This digital library houses the book on Oncology and Orthopedic Oncosurgery.

It includes academic lectures, presentations from national and international congresses, published papers, case discussions, performed surgical procedures, and proprietary techniques developed.

The digital format was chosen because the web allows the inclusion of texts with numerous visual resources, such as images and videos, which would not be possible in a printed book.

The content is intended for students, healthcare professionals, and the general public interested in the field.


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Biopsy – Concept – Types – Indications – Planning


Biopsy Considerations

Biopsy – Concept – Types – Indications – Planning

1.  Only after the clinical evaluation, with careful history taking and clinical examination, which will allow us to raise diagnostic hypotheses, should we request additional tests.

With the analysis of complementary exams, we should verify:

A- If our hypotheses are compatible with the tests and continue to qualify as possible diagnoses; 

B- A new hypothesis has appeared, which we had not thought of, and we will have to redo our clinical reasoning.

C- If the exams are correct, well done, images centered on the lesion, with good quality or we will have to repeat them.

          2.  Diagnosis hypotheses must first be made through clinical examination, laboratory tests and imaging.

    3.  Pathology   must be used as a  “tool”  to  confirm  or  not confirm the  suspected diagnosis.

If the anatomopathological examination reveals a diagnosis that was not on our list, we must reanalyze the case, redo our reasoning. If there is no  clinical, radiological and anatomopathological correlation  , something may be wrong and we will need to review it together, in a multidisciplinary team, to determine the best course of action. New biopsy?

4.  To reason about the diagnosis, it is first necessary to frame the condition we are analyzing within the five chapters of pathology, figures 1 and 2.

Biopsy – concept – types – indications – planning

Figura 1: Reunião Multidisciplinar - oncocirurgião, radiologista, patologista, oncologista, radioterapeuta, psicólogo, assistente social, fisioterapeuta, enfermagem e outros profissionais envolvidos no caso, ura.
Figure 1: Multidisciplinary Meeting - oncosurgeon, radiologist, pathologist, oncologist, radiotherapist, psychologist, social worker, physiotherapist, nursing and other professionals involved in the case, ura.
Figura 2: Em nossa biblioteca cerebral devemos pesquisar os cinco volumes da PATOLOGIA: 1- Malformações Congênitas, 2-Transtornos Circulatórios, 3- Processos Degenerativos, 4- Inflamações e 5- Neoplasias.
Figure 2: In our brain library we must research the five volumes of PATHOLOGY: 1- Congenital Malformations, 2- Circulatory Disorders, 3- Degenerative Processes, 4- Inflammations and 5- Neoplasms.

5.  If we conclude that our patient has a neoplasm, we need to carry out the reasoning exercise already described in the Introduction to the Study of Tumors and Tumor Diagnosis chapters (Links: dos-tumores-osseos/   and  ).

After these steps, we can think of the biopsy as a  “tool”  for the definitive diagnosis.

Before we address the topic  “biopsy”,  let’s analyze some cases.

Patient  A : figures 3 and 4.

Figura 3: Tomografia com lesão na parede abdominal. Abaulamento do músculo reto anterior e espessamento da musculatura lateral, assinalado em amarelo.
Figure 3: Tomography showing injury to the abdominal wall. Bulging of the anterior rectus muscle and thickening of the lateral muscles, marked in yellow.
Figura 4: Tomografia, ultrassom e aspecto clínico. Paciente ictérico, asmático, com grande equimose, internado havia dias para investigação.
Figure 4: Tomography, ultrasound and clinical appearance. Jaundiced, asthmatic patient, with severe bruising, hospitalized for days for investigation.

Thirty days ago, they requested a biopsy of an abdominal wall lesion on a patient admitted for investigation.

The patient’s doctor found me in the radiology room, analyzing the CT scan.

Following the  “how I think”  about injuries I asked myself: – what structures form the abdominal wall? The. skin  (squamous cell carcinoma, basal cell carcinoma, melanoma) ; B. subcutaneous  (lipoma, liposarcoma) ; w. muscular fascia  (desmoid fibroma) ; d. striated muscle  (fibroma, fibrosarcoma, desmoid fibroma, rhabdomyosarcoma) ; It is. vessel  (hemangioma, leiomyosarcoma) ; f. peritoneum and abdominal cavity  (no longer my jurisdiction).

It seemed like an extensive lesion and I suggested that I look for a surgeon in the area, as I wouldn’t know how to drive if it was a malignant neoplasm. Ideally, the biopsy should be performed by the person who will operate on the patient.

He told me that the patient was jaundiced, an ultrasound and several laboratory tests had been performed, insisting that I perform a biopsy. I asked him some information and as I didn’t know how to find out, I suggested that we visit the bed. We could extract the clinical history and examine the patient.

The patient reported being asthmatic and reported that the symptom began abruptly after a coughing fit eleven days ago, in a sudden change of weather, cold and drizzling. He had severe pain in the anterior wall of the abdomen, where a “ball” appeared. The bulging and pain were decreasing and the side wall had hardened.

Leaving the room, I suggested that we not do a biopsy, that we discharge the patient, that the jaundice with elevated bilirubin was the result of a large hematoma that had infiltrated the lateral wall, due to the spontaneous rupture of the anterior rectus abdominis. This lesion was already undergoing repair and the biopsy would only show the scarring inflammatory process  (with the risk of proliferative myositis).

Still not convinced, he asked me if I had ever seen a case of spontaneous rupture of the rectus abdominis muscle. I answered no, but that was what common sense said. Going down the stairs we met a general surgeon and I asked him about the matter. This clarified that it was common in patients with chronic bronchitis who were taking corticosteroids, as was the case with our patient.  The  clinical history  made the diagnosis.

Patients  B  and  C : Figures 5 and 6.
Pacientes B e C: Figuras 5 e 6.
Figura 5: Radiografia da pelve esquerda com lesões de rarefação no ramo ílio-isquiático, paciente mostrando a lesão, destacada em vermelho.
Figure 5: Radiograph of the left pelvis with rarefaction lesions in the ilio-ischial branch, patient showing the lesion, highlighted in red.
Figura 6: Lesão na coxa assinalada em azul, reação periosteal ao redor de corpo estranho, destacada em amarelo, ponta de lança de portão, circundada em vermelho.
Figure 6: Thigh injury marked in blue, periosteal reaction around a foreign body, highlighted in yellow, gate spearhead, circled in red.

Patients  B : Figure 5.

At the outpatient clinic, the resident asks:

– “By which access route should we perform the biopsy?”

I see the image and ask: – How old is the patient?

– “Um… Dona Maria, how old are you?”

 I reflect in silence, evaluating the learner’s lack of knowledge. The patient responds 67 years old DOCTOR!

… Sixty-seven years, multiple lesions, metastasis? Multiple myeloma? Brown tumor of hyperparathyroidism? – How long has she had symptoms?

– “Um… Dona Maria, how long have you had this problem?”

In the medical record I see symptoms of pain in the  ischial tuberosity noted , measurements of Ca ++ , P ++ , FA, Na + , K + , protein electrophoresis, blood count, ESR, blood glucose, urea, creatinine, ultrasound, x-rays,…, …

When examining the patient, I observed that the “tumor” is  anterior , in the inguinal region, and not  posterior , as noted in the medical record, “ischial tuberosity”.  The patient had not been examined !!! She had an inguinal-crural hernia. Pelvic x-ray images represent gas from the intestine. The “biopsy” would result in intestinal perforation.  The  physical examination  made the diagnosis. 

Patient  C : Figure 6.

Passing through the emergency room, the person on duty asks:

– “Doctor, what tumor do you think this patient has? Can we schedule the biopsy?”

The resident knew nothing about the history and had only taken the frontal x-ray!!! When asked, the patient reports that the inflammatory symptoms began six months ago, with hot pain and the release of purulent secretions. When it was open, secreting, the symptoms improved. When he closed the fistula it started to swell, hurt and he had a fever.

With difficulty, as the patient often withholds information, we learned that he had been injured in the thigh two years ago, when he jumped over the guardrail of a house, which bled a lot, but did not seek treatment  ( clinical history ) . We requested a lateral x-ray which confirmed that it was a foreign body. The spear tip of the grid was surrounded by solid periosteal reaction, giving the false impression of a sclerotic tumor.  Appropriate imaging confirmed   the diagnosis.

After these important considerations, we will study the controversial topic of biopsy.

After these important considerations, we will study the controversial topic of biopsy.


1-  Define the hypotheses of possible diagnoses, for our case, firstly with the  clinical history  and  physical examination ;

2-  Carry out  laboratory and imaging tests, to  corroborate  or  not  our hypotheses,  our reasoning  and

3-  Only after these steps can we perform the biopsy, for the pathology to “ recognize the signature ” of the diagnosis, previously thought out with our anamnesis, physical, laboratory and imaging examination.

“Pathological anatomy is not a short path to diagnosis. We must always correlate it with the clinic, laboratory and imaging tests”.

Figura 7: O médico precisa sentir o paciente.
Figure 7: The doctor needs to feel the patient.
Figura 8: A clínica é a base, que tem o maior peso. Os dados de imagem em equilíbrio com a patologia equilibram a pirâmide, definindo o DIAGNÓSTICO preciso.
Figure 8: The clinic is the base, which has the greatest weight. Image data in balance with pathology balances the pyramid, defining the precise DIAGNOSIS.
Figura 9: Quatro itens devem ser considerados em relação à biópsia.
Figure 9: Four items must be considered in relation to biopsy.
Figura 10: A amostra deve ser representativa da lesão, em qualidade e quantidade.
Figure 10: The sample must be representative of the lesion, in quality and quantity.
Figura 11: A escolha de cada tipo deve ser feita com critério.
Figure 11: The choice of each type must be made carefully.
Figura 12: Lesões que podem permitir a ressecção-biópsia. É preciso analisar caso a caso. Uma equipe multidisciplinar é fundamental.
Figure 12: Lesions that may allow resection-biopsy. It needs to be analyzed case by case. A multidisciplinary team is essential.

Regarding biopsy, we can subdivide musculoskeletal lesions into three groups:   

  1. Cases in which CLINICAL – RADIOLOGICAL diagnosis  (image)  is sufficient for diagnosis and treatment, and biopsy is not indicated.
  2. Cases that may not require this procedure due to difficulty in histological diagnosis, and due to the characteristics of  clinical  and  radiological aggressiveness  , the necessary surgical procedure should not be altered.
  3. Cases that require pathological confirmation for chemotherapy treatment prior to surgery

We will discuss the three groups, analyzing some examples, figures below.

GROUPS 1 and 2 : Biopsy is not necessary or does not change management.

  1a . OSTEOMA, figures 13 to 18.

IDENTITY:  Benign, well-defined neoplastic lesion, characterized by a homogeneous, sclerotic and dense tumor, mature bone tissue. It’s bone within a bone.

Figura 13: Paciente com 43 anos de idade, apresentando tumor no crâneo havia oito anos, indolor, que dificultava para pentear o cabelo. Radiografia com lesão esclerótica homogenia.
Figure 13: 43-year-old patient, with a painless skull tumor for eight years that made it difficult to comb her hair. Radiograph with homogeneous sclerotic lesion.
Figura 14: Tomografia exibindo osteoma no crâneo.
Figure 14: Tomography showing osteoma in the skull.
Figura 15: Radiografia com osteoma na falange proximal do terceiro dedo.
Figure 15: Radiograph showing osteoma in the proximal phalanx of the third finger.
Figura 16: Radiografia com osteoma na cabeça femoral. Enostose assintomática, achado casual em radiografia do quadril.
Figure 16: Radiograph showing osteoma in the femoral head. Asymptomatic enostosis, casual finding on hip radiography.
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Figure 17: Osteoma in the vertebral body, asymptomatic. Casual finding, observation and follow-up.
Figura 18: Osteoma na região frontal do crâneo. Indicação cirúrgica por alteração estética.
Figure 18: Osteoma in the frontal region of the skull. Surgical indication due to aesthetic changes.

These lesions are well-defined, homogeneous, without symptoms. They are diagnosed by occasional imaging findings or by presenting aesthetic changes. Occasionally, they may be symptomatic, as in a case where the nasal cavity was obstructed, making breathing difficult. The diagnosis is clinical and radiological, and does not require a biopsy. Treatment is restricted to observation and monitoring. They are rare and occasionally operated on. 

See:   http://osteoma     and     http://osteoma of the skull

1b . OSTEOID OSTEOMA, figures 19 to 26.

IDENTITY:  Benign neoplastic lesion, characterized by a circumscribed tumor, up to approximately one centimeter in diameter, which presents a central osteoid niche, surrounded by a halo of sclerosis and located in the cortex of the long bones, the most compact part.

Figura 19: TC e Radiografias de osteoma osteóide da região trocanteriana do fêmur. Lesão lítica, com nicho central e halo de esclerose, assinalada em amarelo e cortical marcada com perfuração por fio de Kirchner, assinalada em vermelho.
Figure 19: CT and radiographs of osteoid osteoma of the trochanteric region of the femur. Lytic lesion, with central niche and halo of sclerosis, marked in yellow and cortical marked with Kirchner wire perforation, marked in red.
Figura 20: Radiografia de osteoma osteóide no colo femoral. Lesão lítica, com nicho central e halo de esclerose, seta vermelha.
Figure 20: Radiograph of osteoid osteoma in the femoral neck. Lytic lesion, with central niche and halo of sclerosis, red arrow.

