably, we do see examples where sarcoma maybe hasn't been treated appropriately, and it's largely because it's such a rare cancer.
It's a complicated cancer as well, with over 70 different histological subtypes, we span this benign malignant spectrum, which I'll try and explain to you, but it only makes up 1% of all cancers. And so it's not probably at the front of our brain. Maybe we're not too a busy on-call night, and we see someone who may or may not have a pathological fracture.
Are we thinking that it could be a condron sarcoma? We don't want to take that to fair to a nail. We want to work it up. And my colleague Tom kostka will be talking very much about the workup of these cases tomorrow. I'm going to just concentrate on this range of bone tumors from the benign to malignant spectrum. They have a number of different treatment algorithms. Most involve surgery and another have various degrees of effectiveness with chemotherapy and radiotherapy.
I think the great thing about sarcoma is that it occurs around the body. And so we're mainly hip and knee surgeons who do sarcoma, but we often need to bring in other specialists from other areas. And it was great when we appointed Tom kostka as one of our colleagues at Oxford because he'd done a shoulder fellowship so we could get him really concentrating on upper limb sarcoma.
And I work quite regularly with other surgeons in the bowel, the chest, et cetera, in trying to deal with these difficult cases. Just first, some facts. We see approximately 100 bone tumors a year in Oxford and about 200 to 300 soft tissue sarcomas. Weeks are normal. That rate that the numbers you see is 5 to 1 soft tissues to bone and lovely.
Thank you. Yeah, sorry about that, so yeah, so that's so. So we're here now just talking about the fact that that's a soft tissue sarcoma and the normal sort of relationship between bone and soft tissue is 5 to 1. And there's about 1,500 soft tissue sarcoma in the wells per year and about 350 bone tumors. This is a soft tissue sarcoma here, and this is quite a classic site for a bone tumor.
And I normally ask the question what this is, and most people come up the exam know this is a parasitic osteosarcoma, quite a unique site for that type of tumor and is known by the examiners. So you might see that. The other thing about sarcomas, I said they occur all around the body, but most of them tend to occur in the lower limb, 10% around the pelvic girdle, 40 percent, 6% in the lower limb.
And we do see intra abdominal intrathoracic and the odd head and neck, and about 13% are in the upper limb as well. So yeah, this is where we have to get that site specific expertise sometimes to help us deal with these cases. I'm ready, this is what I just want to highlight why education so important is to try and think always about the potential for not just sakuma, but maybe even metastatic disease when you're seeing sort of unusual presentations of fractures.
And if it doesn't quite seem right, just take your time and your hopefully your radar will get especially attuned as you get more experience to knowing when things is not right. Take your time. You don't need to rush into theater despite maybe the pressure on getting patients on pathways. Try and make a diagnosis if you've got anything unusual.
So this is a case that really. Drove this home to me right at the start of my consultant career in the first year of practice, I got referred this 32-year-old male fit and active who'd been kite surfing in Turkey. He'd fractured his femur and had it nailed and then was flown back. Three months later, the fracture was not healing.
And I think you can see that there is a lytic deposit. And it really wasn't really noticed, even at this stage, three months later, because the patient went for exchange nailing and an exchange nailing. They found. So I'm just trying to make sure I can get take on there and that. And that exchange mailing that they have found renal cell carcinoma, and they also found staph epidermidis, unfortunately.
So we've got this situation where that was a nailing of a metastasis. He also had a they found the primary in one of the kidneys. What do you do? And yeah, ideally we should have before this nailing was put in which that should have been and should have been noted. You can see there's definitely lysis at the bone end and that patient needs to be properly worked up.
Now, metastasis are important. We do see them quite regularly. They're probably they're much more common than actually sarcoma. And these are just some ribbons that people wear to represent the various cancers on fundraising days throughout the year. These are the major metastatic deposits in the bone. So these are the major ostia files, and I just want to mention metastatic disease first because it is so common and it's increasingly becoming more common as a treatment the oncologists give to patients get better.
There's breast, prostate, lung, renal, thyroid. They're the ones that spread to bone. There's actually a difference between a number of these. There's the cancers that really at the moment don't have a lot of oncological treatments, and their survival can be measured as you see here in the lung and the colorectal. And then there's the cancers that actually the survival now is in years breast, prostate, kidney and thyroid.
Many years, in fact. And I've just seen a patient who had kidney cancer 15 years ago who's still alive. And if you look at here about the chance of these fractures healing, you can see that on the whole, if you have a fracture from these metastases, they're not likely to heal. Prostate might, but the rest of them might not.
So that's important when you are faced with patients with pathological fractures of pathological lesions, so you don't want to miss it because it can cause problems. And the other thing is mistaking a primary bone tumor for a secondary, just assuming an elderly patient has got a metastasis if they haven't got any previous history of a primary is wrong. Any solitary lesion in bone is a primary malignant bone tumor until proven otherwise.
The other problems that we see in these is you underestimate patient survival. As I said, you don't realize that some kidney, some patients with kidney cancer can live 10, 15 years now, and so you've got to do the write operation for them. And the other thing is to overestimate the fact that you just nail and you think that radiotherapy is going to kill the cancer and cause bone healing, it won't. Fractures do not heal.
And I just want to emphasize some of the problems we see. This was a beautifully plated distal femoral fracture undertaken in Marseilles. I think that they had a lot of time fitting the screw holes here, and I'm sure the trauma surgeons amongst you would be a little bit critical of the stiffness of this construct. But anyway, at this stage, despite this being a low energy injury, sustained playing tennis, there was no concern about this fracture.
And then, unfortunately, three months later, the plate broke because the fracture wasn't healing, and only at this stage did they diagnose in the fracture that there was a renal cell metastasis and nailing was then undertaken. But really, we're not addressing the issue that renal cell has got a long survival, that it will very rarely heal this fracture. And yet we're asking metal to splint.
This and aim for healing despite maybe some radiotherapy. And so you can imagine what happened. Like, sometimes it happened in my operating theater with some of the instruments that I use. They get metal fatigue and they fracture. And the fact that a lot of these cancers are very radio insensitive, they really don't respond to radiation, whereas breast, prostate partially does.
What we find is that this happened, the nail and the screws failed. What do you do to this patient who's got solitary renal cancer here? And you potentially could live many years. Well, you can't keep doing intra regional surgery in this case, you have to go for an unblocked resection and bring in a tumor type prosthesis. And this patient actually did very well and was walking out of hospital within three days after having what should have been the definitive operation in the first place.
So what do you do with this patient with renal cancer and staph aureus? This is this kite surfer. He only had a kidney cancer. There was no other disease, this is solitary disease, our metastatic disease. You've got to be quite aggressive and this is the patient who now is 15 years after presenting that I still see in my clinic we were very radical.
We did a total femoral section keeping a big soft tissue cuff around the fracture site to make sure we got all the kidney cancer out. We gave him a spacer for six weeks, gave him some antibiotics and then that's a spacer. We make it out of a long nail and old nail that we cover in antibiotic impregnated cement. So there's lots of antibiotic solution into the soft tissues, as well as IV therapy.
