< Back Dr. Sefa Giray BATIBAY Metastatic Bone Disease Metastatic bone disease (MBD) is the most common malignant condition of the skeleton, often originating from breast, prostate, lung, kidney, or thyroid cancers. Treatment targets fracture prevention, functional maintenance and pain relief. Overview Metastatic bone disease (MBD) is the most frequent malignant bone condition. It reflects the spread of systemic cancer to the skeletal system, typically in advanced disease stages. Common primary sites include breast, prostate, lung, kidney, and thyroid. Clinical Presentation Persistent bone pain (often worse at night) Pathological fractures Neurologic symptoms (if spine is involved) Hypercalcemia-related symptoms (confusion, nausea) Systemic cancer signs (weight loss, fatigue) Common Primary Tumours Causing Bone Metastases Breast: Most common in ♀, more than >%50 are blastic Prostate: Mostly sclerotic/blastic lesions, spine predilection, most common in ♂ Lung: Lytic, often aggressive Kidney (RCC): Lytic, vascular; surgical bleeding risk Thyroid: Often solitary, lytic, surgical bleeding risk Frequent Skeletal Sites Involved Spine (especially thoracic) Pelvis Proximal femur Humerus Ribs Skull Imaging X-Ray: Lytic/blastic/mixed lesions; cortical breach CT : Useful for bone imaging and thorax-abdominal metastatic screening. MRI: Marrow involvement, spinal cord assessment Bone Scan: Detects most metastases, but misses pure lytic lesions PET-CT: Helps detect unknown primaries and whole-body disease burden Biopsy Strategy Core needle biopsy is preferred Always after imaging Histopathology reflects the primary tumour (e.g., adenocarcinoma in breast CA) Treatment Principles : Depends on survey expectation Non-Surgical Short life expectancy / If the damage caused by surgery is greater than the tumor itself External beam radiotherapy for pain and local control (It can be used alone or after surgery.) Bisphosphonates or Denosumab (reduce skeletal-related events) > complication ; osteonecrosis of the jaw Systemic therapy based on primary tumour (Chemotherapy and hormone therapy depends on receptor posivity ) Embolization ; especially for thyroid and renal cancers for reducing blood loss Pain control, bracing for support Surgical Indications Impending or complete pathological fracture Neurologic compromise (cord compression) Solitary lesion in a patient with long survival Intractable pain Surgical Techniques Plate fixation with curettage + cementation : In areas close to the joint like elbow, wrist and ankle Intramedullary nailing : Diaphyseal long bones Endoprosthetic reconstruction : Proximal femur/humerus : relatively long life expectancy Curettage + cementation : For small, contained lesions; can be combined with implant fixation Spine decompression and fixation : In cord compression Prognosis & Decision-Making Life expectancy is key (although controversial; ideally >3–6 months for surgery) The Mirels criteria are less useful in the upper extremities. A score of 7 or higher is in the upper extremities, and a score of 9 or higher is an indication for fixation for impending fractures in the lower extremities. Some tools like Pathfx 3.0 helps to estimate. (https://www.pathfx.org/) Prognostic scoring systems: Tomita , Tokuhashi Avoid major surgery in patients with short survival Differential Diagnosis Multiple myeloma Lymphoma Primary bone tumours Bone infections Sources: Campbell’s Operative Orthopaedics, 14th Edition WHO Classification of Bone Tumours, 2020 Current Orthopaedic Oncology guideline Mirels' score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation? doi: 10.1016/j.jseint.2022.03.006. eCollection 2022 Jul.. 2022 Apr 25;6(4):675-681.JSES Int.Hoban et al. External validation of the PATHFx decision-support tool on Turkish patients with skeletal metastasis. 2023 Feb 27.Indian J Cancer. Ozkan et al. doi: 10.4103/ijc.IJC_417_20. Previous Next

< Back Femoral Shaft Fractures femoral-shaft-fractures-peds Previous Next

< Back Polytrauma Evaluation Initial assessment and prioritisation of patients with multiple traumatic injuries involving different body systems. Polytrauma refers to the presence of multiple traumatic injuries that may be life-threatening. Evaluation should follow a systematic approach, typically adhering to ATLS protocols . This includes primary survey (ABCDE) , rapid identification of life-threatening conditions, and secondary survey for a more detailed examination. Imaging (e.g., FAST, X-ray, CT) and monitoring tools are critical. Coordination among trauma teams (orthopaedics, general surgery, neurosurgery, etc.) is essential for optimal outcomes. polytrauma-evaluation Previous Next

