Dr. Giovanni Paraliticci , orthopedic surgical oncologist at Baptist Health’s Miami Orthopedics & Sports Medicine Institute shares the latest advancements in orthopedic oncology. View this pre-recorded lecture to learn more.
Good afternoon and welcome to our orthopedic and sports medicine lecture series. I am dr gallant hakim Assistant vice president of international Health Care partnerships and insurance development at baptist health. It is my pleasure to welcome all of you to this informative presentation. I would like to extend more ingredients to our friends across latin America and the caribbean. And everyone joining us today during this interactive presentation you have the ability to ask questions via the Q. And a feature located on the bottom of your screen. I will be your moderator today this afternoon I had the pleasure of introducing dr giovanni apparently teaching who is an orthopedic surgeon and oncologist at baptist health. His presentation is titled lumps and bumps, what to do. Dr barely teachey is an orthopedic surgical oncologist at Miami Cancer institute and an orthopedic surgeon at Miami Orthopedics and sports medicine Institute, both part of baptist health south florida. He specializes in the surgical treatment of Moscow skeleton tumors including benign and malignant bone and soft tissue tumors and metastatic leashes. He also manages orthopedic problems in oncological patients such as fractures, arthritis, vascular necrosis and osteoporosis. He has extensive training and experience and surgical management of arthritis treated conditions rather of the hip and needs and his skills and procedures such as primary and revision total needs and hip entre plastic partial knee arthur plastic custom knee replacement and robotics. Doctor barely Tichy received his medical training at the University of Puerto rico School of Medicine and Rio piedras where he also served as a clinical internship in general surgery. He then completed a residency in orthopedic surgery. Also at the university of Puerto rico followed by a fellowship in musculoskeletal oncology at the University of Miami miller School of Medicine and the Fellowship and adult hip and need reconstruction at Miami Orthopedics and Sports Medicine Institute. In addition to this medical training, doctor paralytic, he holds a bachelor's degree in Science and Chemistry and biology. Science of the University of Puerto rico. Doctor Paralytic. He has published extensively and scientific articles and has been a presenter at numerous national and international conferences. He is also a member of the American Association of Hip and knee insurgents the Moscow skeletal tumor society and the american Medical Association's Please let us give a warm welcome to Dr Giovanni Pierluigi doctor barely teacher. What a pleasure to see you again. Thank you so much for giving us your time and for joining us this afternoon. Thank you so much for having me Dr Hakim. I appreciate it. Go ahead and if you can share your screen we can go ahead and get started. Thank you and okay good evening everyone. As I mentioned, my name is Dr Giovanni borelli, Tichy. I'm a rare breeding orthopedic surgery. Uh My passion is to do orthopedic oncology but at the same time I also do hip and knee replacement and uh complicated cases of provisions. Uh So I just wanted to talk to you a little bit about what is well as an orthopedic colleges that we encounter in our day and how we can help the community to identify those patients that I've been treated so they can get the best outcomes for their treatment. So why is knowing about lumps and bumps is so important? So primary tumors of bone and soft tissue, even though this is extremely rare and can be easily missed, it's something that is happening in our society as the time continues to pass by. The number of cases continue to grow. As the NSS I stated in 2014, there's approximately 12,000 soft tissue Sarcoma and 3000 bone sarcoma is that are diagnosed annually here in the United States. And of those 15% clear around the shoulder, which makes it the third most common sight. So approximately 11,000 to 12,000 new cases in the United States. The most common though, even though it's benign but still millennium happens and malignant cases, we have to be very aware when they happen. So we should be able to readily identify the ratio that they a cure is 150-1. So by 20 malignant soft tissue masses that we identify in the United States are curing approximately one million of those patients here. Most of these masses are painless. They grow very slowly and they're very prominent in the area that they grow. These tumors are great mimic ear's of other conditions such as infections, metastatic cancer, primary malignancy or benign conditions such as my city specific and secure when we have any kind of trauma in our muscles. They're most commonly occurring the lower extremity compared to the upper extremity and a ratio of 2-1. And most of the time occurred in the Trunk and Pelvis and 33% of the time. I want to give you a little definition about basic concepts that we deal on a daily basis. Uh, sarcoma, when we speak about a sarcoma is a malignant tumor and it has the potential to grow in an area and then travel to