Bone and Soft Tissue Tumours

Question 1

What is a sarcoma?

Answer 1

Malignant tumour arising from connective tissues
Spread along fascial planes
Haematogenous spread to lungs
Rarely to regional lymph nodes

Question 2

What are bone tumours?

Answer 2

Benign are more common compared to malignant
Bony secondaries very common
Bone tumour in patient > 50 years likely metastatic

Question 3

What are some bone-forming tumours?

Answer 3

Benign - osteoid osteoma and osteoblastoma
Malignant - osteosarcoma

Question 4

What are some cartilage forming tumours?

Answer 4

Benign - enchondroma and osteochondroma
Malignant - chondrosarcoma

Question 5

What are some fibrous tissue tumours?

Answer 5

Benign - fibroma
Malignant - fibrosarcoma and malignant fibrous histiocytoma

Question 6

What are some vascular tissue tumours?

Answer 6

Benign - haemangioma and aneurysmal bone cyst
Malignant - angiosarcoma

Question 7

What are some adipose tissue tumours?

Answer 7

Benign - lipoma
Malignant - liposarcoma

Question 8

What are some marrow tissue tumours?

Answer 8

Malignant - Ewing’s sarcoma, lymphoma and myeloma

Question 9

What are giant cell tumours (GCT)?

Answer 9

Benign and are locally destructive
Can rarely metastasise

Question 10

What is the incidence of primary bone tumours in the UK?

Answer 10

Osteosarcoma is commonest primary malignant bone tumour in younger patients
Myeloma - commonest primary bone tumour in older patient

Question 11

What is the patient history of bone tumour?

Answer 11

Pain - activity related and progressive at rest/ night
Mass
Abnormal x-rays - incidental
Bone tumours - PAIN

Question 12

What is looked for when examining a patient with bone tumour?

Answer 12

General health, measurements of mass, location, shape, consistency, mobility, tenderness, local tenderness and neuro-vascular deficits

Question 13

What investigations are used for bone tumours?

Answer 13

Pain x-rays
Calcification - CT
Myositis officans
Phleboliths in haemangioma
Isotope bone scan

Question 14

What does an inactive tumour look like on x-ray?

Answer 14

Clear margins, surrounding rim of reactive bone and cortical expansion can occur with aggressive benign lesions

Question 15

What does an aggressive tumour look like on x-ray?

Answer 15

Less well defined zone of transition between lesion and normal bone
Cortical destruction
Periosteal reactive new bone growth
Codman’s triangle, onion skinning or sunburst pattern

Question 16

What are isotope bone scans used for?

Answer 16

Staging for skeletal metastasis
Multiple lesions - osteochondroma, enchondroma, fibrous dysplasia and histiocytes
Frequently negative in myeloma
Benign also demonstrates increased intake

Question 17

What are other investigations used?

Answer 17

Angiography (embolization of vascular tumours) and PET
Biopsy

Question 18

What are the cardinal features of malignant primary bone tumours?

Answer 18

Increasing pain, unexplained pain, deep-seated boring nature, night pain, difficulty weight-bearing and deep swelling

Question 19

What are the clinical features of osteosarcoma?

Answer 19

Pain, loss of function, swelling, pathological fracture, joint effusion, deformity, neurovascular effects and systemic effects of neoplasia

Question 20

Describe pain in osteosarcoma

Answer 20

Cardinal feature, increasing pain and impending fracture, analgesics eventually ineffective and not related to exercise
Deep boring ache which is worse at night

Question 21

Describe loss of function in osteosarcoma

Answer 21

Limp, reduced joint movement and stiff back (esp. child)

Question 22

Describe swelling in osteosarcoma

Answer 22

Generally diffuse in malignancy, near end of long bone, enlargement may be rapid, warmth over swelling and venous congestion

Question 23

What is the investigation of choice for osteosarcoma?

Answer 23

MRI
Very good for showing intraosseous extent of tumour, extraosseous soft tissue extent, joint involvement, skip metastases and epiphyseal extension

Question 24

What is the treatment for osteosarcoma?

Answer 24

Chemotherapy, surgery and radiotherapy

Question 25

What is the surgery for osteosarcoma?

Answer 25

Limb salvage is possible in most cases Consider involvement of neurovascular structures Pathological fractures Poorly performed biopsy

Question 26

What are the suspicious signs of malignant soft tissue tumour?

Answer 26

Deep (deep to fascia) tumours of any size Subcutaneous tumours > 5cm Rapid growth, hard, craggy and non-tender All suspected tumours are referred to specialist tumour centre

Question 27

What type of swelling is suspicious of malignant soft tissue tumour?

Answer 27

Rapidly growing, hard, fixed, craggy surface, indistinct margins, non-tender, deep ache, worse at night and beware as may be painless

Question 28

What is the incidence of metastatic bone disease?

Answer 28

Secondary bone tumour 25x more common than primary Breast commonly goes to bone and melanoma commonly goes to lung Bone most common secondary site

Question 29

What are the common sites of metastatic bone disease?

Answer 29

Vertebrae> proximal femur> pelvis> ribs> sternum> skull

Question 30

What are the 7 most commonest primary cancers which metastasise to bone?

Answer 30

Lung, breast, prostate, kidney, thyroid, GI tract and melanoma

Question 31

Describe survival rate and pathological fracture

Answer 31

Depends on type of tumour In breast - median survival with bone metastases hugely increased and soft tissue is 12-24 months 50% of patients with fractures will survive more than 6 months and 30% more than 1 year

Question 32

What is the prevention for pathological fracture?

Answer 32

Early chemotherapy/ DXT Prophylactic internal fixation - lytic lesion and increasing pain and/ or 2.5cm diameter/ 50% cortical destruction Possible use of bone cement Embolization Conservatively if non-weight bearing skeleton

Question 33

What is used for fracture risk assessment?

Answer 33

Mirel's scoring system Possible max. score of 12 Site, pain, lesion, and size

Question 34

What is required if surgery is indicated for spinal metastases?

Answer 34

Decompression and stabilisation

Question 35

What is the treatment for solitary renal metastases?

Answer 35

Radically excised

Question 36

Describe soft tissue tumours

Answer 36

Lipoma is most common <5cm 150:1 for sarcoma >5cm then 20:1 >10cm then 6:1 Deep seated tumour 4:1

Question 37

What is the presentation of soft tissue tumours?

Answer 37

Painless, mass deep to deep fascia, any mass over 5cm, any fixed/ hard or indurated mass, and any recurrent mass

Question 38

What imaging is used for soft tissue tumours?

Answer 38

MRI

Question 39

What is a summary for bone tumours?

Answer 39

Pain is persistent, increasing, non-mechanical and nocturnal Deep seated mass X-rays