< Back Dr. Sefa Giray BATIBAY Chemotherapy For Bone Tumors Chemotherapy plays a central role in the multimodal treatment of primary malignant bone tumors, particularly osteosarcoma and Ewing sarcoma. Its main objectives are to eradicate micrometastatic disease, reduce tumor size before surgery, and improve long-term survival. The effectiveness of chemotherapy has transformed previously fatal conditions into potentially curable diseases. Indications Osteosarcoma: Neoadjuvant and adjuvant chemotherapy are standard components of treatment. Ewing Sarcoma: Highly chemosensitive; systemic therapy is essential for all patients. Chondrosarcoma: Generally resistant to conventional chemotherapy; only the dedifferentiated and mesenchymal subtypes may respond. Other rare tumors (e.g., MFH/UPS, Angiosarcoma): Chemotherapy considered in high-grade or metastatic cases. Chemotherapy Timing Type Purpose Typical Use Neoadjuvant Shrink tumor, facilitate limb-salvage surgery, evaluate histologic response Osteosarcoma, Ewing Sarcoma Adjuvant Eliminate residual micrometastatic disease Osteosarcoma Palliative Control symptoms or progression in unresectable/metastatic disease All high-grade sarcomas Evaluation of Response Histologic response is assessed by percentage of tumor necrosis in resected specimens: 90% necrosis → good responder<90% necrosis → poor responder Imaging: MRI and PET-CT can aid in preoperative assessment but are less reliable than pathology. Prognostic impact: Histologic response remains one of the strongest predictors of overall survival. Toxicities and Supportive Care Acute toxicities: Myelosuppression, mucositis, nausea/vomiting, nephrotoxicity (cisplatin), and cardiotoxicity (doxorubicin). Long-term complications: Ototoxicity, infertility, secondary malignancies, and renal or cardiac dysfunction. Supportive strategies: Adequate hydration and mesna for ifosfamide/cyclophosphamide Dexrazoxane for anthracycline cardioprotection Growth factor support (G-CSF) to reduce neutropenia Emerging Therapies Targeted therapy: IGF-1R inhibitors, mTOR inhibitors, and VEGF-targeted agents show limited but growing promise. Immunotherapy: Research into checkpoint inhibitors and cell-based therapies (e.g., CAR-T) is ongoing, particularly in relapsed Ewing sarcoma. Chemo-sensitivity modulation: Nanocarrier drug delivery and combination regimens are under investigation to improve efficacy while minimizing toxicity. Key Points Chemotherapy is mandatory for osteosarcoma and Ewing sarcoma , but ineffective for most low-grade chondrosarcomas . Histologic necrosis after neoadjuvant therapy remains a critical prognostic factor. Ongoing trials aim to optimize drug combinations and identify predictive biomarkers for response. References Bielack SS et al. Osteosarcoma: ESMO Clinical Practice Guidelines. Ann Oncol. 2022;33(12):1344–1356. Ladenstein R et al. Ewing Sarcoma: Current Management and Future Directions. J Clin Oncol. 2021;39(26):3039–3053. Palmerini E et al. Chemotherapy in Chondrosarcoma: When and Why? Eur J Cancer. 2020;140:74–83. Ferrari S et al. MAP and Beyond: New Horizons in Osteosarcoma Chemotherapy. Cancer Treat Rev. 2023;114:102516. Tumor Type Standard Regimen Key Agents Osteosarcoma MAP protocol Methotrexate, Doxorubicin, Cisplatin ± Ifosfamide Ewing Sarcoma VDC/IE alternating protocol Vincristine, Doxorubicin, Cyclophosphamide / Ifosfamide, Etoposide Mesenchymal Chondrosarcoma Ewing-based regimens VDC/IE or VIDE Recurrent Disease Salvage chemotherapy Gemcitabine + Docetaxel, Ifosfamide + Etoposide, or High-dose Ifosfamide Common Regimens Previous Next

< Back Dr. Sefa Giray BATIBAY Osteosarcoma High-grade, malignant, osteoid-producing sarcoma of bone. Most common primary bone sarcoma. Arises predominantly in metaphysis of long bones (esp. around the knee). Epidemiology Bimodal age distribution: Adolescents (10–20y): Most common (~75%) Elderly (>65y): Often secondary to Paget’s, radiation, infarct M:F = 1.5:1 Peak incidence: Distal femur > Proximal tibia > Proximal humerus Epidemiology Bimodal age distribution: Adolescents (10–20y): Most common (~75%) Elderly (>65y): Often secondary to Paget’s, radiation, infarct M:F = 1.5:1 Peak incidence: Distal femur > Proximal tibia > Proximal humerus Aetiology & Genetics Mostly sporadic Associated tumor suppressor mutations: RB gene (Retinoblastoma) TP53 (Li-Fraumeni syndrome) Rare hereditary syndromes: Rothmund-Thomson, Bloom, Werner Histology Malignant mesenchymal spindle cells producing lace-like osteoid High N:C ratio, nuclear atypia, mitoses Diagnostic criteria: Malignant stroma Osteoid production Subtypes INTRAMEDULLARY Conventional (high-grade) Telangiectatic Small-cell Low-grade variants SURFACE Parosteal (low-grade) Periosteal (intermediate-grade) Dedifferentiated surface (high-grade) OTHERS Intracortical (rarest) Extraskeletal (soft tissue OSA, rare, radiosensitive) Clinical Features Progressive pain + swelling , often attributed to trauma Night/rest pain common Mass effect, ↓ROM, neurovascular compromise possible Median delay to diagnosis: ~4 months Imaging X-ray: Mixed lytic–blastic lesion Sunburst , Codman’s triangle , “Hair-on-end” Cortical destruction + soft tissue extension MRI: Assess extent, skip lesions, neurovascular invasion Includes entire bone CT Chest: Mandatory for lung metastasis detection Bone scan / PET-CT: Staging, skip lesions Staging Most are Enneking Stage IIB (high grade, extracompartmental, no mets) Stage III if lung/bone mets Skip lesions → considered metastasis Differential Diagnosis Ewing sarcoma (t(11;22), small round blue cells) Osteomyelitis (sequestrum, Brodie abscess) ABC (vs Telangiectatic OSA) Fibrosarcoma, Lymphoma, EG, Leukemia Labs ↑ ALP & LDH → indicator of high tumor burden Histological response post-chemo: >90% necrosis = good prognosis Biopsy Core biopsy by definitive surgeon Incorrect biopsy track → ↑amputation risk Treatment 1. Neoadjuvant chemotherapy 8–12 weeks: MAP regimen (Methotrexate + Doxorubicin + Cisplatin ± Ifosfamide) 2. Wide resection Limb-salvage preferred Criteria: good chemo response, resectable margins 3. Reconstruction options Endoprosthesis Allograft/autograft Rotationplasty (esp. in children with extensive disease) Amputation (if salvage not possible) 4. Adjuvant chemotherapy Continue for 6–12 months post-op Radiation OSA = radioresistant Reserved for: Extraskeletal OSA Palliative settings Spine/pelvis with close margins Complications Limb salvage: Prosthetic infection (2–10%) Aseptic loosening (esp. tibia) Nonunion/fracture of grafts Local recurrence Rotationplasty: Malrotation Vascular compromise Cosmesis concerns Amputation: Neuroma, phantom pain, wound healing Prognosis 5-yr survival (localized): ~85% (good chemo response) ~65% (general) 5-yr survival (metastatic): ~20% with pulmonary mets Bone mets = poor outcome Prognostic factors: Response to chemo Stage at diagnosis ALP/LDH levels Tumor size/location Surgical margins VEGF or MDR expression Clinical Features Progressive pain + swelling , often attributed to trauma Night/rest pain common Mass effect, ↓ROM, neurovascular compromise possible Median delay to diagnosis: ~4 months References: Whelan JS, Davis LE. Osteosarcoma: Biology, diagnosis, and treatment strategies.Current Oncology Reports. 2018;20(1):2. [DOI: 10.1007/s11912-018-0652-0] Isakoff MS, Bielack SS, Meltzer P, Gorlick R. Osteosarcoma: Current treatment and a collaborative pathway to success. J Clin Oncol. 2015;33(27):3029–3035.[DOI: 10.1200/JCO.2014.59.4895] Orthopaedic Knowledge Update: Musculoskeletal Tumors 4. Eds: Letson GD, Mankin HJ.American Academy of Orthopaedic Surgeons (AAOS), 2016. WHO Classification of Tumours Editorial Board. Soft Tissue and Bone Tumours. WHO Classification of Tumours, 5th Edition, Volume 3. International Agency for Research on Cancer (IARC); 2020. Peabody TD, Attar S, eds.Orthopaedic Oncology: Primary and Metastatic Tumors of the Skeletal System. Cancer Treatment and Research Series. Springer; [Indexed in PubMed/Medline]. Category Subtype Features Intramedullary Conventional Osteosarcoma Heterogeneous histology: may contain cartilaginous, fibrous, giant cell, or small round blue cell components. Telangiectatic Osteosarcoma Resembles aneurysmal bone cyst; blood-filled cavities with scant osteoid lining. Small-cell Overlaps with Ewing sarcoma; small round blue cells producing immature osteoid. Fibrous dysplasia-like High-volume fibrous stroma + immature osteoid. Desmoplastic fibroma-like Low-volume fibrous stroma + immature osteoid. Surface Parosteal Osteosarcoma Low-grade; arises from outer periosteal layer. Periosteal Osteosarcoma Intermediate-grade; from between bone surface and inner periosteum. Dedifferentiated surface High-grade surface variant. Intracortical Intracortical Osteosarcoma Extremely rare; arises within cortical bone. Extraskeletal Extraskeletal Osteosarcoma Soft tissue origin; <5% of all cases; requires wide resection and radiation. Osteosarcoma pathology CT of parosteal osteosarcoma MRI of parosteal osteosarcoma Previous Next

