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View Presentation Notes When is a musculoskeletal condition a tumor? Recognizing common bone and soft tissue tumors Christian M. Ogilvie, MD Assistant Professor of Orthopaedic Surgery University of Pennsylvania University of Pennsylvania Department of Orthopaedic Surgery Purpose • Recognize that tumors can present in the extremities of patients treated by athletic trainers • Know that tumors may present as a lump, pain or both • Become familiar with some bone and soft tissue tumors University of Pennsylvania Department of Orthopaedic Surgery Summary • Introduction – Pain – Lump • Bone tumors – Malignant – Benign • Soft tissue tumors – Malignant – Benign University of Pennsylvania Department of Orthopaedic Surgery Summary • Presentation • Imaging • History • Similar conditions –Injury University of Pennsylvania Department of Orthopaedic Surgery Introduction •Connective tissue tumors -Bone -Cartilage -Muscle -Fat -Synovium (lining of joints, tendons & bursae) -Nerve -Vessels •Malignant (cancerous): sarcoma •Benign University of Pennsylvania Department of Orthopaedic Surgery Introduction: Pain • Malignant bone tumors: usually • Benign bone tumors: some types • Malignant soft tissue tumors: not until large • Benign soft tissue tumors: some types University of Pennsylvania Department of Orthopaedic Surgery Introduction: Pain • Bone tumors – Not necessarily activity related – May be worse at night – Absence of trauma, mild trauma or remote trauma • Watch for referred patterns – Knee pain for hip problem – Arm and leg pains in spine lesions University of Pennsylvania Department of Orthopaedic Surgery Introduction: Lump • Malignant soft tissue tumors – Usually become noticeable over several months – Synovial sarcoma, commonly seen in young adults • May be present and unchanged for years • Most tumors grow steadily – Decrease in size generally means a nontumor process or hemangioma (benign blood vessel tumor) University of Pennsylvania Department of Orthopaedic Surgery Introduction • Be vigilant! • Exceptions exist to most guidelines University of Pennsylvania Department of Orthopaedic Surgery Malignant Bone Tumors • Osteosarcoma – Central – Surface • Ewings Sarcoma University of Pennsylvania Department of Orthopaedic Surgery Central Osteosarcoma • High grade • Metaphyseal: knee, proximal humerus • Permeative, erosions, soft tissue mass, variable bone formation, periosteal elevation • DDx: GCT, ABC, Ewing’s, lymphoma, osteoblastoma, met • Wide resection • Chemotherapy University of Pennsylvania Department of Orthopaedic Surgery Surface Osteosarcoma Parosteal Periosteal • Low grade 90% • High grade • Slow growth, painless mass • Femur and tibia; may be • Posterior distal femur diaphyseal • Well ossified on intact cortex • Well ossified at base • DDx: myositis, periosteal sarcomas, exostosis • Cortical involvement, erosion with soft tissue mass • Lacks cellular atypia • May dedifferentiate • Wide resection • Wide resection • Chemotherpay • Chemo if high grade University of Pennsylvania Department of Orthopaedic Surgery Ewing’s Sarcoma • 5 – 30 years old • Small round blue cells; • Pain, mass, anemia, CD99+; EWS/FLI-1 leucocytosis •Chemotherapy • Pelvis and lower extremity • Surgery if resectable, • Large soft tissue mass with radiation considered if not small periosteal reaction resectable • DDx: osteomyelitis, lymphoma, OGS, EG, neuroblastoma met University of Pennsylvania Department of Orthopaedic Surgery Benign Bone Tumors • Giant cell tumor • Osteochondroma • Osteoid oseoma • Solitary bone cyst – AKA unicameral bone cyst University of Pennsylvania Department of Orthopaedic Surgery Giant Cell Tumor • Aggressive • 20s to 30s; <5% with open physes; 80% > 20 yo • M:F = 2:3 • Pain, fracture, swelling; mets in 2% • 50% around knee; epiphyseal/metaphyseal, may be subchondral • Lytic, expansile, geographic, neocortex University of Pennsylvania Department of Orthopaedic Surgery Giant Cell Tumor • Campanacci stages: I lytic; II expansile; III destructive, soft tissue mass • DDx: ABC, brown tumor, telangiectatic osteosarcoma, spindle cell sarcoma of • Stroma nuclei same as giant bone, osteoblastoma cell nuclei • Curretage, burr, adjuvant, graft/cement, +/- fixation; resect if expendible University of Pennsylvania Department of Orthopaedic Surgery Osteoblastoma • Aggressive, may form • DDx: ABC, osteosarcoma, bone chondrosarcoma, • 10-35 yo chondroblastoma, Brodie’s abcess, giant cell tumor, • M:F=2:1 osteoid osteoma • Pain, min. NSAID relief. • Post. spine, femur, tibia, • May have osteoid, skull; metaph., diaph. fibrovascular stroma. • Lytic, sclerotic or mixed, • Curettage and cementation, nidus usu. >2cm; grafting geographic; neocortex University of Pennsylvania Department of Orthopaedic Surgery Chondroblastoma • Aggressive • Teens • Small • Epiphyseal, next to joint • Inflammatory University of Pennsylvania Department of Orthopaedic Surgery Chondroblastoma University of Pennsylvania Department of Orthopaedic Surgery Osteochondroma • Latent • Pedunculated, sessile; • 10-35 yo cortical and medullary • M:F=2:1 continuity; bursa, cartilage cap – malignant if >2cm • Growth until maturity; usu. painless; late pain, • DDx: Reactive periosteal growth – impingement bone, sclerotic mets, vs. malignancy (<1%, 30 parosteal osteosarcoma, yo); MHE: 5-25% malig, chondrosarcoma Madelung, valgus knees • Cartilage cap, trabecular • Surface, firm, fixed; knee bone, normal marrow shoulder, hip - metaphyseal • Excision if symptomatic University of Pennsylvania Department of Orthopaedic Surgery Simple Bone Cyst • Latent or active • 80-90% < 20 yo • DDx: ABC, FD, CMF, telangiectatic osteosarcoma, • M>F infection, NOF • Fracture • Cyst lining: flattened spindle • Metaphyseal, grow cells away from joint, full • Injection of steroids vs width; 80% in proximal marrow; injection of graft – humerus and femur calcium phosphate; open • Lytic, some expansion, grafting, recurrence risk geographic, thin during growth sclerotic margin University of Pennsylvania Department of Orthopaedic Surgery Osteoid Osteoma • Intracapsular: lacks sclerosis; • Active, bone forming Subperiosteal: min. periosteal • 10-35 yo response, cortical scalloping. • M:F=2:1 • DDx: Stress fracture, • Night pain, NSAID Brodie’s abscess, bone island, relief; effusion; increased osteoblastoma. bone growth, scoliosis • Osteoid at center of nidus • Sclerotic with nidus usu. lined by osteoblasts, <1cm; long bones and fibrovascular stroma. posterior spine elements • RFA vs. resection University of Pennsylvania Department of Orthopaedic Surgery Stress Fracture • 26 yo female runner • Worsening pain for weeks to months University of Pennsylvania Department of Orthopaedic Surgery Malignant Soft Tissue Tumors • Treatment and challenges • Rhabdomyosarcoma • Synovial sarcoma • Malignant Fibrous Histiocytoma • Liposarcoma University of Pennsylvania Department of Orthopaedic Surgery Malignant Soft Tissue Tumors • Treatment – Wide resection – need to get it all out – Preop or postop radiation – Chemotherapy for 5cm or larger – Area of controversy / investigation but widely practiced • Problems – Lung metastases – Wide resection may alter function University of Pennsylvania Department of Orthopaedic Surgery Rhabdomyosarcoma • Most common soft tissue sarcoma in kids • 50% are in first decade • Second peak: 15 - 20 years old • Most common in head and neck and GU track • About 15% are in the extremities • Chemotherapy sensitive University of Pennsylvania Department of Orthopaedic Surgery MFH • Most common soft tissue sarcoma in adults • Painless mass University of Pennsylvania Department of Orthopaedic Surgery Synovial Sarcoma •Cell of origin unknown •May grow slowly or be present for years •May calcify or ossify or contain cysts •May be monophasic or biphasic with more and less cellular areas; epithelioid •Translocation: t(x:18); 2 major types University of Pennsylvania Department of Orthopaedic Surgery Synovial Sarcoma University of Pennsylvania Department of Orthopaedic Surgery Myositis Ossificans •Usually history of trauma •MRI with contrast helpful: rule out enhancing soft tissue component of soft tissue tumor University of Pennsylvania Department of Orthopaedic Surgery Liposarcoma •May be associated with lipoma •Lipoblasts: indented nuclei •Round cell: >5% = worse prognosis University of Pennsylvania Department of Orthopaedic Surgery Hematoma •History of trauma or anticoagulant use University of Pennsylvania Department of Orthopaedic Surgery Benign Soft Tissue Tumors • Lipoma • Hemangioma • Pigmented villonodular synovitis (PVNS) • Myxoma • Benign peripheral nerve sheath tumor – AKA schwannoma, neurilemoma University of Pennsylvania Department of Orthopaedic Surgery Lipoma • Can diagnose on MRI • Treatment – Excision if growing or has atypical features – Biopsy: if discrete area of atypia on MRI • “Atypical” – Sometime referred to as grade I liposarcoma – Higher recurrence rate and malignant transformation rate University of Pennsylvania Department of Orthopaedic Surgery Hemangioma • May be able to diagnose on MRI • Treatment – Embolization for AV malformation – Sclerotherapy: EtOH • High recurrence rate after excision • Can be painful University of Pennsylvania Department of Orthopaedic Surgery Myxoma • Most common adult benign muscle tumor • Typically middle aged female in hip region • Cannot distinguish from myxoid fibrosarcoma with 100% reliability using MRI • Biopsy University of Pennsylvania Department of Orthopaedic Surgery Pigmented Villonodular Synovitis • Interarticular – Diffuse – Localized • Extrarticular – Diffuse –
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