Tumor Mega - ProsthesisTumor Mega - Prosthesis

Chairperson ndash Dr S K SaidapurChairperson ndash Dr S K SaidapurPresenter ndash Dr Srinath GuptaPresenter ndash Dr Srinath Gupta

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone

Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman Dr Codman along with James Ewing and Dr Codman along with James Ewing and

Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

CLASSIFICATION OF BONE TUMORS

HISTORYHISTORY Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone

Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman Dr Codman along with James Ewing and Dr Codman along with James Ewing and

Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

HISTORYHISTORY Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone

Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman Dr Codman along with James Ewing and Dr Codman along with James Ewing and

Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry

Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993

Schajowicz etalCancer 1995 Mar

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites

TNM CLASSIFICATIONTNM CLASSIFICATION

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade

HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Benign Benign LatentLatent

ActiveActive

AggressiveAggressive

MalignantMalignant

Stage IA-Low grade Stage IA-Low grade intracompartmentalintracompartmental

Stage IB-Low grade Stage IB-Low grade extracompartmentalextracompartmental

Stage IIA-High grade Stage IIA-High grade intracompartmentalintracompartmental

Stage IIB-High Stage IIB-High gradeextracompartmentalgradeextracompartmental

Stage III - MetastaticStage III - Metastatic

ENNEKING STAGINGENNEKING STAGING

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

WHO HISTOLOGICAL WHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION

Osteogenic tumoursOsteogenic tumours Cartilage tumoursCartilage tumours Fibrogenic tumoursFibrogenic tumours Round cell lesionsRound cell lesions Giant cell tumour of boneGiant cell tumour of bone Notochordal tumoursNotochordal tumours Vascular tumoursVascular tumours Smooth muscle tumoursSmooth muscle tumours Lipogenic tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

DEFINITIONDEFINITION

HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS HENRY DEGROOT et al LIMB SALVAGE FOR EXTREMITY SARCOMAS

A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic functional and cosmetic result

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND

Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery

(1907)(1907) Major changes since 1970 with the advent of Major changes since 1970 with the advent of

advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques

Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti Getal Bacci G Picci 2 Pignatti Getal

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity

should be considered for limb salvage if should be considered for limb salvage if the tumor can be removed with an the tumor can be removed with an adequate margin and the resulting limb is adequate margin and the resulting limb is worth savingworth saving

No justification for limiting the limb salvage No justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

BARRIERS TO LIMB BARRIERS TO LIMB SALVAGESALVAGE

Poorly placed biopsy incisionsPoorly placed biopsy incisions Major Neurovascular involvementMajor Neurovascular involvement Displaced pathologic fractureDisplaced pathologic fracture Fungating and infected tumorsFungating and infected tumors Recurrence of malignant tumorsRecurrence of malignant tumors Inability to afford chemotherapyInability to afford chemotherapy

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)

In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy

Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope

If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering

THREE STRIKE RULE

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

GOALGOAL Painless limb Painless limb

Functional tumor free limbFunctional tumor free limb

Good psychological outcomeGood psychological outcome

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

SUCCESSSUCCESSEarly Management and ReferralEarly Management and Referral

Work up ndash MultidisciplinaryWork up ndash Multidisciplinary

StagingStaging

Patient EducationPatient Education

Surgical resection and ReconstructionSurgical resection and Reconstruction

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

STAGINGSTAGING

Histogenic type of tumor Local extent

Possibility of metastasis

Radiological staging Surgical staging

The most important step in The most important step in formulating a treatment planformulating a treatment plan

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

RADIOLOGICAL STAGINGRADIOLOGICAL STAGING Probable diagnosisProbable diagnosis

Define the anatomic extent of the Define the anatomic extent of the lesionlesion

MetastasisMetastasis

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

RADIOGRAPHYRADIOGRAPHY Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

CT SCANCT SCAN

Evaluation of cortical Evaluation of cortical penetrationpenetration

Osseous detailsOsseous details Detecting pulmonary Detecting pulmonary

metastasismetastasis

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary

extent of extent of the tumorthe tumor Soft tissue component Soft tissue component Relationship to neurovascularRelationship to neurovascular structuresstructures Skip lesionsSkip lesions Plan the surgical marginsPlan the surgical margins

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed

and and reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP Estimate the local intramedullary extent Estimate the local intramedullary extent Screen for other skeletal areas of Screen for other skeletal areas of

involvement involvement TL- 201 and DMSAVTL- 201 and DMSAV Differentiation of primary amp metastatic Differentiation of primary amp metastatic

lesions benign amp malignant cartilage lesions benign amp malignant cartilage lesionslesions

