Orthopedics

Interview 

Musculoskeletal Tumors

Bennie G.P. Lindeque, MD

Abstract

Dr Lindeque is from the Department of Orthopaedics, University of Colorado, Aurora, Colorado.

Dr Lindeque has no relevant financial relationships to disclose.

Correspondence should be addressed to: Bennie G.P. Lindeque, MD, Department of Orthopaedics, University of Colorado, 12631 E 17th Ave, Ste 4600, Campus Box B202, Aurora, CO 80045-2527 (bennie.lindeque@ucdenver.edu).

My specialty is major reconstruction of the periacetabular and knee regions using modern metallurgical modular tumor prostheses.

We have made progress by leaps and bounds in the past 5 years regarding metallo osseous integration techniques. In simple terms, this means that the binding of the megaprosthesis to the bone is more efficient today than it was 10 years ago. That allows us the opportunity to use these modular prostheses with much less bone available for the reconstruction. Furthermore, active research is in progress regarding antibiotic coatings on the megaprosthesis to further decrease infection rates.

Unfortunately, no symptoms or signs may present initially. It is only when tumors start to become reasonably large in size or when they compromise the biomechanical integrity of the bone that symptoms appear. These usually include pain, specifically worsening pain and night pain. Unfortunately, these are relatively late signs. Occasionally, we are fortunate enough to make a diagnosis by accident when radiographic modalities are used for other reasons.

The way to diagnosis these conditions is to concentrate the clinical examination on an area of symptoms and signs. The most important radiographic modality in the diagnosis of bone tumors is still the radiograph, followed by magnetic resonance imaging (MRI) and computed tomography scans. In terms of diagnosing multiple tumor sites for metastatic disease, bone scans and positron emission tomography scans are invaluable. Soft tissue tumors are usually diagnosed with MRI scans.

Plain radiographs usually give us a good lead to the diagnosis of a bone tumor or at least the differential diagnosis of a bone tumor. Magnetic resonance imaging scans are valuable to differentiate cystic from solid soft tissue tumors. Again, this helps us differentiate benign and malignant lesions. In terms of treatment, MRI scans are accurate in delineating the anatomical extent of a tumor, which makes it easier for us to plan a complete excision of this tumor.

Sex and age are the 2 most important determinants in achieving a correct diagnosis. For example, the differential diagnosis for a 55-year-old woman with a lump in her breast and excruciating back pain would be metastatic breast carcinoma, and the diagnosis for a 70-year-old man with urinary retentive symptoms with excruciating back pain would be metastatic prostrate carcinoma. An 18-year-old adolescent with pain in the proximal tibia and progressive swelling would suggest an osteosarcoma.

In terms of benign tumors, most often extended curettage complemented with cementation or bone grafts would suffice. It is only rarely necessary to completely excise a benign tumor and leave a major bone defect. In terms of malignant tumors, we use a combination of surgery, chemotherapy, and radiation therapy. Primary malignant bone tumors are treated with neoadjuvant chemotherapy, followed by surgery and more chemotherapy. Metastatic bone disease is treated most often with a combination of chemotherapy, radiation therapy, surgery, and radiofrequency ablation. Pending pathological fractures are best treated with surgical stabilization to prevent a catastrophic fracture.

Childhood tumors are usually of different cell types depending on the age of the child and pose unique reconstructive challenges. This occurs because children are still growing and the reconstruction needs to accommodate the growth of the limb involved. Most of the malignant bone tumors in children will be treated by combination bone therapies. A unique factor about children is that they have tremendous healing potential.

The most…

Dr Lindeque is from the Department of Orthopaedics, University of Colorado, Aurora, Colorado.

Dr Lindeque has no relevant financial relationships to disclose.

Correspondence should be addressed to: Bennie G.P. Lindeque, MD, Department of Orthopaedics, University of Colorado, 12631 E 17th Ave, Ste 4600, Campus Box B202, Aurora, CO 80045-2527 (bennie.lindeque@ucdenver.edu).

What is Your Specialty in Orthopedic Oncology?

My specialty is major reconstruction of the periacetabular and knee regions using modern metallurgical modular tumor prostheses.

What Progress Has Been Made in Developing Implants and Prostheses for Your Specialty Area?

