A tumor is a "lump" a portion of tissue that is formed when cells divide uncontrollably. Unaware of the causes of the appearance of most bone tumors. A growing tumor may replace healthy tissue with abnormal tissue. This can weaken the bone, leading to fractures. Most tumors are benign. Some are malignant. Occasionally, there are infections, stress fractures and other conditions with symptoms similar to those of tumors (lesions pseudotumors). Cancer that begins in the bone (primary bone cancer) is different from cancer that begins in another part of the body and spreads to bone (secondary or metastatic bone canceo).
Treatment
Radiograph
Plain radiographs provide more general information about the tumor. This information, combined with clinical presentation, give some idea about primary versus metastatic tumors and malignant versus benign.
The radiograph demonstrates the bone and the area involved, the extent and type of destruction of bone addition reaction. It is also important to study the type of matrix involved. A radiolucent lesion subtrochanteric bone formation with little reaction in a woman 60 years may suggest a metastatic tumor. In contrast, a destructive lesion in the distal femur in a patient 12 years of age with osteogenesis suggests a primary osteosarcoma.
However, approximately 20% of patients, neither the pediatrician nor the radiologist detect early tumor on radiographs. One of the main factors leading to non-diagnosis is the poor quality of the radiographs. Radiographic signs of tumors, though well known, are often "no" - valued. They include ill-defined areas of radio-lucency or sclerosis radio, sub-periosteal new bone formation, cortical destruction and increase in underlying soft tissue injuries.
A radiograph of the opposite side for comparison is easy to perform and always help. Especially in children, where the presence of nuclei of ossification difficult to interpret, the contra-lateral radiograph is of great value.
Mapping bone
Skeletal scintigraphy is performed more frequently with phosphonate labeled with technetium 99-m. This radioisotope is incorporated into bone formation. There is also an increased concentration of radioisotopes in the areas of increased vascularity. The two main functions of this study is the estimation of the local extent of the intramedullary tumor and a demonstration of other skeletal areas involved.
In assessing the tumor site, the extent and intensity of increasing concentration can provide information about the biological aggressiveness of the tumor.
Scintigraphy is also of particular value in the diagnosis of metastases fried, mainly in the initial phase when they are small in size and, in general, are not visualized on radiographs.
Scintigraphy of the skeleton remains, despite new methods of diagnosis, the most reliable technique for early diagnosis and demonstration of bone metastases.
Computed tomography
Since computed tomography is now readily available in our environment, experience with its use is increasing every day. The TAC has been helping in the diagnosis of malignant lesions primarily by its ability to identify small lung metastases, unobserved through conventional radiography and tomography.
The contrast in CT helps in identifying the major neurovascular structures as well as the enhancement of well-vascularized lesions, and demonstrate relationships between the tumor and the adjacent soft tissues, and is also the best method for assessing the impairment of cortical and other details bone. It is also extremely valuable in assessing the calcification and ossification of the matrix.
Nowadays, with the advent of helical CT, the examination can be performed in minutes, avoiding general anesthesia in children.
MRI
MRI is the latest advance in diagnostic imaging of musculoskeletal tumors and added important advantages to staging. In our opinion, MRI and CT scans are complementary and should, if possible, be used together.
The study of a bone tumor by MRI images includes axial T1 and T2 and a set of images on the longitudinal or sagittal plane front.
MRI consider the most accurate method for evaluating the extent of intra and extramedullary bone cancer. This longitudinal T1 is great for demonstrating this relationship. In T1, the neoplastic tissue demonstrates in most tumors, a decrease in signal intensity as compared with the high signal strength of the intramedullary fat. The striking contrast between the signals of fat and neoplastic tissue makes MRI the best method to study the extent of intra and extramedullary bone tumor.
Arteriography
The primary indication for arteriography is in difficult anatomical regions, such as the pelvic and shoulder girdles. It is also useful in the preoperative evaluation of tumors undergoing limb sparing surgery, in which the vascular-nervous bundle must be sacrificed and rebuilt because of the involvement caused by the tumor. The same happens in the preoperative evaluation of extremities that will undergo microsurgery.