And you just jam it into the tibia, you give him a cricket bat splint and they can mobilize, it's actually a reasonably comfortable construct. And then I gave him a total femur replacement really sort of summarizes where I think metastatic is so important because it is a bone tumor. And I think that it is largely poorly served, but you for the exam may well get this case. An 80-year-old male is falling out of bed.
He's got a classic interlock and neck of femur, or maybe even a subtropical naked femur fracture. You've got the scenario that you want to take him to theater or the nieces want to get into theater quickly because the targets are important and they've got to get them done early. What do you do? You've got to be a little bit concerned, haven't you? Just looking at the matrix here that there's something going on, you're going to be concerned that maybe the patient from your history has had some pain previously in the run up to this fall.
And so this patient is to be stopped. It's not to go to theater. You're going to work it up, you're going to work it up with what Tom is going to describe tomorrow. You're going to get an MRI scan. You can maybe get a chest CT abdomen, you're going to try and see what this is. Could this could be a metastatic deposit or as a solitary lesion with this patient having no known history of cancer could be a primary malignant bone tumor.
And so this is really where in the exam they're trying to make sure that you as a consultant on call are safe and that you're going to be of, you know, really just sort of cognizant that there could be other pathologies going on and not letting this go to theater like you could do. And the answer is this was a clear secondary sarcoma. Luckily, it was biopsied. We were then able to take the patient after the biopsy and do this type of operation rather than a neck of femur.
Periostin Moore, that would contaminate the area even further and probably might even necessitate us doing a through hip amputation. So that's what we want you to be sort of thinking about where metastatic disease is a much more common presentation than sarcoma. So this is just in summary of my metastatic talk is don't do this, guys, don't refer to pathologists, refer to your local sarcoma or oncology unit for advice.
All the patients there, if you've got any concerns. So I want you to get an idea on sarcomas, which is quite a big subject that you can actually break it down quite nicely into various different categories. I've already sort of told you that there's bone and soft tissue sarcomas ratio of 5 to one, but also sarcoma as a name because they come from tissue of Mason of mesenchymal origin.
They come from mesoderm tissue and that's cartilage, bow, muscle fat, smooth muscle. And so all these have slightly different types of tumors. As you know, the Latin moniker is given to these the Kondo, the osteo, the Rado lipo and Leia Mayo. I'm sure you can sort of, you know, those and there's this benign malignant spectrum. And I also want you to understand there's a bit of a structure you can do, and then you're further reading will allow you to build up some of the more detail about them.
So there's benign and malignant, the benign tumors tend to be classified into three types of aggressiveness. There's latent like a non falsifying fibromyalgia. There's an active a bit like maybe an ink on and maybe aggressive like a giant cell tumor. Great them down into these major tissue types. Bone cartilage fibrous. Then, unfortunately, because we're not all nice and simple in sarcoma, I've got a fourth group miscellaneous.
And that group, I'm largely going to talk about the cysts. Malignant, your aggressiveness is low intermediate, high grade and gain, you can break them down into these four major categories bone, cartilage and fibrous tissue, and then a miscellaneous in that miscellaneous I tend to put Ewing's around cell tumors because they don't fit really anywhere else. So apart from the miscellaneous category, which is a little bit messy, everything else I'm going to talk to you fits nicely into these categories.
So you can look at these any X-rays and think, is that a bone cartilage or a fibrous tumor? I quickly talked about metastasis. That's probably a subject all on its own. We could have another seminar at some point on that. And occasionally you do get hematologic malignancies as well. Again, we don't have the time really on that. So I'm just going to concentrate on this spectrum of benign to malignant in these categories bone, cartilage, fibrous and miscellaneous.
So you can see that in Bowen, when the matrix is mainly bone forming, the benign lines of these tumors, moving up to the malignant, the obviously the osteosarcoma. And I'll talk about the parallel steel ones, the surface ones, as well as the more classic central osteosarcoma. In cartilage view, these are the benign tumors you should know a little bit about moving over to the Quandre sarcoma. And there's a few different types of condron sarcoma.
I'll touch on as well. Fiber is again, these are the benign fibers, tumors moving onto the slightly more aggressive, malignant version fibrous sarcoma adamantium eight, which actually has changed its name. Now to the polymorphic spindle cell sarcoma. And I'll touch on that later. And then the system, you do see a number of these tests, I think I do need to talk about them.
The giant cell tumour, the ABC unicameral and then the miscellaneous and malignancy is just about the ewings, which we'll touch on at the end. So I really think if you get that sort of structure thinking about whether that's bone, cartilage or whatever, and to get an idea, whether it's benign or malignant, that will help you try and work out what the tumor potentially could be. So the examiners love their X-rays on their computer. You'll sit at the desk, the examiner will turn the computer around to you and you'll have an X-ray on the screen.
They won't want you to touch it. They want you to get your pen out to just touch around what the important features. So this is what the vibe is. Do they get you talking and describing X rays? First thing is to talk about where just want to have some thinking time, so you can just start off just saying what the X-ray shows are. What the X-ray is that's an obviously an X-ray.
And this is a CT scan, and then you can talk a little bit about where there's maybe a lesion. Think about the epithets. Think about the metathesis or the diagnosis. The reason I say that is that the nice thing about sarcoma is even though it's very complex with 70 different types of. Of subtypes, what you find is that there's only a very few that like the epimysium. A few more like the metathesis and then just a few like the deficit, like adamantium renewing.
So this is a really good diagram to commit to memory because it just allows you to see where the lesion is. And it can hopefully trigger, whether it's one of these types of tumors. It's an ability to help. Also, the age you can see whether they're still growth plate. So you can get an idea, whether it's maybe a pediatric problem. And pediatrics would tend to be thinking about Ewing's and osteosarcoma, where it's the growth plates are fully formed.
It's going to be of adult age and then they may be some of the other tumors. So you've got can do this sort of description of the X-ray while you're actually thinking about what it could be. And then why do you think it's a bone matrix, a cartilage matrix, or is it maybe a fibrous matrix? What's the lesion doing to the bone? Is it eroding it or is it just sitting there nicely?
Court located? And is there a soft tissue mass? Try and get in the habit of describing X-rays. In this sort of sequence. So going back to this X ray, this is an artificial tumour, so already after describing it, you'll know there aren't many eprivacy or tumors, so you'll hopefully come up with eventually and maybe a achondroplasia blast stoma. But I sarcoma research, and it's never, always quite so nice, you've always got to just be careful and say, even though I think it may be a conduire blast tumor will always be getting a tissue diagnosis.
And that's important because very occasionally you can get a clear cell sarcoma in the process that you never want to be caught out on. So there's always a little bit of muddying rather than the rules. This isn't a hypothesis. This is a great decanter. This is a pivotal equivalent. This is again a condo blast, douma.
You can see there's a little bit of sprinkling as though it's a cartilage matrix. It's a relatively walled off tumor. So you don't think that aggressive so that a achondroplasia douma, which is a benign, aggressive tumour, fits in quite nicely. So really, think about that diagram. Think about what part of the bone the tumors are in, and it can often give you a good help to come up with a meaningful differential diagnosis.