different part of the of our body, which is called metastatic. So cancer is a common word use for when something grows in an area and then it trials for a different part of our body. This kind of cure and the muscle tendons, soft tissues or any part of our bones. And when we talk about adjuvant treatment is a treatment that we provided his tumors in addition to the surgery. And these are giving after surgery. And this can be chemo radiation or this can be chemotherapy or this could be immunotherapy. And when we speak about neo adjuvant treatment is the same thing as chemo or radiation or immunotherapy that happens prior to the patient undergoing surgical management. What is the most thing that the most important thing that we do when we encountered a patient with an unknown mass or a lump. So we have to do a complete and thorough history with physical examination. I'll tell you that approximately 80-90% of the times this is. Give us the diagnosis. We gotta listen to the patients. We got to examine them. We got to see if they have any other leashes in their body. We got to do a very, very thorough exam and history about when did this happen? How long has this been happening? Is there anyone in the family that have the same condition? Is there any other factors associated any social events or in the family that they live that have been predisposing this? They smoke, They don't smoke. So those are little things that we have to be always aware when we're performing our history and physical examination. We combine this with imaging studies such as X rays and MRI cat scan, head cts or ultrasounds and then sometimes we and relocation that happens that a patient comes with a biopsy already performed. So we have some pathological material that we can analyze what R. M. S. K. Pathologists bear in mind. That benign or malignant lumps can also be painless. So this should not be one way to the certain one versus the other one Most of the time when they cost pain. Uh they are because they're compressing a neurological structure or their size is big enough and it's said that is usually greater than 10 cm as we were mentioning before. When we're asking to the patient evaluating in the history Holland has this vance has been present. Is it painful? Is associated to any kind of trauma that the patient had a prior history of cancer? Or was this related to any other medical condition or syndrome that they have? Are there any other symptoms like for example, fever, chills, unintentional weight loss? The patient has been taking any kind of medical treatment as they change their diet. All those things factor in at the time of making the diagnosis. In our physical examination, we evaluate the size, the depth, the consistency and the mobility of the mass. For me, the criteria that are most important in the mess that is greater than five cm and it's deep and it's firm. This is concerning for malignancy And it's something that is more superficial. The study says that 32% of the time superficial masses are benign. If we have a mass that trans illuminate, this goes more with a benign conditions such as a ganglion cyst. If we have someone that had a history of a trauma and has some superficial bruises, Recchi moses this girl has a traumatic hematoma. If there's something that the mass has a brewery that has some skin changes systems, a hemangioma or a vascular malformation if you tap that mass and produced this tingle sensation and this pins and needles. This is what is called the tunnel. Scientists could be related to a nerve condition or a tumor in the nerve. Another thing important that there's any enlarged regional lift notes. And as we mentioned before any mass greater than five cm that it's firm and deep is concerned for malignancy. We will try to identify there's any kind of labs that we can order that can correlate with with cancer. But so far if we order a cbc and there's increase in white blood cell count and the set rate and crp are elevated, uh this is most likely relevant to an infectious process. Instead of a neo plastic process. Uh We can have an elevation in the costume. We can have elevation, the phosphorus or uric acid level or alkaline phosphate. Then those can have some kind of uh uh idea that this could be related to a neo plastic process, but they're not specific for any kind of condition. I would say. If a patient has a hyper called Senor greater than 10 and an elevation of alkaline fossil days. Then those things are correlated or suggestive of a malignancy. There are different kind of images studies that we can order when they encountered a patient with an unknown mass. Uh We can order a simple plain X ray that is done in the office. We can order an MRI, we can order an ultrasound. A cat scan or a pet ct X ray has a limited role in the diagnosis and staging. But this is a very quick and inexpensive tool. And if we have a large tumor, it can show us a soft tissue prominence and it can help us identify. There's any other features such as a calcifications or any soft tissue uh ossification and mineralization in this area which can lead us in a differential diagnosis. As we can see in the image in the right. This is a forum X ray lateral view. But in the anterior aspect