We can not forget the use of angiography in the treatment of bone tumors, where often it is used for placement of the catheter near the tumor and subsequent infusion of intra-arterial chemotherapy.
Due to its technical difficulty and risks inherent in the examination, rarely use this method for diagnosis in children. Its use is restricted to cases where we perform therapeutic embolization.
Study of tumor response to chemotherapy
Radiographic changes considered as the most significant evidence of tumor response to chemotherapy are:
§ reduction of tumor volume;
§ decreased vascularity and angiographic
§ changes planar radiography, CT and MRI showing bone formation reaction at the periphery of the tumor, together with the soft parts.
However, none of these studies is as accurate or reliable to judge the treatment effectiveness as an adjuvant mapping necrosis dried surgical consisting of histological study of various areas of the tumor, with the purpose of establishing the histological grade of necrosis caused by the effect of chemotherapy.
Biopsy
The biopsy requires considerable planning and study strategy with the aim of making sure that any subsequent surgical procedure, is not hampered by any complications.
The correct region of the tumor to be biopsied with minimal violation of normal tissues. The biopsy site should allow subsequent resection of its course, without compromising the results after conservative surgery. A meticulous hemostasis must be achieved and the use of drains should be avoided whenever possible.
There can be no doubt that the delay in diagnosis allows tumor growth, making limb preservation surgery less likely. The longest delays occurred in patients who had their initial radiographs misdiagnosed as normal. The consequent "false security" cause an additional delay 2-40 weeks before a second radiograph that reveals the correct diagnosis. In this group of patients, diagnosed incorrectly, 58% required amputation or were considered inoperable, unacceptable rate compared with 15% of those whose initial radiographs were interpreted correctly.
We found no place for frozen biopsy in tumors of the skeleton. Even in the hands of experienced pathologists, this type of biopsy is prone to errors and compromising grotesque to conduct definitive, nothing in helping tumor treatment.
The diagnosis of bone tumors after the history, physical examination, laboratory studies and diagnostic imaging is still a presumptive diagnosis. Only after the pathological examination of the material obtained by biopsy is that treatment can be started. The purpose of the biopsies is to obtain sufficient tissue for an accurate diagnosis, without causing harmful effects to the injury and particularly without damaging the definitive treatment.
The biopsies may be performed in different ways. Among them open or percutaneous incision or puncture and. Historically, incisional biopsy has been considered the procedure with greater precision and reliability. Currently, however, percutaneous biopsy has been in our service the procedure of choice for lesions of the skeleton. The accuracy of our results is 90%, which corresponds to the precision of the biopsy best results in other outside services.
Is global concept that biopsy should be performed by the surgeon who will perform the definitive treatment of the patient. It objectionable procedure carried out a biopsy on a service that does not have all the conditions to treat the patient.
Biopsies performed improperly account for changes in the treatment plan. These problems are three to five times more common in biopsies performed at institutions that do not have professionals specializing in orthopedic oncology, compared to biopsies performed in specialized centers and reference (60). Among the problems emphasize the collection of tissue inadequate for definitive diagnosis or diagnostic errors resulting from material not representative excessive contamination of the soft tissues previously not involved by hematoma, wound infection and positioning of the biopsy biopsy such that a resection subsequent surgical compromised, becoming mandatory amputation in a patient who previously could undergo surgery for limb preservation.
Regardless of the technique used, the biopsy should be performed carefully and gathering all the skills, so you can assist in the completion stage and thus help to establish the correct treatment of bone tumors.
Prevention
As the causes of primary bone tumors are unknown, there is no measure of primary prevention, meaning that people can adopt themselves to prevent the disease.
