CASE MANAGEMENT, CASE MANAGEMENT, PRESENTATION, DISCUSSION PRESENTATION, DISCUSSION AND SHARING OF INFORMATION AND SHARING OF INFORMATION ON EXTREMITY SARCOMAS ON EXTREMITY SARCOMAS by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center
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CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON EXTREMITY SARCOMAS by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital.
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CASE MANAGEMENT, CASE MANAGEMENT, PRESENTATION, DISCUSSION PRESENTATION, DISCUSSION
AND SHARING OF AND SHARING OF INFORMATION ON INFORMATION ON
EXTREMITY SARCOMASEXTREMITY SARCOMAS
byMichael Angelo L. Suñaz, M.D.
Department of SurgeryOspital ng Maynila Medical Center
CASE MANAGEMENT, CASE MANAGEMENT, PRESENTATION, DISCUSSIONPRESENTATION, DISCUSSION
E.A., 63/ME.A., 63/MBINAN, LAGUNABINAN, LAGUNA
CHIEF COMPLAINT: NON-HEALING WOUND ON THE RIGHT GLUTEAL
AREA
HISTORY OF PRESENT ILLNESS:HISTORY OF PRESENT ILLNESS:
4 months PTA, the patient noted a pimple-like lesion on his right gluteal area. No other associated signs and symptoms were noted.
HISTORY OF PRESENT ILLNESS:HISTORY OF PRESENT ILLNESS:
3 ½ months PTA, the mass was noted to have increased in size. Consultation of a private physician was done and he was prescribed with unrecalled medications which afforded no relief.
HISTORY OF PRESENT ILLNESS:HISTORY OF PRESENT ILLNESS:
2 weeks PTA, the mass persisted and was now associated with occasional pain and undocumented fever.
HISTORY OF PRESENT ILLNESS:HISTORY OF PRESENT ILLNESS:
Persistence of his condition prompted consultation and subsequent admission.
PAST MEDICAL Hx:
unremarkable
FAMILY Hx:
HPN - paternal side
PERSONAL/SOCIAL Hx:
- no history of smoking or alcoholic beverage intake
PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:
G/S: conscious, coherent, not in cardiorespiratory distress
BP= 120/70 CR=83 RR= 19 T=38.20C
SHEENT: no jaundice; pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPC
PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:
C/L: SCE, no retractions, clear BS
CVS: adynamic precordium, NRRR, no murmur
Abdomen: flat; soft; no palpable masses
PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:
Extremities: 10 x 13 cm firm, slightly movable, ulcerating mass, tender only upon deep palpation towards the right gluteal area
SALIENT FEATURES:SALIENT FEATURES:63 y/o, M10x13 cm firm, slightly movable,
rapidly growing ulcerating mass tender only upon deep palpation towards the right gluteal area
Occasional pain on the affected area Fever (38.20C)
10x13 cm firm, nontender, slightly movable, rapidly growing ulcerating
mass on the right gluteal area
10x13 cm firm, nontender, slightly movable, rapidly growing ulcerating
mass on the right gluteal area
•Rapidly growing
•With associated fever
•Tenderness only upon deep palpation in the direction of the gluteal area
10x13 cm firm, nontender, slightly movable, rapidly growing ulcerating
mass on the right gluteal area
•Rapidly growing
•With associated fever
•Tenderness only upon deep palpation in the direction of the gluteal area
Infectious Neoplastic
Clinical Diagnosis:Clinical Diagnosis:
Diagnosis Certainty Treatment
Neoplastic Disease
75% Surgical
Infectious Disease
25% Surgical/
Medical
BASES:BASES:63 y/o, M10x13 cm firm, slightly movable,
rapidly growing ulcerating mass tender only upon deep palpation towards the right gluteal area
Occasional pain on the affected areaFever (38.20C)
Do I need a para-clinical diagnostic Do I need a para-clinical diagnostic procedure?procedure?
Can provide a histopathologic diagnosis to determine the primary treatment of the lesion.
Bleeding
Pain+
Readily available
MRI
Accurately delineates muscle groups and distinguishes between bone, vascular structures, and tumor. Sagittal and coronal views allow 3D evaluation of anatomical compartments.1
none ++++Not readily available
CT SCAN
Provide detailed survey of the abdomen and pelvis and delineate adjacent organs and vascular structures.1
CT Scan of the Pelvis (9/29/08)– A mixed density mass with areas of
necrosis is seen arising from the right gluteus maximus muscle infiltrating into the subcutaneous fat measuring about 14 x 12.25 x 9.26 (CC x W x AP). The mass displaces the anal opening to the left.