we can see that there's soft tissue shadow compared to the rest of the area that you can tell. There's definitely some kind of mass in that area. Once again, we evaluate the patterns of mineralization with the X ray as we see in the in the image and the upper quarter it's this is a soft tissue shadow with some kind of classification that area. And in the one in the lower there's some ossification in this area or some kind of mineralization that may be suggestive of some kind of benign or malignant condition. Here are three examples of conditions that I encounter in a very frequent setting. And the one on the left we have an X ray of a skeletal immature individual which has a soft tissue mass. In the owner aspect that has some classification or flee bullets in that area, the history of this patient is associated that the mass increases in size with activities and then when the patient rest, the size of the mass increases. This is most commonly associated with a benign tumors such as an hemangioma. Okay, the the image in the middle is a lateral X ray of distal femur that shows a mineral ossification in the posterior aspect of the femur. As we can see, it's a very aggressive pattern of ossification is even more dense, denser than if we compare it to the bone. This is more suggestive of a malignant condition that produces bone and is laying down bone. And this is mostly a extra skeletal osteosarcoma. This is a malignant tumor that is the primary bone tumor that it has to be treated with neo adjuvant treatment surgery and then with adjuvant treatment. Okay. And the image in the right, it's an image that can happen on anyone that have any kind of trauma. And say for example this is a weightlifter that I was producing and he had a little tear and expressing his elbow. So he bled a little bit from the muscle and this kind produced i ossification in this area. And this is what is called Mile Cities of Safety Gas. And this is a benign entity and this resolved on its own MRI memory has become the gold standard for the diagnosis and evaluation of soft tissue masses. Uh It's very sensitive and it's uh easily to localize and characterize a mass in this area. It will tell us the size of the mass, the death of the mass? If there's any fluid or solid content uh Is there any other content that is homogeneous or heterogeneous in this area and if it's uh invading any other vital structure uh we able to see fat muscle and bone. The part that the emery doesn't help us is for soft tissue classifications. Or if there's any bony involvement or any air in a mask, this will be readily evaluated with other studies. Uh MRI are usually performed with a contrast which is called gadolinium which is helpful to identify between a solid and cystic mass. The sequence that we try to identify and when we discussed this case is the radiologist. And if it's a radiologist is we want to see three sequence The T. one sequence the t. to sequence and the fat saturation at the T. One sequence in the MRI shows that mass that is hyper intense, meaning that the amount of the brightness of that mass is very low and then in the T. To sequence the intensity of that mass is very bright. Then this is concerning for a sarcoma. Okay. And if if the mass doesn't suppress with the fat saturation technique, this is also a concern that this is also related to a sarcoma legislation. So gadolinium is, as I was mentioning before, it helps us distinguish in the M. R. I. Uh cystic versus solid mass also help us identify it. There's any small nodules between the cystic lesions um is also help us to uh evaluate the response to the treatment uh it helps uh patient has a recurrence of their tumor after the original surgery or they, if they had performed a unplanned excision, it helps guide the interventional radiology when they're performing guided needle biopsy. And uh it helps distinguish degranulation tissue versus tumor. So overall emery with and without contrast is the gold standard that is ordered when we encountered a mass that we don't know what it is depending where you're practicing. I understand that they're an M. R. I. Machine may not be available or the contrast medium would not be available. Some some people in the third world country where may utilize ultrasound or some people in the office may utilize ultrasounds because it's an expensive tool. It can be used as a screening tool to see if there's any cystic or solid component of the mass that is being questioned. And also depending on the technique, you can identify there's any flow to this mass. This is unknown. And uh if there's no flow to this massive possibility of malignancy in the malignancy decreases. But still its operator dependent has so many variables that the role of ultra stone in our current practice, I would say that it's kind of limited ct scan back in the days before the M. R. I. Era. It was used uh vastly and and throughout the entire world. But now the M. R. I. Has really supplanted it and displays that use of the cat scan. I would say that the M. R. I. That, sorry. The cT scan we use it in patients that they're not able to undergo an MRI because they have a pacemaker. They have a defibrillator that is not an MRI compatible. So then in those cases