The femoral neck region is covered by a thin periosteum that does not present a periosteal reaction. This makes it difficult to locate the lesion during surgery.

Making a hole in the cortical bone, close to the lesion, guided by radioscopy, will facilitate the operation.

After this marking, we perform a tomography to measure the distance from the hole to the center of the lesion, locating it. See the complete technique at:  http://osteoid osteoma resection technique   

Figura 21: Tomografia com osteoma osteóide na região medial do colo femoral. Neste caso a marcação coincidiu com o centro da lesão, o que facilita, mas não é o ideal, pois perfura a lesão.
Figure 21: Tomography showing osteoid osteoma in the medial region of the femoral neck. In this case, the marking coincided with the center of the lesion, which makes it easier, but is not ideal, as it pierces the lesion.
Figura 22: Imagens com osteoma osteóide da tíbia e do pedículo da coluna vertebral. Não há indicação de biópsia e sim de ressecção-biópsia.
Figure 22: Images with osteoid osteoma of the tibia and spinal pedicle. There is no indication for biopsy, but rather for resection-biopsy.
Figura 23: Osteoma osteóide da cortical anterior da tíbia. Não ha indicação de biópsia.
Figure 23: Osteoid osteoma of the anterior cortical bone of the tibia. There is no indication for biopsy.
Figura 24: Osteoma osteóide periosteal da cortical interna do rádio. Não há indicação de biópsia.
Figure 24: Periosteal osteoid osteoma of the inner cortex of the radius. There is no indication for biopsy.
Figura 25: Osteoma osteóide do calcâneo. Não há indicação de biópsia.
Figure 25: Osteoid osteoma of the calcaneus. There is no indication for biopsy.
Figura 26: Osteoma osteóide sub talar do calcâneo. Não há indicação de biópsia.
Figure 26: Subtalar osteoid osteoma of the calcaneus. There is no indication for biopsy.

Osteoid osteoma is a lesion of the cortical bone. In the spine, it occurs in the pedicle, which is the most compact, hardest part, resembling the cortex.

It has a central niche with a halo of sclerosis around it and does not exceed one centimeter.

There is no such thing as a “giant osteoid osteoma”, larger than 1.5 cm, as in this situation there is cortical erosion, there is no delimitation by the sclerosis halo and, although it may present similar histology, we are dealing with an osteoblastoma, which is a benign lesion. , but locally aggressive. Osteoblastoma may or may not be associated with an aneurysmal bone cyst and may also require a differential diagnosis with teleangiectatic osteosarcoma. Read also: http://osteoid osteoma 

1c . OSTEOCHONDROMA, figures 27 to 32.

IDENTITY:  It is an exostosis in which the central cancellous bone continues with the medullary of the affected bone and the dense peripheral, cortical layer of the tumor continues with the cortical layer of the affected bone. It presents with an enlarged,  sessile,  or narrow,  pedicled base . It can be single or multiple  (hereditary osteochondromatosis).

Osteochondromas require surgical treatment when they alter aesthetics or function, displacing and compressing vascular-nervous structures, limiting movement or generating angular deformities. It is the most common benign bone lesion.

They generally grow while the patient is in the growth phase. When an osteochondroma increases in size after completion of skeletal maturity, it may mean post-traumatic bursitis or malignancy to chondrosarcoma and should be treated as such, resecting with an oncological margin. 

Solitary osteochondroma has a 1% malignancy rate. Multiple osteochondromatosis can reach 10%.

Figura 27: Exemplo de osteocondroma pediculado do fêmur e de osteocondroma pediculado da tíbia. A cortical do osso continua-se com a cortical da lesão e a medular do osso também se continua com a medular da lesão. Não há indicação de biópsia.
Figure 27: Example of pedicled osteochondroma of the femur and pedicled osteochondroma of the tibia. The bone cortex continues with the lesion cortex and the bone medullary bone also continues with the lesion medullary. There is no indication for biopsy.
Figura 28: Osteocondroma séssil da tíbia. Não há indicação de biópsia. Indicação de ressecção por bloqueio da flexão do joelho.
Figure 28: Sessile osteochondroma of the tibia. There is no indication for biopsy. Indication of resection by blocking knee flexion.
Figura 29: Osteocondromatose múltipla hereditária. Lesões múltiplas em irmãos, setas brancas, amarelas e azuis. Deformidade angular e encurtamento do membro superior.
Figure 29: Hereditary multiple osteochondromatosis. Multiple lesions in siblings, white, yellow and blue arrows. Angular deformity and shortening of the upper limb.
Figura 30: Osteocondroma múltiplos nos fêmures e nas tíbias. Epifisiodese medial da tíbia esquerda visando corrigir a deformidade angular.
Figure 30: Multiple osteochondromas in the femurs and tibias. Medial epiphysiodesis of the left tibia aiming to correct the angular deformity.
Figura 31: Osteocondroma séssil do fêmur, deslocando os vasos femorais. A cortical do osso continua-se com a cortical da lesão e a medular do osso também se continua com a medular da exostose.
Figure 31: Sessile osteochondroma of the femur, displacing the femoral vessels. The bone cortex continues with the lesion cortex and the bone medullary also continues with the exostosis medullary.
Figura 32: Osteocondroma da fíbula comprimindo lentamente a tíbia, durante o crescimento, e ocasionando deformidade angular em valgo e antecurvatum. Exostose no pé dificultando o uso de calçado. Peças e histologia.
Figure 32: Osteochondroma of the fibula slowly compressing the tibia during growth and causing angular deformity in valgus and antecurvatum. Exostosis in the foot making it difficult to wear shoes. Parts and histology.

The diagnosis of osteochondroma is clinical and radiological and does not require a biopsy for treatment. 

Read:  http://osteochondroma

1d . CONDROMA, figures 33 to 50.

IDENTITY:  Benign, painless, cartilage-forming tumor with foci of calcification in the short bones of the hands and feet, diagnosed by chance or due to deformity or fracture. It can be solitary or multiple  (enchondromatosis, Maffucci syndrome, Ollier disease).

Figura 33: Condromas das falanges, achado casual. Histologia de condroma, cartilagem madura.
Figure 33: Chondromas of the phalanges, casual finding. Chondroma histology, mature cartilage.
Figura 34: Condroma da falange com DOR. Consolidado após fratura havia cinco meses, tratada com imobilização. OPERAR?
Figure 34: Chondroma of the phalanx with PAIN. Healed after fracture five months ago, treated with immobilization. OPERATE?
Figura 35: Ressonância de condroma da falange após fratura há cinco meses, com DOR!
Figure 35: MRI of chondroma of the phalanx after fracture five months ago, with PAIN!
Figura 36: Cortical com insuflação fina causando dor. Captação de gadolínio. OPERAR?
Figure 36: Cortical with fine inflation causing pain. Gadolinium uptake. OPERATE?
Figura 37: Cortical com insuflações finas causando dor e desconforto. Indicação de curetagem e enxerto autólogo S/N.
Figure 37: Cortical with fine insufflations causing pain and discomfort. Indication of curettage and autologous graft S/N.
Figura 38: Acesso dorso lateral, curetagem cuidadosa da lesão, cavidade sem lesão, material cartilaginoso curetado e enxerto autólogo do ilíaco, para preenchimento da cavidade.
Figure 38: Dorso-lateral access, careful curettage of the lesion, cavity without injury, cartilaginous material curetted and autologous iliac graft to fill the cavity.

In the fingers and toes, cartilaginous lesions generally behave benignly.

The eventual unwanted evolution to chondrosarcoma, resulting from curettage surgery in these locations, does not compromise the possibility of a cure, as complete resection of the finger,  which is the treatment of chondrosarcoma , would continue to be possible.


        Chondroma occasionally occurs in the metaphysis of long bones  (distal femur, humerus and proximal tibia)  and limb roots  (shoulder, pelvis) . In these cases, it can be confused with bone infarction or grade I chondrosarcoma.

In occasional findings, as  the anatomopathological diagnosis  between chondroma and grade I chondrosarcoma  is controversial , it is preferable not to perform a biopsy and monitor clinically and radiographically whether there is progress.

Grade I chondrosarcoma is slow to evolve, which allows monitoring, enabling observation for a safe diagnosis of its activity or not.

The exams are repeated at one, three and six months, and then annually. The tumor must be treated surgically as  chondrosarcoma  at any time if comparison between images reveals changes in the lesion.

If the injury remains unchanged, the best course of action is to continue monitoring. Some patients ask until when? The answer is: – Always. Reevaluation should continue regardless, whether the patient undergoes surgery or not.

Treating an asymptomatic lesion, a casual finding, without changing the image with minor surgery is “ overtreatment”,  which will also require follow-up or worse, if the anatomopathological examination reveals malignant histology.

Exemplifying this conduct, we will analyze the following case, followed for 14 years, figures 39 to 42.

Figura 39: Paciente com dor na interlinha do joelho após esporte. Ressonância para estudo da articulação mostra achado casual de lesão na metáfise distal do fêmur. CONDROMA / CONDROSSARCOMA GRAU I? QUAL A MELHOR CONDUTA?
Figure 39: Patient with pain in the knee joint after sports. MRI to study the joint shows a casual finding of a lesion in the distal metaphysis of the femur. CHONDROMA / CHONDROSSARCOMA GRADE I? WHAT IS THE BEST CONDUCT?
Figura 40: Radiografia com lesão provavelmente cartilaginosa, na metáfise distal do fêmur. Achado casual: CONDUTA = OBSERVAÇÃO.
Figure 40: Radiograph showing a probably cartilaginous lesion in the distal metaphysis of the femur. Casual finding: CONDUCT = OBSERVATION.
Figura 41: Radiografia de controle após doze anos, queixa de dor recente no joelho. Calcificação na interlinha medial, paciente joga Squash! A dor não tem nada a ver com a lesão em acompanhamento, que continua inalterada.
Figure 41: Control x-ray after twelve years, complaint of recent knee pain. Calcification in the medial interline, patient plays Squash! The pain has nothing to do with the ongoing injury, which remains unchanged.
Figura 42: Controle após 14 anos de acompanhamento, sem biópsia. Inalterado e assintomático, discreta "sensação de? ..., desconforto, quando muda o tempo".
Figure 42: Control after 14 years of follow-up, without biopsy. Unchanged and asymptomatic, discreet "sensation of?..., discomfort, when the weather changes".

CHONDROMA or  CHONDROSSARCOMA?  In these cases  common sense  must prevail, he warns us that  the paper accepts any writing.

We must base ourselves on the clinical behavior of the lesion. Was there a change or not? If we choose to perform a biopsy, we can only add whether or not it is a  “cartilaginous lesion” . We cannot change our behavior:  OBSERVE OR  OPERATE AS CHONDROSSARCOMA .  To be safe, if we choose to operate, we must treat it surgically as chondrosarcoma, which is our only “ tool” , as they do not respond to chemotherapy or radiotherapy.

Continuing, let us analyze figures 43 to 50.
Figura 43: Lesão cartilaginosa latente, acompanhada desde 2003, sem a realização de biópsia, comportamento de condroma. Imagem em 2016 sem alteração. Conduta = manter o acompanhamento, se houver alteração deve ser tratada como condrossarcoma.
Figure 43: Latent cartilaginous lesion, monitored since 2003, without biopsy, chondroma-like behavior. Image in 2016 without changes. Management = maintain monitoring, if there is a change it should be treated as chondrosarcoma.
Figura 44: Lesão cartilaginosa no ramo ílio-púbico direito. Acompanhada havia dois meses, houve piora da imagem, com ruptura da cortical! Foi operado como condrossarcoma, com ressecção segmentar da lesão, sem a realização de biópsia, pois independente do resultado, fosse este condroma ou condrossarcoma o tratamento deve ser cirúrgico, com ressecção ampla.
Figure 44: Cartilaginous lesion in the right iliopubic branch. Followed up for two months, the image worsened, with cortical rupture! It was operated on as chondrosarcoma, with segmental resection of the lesion, without performing a biopsy, because regardless of the result, whether it was chondroma or chondrosarcoma, the treatment must be surgical, with wide resection.
Figura 45: Lesão cartilaginosa, focos de calcificação e erosão da cortical, em cuja amostra de biópsia ¨diagnosticou¨ CONDROMA. Operado com prótese convencional, sem ressecção com margem. Em pouco tempo houve evolução do tumor, CONDROSSARCOMA, levando a uma necessidade de hemipelvectomia, cirurgia ablativa.
Figure 45: Cartilaginous lesion, foci of calcification and cortical erosion, in which the biopsy sample ¨diagnosed¨ CHONDROMA. Operated with conventional prosthesis, without resection with margin. In a short time, the tumor, CHONDROSSARCOMA, evolved, leading to the need for hemipelvectomy, ablative surgery.
Figura 46: Lesão cartilaginosa do fêmur com todas as características de lesão agressiva. Deve ser tratada como CONDROSSARCOMA.
Figure 46: Cartilaginous injury of the femur with all the characteristics of an aggressive injury. It should be treated as CHONDROSSARCOMA.
Figura 47: Radiografia de lesão no úmero, com todas as características de agressividade da lesão cartilaginosa: dor, erosão da cortical, alargamento do canal medular por atividade do tumor - o comportamento não é latente: é ativo e agressivo. Na ressonância podemos acompanhar o trajeto da biópsia, contaminado pela implantação da neoplasia.
Figure 47: X-ray of a lesion in the humerus, with all the aggressive characteristics of a cartilaginous lesion: pain, cortical erosion, widening of the spinal canal due to tumor activity - the behavior is not latent: it is active and aggressive. On MRI we can follow the biopsy path, contaminated by the implantation of the neoplasm.
Figura 48: Laudo de biópsia realizada, revela tratar-se de lesão cartilaginosa sem atipias, nesta amostra recomendando nova biópsia? Precisa? Que conduta o médico tomaria se em uma eventual nova biópsia, a qual continuaria sendo uma amostra, continuasse a impressão de condroma? Deve-se considerar o comportamento evolutivo da lesão e tratar como condrossarcoma.
Figure 48: Biopsy report performed, reveals that it is a cartilaginous lesion without atypia, in this sample recommending a new biopsy? It needs? What action would the doctor take if in a possible new biopsy, which would still be a sample, the impression of chondroma continued? The evolutionary behavior of the lesion must be considered and treated as chondrosarcoma.
Figura 49: Paciente tratada como condrossarcoma. Peça de paciente operada sem nova biópsia. Podemos verificar em destaque a implantação da neoplasia agressiva nos tecidos moles, através do trajeto da biópsia.
Figure 49: Patient treated for chondrosarcoma. Part of a patient operated on without a new biopsy. We can clearly see the implantation of the aggressive neoplasm in the soft tissues, through the biopsy path.
Figura 50: Ressecção e reconstrução com endoprótese, no membro dominante de paciente odontóloga, após quatorze anos.
Figure 50: Resection and reconstruction with endoprosthesis, in the dominant limb of a dental patient, after fourteen years.
The message we want to leave is:

