Suspected Soft Tissue amp Bone Sarcomas A m it Kumar 12 th October 2019 Greater Manchester Cancer Aims Greater Manchester Cancer Increase awareness of MSK tumours Appropriately manage a patient with a concerning lump suspected bone ID: 912958
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Slide1
Referral & Assessment for
Suspected Soft Tissue & Bone Sarcomas
Amit Kumar12th October 2019
Greater Manchester
Cancer
Slide2Aims
Greater Manchester Cancer
Increase awareness of MSK
tumours
Appropriately manage a patient with a concerning lump / suspected bone tumour
Slide3Objectives
Greater Manchester Cancer
Background
Symptoms
& SignsClinical assessmentInitial Management
Referral Criteria
Slide4Must Read
Greater Manchester Cancer
NICE Sarcoma
Guidelines
Familiarity with 2WW local referral formSarcoma UK
Bone Cancer Research UK
Slide5Introduction
Greater Manchester Cancer
A rare type of cancer arising from
mesenchymal
/connective tissue
Soft Tissue, Bone or GIST1% of all primary cancerApprox 5300 per year (15/day)100 different sub-types.5 year survival rate for sarcoma is 55%
Slide6Sarcoma
Greater Manchester Cancer
40-60 years, young adults,
children
No significant
aetiologyAssociations: HIV / Kaposis, Neurofibromatosis, other cancers – 2nd hit hypothesis50% extremities: LL > ULOther: Retroperitoneal, Chest, Gynae
, Breast
Slide7World Health Organization classification of tumours
Tumours are classified by differentiation and biological behaviour. Adipocytic tumoursFibroblastic/myofibroblastic
tumoursSo-called fibrohistiocytic tumoursSmooth-muscle tumoursSkeletal muscle tumoursVascular tumoursChondro-osseous tumoursGastrointestinal stromal tumours Nerve sheath tumoursTumours of uncertain differentiationUndifferentiated/unclassified sarcomas.
Slide8Common Sarcomas
Soft TissueLeiomyosarcomaFibroblastic SarcomaLiposarcomaRhabdomyosarcomaMalignant peripheral nerve sheath
tumourAngiosarcomaSynovial sarcomaGISTKaposi’sBone EwingsOsteosarcomaChondrosarcomaChordoma
Greater Manchester
Cancer
Slide9Greater Manchester
Cancer
Slide10Greater Manchester
Cancer
Slide11Approach to Patient with a lump
History:How longPainfulIncreasing in size Bigger than 5cm?Previous surgery/Rxt
Discharge or skin changesFHx – other cancers: melanoma, lymphoma, lungAsk what has been done: other GP, hospital, private
Greater Manchester
Cancer
Slide12Symptoms & Signs
SymptomsPainStiffnessLocal effectsNon weight bearingVague symptomsSigns
Noticeable lumpJoint swellingSkin changesFungating tumour
Greater Manchester
Cancer
Slide13Clinical Examination
Slide14Greater Manchester
Cancer
Clinical Examination
Look: skin changes,
naevi, neurofibromas, multiple lumpsFeel/Move:Location – limb, trunk, areas of lymph nodes?Soft or hard
Mobile or adherent to deeper structuresSize >5cm?PainJoint functionNeurological symptoms
Slide15Greater Manchester
Cancer
Investigations
Basic Work up: Ultrasound: Will rule out most benign
MRI (Tumour protocol) Limb Xray CXR
Baseline BloodsBone Profile/Calcium
Slide16Greater Manchester
Cancer
WHOOPS
Do NOT not biopsy Do NOT excise without imaging and discussion
If in-advertent incision – biopsy and close
Slide172WW Referral Criteria
Greater Manchester Cancer
Lump increasing in size, deep, bigger than
5cm
Painful,
fungating, previous surgery, RxtBone changes on Xray
Slide182WW Referral Form
Greater Manchester Cancer
Slide19Greater Manchester
Cancer
Sarcoma Service
Clinical assessmentImagingBiopsy: Core
biospy. No role for FNAHistopathologyMDT review locallyRegional MDTManagement Plan
Slide20Greater Manchester
Cancer
Treatment
Surgical Excision: Marginal, Wide, AmputationPre or Post op Radiotherapy
ChemotherapyPalliative treatment
Slide21Greater Manchester
Cancer
Pitfalls in patient pathway
Delayed referral – biggest cause of litigation
Patients referred to non-tumour specialistsPoor knowledge of tumours and clinical skillsWHOOPSWhere are the scans? Urgent? 2WW? Beware the persistent
haematomaNot taking a history
Slide22Sarcoma Clinic
GP Referral
Specialist ReferralSoft Tissue Mass/Bone lesion Diagnostic Clinic USS + Bx
GMOSS MDT
MRI / CT
Return to referrer
Refer to other specialty
GMOSS
Greater Manchester &
Oswestry
Sarcoma Service
Soft Tissue & Bone Guidelines
Arrange Surgery
Sarcoma
Diagnostic Triage/MDM
Slide23Current Patient Pathway
Greater Manchester Cancer
Clinic and/or MDT < 2 weeks
Biopsy < 2 weeks
Results and MDT 2-3 weeks
Back to Clinic Total = Min 6 weeks
Slide24NHS England
Greater Manchester Cancer
Slide25Doctor, I have got a lump, what do I do with it?
Greater Manchester Cancer
History: how
long, is it getting bigger and
painfulExamine to see is it soft, hard, mobile and deep; joint swelling –
Xrays?Refer to local sarcoma service if meets criteriaDiscuss/refer if concernedIts not a pathway for: Unknown malignancy, get seen quicker, small benign proven lumps
Slide26Thank you
Greater Manchester Cancer