we have to order a CT scan. The city's can help us identify any pattern memorization, any lesion that involves the bone or with the contrast medium. We can identify the vascular structures. Pet ct pet ct as a modality. That has been Ongoing I would say for the last 10, 15 years. Uh there's still no specific role for it. Uh but it has been found its way in order to combine the data that this gives us to use it in specific situations. Let's say for example, the pet ct evaluates the metabolic activity of these tumors or these unknowns. Uh you can evaluate there's any soft tissue tumor as in their initial staging to see how much uptake they have from that um from that metabolic component. And then as the patient undergoes a treatment, you can see that activity has gone down or has stayed the same or has getting worse. Um Also can stay if there's any prior evidence of treatment that the patient you want to see there's any recurrence in the area that was treated with radiation or with surgery, then you can also utilize the Pet cT for evaluation. It gives you a specific number which is called suv. And that's what the radiologist and us utilize evaluated as a response of treatment or recurrence of the the management of this lumps and bumps. First of all, we got to identify what is the underlying diagnosis relations can be benign or it can be malignant. If a lesion is benign, we can treat it with a marginal excision, I'll go a little bit further and explain it later on. And if it's a malignant lesion, then we should consider what is called a multi modality approach. Uh and most likely recommend the patient to go to a tertiary institution that specializes in this kind of muscle skeletal tumors. Uh The key aspect to consider for this management is that the patients should undergo a tissue diagnosis followed by an oncological resection. And we should always avoid unplanned oncological excision to get the better chances for treatment and response and decrease the complications for the patients biopsy, even though a biopsy seems to be simple. Uh there's a lot of complications that can happen. It can compromise the surgical outcome of this patient if you don't follow some sound principles that are related for the biopsy. That's why once again, the recommendations from the MST MST. S. Is to refer the patient to a tertiary center that specializes in most skeletal tumors in order to provide a patient for a limb salvage procedure and can have the access of a specialized muscle skeletal pathologists and complete the necessary imaging for the patient. The MSC has conducted a study in 1996 I think this is a very good one that has stated that 19 approximately 20% of those patients that had a biopsy performed and an outside institution that did not have an m escape pathologist, 18 patients underwent unnecessary amputations. So overall it was 12 times greater than a patient that underwent a biopsy by a trained muscle skeletal surgeon. So there's two types of biopsies that we can perform uh in the office, which is a fine needle aspiration and uh it's a very simple procedure you can see in the image and the ride. It shows that it's a fine needle. No anesthetic is required. It just limits the amount of tissue that you can collect And uh and this process very quickly and it's inexpensive. The sense of the divinity ranged between 80-89%, depending in which case series and the specificity goes between 72-89% the one that we use the most is called. The core needle biopsy as you can see in the image in the middle. It's a bigger large borehole needle that goes between one centimeter to 1.5 centimeter. We have to use local anesthetic and we do several core samples from this. This will help us increase the accuracy of the diagnosis for this patient and once again it is imperative that this core needle biopsy is being interpreted by a skill and experience muscle skeletal pathologist to give the most accurate diagnosis. But what happened when the fine needle biopsy or the core needle biopsy don't work or they don't give us a diagnosis or they're inconclusive. So that's when we have to go and perform what we call an open biopsy. The open biopsy. There are two types. The institutional one. This is mostly reserved for the patient that we have. That there is a tumor that can be that looks as small as in 3cm superficial is not attached to anything. And we just wanted to provide a a sample diagnosis for a tissue. So we'll perform a directly on top of the mass along to where it will be the plan surgical elliptical incision and we'll just remove a piece of that and send it to the pathologist versus the exceptional biopsy is that M. S. A. Mass less than three centimeters. We perform the resection of this mess with a small cuff of normal tissue surrounding it. Uh And this will provide us with the most accurate diagnosis and decreases the chance of complications as compared to the institutional biopsy. Even though institutional biopsies performed for for small masses, the possibility of Uh performing this and a malignant tumor is still around 30-40%. So once we have the diagnosis and we know this is a malignant tumor, uh We plan for what is called oncological resection uh Before we mentioned, the international, which