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Musculoskeletal > Bone and Soft Tissue Tumours > Flashcards

Bone and Soft Tissue Tumours Flashcards

1
Q

Define sarcoma

A

Malignant tumours arising from connective tissue

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2
Q

What is the spread of sarcomas?

A
  • Spread along fascial planes
  • Haematogenous spread to lungs
  • Rarely to regional lymph nodes (rhabdomyosarcomas, epithelioid sarcomas & synovial sarcomas)
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3
Q

How common are benign and malignant tumours of the bone?

A
  • benign tumours of skeleton common
  • malignant tumours of skeleton RARE
  • bony secondaries very common
  • bone tumour in patient >50y likely to be metastatic
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4
Q

What are the bone forming tumours?

A

–benign: osteoid osteoma, osteoblastoma

–malignant: osteosarcoma

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5
Q

What are the cartilage forming tumours?

A

–benign: enchondroma, osteochondroma

–malignant: chondrosarcoma

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6
Q

What are the fibrous tissue tumours?

A

–benign: fibroma

–malignant: fibrosarcoma, malignant fibrous histiocytoma (MFH)

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7
Q

What are the vascular tissue tumours?

A

–benign: haemangioma, aneurysmal bone cyst

–malignant: angiosarcoma

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8
Q

What are the adipose tissue tumours?

A

–benign: lipoma

–malignant: liposarcoma

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9
Q

What are the marrow tissue tumours?

A

–malignant: Ewing’s sarcoma, lymphoma, myeloma

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10
Q

What are other tumours?

A

Benign, are locally destructive and can rarely metastasise - Giant Cell tumours (GCT)

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11
Q

What are the tumour like lesions?

A

Benign: simple bone cyst, fibrous cortical defect

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12
Q

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

A

Osteosarcoma 3 per million popu./yr

Chondrosarcoma 2 ..

Ewing’s tumour 1.5 ..

Malig. fibrous histiocytoma <1 ..

  • Osteosarcoma = commonest primary malignant bone tumour in younger patient
  • Myeloma = commonest primary malignant “bone” tumour in older patient
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13
Q

What is the history of bone tumours?

A
  • Pain
  • mass
  • Abnormal x-rays - incidental
  • Bone Tumours - PAIN
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14
Q

What is loked for on examination of the bone cancer?

A
  • General health
  • measurements of mass
  • location
  • shape
  • consistency
  • mobility
  • tenderness
  • local temperature
  • neuro-vascular deficits
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15
Q

What are the investigations for bone cancers?

A
  • Plain x-rays - most useful for bone lesions
  • Calcification - synovial sarcoma
  • Myositis ossificans - calcification occurs followed by formation of bony tissue within affected muscles
  • Phleboliths in haemangioma

Phlebolith is a calcification within a vein

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16
Q

What are the signs on X-ray that the tumour is inactive?

A

Clear margins

Surrounding rim of reactive bone

Cortical expansion can occur with aggressive benign lesions

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17
Q

What are the signs on x-ray that the lesion is aggressive?

A
  • less well defined zone of transition between lesion and normal bone (permeative growth)
  • cortical destruction = malignancy
  • Periosteal reactive new bone growth occurs when the lesion destroys the cortex.
  • Codman’s triangle, onion-skinning or sunburst pattern

So there is a less well defined border, destruction of the cortex and new periosteal bone growth after the lesion has destroyed the cortex.

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18
Q

What is the function of CT in the investigation of bone cancer?

A
  • Assessing ossification and calcification
  • integrity of cortex
  • best for assessing nidus in osteoid osteoma
  • Staging - primarily of lungs
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19
Q

What is the main purpose of isotope bone scans?

A

Staging for skeletal mets

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20
Q

What might multiple lesions on a bone scan indicate?

A

•osteochondroma, enchondroma, fibrous dysplasia & histiocytosis

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21
Q

What condition are isotope bone scans frequently negative for?

A

Myeloma

22
Q

What is the point of using an MRI for supsected bone cancer?

A

Determines the size, extent, anatomical relationships

It is accurate for limits of disease both within and outside bone

Specific for lipoma, haemangioma, haematoma or PVNS

Non-specific for benign vs maignant

23
Q

What are other investigations for bone cancer?

A

Angiography - replaced by MRI

(used for pseudoaneurysms, AV malformations, embolisation of vascular tumours - renal ABC

PET - may be useful for investigating response to chemo

Biopsy

24
Q

What investigations are needed to be completed before a biopsy?

A
  • Bloods
  • X-rays of affected Limb

& Chest

  • MRI of lesion
  • Bone Scan
  • CT Chest, abdo & pelvis
25
Q

What are the cardinal features of malignant primary bone tumours?

A
  • Increasing pain
  • unexplained pain
  • Deep-seated boring nature
  • Night pain
  • Difficulty weight-bearing
  • Deep swelling
26
Q

What are some examples of malignant bone tumours?

