1. Night pain
2. Onset of swelling, pain

• 1-2d onset: vascular event, infection
• Months: malig process
• Years: benign
• If chance in size over months: malignant change in prev benign lesion

1. Constitutional symptoms
2. Wt loss, fever, etc

1. Swelling (description): medial, lateral, anterior, posterior

• In femur, tibia, knee jt
• Skin, subcut, deep fascia, m's, bone

1. Site, size, depth, borders (definite, obscure)

• Pulsatile, transiluminate (IPPA)
• Size matters with tumours (if >5-6cm: consider as potentially malignancy; esp. with Hx of change in size; esp. if deep)

1. Lymphadenopathy

• Regional metastasis

1. Abdomen

• Hepatomegaly in case of metastases

1. Chest

• Listen
• CXR

1. Signs of infection

• Eg. Indolent infection (like TB)

Tumours are graded not only on their cytological appearance but also on their clinical behaviour (ie. Likelihood of recurrence and spread after surgical removal)

• Benign/ latent (eg. Bone non-ossifying fibroma, ST lipoma)
• Benign/ active: can grow locally with time, but never metastasise (eg. Bone aneurysmal bone cyst, ST angiolipoma)
• Benign/ aggressive: grow aggressively locally, but never metastasise (eg. Bone Giant-cell tumour, ST aggressive fibromatosis)

Grade 1 = Malig low-grade (eg. Bone paraosteal osteosarcoma, ST myxoid liposarcoma)

• If tumour has malig low-grade -> biopsy (if within quads) = malignant low-grade ST tissue intra-compartmental

Grade 2 = Malig hi-grade (eg. Bone classic osteosarcoma, ST malignant fibrous histiocytoma)

• If extensive, eg. Involves quads and adductors - inv 2 compartments ("extra-compartmental)

A = intracompartmental

B = extracompartmental

1. Intracapsular excision: aka intra-lesional, curettage (eg. Benign lesion)

2. Marginal excision: (en bloc removal of tumour through reactive zone)

• eg. Benign - angiolipoma, aggressive fibromatosis) may be adequate
• Tumours cells always present in reactive zone
• Inadequate for malig (even low-grade) lesions

• En bloc removal of tumour reactive zone, surrounding margin of normal tissue (normal cup) (eg. Myxoid liposarcoma) b/c lesion will recur if marginal excision
• As wide as surrounding tissue will allow

• Eg. En block removal of entire tissue (bone, muscle compartment)
• Eg. Quads: may excise whole quadriceps (compartmental resection) - clears of tumour but v damaging
• Previously method of choice for high-grade malignant tumours (before adjunct Tx available)

• ESR
• CBP
• RLFT: liver metastasis
• LDH
• Ca

Suspect malignancy because of size of lump (check regional + distant metastases)

• MRI
• CXR (not very sensitive)
• CT thorax + abdomen (metastasis, liver mass)
• Bone scan (metastasised to skeleton?)

SLIDE: X-RAY KNEE

• Huge swelling in distal thigh: bony outgrowth from (location) metaphysis of distal femur, surrounding whole distal femur circumferentially
• Pattern: Sunray appearance? Cauliflower?
• Describe X-ray: AP/ lateral, region (eg. Knee including distal femur + proximal tibia)

• Yes - have regional description, performed distant investigations to exclude metastases

1. Fine needle aspirate for cytology

• Ads: minimally invasive
• Disadv: gives cells cytology (not tissue architecture)

1. Trucut (core biopsy): "apple-corer" punch into tissue (2mm W x 5mm L core of tissue), no suture necessary

• Ads: gives tissue architecture, usu. adequate
• Disadv: some pathologists not satisfied

1. Incisional biopsy: cut lesion open, obtain block of tissue (usu. 1 cm block), done by person who is going to perform the definitive surgery (have to incorporate incisional site in surgical site b/c contaminated with tumour cells)

• Disadv: invasive

1. Excisional biopsy: only if benign lesion

1. Oncologist: chemo + rad will help osteosarcoma (if not, osteosarcoma without chemo will not survive > 2y, even with amputation)
2. Social worker
3. Psychologist
4. Prosthetist: makes prosthesis

• If lipoma, can do marginal excision, may be safer to do
• This Pt: osteosarcoma
• If pre-op chemo response favourable -> wide excision, chemo, tumour prosthesis
• (Note; osteosarcoma usu. responds well to chemotherapy)
• If pre-op chemo no cytological and clinical response -> radical resection/ amputation

• Describe swelling
• Systemic examination - other symptoms
• LN

• As above

PART B - STAGING & TREATMENT'

• MRI
• X-ray
• Define whether within compartment,, closeness to BV and nerves, extra-compartmental?
• Exclude distant metastasis: CT thorax/ ab, bone scan

• Trucut and incisional biopsy similar - have tissue
• Fine needle does not give architecture (if cytologists are really good, can rely on aspiration) - but QMH should use Trucut?!
• Cob biopsy: if trucut of bone
• In general, tissue Dx is best (Trucut)

• Liposarcoma = low-grade malignant tumour (malignant = can metastasise)
• Option = wide excision (b/c of large size of tumour, margin cannot be that big, maybe only 2cm cup of normal tissue)
• Tx = wide excision plus intra-operative placement of brachytherapy, plus/minus external radiation later on
• For ST tumour, always consider inserting brachytherapy tubes (after operation, oncologist will pour radioactive substance through these tubes b/c radioactive substances can only kill off tumours within 1 cm)
• (Brachy = short, therapy = Tx)
• Performed in leaded Tx room
• For malignant ST tumour in MSS, wide excision combined with brachyradiotherapy is very effective
• For liposarcoma, chemotherapy is useless

• Oncologist
• Community nurse
• Social worker
• Psychologist