was one in the middle And it's a piecemeal fashion. This is as we said before for benign leashes. And we can do also a marginal resection which is an en bloc accession at the reactive zone which is the border where the tumor producer studio capsule. As you can see in the image here surrounding where the tumor is, there's a little gray halo around it. So that's a reactive zone that's also performed for benign lesions but in the malignant ones, the oncological resection. That's when we do a wide local excision which is removing the tumor but with a normal cuff. Uh Teachers so decreases the chances of local recurrence and complications around this area. And back in the days they used to perform a more radical procedure. As it says a radical excision which was removing the entire compartment. As you guys can see the images removing basically the entire female here now in the days because of the advances of limb salvage procedures we don't we rarely produce have to produce uh sorry, perform that kind of surgery. So this is our goal. We want to avoid on plan oncological exhibition. We want to avoid having inadequate images before any procedure. We want to avoid inappropriate interpretation of imaging studies. We wanted to decrease the local recurrence and we want the best survival for this patient to decrease their re excision. Uh This is what we have in mind. And this is the reason why we perform uh tumor boards and discuss this complex cases with a muscle skeletal pathologist and muscle skeletal radiologist, surgical oncologist, medical oncologist and us of the orthopedic and surgical oncologist team. So every time we're contemplate, we gotta think every time we're contemplating to remove our masks, we should consider that that massive malignant until proven otherwise. We should follow the sound principle for a tumor excision to minimize the contamination of this area. And if any time there's any question about the tumor or a unknown that you encounter in surgery, I would say you should send a frozen section for that area. Send it to the pathologist and wait for that. The pathologist is able to tell you a preliminary and to rule on maleness and then you can proceed. But if the pathologist is still in doubt or you don't feel comfortable or you you have your doubts about it. This is a malignancy. You should close and wait for the final pathologist. This is a table that is very, very good. It summarizes what we should do at the time of performing surgery for soft tissue masses. The lip service should be the first thing that we try to strike and get for these patients. And if the surgeon doesn't know the incision or the biopsy, this should be sent to a place that deals with this kind of tumors or this kind of unknowns. They should always avoid transfers incision. Okay, this complicates the scenario and increases the chances of uh pure for this patient and success. And increases the co morbidity, morbidity. Uh If there's a need to perform local anesthetic, it should be performed in the same track as a needle. In order to avoid less contamination. We should always perform the biopsy and the most direct approach that we can see. So we can avoid developing multiple planes or inter muscular planes, which may produce a contamination for the surrounding tissues or the contamination of the neurovascular structure. So we should always avoid developing any flaps are moving muscles around. We just go straight to where the tumor is. It should be the meticulous homeostasis in order to decrease the chances of local contamination. A tourniquet. If it's thought about using it, you should not examining the tourniquet. You should leave it for gravity and weight 23 minutes or a little bit more until then the limits exsanguination by gravity and then you can raise the tourniquet. If a drain is the necessary in this area, it should be placed along where the surgical incision is planned for the final reception of this tumor in order to incorporate this track with the final incision of the surgery. Um Open biopsy should be avoided in certain areas of the body, such as the exhilarate pappardelle Phosa and carpal tunnel because it's a very small area and increases the chances of local contamination. Which may lead eventually in an amputation of that limit and for certain conditions even though we can use arthroscopic procedures. But we should avoid at the time for diagnosis performing them because the possibility of having a malignant tumor, it's in the equation. So we should avoid it to decrease the contamination. So I I found this flow charts. I think they're really really useful at the time that we encounter unknown. This is for superficial masses. If we encountered. If you think that it's a fluid and it trans illuminate in the office then you can do an ultrasound and you can confirm it. This is solid that this is uh this is fluid. If you if the ultrasound shows that this can be a solid component then you should order an M. R. I. With and without contrast that extremity, if it's shown to be more fluid then you can observe it as clinically indicated. Excuse me. If the mass is less than three cm, you can observe it unless it's painful, it's is greater than three cm. You could always