Edited by Nathan Thomas - 7/1/2021
Descriptors
Oncologic history - cancers / when diagnosed and how (biopsy/resection / treatments (chemotherapy, radiation, surgery), family history of cancer, up to date on routine screenings (mammogram, colonoscopy)
COMPLETE review of systems
“ All Sensible People Must Make Clear/Proper Sense”
A - Age
S - Site: which bone and in what part, isolated vs multifical
P - Pattern: lytic (bone replacing), blastic (bone producing), mixed
M - Margins: geographic vs poorly-defined
M - Matrix: bony, chondroid, fibrous
C - Cortical response: preserved or destroyed cortex
P - Periosteal reaction: onion skinning, codman’s triange
S - Soft tissue Involvement: calcified masses
Exam Pearls
During exam, pay attention to axial loading pain.
Workup
Radiographs: Orthogonal imaging of entire bone in question, skeletal survey (screening images of all bones)
Other imaging: Unknown primary site - staging studies (CT chest, abdomen, pelvis), suspected osteomyelitis - MRI, spinal lesions - MRI
Labs:
CBC with differential
Chem-7
SPEP
UPEP
LDH
CEA
PSA
TSH
PTH
Ionized calcium
LFTs
Albumin
ESR
CRP
Coagulation panel
Other: Medical oncology consultation and tissue biopsy if unknown primary lesion
Management
Need for acute intervention: None usually indicated, urgent medical consultation for hypercalcemia
Weight-bearing and range of motion: NWB pending full work-up or if pathologic fracture
Type of immobilization: variable depending on fracture
Admission or discharge status:
Admission for pathologic completed or impending fracture
Consider medical admission for lesions of unknown primary Consider discharge and urgent orthopedic oncology referral for comprehensive evaluation if no acute issues
Anticoagulation: LVX 40mg QD
Antibiotics: none
Surgical Indications
Absolute: Completed pathologic fractures, spinal lesions with cauda equina
Relative: Impending pathologic fractures
Not an indication: Asymptomatic, incidental lesions