And you can see on the MRI scan there was a cartilage matrix. So this X ray, you can say you can describe this a little bit further, it's a metaphysical artificial lesion. It's quite permeate, permeated. There's cortical destruction. Yeah, you don't know where the tumor finishes really do you? It's all like spreading through quite a lot of bones. So this is definitely got an aggressive air to it.
And this actually was a lymphoma, which was destroying the proximal femur. So those sort of few phrases that you can use to describe it are useful for you to come up with a differential. And I would say that you can often use differential tumors, such as different in your differential diagnosis tumors, such as fibrous dysplasia, and you can always often say it could be infection as well infections a big tumor mimic, and that can often be brought into your diagnosis.
So you can see that it's quite disruptive there, and that was an much so. And here now you can see what's this matrix, you can see it's probably bone forming. And you can see there's probably some bone out in the soft tissues here. There's some little bit of Codman triangle there with a dostum's raised up.
It's a mixed lytic picture here. So that's it's also eccentric in the metathesis, so that's hopefully triggering you to come up. This could well be an osteosarcoma, and that's what it was. So, yeah, unfortunately, I can't sort of get you talking, but normally in my talks, I get the delegates to describe these because it just gets people sort of coming up with a vocabulary to describe these X-rays.
And then you've got here. That's quite nice. You can see that we can definitely know where the tumor is. There's not a nice, thin geographic zone around it, and that could either be fibrous dysplasia or a unicameral bone cyst. Maybe infection could be brought in the differential if you as well.
This is an expanse slap lesion distal radius and it's a metathesis sealed tumor going into the epimysium, and we'll see that later in the talk is a giant cell tumor. And these are the sun spit kills, you see an aggressive. And this is actually more in the dialysis than the epimysium than the metathesis. And this actually in a pediatric patient is a Ewing sarcoma.
So let's just carry on straight on to just go through some of the routine tumors, which are the benign bone tumors. This is a patient who had pain at NIPE seemed to be relieved by aspirin. You can see something here in the neck and you can see this on the CT scan. So this is a classic history for an osteosarcoma, which is an osteoblast tumor.
It's a few details here, which you can get from all the textbooks. A lot of these tubers, like the younger patient, most of them tend to have a male predisposition. And as you know, the classic history for Australia is NIPE pain relieved by aspirin and nonsteroidal as it can occur in the back and cause of scoliosis, it can occur near the knee joint. The hip joint and sometimes cause a joint effusion as well.
The treatment is with radiofrequency ablation or potentially cure a charge, a CT scan often nicely shows that there's a lesion in the bone and it's never really bigger than a centimeter. And you occasionally on block size them, but we largely just put a probe in under CT control. That probe heats up to about 90 degrees for about 10 minutes. That completely heats up the tumor. That often causes resolution and bone in filling.
So that's the start of saying, we're really the start of this spectrum of bone tumors from benign to malignant. This is the bigger brother of the. This is again a lesion in here and it's in the metathesis. It's a little bit bigger. It's a bigger than a centimeter. And actually, it can be a little bit more aggressive than Osteria stoma.
And this is called an osteoblast tumor. Again, you can see a little less common than osteosarcoma. Same sort of demographics again still likes going into the spine and seen in the posterior element and about 30% of cases. Again, very similar investigations, MRI and thin sections, CT scan is often hot on bone scan. And it can be mixed up with ABC'S giant cell tumors, even Kundera elastomers sometimes.
And you would tend to want to treat these with on incisions or curettage and bone graft. And you'll see whenever we do curettage these lesions, these benign lesions, we always tend to unfortunately claim about 10% to 20% recurrence rate. So you can always say that in the exam, that seems to be uniform amongst any tumor that we cure at large. Just being always a bit careful, though, even though it looks benign, you can get an osteosarcoma called a 10 10 static osteosarcoma, which I'll show you later, which unfortunately is a very lytic lesion.
And so you always got to make sure that you never really diagnose an osteoblast donor until you've got a tissue diagnosis because you don't want to miss a classic osteosarcoma. Then we're moving on to the cartilage benign tumors. We've got something called Gnostic syndrome, which is that a disorder of the growth plate where rather than the growth plate expanding horizontally, cartilage gets chewed out laterally.
And so that's how you tend to get off to romer's from childhood. Again, very similar demographics that we've seen before. Two types really of plastic and romer's. There can be the sessile flat type or the explosive stalk like often asymptomatic, but can cause some mechanical symptoms on adjacent tendon. The ligaments can be painful if they're not. You really only treat these, though, if they're symptomatic.
However, if after maturity, after you've got skeletal maturity, you're getting increasing growth in one of these Oscar dramas, that is worrying and that does increase the risk of becoming a malignant Conroe sarcoma. Also, if there's a cartilage cap bigger than 2 centimeters that would worry us for changing to a sarcoma. And there the indications for treatment. So we see them around the knee, shoulder and hip.
I'm often the bone scan is relatively cool. But yeah, this is a sessile loss to control here between the tibia and fibula, you can see how long standing it's been there with that long standing erosion of the adjacent fibula. So if you just saw that X ray, you could be a little bit worried that maybe a bone tumor and another type of bone tumor there, but that long standing change in the fibula should reassure you.
That's actually what on cross-sectoral imaging you saw in the human drama, and that cartilage cap is bigger than 2 centimeters. So that would worry us that there may be within this cartilage cap. There is some malignant transformation into a low grade Convery sarcoma. So you're going to get pictures like this, and there is going to say, what is this?
And you know that you've got austere controllers here, but you've got multiple maybe causing sort of gross abnormalities. And so you've got a condition of multiple exhaust doses, multiple and controllers, and it's called hereditary multiplexer stenosis, or previously known as axilo ecclesia autosomal dominant condition variable degrees of penetrance. Number of clinical manifestations, very occasionally malignancy.
Just because you have so many of the consumers they add, they recommend about a very small chance of an interest in each one so that though you do have to be a bit careful and the books vary on what they say is a risk of malignancy. I've seen some textbooks talk about 1% risk of malignancy. I've always known it about 0.2% in every hospital syndrome. So if you've got maybe 100 or so, that might be significant. But we're much more keen on these patients just reporting increased growth after skeletal maturity or increased symptoms like pain.
And then we'll treat them. We don't routinely follow these patients up. So HMD is an important one. Then you've got cartilage tumors within the bone. And these are calls Inc and romer's, and these are very common, and they often do sometimes cause some difficulty when they're seen in other otherwise patients are asymptomatic because of adjacent joint problems.
So we get a lot of cases just sent up from our knee surgeons who just done the X-rays and they see these cartilage tumors above them. Nine tumor is quite common again, relatively effective in young people, mainly in the long bones, though we do see them in the hands. And just to show these are how these tumors are formed, these are just being chewed out from the growth plate, become X or doses or second romer's, or they remain as remnants of the osteogenesis of the bone formation when kids mature and they became they, they come inside the bone.
And the question is, are they Quandre sarcomas or are they in control? Was that you can watch this is with them in the hands, in the hands. They're often lytic, actually. And you don't often see the cartilage stippling, but tumors in the hand are very often benign. They're very, very rarely malignant. So you can be relatively reassured about having tumors.