¨The doctor  can perform the biopsy , as it is an academic procedure, which gives him more support as to whether it is a cartilaginous lesion. But  you should not operate with a curettage technique , such as chondroma, as latent chondromas of long bones, casual findings, do not require surgical treatment but rather observation. The biopsy hinders this observation because we will not know whether the pain and changes in the image, which may occur after the biopsy, would be due to the aggression of the biopsy or whether it is a chondrosarcoma manifesting itself. In conclusion, if the doctor chooses to intervene,  he must operate on chondrosarcoma . We also remember that surgery, performed using any technique, will not eliminate the need for observation and monitoring¨.

Read:  http://chondrosarcoma or chondroma?

 1 and .  CHONDROBLASTOMA, figures 51 to 54.

IDENTITY: Benign epiphyseal  neoplastic lesion   of the growing skeleton  (1st and  2nd decades  ),  characterized by bone rarefaction, erosion of the articular cartilage with inflation, cartilaginous cells  (chondroblasts), giant cells  and foci of calcification.

Figura 51: Condroblastoma, tumor epifisário ou apofisário dos ossos longos DO ESQUELETO EM CRESCIMENTO.
Figure 51: Chondroblastoma, epiphyseal or apophyseal tumor of the long bones OF THE GROWING SKELETON.
Figura 52: Lesão com matriz cartilaginosa, epifisária, em adolescente (esqueleto em crescimento), halo de esclerose, erosão da cartilagem articular e da cortical óssea, com focos de calcificação = CONDROBLASTOMA.
Figure 52: Lesion with cartilaginous matrix, epiphyseal, in an adolescent (growing skeleton), halo of sclerosis, erosion of the articular cartilage and cortical bone, with foci of calcification = CHONDROBLASTOMA.
Figura 53: Lesão com matriz cartilaginosa, epifisária, em criança (esqueleto em crescimento), halo de esclerose, com focos de calcificação = CONDROBLASTOMA.
Figure 53: Lesion with cartilaginous matrix, epiphyseal, in a child (growing skeleton), halo of sclerosis, with foci of calcification = CHONDROBLASTOMA.
Figura 54: Acesso póstero medial à cabeça femoral, para permitir o tratamento cirúrgico da lesão com curetagem, eletro termia e reconstrução com enxerto autólogo do ilíaco.
Figure 54: Posteromedial access to the femoral head, to allow surgical treatment of the injury with curettage, electrothermia and reconstruction with an autologous iliac graft.

Adjuvant curettage and electrothermal surgery for this neoplasm, in these locations and in small-sized lesions, is nothing more than an incisional biopsy, in which the macroscopic appearance of cartilage allows complete curettage of the tumor. The presence of the pathologist in the surgery is useful to corroborate and assist the surgeon. Read:  http://chondroblastoma

 1f . SIMPLE BONE CYST – COS, figures 55 to 58.

IDENTITY: Pseudoneoplastic lesion, unicameral, surrounded by a membrane, well delimited, filled with serous fluid, central metaphyseal  location  , which does not exceed its width and occurs in children and adolescents.  

Figura 55: Cisto ósseo simples do úmero. Lesão bem delimitada que não ultrapassa a largura da metáfise. Descoberta devido à dor por micro fratura. Com o crescimento distancia-se da linha epifisial. Cavidade única, revestida por membrana contendo líquido seroso.
Figure 55: Simple bone cyst of the humerus. Well-defined lesion that does not exceed the width of the metaphysis. Discovery due to pain due to micro fracture. With growth it distances itself from the epiphyseal line. Single cavity, lined with a membrane containing serous fluid.
Figura 56: Cisto ósseo simples na fíbula. Esta é a única localização que pode eventualmente ser mais largo do que a metáfise, devido à cortical fina poder insuflar-se. A fíbula não é osso de carga, podemos observar. Com o crescimento afasta-se da linha epifisial e mineraliza, evoluindo para cura.
Figure 56: Simple bone cyst in the fibula. This is the only location that may eventually be wider than the metaphysis, due to the thin cortex being able to inflate. The fibula is not a load-bearing bone, we can see. As it grows, it moves away from the epiphyseal line and mineralizes, progressing towards healing.
Figura 57: Cisto ósseo simples da tíbia. Dor por tração da tuberosidade tibial pelo ligamento patelar, devido ao afilamento da cortical.
Figure 57: Simple bone cyst of the tibia. Pain caused by traction of the tibial tuberosity by the patellar ligament, due to cortical thinning.
Figura 58: Cisto ósseo simples. Cavidade única, bem delimitada, com conteúdo líquido envolto por uma membrana, seta em vermelho (captação de contraste apenas na periferia).
Figure 58: Simple bone cyst. Single, well-defined cavity, with liquid content surrounded by a membrane, red arrow (contrast capture only at the periphery).

Read: http://simple bone cyst 

          1g . JUSTAARTICULAR BONE CYST – GANGLION, figures 59 to 62.

IDENTITY:  Pseudoneoplastic lesion,  epiphyseal in location , unicameral, surrounded by synovial membrane, well defined and filled with serous fluid, which communicates with the adjacent joint.

Figura 59: Lesão epifisária de rarefação óssea bem delimitada. Ressonância sagital revelando pertuito na cartilagem articular comunicando o líquido da articulação com o do conteúdo da cavidade. GANGLION (cisto ósseo justa articular).
Figure 59: Well-defined epiphyseal bone rarefaction lesion. Sagittal resonance revealing a hole in the articular cartilage communicating the joint fluid with the contents of the cavity. GANGLION (just articular bone cyst).
Figura 60: Lesão homogênea, com conteúdo líquido (baixo sinal em T1 e Alto sinal em T2). Em sagital T1 com contraste observamos captação apenas na periferia da lesão, destacando a membrana sinovial secretora do líquido seroso que preenche a cavidade.
Figure 60: Homogeneous lesion, with liquid content (low signal on T1 and high signal on T2). In sagittal T1 contrast, we observed uptake only at the periphery of the lesion, highlighting the synovial membrane that secretes the serous fluid that fills the cavity.
Figura 61: Lesão epifisária de rarefação óssea bem delimitada. Ressonância coronal e axial destacando o aspecto homogêneo e circunscrito da lesão. Ganglion? Provavelmente não, pois não há comunicação com a articulação. Provável cárie óssea, sequela de processo inflamatório.
Figure 61: Well-defined epiphyseal bone rarefaction lesion. Coronal and axial resonance highlighting the homogeneous and circumscribed appearance of the lesion. Ganglion? Probably not, as there is no communication with the joint. Probable bone caries, sequelae of an inflammatory process.
Figura 62: Ressonâncias sagitais T1 e com contraste evidenciando a delimitação periférica da lesão, que não se comunica com a articulação. Lesão de conteúdo líquido homogêneo e muito pequena, pode ser tratada sem biópsia.
Figure 62: Sagittal T1 and contrast-enhanced MRI scans showing the peripheral delimitation of the lesion, which does not communicate with the joint. Lesion with homogeneous liquid content and very small, can be treated without biopsy.

These lesions do not require a biopsy for treatment.

          1h . CORTICAL FIBROUS DEFECT / NON-OSSIFYING FIBROMA, figures 63 and 64.

IDENTITY:  Pseudoneoplastic lesion in the  cortical bone  with precise limits, asymptomatic. Occasional find.

Figura 63: Radiografia com lesão circunscrita na cortical do fêmur. Na tomografia observamos que é homogênea, pequena, menor que 1.5 cm, delimitada por halo de esclerose. Defeito fibroso cortical operado por desconforto leve, devido à inserção do músculo adutor.
Figure 63: Radiograph with circumscribed lesion in the cortical bone of the femur. On the tomography we observed that it is homogeneous, small, less than 1.5 cm, delimited by a halo of sclerosis. Cortical fibrous defect operated for mild discomfort, due to the insertion of the adductor muscle.
Figura 64: Lesão circunscrita na cortical lateral da tíbia, maior que 1.5 cm. Neste fibroma não ossificante, observamos que a lesão se distancia da linha epifisial e ocorre discreta mineralização. Achado de exame, acompanhamento sem biópsia.
Figure 64: Circumscribed lesion in the lateral cortex of the tibia, greater than 1.5 cm. In this non-ossifying fibroma, we observed that the lesion distances itself from the epiphyseal line and slight mineralization occurs. Examination finding, follow-up without biopsy.
These lesions occur in the  cortical bone  and do not require a biopsy for treatment/monitoring.


IDENTITY:  Pseudoneoplastic lesion in the  tibial diaphysis  with bone rarefaction of intermediate density, as if the bone had been  “erased” , with a ground-glass appearance. It can occur in more than one location. Its evolution is variable and can cause deformity, dedifferentiation or harmonious growth, stabilizing at skeletal maturity. 

Figura 65: Lesão diafisária em criança com um ano de idade, com aumento acentuado e deformidade progressiva em dezoito meses. OSTEOFIBRODISPLASIA.
Figure 65: Diaphyseal injury in a one-year-old child, with marked increase and progressive deformity in eighteen months. OSTEOFIBRODYSPLASIA.
Figura 66: Paciente operada sem biópsia prévia, com ressecção da lesão, controlando sua progressão e corrigindo a deformidade. Reconstrução biológica com enxerto autólogo e homólogo.
Figure 66: Patient operated on without prior biopsy, with resection of the lesion, controlling its progression and correcting the deformity. Biological reconstruction with autologous and homologous graft.
Figura 67: Paciente com cinco anos de idade. Em 1990, foi encaminhado para “amputação” devido a lesão na tíbia! Displasia fibrosa? Osteofibrodisplasia? Adamantinoma da tíbia? Conduta: OBSERVAÇÃO.
Figure 67: Five-year-old patient. In 1990, he was sent for “amputation” due to an injury to his tibia! Fibrous dysplasia? Osteofibrodysplasia? Adamantinoma of the tibia? Conduct: OBSERVATION.
Figura 68: Acompanhamento anual. Crescimento proporcional da lesão e alinhamento harmônico da perna. Conduta: OBSERVAÇÃO, sem biópsia.
Figure 68: Annual monitoring. Proportional growth of the lesion and harmonious alignment of the leg. Management: OBSERVATION, without biopsy.
Figura 69: Cintilografia e radiografias de 2016, após vinte e cinco anos de observação, sem biópsia. Paciente adulto, tíbia alinhada.
Figure 69: Scintigraphy and radiographs from 2016, after twenty-five years of observation, without biopsy. Adult patient, tibia aligned.
Figura 70: Aspecto clínico e funcional do paciente, após vinte e cinco anos de observação, sem biópsia. Não se deve tratar um rótulo.
Figure 70: Clinical and functional appearance of the patient, after twenty-five years of observation, without biopsy. A label should not be treated.

 1J . MYOSITIS OSSIFICANS, figures 71 and 72.

IDENTITY:  Injury located close to a bone and in soft tissues, related to previous trauma, whose ossification begins in the periphery. 