We have made progress by leaps and bounds in the past 5 years regarding metallo osseous integration techniques. In simple terms, this means that the binding of the megaprosthesis to the bone is more efficient today than it was 10 years ago. That allows us the opportunity to use these modular prostheses with much less bone available for the reconstruction. Furthermore, active research is in progress regarding antibiotic coatings on the megaprosthesis to further decrease infection rates.

What Are the Symptoms of Musculoskeletal Tumors?

Unfortunately, no symptoms or signs may present initially. It is only when tumors start to become reasonably large in size or when they compromise the biomechanical integrity of the bone that symptoms appear. These usually include pain, specifically worsening pain and night pain. Unfortunately, these are relatively late signs. Occasionally, we are fortunate enough to make a diagnosis by accident when radiographic modalities are used for other reasons.

How Do You Diagnose Musculoskeletal Tumors?

The way to diagnosis these conditions is to concentrate the clinical examination on an area of symptoms and signs. The most important radiographic modality in the diagnosis of bone tumors is still the radiograph, followed by magnetic resonance imaging (MRI) and computed tomography scans. In terms of diagnosing multiple tumor sites for metastatic disease, bone scans and positron emission tomography scans are invaluable. Soft tissue tumors are usually diagnosed with MRI scans.

What Role Does Imaging Play in the Diagnosis or Treatment of Musculoskeletal Tumors?

Plain radiographs usually give us a good lead to the diagnosis of a bone tumor or at least the differential diagnosis of a bone tumor. Magnetic resonance imaging scans are valuable to differentiate cystic from solid soft tissue tumors. Again, this helps us differentiate benign and malignant lesions. In terms of treatment, MRI scans are accurate in delineating the anatomical extent of a tumor, which makes it easier for us to plan a complete excision of this tumor.

What Role Do a Patient’s Demographics Play in the Diagnosis of Musculoskeletal Tumors?

Sex and age are the 2 most important determinants in achieving a correct diagnosis. For example, the differential diagnosis for a 55-year-old woman with a lump in her breast and excruciating back pain would be metastatic breast carcinoma, and the diagnosis for a 70-year-old man with urinary retentive symptoms with excruciating back pain would be metastatic prostrate carcinoma. An 18-year-old adolescent with pain in the proximal tibia and progressive swelling would suggest an osteosarcoma.

Describe the Most Common Treatment Options for Musculoskeletal Tumors

In terms of benign tumors, most often extended curettage complemented with cementation or bone grafts would suffice. It is only rarely necessary to completely excise a benign tumor and leave a major bone defect. In terms of malignant tumors, we use a combination of surgery, chemotherapy, and radiation therapy. Primary malignant bone tumors are treated with neoadjuvant chemotherapy, followed by surgery and more chemotherapy. Metastatic bone disease is treated most often with a combination of chemotherapy, radiation therapy, surgery, and radiofrequency ablation. Pending pathological fractures are best treated with surgical stabilization to prevent a catastrophic fracture.

Do Tumors in Adolescents Require Different Treatments?

Childhood tumors are usually of different cell types depending on the age of the child and pose unique reconstructive challenges. This occurs because children are still growing and the reconstruction needs to accommodate the growth of the limb involved. Most of the malignant bone tumors in children will be treated by combination bone therapies. A unique factor about children is that they have tremendous healing potential.

What is Today’s Expected Rate of Survival for Patients with Various Musculoskeletal Tumors

The most common tumors include osteosarcoma and Ewing’s sarcoma. The 5-year survival rate of osteosarcoma is approximately 70% and that of Ewing’s sarcoma is approximately 65%.

What Does the Future Hold for the Treatment of Musculoskeletal Tumors?

The future of treating malignant musculoskeletal tumors lies in finding even more effective chemotherapy drugs and possible immune therapy modalities. Genetic manipulation of the tumor also lies in the future. Modern metallurgical prosthetic devises should also be improved to accommodate the long-term survival of children with cancer.

In this issue of ORTHOPEDICS, Dr Bennie Lindeque discusses the progress made in the treatment of musculoskeletal tumors and the role of imaging in their diagnosis.

Authors

Dr Lindeque is from the Department of Orthopaedics, University of Colorado, Aurora, Colorado.

Dr Lindeque has no relevant financial relationships to disclose.

Correspondence should be addressed to: Bennie G.P. Lindeque, MD, Department of Orthopaedics, University of Colorado, 12631 E 17th Ave, Ste 4600, Campus Box B202, Aurora, CO 80045-2527 ().bennie.lindeque@ucdenver.edu

10.3928/01477447-20120222-06

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