So this is how you decide whether you've got a condren sarcoma or an enlightened rohmer, and it can be a little bit tricky. And this is where you useful to get your advice of your local oncologist to or to give you that idea. So you can see here this is a little bit more extensive this stippling in the distal femur here. And there's also intermittent lytic areas and there's also some industrial scalloping here.
And the patient would probably have some pain at rest as well. And this is quite clearly a change. And this is going to become a Quandre sarcoma as compared to, let's just go back to here. There's no industrial scalloping. This is just looking like, yeah, a cartilage tumor, and this is still an ink on Roma. So where how do you sort of tell the difference? That just my little table to try and give you an idea, you tend to just have to weigh up all the evidence, you get a clinical history.
You look at the cross-sectional imaging. You also maybe look at the bone scan and you do have to make a judgment call on how where, how far the evidence forms into became potentially being a low grade sarcoma in consumer low grade contro sarcoma, as you'd want to treat with a charge encontramos. You don't treat, but you probably want to watch them and get another MRI scan in six months just to make sure there's been no change if there has been a change.
They become low grade Conrad sarcomas and you need a treat with a curettage. Radiologists or your local tumor center can often help here. This is a condition of multiple anchor syndrome, a ptosis and again, a nice question that you get asked in the mix. It's called Oliver's disease. It's non hereditary, frequently affects one side of the body, often causes growth disturbance, and the key thing is that this has got a 25% risk of malignancy.
So this is a much more sinister condition and you do need to follow these patients up. So when they've got multiple encke syndrome, is that significant and should be referred to the oncology unit. This is a patient who's had multiple income remittances. He had some changes now in his proximal humerus. We saw that there's significant cartilage here, so this had changed into a condren sarcoma.
And you can see there's cartilage tumor almost all the way down the humerus, very close to the elbow joint. So the only way that we can get a full clearance here was to give him a total humoral replacement. And he's been followed up for some cartilage tumors that has got in his wrist and hand as well, that you can probably see a little bit on his bone scan here. So we're watching him closely. He is part of a regular surveillance.
There's another type of form of multiple income remittances, which also has he meningiomas in the soft tissues. And again, it's nicely favored by examiners. That's called mahfouz's syndrome. And here you've got 100% risk of malignancy in these patients. It's very rare. No genetic background. But yeah, you often have to be quite prophylactic in treating these patients because the risk malignancy is very high.
Then coming on to another X-ray that often gives you almost like a pattern mnemonic clue as to what this tumor is. This is called a shark bite out of the proximal tibia. And if you see this, this is a classic sight for another type of cartilage tumor called a condren mixed Lloyd fried Roma. Which, again, is a slightly more aggressive cartilage tumor, but still benign, similar demographics that we've seen previously, and it's like a shark or rat bite out of the proximal tibia.
So anything in here, it's often classically this and that could look like a tender to osteosarcoma that is where you have to have a differential. It could be a conduit of five braimah, but you would also talk about fibers, dysplasia and infection if you saw an X-ray like this. So this is where you've got to describe the X-ray. Come up with some dark differential diagnosis and but try and rank them in the order of likelihood.
You don't want to go straight in with a.b. five as dysplasia here, you'd want to probably mix five grain with your number one. Treatment is often curettage and again, a similar sort of recurrence rates with curettage. Then you've got the condomless douma, which we talked about right at the start of the talk about the epimysium tumors, and we talked about them being one of the few tumors in this, and the only thing that sometimes can recreate it is a clear cell sarcoma just to be careful.
Again, these benign tumors are often treated with curettage and bone graft. So again, a hypothesis is an activity or equivalent. And so you could have a tumor here in the left. So again, very similar. It would be like to be a secondary blast tumor, and the tolerance bone is also in the pivotal equivalent. And so if you've got a lesion, the tail that's often achondroplasia stoma as well.
Then we're coming onto the fibrous type tumors now we've done bone cartilage fibrous. This is called fibrous dysplasia, and you can see that can actually be used in quite a lot of your differential diagnosis when you have lytic tumors. And this is meant to have this glass is ground glass matrix appearance, but on some of the quality x-ray, that's sometimes difficult to sometimes appreciate that.
So it probably is very common, not hereditary, often seen in the femur of tibia. Can also be seen in the upper limb and can be polycystic when it affects just one side of the body. We only treat it if it's symptomatic, largely it can be left alone. If you just correct for obvious dysplasia, fibrous tissue will come back.
So the only way you can really turn fried with tissue into bone is to do is to do proper bone grafting with structural allograft or structural autographed. And so if you've got a lesion in the neck of the femur, you may want to bring a fibular graft into it to stop it becoming that scaffold deformity that you see. So here we put a fibular graft up that was vascularized, and that does luckily then turned fully to bone.
If you just curettage this and put some more solid bone graft in, that bone graft would be taken away and you get five dysplasia back within a year within a year. So you can only really use structural, adequate graft and proper dysplasia. Again, a nice one for the mic is McKeown Albright syndrome, which is polio orthotic Fryer dysplasia with cafe Au lait spots, precocious puberty accelerated body growth and premature fusion of growth plates.
So so that's an important sort of thing that sometimes you need to speak to know some of the stigmata and some of the signs of this. And then we're now coming on from bone, cartilage, fibrous to the cysts, the miscellaneous group. And again, it's this idea that you can see that could be five of these plays potentially, so you might want to bring that differential. It could be infection, but it's a little lesion at the end of the bone.
It's more metathesis emphasis. So the other option is it could be a giant cell tumor or an aneurysm bone cyst. You get an MRI scan and you nicely see fluid levels, and that gives you a lot of reassurance, this is now an aneurysm or bone cyst. Where the giant cell tumor would be solid. So an annual bonus system system is again relatively rare young patient presents with pain, quite an eccentric lesion and can be expensive.
While we sometimes see ABC'S primarily or we see ABC'S around another Sar coma. So when you look at the MRI scan, you've got to go, you've got to look and make sure there isn't a solid tumor being hidden beneath the aneurysm or bonuses, because that's the bit that near them will need to be biopsied. So it can be an ABC on its own, or it can be secondary to another tumor. Lie, if it's on its own, you would just again treat ABC'S with curettage and bone grafts.
Just a really again, reiterate that you've always got to be thinking, is this a malignancy? And the energetic osteosarcoma, i.e. the osteosarcoma that doesn't produce bone is often a mimic of annuals and bone cyst, and you don't want to treat an annual basis without a biopsy just in case it's this, as this can be obviously a very different treatment. So you've got to be always mindful of that benign malignant spectrum, I'm afraid.
This is a unicameral bone cyst, and the classic thing about this on X-ray is you get the falling leaf sign, which is a freight flake of bone that's within the cystic milieu of this cyst. It sort of works away from the growth plate as the bone enlarges in the upper limb. You can often leave this alone, occasionally fracture. They often heal up, and within a few years they stabilize. And the lower limb, unicameral bone cyst often do need a stabilization because you don't want them to fracture.
Occasionally, they've been treated with steroids, but my recommendation, if you do have upper limb, unique elbows, this is masterly inactivity. Don't touch them, occasionally stabilize the lower limb ones. This has been talked about doing injections of steroids, but we don't bother when we see them in Oxford. The case KGB might need to stabilize a lower limb one. And then the giant cell tumour, which actually is probably a different beast, you've got to be a bit more aggressive with this.