Figura 71: Dor na face medial da coxa esquerda havia oito meses, após trauma. Hipotrofia do quadríceps denotando lesão cônica. Radiografia e cintilografia revelando ossificação.
Figure 71: Pain on the medial side of the left thigh for eight months, after trauma. Quadriceps hypotrophy denoting conical injury. Radiography and scintigraphy revealing ossification.
Figura 72: Tomografia e ressonância evidenciando ossificação em tecidos moles, principalmente na periferia da lesão. A biópsia pode dar falso diagnóstico de osteossarcoma!
Figure 72: Tomography and resonance showing ossification in soft tissues, mainly on the periphery of the lesion. Biopsy can give a false diagnosis of osteosarcoma!

1k . SOFT TISSUE TUMOR –  SOME , figures 73 to 78.

IDENTITY:  Delimited, homogeneous lesions, with typical images, without contrast uptake or with uptake only in the periphery, can be operated on without prior biopsy, when the surgical approach would not be different, even in the case of a malignant neoplasm.

Figura 73: Tumor de tecidos moles da região glútea, homogêneo, densidade de gordura em T1, que continua com o mesmo aspecto na saturação. LIPOMA.
Figure 73: Soft tissue tumor of the gluteal region, homogeneous, fat density on T1, which continues with the same appearance at saturation. LIPOMA.
Figura 74: Ressonância confirmando ser tecido gorduroso homogêneo, captação de contraste apenas na periferia do tumor. Ressecção da lesão envolta em sua pseudocápsula. LIPOMA.
Figure 74: MRI confirming that it is homogeneous fatty tissue, contrast uptake only at the periphery of the tumor. Resection of the lesion enclosed in its pseudocapsule. LIPOMA.

Malignant soft tissue tumors would have the same surgical resection procedure, with the narrow margins presented in the case above and would be complemented with local radiotherapy.  Soft tissue sarcomas, to date, do not respond to chemotherapy nor show an improvement in the patient’s survival rate.

See:  http://soft tissue sarcomas / chemotherapy

Figura 75: Ressonância evidenciando lesão em tecidos moles no trajeto do nervo interósseo posterior. Sinal de tinel positivo. SCHWANNOMA. Ressecção biópsia, abrindo o perineuro e enucleando o tumor, que se desprende facilmente ("como o caroço do abacate").
Figure 75: MRI showing injury to soft tissues in the path of the posterior interosseous nerve. Positive tinel sign. SCHWANNOMA. Biopsy resection, opening the perineurium and enucleating the tumor, which detaches easily ("like an avocado pit").
Figura 76: Radiografia com tumor no cavo poplíteo. Ressonância em T1 e T2 desenhando a “cauda de cometa” em trajeto nervoso. Exérese da lesão que parece uma cebola. Abre-se cuidadosamente a bainha (“casca da cebola”) e a lesão é retirada por completo, sem lesar o nervo.
Figure 76: Radiograph showing tumor in the popliteal cavity. MRI in T1 and T2 drawing the “comet tail” in the nervous path. Excision of the lesion that looks like an onion. The sheath (“onion skin”) is carefully opened and the lesion is removed completely, without damaging the nerve.

A possible biopsy could cause nerve damage and would not change the management.

Figura 77: Tumor heterogêneo da região posterior da coxa, deslocando os vasos femorais e o nervo ciático. SARCOMA DE TECIDOS MOLES.
Figure 77: Heterogeneous tumor of the posterior region of the thigh, displacing the femoral vessels and the sciatic nerve. SOFT TISSUE SARCOMA.
Figura 78: Ressecção com margens exíguas, apenas com sua pseudocápsula, liberando-se o nervo da lesão. Patologia confirma a hipótese de lipossarcoma mixóide. Após a completa cicatrização da ferida operatória, é realizada a radioterapia adjuvante.
Figure 78: Resection with tight margins, with only its pseudocapsule, freeing the nerve from the lesion. Pathology confirms the hypothesis of myxoid liposarcoma. After complete healing of the surgical wound, adjuvant radiotherapy is performed.

Biopsy can be performed, it is academic, it complements the case studies, but surgical resection must prevail, even in the case of malignant neoplasia. Soft tissue sarcomas, to date, do not benefit from neoadjuvant treatment and ablative surgery does not alter survival.

GROUPS  3 : Biopsy is necessary for treatment  (surgery; with/without neoadjuvance) 

We need to emphasize that the biopsy must be  performed/ monitored  by the surgeon who will perform the surgery. Your presence is essential for this to be carried out in accordance with the surgery planning.

Transverse incisions should not be made, nor extensive incisions where there is no musculature for subsequent coverage, such as on the leg, for example. The suture should not have points far from the incision, as this will require a larger resection of tissue and much less more than one incision, figures 79 (tables A, B, C and D) and 80.

Figura 79: Quadro A - incisão transversa INADEQUADA; quadro B - incisão grande e larga na tíbia lesando a pata de ganso; quadro C - pontos de sutura distantes da linha da incisão e quadro D - uma, duas, TRÊS INCISÕES !!!
Figure 79: Chart A - INADEQUATE transverse incision; table B - large and wide incision on the tibia damaging the pes ansus; frame C - suture points distant from the incision line and frame D - one, two, THREE INCISIONS!!!
Figura 80: Duas incisões !!! Distantes e com nódulo subcutâneo de implantação de tumor de células gigantes !!!
Figure 80: Two incisions!!! Distant and with a subcutaneous nodule of giant cell tumor implantation!!!
 See the complete case of figure 80 at:  http://tgc-prótese intraepifisária
Figura 81: Duas incisões!!! Trajetos inadequados dificultando a ressecção com margem do condrossarcoma. Foi necessária uma ressecção extra articular e reconstrução com uma artrodese empregando-se uma prótese rígida de joelho, feita sob medida.
Figure 81: Two incisions!!! Inadequate routes making resection with chondrosarcoma margin difficult. An extra-articular resection and reconstruction with arthrodesis using a custom-made rigid knee prosthesis were necessary.
Figura 82: Incisão transversa!!! Trajeto inadequado dificultando a ressecção com margem deste condrossarcoma da pelve. Foi necessária uma ampla ressecção de pele nesta hemipelvectomia interna.
Figure 82: Transverse incision!!! Inadequate path making it difficult to resect this chondrosarcoma of the pelvis with margin. A wide skin resection was required in this internal hemipelvectomy.
See the complete case in figure 82 at: http://internal pelvectomy

Below, we exemplify two cases of biopsies performed correctly, figures 83 to 86.

Figura 83: BIÓPSIA CORRETA. Puntiforme, com agulha de Jamshid, permitindo a ressecção do tumor com margem, juntamente com o trajeto da biópsia.
Figure 83: CORRECT BIOPSY. Punctate, with a Jamshid needle, allowing resection of the tumor with a margin, along with the biopsy path.
Figura 84: Peça ressecada com margem, incluindo o trajeto da biópsia. Reconstrução com dispositivo de fixação interna extensível e autotransplante com a cartilagem de crescimento da fíbula.
Figure 84: Resected piece with margin, including the biopsy path. Reconstruction with an extensible internal fixation device and autotransplantation with fibula growth cartilage.
*See the complete case of figures 83 and 84 at:  http://growth cartilage transplant
Figura 85: Radiografia e ressonância de osteossarcoma. A seta indica o ponto correto para a coleta da biópsia.
Figure 85: Radiography and resonance of osteosarcoma. The arrow indicates the correct point for biopsy collection.
Figura 86: Cicatriz puntiforme de BIÓPSIA CORRETA, realizada com agulha de Jamshid, permitindo a ressecção do tumor com margem, juntamente com o trajeto da biópsia.
Figure 86: Punctate scar from CORRECT BIOPSY, performed with a Jamshid needle, allowing resection of the tumor with a margin, along with the biopsy path.
*See the complete case of figures 85 and 86 at:  http://partial rotational prosthesis
Case 1 Considerations :  We will describe how we proceeded in this female patient, 40 years old, with pain in the right posterior superior iliac crest for six months, figures 87 to 116.
Figura 87: Radiografia de bacia obturatriz com lesão na crista ilíaca direita, seta e círculo em vermelho.
Figure 87: X-ray of the obturator pelvis with injury to the right iliac crest, arrow and circle in red.
Figura 88: Radiografia de bacia em alar com áreas de rarefação e outras de condensação (focos de calcificação?).
Figure 88: X-ray of the alar pelvis with areas of rarefaction and others of condensation (calcification foci?).
Figura 89: Tomografia axial evidenciando a lesão lítica agressiva no ilíaco direito, com erosão da cortical e tumor extra cortical com focos salpicados de condensação óssea.
Figure 89: Axial tomography showing the aggressive lytic lesion in the right iliac, with cortical erosion and extra-cortical tumor with speckled foci of bone condensation.
Figura 90: Tomografia coronal. Observamos a lesão na crista ilíaca, círculo vermelho e a região póstero inferior sem lesão, podendo-se preservar uma ponte sacro ilíaca, seta amarela.
Figure 90: Coronal tomography. We observed the lesion on the iliac crest, red circle and the inferior posteroregion without injury, with a sacroiliac bridge being able to be preserved, yellow arrow.
In the MRI analysis, we studied the involvement of the lesion, planned the surgical access and resection tactics with margin, and then chose the most appropriate and safe route for our biopsy, figures 91 and 92.
Figura 91: Ressonância axial exibindo os limites do tumor. A lesão extraóssea está delimitada internamente pelo peritônio, seta vermelha, externamente pelo músculo glúteo, seta amarela, recoberta pelo plano gorduroso, seta branca. O trajeto ideal para a biópsia deve ser pela crista ilíaca, seta azul.
Figure 91: Axial resonance showing the limits of the tumor. The extraosseous lesion is delimited internally by the peritoneum, red arrow, externally by the gluteal muscle, yellow arrow, covered by the fatty plane, white arrow. The ideal route for the biopsy should be through the iliac crest, blue arrow.
Figura 92: Ressonância coronal destacando a lesão, círculo vermelho e o plano de corte planejado, seta amarela.
Figure 92: Coronal resonance highlighting the lesion, red circle and the planned cutting plane, yellow arrow.
Thus, the planned resection is to be accessed through an incision following the iliac crest, dissecting externally through the fat plane and internally detaching the peritoneum. We intended to place the patient in the supine position, but while dressing the patient was anesthetized and placed in the prone position, which made the procedure difficult, in our opinion, figures 93 and 94.
Figura 93: Paciente anestesiada em decúbito prono, realizada a marcação da incisão por sobre a crista ilíaca, que permitisse abordar ambos os lados da lesão, linha azul.
Figure 93: Patient anesthetized in prone position, marking the incision above the iliac crest, which allowed both sides of the lesion to be approached, blue line.
Figura 94: Controle tomográfico da lesão, com o paciente em decúbito prono.
Figure 94: Tomographic control of the lesion, with the patient in the prone position.

The Rx operator argued that that position was the best and that we could easily obtain the material for the histological study and… made an X where he would obtain the sample! Figures 95 and 96.

