Bone and Soft Tissue Tumours Flashcards

Question

What would be seen on x-ray of a malignant bone/soft tissue tumour?

Answer 1

Less well-defined zone of transition between lesion and normal bone - permeative growth Cortical destruction Periosteal reactive new bone growth when lesion destroys the cortex - Codman's triangle - sunburst pattern - onion skinning

Answer 2

Bony destruction and periosteal reaction Conventional 2 views; - bone destruction - bone expansion - bone production - pathological fracture - soft tissue swelling

Answer 3

80% of primary malignant bone tumours metastasise to the chest

Answer 4

Size, extent and anatomical relationships of lesions ``` Intraosseous extent of tumour Extraosseous soft tissue extent of tumour Joint involvement Skip lesions Epiphyseal extension ```

Answer 5

Lipoma Haemangioma Haematoma PVNS

Answer 6

Benign vs malignant

Answer 7

Assessing ossification and calcification Integrity of cortex Good for subtle bony cortical destruction, features and calcification Best for assessing nidus in osteoid osteoma Staging - primary of lungs

Answer 8

Staging for skeletal metastasis Benign also demonstrate increased uptake Multiple lesions Frequently negative in myeloma

Answer 9

Cystic vs solid soft tissue lesions

Answer 10

``` Superseded by MRI Pseudoaneurysms and AV malformations Embolisation of vascular tumours Defines vascular characteristics Renal secondaries, aneurysmal bone cyst Allows pre-operative embolisation ```

Answer 11

For investigating response to chemotherapy

Answer 12

``` Complete work up Bloods X-rays of affected limb and chest MRI Bone scan CT chest, abdomen and pelvis Angiography Careful evaluation and planning ```

Answer 13

Needle, core or open biopsy Track is contaminated so placement is crucial for later excision Tourniquet - elevation not exsanguination Avoid transverse incisions Avoid major neuromuscular structures Sample soft tissue extensions of bone tumours Frozen section Open biopsy yields greatest tissue but highest complications Core biopsy > 90% accurate Excision biopsy for < 5cm subcutaneous lesions in expendable bones

Answer 14

``` Enneking staging system Benign vs malignant Histological grade - low/high Local extent - site, intra/extra-compartmental Metastases ``` Aids in treatment decision making and allows meaningful comparisons of treatment methods

Answer 15

Size Histological grade Presence/absence of metastases Soft tissue - depth

Answer 16

``` Stage I Well-differentiated Few mitoses Moderate cytological atypica < 25% risk for metastases ```

Answer 17

Stage II Poorly differentiated High mitotic rate High cell/matrix ratio

Answer 18

Cortical bone Articular cartilage Fascial septa Joint capsules

Answer 19

Beyond the compartment of origin

Answer 20

Any lesion that has metastasised | Regardless of size or histological grade

Answer 21

``` Pain Loss of function Swelling Pathological fracture Joint effusion Deformity Neurovascular effects Systemic effects of neoplasia ```

Answer 22

Cardinal feature, especially in children Severity does not correspond with degree of malignancy Increasing pain indicates impending fracture, especially lower limb Analgesics eventually ineffective Not related to exercise Deep ache Worse at night is a red flag

Answer 23

Limp Reduced joint movement Stiff back, especially in children

Answer 24

Generally diffuse in malignancy Generally near end of long bone Once reaching notable size, enlargement may be rapid Warmth over swelling and venous congestion = active Pressure effects

Answer 25

Usually weight-bearing bone | Minimal trauma and history of pain prior to fracture

Answer 26

Peripheral nerves affected e.g. common peroneal nerve at fibular neck

Answer 27

``` Weight loss Anorexia Malaise Fatigue Mood change Anaemia ```

Answer 28

``` Goal is to make patient disease-free Chemotherapy Surgery Radiotherapy MDT approach ```

Answer 29

Approaching 70%

Answer 30

Osteosarcoma High grade bone lesions High grade soft tissue lesions of childhood Less well defined for adult soft tissue tumours In general not used for cartilaginous or low grade lesions Adjuvant - post-operatively for micro-metastases Neoadjuvant - before surgical resection, limb salvage easier but no significant difference to survival

Answer 31

Surgery 3-4 weeks after last cycle | Restarted when wound healed

Answer 32

When tumour is small, combinations more effective

Answer 33

Dosage, sequence of drugs and schedule

Answer 34

Reduces risk of tumour spill at surgery | Treats micro-metastases early

Answer 35

Limb salvage Involvement of neurovascular structures Pathological fracture Poorly-performed biopsy

Answer 36

