Diagnostic Approach to Musculoskeletal Tumors

Nur Fatini bt Chok 11 2011 142

Department of Surgry RSUD Ciawi July August 2013 Acknowledgments

Alhamdulillah, thanks to God because allowed me to submit this manuscript within the time given. Although there were a lot of things to settle down within this seven weeks, He had help me to sFpent some time to finish this manuscript. Second, I would like to thank to my consulant, dr. Dhevariza, the Orthopedist who sincere and faithfully guide and help me to write this manuscript. Not forgotten, thank you to my team-mate, who had help me in order to finish up this manuscript. Thank you for all your ideas and discussion that we had about this topic.

Sincerely,

The consulant,

(Nur Fatini Binti Chok)

(dr. , Dhevariza, the Orthopedist )

Introduction Musculoskeletal tumors are a rare and diverse group. Sarcomas of the bone and cartilage comprise only 0.5% of all malignancies in humans. Their incidence is considerably higher

in children than adults. The incidence of soft tissue sarcomas is 3 to 4 times higher, and the majority of these cases are seen after the fifth decade. Benign bone and soft tissue tumors are 100 times more common than malignant tumors, with an overall incidence of 300 per 100,000 population. The incidence per year of breast, prostate, and lung cancers in the United States of America is nearly 180,000 to 200,000 each, reflecting the low incidence of primary bone and soft tissue tumors. As the survival of patients with carcinomas is gradually extending, presentation with bone metastases will also rise. A general orthopedic surgeon or radiologist in the community may encounter only few cases of bone tumors per year. Patients with an unknown musculoskeletal tumor should be referred to a specialist center, because the cases are managed in close interaction between the orthopedic oncologist, radiologist, and the pathologist, and the outcomes are superior.2 This approach will often eliminate unnecessary diagnostic studies and inappropriate and inadequate biopsies, which may delay the diagnosis and adversely affect the outcome.

Approach to Bone Tumor Diagnosis

General Considerations:

Bone Tumors can be divided into primary and secondary. Secondary tumors can be further subdivided into Metastatic tumors Tumors resulting from contiguous spread of adjacent soft tissue neoplasms Tumors representing malignant transformation of the pre-existing benign lesions.

Metastatic cancers are the most frequent malignant tumors found in bone. They are by far more common than primary bone tumors and are characterized by the following: Predominant occurrence in two age groups: adults over 40 years of age and children in the first decade of life. Multifocality and predilection for the hematopoietic marrow sites in the axial skeleton (vertebrae, pelvis, ribs and cranium) and proximal long bones. Metastases to long bones distal to the elbows and knees are unusual. Metastases to the small bones of the hands and feet are even rarer. Occasionally, metastases may appear as solitary lesions (particularly true for the lung, kidney and thyroid cancer).

Most common malignancies producing skeletal metastases: Adults More than 75% of skeletal metastases originate from carcinomas of the prostate, breast, kidney, and lung. Also common are metastases from thyroid and colon cancers. And do not forget melanoma. Children Neuroblastoma, rhabdomyosarcoma, and Retinoblastoma

Radiographic appearance of the metastatic tumors can be : Purely lytic (kidney, lung, colon, and melanoma) Purely blastic (prostate and breast carcinoma) Mixed lytic and blastic (most common appearance)

Primary bone tumors are characterized by the following: 1. Predominant occurrence in the first 3 decades of life, during the ages of the greatest skeletal growth activity. The commonest sites for many primary tumors, both benign and

malignant, are in the distal femur and proximal tibia, the bones with the highest growth rate. 2. Relatively specific radiographic presentations. In some cases, the diagnosis can be confidently made based on the radiographic features alone. 3. Benign tumors are by far more common than malignant ones. Some of them are not true neoplasms, but rather represent hamartomas (eg., osteochondroma). The most common benign tumors are osteochondroma, non-ossifying fibroma, and enchondroma. 4. Some primary bone tumors are difficult to classify as benign or malignant. For example, giant cell tumor of bone is very aggressive locally but only rarely metastasizes. 5. Among primary malignant neoplasms, osteosarcoma and multiple myeloma have the highest incidence, followed by chondrosarcoma and Ewing's sarcoma.

