Lumps & Bumps · Often extensive radiologic imaging ... Surgery: Knee disarticulation with epiphysiodesis of the distal femoral growth plates Adjuvant Chemotherapy Case #2 Healthy

Lumps & Bumps--When to be concerned--

Eric Silverstein, MDDirector of Musculoskeletal Oncology

Academic Director of Orthopaedic SurgerySaint Francis Hospital & Cancer Center

Trinity Health of New England

33rd Sports Medicine

Symposium

March 6, 2018

Disclosure

I have nothing to disclose and have no potential conflict of interest with any company or service industry

Objectives

Identify the “red flags” of musculoskeletal lesions

Case examples of tumors that may emulate sports pathology

Understand the basics of musculoskeletal oncologic staging

Provide an introduction to the pitfalls of poorly planned and performed biopsies

Know when to refer a patient with musculoskeletal lesions

CCSU Sports Medicine Symposium 2018 Tuesday March 6, 2018

Musculoskeletal Oncology

Division of orthopaedics focusing on surgical treatment of soft-tissue and bone tumors (and simulators)

Requires multi-disciplinary approach

Often extensive radiologic imaging

Staging / Carefully planned biopsies

Vast array of surgical intervention and reconstruction

Case #1

30 year old male

Chief complaint: Mass in left thigh

HPI: Healthy male with slowly enlarging mass in anterior thigh over 6 months. Causing minimal to mild discomfort.

ROS: negative

X-RAYS: negative

Case #1


Case #1

In contrast to…

59 year old male noticed a mass in the right proximal thigh ~ 6 months ago

Has remained the same size

Denies any pain or trauma

Notices it more with contraction of the quadriceps (proximal 1/3rd of anterior thigh)

No significant PMHx or PSHx

Meagher, M ichaelMeagher, M ichael

37677683767768

7/5/19587/5/1958

59 YEA R59 YEA R

MM

Page: 25 of 50Page: 25 of 50

A Q M:358\512A Q M:358\512

TE: 90TE: 90

TR: 8350TR: 8350

FA : 140FA : 140

SESE

EC : 1EC : 1

NEX: 1NEX: 1

------

St Franc is Hospital Skyra St Franc is Hospital Skyra

MRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA STMRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA ST

t2_tse_sag_rightt2_tse_sag_right

2/15/2018 9:54:38 A M 2/15/2018 9:54:38 A M

52687615268761

------

LO C : -120.61LO C : -120.61

THK: 4 .50SP : 4 .50THK: 4 .50SP : 4 .50

FFSFFS

IM:25 SE:6IM:25 SE:6

C ompressed 7:1C ompressed 7:1

DFO V :45x45cmDFO V :45x45cm

W: 732W: 732

C : 210C : 210

Z: 1Z: 1

AA PP

HH

FF

Meagher, M ichaelMeagher, M ichael

37677683767768

7/5/19587/5/1958

59 YEA R59 YEA R

MM


A Q M:384\378A Q M:384\378

TE: 12TE: 12

TR: 750TR: 750

FA : 120FA : 120

SESE

EC : 1EC : 1

NEX: 1NEX: 1

------

St Franc is Hospital Skyra St Franc is Hospital Skyra

MRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA STMRI FEMUR RIGHT WITH A ND WITHO UT IV C O NTRA ST

t1_tse_tra_p2_t1_tse_tra_p2_

2/15/2018 10:04:36 A M 2/15/2018 10:04:36 A M

52687615268761

------

LO C : -72.92LO C : -72.92

THK: 5 .50SP : 5 .50THK: 5 .50SP : 5 .50

FFSFFS



DFO V :34.1x34.1cmDFO V :34.1x34.1cm

W: 1308W: 1308

C : 616C : 616

Z: 1 .02Z: 1 .02

RR LL

AA

PP

Not all masses are Tumors…

65 y.o. male with anterior thigh massfor 5 years… slowly increasing in sizewith occasional discomfort

In contrast to…


MRI


Case #2

10 y.o. female

Chief complaint: Left knee pain

Healthy with no PMHx

Was sailing and struck Left leg against

the boat during turbulence

Had pain but able to walk

Pain persisted despite conservative management for the next 4-6 weeks

Case #2

Case #2

Axial ViewSagittal View

Coronal View


Case #2

Open biopsy confirms osteosarcoma

Proceeded with Neoadjuvantchemotherapy

Doxorubicin, Cisplatin, and Methotrexate Current gold standard of treatment

Radiation has little to no role

Surgery: Knee disarticulation with epiphysiodesis of the distal femoral growth plates