Probably it does have a slightly higher chance of coming back to bite you with recurrences. The classic thing of a giant cell tumor is that it's a metaphysical tumor that goes into the epimysium, so it's never going to be mistaken really for a secondary blast, which is often purely epicondyle. So we ask we do see it in expendable bones. You can do a normal block resection, but largely treat with curettage, and I just want to show you how you correct these lesions because the cure is very important.
You can just window it. But on this case, I'm just going to show you. We take the tumor out with the knife. We do a full Curatola taking anything that we can see out and send it off for histology. This is a curettage spoon. We often get the assistant to have a go as well. Then I inject the cavity with methylene blue and then we come in with a Burr and we take all that methylene blue from without from in the cavity to make sure we burn every single area of the cavity, hopefully doing a good curing and removing any tumor cells.
And then we want to use a adjuvant is to try and kill any tumor cells still, and we use a mixture of fennel or hydrogen peroxide. And finally, we often put cement into the cavity, which heats up and kills tumor cells as well. And that is probably the best way of doing a cure, but still has a 10% to 20% chance of recurrence. And if it recurs, you might need to then think of an unblocked resection.
That's the it's the slides with a giant cell tumor. Luckily, I don't think you see too many tumor slides in the exam, but that's quite a classic, one of a giant cell tumor. This is the expendable bone, the fibula and the giant cell tumor likes to go to the proximal fibula. Here you would actually just probably do an en bloc resection. Being very careful of the nerves as it wraps around the neck here.
So that's a bit of a trawl through the benign. Now we're going finishing under the malignant tumors. These are the three major malignant tumors the osteosarcoma, the bone, the Ewing sarcoma, the miscellaneous and the Quandre sarcoma, the cartilage and the sarcomere. I'll probably just miss out because these are the three commonest ones. And these are their incidences in the population.
Key thing is you osteosarcoma and Ewing's a young people's diseases. Where's a sarcomere affects the middle age and elderly? There's a little peak of osteosarcoma in the elderly where that's due to pageants. So Ewing sarcoma loves the pelvis, marc-andre sarcoma is not the pelvis, osteosarcoma is love the knee, that's what you take home from the incidence of their location.
On that when they present. They tend to ewings likes the diagnosis, osteosarcoma, marc-andre sarcoma as they like the metathesis, so osteosarcoma is a bone forming tumor. Most of called central attente, occasionally 10% of surface. So the interim medullary or classic osteosarcoma is a high grade lesion where some of the surface osteosarcoma is a bit more low grade.
They still need good surgery, but they don't need to have chemotherapy. When you have a classic osteosarcoma, majority of them are a to be presentation, which means they have burst out of the bone, but they haven't got chest metastases. You'll know more about the classifications and staging of sarcoma tomorrow. The key thing to think about when you're dealing with osteosarcoma or ewings is it's a systemic disease with just an orthopedic manifestation at the tumor site.
So neoadjuvant chemotherapy is a key treatment near adequate means. The first thing the patient gets is chemotherapy. They then have about three cycles of quite toxic chemotherapy. Then they get restaged. And then they have the surgery, and after surgery, they have more post-operative chemotherapy up to about 6 to 10 cycles, really, depending on what the kill rate of the tumor is done by assessing the tumor resection that is taken out.
How we do surgery. Tom, we'll talk about this tomorrow. We often do wide margins on malignant tumors, balancing up preservation of limb with risk of local recurrence. We've often some quite complex reconstructions. The essential osteosarcoma do sometimes when you get the out phosphatase raise, they like the distal femur and proximal tibia, and primarily it's a bone producing tumour, which can be permitted because it's very disordered.
So you often have a mixed lytic bone picture. Can you see the x-ray? You don't know where that tumor ends or where it finishes. So the bone is being destroyed here and you've got some lytic areas and some bone forming areas. And that's what you should describe in the it's going from the metathesis into the epidermis. And this is the MRI scan, this needs a tumor prosthesis in the reconstruction.
And the thing about this is you need to reconstruct the extent mechanism and how we do proximal tibial restrictions is we always use a gastronomy is flat, that gastronomy is flat, covers the tuber prosthesis and reduces the infection risk, but also it can help stabilize the extensor mechanism reconstruction. So after about three months of keeping the knee still and stiff, they can then start flexing with no extensive leg.
Bend it. And that's the type of thing you try and do by bringing a gastronomy is to protect your proximal ears. And that's what we hope is a good result. I've mentioned this, this, we Beastie a few times the ecstatic osteosarcoma. It's a bit of a nuisance because it doesn't form bone, it's lytic and you have to be mindful of this when you see other tumors like giant cell tumors and ABCs and even sometimes fibrous dysplasia.
So just remember this it's not a bone forming tumor. It's Oscar lytic blood filled sponge, I'm afraid. Luckily, not a common osteosarcoma, but you can see how you could maybe describe this as a benign tumor like fibrous dysplasia or a big unicameral bone sis, couldn't you? Or but actually, that's why it needed a biopsy and a biopsy would have shown very blood filled lesion with tumor cells within it, and that needed treatment like any osteosarcoma with near adjuvant chemotherapy, surgical resection and post-operative chemotherapy.
Then you have surface osteosarcoma as the period deal and that paper mnemonic x-ray, I showed earlier, the power of steel, both the surface. Tend to be lower grade tumors, so they might not need chemotherapy, but still often need wide local excision in their surgery. So just make your own table up of the differences between the perilous deal and the Paris deal, because there are some differences about where they come from, but really, I'm not really ever seen a parallel still in any other place apart from the distal femur.
So if you get a distal femur, a posterior tumor coming out looking like bone forming, it's probably going to be a pair of steel. And that tends to be low grade, but you still do a distal femoral section to get a wide resection. So that's the power of steel. I don't think I've seen one anywhere else. I've seen perilous deals elsewhere. But paracels, that's a realistic one bone forming surface on the surface of the tumor coming from the parasitism, and that actually was a bit high grade that she was given chemotherapy.
The classic teaching on this is that your chemotherapy is the big difference in your survival, and we're now getting up to about 70% five year survival with chemotherapy when we didn't really appreciate it was systemic disease, we were only getting about 20% With very active, with anyone with pulmonary disease, we respect them, and we've got about eight or nine patients discussed on our tumor board every week or being referred to the cardiac surgeons for pulmonary mastectomies, we are very aggressive and that really does help lift patients with advanced disease.
But the adjuvant treatment is important. I don't think you need to know a lot about chemotherapy, apart from that, it's near adjuvant. It's quite toxic. It affects your fertility. It affects your hair. But it's a key thing to get that five year survival up. If you just operate, they'll have only a 20% five year survival.
So I just move on and just show maybe sort of what chemotherapy can do, this was a Ewing's that had chemotherapy. It shrunk down, but the tumor cells could still be in this tissue around the fibula. So we wouldn't just do a feeble economy here. We will still go and take all the muscle around where the tumor was before, because even though the chemotherapy had been effective, we don't think chemotherapy kills 100% of the tumor cells.