Two important features of bone tumors: 1. The ability of some to dedifferentiate (eg., enchondroma or a low-grade chondrosarcoma transforming into a high-grade sarcoma) 2. Tendency of high-grade sarcomas to arise in damaged bone, at the sites of bone infarcts, radiation osteitis and Paget's disease.

Relevant clinical information 1. Age (probably the most important clinical clue).

Age group 0 10

Most common benign Lesions simple bone cyst eosinophilic granuloma

Most common malignant tumors Ewing's sarcoma leukemic involvement metastatic neuroblastoma

10 20

non-ossifying fibroma fibrous dysplasia simple bone cyst aneurysmal bone cyst osteochondroma (exostosis) osteoid osteoma

osteosarcoma, Ewing's sarcoma, Adamantinoma

osteoblastoma chondroblastoma chondromyxoid fibroma 20 40 Enchondroma giant cell tumor 40 and above Osteoma metastatic tumors myeloma leukemic involvement chondrosarcoma osteosarcoma (Paget's associated) MFH Chordoma chondrosarcoma

Summary: Primary osteosarcoma and Ewing's sarcoma are tumors of children and young adults. Occurrence of chondrosarcomas in children or Ewing's sarcoma in middle-aged patients is extremely unusual. In individuals older than 40 years, the commonest form of skeletal malignancy is metastatic cancer. Of the primary bone tumors in this age group, multiple myeloma and chondrosarcoma are most commonly encountered. Osteosarcomas in this age group are often secondary malignancies, which develop at the the sites of bone damage. Giant cell tumor, a locally aggressive lesion, almost exclusively occurs in skeletally mature patients, 20 to 50 years of age, with closed epiphyses. It is practically never seen in children or patients older than 60 years.

2. Pain (although a non-specific symptom, it may help in differential diagnosis) Generally, benign non-growing lesions tend to be asymptomatic and represent incidental findings. Pain may be a symptom of: Growing lesions. This category includes locally aggressive lesions (eg., aggressive osteoblastoma and GCT), and malignant tumors Pathologic fracture complicating either benign or malignant tumor Significant local tissue reaction to the tumor.

The following clinical symptoms are worth remembering since they may help in the differential diagnosis: Osteoid osteoma - small lesion, but highly irritative to adjacent tissues and typically causes intense night pain relieved by non-steroidal antiinflammatory drugs. Osteoid osteomas may also occur close to the articular surface of a joint, causing severe inflammatory synovitis, which often obscures the presence of the tumor. Enchondroma vs. chondrosarcoma, grade 1 - histologically, the distinction between a grade 1 chondrosarcoma and an enchondroma is extremely difficult, as histologic features overlap considerably. The distinction is based on the behavior of the lesion. One of the clues to clinical behavior is the presence of pain. Lowgrade chondrosarcoma is a growing tumor and, therefore, presents with pain. Enchondromas tend to be asymptomatic, unless associated with a pathologic fracture.

3. Multiple lesions Although both benign and malignant tumors may be multifocal, benign lesions tend to show symmetrical distribution.

Radiological correlation

The following imaging studies are commonly used in evaluation of bone tumors: 1. Plain radiograph usually the first imaging technique for a suspected bone lesion since it is inexpensive and easily obtainable. It is also the best for assessment of general radiological features of the tumor. 2. Computer tomography is a method of choice when plain film assessment is difficult owing to the nature of the lesion (eg., permeative pattern of destruction) or anatomic site (eg., sacrum). In addition, CT is the best technique in assessment of matrix mineralization, cortical detail, and detection of the cystic and fatty lesions. 3. MRI ( method of choice for local staging. ) It is superior to CT in the definition of medullary and extracortical spread and of the relationship of the tumor to critical neurovascular structures. However, remember that the

MRI appearances of the majority of bone tumors are totally non-specific. You need to examine plain films or CT films to define a neoplasm. 4. Bone scintigraph is a highly sensitive but relatively non-specific technique. Its main role is in detection of suspected metastases in the whole skeleton. It may also be helpful in the detection of osteoid osteomas ("double density sign" is present in about 50% of cases and is highly suggestive of this tumor).

