Malignant Tumors Rahaf - PowerPoint Presentation

Slide1

Malignant Tumors

Rahaf

Jreisat

Slide2

Approach

History

-Age:

most primary lesions appear in childhood and

adolescence

while lesions in elderly are usually metastatic

-Pain:

indicates nature and site of tumor

-Swelling:

Size indicates tumor

progression

Slide3

-Other symptoms:

Fever, weight loss, night sweats

Neurological symptoms (compression)

Examination

-Lump: SPACESPIT

-Lymph nodes

-Joint effusion

-Spine

Slide4

Imaging:

Plain X-Ray is the gold standard diagnostic tool

CT: Staging and Mets identification

MRI

Bone Scan: skip lesions

Lab Tests:

CBC, ESR

Alkaline

Phosphatase

Bence

Jones Proteins in urine

Slide5

Biopsy:

All imaging studies should be completed before undertaking a biopsy, which may itself distort the appearances.

Tumor biopsy should never be regarded as a ‘minor’ procedure. Complications include

haemorrhage

, wound breakdown, infection and pathological fracture.

Slide6

Primary malignant bone tumours

Multiple Myeloma

Osteosarcoma

-Paget Sarcoma

Chondrosacoma

Ewing Sarcoma

■ The most common malignant lesions in bone are metastatic tumors, while the most common primary malignant lesion is Multiple Myeloma.

Slide7

Osteosarcoma

a highly malignant

tumour

arising within the bone and spreading rapidly outwards to the

periosteum

and surrounding soft tissues.

The histological appearances show considerable variation.

Slide8

Clinical features

occurs predominantly in children and adolescents.

It may affect any bone but most commonly the long-bone

metaphyses

, especially around the knee and at the proximal end of the

humerus

.

Pain is usually the first symptom; it is constant, worse at night and gradually increases in severity.

sometimes the patient presents with a lump.

The erythrocyte sedimentation rate (ESR) is usually raised and there may be an increase in serum alkaline

phosphatase

.

Slide9

Imaging

-On x-ray: mixed

lytic

and

blastic

, the

tumour

margins are poorly defined.

-Often the cortex is breached and the

tumour

extends into the adjacent tissues; when this happens, streaks of new bone appear, radiating outwards from the cortex – the so-called ‘sunburst’ effect.

-Where the tumor emerges from the cortex, reactive new bone forms in the angle between

periosteum

and cortex (Codman’s triangle).

About 10% of patients have pulmonary metastases by the time they are first seen which is detected by CT

Slide10

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Treatment

Multi-agent chemotherapy is given for 8–12 weeks and then, provided that the tumor is

resectable

and there are no skip lesions, a wide resection is carried out.

It is important to eradicate the primary lesion completely; the mortality rate after local recurrence is far worse than following effective ablation at the first encounter.

Slide12

Paget’s sarcoma

Paget’s disease of bone occasionally undergoes malignant transformation; most

osteosarcomas

appearing after the age of 50 years fall into this category.

This

tumour

is more malignant than classic

osteosarcoma

Most patients have pulmonary metastases by the time the

tumour

is diagnosed.

Even with radical resection or amputation and chemotherapy the 5-year survival rate is low.

If the lesion is definitely extra compartmental, palliative treatment by radiotherapy may be preferable; chemotherapy is usually difficult because of the patient’s age and uncertainty about renal and cardiac function.

Slide13

Chondrosarcoma

Chondrosarcoma

occurs either as a primary

tumour

or as a secondary change in a pre-existing benign

chondroma

or

osteochondroma

.

Cartilage capped

exostoses

of the pelvis and scapula seem to be more susceptible than others to malignant change, but perhaps this is simply because at these sites the

tumour

can grow without being detected and removed at an early stage.

Slide14

Clinical features

highest incidence in the fourth and fifth decades, men are more affected.

Patients may complain of a dull ache or a gradually enlarging lump.

Slide15

Imaging

Primary

chondrosarcoma

can occur in any bone that develops in cartilage but is usually seen in the

metaphysis

of long bones. X-ray examination shows a radiolucent area with central flecks of calcification.

Secondary

chondrosarcoma

usually arises in the cartilage cap of an

osteochondroma

that has been present since childhood.

Slide16

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Treatment

Chondrosarcomas

are usually slow-growing and metastasize late.

They present the ideal case for wide excision and prosthetic replacement, provided it is certain that the lesion can be completely removed without exposing the

tumour

and without causing an unacceptable loss of function. Otherwise amputation may be a safer option.