Figura 95: Marca onde pretendiam puncionar! Fora do trajeto planejado!
Figure 95: Mark where they intended to puncture! Off the planned route!
Figura 96: Tomo da pretendida punção! Como resgatar este trajeto na ressecção? Marca onde pretendiam puncionar! Fora do trajeto planejado!
Figure 96: Tome of the intended puncture! How can this path be recovered during resection? Mark where they intended to puncture! Off the planned route!
I explained that we should not change the direction of the planned surgical incision, as this would make internal access to the pelvis difficult. We advise you to puncture at the lateral point of the crest, despite the difficulty in angulating the needle, due to the prone position. This procedure is described as  ¨freezing biopsy¨ , figures 97 to 102.
Figura 97: Orientação para lateralizar o ponto de punção da biópsia, seta amarela.
Figure 97: Orientation to lateralize the biopsy puncture point, yellow arrow.
Figura 98: Controle tomográfico do novo posicionamento, o mais lateral possível, sobre a linha de incisão planejada.
Figure 98: Tomographic control of the new positioning, as lateral as possible, on the planned incision line.
Figura 99: Biópsia sob sedação e controle de tomografia.
Figure 99: Biopsy under sedation and tomography control.
Figura 100: Tomografia com esquema detalhando o planejamento da ressecção, com margem oncológica, incluindo o trajeto da biópsia.
Figure 100: Tomography with a diagram detailing the resection planning, with oncological margin, including the biopsy path.
Figura 101: Agulha de Tru-cut e material de anestesia local.
Figure 101: Tru-cut needle and local anesthesia material.
Figura 102: Estudo da amostra colhida pelo patologista, na sala de radiologia, conhecida como biópsia de congelação.
Figure 102: Study of the sample collected by the pathologist, in the radiology room, known as frozen section biopsy.
With the confirmation of a cartilaginous tumor, likely chondrosarcoma GII, we performed partial resection of the right pelvis, as planned, without neoadjuvance, figures 103 to 116.
Figura 102: Estudo da amostra colhida pelo patologista, na sala de radiologia, conhecida como biópsia de congelação.
Figure 103: Frozen biopsy report and subsequent paraffin review: Chondrosarcoma GII.
Figura 104: Paciente posicionada em decúbito lateral, marcação da incisão planejada na pele, com ressecção do trajeto da biópsia.
Figure 104: Patient positioned in lateral decubitus, marking of the planned skin incision, with resection of the biopsy path.
Figura 105: Incisão e hemostasia cuidadosa. Trajeto de biópsia, seta em azul.
Figure 105: Incision and careful hemostasis. Biopsy path, blue arrow.
Figura 106: Dissecção pelo plano gorduroso, que reveste os músculos glúteos a serem ressecados como margem. Hemostasia cuidadosa, não há sangramento.
Figure 106: Dissection through the fatty plane, which covers the gluteal muscles to be resected as a margin. Careful hemostasis, there is no bleeding.
Figura 107: Peça ressecada, face externa, plano gorduroso cobrindo a musculatura glútea ressecada.
Figure 107: Dried piece, external face, fatty plane covering the dry gluteal muscles.
Figura 108: Peça ressecada, face interna, margem exígua da pseudo cápsula, peritônio rebatido.
Figure 108: Resected piece, internal surface, narrow margin of the pseudo capsule, folded peritoneum.
Video 1: Exposure of the internal surface of the pelvis and delicate osteotomy, performed with minimally invasive drills.
Figura 109: Corte da peça ressecada, observando-se as margens marcadas com tinta nanquim.
Figure 109: Section of the dried piece, observing the margins marked with Indian ink.
Figura 110: Hematoxilina e eosina, histologia de Condrossarcoma grau II.
Figure 110: Hematoxylin and eosin, grade II chondrosarcoma histology.
Figura 111: Erosão óssea por neoplasia cartilaginosa.
Figure 111: Bone erosion due to cartilaginous neoplasia.
Figura 112: Neoplasia cartilaginosa, com mitoses atípicas e hipercromasia.
Figure 112: Cartilaginous neoplasm, with atypical mitoses and hyperchromasia.
Figura 113: Neoplasia cartilaginosa, com polimorfismo celular.
Figure 113: Cartilaginous neoplasm, with cellular polymorphism.
Figura 114: Laudo da peça cirúrgica. Condrossarcoma GII, com focos entre 5 a 10 % de GIII.
Figure 114: Report of the surgical specimen. Chondrosarcoma GII, with foci between 5 and 10% of GIII.
Case 2 Considerations :  Let’s now discuss the biopsy in this eleven-year-old patient, with pain and a tumor in the left thigh for two weeks. Probable osteosarcoma, figures 115 to 118.
Figura 115: Radiografia de frente com lesão na face lateral da metáfise distal do fêmur esquerdo, seta em vermelho e face posterior, radiografia em perfil.
Figure 115: Frontal radiograph with lesion on the lateral aspect of the distal metaphysis of the left femur, arrow in red and posterior aspect, lateral x-ray.
Figura 116: Tomografia axial destacando a lesão que ocupa a região central do osso e ultrapassa a cortical nas faces anterior, lateral e posterior, lesão osteoblástica, agressiva.
Figure 116: Axial tomography highlighting the lesion that occupies the central region of the bone and goes beyond the cortex on the anterior, lateral and posterior surfaces, an aggressive, osteoblastic lesion.
Figura 117: Ressonância coronal T1, com supressão de gordura destacando a extensão medular da lesão, que compromete a cartilagem de crescimento.
Figure 117: Coronal T1 resonance, with fat suppression highlighting the medullary extension of the lesion, which compromises the growth cartilage.
Figura 118: Ressonância axial T1, com supressão de gordura, lesão intramedular e extra cortical. Seta amarela aponta a fáscia lata. A seta amarela indica o trajeto adequado para a biópsia.
Figure 118: Axial T1 resonance, with fat suppression, intramedullary and extra-cortical lesion. Yellow arrow points to the fasciae latae. The yellow arrow indicates the appropriate path for the biopsy.

We very frequently see patients with biopsy scars performed in the anterolateral region of the distal metaphysis of the femur. The  red arrow  points to the fascia lata, which is most often interrupted by the biopsy path, carried out by professionals who will not operate on the patient, making it difficult to cover future surgery and the function of this limb that will need to be reconstructed.

The  yellow arrow  indicates the posterolateral path, most suitable for biopsy and reconstruction, providing the best coverage and function.

To perform the biopsy using this route, the appropriate positioning of the patient is in the prone position, figures 119 to 122.

Figura 119: Paciente em decúbito prono, para facilitar a realização da biópsia, posteriormente à inserção da fáscia lata, seta em vermelho. A Seta amarela destaca o controle tomográfico da posição.
Figure 119: Patient in prone position, to facilitate the biopsy, after insertion of the fascia lata, red arrow. The yellow arrow highlights the tomographic control of the position.
Figura 120: Paciente sob sedação, anestesia local e controle tomográfico do procedimento.
Figure 120: Patient under sedation, local anesthesia and tomographic control of the procedure.
Figura 121: Biópsia realizada abaixo da fáscia lata. Setas em vermelho, controle tomográfico do procedimento, seta amarela.
Figure 121: Biopsy performed below the fascia lata. Red arrows, tomographic control of the procedure, yellow arrow.
Figura 122: Patologia de congelação realizada atesta neoplasia maligna de grandes células, provável osteossarcoma.
Figure 122: Frozen section pathology performed attests to a large cell malignancy, likely osteosarcoma.

For the treatment of tumors of the distal end of the femur, such as this lesion, with this degree of involvement and location, we recommend biopsy as described and neoadjuvant induction chemotherapy, resection with oncological margin and reconstruction with modular prosthesis and adjuvant chemotherapy.

The patient in this example is out of treatment, with excellent function, and the complete case can be seen at Link:  http://osteosarcoma-length discrepancy  .

The performance of musculoskeletal biopsy, aiming at the diagnosis and adequate treatment of neoplasms, must be very well planned and carried out by experienced professionals.

“Carrying out musculoskeletal biopsies, aiming at the diagnosis and adequate treatment of neoplasms, must be very well planned and carried out by experienced professionals and with the participation of the surgeon who will be managing the case”. 

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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Thigh Soft Tissue Sarcoma Resection Technique

Thigh Soft Tissue Sarcoma Resection Technique. Female patient, 33 years old, reports a tumor on the posterior and distal aspect of the left thigh for a year, with greater growth in the last three months, during the end of pregnancy. After consultation with another professional, in which she underwent ultrasound examinations, bone scintigraphy, magnetic resonance imaging and biopsy, Figures 1-20, she was referred to us for evaluation and treatment.