Tabel 1 : Morphology of a bone lesion is combined with the age of the patient.

Radiographic examination should answer the following questions:

 What is the precise location of the lesion (type of bone and, if the long bone is affected, where exactly the lesion is centered - cortex or medulla; epiphysis, metaphysis or diaphysis)? Some tumors almost exclusively occur at specific sites; many oth ers favor certain locations. Is there any evidence of underlying bone abnormality (eg., bone infarct, Paget's disease)? High-grade sarcomas tend to arise in damaged bone. Is the lesion multifocal? Does the tumor have a well-defined margin? Is there a rim of sclerotic bone? The presence of a well-defined margin and a sclerotic rim strongly suggests a benign nongrowing lesion. Is there evidence of significant cortical expansion or destruction? These findings are seen with locally aggressive or malignant tumors. Is there an associated periosteal reaction and, if so, of what type? Does the lesion produce mineralized matrix (osteoid or cartilage)? Is there a soft tissue mass?

In many cases, the radiographic appearance of the lesion provides clues to its clinical behavior. It allows estimation of tumor growth rate and discloses expansive or infiltrative growth patterns characteristic of locally aggressive and malignant tumors.

Skeletal location

While many lesions favor certain bones, some tumors almost exclusively occur at specific sites : Lesions Ewing's sarcoma Multiple myeloma Leukemia/lymphoma Metastatic cancers Most common skeletal sites Hematopoietic marrow sites in the axial skeleton (vertebrae, ribs, sternum, pelvis, cranium) and proximal long bones (femur, humerus) Non-ossifying fibroma Metadiaphyseal regions of the tibia and distal femur (80%) Does not occur in the flat bones, craniofacial bones, the spine, or the small bones of the hands/feet.

Simple bone cyst

The vast majority of SBCs is found in the proximal humerus (55%) and proximal femur (20%).

Chordoma Adamantioma Chondroblastoma

Base of the skull or sacrum(90%) Mid-shaft of tibia (90%), jaw bones Long bones (knee area, proximal humerus)-70%

Giant cell tumor Enchondroma

Knee area, distal radius (65%) Small bones of the hands and feet (60%). This is in fact the commonest tumor at these sites.

Chondrosarcoma (primary, and to the less extent secondary)

Tends to develop in the axial skeleton with 25% to 30% occurring in the pelvic bones

Fibrous dysplasia Ostochondroma

Femur, tibia, skull and ribs Knee area, proximal humerus, Pelvis

Osteoblastoma Aneurysmal bone cyst

Spine (30%), mandible, long bones Any bone; common in the Spine

Chondromyxoid fibroma

Knee area (30%), pelvis, small bones of the feet

Hemangioma

Spine, craniofacial bones

Site of Long Bone Involvement (most primary bone tumors have favored sites within long bones; this may provide a clue to diagnosis).

Epiphyseal lesions: 1. Chondroblastoma (Ch) and Giant Cell Tumor (GCT) are almost invariably centered in the epiphysis. 2. Chondroblastoma is a rare tumor seen in children and adolescents with open growth plates. GCT is the most common tumor of epiphyses in skeletally mature individuals with closed growth plates. GCT often shows metaphyseal extension. Metaphyseal intramedullary lesions: 1. Osteosarcoma is usually centered in the metaphysis. 2. Chondrosarcoma and fibrosarcoma often present as metaphyseal lesions. Osteoblastoma, enchondroma,

fibrous dysplasia, simple bone cyst, and aneurysmal bone cyst are common in this location. Metaphyseal lesions centered in the cortex: Classic location for a non-ossifying fibroma (NOF). Also, a common site for osteoid osteoma. Metaphyseal exostosis: Osteochondroma Diaphyseal intramedullary lesions: Favored location for Ewing's sarcoma, lymphoma, myeloma. Common for fibrous dysplasia and enchondroma. Diaphyseal lesions centered in the cortex: Adamantinoma, osteoid osteoma

