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Silent but deadly – how to spot a sarcoma

Silent but deadly – how to spot a sarcoma. Craig Gerrand Consultant Orthopaedic Surgeon Freeman Hospital, Newcastle. Introduction. What is a sarcoma, and why does it matter? Who gets sarcomas? What is the best treatment for a sarcoma? How can I tell a sarcoma from a ganglion?.

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Silent but deadly – how to spot a sarcoma

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  1. Silent but deadly – how to spot a sarcoma Craig Gerrand Consultant Orthopaedic Surgeon Freeman Hospital, Newcastle

  2. Introduction • What is a sarcoma, and why does it matter? • Who gets sarcomas? • What is the best treatment for a sarcoma? • How can I tell a sarcoma from a ganglion?

  3. What is a lipoma? Benign tumour of mature adipose tissue

  4. What is a ganglion? A simple fluid filled cyst usually arising from a joint or tendon.

  5. What is a sarcoma?

  6. Bone and soft tissue sarcomas • Are rare malignant tumours arising from connective tissues • Heterogenous in type and location • Most are mesenchymal in origin

  7. How rare is rare? • Soft tissue masses are common (many hundreds in a GP lifetime) • Malignant soft tissue sarcomas are uncommon (1 or 2 in a GP lifetime) • England and Wales • 400 primary bone tumours per annum • 1500 soft tissue sarcomas per annum

  8. How malignant 1? • Survival of all patients with bone sarcomas

  9. How malignant 3? • Survival of all patients with soft tissue sarcomas

  10. Primary bone tumoursMorphological classification • Over 30 variants

  11. Soft tissue sarcoma Morphological classification • Over 100 variants

  12. Aetiology • Most are sporadic • Predisposing factors • inherited predisposition • immunosuppression • irradiation • specific chemicals • Genetic changes within cells lead to tumours

  13. Age distribution of primary bone tumours

  14. Age distribution of soft tissue sarcomas

  15. Soft Tissue SarcomaDistribution • 55% extremities • 35% retroperitoneum and viscera • 10% head and neck

  16. What is the best treatment for sarcomas?

  17. Best treatment • Early detection and referral • Multidisciplinary team management

  18. Why refer early? • Delays in diagnosis are common • Risk of metastasis relates to size of tumour

  19. Where do delays occur? • Patient (7 months) • GP (7 months) • Hospital

  20. Biopsy of sarcomas Sarcomas are implantable Therefore Careful planning is mandatory

  21. The Whoops! procedure • Excision without regard to principles of tumour surgery and usually without imaging • ie tumour “shelled out” without considering the possibility of malignancy • Further treatment complicated

  22. Principles of biopsy • Image first • Careful planning with regard to definitive surgery • If in doubt, discuss! • Excise the biopsy track during definitive surgery • Extensile incisions • Avoid neurovascular structures • Good haemostasis • Drain through or close to the wound

  23. Treatment of sarcomas • Multidisciplinary team • Combined approach with radiotherapy, surgery and chemotherapy • Specialist centre

  24. Patient perspective • Rare tumour • Often incorrectly reassured • May have to travel for treatment

  25. Low grade fatty tumours • Low risk of local recurrence • Low risk of metastatic disease • Treatment by planned marginal excision

  26. Indications for amputation • Adequate margins not possible with limb salvage • Major complications of radiotherapy would follow • A below knee amputation may be more serviceable than a salvaged distal extremity • Some cases of local recurrence may not be treatable by standard surgery and radiotherapy

  27. The future • Changes in administrative structure (NICE, NSCAG, NCRI) • Better identification of risk groups • Better chemotherapy • Better radiotherapy • Tissue engineering • Gene therapy • New imaging modalities

  28. Who to refer 1? • Soft tissue masses • Size >5cm • Painful • Increasing in size • Deep to fascia • Recurring after previous excision

  29. Who to refer 2? • Undiagnosed bone pain needs an x-ray! • Bone abnormalities on X-ray • Bone destruction • New bone formation • Associated soft tissue swelling • Periosteal elevation

  30. North of England Bone and Soft Tissue Tumour Service • Orthopaedics • Shona Murray • Craig Gerrand • Mike Gibson • Plastic Surgery • Rick Milner • General Surgery • Derek Manus • Paul Hainsworth • Thoracic surgery • Sion Barnard • Clinical Oncology • Helen Lucraft • Charles Kelly • Medical Oncology • Mark Verrill • Ruth Plummer • Paediatric Oncology • Juliet Hale • Quentin Campbell Hewson • Alan Craft • Radiology • Geoff Hide • Chris Baudoin • Pathology • Petra Dildey • Macmillan nurse • Joy Dowd

  31. Thank you

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