Thigh soft tissue sarcoma resection technique

Figura 1: Observação clínica da face posterior da coxa esquerda, com abaulamento posterior no terço distal e cicatriz da biópsia realizada com agulha, em outro hospital.
Figure 1: Clinical observation of the posterior surface of the left thigh, with posterior bulging in the distal third and scar from the biopsy performed with a needle, in another hospital.
Figura 2: Perfil da coxa esquerda, com tumor abaulando o terço posterior e distal da coxa.
Figure 2: Profile of the left thigh, with tumor bulging the posterior and distal third of the thigh.
Figura 3: Ultrasonografia da coxa esquerda
Figure 3: Ultrasonography of the left thigh
Figura 4: Ultrasonografia da coxa esquerda
Figure 4: Ultrasonography of the left thigh
Figura 5: Ultrasonografia da coxa esquerda
Figure 5: Ultrasonography of the left thigh
Figura 6: Laudo da ultrasonografia da coxa esquerda.
Figure 6: Ultrasonography report of the left thigh.
Figura 7: Cintilografia óssea, fase angiográfica ou de fluxo.
Figure 7: Bone scintigraphy, angiographic or flow phase.
Figura 8: Cintilografia óssea, fase tardia.
Figure 8: Bone scintigraphy, late phase.
Figura 9: Laudo da cintilografia óssea.
Figure 9: Bone scintigraphy report.
Figura 10: Rm cor T1, com lesão de tecidos moles no terço distal da coxa esquerda com baixo sinal.
Figure 10: T1 color MRI, with soft tissue lesion in the distal third of the left thigh with low signal intensity.
Figura 11: Rm sag T1 com supressão de gordura, lesão de tecidos moles na face posterior e distal da coxa esquerda.
Figure 11: MRI sag T1 with fat suppression, soft tissue injury on the posterior and distal aspect of the left thigh.
Figura 12: Rm ax T1 com saturação de gordura, lesão de tecidos moles posterior da coxa esquerda.
Figure 12: MRI ax T1 with fat saturation, posterior soft tissue injury of the left thigh.
Figura 13: Rm ax T1 com saturação de gordura e contraste, lesão heterogênea, com áreas de baixo sinal, sinal intermediário e alto sinal, captação de contraste no interior da lesão, revelando neoplasia agresiva.
Figure 13: MRI ax T1 with fat saturation and contrast, heterogeneous lesion, with areas of low signal, intermediate signal and high signal, contrast uptake inside the lesion, revealing aggressive neoplasia.
Figura 14: Laudo da ressonância magnética.
Figure 14: MRI report.
Figura 15: Radiografia de tórax PA, normal.
Figure 15: PA chest x-ray, normal.
Figura 16: Radiografia de tórax perfil, normal.
Figure 16: Normal lateral chest x-ray.
Figura 17: Tomografia do tórax sem alteração. Sem sinais de lesão secundária.
Figure 17: Chest tomography without changes. No signs of secondary injury.
Figura 18: Radiografia do fêmur frente.
Figure 18: X-ray of the front femur.
Figura 19: Radiografia do fêmur, perfil revela lesão de tecidos moles com aumento de densidade na face posterior e distal da coxa.
Figure 19: X-ray of the femur, profile view reveals soft tissue injury with increased density on the posterior and distal aspect of the thigh.
Figura 20: Radiografia de bacia frente, normal.
Figure 20: X-ray of the front pelvis, normal.
It is instructive to comment that some requested tests could be waived. Bone scintigraphy for this soft tissue injury is an exam that does not add value, as well as radiography of the pelvis, since the lesion is not in this location, the best imaging test to evaluate soft tissue injury is magnetic resonance imaging. new resonance, seeking to obtain better definition of the images, without granulation and in all routine weightings, aiming to evaluate in detail the relationship of the lesion with the vascular and nevus bundles. Figures 21 to 33.
Figura 21: Rm ax, lesão com baixo sinal em T1.
Figure 21: Rm ax, lesion with low signal on T1.
Figura 22: Rm cor, lesão com baixo sinal em T1.
Figure 22: Color MRI, lesion with low signal on T1.
Figura 23: Rm sag, lesão com baixo sinal em T1.
Figure 23: Rm sag, lesion with low signal on T1.
Figura 24: Rm ax, lesão com alto sinal em T2 spir.
Figure 24: MRI ax, lesion with high signal on T2 spir.
Figura 25: Rm cor, lesão com alto sinal em T2.
Figure 25: Color MRI, lesion with high signal on T2.
Figura 26: Rm sag, lesão com alto sinal em T2.
Figure 26: Rm sag, lesion with high signal on T2.
Figura 27: Rm apresenta lesão com sinal intermediário e alto sinal em ax T1 com supressão de gordura.
Figure 27: Rm presents a lesion with intermediate signal and high signal on ax T1 with fat suppression.
Figura 28: Rm ax FFE.
Figure 28: Rm ax FFE.
Figura 29: Rm ax T1 spir, com baixo sinal e captação de contraste.
Figure 29: Rm ax T1 spir, with low signal and contrast uptake.
Figura 30: Rm cor T1 spir, com baixo sinal, vascularização e captação de contraste.
Figure 30: MRI color T1 spir, with low signal, vascularization and contrast uptake.
Figura 31: Rm sag T1 spir, com baixo sinal e captação de contraste.
Figure 31: Rm sag T1 spir, with low signal and contrast uptake.
Figura 32: Laudo da segunda ressonância magnética.
Figure 32: Report of the second magnetic resonance imaging.
Figura 33: Laudo da biópsia.
Figure 33: Biopsy report.
Tumor resection surgery was performed on 10/28/2014. We indicate an incision that begins at the posterior fold of the knee and goes proximally over the path of the internal saphenous muscle, to provide access to the entire path of the artery, vein and femoral nerve, figures 34 to 55.
Figura 34: Paciente em decúbito prono, cuidados de asepssia e antissepsia.
Figure 34: Patient in prone position, asepsis and antisepsis care.
Figura 35: Incisão póstero medial da coxa, curvando-se horizontalmente sobre a interlinha articular do joelho, sem uso de garroteamento do membro.
Figure 35: Posteromedial thigh incision, curving horizontally over the knee joint line, without using a tourniquet of the limb.
Figura 36: Hemostasia cuidadosa com eletrocautério e abertura do subcutãneo e fascia medial.
Figure 36: Careful hemostasis with electrocautery and opening of the subcutaneous tissue and medial fascia.
Figura 37: Prossegue-se dissecando todo o subcutâneo da incisão cirúrgica e cauterizando os vasos sangrantes, para uma cirurgia segura.
Figure 37: Continue dissecting the entire subcutaneous layer of the surgical incision and cauterizing the bleeding vessels, for safe surgery.
Figura 38: Afasta-se o músculo bíceps femoral, expondo o nervo ciático.
Figure 38: The biceps femoris muscle moves away, exposing the sciatic nerve.
Figura 39: Abertura do perineuro e liberação cuidadosa do nervo ciático, liberando-o do tumor.
Figure 39: Opening the perineurium and carefully releasing the sciatic nerve, freeing it from the tumor.
Figura 40: Dissecção do septo para liberação do polo distal da lesão.
Figure 40: Dissection of the septum to release the distal pole of the lesion.
Figura 41: Ligadura dos vasos nutrícios do tumor.
Figure 41: Ligation of the tumor's nutrient vessels.
Figura 42: Continua-se liberando a lesão no plano profundo, afastando-se os vasos femorais e expondo a extremidade distal do músculo envolvido para sua secção.
Figure 42: Continue releasing the lesion in the deep plane, moving the femoral vessels apart and exposing the distal end of the muscle involved for sectioning.
Figura 43: Exposição do segmento do músculo semimembranoso acometido pela lesão.
Figure 43: Exposure of the semimembranous muscle segment affected by the injury.
Figura 44: O corte do músculo afetado é feito preferencialmente com o eletrocautério, mantendo-se uma margem de tecido macroscopicamente sadio.
Figure 44: The affected muscle is cut preferably using electrocautery, maintaining a margin of macroscopically healthy tissue.
Figura 45: Separa-se o feixe muscular e prende-se as duas extremidades com pinças, para a secção e ligadura.
Figure 45: The muscle bundle is separated and the two ends are clamped with forceps for sectioning and ligation.
Figura 46: A ligadura deve ser realizada nas duas extremidades, para uma cirurgia limpa e oncológica .
Figure 46: The ligation must be performed on both ends, for a clean and oncological surgery.
Figura 48: Secção do segmento muscular envolvido, mantendo uma boa margem de tecido macroscopicamente sadio junto com a peça.
Figure 47: The muscle is sectioned and must be ligated into small bundles to ensure hemostasis.
Figura 48: Secção do segmento muscular envolvido, mantendo uma boa margem de tecido macroscopicamente sadio junto com a peça.
Figure 48: Section of the involved muscle segment, maintaining a good margin of macroscopically healthy tissue along with the piece.
Figura 49: Peça ressecada, vista profunda.
Figure 49: Dried piece, deep view.
Figura 50: Peça ressecada, vista lateral.
Figure 50: Dried piece, side view.
Figura 51: Peça ressecada, vista medial.
Figure 51: Resected piece, medial view.
Figura 52: Leito operatório após a retirada do tumor, com a margem possível nesta região.
Figure 52: Operative bed after removal of the tumor, with the possible margin in this region.
Figura 53: Clips metálicos são colocados para delimitar o sítio anterior do tumor, fascilitando ao radioterapeuta.
Figure 53: Metal clips are placed to delimit the previous site of the tumor, facilitating the radiotherapist.
Figura 54: Mesmo com uma boa hemostasia, a colocação de dreno aspirativo é bem indicada.
Figure 54: Even with good hemostasis, the placement of an aspiration drain is well indicated.
Figura 55: Fechamento cuidadoso por planos.
Figure 55: Careful closure by planes.
The resected piece was sent for pathological anatomical study, figures 56 to 61.
Figura 56: Peça ressecada em bloco, com a margem oncológica possível, dada a localização do tumor.
Figure 56: Piece resected en bloc, with the possible oncological margin, given the location of the tumor.
Figura 57: Peça ressecada em bloco, com a margem oncológica possível, dada a localização do tumor, vista medial
Figure 57: Piece resected en bloc, with the possible oncological margin, given the location of the tumor, medial view
Figura 58: Cortes da peça cirúrgica, marcada com nankin, para estudo da margem.
Figure 58: Sections of the surgical specimen, marked with nankin, to study the margin.
Figura 59: Peça cortada ao meio, para estudo da macroscopia, lado A.
Figure 59: Piece cut in half, for macroscopic study, side A.
Figura 60: Peça cortada ao meio, para estudo da macroscopia, lado B.
Figure 60: Piece cut in half, for macroscopic study, side B.
Figura 61: Laudo da peça cirúrgica.
Figure 61: Report of the surgical specimen.
Figura 62: Pós operatório de duas semanas.
Figure 62: Two weeks post-operative.
Figura 63: Pós operatório de um mês. Aspecto cosmético da cicatriz
Figure 63: One month post-operative. Cosmetic appearance of the scar
Figura 64: Pós operatório de um mês, perfil com carga. Boa função.
Figure 64: One month post-operative, weight-bearing profile. Good function.
Figura 65: Pós operatório de um mês, flexão com carga.
Figure 65: One month post-operative, flexion with weight.
Figura 66: Pós operatório de sete semanas, aguardando cicatrização adequada e planejamento para inicio de radioterapia adjuvante.
Figure 66: Seven weeks post-operative, awaiting adequate healing and planning for the start of adjuvant radiotherapy.
Figura 67: Pós operatório de sete semanas, em programação para radioterapia adjuvante, dezembro de 2014.
Figure 67: Seven weeks post-operative, scheduled for adjuvant radiotherapy, December 2014.
After discussing the case again with the oncologists, adjuvant chemotherapy (after surgery) was not indicated, nor was neoadjuvant use recommended (before surgery). With the healing of the surgical wound progressing satisfactorily, we indicated the consolidation of local treatment with adjuvant radiotherapy.
Figura 68: Paciente após dois meses da cirurgia, em 30/12/2014, com boa cicatrização, apta ao tratamento re radioterapia adjuvante.
Figure 68: Patient two months after surgery, on 12/30/2014, with good healing, suitable for adjuvant radiotherapy treatment.
Figura 69: A radioterapia tem sua efiácia no tratamento local, mas também apresenta efeito colateral, como se tivesse ocorrido uma exposição solar exagerada, uma ¨queimadura¨.
Figure 69: Radiotherapy is effective in local treatment, but it also has side effects, as if excessive sun exposure had occurred, a ¨burn¨.
Figura 70: Aspecto da pele após aplicações de radioterapia, em 26/01/2015
Figure 70: Appearance of the skin after radiotherapy applications, on 01/26/2015
Figura 71: Aspecto da pele lateral da coxa, após aplicações de radioterapia, em 26/01/2015.
Figure 71: Appearance of the lateral skin of the thigh, after radiotherapy applications, on 01/26/2015.
Figura 72: Em detalhe, visão da face posterior da coxa, após término da radioterapia adjuvante.
Figure 72: In detail, view of the posterior aspect of the thigh, after completion of adjuvant radiotherapy.
Figura 73: Após o término das sessões de radioterapia, ocorre recuperação do tecido, Aspecto após a radioterapia, em 15/04/2015
Figure 73: After the end of radiotherapy sessions, tissue recovery occurs, Appearance after radiotherapy, on 04/15/2015
Figura 74: Evidente melhora progressiva do aspecto cosmético, em 11/05/2015.
Figure 74: Evident progressive improvement in the cosmetic appearance, on 05/11/2015.
Figura 75: Pet-cet em novembro de 2015, após um ano da cirurgia. Este exame representa a fotografia inicial para o controle comparativo do acompanhamento pós tratamento.
Figure 75: Pet-cet in November 2015, one year after surgery. This examination represents the initial photograph for comparative control of post-treatment follow-up.
Figura 76: Laudo do Pet-Cet, com uma interpretação equivocada, sugerindo "atividade da doença de base". Na realidade trata-se da expressão inflamatória residual da radioterapia, SUV 2.0, baixo. Os "focos de calcificação" nada mais são do que os clips de demarcação do leito operatório, para orientação da radioterapia.
Figure 76: Pet-Cet report, with a mistaken interpretation, suggesting "activity of the underlying disease". In reality, it is the residual inflammatory expression of radiotherapy, SUV 2.0, low. The "calcification foci" are nothing more than the demarcation clips of the surgical bed, to guide radiotherapy.
Figura 77: Rm sagital após um ano, sem sinais de recorrência.
Figure 77: Sagittal MRI after one year, with no signs of recurrence.
Figura 78: Rm coronal após um ano. As setas assinalam a presença dos clips metálicos marcadores do leito cirúrgico para a radioterapia.
Figure 78: Coronal Rm after one year. The arrows indicate the presence of metallic clips marking the surgical bed for radiotherapy.
Figura 79: Rm axial após um ano da cirurgia, sem sinal de recidiva. A seta amarela assinala a cicatriz do acesso cirúrgico.
Figure 79: Axial MRI one year after surgery, with no sign of recurrence. The yellow arrow marks the surgical access scar.
Figura 80: Flexão simétrica, com carga total.
Figure 80: Symmetrical bending, with full load.
Figura 81: Pele posterior da coxa com hiperpigmentação sequelar da radioterapia. Evolução do aspecto cosmético em dezembro de 2015.
Figure 81: Posterior skin of the thigh with hyperpigmentation resulting from radiotherapy. Evolution of the cosmetic appearance in December 2015.
Figura 82: Avaliação em maio de 2016, após um ano e sete meses da cirurgia.
Figure 82: Assessment in May 2016, one year and seven months after surgery.
Figura 83: Recuperação bastante satisfatória do aspecto cosmético, em fevereiro de 2017.
Figure 83: Very satisfactory recovery of the cosmetic appearance, in February 2017.
Figura 84: Rm axial em fevereiro de 2017, após 2 e1/2 anos da cirurgia.
Figure 84: Axial MRI in February 2017, 2 and 1/2 years after surgery.
Figura 85: Laudo da ressonância de controle de fevereiro de 2016, sem sinais de recidiva.
Figure 85: Control MRI report from February 2016, with no signs of recurrence.
Analysis of the history, clinical picture and images of a homogeneous, compact lesion, with precise limits, producing mature bone, allowed the diagnosis of osteoma, with resection of this lesion for aesthetic reasons. The surgery was performed under general anesthesia and local infiltration to reduce bleeding (figures 10 to 20).

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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Technique for Revision of Infected Hip Prosthesis

Technique for Revision of Infected Hip Prosthesis. A 52-year-old patient, with bilateral osteoarthritis of the hips, due to aseptic necrosis of the femoral heads, with more severe pain and disability on the left, underwent total hip arthroplasty E, figures 1 and 2.

Technique for revision of infected hip prosthesis – Arthrosis due to femoral head necrosis – Loosening and breakage of prosthesis, infection and fracture.

