Explore more about Determining your Diagnosis

First Office Visit

Your first office visit may be overwhelming because we are attempting to confirm a diagnosis for you. You meet many members of our staff, hear quite a bit of information and may have a number of tests performed. Your first visit maybe tiring, somewhat confusing and stressful depending on your situation.

If you brought blood results, MRI, bone or CT scans, we review all of them. If you have had a biopsy, we consult with our pathologists to review your pathology slides. If you have not had any of these studies done, we attempt to schedule all of them during your first visit.

Plain x-rays, CT scans of the tumor area and of your chest, MRI, PET and bone scans are called staging studies. These are the common studies performed to 'workup' a patient with a questionable tumor of the soft tissues or bone. They assist us in determining whether your tumor is benign or malignant, and whether the malignant ones (sarcomas) have traveled to other sites of your body. When a sarcoma has traveled, this is called a metastasis. If sarcomas metastasize, the most common site is the lung.

Your Care Team

  • Diagnostic Radiologist: Reviews all x-rays and scans showing the tumor
  • Pathologist: Examines biopsied tissue and determines diagnosis
  • Orthopedic Oncology Surgeon: Removes all types of tumors, performs limb-sparing surgeries, as well as pelvic and spine reconstruction
  • Advanced Practitioners (Nurse Practitioners & Physician Assistants): Coordinate all aspects of care, including assist in surgery
  • Medical Oncologist: Coordinates chemotherapy, trails, on-going surveillance visits and survivorship issues
  • Radiation Oncologist: Coordinates and deliveries all types of radiation
  • Surgical Oncologist: Works in conjunction with orthopaedic oncology surgeons, mainly to protect the abdominal organs (bowel, bladder, vessels, etc.) due to the complex nature of tumor surgery
  • Plastic Reconstructive Surgeon: Works in conjunction with orthopaedic oncology surgeon to repair the defects caused by tumor removal
  • Fellows: Physicians who have completed residency and are specializing in cancer care
  • Residents: Physicians who are still in specialized field of training
  • Nurses: Provide care 24/7 following surgery
  • Rehabilitation Specialist: These healthcare providers include physical medicine & rehabilitation physicians, physical therapists and occupational therapists, who all help you regain mobility, strength and endurance needed for daily work and recreational activities and adapt/adjust to limitations
  • Nutritionist (Registered Dietician): Evaluate caloric intake and provides counseling to overcome side effects of surgery and treatment (i.e. weight loss, poor appetite, nausea/vomiting, etc.)
  • Psychiatrists, psychologists, social workers & nurse case managers: Help you and your loved ones cope with the emotional and practical concerns of having cancer and navigate the health care system

Typically, your orthopaedic oncology surgeon can determine if a tumor is benign or malignant from viewing your scans and x-trays.

Most benign tumors are treated conservatively (monitoring) or with surgery. Read more about benign bone tumors or benign soft tissue tumors.

If your surgeon determines that you most likely have a malignancy, you will undergo a biopsy and additional staging studies.

Biopsy

On the day of your appointment, we may schedule a biopsy, if deemed necessary. A biopsy is a needle aspirate or surgical removal of a small piece of tissue for microscopic examination. There are four types of biopsies which are done to make a diagnosis:

Fine needle aspiration (FNA)

A fine needle aspiration (FNA) is performed in the office by pathologists from the FNA Biopsy Service. It takes about 10-15 minutes, uses a very small needle and usually the results are ready during your visit. A Band-Aid is placed at the biopsy site.

Tru-cut needle biopsy

A tru-cut needle biopsy is performed in the office by one of the surgeons. A local anesthetic is used to numb your skin and a larger needle is used to get several samples of tissue. You may have some discomfort or pressure like sensation when a sample is taken. Samples are taken to our pathologists and preliminary results are ready in an hour or so. Many times results take 24 hours or longer. A pressure dressing is applied to the biopsy site.

Refer to the home guidelines for questions you may have following your biopsy.

CT scan or ultrasound-guided needle biopsy

CT scan or ultrasound-guided needle biopsy is performed in the Musculoskeletal Radiology Department by one of the radiologists. It may take one hour. The CT is used to guide the radiologist to position the needle into the tumor and get several samples of tissue. Some patients have stated that the procedure is painful despite local anesthetics. A small bandage or larger pressure dressing is applied at the site. Results usually take 24 hours or longer. Radiologists prefer that you not eat or drink 6 hours before the procedure, and have someone with you to take you home. You will be medicated for the procedure, thus driving or taking public transportation is not advised.

Refer to the home guidelines for questions you may have following your biopsy.

Open biopsy

An open biopsy is a surgical procedure usually requiring general anesthesia in which a small incision is made to take an adequate tissue sample to be examined by the pathologist. Tumor diagnosis determines treatment plan. Thus, an open biopsy is performed when any of the other needle biopsies can not confirm a diagnosis or in children when this type of biopsy maybe more appropriate. An open biopsy can not be done on the same day as the office visit since it requires booking operative time and preadmission testing. Results may be ready following the procedure, but usually it takes 24 hours or longer.

Refer to the discharge guidelines for questions you may have following your biopsy.