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< Back Dr. Korhan OZKAN / Dr. Krishna A. REDDY Ewing Sarcoma Ewing sarcoma is a high-grade malignant small round cell tumor of bone and soft tissue, primarily affecting children and young adults. It represents the second most common primary malignant bone tumor after osteosarcoma. The hallmark of Ewing sarcoma is a chromosomal translocation involving the EWSR1 gene, most commonly t(11;22)(q24;q12), resulting in the EWSR1–FLI1 fusion gene. Epidemiology Peak incidence: ages 10–20 years . Slight male predominance (M = 1.5:1) . Common locations: diaphysis of long bones (femur, tibia, humerus) and pelvis . Rare in individuals of African or Asian descent. Pathophysiology Arises from primitive neuroectodermal cells (PNET family) . The EWSR1–FLI1 fusion protein acts as an aberrant transcription factor promoting uncontrolled proliferation. Highly aggressive , with early hematogenous metastasis—most often to lungs, bone, and bone marrow. Clinical Features Localized pain and swelling , often progressive and worse at night. Systemic symptoms (fever, fatigue, weight loss) may mimic infection. Palpable mass , warmth, and tenderness in affected region. Pathological fractures in advanced cortical destruction. Imaging Findings Radiographs: Permeative, moth-eaten lytic lesion with cortical destruction. Characteristic “onion-skin” periosteal reaction from layered new bone formation. May exhibit Codman’s triangle or sunburst periosteal reaction in aggressive forms. MRI: Defines intramedullary extent and soft tissue mass . Low-to-intermediate T1 and high T2 signal intensity. Post-contrast enhancement of tumor and surrounding edema. CT and PET-CT: Evaluate cortical erosion, lung metastases , and treatment response . Histopathology Sheets of small round blue cells with scant cytoplasm and round nuclei. Glycogen-rich cytoplasm (PAS positive). CD99 (MIC2) shows strong membranous positivity. EWSR1–FLI1 fusion gene detected via FISH or RT-PCR confirms diagnosis. Differential Diagnosis Condition Distinguishing Feature Osteomyelitis Presence of fever, elevated inflammatory markers, response to antibiotics Lymphoma of bone LCA positive, CD99 negative Small cell osteosarcoma Osteoid production by tumor cells Rhabdomyosarcoma Desmin and MyoD1 positivity Neuroblastoma metastasis Pediatric patients, abdominal primary Treatment Ewing sarcoma requires a multimodal approach combining systemic and local therapy: Neoadjuvant chemotherapy – for tumor control and early metastasis treatment.Standard protocol: VDC/IE (Vincristine, Doxorubicin, Cyclophosphamide / Ifosfamide, Etoposide). Administered for 12–14 cycles over ~10 months. Local controlLimb-salvage surgery preferred if negative margins achievable. Radiotherapy indicated for unresectable lesions or positive margins. Combined surgery and RT may enhance local control but increase complications. Adjuvant chemotherapy Continued systemic therapy post-surgery for micrometastatic disease. Prognosis Localized disease: 5-year survival ~70–75%. Metastatic disease: 5-year survival ~25–30%. Poor prognostic indicators: Metastases at presentation (especially to bone or bone marrow) Large tumor size (>8 cm) Pelvic location Poor histologic response to neoadjuvant chemotherapy (<90% necrosis). Key Points Second most common primary malignant bone tumor in youth. Defined by EWSR1–FLI1 fusion and CD99 positivity . Managed with VDC/IE chemotherapy and limb-salvage surgery. Prognosis strongly linked to metastatic status and histologic response. References Ladenstein R et al. Ewing Sarcoma: Current Management and Future Directions. J Clin Oncol. 2021;39(26):3039–3053. Gaspar N et al. Ewing Sarcoma: ESMO–EURACAN Clinical Practice Guidelines. Ann Oncol. 2022;33(12):1344–1358. Balamuth NJ, Womer RB. Ewing’s Sarcoma. Lancet Oncol. 2010;11(2):184–192. Patel SR, Benjamin RS. Chemotherapy for Bone Sarcomas: Ewing and Beyond. Cancer Treat Rev. 2023;115:102521. Previous Next

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< Back Forearm (Monteggia, Galeazzi) Monteggia and Galeazzi fractures represent classic forearm injury-dislocation patterns requiring precise diagnosis and surgical fixation. Early mobilization and functional recovery are critical goals. forearm-monteggia-galeazzi Previous Next