For those who have cases in the family, however, it is recommended to keep a more strict medical supervision in order to track suspicious lesions even earlier. In turn, anyone who has had cured cancer in another organ, especially in breast, lung, kidney, prostate and thyroid, can not give up doing consultations and routine tests at intervals prescribed by the oncologist. This care does not prevent the emergence of new foci, but makes it possible to identify any changes yet in its infancy.
Treatment
Radiograph
Plain radiographs provide more general information about the tumor. This information, combined with clinical presentation, give some idea about primary versus metastatic tumors and malignant versus benign.
The radiograph demonstrates the bone and the area involved, the extent and type of destruction of bone addition reaction. It is also important to study the type of matrix involved. A radiolucent lesion subtrochanteric bone formation with little reaction in a woman 60 years may suggest a metastatic tumor. In contrast, a destructive lesion in the distal femur in a patient 12 years of age with osteogenesis suggests a primary osteosarcoma.
However, approximately 20% of patients, neither the pediatrician nor the radiologist detect early tumor on radiographs. One of the main factors leading to non-diagnosis is the poor quality of the radiographs. Radiographic signs of tumors, though well known, are often "no" - valued. They include ill-defined areas of radio-lucency or sclerosis radio, sub-periosteal new bone formation, cortical destruction and increase in underlying soft tissue injuries.
A radiograph of the opposite side for comparison is easy to perform and always help. Especially in children, where the presence of nuclei of ossification difficult to interpret, the contra-lateral radiograph is of great value.
Mapping bone
Skeletal scintigraphy is performed more frequently with phosphonate labeled with technetium 99-m. This radioisotope is incorporated into bone formation. There is also an increased concentration of radioisotopes in the areas of increased vascularity. The two main functions of this study is the estimation of the local extent of the intramedullary tumor and a demonstration of other skeletal areas involved.
In assessing the tumor site, the extent and intensity of increasing concentration can provide information about the biological aggressiveness of the tumor.
Scintigraphy is also of particular value in the diagnosis of metastases fried, mainly in the initial phase when they are small in size and, in general, are not visualized on radiographs.
Scintigraphy of the skeleton remains, despite new methods of diagnosis, the most reliable technique for early diagnosis and demonstration of bone metastases.
Computed tomography
Since computed tomography is now readily available in our environment, experience with its use is increasing every day. The TAC has been helping in the diagnosis of malignant lesions primarily by its ability to identify small lung metastases, unobserved through conventional radiography and tomography.
The contrast in CT helps in identifying the major neurovascular structures as well as the enhancement of well-vascularized lesions, and demonstrate relationships between the tumor and the adjacent soft tissues, and is also the best method for assessing the impairment of cortical and other details bone. It is also extremely valuable in assessing the calcification and ossification of the matrix.
Nowadays, with the advent of helical CT, the examination can be performed in minutes, avoiding general anesthesia in children.
MRI
MRI is the latest advance in diagnostic imaging of musculoskeletal tumors and added important advantages to staging. In our opinion, MRI and CT scans are complementary and should, if possible, be used together.
The study of a bone tumor by MRI images includes axial T1 and T2 and a set of images on the longitudinal or sagittal plane front.
MRI consider the most accurate method for evaluating the extent of intra and extramedullary bone cancer. This longitudinal T1 is great for demonstrating this relationship. In T1, the neoplastic tissue demonstrates in most tumors, a decrease in signal intensity as compared with the high signal strength of the intramedullary fat. The striking contrast between the signals of fat and neoplastic tissue makes MRI the best method to study the extent of intra and extramedullary bone tumor.
Arteriography
The primary indication for arteriography is in difficult anatomical regions, such as the pelvic and shoulder girdles. It is also useful in the preoperative evaluation of tumors undergoing limb sparing surgery, in which the vascular-nervous bundle must be sacrificed and rebuilt because of the involvement caused by the tumor. The same happens in the preoperative evaluation of extremities that will undergo microsurgery.
We can not forget the use of angiography in the treatment of bone tumors, where often it is used for placement of the catheter near the tumor and subsequent infusion of intra-arterial chemotherapy.