Pattern of Growth and Bone Destruction

Benign and non-growing (or extremely slowly growing) lesions are well circumscribed and show geographic pattern of bone destruction with a sclerotic rim. 1. Geographic pattern refers to a welldefined area of lysis. 2. The sclerotic rim is more commonly seen in the weight-bearing bones and represents bone reaction to the lesion. Its presence means that the bone has been given sufficient time to react. Some authors say that the sclerotic rim signifies benignancy to about 95%. If the lesion is growing more rapidly,it may still show a well-demarcated zone of bone destruction (geographic pattern), but it will lack a sclerotic rim. With continued growth, such lesions may show cortical expansion. Expansile growth pattern is defined as visible widening of the affected portion of bone. In many cases, an interrupted periosteal rim will surround the expanded portion of bone. This pattern may be seen in locally aggressive tumors and in lowgrade malignancies.

Rapidly growing lesions are poorly defined and may show aggressive, infiltrative

patterns of bone destruction (permeative or "motheaten"). "Moth-eaten" pattern is defined as an illdefined zone of multiple small radiolucencies that may coalesce.

Permeative

pattern

is

characterized

by

numerous tiny radiolucencies in between the residual bone trabeculae. Due to the minute size of radiolucencies the lesion may be difficult to see and to delineate on the plain film. Generally, the more rapidly growing a lesion, the more difficult it is to see on plain film. "Moth-eaten" and permeative patterns are indicative of destruction involving both medullary and cortical bone. They are seen in highgrade malignant neoplasms and in osteomyelitis.

Types of Periosteal Reaction The periosteum responds to traumatic stimuli or pressure from an underlying growing tumor by depositing new bone. The radiographic appearances of this response reflect the degree of aggressiveness of the tumor.

Slow-growing tumors provoke focal cortical thickening (solid periosteal reaction, or "buttress")

Rapidly growing lesions penetrate through the cortex causing separation of the periosteum and formation of lamellated new bone. If the periosteum elevates to a significant degree, it can break forming an acute angle (Codman's triangle). This is seen in malignant bone tumors and in some other rapidly growing lesions such as aneurysmal bone cyst, or in reactive processes (osteomyelitis, and subperiosteal hematoma). Codman's triangle is usually free of tumor unless infiltrated through its open end or by transcortical growth.

Other types of periosteal reaction in response to a rapidly growing lesion include "onion-skinning" and spiculated "hair-on-end" types.

Note that bone metastases usually do not provoke a periosteal reaction.

Pattern of matrix Mineralization Mineralization patterns (calcification or ossification) are helpful in identification of bone producing and cartilage producing tumors.

Osteoid. Malignant osteoid can be recognized radiologically as cloudlike or ill-defined amorphous densities with haphazard mineralization. This pattern is seen in osteosarcoma. Mature osteoid, or organized bone, shows more orderly, trabecular pattern of ossification. This is characteristic of the benign boneforming lesions such as osteoblastoma. Chondroid. Radiologically, it is usually easier to recognize cartilage as opposed to osteoid by the presence of focal stippled or flocculent densities, or in lobulated areas as rings or arcs of calcifications. They are best demonstrated by CT. Whatever the pattern, it only suggests the histologic nature of the tissue (cartilage) but does not reliably differentiate between benign and malignant processes.

General Histologic Assessment of the Lesion

The following are the most important histologic features to consider: Pattern of growth (eg., sheets of cells vs. lobular architecture) Cytologic characteristics of the cells Presence of necrosis and/or hemorrhage and/or cystic change Matrix production Relationship between the lesional tissue and the surrounding bone (eg., sharp border vs. infiltrative growth)

You should never try to make a diagnosis of bone tumor without integrating clinical, radiological, and histologic appearances. Biologically different types of tumors may have overlapping histologic features. Always obtain a list of differential diagnoses from a radiologist, make a habit of reviewing the films, and develop a good working relationship with an orthopedic surgeon. You are a part of a team.