Adjuvant Chemotherapy

Case #2

Healthy 10 year old with LEFT hip pain for nearly 6 months

Avid soccer player

Does not recall an injury

Pain with activity but mostly at night

NSAIDs completely relieve the pain but returns as soon as the meds wear off

Case #3


Case #3Nathan, BrynnNathan, Brynn

60060826006082

11/2/200011/2/2000

13 YEAR13 YEAR

FF


DELPHI ORTHOPEDIC DELPHI ORTHOPEDIC

XR HIP LEFT (2 VIEW)XR HIP LEFT (2 VIEW)

HIP APHIP AP

10/9/2014 2:50:52 PM 10/9/2014 2:50:52 PM

41395534139553

------

------

------

IM: 1001IM: 1001Compressed 32:1Compressed 32:1

W: 1024W: 1024C: 512C: 512Z: 0.51Z: 0.51S: 220S: 220

Case #3

Nathan, BrynnNathan, Brynn

60060826006082

11/2/200011/2/2000

13 YEA R13 YEA R

FF


A cq no: 3A cq no: 3

KV p: 130KV p: 130

mA : 44mA : 44

T ilt: 0T ilt: 0

RD: 149RD: 149

Tech com: ---Tech com: ---

RA H Rad RA H Rad

C T HIP LEFT WITHO UT IV C O NTRA STC T HIP LEFT WITHO UT IV C O NTRA ST

Hip 5 .0 B70sHip 5 .0 B70s

5/28/2014 4:56:00 PM 5/28/2014 4:56:00 PM

40446624044662

------

LO C : -1319.90LO C : -1319.90

THK: 5THK: 5

HFSHFS



DFO V :14.9x14.9cmDFO V :14.9x14.9cm

W: 2000W: 2000

C : 500C : 500

Z: 1Z: 1

RR LL

AA

PP


60060826006082

11/2/200011/2/2000

13 YEA R13 YEA R

FF


A cq no: 3A cq no: 3

KV p: 130KV p: 130

------

T ilt: 0T ilt: 0

------

Tech com: ---Tech com: ---

RA H Rad RA H Rad

C T HIP LEFT WITHO UT IV C O NTRA STC T HIP LEFT WITHO UT IV C O NTRA ST

C oronalC oronal

5/28/2014 4:55:53 PM 5/28/2014 4:55:53 PM

40446624044662

------

------

THK: 2THK: 2

HFSHFS

IM:30 SE:607IM:30 SE:607


DFO V :16x16cmDFO V :16x16cm

W: 1500W: 1500

C : 450C : 450

Z: 1Z: 1

RR LL

HH

FF

Radiolucent Nidus – pathognomonic of

an Osteoid Osteoma

Case #3

Conservative management with daily NSAIDs Although osteoid osteomas are self limiting

they often persist on average 3-5 years before “burning out”

Prolonged use of NSAIDs – ulcers*, kidney damage, etc.

Surgery Radiofrequency ablation

Open excision

Other modalities (?)


RADIOFREQUENCY ABLATION (RFA)

RADIOFREQUENCY ABLATION (RFA)