A

Osteosarcoma

Ewings sarcoma

Chondrosarcoma

27
Q

What are the clinical features of bone tumours?

A
  • pain
  • loss of function
  • swelling
  • pathological fracture
  • joint effusion
  • deformity
  • neurovascular effects
  • systemic effects of neoplasia

Pain (increasing, analgesics eventually ineffectvie, not related to exercise, deep boring ache - worse at night)

28
Q

What may indicate loss of function?

A

–limp

–reduced joint movement

–stiff back (esp. child)

29
Q

Describe the swelling associated with the tumour

A

–generally diffuse in malignancy

–generally near end of long bone

–once reaching noticeable size, enlargement may be rapid

–warmth over swelling + venous congestion = active!

–pressure effects e.g. intrapelvic

30
Q

What else can cause pathological fractures?

A

Osteoporosis is the commonest causes

many causes, of which primary bone tumour (benign or malignant)

31
Q

How can we determine if the fracture is a pathological fracture?

A

–minimal trauma + h/o pain prior to # !!

32
Q

WHat is the MRI scan good for showing

A
  • intraosseous (intramedullary) extent of tumour
  • extraosseous soft tissue extent of tumour
  • joint involvement
  • skip metastases
  • epiphyseal extension

Used to determine resection margins

33
Q

What are the available treatment options for bone cancer?

A
  • Goal is to make free of disease
  • Chemotherapy
  • Surgery
  • Radiotherapy
  • TEAM !!
34
Q

What are suspicious signs of soft tissue tumours?

A

Deep (deep to deep fascia)

Subcutaneous tumours greater than 5 cm

Rapid growth, hard, craggy, non-tender

35
Q

When should we be aware of swellings? (these are for soft tissue tumours)

A
  • rapidly growing
  • hard, fixed, craggy surface, indistinct margins
  • non-tender to palpation, but assoc. with deep ache, esp. worse at night
  • BEWARE – may be painless
  • Recurred after previous excision

= NASTY - suspicious of malignant tumour (1° or 2° ) until proven otherwise

36
Q

Which is more common, primary or secondary bone cancer?

A
  • 2° bone tumour 25 x commoner than 1°
  • bone most common site for 2° after lung and liver
37
Q

What are the common sites of bone cancer in order of frequency?

A

–vertebrae > proximal femur > pelvis > ribs > sternum > skull

38
Q

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

A
  1. LUNG - smoker; CXR, sputum cytology
  2. BREAST - commonest; examine!
  3. PROSTATE - osteosclerotic 2°; PR, PSA
  4. KIDNEY - solitary, vascular; IVP + US, angiography & embolise
  5. THYROID - esp. follicular Ca; examine
  6. GI TRACT - FOB, endoscopy, Ba studies, markers
  7. MELANOMA - examine!

[neuroblastoma (of adrenal medulla) - aet. <4 y]

39
Q

What is prognosis for pathological fracture?

A

•in general, approx. 50% of patients with pathological fractures will survive >6 m, & 30% greater than or equal to 1 y

40
Q

What are the prevention mechanisms for pathological fracture?

A

Early chemotherapy/DXT (deep x-ray therapy)

Prophylactic internal fixation

Bone cement

Embolisation

Prophylactic stabilisation of bone should be performed if there is a substantial risk of fracturing. If the risk of fracturing is low, the appropriate treatment is radiotherapy.

41
Q

What is the scoring system used for fracture risk assessment?

A

Mirel’s scoring system

42
Q

Never assume that a lytic lesion, particularly if solitary, is a metastasis

A
43
Q

What is the failure rate of fixation of pathological fractures or lytic lesion, especially around the hip / proximal femur vs cemented hip prosthesis

A

Fixation of pathological fractures have a high failure rate, cemented hip prosthesis, either standard or tumour prostheses have a low failure rate

Fixation involves the use of nails or plates

For all pathological fractures of the long bones, three principal surgical treatment options exist: intramedullary nail, plate, or (endo) prosthesis.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367617/

44
Q

What is required during surgery of spinal metastases?

A

Decompression and stabilisation

45
Q

• Constructs, whether spinal or appendicular, should allow immediate weightbearing and aim to last the lifetime of the patient.

A
46
Q

•Solitary renal metastases should, where possible, be radically excised.

A
47
Q

What is the commonest soft tissue tumour?

A

Lipoma

48
Q

As the soft tissue tumour gets larger - the chances of it being a sarcoma (vs lipoma) gets larger. But it is still more likely to be a lipoma

80% of deep sarcomas are greater than 5cm

A
49
Q

What are the features of soft tissue tumours?

A
  • painless
  • mass deep to deep fascia
  • any mass >5cm
  • any fixed, hard or indurated mass
  • any recurrent mass
50
Q
A

Musculoskeletal (28 decks)

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