It's a good result when we get up to about 90% So you can see from this graft, over the years, we've had increasing survival with our osteosarcoma and Ewing's largely because we're treating them with chemotherapy, allowing us to do tumor prosthesis and limb salvage, whereas in the old days, we were doing lots of amputations. So I think we are looking more and more at the molecular problems that are occurring in our sarcomas, we're really understanding the molecular disorders that occurs and these were the new biological therapies are being targeted.
The trouble about a number of our sarcomas is that some of the genetic abnormalities are quite extensive. Osteosarcoma has multiple genetic abnormalities, and so it's not at the moment very sensitive to biological treatments. But this is where the future of treating sarcoma is being undertaken. So I'm just going to move on a little bit to just finishing on with Cassandra sarcomere.
Condesa coma is malignant, cartilaginous differentiation. It's that cartilage that if calcified matrix. You've got various different grades of chondrocyte coma from one, two and three low grade intermediate grade, high grade and even within a tumour, you can have different types of grade. All of them can only really be treated with surgery and the fortunately, as you get more aggressive, the chance of you actually dying from the disease becomes higher.
So low grade has got a 90% five year survival a high grade 29% but differentiated, which is a very aggressive type of cartilage tumor, has got less than 10% chance. Just to come, just to highlight that a primary conduit sarcoma, a rise in normal bone, but secondary Quandre sarcoma is arise from those benign tumors that I've talked about earlier, such as an ink syndrome or an nastier consumer.
And I just sort of show that calmly stippling here, this is a pelvic tumor. And you can see that popcorn type appearances. This isn't a bone forming tumor. This has got calcification in it, little rings and arcs and this is cartilage, and this was enormous cartilage tumor arising from the ideal blade in a '41 year old male. Here we have to do a very joint preserving osteotomy resection through the side joint, and that allowed us to get this out.
And these are just the various types of pelvic resection you sometimes have to do. Type one is just taking out the ileum type 2s, taking out the sake, the Alex tableland type 3s, taking out the pelvis or eskin. Obviously, this is the one that's a challenge to reconstruct big tumor. We brought all the abductor muscles down, and that's the tumor here that we're going to do in osteotomy just above the hip joint.
The only way this patient can be treated with surgery. So we've got to get the margin. So this margin is absolutely imperative that it doesn't go through tumor. Luckily, we did. We kept a bit of the hip joint. We were able to span the gap between the sacrum and the hip joint with a free fibula graft, which the plastic surgeons raised for us.
They plumb that in. We put that in to give the gait the guy, his pelvic ring back. And you can see after taking all that out, that fibular graft nicely high feet up over the next year and gave him intact pelvic ring. He was a bit weak with his abductors, but his tumor free and didn't get any recurrence. So I'm just going to just sort of finish off if I can, just talking about Ewing's.
So ewings is the final one, it's that miscellaneous one. It's a small round cell tumor of unknown origin. It's a little bit distinguish that, yeah, it doesn't quite fit into anyone's classification, but it's often present systemically. It's got a diaper seal location often. And it managed with osteosarcoma, with chemotherapy. If you do have expendable bones, they can be excised if it's like a pelvic bone.
You sometimes just treat with chemotherapy and radiotherapy. Um, the treatment survivor with chemotherapy is similar to osteosarcoma, about 60% to 70% And if you don't give chemotherapy, the outcome is very poor. So this is a poor girl who had this little lesion in the femur that looks maybe could be fibrous dysplasia, it could be infection, looks a bit irregular for a cyst. But if you get the MRI scan, you can see there's tumor permeating all the way down the femur.
She had systemic symptoms, if I remember this was a ewings, she ended up with a total femoral replacement because these tumors often occur in the young, the children you maybe have to think about. Can this tumor grow to allow the leg to maintain the same side as the other leg? And so we often use things called extendable prosthesis. This is where the implant can actually grow as a child grows in the old days used to just have to come into theater and put a screwdriver in to yank out the implant.
There was a high infection rate with that. So now in tumor surgery, we now use non-invasive growing implants. This is a magnet that the patient goes in every month and every month. They can be lengthened just a few millimeters by going into this electromagnetic field, which means you don't have to come into. You don't have any risk of infection.
And because Ewing's is the predominant pediatric condition we treat, we're often treating them with noninvasive growing implants. So I'm conscious, I've just slightly gone over my time. I'm happy to stay on and do the mdc's, so this is where I'm going to stop. I've tried to give you a flavor of the classification to try and give a framework on which you can get a bit more detail into.
Bone tumors are common, but there's a spectrum, and just using that description of the X-ray can often give you that stepwise assessment. Think about age, site and matrix. What's a tumor doing to bone or what's the bone doing to the tumor and always consult your local tumor center and always be ready to talk about that in the exam, I think. I mean, in general, sarcoma is a rare it's early detection.
Referral treatment requires an extensive MDT, lots of different types, subtypes, lots of specific surgery required. Oncological and reconstruction are the Twin surgical aims, and your adjuvant treatment is dependent on the type and grade of the tumor. So I just asked you, even in your not just your exam, in your clinical practice, be alert. Always assess your patients.
No shortcuts here in sakuma, work them up like as Tom will describe tomorrow. And when you do see these patients always have the right tools for the job. And we're always here for advice. Thank you very much. Thank you very much, Mr. Well, that's excellent talk and quite an important topic for these folks. There's always going to be one religion on the FRC exam, on the Bible section, and we'll move straight on to the mix.
And then from there, we'll answer any questions after that, if you could kindly share the poll. Thank you very much. OK, so the poll started, guys, if you don't mind to answer, it's completely anonymous. We won't know who's answered what, but it gives us an idea of how you guys are doing and what areas of knowledge we're imparting on you. And if it's working or not.
Mr Whitwell will go through the questions at the end. In the meantime, just a reminder to everybody, or UK is a charity organization involved in research and education for orthopedic conditions, including arthritis and other conditions. Their website is our UK dot org.
They have quite a number of educational activities going on. The most recent one is going to be on the 20th of October Tuesday evening. Five a practice session for foot and ankle the FRCS mentor site is FRC assessment or code. Again, it's another charity of orthopedic surgeons who passed the exam and passionate about teaching. Again, we have a number of vyver courses.
Please do take advantage of going to that site to register for those courses, as well as our usual webinars every Wednesday and everything. All lectures are recorded and put on to our YouTube channel, as well as on our UK website. We also published a book that you can see just over my shoulder. Concise orthopedics notes. It is a we believe is a good solution for preparing for the revision notes for the FRCS, but we want to remind you that all proceeds go to maintaining the Zoom channel and on their website.
Essentially, everything's plowed back into making sure that we can provide a better service each time. OK, we're up to two minutes, I think, on 77% The quicker you guys can answer that would be great, so we can maximize the answer. We'll close the polls in a minute. Nikki, I know you've been taking notes of all the questions for later.
Thank you. And thank you to all our mentors today who are supporting without their help and administration today. These sessions are very difficult to run and I apologize today. We are just not. We don't have enough hours in our week to be able to provide the mentors for a revival session today.