Figura 1: Radiografia da bacia frente, com artrose bilateral dos quadris.
Figure 1: X-ray of the front pelvis, with bilateral osteoarthritis of the hips.
Figura 2: Radiografia da bacia frente, em junho de 1999, após artroplastia total do quadril esquerdo.
Figure 2: Radiograph of the front pelvis, in June 1999, after total arthroplasty of the left hip.
He later underwent surgery on the hip on the right side. During follow-up, the left femoral component became loose and, in February 2008, the stem broke. In May, the first revision was carried out, with a new prosthesis using a long neck and short stem, figures 3 and 4.
Figura 3: Soltura do componente femoral e quebra da haste à esquerda, fevereiro de 2008.
Figure 3: Loosening of the femoral component and breakage of the nail on the left, February 2008.
Figura 4: Revisão do quadril esquerdo com troca da prótese femoral, com colo longo, haste curta e placa com tela e cerclagem, em maio de 2008.
Figure 4: Revision of the left hip with replacement of the femoral prosthesis, with long neck, short stem and plate with mesh and cerclage, in May 2008.
Figura 5: Fratura do fêmur no final da haste femoral curta, em setembro de 2008, apenas quatro meses após a segunda cirurgia, do lado esquerdo.
Figure 5: Femur fracture at the end of the short femoral stem, in September 2008, just four months after the second surgery, on the left side.
Figura 6: Osteossíntese da fratura periprotética com placa e enxerto ósseo, terceira cirurgia.
Figure 6: Osteosynthesis of the periprosthetic fracture with plate and bone graft, third surgery.
Figura 7: Soltura da placa, em maio de 2009, após oito meses da terceira cirurgia.
Figure 7: Plate release, in May 2009, eight months after the third surgery.
Figura 8: Nova revisão, com troca da prótese femoral, agora com haste longa, em junho de 2009, quarta cirurgia.
Figure 8: New revision, with exchange of the femoral prosthesis, now with a long stem, in June 2009, fourth surgery.
In February 2010, the long femoral stem was loosened, followed by a new revision with a plate, mesh, homologous graft and reinforced plate. Infection with active fistula and new releases, now with the patient presenting diabetes, figures 9 to 12.
Figura 9: Soltura da haste femoral longa, em fevereiro de 2010.
Figure 9: Loosening of the long femoral stem, in February 2010.
Figura 10: Nova cimentação da haste femoral longa, acrescida de enxerto homólogo, com troca da tela e nova placa reforçada, junho de 2010.
Figure 10: New cementation of the long femoral stem, added with a homologous graft, with replacement of the mesh and new reinforced plate, June 2010.
Figura 11: Reabsorção parcial do enxerto e infecção, março de 2011.
Figure 11: Partial graft resorption and infection, March 2011.
Figura 12: Calo reativo, pela movimentação do conjunto. Soltura da placa e infecção, com fístula produtiva. Realizada nova limpeza cirúrgica, outubro de 2013.
Figure 12: Reactive callus, due to movement of the assembly. Plaque loosening and infection, with productive fistula. New surgical cleaning was performed, October 2013.
From 2010 to 2014, the patient underwent surgical cleaning and systemic antibiotic therapy, under the supervision of an infectious disease specialist, in successive hospitalizations, aiming to achieve control of the infection for a two-stage revision. In March 2014, we evaluated the patient and analyzed the case. We recommend a single-stage revision, resecting the proximal segment en bloc, with prosthesis, plate, screws, mesh, wires, grafts, sequestrations and necrotic tissue, as if it were a neoplasm, and replacing it with a non-conventional polyethylene endoprosthesis. This endoprosthesis is nothing more than a spacer, with the advantage of immediately filling the dead space and providing immediate function of the operated limb, figures 13 to 15.
Figura 13: Infecção, soltura da placa, fístula ativa em paciente agora diabético, após quatro limpezas cirúrgicas e antibioticoterapia sistêmica nos últimos quatro anos.
Figure 13: Infection, plaque loosening, active fistula in a now diabetic patient, after four surgical cleanings and systemic antibiotic therapy in the last four years.
Figura 14: Aspecto clínico em março de 2014, pré-operatório. Antibioticoterapia pré-operatória, diabete compensada, apesar de fístula ativa.
Figure 14: Clinical appearance in March 2014, pre-operative. Preoperative antibiotic therapy, diabetes compensated, despite active fistula.
Figura 15: Prótese modular de polietileno e titânio.
Figure 15: Modular polyethylene and titanium prosthesis.
Pre-operative radiographs of the revision in a surgical procedure, in April 2014, figures 19 to 128.
Figura 16: Radiografia pré-operatória da revisão em um tempo de artroplastia infectada do quadril esquerdo.
Figure 16: Preoperative radiograph of the revision in an infected arthroplasty of the left hip.
Figura 17: Radiografia do quadril esquerdo frente, com régua, evidenciando a má qualidade do osso e a soltura da prótese e da osteossíntese.
Figure 17: Radiograph of the front left hip, with a ruler, showing the poor quality of the bone and the loosening of the prosthesis and osteosynthesis.
Figura 18: Radiografia com detalhe da soltura no segmento distal, pré-operatório de revisão em um tempo.
Figure 18: Radiograph with detail of the loosening in the distal segment, pre-operative revision at a time.
Revision surgery, April 8, 2014, figures 19 to 15.
Figura 19: Paciente em decúbito lateral, fixado com posicionador, destacando-se o azul de metileno injetado pelas duas fístulas, cujos trajetos serão ressecados em bloco com todos os tecidos desvitalizados, juntamente com a prótese, enxertos necróticos e materiais de osteossínteses soltos, que foram empregados nas cirurgias anteriores.
Figure 19: Patient in lateral decubitus, fixed with a positioner, highlighting the methylene blue injected through the two fistulas, whose paths will be resected en bloc with all devitalized tissues, together with the prosthesis, necrotic grafts and loose osteosynthesis materials, which were used in previous surgeries.
Figura 20: Assepsia e antissepsia. Figura 21: Passagem de sonda pela fístula inferior, drenagem de secreção e lavagem da ¨cavidade¨. Incisão na coxa.
Figure 20: Asepsis and antisepsis. Figure 21: Passing a probe through the inferior fistula, draining secretion and washing the ¨cavity¨. Incision in the thigh.
Figura 22: Podemos evidenciar a placa, parafusos, cerclagem com amarrilho no fêmur esquerdo.
Figure 22: We can see the plate, screws, cerclage with ligature on the left femur.
Figura 23: Dissecção do segmento de 2/3 proximais do fêmur a ser ressecado.
Figure 23: Dissection of the proximal 2/3 segment of the femur to be resected.
Figura 24: Dissecção anterior e posterior do segmento a ser ressecado em bloco.
Figure 24: Anterior and posterior dissection of the segment to be resected en bloc.
Figura 25: Liberação de fibras do vasto medial aderidas à fibrose da pseudo cápsula ao redor do complexo processo infeccioso (prótese, placa, tela e amarrilhos soltos e sequestros ósseos).
Figure 25: Release of vastus medialis fibers adhered to the pseudocapsule fibrosis around the complex infectious process (prosthesis, plate, mesh and loose ties and bone sequestrations).
Figura 26: Luxação do segmento e liberação posterior. Observem os inúmeros componentes inoperantes nesta montagem.
Figure 26: Segment dislocation and posterior release. Note the numerous inoperative components in this assembly.
Figura 27: Ressecção de fibrose póstero inferior e preparação do nível de osteotomia femoral.
Figure 27: Resection of posteroinferior fibrosis and preparation of the femoral osteotomy level.
Figura 28: Ao dissecarmos a região medial distal, encontramos uma outra loja, extraóssea, com abcesso purulento.
Figure 28: When dissecting the distal medial region, we found another store, extraosseous, with a purulent abscess.
Figura 29: Em detalhe, abcesso envolto por tecido fibroso cicatricial, sem continuidade com a montagem, que necessita ser ressecado em bloco também.
Figure 29: In detail, abscess surrounded by fibrous scar tissue, without continuity with the assembly, which also needs to be resected en bloc.
Figura 30: Osteotomia com serra de Giglê.
Figure 30: Osteotomy with a Gigle saw.
Figura 31: Liberação de aderências na linha áspera e desinserção muscular.
Figure 31: Release of adhesions in the linea aspera and muscle disinsertion.
Figura 32: Ressecção de 2/3 proximais do fêmur, em bloco (fibrose, amarrilho, tela, placa, prótese, cimento e enxerto ósseo sequestrado).
Figure 32: Resection of the proximal 2/3 of the femur, en bloc (fibrosis, ligature, mesh, plate, prosthesis, cement and sequestered bone graft).
Figura 33: Visualização posterior do segmento ressecado em bloco.
Figure 33: Posterior view of the en bloc resected segment.
Figura 34: Desmontagem do amarrilho e abertura da tela. Observem os sequestros resultantes do enxerto homólogo.
Figure 34: Dismantling the tie and opening the screen. Observe the sequestrations resulting from the homologous graft.
Figura 35: Os sequestros estão até esverdeados, devido à intensa proliferação bacteriana, apesar de quatro anos de antibioticoterapia.
Figure 35: The sequestrations are even greenish, due to intense bacterial proliferation, despite four years of antibiotic therapy.
Figura 36: Leito ressecado e curetagem dos tecidos moles, para retirada do excesso de tecido desvitalizado.
Figure 36: Resected bed and soft tissue curettage, to remove excess devitalized tissue.
Figura 37: Canal femoral curetado e fresado, pronto para a reconstrução com endoprótese modular de polietileno.
Figure 37: Curetted and milled femoral canal, ready for reconstruction with modular polyethylene endoprosthesis.
Figura 38: Área preparada para a colocação da endoprótese modular. Optamos por manter o componente acetabular.
Figure 38: Area prepared for the placement of the modular stent. We chose to maintain the acetabular component.
Figura 39: Montagem da prótese de prova, comparação com o segmento removido.
Figure 39: Assembly of the trial prosthesis, comparison with the removed segment.
Figura 40: Colocação e teste com a prótese de prova.
Figure 40: Placement and testing with the trial prosthesis.
Figura 41: Montagem da prótese modular a ser implantada, conforme a dimensão da prótese de prova.
Figure 41: Assembly of the modular prosthesis to be implanted, according to the size of the trial prosthesis.
After testing with the trial prosthesis and choosing the definitive modules, we proceed to cementing the endoprosthesis components, figures 42 to 53.
Figura 42: Preparo do cimento na cuba.
Figure 42: Preparation of cement in the vat.
Figura 43: Cimento pronto, colocação de pouca quantidade dentro do canal sextavado do componente proximal da prótese.
Figure 43: Ready cement, placing a small amount inside the hexagonal canal of the proximal component of the prosthesis.
Figura 44: Encaixa-se o componente proximal com o prolongador diafisário dimensionado, cimentando-se e fixando os módulos, para evitar eventual pistonagem.
Figure 44: Fit the proximal component with the sized diaphyseal extender, cementing and fixing the modules, to avoid possible pistoning.
Figura 45: Com o polegar tamponamos o orifício de respiro para saída do excesso de cimento e comprimimos os componentes.
Figure 45: Using our thumb, we plug the breather hole to allow excess cement to escape and compress the components.
Figura 46: Diminuímos o tamponamento, permitindo a saída do excesso de cimento, permitindo a exata compactação dos módulos.
Figure 46: We reduced the plugging, allowing excess cement to escape, allowing the exact compaction of the modules.
Figura 47: Colocamos também um pouco de cimento ao redor do encaixe do anel metálico de acabamento.
Figure 47: We also placed a little cement around the fitting of the metal finishing ring.
Figura 48: Cimentação do espessor de acabamento. (variam de 0, 0.5, 1.0 e 1.5 de espessamento, para ajustes do comprimento, quando necessário).
Figure 48: Cementation of the finishing thickener. (they vary from 0, 0.5, 1.0 and 1.5 thickening, for length adjustments, when necessary).
Figura 49: Limpeza e retirado do excesso de cimento da parte proximal da endoprótese.
Figure 49: Cleaning and removing excess cement from the proximal part of the endoprosthesis.
Figura 50: Retirada do excesso de cimento. Endoprótese modular montada no intraoperatório pronta, para ser empregada na reconstrução.
Figure 50: Removal of excess cement. Modular endoprosthesis assembled intraoperatively ready to be used in reconstruction.
Figura 51: Colocação de cimento no canal femoral.
Figure 51: Placement of cement in the femoral canal.
Figura 52: Introdução da prótese definitiva no segmento distal da diáfise do fêmur.
Figure 52: Introduction of the definitive prosthesis in the distal segment of the femoral shaft.
Figura 53: Cimentação da endoprótese, com atenção a fixar com 10 graus de rotação em anteversão.
Figure 53: Cementation of the endoprosthesis, paying attention to fixing it with 10 degrees of rotation in anteversion.
Figura 54: Endoprótese cimentada, manter compressão até a completa polimerização do cimento.
Figure 54: Cemented endoprosthesis, maintain compression until the cement is completely polymerized.
Figura 55: Conferência do posicionamento, reparo do tendão dos psoas e colocação da cabeça escolhida no colo da prótese.
Figure 55: Positioning check, repair of the psoas tendon and placement of the chosen head on the neck of the prosthesis.
Figura 56: Prótese reduzida.
Figure 56: Reduced prosthesis.
Figura 57: Inserção do tendão do médio glúteo nos orifícios da prótese.
Figure 57: Insertion of the gluteus medius tendon into the prosthesis holes.
Figura 58: Médio glúteo reinserido e dreno colocado.
Figure 58: Gluteus medius reinserted and drain placed.
Figura 59: Fechamento da ferida operatória.
Figure 59: Closing the surgical wound.
Figura 60: Radiografia pós-operatória de 14/05/2014.
Figure 60: Postoperative radiograph of 05/14/2014.
Figura 61: Radiografia da bacia de 14/05/2014, após um mês da ressecção em bloco e reconstrução com endoprótese não convencional modular de polietileno e titânio.
Figure 61: X-ray of the pelvis on 05/14/2014, one month after en bloc resection and reconstruction with an unconventional modular polyethylene and titanium endoprosthesis.
Around any endoprosthesis, fibrosis forms as a result of a foreign body reaction, resulting in a thick pseudo capsule, forming a case, which practically isolates this endoprosthesis from the body. The muscles and tendons, which were initially inserted into the prosthesis with ethibond threads, end up definitively adhering to this pseudo capsule. This pseudo capsule has a lining of fluid-secreting synovial epithelium, which ends up covering the endoprosthesis. This reactional fibrosis of the pseudocapsule can reach 5 mm in thickness. In revisions and even in surgeries with major muscle detachment, an increase in dead space may occur, resulting in the formation of excess synovial fluid, which increases the ¨case¨ that surrounds the prosthesis. This increase in volume, associated with weakness of the abductor muscles, can facilitate hip dislocation. On May 15, 2014, one month after surgery, the patient returned with an increase in thigh volume, no fever, no local heat, and signs of excess liquid content around the prosthesis. This liquid, when in excess, must be drained. Sometimes more than one procedure is necessary. It must be done with complete asepsis, using a large-caliber needle and emptying the contents as much as possible, figures 62 to 64.
Figura 62: Drenagem com equipos de soro e punção utilizando duas agulhas grossas, anestesia local se necessário.
Figure 62: Drainage with serum and puncture equipment using two thick needles, local anesthesia if necessary.
Figura 63: Observe a grande quantidade de líquido que pode se formar em casos de grandes descolamentos. Este líquido deve ser colhido para cultura e antibiograma, para o caso de haver recorrência da infecção. Neste caso não apresentou mais infecção.
Figure 63: Note the large amount of liquid that can form in cases of large detachments. This liquid must be collected for culture and antibiogram, in case the infection recurs. In this case, there was no further infection.
Figura 64: Na drenagem, quando diminui a drenagem espontânea, devemos colocar o paciente em pé e realizar compressão na coxa, ordenhando para o melhor esvaziamento.
Figure 64: During drainage, when spontaneous drainage decreases, we must place the patient in a standing position and apply compression to the thigh, milking for better emptying.
A new drainage was performed by puncture, on 05/28/2015, after two weeks. The patient was already able to walk with a walker and had no recurrence of the infection, figures 65 to 67.
Figura 65: Pós-operatório de dois meses.
Figure 65: Two months post-operative.
Figura 66: Carga total monopodal, após dois meses.
Figure 66: Total single-leg load, after two months.
Figura 67: Deambulando com andador, após dois meses da revisão em um só tempo com endoprótese não convencional.
Figure 67: Walking with a walker, two months after the one-time revision with a non-conventional endoprosthesis.
Video 1: Patient walking with a walker two months after the review.
In June 2014, he performed a hyperflexion and internal rotation movement, while sitting on a low toilet, presenting hip dislocation. A closed reduction was performed and we reoriented again regarding the movements that facilitated the dislocation, as there was significant hypotrophy of the gluteus medius, which made stabilization of the prosthesis even more difficult. A new episode of dislocation in July 2014, three months after surgery. We performed reduction maneuvers under radioscopy, without the need for sedation and obtained easy reduction and also easy displacement, confirming the inability to contain the reduced hip, due to the insufficiency of the abductor muscles and the femoral head that we used, which was small in size, figures 65 to 67 .
Figura 68: Radiografia do quadril luxado, em julho de 2014, após três meses da revisão.
Figure 68: Radiograph of the dislocated hip, in July 2014, three months after the review.
Figura 69: Prótese luxada: falta de troca do acetábulo, seta amarela; cabeça femoral pequena, seta laranja e insuficiência do médio glúteo, seta vermelha.
Figure 69: Dislocated prosthesis: lack of replacement of the acetabulum, yellow arrow; small femoral head, orange arrow and gluteus medius insufficiency, red arrow.
Figura 70: Quadril luxado, aspecto da cicatriz antes da revisão do componente acetabular, em 27/07/2014.
Figure 70: Dislocated hip, appearance of the scar before revision of the acetabular component, on 07/27/2014.
We had not changed the acetabulum in the previous surgery, maintaining a smaller head than the size of the previous acetabulum, which could also be contributing to the instability. We decided on re-intervention with replacement of the acetabulum for a constricted module, also employing a larger head.
Figura 71: Revisão da reconstrução. Abertura proximal para a troca do acetábulo, utilizando componente constrito.
Figure 71: Reconstruction review. Proximal opening for replacing the acetabulum, using a constricted component.
Figura 72: Abertura da cápsula articular e exposição do acetábulo.
Figure 72: Opening of the joint capsule and exposure of the acetabulum.
Figura 73: Retirada do polietileno acetabular.
Figure 73: Removal of the acetabular polyethylene.
Figura 74: Componente metálico do teto acetabular exposto, após a retirada do polietileno.
Figure 74: Metallic component of the acetabular roof exposed, after removing the polyethylene.
Figura 75: Colocação do novo acetábulo, detalhe dos orifícios para a fixação com parafusos.
Figure 75: Placement of the new acetabulum, detail of the holes for fixation with screws.
Figura 76: Novo componente acetabular, agora constrito.
Figure 76: New acetabular component, now constricted.
Figura 77: Colocação do novo polietileno.
Figure 77: Installing the new polyethylene.
Figura 78: Redução da prótese com acetábulo bloqueado e cabeça maior, com dificuldade.
Figure 78: Reduction of the prosthesis with blocked acetabulum and larger head, with difficulty.
Figura 79: Prótese reduzida, com cabeça femoral maior e acetábulo constrito.
Figure 79: Reduced prosthesis, with larger femoral head and constricted acetabulum.
Figura 80: Reinserção do médio glúteo na região trocanteriana da endoprótese.
Figure 80: Reinsertion of the gluteus medius into the trochanteric region of the endoprosthesis.
Figura 81: Radiografia do pós-operatório imediato da revisão com acetábulo bloqueado.
Figure 81: Immediate post-operative radiograph of revision with blocked acetabulum.
Figura 82: Sutura do tensor da fáscia lata e fechamento da ferida operatória.
Figure 82: Suturing the tensor fasciae latae and closing the surgical wound.
The patient evolved well, without complications, and was evaluated after one year, figures 83 to 86.
Figura 83: Paciente evoluindo bem, sem novo episódio de luxação, sem infecção, em 27/07/2015, após um ano.
Figure 83: Patient progressing well, without a new episode of dislocation, without infection, on 07/27/2015, after one year.
Figura 84: Bom alinhamento e equalização dos membros, em 27/07/2015, após um ano.
Figure 84: Good alignment and equalization of members, on 07/27/2015, after one year.
Figura 85: Flexão com carga satisfatória, em 27/07/2015, após um ano.
Figure 85: Flexion with satisfactory load, on 07/27/2015, after one year.
Figura 86: Carga total monopodal, em 27/07/2015, após um ano.
Figure 86: Total single-leg load, on 07/27/2015, after one year.
Video 2: Patient walking with trendelenburg, one year after the last surgery, acetabulum blocked, to overcome gluteus medius insufficiency.
Video 3: Patient walking without support, despite trendelemburg, after one year, on 07/27/2015.
To date, April 2, 2017, the patient is doing well, walking with a slight limp due to Trendelemburg, without any complications, three years after the last surgery.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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Epiphysiodesis technique and rotating partial prosthesis