The

tumour

does not respond to either radiotherapy or chemotherapy

Slide18

Ewing’s sarcoma

Ewing’s sarcoma is believed to arise from endothelial cells in the bone marrow.

Translocation 11/22

It occurs most commonly between the ages of 10 and 20 years, more in males

11 + 22 = 33

Patrick Ewing

Slide19

Clinical features

The patient presents with pain – often throbbing in character – and swelling.

Generalized illness and pyrexia, together with a warm, tender swelling and a raised ESR

Slide20

imaging

X-ray usually shows an area of bone destruction which, predominantly in the mid

diaphysis

.

New bone formation may extend along the shaft and sometimes it appears as

fusiform

layers of bone around the lesion – the so-called ‘onion-peel’ effect.

Slide21

Treatment The prognosis is always poor and surgery alone does little to improve it. Chemotherapy offers a 5-year survival rate of about 50%.

The best results are achieved by a combination of all three methods:

a course of preoperative

neoadjuvant

chemotherapy; then wide excision if the

tumour

is in a

favourable

site, and then a further course of chemotherapy for 1 year.

Slide22

Metastatic bone disease

The commonest source is carcinoma of the breast; next in frequency are carcinomas of the prostate, kidney, lung, thyroid, bladder and gastrointestinal tract.

In about 10% of cases no primary

tumour

is found. The commonest sites for bone metastases are the vertebrae, pelvis, the proximal half of the femur and the

humerus

.

Metastases are usually

osteolytic

, and pathological fractures are common.

Osteoblastic

lesions are uncommon; they usually occur in prostatic carcinoma.

Slide23

Routes of mets

Hematogenous

: mc route

Lymphatic: rare

Direct implantation like surgical procedures and biopsy

CSF: spread of malignant lesions from

meninges

to vertebrae

Slide24

Clinical features

The patient is usually aged 50–70 years; with any destructive bone lesion in this age group, the differential diagnosis must include metastasis.

Pain is the commonest – and often the only – clinical feature.

Symptoms

of

hypercalcaemia

may

occur.

These

include anorexia, nausea, thirst,

polyuria

, abdominal pain, general weakness and depression.

Slide25

Imaging

If x-rays do not show anything, a radionuclide scan might. Some deposits remain clinically silent and are discovered incidentally on x-ray, or after a pathological fracture.

Sudden

collapse of a vertebral body or a fracture of the

midshaft

of a long bone in an elderly person are ominous signs; if there is no history and no clinical clue pointing to a primary carcinoma, a biopsy of the fracture area is essential.

Slide26

Special investigations

The

ESR may be increased and the

haemoglobin

concentration is usually low.

The

serum alkaline

phosphatase

concentration is often increased, and in prostatic carcinoma the acid

phosphatase

also is elevated

Slide27

Treatment

By

the time a patient has developed secondary deposits, the prognosis for survival is almost hopeless.

I

n

the great majority of cases, and certainly in those with multiple

secondaries

, treatment is entirely

symptomatic.

Analgesics, the more powerful narcotics should be reserved for the terminally ill. Unless specifically contraindicated, radiotherapy is used both to control pain and to reduce metastatic growth.

Slide28

Secondary

deposits from breast or prostate can often be controlled by hormone

therapy.

Hypercalcaemia

should

be treated by ensuring adequate hydration, reducing the calcium intake and, if necessary, administering

bisphosphonates

.

Slide29

Treatment of

shaft

fractures should almost always be treated by internal

fixation.

Spinal stabilization for vertebral fractures. If the spine is stable, a well-fitting brace may be sufficient. However, spinal instability may cause severe pain, making it almost impossible for the patient to sit or stand – with or without a brace. For these patients, operative stabilization is

indicated

Slide30

MM

Osteosarcoma

Chondrosarcoma

Ewing sarcoma

Secondary

tumors

Age

6

th

decade

2

nd

and 4

th

decade

4

th

decade

10-20

years

Over 50 years

Symptoms

Pain and swelling

Pain and swelling

Pain, swelling, systemic

symptoms

XRay

Multiple punched out lesions

purely

lytic

Sunburst and

Codman’s triangle

Lytic

and

blastic

calcificatons

Onion-skin

periosteal

reaction

Mostly

lytic

lesions

Tx

Hematological

tx

Surgery for fracture and spinal compression

Neoadjuvant

chemotherapy

and surgery

Surgery

Not sensitive to chemo

or radiation

Neoadjuvant

chemotherapy

and surgery

Surgery is palliative