Final Pathology/Histology

Histology refers to a pathologist looking at tissue cells under the microscope to determine diagnosis. Most soft tissue sarcomas have a number of histological subtypes. It usually takes 1-2 weeks to confirm a final diagnosis.


Staging Studies

During your work-up to determine the type of tumor you have, you will hear your physicians use the term “initial staging studies.” This means the different types of radiographs used for diagnosis, including x-rays, MRI, CT, PET and bone scans.

If diagnosed with a malignant tumor, you will hear the term “restaging studies.” These are the scans used to evaluate whether a malignant tumor has recurred or spread.

In addition to the two major categories of benign or malignant, bone and soft tissue tumors are further classified or staged. The stage of a lesion depends on three factors:

  1. The grade of the tumor which is a microscopic evaluation of the tumor cell's biologic behavior and aggressiveness, that is, its ability to grow and extend beyond its natural barrier (capsule).
  2. Whether the tumor stops in its area (compartment) or grows and penetrates out of the compartment.
  3. Whether or not there are metastases.

A biopsy which involves the microscopic evaluation of the tumor cell's biologic behavior will determine the grade. Pathologists grade malignant tumors ranging from low grade (1) to high grade (3). Low grade tumors are made of cells whose behavior is not aggressive, that is they seldom spread beyond their local site (Grade 1/3). Intermediate to high grade tumors are made of cells that behave very aggressive and most often than not spread to other parts of the body (Grade 2 or 3).

Patients must undergo many scans (MRI, CT, bone or PET) called staging studies. These scans are done to evaluate the extent of the tumor, locally or at distant sites. The tumor is then staged which helps determine the best treatment plan for that type of tumor. Many of these imaging studies need to be done prior to the biopsy. In most circumstances the biopsy is the last part of the staging process.

MRI - Magnetic Resonance Imaging

A technique using magnetic fields to produce images of the body. Used to evaluate soft tissue tumors of the spine.

CT Scan - Computerized Tomography Scans

These specialized x-ray studies can find cancer or mestastases in the lungs, abdomen, pelvis or bones. You may need to fast for a few hours if a contrast medium is used, such as the abdominal-pelvic scan. These scans also assist us with evaluation of fluid collections that can occur at the operative site after surgery.

PET Scan

A test used to assess the metabolic activity of your tumor. An isotope of glucose is injected into your veins. The isotope travels to your tumor where it collects and then can be imaged with a special scanner.

X-rays

While new technologies in imaging have been developed over the years (i.e. computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound imaging), plain film x-rays are still an important diagnostic tool. For a plain x-ray, a beam of x-rays is transmitted through an object (like the part of the body being scanned). Then a doctor is able to examine the film.

Nuclear Bone Scan

A procedure which involves the injection of a radioactive substance, called a radioactive tracer, into the bloodstream. The material is taken up by the bone and a machine that looks like an x-ray machine moves over your body and takes pictures. If a tumor is present, the body area will be described as having 'increased activity,' which is seen on the bone scan as a blackened area.

Ultrasound

The use of high frequency sound waves to locate a tumor deep inside the body. Also used to identify thromboses (DVT-blood clot) in the lower extremities or evaluate the presence of fluid in a postoperative incision area.

Many of our patients have expressed confusion about staging and grading of tumors because of information read in books or found on the internet. Hopefully the above information will help you understand how tumors are staged and graded.


Frequently Asked Questions

FAQs from your Initial Consultation

Will surgery be scheduled immediately?

No. Additional images and possible biopsy need to take place to determine a diagnosis. The timeframe of determining a diagnosis can be one of the most anxiety-provoking times for a patient, BUT it takes time for all of the images to be completed, pathology determined (1-2 weeks) and the team to meet to consult on your unique case.

What stage am I?

The stage of your tumor refers to whether your tumor is localized (remains in the same spot) or has spread (metastasized to other sites in your body).

There are many classifications described online and in literature ranging from stage 1 to stage 4 with subcategories, which can be confusing and overwhelming. Our team keeps it simple and uses the terminology local disease vs. metastatic disease.

Pathology results determine how aggressive your tumor is: low-grade (1/3), intermediate grade (2/3) or high-grade (3/3).

FAQs from your Biopsy

Will the biopsy hurt?

For soft tissue tumors, visible masses, a local anesthetic is given. The pain is minimal to moderate, depending on pain tolerance. For bone tumors, conscious sedation usually is used to enhance comfort during the procedure. No pain is felt during the procedure, but the patient may have minimal to moderate pain after.

Is pain medication required after a biopsy?

If the patient has been taking pain medication before the procedure, s/he can continue to take the pain medication after the procedure. Tylenol, Motrin, Advil or Aleve should be sufficient after the procedure to relieve pain. If the pain persists, call your surgeon's office.

Can I drive after a biopsy?

If you had a local anesthetic, yes, you can drive yourself home. If you had conscious sedation, no, you cannot drive home and need an somebody to drive you home.

Can I return to work the same day as the biopsy?

If you had a local anesthetic, yes, you can return to work. If you had conscious sedation, no, you should not return to work.