observant or exercise it with uh cover normal tissue. If the mass is greater than three but it's firm or it's fixed. You should always get an MRI with or without contrast and subsequently most of the time it would follow by a biopsy, it's a superficial masses continued to grow. Then this is also a concern that should have further evaluation. But what if we're talking about deep masses which is the one that we have in the thighs. We can see in other parts of the body. So once again the same principle, see if it's solid or is it fluid. And but I will tell you at the end of the day all then circle back to do an MRI and depending on what the findings of the MRI. If it's heads are a genius in determined, then you should always followed by a biopsy. Very very few times it will be homogeneous. Unless we're talking about a like tomatoes tumor, then it will be more homogeneous. But still there is a variant of like tomatoes tumor which may be a lipo sarcoma that also would show more indeterminate or heterogeneous. And then that should be followed by a biopsy. And again, no, I would not advise to observe any of this deep uh lesions because they can very easily uh mimic any other conditions. And they can full any physician thinking that this is a benign thing. What is indeed. This is a sarcoma. So conclusion we should follow this proper algorithm at the time that we encountered this soft tissue mass. We should refer these patients to train musculoskeletal tumours and a facility that deals with this kind of conditions on a daily basis to give the better chances for the patient and decrease the complications and comparability By 9" even though they're more common than malignant but still malignant conditions happen and they show up. So we always got to be aware of that and we should recognize the signs of malignancy, Assuming that this is not an acquis more than five cm hard firm fixed of the fashion. Always follow anna Marie and then buy at a biopsy of that nation, imaging is essential and don't hesitate to refer the patient if you encounter this unknown. As I mentioned, any mass greater than five firm and deep it's been looking into improvement. Otherwise, if the if the diagnosis remains unclear, always should biopsy it and multidisciplinary care and I don't get tired saying it. Multidisciplinary team is the key of success to decreases the comparability for these patients and increases their chances of survival. So before we end, I want to show you a couple of cases that we've done here at baptist. This is first one. This is a Female with initials f. K 59 with the right fight mass that started rapidly growing as you can see in the image. In the upper part it looks homogeneous all around the same area. The part of the left is a skin muscle and fat muscle bone and all of that in the medial side is the tumor. That was an axle rear view. And the other one is more like a sagittal view as you can see it goes basically from her growing to the distal aspect of her of the mid aspect of the thigh. And uh this is how she looked. She was biopsy to be a spindle cell sarcoma. Even more of a spindle cell sarcoma. So the protocol for that is to undergo radiation treatment and then followed by surgical radical resection. As you can see in the image in the middle. You see how we mark the extent of our reception. So that tells you even though this is a huge mass, a large mass. But we have to go broad in order to have a clear margin and to decrease the chances of contamination and local recurrence in this patient. So you can see look at where the knee is is sitting down there in the in the autonomy position and the growing area. That's where we ended up our proximal incision. And this is after the resection of the tumor. So this is a structure that are the vessel, the femoral vessels there and the remaining of the muscles after the tumor was resected. Unfortunately, this we're able to close this wound primarily and did not require the assistance as a muscle flab or a transfer or free flat from the plastic surgeon. And quickly this is another case. A patient uh initials R. G. 51 year old male. We had a right calf mass that was being in growing and getting painful and he was limiting his ambulance nation. Uh he was seeing an outside institution and then once he realized that this is more serious, he came to Miami cancer institute. He underwent a biopsy and it was diagnosed to be applied to morphine mix of fibrous sarcoma. As you can see in the upper image. This is an actual view of the right leg. Uh the part of the skin muscle bone and the entire posterior compartment including a superficial and deep is invaded by the tumor. This is the saddle view. You can see the same thing the skin muscle and in the posterior aspect the heterogeneous mass that is in that area comprising very closely where the strong neurovascular structures are and engulfing Mosul of the muscle of the calf. So again you can see the images how we mark our resection and sometimes we even redraw the images again about where we're planning to do our reception for this tumor in order to provide the patient with a wide surgical margin and intra op we'll still send some frozen if we have doubt that our margin is. If we're considering