OK, we're up to 80 percent, I think we should close the polls soon. OK which can you see the results of the poll? Yeah, yeah, thank you very much, everyone. I think, yeah, just quickly looking. It looks like most people were listening, which is good, and probably most people knew these because I try to highlight what I know the examiners like.
Yeah and I think the first one is, which of the following is the most commonly placed patient at risk of malignancy. I largely talked about all these. I think I didn't talk about neurofibromatosis. And that really is quite low. That that doesn't really does have some risk, but very low. And I did emphasize quite strongly the 100% from the Fauci. That's multiple income drummer.
Ptosis with human genome is very rare, but that's rare in clinical practice, a bit more common in the exam. Mcewan, Albright that's got a small risk. We talk about that. Ollie is 25 percent, the future up to 100% HMG the exam. The other said the books change about 0.2% for every yardstick and Roma. So look at question number two, what current chemotherapy regimens, again, I try to give you a bit of a structure.
The three major malignant bone tumors, Ewing's osteosarcoma, they're treated with neoadjuvant chemotherapy. You then do the surgery. You look at the histological kill rate and then you put them back on chemotherapy for another 6 to 10 cycles. After that Convery sarcoma only surgery. Really, no sensitivity to radiation or chemotherapy. So, yeah, it quite clearly that I think you've got that right, that it's Andre sarcoma that.
So sorry. So I'm actually looking at question three, so I apologize. I'm talking about chemotherapy and improve survival for all of the following malignancies, except on question number three, it's condron sarcoma, and I think I emphasize osteosarcoma, Ewing's lymphoma. I didn't mention those last two, but chemotherapy is vital. And then just going back to question number two, like axilo, I'm sorry, I'm not.
I've got all the I haven't got all the screen. I think that's the one where we talked about with current chemotherapy regimens. What are the typical five year survival rate? I think if you didn't do chemotherapy, it's 20% I think you do well. If you get up to 70% with your chemotherapy and osteosarcoma, and that's for patients with non metastatic disease, it obviously goes down significantly if you do have a meritocracy.
So everyone, most people got that answer right as well. So Thanks very much. Thank you very much. Well, we have had 220 participants on our session today and quite a few questions. Excellent talk. And obviously by the questions it's coming up. It's been it's a topic, which is burning hot in the minds of the guys who are preparing for the exam.
Nikki, do you want to go ahead? So the first question is from Mohammed egawa test. It's a bit of a staged question. What if we know before nailing the FEMA that it was a pathological fracture as a result of a renal deposit, would that change the decision? And then what after if we nail it, if it then went on to a nonunion, is it indicated to radically excise and replace?
Yeah, I think an hour to cover metastatic disease in all its depth as well as sarcoma is a tall order, but it needs to be talked about because it does overlap and it is so important. And I think it's changing. It really is. With these new biological therapies and the elderly population, we are facing a big onslaught of metastatic disease.
Kidney cancer does not respond very well to radiation. It's got a number of new biological therapies. And actually, there is a feeling that you can maybe cure solitary renal cancer to bone. So if we had known that was a pathological fracture second to renal cancer and it was his only deposit in the skeleton, absolutely he would have had a wide resection. But in that case, it probably would have been a proximal femoral replacement.
Why it had to become a total femur was that the nail had pushed all the tumor down into the distal femur. It was all infected and so that's why we had to be aggressive with a distal femur. So that's my. So I think we should have not nailed it. It should have been biopsied. It should have been kept in traction.
There should have been an MRI scan, a bone scan, a CT chest, Abdo pelvis, and then it would have been clear what the problem was and we would have recommended a proximal femur and then a secondary nephrectomy once. What a few weeks after the proximal femur replacement. Thank you. The next question is from masood Khan. If there's a past history of cancer, but no Mets and the cancer is known to be in remission, but the patient presents with a long bone fracture, which looks suspicious should we do local and systemic staging first before attempting to fix?
Absolutely Well picked up. I think you've got it because you're in a busy trauma meeting and maybe some corners are being cut. But when you're coming to the exam, you're not in a busy trauma meeting. You're trying to do best practice to show you're a safe and considered consultant. So if there's any idea that this maybe could be a malignant bone tumour, you have to do all the appropriate staging.
Keep the patient interaction if necessary. MRI scan workup for metastatic disease I would only go straight to theater if the patient had known metastatic skeletal disease. So if you've got someone who's got a good history or has got an MRI scan with multiple metastatic disease, then you probably could go straight to theater. But if you don't have that, it's a primary malignant bone tumor until proven otherwise, and it's beholden on you to keep the patient in bed or whatever and do the investigations, and you can get the investigation done reasonably quickly on the whole.
And so definitely for the exam, if there's any question you do that. So it's important if there is no need to metastasis from a cancer, then you can go straight to the FDA unless you've got that. Which I think is your scenario of a previous cancer, that is to me that still could be a prime target bone tumor. Does that make sense? Yep, Yep.
Oh, that's great that to your question. So the next question is from motel's al-masri. How can I differentiate between non-roma and bone island? It's a very logical thing, it's yeah, if your matrix really, I think that once you get an MRI scan, you'll clearly see that the ink on has got a cartilage matrix of bone island won't. It will be.
And the radiologist can easily tell you the difference on an X-ray. Yeah, it might be a bit harder for you to tell, but an MRI scan will be the key. The key investigation. Thank you. We've got a question from Ali Abdul Hamid. What are the worrisome signs of encontramos? Yeah, again, it does take quite a lot of explaining and it's that spectrum, isn't it, between income drummers and low grade Andre sarcomas?
And it's not an easy one. There's not an exact answer. As I tried to explain, you've got to just look at all the evidence and largely be talking to your local oncology unit. Yeah, come down. Where I get worried about income and rumors is they've expanded. So sequential imaging has shown a change. Looking at the matrix, there's a bit more lysis around the cartilage component than normal.
There's industrial scalping. The patient actually experiences pain in the area. And the bone scan is maybe a bit is very active rather than just being a little bit lukewarm, the ink syndrome is tend to and you tend to balance all that evidence up to decide whether you should do a cure or charge. But if you think it's an end controller, I would still recommend that you get sequential imaging and you recommend that another scan is done in six months time, just so you can make sure that there's no change.
Thank you. And the next question, two people have asked the same question I've got AJ Eurasia and Mohammed Hamid Hamdi Abdul Hamid of both asked, what's the difference between a warm and a hot scan? I think just how it's reported, I think when you do a PET scan, which is the time will tell to you tomorrow, which is our major investigation now for systemic staging, the PET scan will actually give you an SUV, which is the activity of the tumor.
The amount of sort of glucose radiated glucose that's deposited and that gives you actual value. Yeah, I'm afraid it's much more subjective with bone scans, and it largely is dependent on the radiology reporting. There isn't a scale that they can really assess. It's a bit gray rather than Black on the scan, et cetera. But they'll talk about lukewarm, tepid. We'll give you an idea whether it's bright or whether it is that again, that really doesn't help me that much.
It gives a bit of evidence when you look at encontramos and no great contrast comas, but it's not the essential evidence. But PET scans are much better now at giving us an actual figure. Thank you. We've got Imran Ali who said his moral score of pathological fractures valid for pediatric cases, or do we have another similar scoring system to guide a treatment decision?
