医学精品课件:07.Bone Tumor(2017).ppt-teaching.ppt
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1、Bone TumorGao shichangThe First affiliated hospital of ChongQing Medical University1Epidemiology Incidence of bone sarcomas 0.2%of all cancers 0.8 new cases per 100,000 population per year in North America and Europe Most common bone sarcomas#1:Osteosarcoma#2:Chondrosarcoma#3:Ewing sarcoma2 Age dist
2、ribution is bimodalFirst peak:Second decade of life Osteosarcoma predominates at this age Ewing sarcoma Second peak:60 years old Chondrosarcoma predominates Secondary osteosarcomasPagets osteosarcomaPostradiation osteosarcoma3Gerneral principles Diagnostic Evaluation An adequate history and physical
3、 examination are the first and most important steps in evaluating a patient with a musculoskeletal tumor.Patients present to the orthopaedic oncologist with pain,a mass,or with an abnormal radiographic finding detected during the evaluation of an unrelated problem.4Gerneral principles The pain initi
4、ally may be activity related,but the patient with a malignancy of bone often complains of progressive pain at rest and at night.Patients with benign bone tumors also may have activity-related pain if the lesion is large enough to weaken the bone5Gerneral principles Most notably osteoid osteoma,may i
5、nitially cause night pain.6Gerneral principles Age may be the most important information obtained in the history because most musculoskeletal neoplasms,both benign and malignant,occur within specific age ranges.The physical examination should include evaluation of the patients general health,as well
6、 as a careful examination of the part in question.7Gerneral principles A mass should be measured,and its location,shape,consistency,mobility,tenderness,local temperature,and change with position should be noted.Atrophy of the surrounding musculature should be recorded,as well as neurological deficit
7、s and adequacy of circulation.8Gerneral principles Potential sites of lymph node metastases should be palpated.All suspected musculoskeletal neoplasms should be evaluated initially with plain roentgenograms.9Gerneral principles Often,the patients age and plain roentgenographic findings are sufficien
8、t to arrive at a specific diagnosis.10Gerneral principles Inactive lesions usually are well marginated,often with a surrounding rim of reactive bone formation.Aggressive lesions usually have a less well-defined zone of transition between the lesion and the host bone.Cortical expansion can be seen wi
9、th aggressive benign lesions,but frank cortical destruction usually is a sign of malignancy.1112Gerneral principles Periosteal reactive new bone formation results when the tumor destroys cortex and may take the form of a Codmans triangle,onion-skinning,or a sunburst pattern.It usually is a sign of m
10、alignancy but may be present with infection or histiocytosis.1314Gerneral principles Computed tomography(CT)is most helpful in assessing ossification and calcification and in evaluating the integrity of the cortex.CT of the lungs also is the most effective study to detect pulmonary metastases.15Gern
11、eral principles CT also is the best imaging study to localize the nidus of an osteoid osteoma,to detect a thin rim of reactive bone around an aneurysmal bone cyst.16Gerneral principles Technetium bone scans are indicated to detect skeletal metastases and to determine the presence of multiple lesions
12、.Virtually all malignant neoplasms of bone demonstrate increased uptake on technetium bone scans.1718Gerneral principles A normal bone scan is therefore very reassuring;however,the converse statement is not true because most benign lesions of bone also demonstrate increased uptake.19Gerneral princip
13、les Magnetic resonance imaging(MRI)has replaced CT as the study of choice to determine the size,extent,and anatomical relationships of both bone and soft tissue tumors.It is the most accurate technique for determining the limits of disease both within and outside bone.2021Gerneral principles MRI is
14、not very useful in differentiating benign from malignant lesions.In general,any soft tissue neoplasm deep to the fascia or larger than 5 cm in its greatest dimension should be considered highly likely to be a sarcoma.22Gerneral principles Ultrasonography is useful for distinguishing cystic from soli
15、d soft tissue.23Gerneral principles Blood and urine tests rarely lead to a diagnosis but can be useful in selected situations.Risk of wound-healing problems and infection have been shown to be significantly greater in patients whose serum albumin is less than 3.5 g/dl or whose total lymphocyte count
16、 is less than 1500/ml.24Gerneral principles A complete blood count may be helpful to rule out infection and leukemia.The erythrocyte sedimentation rate(ESR)usually is elevated in infection,metastatic carcinoma,and Ewing sarcoma.A prostate-specific antigen(PSA)should be ordered if prostate carcinoma
17、is a possibility.25 Benign tumors are staged as follows:Stage 1 lesions are intracapsular,usually asymptomatic,and frequently incidental findings.Roentgenographic features include a well-defined margin with a thick rim of reactive bone.There is no cortical destruction or expansion.STAGING 26Gerneral
18、 principles These lesions do not require treatment because they do not compromise the strength of the bone and usually resolve spontaneously.27Gerneral principles Stage 2,active 1 The lesions also are intracapsular but are actively growing and therefore can cause symptoms or lead to pathological fra
19、cture.2 They have well-defined margins on roentgenograms but may expand and thin the cortex.Usually they have only a very thin rim of reactive bone.3 Treatment usually consists of extended curettage.28Gerneral principles Stage 3,aggressive The lesions are extracapsular.Their aggressive nature is app
20、arent both clinically and roentgenographically.29Gerneral principles They usually have broken through the reactive bone and possibly the cortex.MRI may demonstrate a soft tissue mass,and metastases may be present in up to 5%of patients with these lesions.Treatment consists of extended curettage and
21、marginal or even wide resection,and local recurrences are common.30Gerneral principles Musculoskeletal sarcomas also can be staged according to the surgical staging system as described by Enneking et al.The system is based on the histological grade of the tumor,its local extent,and the presence or a
22、bsence of metastases.31Gerneral principles Low-grade lesions are designated as stage I.These lesions are well-differentiated,have few mitoses,and exhibit only moderate cytological atypia.The risk for metastases is low(3 cm)and that do not involve major neurovascular structures.45Results Diagnostic a
23、ccuracy rate 83%to 93%for musculoskeletal tumors Diagnostic accuracy is lower if the lesion is thought to be benign.46Open incisional BiopsyAdvantages Principal advantage relates to the larger size of the tissue sample obtained,reducing the risk of sampling error and allowing for more extensive hist
24、ologic assessment as well as molecular diagnostic assessment when needed.Gold standard in achieving high diagnostic accuracy.47Disadvantages Principal disadvantage of open biopsy is potential for improper execution by surgeon.Potential adverse consequences of tissue contamination/exposure during ope
25、n biopsy.48Indications Many bone and less accessible deep soft tissue tumors are best approached with open biopsy(see details below for incisional versus excisional biopsy).Results Accuracy rates of 96%for extremity bone and soft tissue lesions following final analysis have been reported at major ca
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