Bone and soft tissue tumours Flashcards
What is a sarcoma?
Malignant tumours arising from conn tissue. Spread along fascial planes
How do sarcomas spread to lungs?
Haematogenous spread to lungs.
Rarely spread to regional lymph nodes
Are benign or malignant tumours of skeleton more common?
Benign are more common, malignant are actully rare. Tumour in 50yo+ likely to be metastatic (secondaries v common)
Name some benign and malignant bone forming tumours
Benign: osteoid sarcoma, osteoblastoma
Malignant: osteosarcoma
Name some benign and malignant cartilage forming tumours
Benign: enchondroma, osteochondroma
Malignant: chondrosarcoma
Name some benign and malignant fibrous tissue tumours
Benign: fibroma
Malignant: fibrosarcoma, malignant fibrous histiocytoma (MFH)
Name some benign and malignant vascular tissue tumours
Benign: haemangioma, aneurysmal bone cyst
Malignant: angiosarcoma
Name some benign and malignant adipose tissue tumours
Benign: lipoma
Malignant: liposarcoma
Name some malignant marrow tissue tumours
Ewings sarcoma, lymphoma, myeloma
What are the characteristics of giant cell tumours?
Benign, locally destructive and rarely metastasise
What are some benign tumour like lesions?
Simple bone cyst, fibrous cortical defect
What is the commonest primary malignant bone tumour in younger/older patient?
Younger: osteosarcoma
Older: myeloma
What are some features of history?
Pain, mass, abnormal x rays - incidental
What are the features of the pain associated with bone tumours?
- Activity related
- Progressive pain at rest and night
When might benign tumours present with pain?
Activity related pain if large enough to weaken bone
What features of the mass do you study on exam?
- Patients general health
- Measurements
- Location
- Shape
- Consistency
- Mobility
- Tenderness
- Local temp
- Neuro-vascular deficits
What investigation is very helpful for these masses?
-X-ray
When do phleboliths occur?
In haemangiomas
On x ray, what features indicate an inactive mass?
- Clear margins
- Surrounding rim of reactive bone
- Cortical expansion in aggressive benign lesions
On x ray, what features indicate an aggressive mass?
- Less well defined margin between lesion and normal bone
- Cortical destruction
- Periosteal reactive new bone growth occurs when lesion destroys cortex
- Codmans triangle, onion skinning or sunburst pattern
What are CTs used for in these masses?
- Assessing ossification and calcification, integrity of cortex
- Staging - primarily of lungs
What are isotope bone scans used for in these masses?
- Staging for skeletal metastasis
- Identifying multiple masses (osteochondroma, enchondroma) (not so much myeloma)
What are MRI’s used for in these masses?
- Size, extent, anatomical relationships
- Accurate for limits of disease both within/outside bone
- Specific for lipoma/haemangioma/haematoma. Non specific for benign vs malignant
What are useful for vascular tumours?
Angiography. Pseudo-aneurysms, A-V malformations, embolisation of vasculat tumours
What is useful for investigating response to chemo?
PET scan
A biopsy is useful in diagnosis. What would you do in a complete work up prior to biopsy?
- Bloods
- X-ray of affected limb/chest
- MRI
- Bone scan
- CT chest/abdo/pelvis
What are cardinal features of malignant primary bone tumours?
- Inc. pain
- Unexplained pain
- Deep seated boring nature
- Night pain
- Hard to weight bear
- Deep swelling
What are some clinical features of bone tumours?
- Pain
- Loss of function
- Swelling
- Pathological fracture
- Joint effusion
- Deformity (eg fixed flexion)
- Neurovascular effects
- Systemic neoplasia effects
Discuss the pain associated with bone tumours
- Inc pain - impending #
- Analgesics eventually ineffective
- Not related to exercise
- Deep boring ache, worse at night
Discuss loss of function associated with bone tumours
- Limp
- Dec. joint movement
- Stiff back (esp child)
Discuss swelling associated with bone tumours
- Generally diffuse in malignancy/near end of long bone
- Warmth over swelling + venous congestion = active
Discuss pathological fracture associated with bone tumours
- Many causes (primary bone tumour rarest, osteoporosis commonest)
- Minimal trauma preceding
MRI is investigation of choice for bone tumours as it is v sensitive. What is it good for showing?
- Intraosseous/Intramedullary extent of tumous
- Extraosseous soft tissue extent of tumour
- Joint involvement
- Skip metastases
- Epiphyseal extension
- Determines extension margins
What 3 treatments are important in bone tumours?
- Chemo
- RT
- Surgery
What must be considered in surgery in bone tumours?
- Salvaging bone (possible in most cases)
- Involvement of neurovascular structures
- Pathological #
- Porrly performed biopsy
What are suspicious signs of soft tissue tumours?
- Deep tumours of any size
- Subcutaneous tumours >5cm
- Rapid growth, hard, craggy, non-tender
In soft tissue tumours what swelling should make you suspicious?
- Rapidly growing
- Hard, fixed, craggy, indistinct margins
- Non-tender, assoc. with deep ache thats worse at night
- May be painless
- Recurred after previous excision
How common is metastatic bone disease?
- Secondary bone tumour 25x commoner than primary
- Bone most common metastasis site after lung and liver
Where does breast tumour commonly metastasise to?
Bone
Where does melanoma commonly metastasise to?
Lung
Most common place for secondary bone tumours?
Vertebrae
What are the 7 commonest tumours which metastasise to bone?
- LUNGS -smoker. CXR, sputum cytology
- BREAST -commonest: examine
- PROSTATE -osteosclerotic, PSA, PR
- KIDNEY -solitary, vascular. IVp and US, angiography and embolise
- THYROID -esp follicular Ca, examine
- GI - FOB, endoscopy, Ba studies, markers
- MELANOMA -examine
How many patients with pathological # will survive over 6m and 1y?
6m - 50%
1y - 30%
How do pathological # get prevented?
- Early chemo
- Prophylactic internal fixation determined by Mirels scoring system
- Use of bone cement
- Embolisation esp renal, thyroid
- Only one long bone at a time (surgery)
- Aim for early painless weight bearing and mobilisation post surgery
Explain Mirels scoring system
Scored based on
- Site
- Pain
- Lesion type
- Size
Should you assume lytic lesion is metastasis?
No, especially if solitary