Microscopic Microsections disclose loose aggregates of
malignant round cells exhibiting marked hyperchromasia, anisoneuclosis and prominent nucleoli. These have marked eosinophilia and moderate polymorphism. Some tumor giant cells are seen. These are admixed with necrotic and inflammatory material.
Size of the pre-operative radiation fields and the number of joints included in the field are significantly smaller which may result in an improved functional outcome.1
Statistically significant improvements in local recurrence, distal recurrence,and disease-free survival rates ranging from 6%-10%. 4% improvement in overall survival.2
Ability to assess tumor responsiveness to the give chemo-therapeutic agents, early treatment of metastatic disease, and downstaging of primary tumor.2
Potential toxicity ++++ Available
TREATMENT OF CHOICETREATMENT OF CHOICE
WIDE RESECTION AND POST-OPERATIVE RADIATION THERAPY
PREOPERATIVE PREPARATIONPREOPERATIVE PREPARATION
Informed consentPsychosocial supportOptimize patient’s healthScreen for any condition that will
interfere with treatmentPrepare materials
OPERATIVE TECHNIQUEOPERATIVE TECHNIQUE
Patient supine under CLEA Asepsis/Antisepsis Sterile drapes placed Intraoperative findings noted: Mass noted
to have extended partially to the serosal layer of the rectum and outermost layer of the sphincter muscle. Gluteus maximus muscle mass and sciatic nerve intact.
OPERATIVE TECHNIQUEOPERATIVE TECHNIQUE
Wide excision with 1 cm margin; flap created.
HemostasisPlacement of drainCorrect sponge and instrument
countApposition of flap with silk 2-0Dry sterile dressing
OPERATION DONE:OPERATION DONE:
WIDE RESECTION OF RIGHT GLUTEAL MASS
POST OPERATIVE DIAGNOSISPOST OPERATIVE DIAGNOSIS
Malignant round cell tumor (liposarcoma), right gluteal area
*Final histopathology report still pending
SHARING OF INFORMATIONSHARING OF INFORMATION
SARCOMASSARCOMAS
Refer to tumors that show evidence of mesenchymal differentiation.
1% of adult malignancies 15% of pediatric malignancies
Tx – primary tumor cannot be assessed T0 – no evidence of primary tumor T1 – tumor is < or equal to 5 cm in its
greatest dimension• T1a – tumor is above the superficial fascia• T1b – tumor invading or deep to the superficial
fascia
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
EXTREMITY SARCOMASEXTREMITY SARCOMAS
Staging– Primary Tumor (T)
T1 – tumor is > 5 cm in its greatest dimension
• T2a – tumor is above the superficial fascia• T2b – tumor invading or deep to the
superficial fascia
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
EXTREMITY SARCOMASEXTREMITY SARCOMAS
Distant Metastasis (M)– Mx – distant metastasis cannot be
assessed– M0 – no distant mmetastasis– M1 – distant metastasis
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
EXTREMITY SARCOMASEXTREMITY SARCOMAS
Stage Grouping– Stage 1
A – G1-2, T1a-1b, N0, M0 B – G1-2, T2a, N0,M0
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
EXTREMITY SARCOMASEXTREMITY SARCOMAS
Stage Grouping– Stage II
A – G1-2, T2b, N0, M0 B – G3-4, T1a-1b, N0,M0 C – G3-4, T2a, N0,M0
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
EXTREMITY SARCOMASEXTREMITY SARCOMAS
Stage Grouping– Stage III
G3-4, T2b, N0,M0
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
EXTREMITY SARCOMASEXTREMITY SARCOMAS
Stage Grouping– Stage IV
Any G, Any T, N1, M0 Any G, Any T, N0, M1
• Delamn KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
Size of the pre-operative radiation fields and the number of joints included in the field are significantly smaller which may result in an improved functional outcome.1
Statistically significant improvements in local recurrence, distal recurrence,and disease-free survival rates ranging from 6%-10%. 4% improvement in overall survival.2
Ability to assess tumor responsiveness to the give chemo-therapeutic agents, early treatment of metastatic disease, and downstaging of primary tumor.2