Epiphysiodesis technique and rotating partial prosthesis. 11-year-old patient, presenting with knee pain and increased volume in the lower third of the right femur. X-rays from February 2014 showed a lesion producing bone tissue in the metaphysis, figures 1 and 2. The scintigraphy revealed that it was a single lesion with intense uptake in the distal metaphyseal region of the femur, figures 3 and 4.

Epiphysiodesis technique and rotating partial prosthesis, with preservation of the tibial growth physis, in osteosarcoma of the femur.

Figura 1: Radiografia do 1/3 distal do fêmur direito, com lesão de condensação óssea de limites imprecisos e triângulo de Codman com reação periosteal em raios de sol.
Figure 1: Radiograph of the distal 1/3 of the right femur, with bone condensation lesion with imprecise limits and Codman's triangle with periosteal reaction in sunlight.
Figura 2: Na radiografia em perfil, observa-se a área de condensação irregular, e a expansão tumoral extracortical na face anterior. Triangulo de Codman e reação periosteal lamelar fina.
Figure 2: On the lateral x-ray, the area of ​​irregular condensation and extracortical tumor expansion on the anterior surface are observed. Codman's triangle and thin lamellar periosteal reaction.
Figura 3: Cintilografia óssea, fase tardia, vista anterior e posterior, com intensa captação na região metafisária distal do fêmur direito.
Figure 3: Bone scintigraphy, late phase, anterior and posterior view, with intense uptake in the distal metaphyseal region of the right femur.
Figura 4 : Cintilografia ampliada evidenciando hipercaptação no fêmur direito.
Figure 4: Magnified scintigraphy showing high uptake in the right femur.
To expand the study of the lesion, a Pet-Ct examination was performed, figures 5 to 8.
Figura 5: Pet-Ct realizado em fevereiro de 2014 com captação na região metafisária distal do fêmur direito, junto à placa de crescimento.
Figure 5: Pet-Ct performed in February 2014 with capture in the distal metaphyseal region of the right femur, next to the growth plate.
Figura 6: Hipercaptação na metáfise distal do fêmur direito.
Figure 6: Hyperuptake in the distal metaphysis of the right femur.
Figura 7: Alta concentração de contraste no fêmur direito.
Figure 7: High contrast concentration in the right femur.
Figura 8: Laudo do Spect-Ct de 26/02/2014.
Figure 8: Spect-Ct report of 02/26/2014.
Continuing the staging, magnetic resonance imaging was performed, figures 9 to 18.
Figura 9: RM coronal T1, com lesão de alto e baixo sinal, com limites imprecisos.
Figure 9: Coronal T1 MRI, with high and low signal lesions, with imprecise limits.
Figura 10: RM sagital T1 com lesão de baixo sinal, ocupando a metáfise femoral e lesão extracortical anterior e posterior no fêmur.
Figure 10: Sagittal T1 MRI with low signal lesion, occupying the femoral metaphysis and anterior and posterior extracortical lesion in the femur.
Figura 11: RM sagital T1 com supressão de gordura, lesão de alto e baixo sinal, heterogênea e grande lesão extracortical anterior e posterior no fêmur.
Figure 11: Sagittal T1 MRI with fat suppression, high and low signal, heterogeneous lesion and large anterior and posterior extracortical lesion in the femur.
Figura 12: RM sagital T1, supressão de gordura, com intensa captação de contraste.
Figure 12: Sagittal T1 MRI, fat suppression, with intense contrast uptake.
Figura 13: RM axial fat T1, lesão metafisária e tumor extracortical.
Figure 13: Axial fat T1 MRI, metaphyseal lesion and extracortical tumor.
Figura 14: RM axial fat T1, corte mais proximal, lesão metafisária e grande tumor extracortical, delimitado externamente pelo periósteo que foi descolado da cortical.
Figure 14: Axial fat T1 MRI, most proximal section, metaphyseal lesion and large extracortical tumor, externally delimited by the periosteum that was detached from the cortex.
Figura 15: RM axial fat T1, com intensa captação de gadolínio.
Figure 15: Fat T1 axial MRI, with intense gadolinium uptake.
Figura 16: RM axial fat T1, com intensa captação de gadolínio, corte mais proximal.
Figure 16: Fat T1 axial MRI, with intense gadolinium uptake, more proximal section.
Figura 17: RM axial fat T1, com intensa captação de gadolínio. A seta aponta o periósteo deslocado e crescimento de tumor entre o periósteo e a cortical.
Figure 17: Axial fat T1 MRI, with intense gadolinium uptake. The arrow points to the displaced periosteum and tumor growth between the periosteum and the cortex.
Figura 18: Laudo da ressonância de 23/02/2014.
Figure 18: MRI report from 02/23/2014.
A puncture biopsy was performed, via a lateral approach, by another professional.
Figura 19: Face interna do terço distal da coxa direita.
Figure 19: Inner surface of the distal third of the right thigh.
Figura 20: Face externa do joelho direito, com a cicatriz da biópsia.
Figure 20: External face of the right knee, with the biopsy scar.
Note that the biopsy site, figure 20, is much anterior, passing through the middle of the fascia lata, making future coverage of the surgery difficult, as the lower segment of the fascia would be sectioned both in the biopsy area, above, and at the edge below.
Figura 21: Histologia, osteossarcoma osteoblástico.
Figure 21: Histology, osteoblastic osteosarcoma.
Figura 22: Histologia, osteossarcoma osteoblástico.
Figure 22: Histology, osteoblastic osteosarcoma.
Figura 23: Laudo da biópsia.
Figure 23: Biopsy report.
Figura 24: Radiografia coronal, com régua para o desenho da endoprótese e planejamento da cirurgia.
Figure 24: Coronal radiograph, with ruler for designing the endoprosthesis and planning the surgery.
Figura 25: Radiografia sagital, com régua para o desenho da endoprótese e planejamento da cirurgia.
Figure 25: Sagittal radiograph, with ruler for designing the endoprosthesis and planning the surgery.
Before the last stage of neo-adjuvant chemotherapy, we take radiographs with a ruler of the segment to be resected, to plan the surgery and create a special prosthesis, when necessary, figures 23 and 24. In growing children, this procedure is generally necessary due to the different widths of the medullary canal, varying sizes of the femoral condyles, in addition to special devices that allow the growth potential of the epiphyseal plate to be preserved. At this stage we also perform a new MRI to image the evolution of the lesion, figures 26 to 41. It is rare, but the tumor may have increased during chemotherapy and will need to be resected with an oncological margin. However, the segment to be removed with margin can never be smaller than the size planned with the initial resonance, sized in the T1 view.
Figura 26: RM axial T1, pós quimioterapia de indução, mostrando condensação da lesão, que traduz boa resposta ao tratamento.
Figure 26: Axial T1 MRI, after induction chemotherapy, showing condensation of the lesion, which reflects a good response to treatment.
Figura 27: RM axial T1 - perfusão.
Figure 27: Axial T1 MRI - perfusion.
Figura 28: RM axial T1 - pós-contraste.
Figure 28: Axial T1 MRI - post-contrast.
Figura 29: RM axial T2.
Figure 29: Axial T2 MRI.
Figura 30: Difusão.
Figure 30: Diffusion.
Figura 31: Mapa, lesão tumoral.
Figure 31: Map, tumor lesion.
Figura 32: RM cor T1.
Figure 32: T1 color MRI.
Figura 33: RM cor-stir.
Figure 33: Cor-stir MRI.
Figura 34: RM sag-T1.
Figure 34: sag-T1 MRI.
Figura 35: RM sag-stir.
Figure 35: MR sag-stir.
Figura 36: RM sag-T2-fat.
Figure 36: sag-T2-fat MRI.
Figura 37: Screensaver.
Figure 37: Screensaver.
Figura 38: Screensaver-2.
Figure 38: Screensaver-2.
Figura 39: Screensaver-3.
Figure 39: Screensaver-3.
Figura 40: Tomografia de tórax de 25/02/2014, sem evidência de metástase.
Figure 40: Chest tomography on 02/25/2014, with no evidence of metastasis.
Figura 41: Tomografia de tórax de 25/02/2014, sem alteração.
Figure 41: Chest tomography on 02/25/2014, no changes.
Tumor resection surgery was performed medially, removing the entire biopsy path and the lateral skin incision along with the surgical specimen. The surgical technique is explained in figures 42 to 98.