Thanks to Alex Liddle for this excellent presentation discussing how to critique a scientific paper.
We have compiled the following unofficial guide to trainees coming to an Orthopaedic Oncology attachment. It contains key topics in the curriculum to which you may get exposure in the attachment, competence levels for surgical procedures and other useful information.
- Know the diagnosis
- Consider other modalities of treatment
- Treat the whole bone
- Assume it won’t heal
- Avoid load sharing devices (eg DHS)
- Where is the lesion?
- How large is the lesion?
- What is the lesion doing to the bone?
- What is the bone doing in response?
- Is the lesion making matrix?
- Is the cortex eroded?
- Is there a soft tissue mass?
The MSTS (Enneking) staging system for sarcomas is another exam classic. This is a very straightforward system which allows the user to describe the extent of the tumour locally and systemically. Tumours are either low grade (Stage 1, <15% risk of metastasis), high grade (Stage 2, >15% risk of metastasis) or metastatic (Stage 3).
Intracompartmental tumours are classified as “A” and extracompartmental tumours as “B”.
For example, an osteosarcoma of the distal femur, which has an associated soft tissue mass but no detectable metastases would be staged as “2B” in this system.
Other systems include the AJCC system for staging.
Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint Surg Am 1980;62(6):1027-30.
The description of surgical margins requires an understanding of the local behaviour of sarcomas. Classically, sarcomas grow centrifugally, and around the central tumour is a “reactive zone” comprising compressed normal tissues, inflammatory cells and small numbers of tumour cells. Tumours also tend to stay within osteofascial anatomical compartments. These concepts were popularised by Enneking, in the era before the widepsread availability of cross-sectional imaging.
The text-book answer is that surgical margins are described as follows:
- Intralesional – when the resection passes through tumour
- Marginal – when the resection passes through the reactive zone
- Wide – when the resection passes through normal tissue
- Radical – when the whole of the involved compartment is removed.
However, given that the majority of tumours are close to critical neurovascular structures for at least part of their circumference, most resections are technically marginal. A more helpful description is often whether or not the margin is microscopically positive (tumour at or within 1mm of the resection margin) or microscopically negative.
The surgical margin achieved is the strongest predictor of the risk of local recurrence in several large series.
Taking a history from a patient with a suspected bone or soft tissue tumour requires a different emphasis from the rest of orthopaedics. Particular features to note include:
- Length of history (is this a preexisting mass that has changed?)
- Rate of growth
- Pain history (site, character, severity, radiation, modifying factors, periodicity – is there mechanical or night pain?)
- Previous surgery at the site of interest (ie is this a local recurrence?)
- History of malignancy (could this be a metastasis?)
- History of a predisposing condition (eg Hereditary Multiple Exostoses)
- Previous radiotherapy
- Family history (think inherited disorders like Li Fraumeni syndrome)
- Symptoms suggestive of malignancy (eg weight loss, lethargy)