PP

RR LL

AA


A cq no:5A cq no:5

KV p:120KV p:120

mA :192mA :192

T ilt:0T ilt:0

RD:279RD:279

B30fB30f

------

------



DFO V :27.9x27.9cmDFO V :27.9x27.9cm

W:3128W:3128

C :714C :714

Z:1Z:1


60060826006082

11/2/200011/2/2000

13 YEA R13 YEA R

FF

------

SFH RadSFH Rad

C T RA DIO FREQ UENC Y A BLA T IO N - BO NEC T RA DIO FREQ UENC Y A BLA T IO N - BO NE

BiopsySingle 0 .75 B30fBiopsySingle 0 .75 B30f

6/27/2014, 10:37:40 A M6/27/2014, 10:37:40 A M

40471984047198

------

LO C :442.10LO C :442.10

THK:0.75 ---THK:0.75 ---

FFSFFS

PP

RR LL

AA


A cq no:3A cq no:3

KV p:120KV p:120

mA :362mA :362

T ilt:0T ilt:0

RD:279RD:279

B30fB30f

------

------

IM:1 SE:5IM:1 SE:5


DFO V :27.9x27.9cmDFO V :27.9x27.9cm

W:3128W:3128

C :714C :714

Z:1Z:1


60060826006082

11/2/200011/2/2000

13 YEA R13 YEA R

FF

------

SFH RadSFH Rad

C T RA DIO FREQ UENC Y A BLA T IO N - BO NEC T RA DIO FREQ UENC Y A BLA T IO N - BO NE

BiopsySingle 0 .75 B30fBiopsySingle 0 .75 B30f

6/27/2014, 10:19:00 A M6/27/2014, 10:19:00 A M

40471984047198

------

LO C :445.40LO C :445.40

THK:0.75 ---THK:0.75 ---

FFSFFS

Case #4

37 y.o. female

Chief complaint: Shoulder pain w/ mass

and swelling

30 weeks pregnant

Symptoms present for nearly 7 months

Otherwise healthy

Went to see sports doc


Case #4

Large soft-tissue mass surrounding scapula

Agreed to x-ray

Days before had outside open biopsy done (2.5” oblique incision)

Urgent percutaneousbiopsy done in my office

Consistent with high-grade osteosarcoma(poorly differentiated)

Case #4

Soft-tissue mass with little bony change

Case #4

Urgent c-section at 31 weeks

Pre-operative clinical photos


Case #4

Post-operative follow-up x-rays

“Red Flags”

New or old mass with rapid growth

Within weeks or months is a concern

Night Pain

Persistent pain

Radicular symptoms

Signs of mass effect – bowel / bladder issues, DVT, swelling, …

Systemic symptoms

Case #5

42 year old woman with vague pain in right flank with small mass

CT showed 3-4 cm mass

Felt to be benign or a hematoma

Schizo-affective disorder, poor family / social situation

Non-compliance issues


Case #5

Case #5

Six Months Later…

Case #5


Case #6

15 year old female

High school student and volleyball player

Long history of bilateral patello-femoral symptoms

Otherwise healthy

X-ray showed abnormality and sent for evaluation

Case #6

Case #6


Case #6

Case #6

1. Open biopsy of femur

2. Extensive curettage,

high-speed burring,

allograft

3. Prophylactic fixation

Case #7

64 year old male s/p right THA 2 ½ years ago for OA

No history of cancer

Fairly healthy and

active

New onset of severe right hip pain


Greater Sciatic

Foramen


Case #7Post-Op

Case #7Post-Op


Initial evaluation:

Comprehensive H&P

Mass

Pain

Fever

Systemic symptoms: weight loss, appetite decreased, N/V/D, etc.

Incidental finding – traumatic event

Pathologic fracture



Radiologic Work-up: Plain X-Ray

CT scan area of interest CT chest / abdomen / pelvis

MRI

Bone Scan

PET Scan

Staging

Pre-operative planning if necessary

Last Words

Listen to patients History is critical when you can get it

Recognize “Red Flags” If it doesn’t seem normal, it probably isn’t

Rapid growth, night pain, etc.

An injury doesn’t mean there can’t be another pre-existing or underlying problem

Staging helps provide diagnostic information and guides treatment

A biopsy is a critical first step in management with potential implications

References

1. Biazzo, A, De Paolis, M. Multidisciplinary approach to osteosarcoma. Acta Orthop Belg. 2016 Dec; 82(4):690-698

2. Zhang, Y, Rosenberg, AE. Bone-Forming Tumors. Surg Pathol Clin. 2017 Sep;10(3):513-535

3. Huang, AJ. Radiofrequency ablation of Osteoid Osteoma: Difficult-to-reach places. Semin Musculoskelet Radiol. 2016 Nov;20(5):486-495

4. Terpos, E, et al. Pathogenesis of bone disease in multiple myeloma: from bench to bedside. Blood Cancer J. 2018 Jan;8(1):7

5. Brown, TS, et al. Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review. Bone Joint J. 2018 Jan;100-B(1 Supple A):22-30


Thank You


Documents

Lumps & Bumps · Often extensive radiologic imaging ... Surgery: Knee disarticulation with epiphysiodesis of the distal femoral growth plates Adjuvant Chemotherapy Case #2 Healthy