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy

(Necrosis of tumor (Necrosis of tumor mass)mass)

Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion

Residual tumor Residual tumor Recurrence of tumor Recurrence of tumor

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

SURGICAL STAGINGSURGICAL STAGING

FNAC or Needle biopsyFNAC or Needle biopsy Core biopsyCore biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

BIOPSYBIOPSYAccurate diagnosisAccurate diagnosisHistological gradeHistological grade

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY

Total excision of the tract Longitudinal incision

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Work through muscle not anatomical plane

Oval window

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

RESTAGING AFTER PRE OP RESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY

Indicators for favorable responseIndicators for favorable response tumor volumetumor volume

in angiographic vascularityin angiographic vascularity

Changes in plain X-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance

PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

PRINCIPLESPRINCIPLES Resection of tumorResection of tumor

Skeletal reconstructionSkeletal reconstruction

Soft tissue amp muscle transferSoft tissue amp muscle transfer

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

RESECTIONRESECTION

SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional

MarginalMarginal

Wide resectionWide resection

Radical resectionRadical resection

(As described by Enneking)

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial

For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate

In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Tumor resection Margin Curetting of the tumor site

Burring of the resected tumor site Lavaging with Adjuvants amp curetting

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

SURGICAL ADJUVANTSSURGICAL ADJUVANTS Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard Merthiolate HypertonicNitrogen mustard Merthiolate Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of bone Bisphosphonates in Giant cell tumor of bone

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant

RadiotherapyRadiotherapy Immunotherapy Immunotherapy Specific ndash Active and PassiveSpecific ndash Active and Passive Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

RECONSTRUCTIONRECONSTRUCTION

ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to

replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint

Modified hinge designModified hinge design

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

PRE ndash OPERATIVE WORK-UPPRE ndash OPERATIVE WORK-UP

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Proximal femoral prosthesis Saddle prosthesis

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Proximal humeral prosthesis

Proximal tibial prosthesis Distal femoralprosthesis

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

MATERIAL1 Titanium

2 Cobalt ndash chromium - molybdeneum

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

TUMORS INVOLVING THE HIP

These patients may need excision of proximal femur and the pelvis depending on the extent of involvement of the tumor

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

Tumor involving proximal tibiaResection of tibia with femur will be needed in these cases

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

COMPLICATIONS1 soft-tissue failure (type I)2 aseptic loosening (type II) 3 structural failure (type III) 4 infection (type IV) 5 and tumor progression (type V)

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE

Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograft allograft

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY

HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or

ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or

ReconstructionReconstruction

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY

ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or ReconstructionReconstruction

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN RotationplastyRotationplasty Tibial turn upTibial turn up ( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable prosthesisprosthesis

Michael D Neel etal Cancer control Aug 2001

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

CONCLUSIONCONCLUSION Limb salvage has become accepted standard care of Limb salvage has become accepted standard care of

the patients with malignant bone tumorsthe patients with malignant bone tumors Success depends on prompt and early referral by Success depends on prompt and early referral by

primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated sequencing of eventssequencing of events

Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low rate of local recurrence is paramount rate of local recurrence is paramount

Multidisciplinary approach is requiredMultidisciplinary approach is required

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67

• Tumor Mega - Prosthesis
• PowerPoint Presentation
• HISTORY
• TNM CLASSIFICATION
• HISTOPATHOLOGICAL GRADING
• ENNEKING STAGING
• WHO HISTOLOGICAL CLASSIFICATION
• PRINCIPLES OF LIMB SALVAGE SURGERY
• DEFINITION
• HISTORY AND CHANGING TREND
• INDICATION
• BARRIERS TO LIMB SALVAGE
• Slide 13
• Slide 14
• GOAL
• SUCCESS
• STAGING
• RADIOLOGICAL STAGING
• RADIOGRAPHY
• CT SCAN
• MRI
• ANGIOGRAPHY
• SCINTIGRAPHY
• PET SCAN
• SURGICAL STAGING
• PRINCIPLES OF BIOPSY
• Slide 27
• RESTAGING AFTER PRE OP ADJUVANT THERAPY
• PRINCIPLES
• RESECTION
• Slide 31
• Slide 32
• SURGICAL ADJUVANTS
• Slide 34
• RECONSTRUCTION
• ENDOPROSTHESIS
• PRE ndash OPERATIVE WORK-UP
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• ALLOGRAFT PROSTHETIC COMPOSITE
• Slide 62
• LIMB SALVAGE IN UPPER EXTREMITY
• LIMB SALVAGE IN LOWER EXTREMITY
• LIMB SALVAGE IN CHIDREN
• CONCLUSION
• Slide 67