Moderators: Daniel M. Sciubba, MD, Joseph H. Schwab, MD
This interactive session will start with a pre-test with audience participation. The same questions will be asked at the end of the session (pre/post-test). Four cases will be presented and the cases will serve as topics for interactive discussion. One of the faculty will be presenting the case while the two chairs will walk around with a microphone and ask for volunteers to answer the questions as they arise during the case. Each case will cover a particular pathology or approach to pathology. We will start with an unknown lesion of the mobile spine (case 1) and then sacrum (case 2). Both cases will involve various scenarios that arise in the diagnosis, workup, and treatment of the lesion. This will include staging, biopsy, surgical timing, etc. We will present a malignant primary as case 1 and a benign primary as case 2; after this the audience should be comfortable with the approach to an unknown lesion in the spine and sacrum (both malignant and benign). With case 3 we will introduce an insufficiency fracture that may be pathologic. This patient may have one or more insufficiency fractures, and the case will take the participants through an approach to work up such a patient. The case may end, for example, with the diagnosis of hyperparathyroidism from a parathyroid tumor. Finally, we will end with an unknown lesion about the neural elements (case 4), as participants work through an unknown primary tumor about a nerve root (schwannoma, MPNST, etc.). At the end of the four cases the post-test will be given.
Upon completion of this session, participants should gain strategies to:
- Perform appropriate workup/treatment of spinal tumors of unknown origin (malignant and benign);
- Consider appropriate factors in work up for a patient with newly diagnosed vertebral insufficiency fracture;
- Learn the criteria for diagnosis and treatment options for pathologic insufficiency fractures;
- Learn an approach to high grade spinal cord compression from metastatic tumor;
- Perform appropriate workup/treatment of tumors about the neural elements.
Agenda
Introduction
Daniel M. Sciubba, MD, Joseph H. Schwab, MD
Pre-Test
Daniel M. Sciubba, MD, Joseph H. Schwab, MD
Case 1: Lesion of Unknown Origin in Spine
Matthew L. Goodwin, MD, PhD
- Present case, lesion of unknown origin in mobile spine. Present classic case of new lesion and some neurologic deficits. Titrate scenarios and determine when you go to OR without path. What about without properly staging (CT CAP, MRI entire spine, SPEP, UPEP)? Case will be primary tumor of the spine. Treatment? En bloc? Can we use BMP? What about in a few years if clean margins? Any data for BMP causing increased cancer risk here? Vascularized graft? Expandable vs harms cage? Allografts? Role of pre- and post- op radiation? Heavy particle? When is an en bloc NOT the right answer? What do we use and what should we use in determining if patient is surgical candidate?
Case 2: Lesion of Unknown Origin in the Sacrum
Matthew L. Goodwin, MD, PhD
- Present case, lesion of unknown origin. Lytic lesion in sacrum with thinning of bone and nonspecific pain. Path continues to come back as benign bone, some vascularity noted. Continues to erode bone. Another path? En bloc? Intralesional? Discuss options at this point vs what it could be. Discuss tumor “mimics” like infection and benign vascular entities. Discuss how common this is in sacrum (and spine). Review imaging. Change case slightly to other lesions that might have vascularity like ABC, telangiectatic OS, hemangioma, etc.
Case 3: New Diagnosis of Insufficiency Fracture versus Path Fracture
Matthew Colman, MD
- Present case with insufficiency/path fracture. How to tell when this needs biopsy/path vs nonpath fracture. Include in this endocrine abnormalities / brown tumor, etc. How to reconstruct? What is the role for being aggressive if metastatic / pathologic? En Bloc for oligometastatic or does that violate basic principles? What are the goals of surgery when treating metastatic disease? VCR vs separation surgery? Again, role of radiation, particularly now with trauma and fracture.
Case 4: Unknown Lesion of Spinal Corse/Nerve Roots
John H. Shin, MD
- Present case with soft tissue tumor that is schwannoma vs MPNST. When/how to biopsy? Discuss NFT in this setting. Change case to radiation-induced tumor. For all of these, when do you not need a biopsy? Surgical plan?
Questions
Faculty
Post-Test
Daniel M. Sciubba, MD, Joseph H. Schwab, MD
Closing
Daniel M. Sciubba, MD, Joseph H. Schwab, MD