Due to its technical difficulty and risks inherent in the examination, rarely use this method for diagnosis in children. Its use is restricted to cases where we perform therapeutic embolization.
Study of tumor response to chemotherapy
Radiographic changes considered as the most significant evidence of tumor response to chemotherapy are:
§ reduction of tumor volume;
§ decreased vascularity and angiographic
§ changes planar radiography, CT and MRI showing bone formation reaction at the periphery of the tumor, together with the soft parts.
However, none of these studies is as accurate or reliable to judge the treatment effectiveness as an adjuvant mapping necrosis dried surgical consisting of histological study of various areas of the tumor, with the purpose of establishing the histological grade of necrosis caused by the effect of chemotherapy.
Biopsy
The biopsy requires considerable planning and study strategy with the aim of making sure that any subsequent surgical procedure, is not hampered by any complications.
The correct region of the tumor to be biopsied with minimal violation of normal tissues. The biopsy site should allow subsequent resection of its course, without compromising the results after conservative surgery. A meticulous hemostasis must be achieved and the use of drains should be avoided whenever possible.
There can be no doubt that the delay in diagnosis allows tumor growth, making limb preservation surgery less likely. The longest delays occurred in patients who had their initial radiographs misdiagnosed as normal. The consequent "false security" cause an additional delay 2-40 weeks before a second radiograph that reveals the correct diagnosis. In this group of patients, diagnosed incorrectly, 58% required amputation or were considered inoperable, unacceptable rate compared with 15% of those whose initial radiographs were interpreted correctly.
We found no place for frozen biopsy in tumors of the skeleton. Even in the hands of experienced pathologists, this type of biopsy is prone to errors and compromising grotesque to conduct definitive, nothing in helping tumor treatment.
The diagnosis of bone tumors after the history, physical examination, laboratory studies and diagnostic imaging is still a presumptive diagnosis. Only after the pathological examination of the material obtained by biopsy is that treatment can be started. The purpose of the biopsies is to obtain sufficient tissue for an accurate diagnosis, without causing harmful effects to the injury and particularly without damaging the definitive treatment.
The biopsies may be performed in different ways. Among them open or percutaneous incision or puncture and. Historically, incisional biopsy has been considered the procedure with greater precision and reliability. Currently, however, percutaneous biopsy has been in our service the procedure of choice for lesions of the skeleton. The accuracy of our results is 90%, which corresponds to the precision of the biopsy best results in other outside services.
Is global concept that biopsy should be performed by the surgeon who will perform the definitive treatment of the patient. It objectionable procedure carried out a biopsy on a service that does not have all the conditions to treat the patient.
Biopsies performed improperly account for changes in the treatment plan. These problems are three to five times more common in biopsies performed at institutions that do not have professionals specializing in orthopedic oncology, compared to biopsies performed in specialized centers and reference (60). Among the problems emphasize the collection of tissue inadequate for definitive diagnosis or diagnostic errors resulting from material not representative excessive contamination of the soft tissues previously not involved by hematoma, wound infection and positioning of the biopsy biopsy such that a resection subsequent surgical compromised, becoming mandatory amputation in a patient who previously could undergo surgery for limb preservation.
Regardless of the technique used, the biopsy should be performed carefully and gathering all the skills, so you can assist in the completion stage and thus help to establish the correct treatment of bone tumors.
Prevention
As the causes of primary bone tumors are unknown, there is no measure of primary prevention, meaning that people can adopt themselves to prevent the disease.
For those who have cases in the family, however, it is recommended to keep a more strict medical supervision in order to track suspicious lesions even earlier. In turn, anyone who has had cured cancer in another organ, especially in breast, lung, kidney, prostate and thyroid, can not give up doing consultations and routine tests at intervals prescribed by the oncologist. This care does not prevent the emergence of new foci, but makes it possible to identify any changes yet in its infancy.
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