this could be some tumor left in this area. So we'll send some samples to the pathologist in the toilet. There's tumor. Yes. No. Okay, proceed. And there's tumor. We gotta reset more more tissue from that area. And this is an image. I told you after the tumor was your section how the dead space ended up in that area. Uh This patient requires closure by plastic surgery due to the extent of the reception of this large tumor. So these are the reference and thank you for your time. I appreciate it, wow dr paralytic. You are an incredible presentation. Thank you so much. I hope we have some students in the in the and the conference because I think that they will be the ones to take more advantage of such incredible incredible insight. Um we have a couple of questions but I wanted to ask you dr barely teacher, you know how sometimes um physicians from abroad tend to struggle. As of do we refer this to an Ortho oncologist or do we refer him to a surgeon that does sarcoma? And simply because of what you describe this solid type tumor, the lack of potential resources, meaning that they probably did an ultrasound instead of an M. R. I. And they think it is muscular but at the same time it looks like a bone issue. How do we go ahead and differentiate? Uh as of whom should be the one to see this type of cases? Yes, that's a very good question. Thank you. So most of the time we can have we have a combination of the surgical oncologist and the orthopedic oncologist that see this kind of tumors. Uh the surgical college. Uh my experience from what I've seen here and in our institution, they do extremities are comas and most of the parts in the atom and retro peritoneum, but the one that it goes around the hip, knees, elbows, shoulders. Um basically the orthopedic oncologist is they want to take care of them because they involve part of the bone or functionality then the surgical oncologist don't deal with most of the part of the functionality. If we have to reconstruct part of the muscles around the area of the shoulder or the muscles around the knee. So then that's when we come into play or we have to say for example it's involved in the bone and we have to remove part of the bone. So then we have to put a prosthesis. And the surgical oncologist doesn't do that part but us the orthopedic colleges we do that part of reconstruction. Mhm. In the case of uh tumors for instance in the synovial uh that tend to recur uh do you guys see him also his first stance and then refer maybe two radio oncology or how does that work? Can you clarify that? Yes. Very good question to also. So uh synovial tumors that we see the most commonly one I see is a benign one known as P. B. And S. Pigmented villain Oculus. In Uveitis patients have recurrent uh him or throw sis that they're joined. They get current infusion. The young are painful. So they usually are seen by some orthopedic in the community and then they do an MRI and then they see a lot of innovators in that area. And a lot of celebrity from the from the zenobia. Some of them have the the variant that is localized. So it's only inside the knee but I've seen the other variant which is the diffused one that not only it's inside the knee but it's also around the soft tissues outside the need. So those are the ones that we see, the ones that are in particular localized. We can treat it with arthroscopic or open sign of ectomy. Uh I prefer to treat him with opens in a victim because it gives you better chances of eliminating and clearing the synovial from this part of that tumor and increases the chances local recurrence Patients that have failed multiple surgical managed from the local one. We send them to the racial colleges that they can talk to him about low dose radiation in this area. And also there's a treatment that came out a couple of years ago for immunotherapy that those patients are they evaluate the patients a candidate for for this kind of immunotherapy which also gives good response to them. That is wonderful. But you still recommend that you can actually see them. And then this heifer through the interdisciplinary team. What approach to take. We work as a quarterback to to see where we got to put those patients out there we treated and where they got to go. So we got to see the people that they need to see. Wonderful. Um We have a question from the D. R. At the beginning of your presentation, You mentioned that there are cases um that these are rare cases rather um what incidents of the sarcoma cases you have seen that have been hereditary? Well, in my practice there, depending that they have certain mutations. I have seen some of them breast cancer. I've seen patients with family uh that have a strong family tendency and breast cancer. Uh I don't treat the breast cancer, but I treat the metastatic disease from the breast cancer if they have metastatic disease to their bones. And then one treating them, for example, in their pelvis or hips, they're humorous, their knees. Uh So I'm the one taking care of them. There's some people that have some hereditary column cancer. Again, I don't treat they call them cancer, but I do treat them for other conditions. Uh They develop metastatic disease. Again, I see them. Uh there's some other