Soft Tissue Mass Introduction A soft tissue mass is one of the most common manifestations of a musculoskeletal tumor. Proper diagnosis and treatment are essential to avoid the potential for loss of limb function and to maximize the opportunity to cure a soft tissue sarcoma. The large majority of soft tissue tumours are benign, with a very high cure rate after surgical excision. Malignant mesenchymal neoplasms amount to less than 1% of the overall human burden of malignant tumours but they are lifethreatening and may pose a significant diagnostic and therapeutic challenge since there are more than 50 histological subtypes of STS, which are often associated with unique clinical, prognostic andtherapeutic features. Over the past decade, our understanding of these neoplasms has increased significantly, both from a histopathological and genetic point of view. Careful physical examination and radiographic evaluation to evaluate the size, depth and location of the mass, along with signs of neurovascular involvement are essential for designing the best therapeutic approach. History When obtaining the patient history, consider: 1. The patient's age. Infants and children may present with benign lesions that can demonstrate local growth, disfigurement, overgrowth of the extremity or loss of function (lipomas, hemangiomas, lymphangiomas, neurofibromas, hamartomas, congenital or infantile fibromatosis). Soft tissue sarcoma is extremely rare in children, but when it occurs, it is most likely to be rhabdomyosarcoma. In adults, rhabdomyosarcoma is rare in the extremities. 2. The length of time that the lesion has been present. The patient may have had a benign soft tissue lesion for several years that has not grown during that time. He or she may finally decide to "get this bump looked at," or may be encouraged to consult a physician by a spouse or a friend. The pattern of growth is important: A mass that has been present for years and that begins to grow may be transforming from a benign to a malignant lesions, or it may simply be growth of a benign soft tissue tumor. Rapid growth may also indicate that the mass may be malignant. Growth of a soft tissue tumor, therefore, warrants further evaluation.

3. The presence of pain. Although often tender to direct pressure, a soft tissue tumor itself rarely causes the patient pain. The exceptions are peripheral nerve sheath tumors and rapidly growing soft tissue sarcomas, which may cause pressure on surrounding structures and intra-compartmental compression. If the patient is experiencing pain, also consider other diagnoses, such as infection. 4. A history of trauma. Chronic repetitive trauma to the soft tissues may cause reactive fibrosis; a more acute, severe injury may suggest myositis ossificans. It is not unusual for a patient to discover a soft tissue mass after a major or minor trauma to the anatomical area -- or to mistakenly believe that the injury caused the lesion. If the mass persists following trauma, a complete workup is needed to establish whether it is related to the trauma (such as a persistent hematoma) or is, in fact, a soft tissue tumor. Ask about a past history of penetrating trauma or infection -- an old soft tissue infection or foreign body reaction may lead to the late presentation of a calcified soft tissue mass. 5. Possible generalized conditions. Neurofibromatosis is the best example of a generalized disease that may be associated with one or more soft tissue masses. A patient with this disease may present with benign growth of a plexiform neurofibroma, or alternatively, a benign nerve sheath tumor may transform into a neurofibrosarcoma. Multiple soft tissue benign myxomas may develop in a patient with extensive fibrous dysplasia of the bones and cafe au lait spots (possibly associated with premature onset of menses in the McCune-Albright syndrome). A patients with Maffucci's syndrome (multiple bone enchondromas associated with soft tissue hemangiomas) may present with transformation of a hemangioma to angiosarcoma. 6. Family history of soft tissue masses. This is particularly pertinent to the diagnosis of neurofibromatosis. In some cases of familial cancer syndromes (Li-Fraumeni syndrome related to the inheritance of a mutant p53 allele, for example), family members may have a high risk of developing soft tissue sarcoma as well as other forms of cancer.