That's an interesting question. I must admit miralles, yeah, it probably is the 1 to use for the exam. I think it is still quite valid. Yeah again, Merrill's is largely due to metastatic disease, isn't it? And that's very uncommon in pediatrics. So I don't know a pediatric specific one, to be quite honest.
I think if you do have a pathological fracture, I think you do need to often get a biopsy or you need to look at the imaging very closely. But no, there isn't. The answer to your question is there isn't a specific pediatric one that I know of. I don't think that minerals is more for disease, as you said. I don't believe there is anything pediatric at all. So we do use miralles to a degree, but yeah, it does help.
So I think that's still very valid for the exam to have an understanding of miralles, which again, I haven't had time to describe, but it's quite easy to understand if you read the books. OK, thank you. We've got Cameron hafeez, who's asked our monastic fibrous dysplasia and non-islamic Vibram of the same. No, no, they are, they are different and not answering five Roma is really is the very on aggressive tumor.
We'd almost call it late and it doesn't do anything at all. It very rarely causes pain. It's got a big, coordinated margin around it. So you know that the boat is really warded off and it's very different from private dysplasia, which is this ground glass appearance without the bone doesn't show any evidence that it's warded off. So there are different pathologies, probably dysplasia, not promover, but you'd largely just observe anyway.
You wouldn't actually treat. OK, thank you. We've got ours, Sheikh, who's asked, do you use the bench on traject, even at a young patient? Very good question. I think that's a little controversial area. I like cement. I think it's a very good adjuvant. It heats up.
It gives structure and that heating up really does belies any remaining tumor cells. So but still, we get 10% to 20% risk of recurrence. I think a pediatric patient is obviously got some bone growth still to do. Yeah, that could potentially affect it. So yeah, we do in pediatric cases do largely just put bone graft in. Thanks we've got amre Abdullah, how do we differentiate traject osteosarcoma from mimicking benign tumors?
How do you do that is to educate all orthopedic surgeons, to be mindful about it and to make sure that they work the patients up properly with the scans and they get a biopsy and you've got to have it at the front of your cortex and not have it at the back of your cortex and you don't think about it. So yeah, the biopsy, unfortunately, is so vital. So we see benign tumors and we're saying we think they're benign.
But we'll probably get a biopsy, just to be sure. And that really can only happen in a tumor unit, so these cases get referred up. So think about that because you can always get caught out and we see examples of that happening, unfortunately quite regularly. So it's not just hoping to scare you. It still happens regularly. But osteosarcoma is a missed, I'm afraid, with will with any radiological investigations, including bone scans and/or MRI in these situations, and not particularly bone scans, could still be quite active.
An MRI scan would we know you might see a bit more primitive than MRI scan than an x-ray, but the biopsy is the critical thing there. OK, I think we just got two more so. Harry Benjamin Lang has said for isolated renal cell metastases, how soon after ablation can you operate and what is the window? Oh, Yeah. Good question, so renal cell again, is the subject all on its own because kidney cancers are very vascular and we've had some frightening days in theater treating kidney cancers intra regionally.
And so yeah, you tend to well, you always have to recommend that if you're going to go into a lesion into a kidney metastasis, you've got to embellish it. First of all, and how we analyze it is with our interventional radiologists. And we tend to try and do that within three days of the operation. So, yeah, 72 hours is the recommendation. Yeah, I probably if the worst comes to the worst and and we and we've missed that, I would be happy to go up to about a week.
But after about a week, new vessels will be growing into that tumor. And so it could be a bit more vascular than you'd like it. Still, be prepared when you're treating a renal cell. The classic teaching the classic example is in the pelvis. It's eroded the hip joint you're trying to put a hip replacement in. The classic thing is that it could still bleed a lot. So even though you've embolism it, it could still be a bit challenging.
So I get lots of adrenaline soaked gauze swabs. And if it does bleed, just pack it with adrenaline so-called swabs. And that can often staunch the blood flow quite significantly, allowing you to carry on. So that's a little tip if you do ever encounter quite brisk bleeding from some of these metastasis. Thank you. Then we've got Suleiman Yunus, he said, in a case of you in Tacoma, or maybe it's in your case of the Ewing sarcoma islet wing, would you recommend chemotherapy after resection and pasteurization?
Yeah, that's a really nice point. So you know, what's interesting about treating sarcoma is if you go around the world, there are lots of different ways of doing it. Some people use liquid nitrogen inside lesions which get curative, et cetera, and there's some funny sort of treatments out there. What that question is alluding to is the fact that you can take bone, which is affected by tumor away at the time of surgery, and you can take it out of the body.
And you can go and treat that cancer with some other type of adjuvant. And then in the same operation, you can put it back in and you just basically plate it back in and then hopefully with creeping substitution that the fracture will heal and you'll have the tumor treated. But the patient's own bone back in and the pelvis is a classic situation for this. I've had experience of radiation, so it's called extracorporeal irradiation, where the pelvis is taken out.
It's given high dose radiation that otherwise could not be given to the patient with the bone in because it would be too toxic to the running tissues. The tumors killed and then you put that bone back in like a bone graft. Another option is pasteurization, which you can put it into liquid nitrogen or things like that. So there are those techniques around. I don't do it.
And often at the moment, because it's quite logistically challenging to do. But yeah, it is well recognized as treatments for these conditions. So yeah, it does talk about some ways that some units do treat and their Ewing's sarcoma. OK, thank you. Mohammed nail, this is like an exam question, would you advise to do a biopsy in A or better by a tumor unit?
The class, I think again, Tom, we'll talk about this tomorrow because there is Catholic teaching on how you do a biopsy. The key thing about a biopsy that should be excised, that definitive surgery, the biopsy track should be excised could potentially the needle or the operation has led some tumor seeding along that biopsy track. So if you're not going to do the definitive surgery, how do you know where the biopsy will be?
So we do recommend that any tumor gets biopsied in the tumor unit and then we can direct our radiologists or we can do the surgery with a biopsy tract in mind for our definitive surgery. So any tumor specimen we take out often has to biopsy tract attached to it. OK, I know this. This is a really hot topic. I really know that a lot of people are got a lot of questions, but to be honest with you, a lot of these questions are now getting to the high level.
And I know Mr Whitwell has gone way over the time that he had allocated to us, and we really appreciate it. Thank you so much for the time you've given us, Mr Whitlow. Those the questions, the rest of those questions are pretty much beyond the scope of the parks exam. In fact, some of those questions were already beyond. Thank you very much for answering them. I'm thank you for your patience. Really amazing talk.
Once again, thank you very much. Well over 220 participants. Watch this and I'm sure we'll get a lot more hits on the different platforms that we're going to be putting this up on once again, guys tomorrow. Prof prof. Costco will be here to discuss how to investigate and manage these patients in the special metastatic disease as well to everyone.
Thank you so much for attending. We are, as always here every Wednesday except tomorrow, which will be Thursday and look forward to seeing you again. Thank you. Thank you very much. Best of luck, everyone. Thank you. Thank you.
OK, if we can stop recording now. And
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