people that have familiar like tomatoes, tumors, so they have multiple uh diplomas in their body. Uh So they're more prone to develop this tumor. Uh I also seen a couple of patients with multiple harry to exhaust doses, meaning that they developed this exhaust doses throughout their skeletal body. And as soon as they stop growing and they it is tumor, they formed their boners, causing them pain or that has a fracture. So I'm the one who intervened and and take care of them. I I think that you're at the time in in in in the place where I think practicing your particular room of practice is so important simply because many years ago, as you mentioned initially. Uh this was a very dramatic result, especially in Children that has her comas of lower limbs. Uh Now with the limb salvage approach that you have implemented or that you actually do with your to pedic group, how does that compare to, let's say five years or 10 years ago for Children in particular, where those diagnoses are severe enough. That will require perhaps a complete excision of the tumor and probably not necessarily salvaging it than now versus now where you can actually do something to salvage that Lynn Yeah. So there's certain patients that depending on which time they arrived to our institution and depending if it's accessible for them or not, the tumor is still in in the in a way that is controllable and it's amenable for a limb salvage procedure. Were able to treat this patient with the resection of that tumor and we use a growth spending prosthesis. Okay. Uh there's certain parts of the world that for pediatric patients that have this kind of comas they produce. They do another kind of started with the rotation classy, which is also shown to give good results. I personally don't practice that one. I don't do that. Uh but I do the one of the expandable prosthesis for this patient. So as they grow, the prosthesis grows with them and it decreases the amount of revision surgeries that those patients will require until they reach their adult size, wow, That is remarkable. Uh 2020 malignant cases per million that you mentioned. Do you know what percentage are athletes? Oh, that's a very good question. I wish I had that answer. But I don't know. I don't know the end. I'm going to make you think now. I wonder how many athletes are. I've seen a few, but I don't know the number. We don't label athletes. That's as a community that must be followed in that. What is the recurrence rate of this type of masses? Both benign and malignant? So depending on which type of tumor it is, for example, there's some kind of like dramatist tumors that are more from the spindle cell subtype That even though they are benign tumors, but they recur in a higher rate in between 810%. As compared as the normal life moment. That even though you resected and it's a benign thing, the possibility of that tumor coming back is very, very low. The I would say that the more aggressive, the more malignant have a higher chances of occurrence uh depending on the tumor sarcoma. Uh We give us one of the uh two of the example that I show you we gave them both preoperative radiation and and some of the second one we gave preoperative radiation and chemotherapy? Uh to increases the chances of survival and decreases the chances of local recurrence from this. There's one thing we can see with our naked eye, which is the gross tumor, but there's always the microscopic part that we're not able to see. And that's why we can combine this with other medical modalities and it increases the chances of survival of the patient, increases local recurrence. I think it's a win win. Wonderful. Do you do you see pediatric patients? Are we seeing pediatric patients with these types of tumors and your practice? We've seen we've seen a few, a few of them. Uh, we treated uh, I'm from since I've been here at three, like four or five of them. You welcome those cases. I mean that provide and they need to come then we will absorb them as well. And you will work with the pediatric oncologist as well. Wonderful. Look, doctor. I mean, I wish you were my professor back in the days because this made perfect sense. And uh, I mean it is exciting what you guys are doing, especially for these horrendous type of of tumors. We can keep you here for hours, you know that. But we're going to be considerate to you and we're gonna say goodbye and thank you and on behalf of our entire team, you have been phenomenal and thank you so much for always being there for our patients, especially our international patients and to all of you, participants for attending and for being so always participated. If you have additional questions about today's presentation, Please feel free to email them at ph I webinar about this health at Net. We'll make sure to forward those to dr probability chief for his response and we'll send them back to you. We look forward to seeing you at our next orthopedic and sports medicine lecture. Syria scheduled for Wednesday december 1st 2021. Thank you. Once again, have a great afternoon. Please stay safe and get vaccinated. We'll see you soon. Thank you. Dr Bradley. Did she have a great afternoon? Thank you guys. Have a good one. Thank you. They save Mitchell.