Physical Examination The physical examination of a patient with a possible soft tissue tumor includes the following: 1. Depth. One of the most critical aspects of the physical examination is determining whether a lesion arising deep to dermis is superficial or deep to fascia; most lesions developing superficial to fascia are benign. In making this determination, attempt to move the lesion over the fascia, both before and after the patient tenses the underlying muscle. If the lesion moves with the muscle, it is likely deep to fascia. In some instances, it may be impossible to tell if the lesion is deep or superficial; the lesion may even arise from the fascia. As discussed below, the investigation and management of soft tissue lesions depends on the depth of the mass. Those arising deep to fascia have the greatest risk of malignancy. If the physical examination indicates that the lesion arises in fascia, deep to fascia, or is uncertain, obtain imaging of the mass. 2. Size. After determining the depth, document the clinical size of the lesion in three dimensions. Evaluate the condition of the overlying tissues, determining whether there is evidence of inflammation that suggests either soft tissue infection or a rapidly growing tumor. Tenderness could also indicate a rapidly growing tumor, a peripheral nerve sheath tumor, or infection. Observe the surrounding skin for evidence of vascular changes that may suggest multiple vascular malformations. Particularly in children, document evidence of extremity overgrowth, including measurement of the extremity length and diameter. 3. Distal neurovascular status. Test for a nerve deficit or evidence of venous or arterial obstruction by evaluating distal neurovascular status. Soft tissue tumors rarely cause a neurological deficit. Instead, nerve deficit usually indicates that the tumor is arising in the peripheral nerve or is invading the nerve. Examine the skin should for evidence of cafe au lait spots, dermatofibromas, or axillary freckling, which may suggest neurofibromatosis or, in the case of cafe au lait spots, fibrous dysplasia. 4. Regional nodes. Palpate the regional nodes, although soft tissue sarcomas rarely metastasize by lymphangitic spread. Rhabdomyosarcoma and synovial sarcoma are the most likely diagnoses if nodal metastases are found. Examine the other extremities and trunk for soft

tissue masses; lipomas -- and less commonly liposarcoma -- may present in multiple sites. Advanced metastatic carcinoma or lymphoma may spread to the non-nodal soft tissues; therefore, evidence of a primary cancer elsewhere must be evaluated on both history and physical examination. 5. Dermatological lesions. The only dermatological lesion related to musculoskeletal tumors is dermatofibrosarcoma protuberans. This lesion is elevated above the dermis, purplish in color, and characteristically develops satellite nodules as it grows. It behaves like a low-grade soft tissue sarcoma and is generally managed in a similar manner. Subcutaneous malignant fibrous histiocytomas may also result in invasion of the dermis, but generally malignant mesenchymal lesions do not develop primarily in the skin. Investigations Results of the history and physical examination will guide the next steps: 1. Lesion Less than 5 cm in Diameter Observation is appropriate for this size lesion if it is also soft in consistency, superficial to fascia, not enlarging, and not cosmetically or functionally troubling. Measure and record the size of the lesion annually for 2 or 3 years. If a lesion this size bothers the patient or is firm, painful, or enlarging, it can generally be removed by excisional biopsy , taking care to avoid violating the underlying fascia. Send the specimen for appropriate pathological analysis, and if the pathologist determines it to be a soft tissue sarcoma, locally curative management can then be achieved by re-excising the surgical scar and incorporating the fascia as a deep margin. Avoid excisional biopsy and obtain imaging and a needle or incisional biopsy prior to excision if the lesion is located in an anatomical region that would preclude later re-excision (for example, if a small lesion is located directly over the bone in the subcutaneous tissues overlying the ulna or tibia). 2. Superficial Lesion Larger than 5 cm in Diameter Before attempting excision, evaluate a lesion this size by magnetic resonance imaging (MRI) . MRI is more appropriate for evaluating soft tissue tumors than computerized tomography (CT) scan because the enhanced soft tissue contrast of MRI allows for optimal demarcation of the lesion from surrounding normal soft

