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Saturday, October 30, 2010

ENNEKING STAGING OF MUSKULOSKELETAL TUMOURS

The Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G), site (T), and metastasis (M) and uses histologic, radiologic, and clinical criteria.

Grade

In the Enneking system, bone tumors are graded as follows:

  • G0 - Benign lesion
  • G1 - Low-grade malignant lesion
  • G2 - High-grade malignant lesion

Surgical grade generally follows histologic grade; however, a higher surgical grade may be applied if the radiographic features and clinical behavior of a lesion indicate an aggressiveness that is incompatible with its benign histologic features.

Site

In the Enneking system, the site and local extent of bone tumors are classified as follows:

  • T0 - A benign tumor that is confined within a true capsule and the lesion's anatomic compartment of origin (ie, a benign intracapsular, intracompartmental lesion)
  • T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie, an intracompartmental lesion)
  • T2 - A lesion that has spread beyond its anatomic compartment of origin (ie, an extracompartmental lesion)

Metastasis

Metastatic classification in the Enneking system is as follows:

  • M0 - No regional or distant metastasis
  • M1 - Regional or distant metastasis

Benign:
1 Latent G 0 T 0 M 0
2 Active G 0 T 0 M 0
3 Aggressive G 0 T 1-2 M 0-1

Enneking's Staging System of Malignant Bone Tumors
Ia Low grade, intracompartmental G 1 T 1 M 0
Ib Low grade, extracompartmental G 1 T 2 M 0
IIa High grade, intracompartmental G 2 T 1 M 0
IIb High grade, extracompartmental G 2 T 2 M 0
IIIa Low or High grade, intracompart. G 1-2 T 1 M 1
w/ metastases.
IIIb Low or High grade, extracompart. G 1-2 T 2 M 1
w/ metastases.

The Enneking classification correlates the tumor stage with the excision margins as follows:

  • Benign tumors
    • Stage 1 tumors - Intracapsular excision (or curettage) is adequate.
    • Stage 2 tumors - Extracapsular excision passing through the reactive zone is needed.
    • Stage 3 tumors - Wide margins of resection are required in stage 3 lesions (aggressive benign tumors). In areas that are not amenable to wide excision, marginal excision together with adjuvant treatment (eg, radiation therapy) may be acceptable.
  • Malignant tumors
    • Stage IA - These tumors are treated with wide excision and are usually amenable to limb salvage procedures.
    • Stage IB - Such tumors may be treated with wide excision, but the choice between amputation and limb salvage depends on the estimated amount of residual tumor left behind after a limb salvage procedure.
    • Stage II - These tumors are high grade, are usually extracompartmental, and have a significant risk for skip metastases. They usually are not amenable to limb salvage operations and require radical amputation or disarticulation in most patients. However, bone tumors responsive to chemotherapy may be treated successfully using wide excision and adjuvant therapy.
    • Stage III - Tumors at this stage are responsive to chemotherapy and may be treated with aggressive resection. Those that are not responsive to adjuvant therapy should be treated with palliative resection.

Saturday, October 2, 2010

MNEUMONICS FOR PHAECHROMOCYTOMA

Phaechromocytoma is a rare tumor. It is the tumor of the adrenal medulla of adrenal glands. It produces epinephrine and/or norepinephrine. Approximately 90% of the tumor arise from the adrenal glands itself while the rest occur at extra adrenal.

Clinical features of phaechromocytoma = 5H

H = Headache

H = Hypertension (non paroxysmal in up to 50%, may paradoxically worsen following beta blocker)

H = Hypotension (orthostatic) – in up to 50%

H = Heart beat awareness (tachycardia)

H = Hyperhidrosis

Phaechromocytoma = Rule of 10’s

10% malignant (histology not predictive)

10% extra adrenal (greater risk of malignancy)

10% familial usually non secretory

10% bilateral

10% multiple

10% occur in children

10% are normotensive

Complication of phaechromocytoma = 7C

C = Constipation

C = Cardiomegaly

C = Cerebral hemorrhage

C = Cholelithiasis

C = Chronic renal failure

C = Carcinoma of thyroid

C = Cushing syndrome