``` Wide surgical margins Marginal with adjuvant or neoadjuvant therapies Osteoarticular allograft Endoprosthetic reconstruction Allograft prosthesis composite Rotationoplasty ```

Answer 37

Intralesional - debulking, benign or metastatic Marginal - pseudocapsule, benign or low grade Wide - plane through normal tissue, goal for high grade tumours Radical - all compartments containing tumour removed

Answer 38

Extensive surgery - infection - wound dehiscence - flap necrosis - blood loss - DVT - peri-prosthetic fractures - loosening, dislocation, non-union of graft-host junction - allograft fracture - limb length discrepancy - late infection

Answer 39

Will survival be affected? How do short and long-term morbidity compare? Function of salvaged limb compared to prosthesis Psychological consequences

Answer 40

``` Technically demanding, non-standard Infection Wound dehiscence Chronic pain Phantom pain ```

Answer 41

Cell's position in cell cycle, actively mitotic are more sensitive Tissue oxygenation, hypoxia is protective of O2 free radicals Cell's ability to repair DNA damage Cell's inability to undergo apoptosis in response to injury

Answer 42

Most are relatively radio-resistant Exceptions; - multiple myeloma - lymphoma - Ewing's - metastatic carcinoma

Answer 43

Used to reduce local recurrence, particularly in marginal resections

Answer 44

Skin complications Osteonecrosis Sarcoma (10 years) Pathological fracture (29% are 5 years)

Answer 45

Diaphyseal aclasis Autosomal dominant Cartilage-capped bony outgrowths typically near physes of long bones May cause deformity/loss of function/pain May be sessile or pedunculated Perichondrial covering and cartilage cap consisting of zones of maturing cartilage similar to growth plate Benign bone tumours

Answer 46

5% | Especially in large exostoses with thick cartilage cap, axial location or continuing to grow in adulthood

Answer 47

To a specialist tumour centre

Answer 48

Deep to deep fascia, tumour of any size Subcutaneous tumours > 5cm Rapid growth, hard, craggy, non-tender Lipoma

Answer 49

Rapidly growing Hard, craggy surface, fixed, indistinct margins Non-tender to palpation but associated with deep ache, especially if pain is worse at night Recurred after previous excision (severe)

Answer 50

Secondary bone tumour 25 times commoner than primary Bone most common site of secondaries after lung and liver

Answer 51

Approx 9000

Answer 52

From most common to least - vertebrae - proximal femur - pelvis - ribs - sternum - skull

Answer 53

Lung - smoker, CXR, sputum cytology Breast - commonest, examine Prostate - osteosclerotic secondary, PR, PSA Kidney - solitary, vascular, IVP and US, angiography and embolise Thyroid - especially follicular cancer, examine GI tract - FOB, endoscopy, Ba studies, tumour markers Melanoma - examine

Answer 54

Local invasion of normal stromal cells by primary tumour Increased local pressure and dissection by tumour cells along lines of least resistance and release of lytic enzymes Tumour cells invade local lymphatics and/or vessels, may remain or may be dislodged (embolisation) Tumour emboli normally destroyed by killer cells or vascular turbulence etc. Few tumour emboli survive to become embedded and adherent to distant capillary bed of preferred organ Invasion continues and tumour angiogenesis occurs

Answer 55

Red marrow bones only e.g. vertebrae, ribs, pelvis, skull, proximal femur Rare distal to knee/elbow

Answer 56

``` Nausea Vomiting Anorexia Lethargy Confusion Coma ```

Answer 57

Chemotherapy/DXT

Answer 58

Lytic lesion 2.5cm+ diameter 50%+ cortical destruction Increasing pain

Answer 59

Only one long bone at a time | Aim for early painless weight-bearing and mobilisation

Answer 60

High failure rate

Answer 61

Low failure rate

Answer 62

Decompression and stabilisation