Evaluation of Pathologic Lesions

Stephen BecherAtlanta Medical Center

1 – Decide your comfort level

Relationships are key• Radiation oncology• Medical oncology• Pathology• Palliative Care – know when it is time to

STOP intervening

• Co-ordination is key

Main object is to avoid contaminating a field that needs resection.• Be prepared for transfer to a

sarcoma center• "Do no harm"

2 – Determine the nature of the lesion

• Age > 40 – Mets Mets Mets• Bony Lesion/Mass vs. Soft tissue

lesion/Lump• Patience is key with oncologic

workup• Know the diagnosis prior to any

surgical stabilization• Wait for final histologic analysis if

needed

2 – Determine the nature of the lesion

• History and Physical is important• BLTKP - Breast, RCC, Thyroid, Lung and

Prostate • Any breast lumps, last mammography• Any throat lumps, history of cold/heat

intolerance• Dysuria, Hematuria• Cough, Hemotypsis, History of smoking• Any oncologic history – even remote: Prior

melanomas excised, had a plasmacytoma 10 years ago, was "cured" of breast cancer 20 years ago, etc.

2 – Determine the nature of the lesion

• X-Rays of the lesion• MRI vs. CT of the lesion • Bone Scan vs. PET

• Bone scan can be cold in up to 30% of myeloma

• PET scan can see metastatic lesions in soft tissue in addition to bone

• Bone scan is the traditional test obtained

• CT of the Chest/Abdomen/Pelvis• Lab tests – CBC, CMP, SPEP/UPEP,

PSA

2 – Determine the nature of the lesion

• Biopsy: A time-out• An old adage is the person to biopsy should

be the person to treat• All biopsies should be made with a thought to

a histologic diagnosis requiring excision of the biopsy tract

• If the pathologist waffles on frozen, close up and wait for final – have this discussion with the patient prior to surgery.

• Biopsy principles• As small an incision as necessary• In line with limb, any drains in line with

incision• In line with any incision needed for full

resection• Sharp dissection straight down to

lesion• Avoid contamination of multiple

compartments• Frozen section – discuss if adequate

tissue is had for permanent section• Good hemostasis and closure

3 – Surgical Stabilization

• Goals should be• Palliation of fracture pain through

stabilization of fragments• Ability for as much weight bearing as

soon as possible – early mobility is key• As durable a construct as possible:

keep in mind pathologic bone does not heal as reliably as physiologic bone• Interlocking• Cemented rather than press fit

prosthesis• Longer stems for prophylaxis of bone• PMMA as adjunct for bone loss• Locked plating rather than relying on

Absolute stability

4 – Ensure appropriate adjuvant treatments

• Any metastatic, myleoma lesion will need adjuvant radiation• Referral to radiation oncology is key• May wish to wait 2-3 weeks to allow soft

tissues to heal prior to radiation

• Referral to medical oncology for medical management of disease• Stage IV cancer in the modern era is

mostly a chronically managed disease• Durability of construct is important for this

reason

Example Case

• 50 year old male, 3 month history of right hip pain.• Treated for troch bursitis with normal x-ray

2 months ago• Increased pain and inability to ambulate

after getting up from toilet• 30 Pack year history of smoking• No hematuria, no thyroid nodules• FNF seen in ED

• 1 – Decide MY comfort level

2 – Determine the nature of the Lesion

Lesions in proximal Femur, Femoral Neck (broken) and Pelvis

Mass in Lung with associated adenopathy

2 – Determine the nature of the lesion

CT rather than MRI due to patient pain Biopsy - Transtrochanteric

3 – Surgical Stabilization4 – Adjuvant Treatments coordinated

Thanks for your attention