tissues and for assessment of possible neurovascular involvement. It is likely that a superficial lesion greater than 5 cm is lipoma. If this is confirmed by MRI, the lesion may be observed or treated by excisional biopsy, depending on growth characteristics and patient preference. 3. Needle or incisional, rather than excision al, biopsy should be undertaken if the lesion does not demonstrate a lipoma's typical well-demarcated, homogeneous pattern of fat on MRI, or if there are any regions of high (bright) T2-weighted signal within the fat of the tumor. Critically evaluate whether there is any evidence of edema surrounding the superficial tumor. If the margin with normal surrounding subcutaneous fat is not sharp and discrete on MRI, a biopsy should be done prior to excision. 4. Lesion Attached to Fascia, Deep to Fascia, or Depth Unknown MRI should be undertaken to diagnose the lesion. The potential diagnoses for deep lesions include benign conditions (intramuscular lipoma, hemangioma, myxoma, benign peripheral nerve sheath tumor), benign aggressive tumors likely to recur locally after simple excision (fibromatosis, hemangiopericytoma), and soft tissue sarcoma. Effective treatment of many of these lesions will include wide surgical excision, and the likelihood of achieving adequate surgical removal with minimal functional deficit is enhanced if the patient is initially evaluated with MRI and carefully planned biopsy. Conversely, it may be very difficult to perform adequate surgical excision with conservation of function if the initial treating physician performed an excisional biopsy of a subfascial sarcoma, which would cancer cells throughout the extremity. If the depth of the lesion is not apparent on physical examination, the clinician should err on the side of ordering imaging before attempting a biopsy. Suspected or Confirmed Diagnosis of Soft Tissue Sarcoma In these cases, metastatic staging with chest CT is necessary. Lymphatic spread to nodal groups may be assessed clinically and, if suspected, assessed by CT scan. If there is a history of trauma in a patient with a soft tissue mass, plain radiographs may demonstrate the typical peripheral ossification pattern seen in myositis ossificans. In most cases of soft tissue masses however, plain radiographs are of little value, although they may demonstrate increased soft tissue lucency caused by a large fatty lesion or the calcification occasionally observed in lipomas, liposarcomas, or synovial sarcomas. Bone scans are not useful in most cases either, since soft tissue tumors rarely invade the bone cortex. If the bone cortex is invaded, a CT scan may be more useful than either a bone scan or an MRI because a

CT scan usually gives the best anatomical definition of the extent of bony destruction. In general, though, MRI is the most effective imaging modality for soft tissue masses. Blood work is not usually helpful in the diagnosis of soft tissue masses, although a complete blood count, ESR and C-reactive protein may be helpful if infection is suspected. Patients with myositis ossificans or soft tissue osteosarcoma may have an elevated serum alkaline phosphatase. Conclusion In summarizing the investigation of patients with soft tissue masses, the following guidelines are suggested:

If the lesion originates in or deep to fascia, or if the depth is uncertain, cross-sectional imaging should be ordered.

1.

If the lesion is superficial to fascia and larger than 5 cm, imaging should be undertaken. In our experience, MRI is preferred to CT. However, if MRI is not available, CT is often sufficient for initial investigation.

After localizing the lesion anatomically, it is necessary to obtain a biopsy of most deep lesions. An initial biopsy for superficial lesions that are greater than 5 cm is also suggested. Deep soft tissue lesions should never be treated with an excisional biopsy. Doing so makes definitive management much more difficult and therefore should be avoided.

WHO classification of soft tissue tumours

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2.

Violetta Barbashina, Joseph Benevenia, Meera Hameed ( 2004 ). Bone Tumors Tutorial for Residents. Retrieved from http://www.umdnj.edu/tutorweb/ HJ, Robih Smithuis ( 2010 ). Bone Tumors Systemic Approach and Diagnosis. Retrieved from http://www.radiologyassistant.nl/ en/

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Woulde

Differential
4.

p494e15cbf0d8d Soft tissue mass. Retrieved from http://www.orthopaedicsone.com /display/ Main/ Soft+tissue+mass