Potential toxicity ++++ Available
MCQMCQ
1. Sarcomas comprise how much of adult malignancies?
a. 1%
b. 3%
c. 15%
d. 20%
MCQMCQ
1. Sarcomas comprise how much of adult malignancies?
a. 1%
b. 3%
c. 15%
d. 20%
MCQMCQ
2. Sarcomas comprise how much of pediatric malignancies?
a. 1%
b. 3%
c. 15%
d. 20%
MCQMCQ
2. Sarcomas comprise how much of pediatric malignancies?
a. 1%
b. 3%
c. 15%
d. 20%
MCQMCQ
3. Extremity sarcomas comprise how much of adult sarcomas?
a. 10%
b. 30%
c. 50%
d. 20%
MCQMCQ
3. Extremity sarcomas comprise how much of adult sarcomas?
a. 10%
b. 30%
c. 50%
d. 20%
MCRMCR
A – 1, 2, and 3 are correctB – 1 and 3 are correctC – 2 and 4 are correctD – only 4 is correct E – none are correct
MCRMCR
I. Which of the following represents stage I soft-tissue sarcoma?1. G1-2, T1a-T1b, N0,M02. G1-2, T2b, N0, M03. G1-2, T2a, N0,M04. Any G, Any T, N1, M0
MCRMCR
I. Which of the following represents stage I soft-tissue sarcoma?1. G1-2, T1a-T1b, N0,M02. G1-2, T2b, N0, M03. G1-2, T2a, N0,M04. Any G, Any T, N1, M0
MCRMCR
I. Which of the following represents stage III soft-tissue sarcoma?1. G1-2, T1a-T1b, N0,M02. G1-2, T2b, N0, M03. G3-4, T2a, N0,M04. G3-4, T2b, N0, M0
MCRMCR
I. Which of the following represents stage III soft-tissue sarcoma?1. G1-2, T1a-T1b, N0,M02. G1-2, T2b, N0, M03. G3-4, T2a, N0,M04. G3-4, T2b, N0, M0
THANK YOU!!!
REFERENCESREFERENCES
Delman KA, Cormier JN: Soft-tissue and bone sarcoma, in Feig BW, Berger DH, Fuhrman GM (ed): The M.D. Anderson Surgical Oncology Handbook 4th ed . Philadelphia, Lippincott Williams and Wilkins, 2006, pp 125
Singer S, Canter RJ: Soft-tissue sarcoma, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 1101-1105
Spinal metastases from myxoid Spinal metastases from myxoid liposarcoma warrant screening with liposarcoma warrant screening with magnetic resonance imagingmagnetic resonance imaging
Joseph H. Schwab, MDJoseph H. Schwab, MD 1 1, Patrick J. Boland, MD, Patrick J. Boland, MD 1 1, Cristina Antonescu, , Cristina Antonescu, MDMD 2 2, Mark H. Bilsky, MD, Mark H. Bilsky, MD 3 3, John H. Healey, MD, John H. Healey, MD 1 * 1 *
11Department of Surgery, Orthopedic Service, Memorial Sloan-Department of Surgery, Orthopedic Service, Memorial Sloan-Kettering Cancer Center, New York, New YorkKettering Cancer Center, New York, New York22Department of Pathology, Memorial Sloan- Kettering Cancer Center, Department of Pathology, Memorial Sloan- Kettering Cancer Center, New York, New YorkNew York, New York33Department of Surgery, Orthopedic and Neurosurgery Services, Department of Surgery, Orthopedic and Neurosurgery Services, Memorial Sloan-Kettering Cancer Center and Medical College of Memorial Sloan-Kettering Cancer Center and Medical College of Cornell University, New York, New YorkCornell University, New York, New York
email: John H. Healey (email: John H. Healey (healeyjhealeyj@@mskccmskcc.org.org))**Correspondence to John H. Healey, Department of Surgery, Correspondence to John H. Healey, Department of Surgery, Orthopedic Service, Memorial Sloan-Kettering Cancer Center, 1275 Orthopedic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Suite A342, New York, NY 10021York Avenue, Suite A342, New York, NY 10021
unusual tendency for extrapulmonary metastasis, particularly to the spine and soft tissues. The objective of this study was to determine the prevalence of spinal metastasis, treatment outcomes, and optimal screening method for spinal metastasis in patients with MLS.
ABSTRACTABSTRACT
Methods:– Data from patients with had spinal metastases
were obtained from the authors' institutional soft tissue sarcoma database. The accuracy with which positron emission tomography (PET) scans and bone scans identified metastatic lesions was compared with the accuracy of magnetic resonance imaging (MRI). Clinical response to treatment was based on pain, neurologic scores, and survivorship analysis.
ABSTRACTABSTRACT
Results:– There were 33 patients who developed
spinal metastasis after a median 36 months of follow-up (range, from 7.5 months to 33 years). Known spinal metastases were detected by bone scans in 16% of patients and by PET scans in 14% of patients.
ABSTRACTABSTRACT
Results:– Patients who underwent surgery had high-
grade spinal cord compression more often than patients who did not undergo surgery (72% vs 19%, respectively; P = .002). Pain and neurologic function were improved or maintained in all patients who received radiation alone (n = 8 patients) and in all but 1 patient who underwent surgery (n = 18 patients). The median overall survival was 51.4 months from the time of primary diagnosis and 21.9 months from the time of first metastasis.