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Systems: MSK AB > Bone and Soft Tissue Tumours > Flashcards

Bone and Soft Tissue Tumours Flashcards

1
Q

What is a sarcoma?

A

Malignant tumour that arises from connective tissue

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2
Q

How do sarcomas spread?

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

What is a bone tumour in a patient over 50 likely to be?

A

Metastatic

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4
Q

Bone tumours: Malignant vs benign

A
  • Benign tumours are common
  • Malignant tumours are RARE
  • Bony secondaries are common
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5
Q

Name some benign bone-forming tumours.

A
  • Ostoid osteoma

- Osteoblastoma

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6
Q

Name a malignant bone forming tumour.

A

Osteosarcoma

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7
Q

Name some benign cartilage forming tumours.

A
  • Enchondroma

- Osteochondroma

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8
Q

Name a malignant cartilage forming tumour.

A

Chondrosarcoma

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9
Q

Name a benign fibrous tissue tumour.

A

Fibroma

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10
Q

Name some malignant fibrous tissue tumours.

A
  • Fibrosarcoma

- Malignant fibrous histiocytoma (MFH)

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11
Q

Name some benign vascular tissue tumours.

A
  • Haemangioma

- Aneurysmal bone cyst

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12
Q

Name a malignant vascular tissue tumour.

A

Angiosarcoma

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13
Q

Name a benign adipose tissue tumour.

A

Lipoma

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14
Q

Name a malignant adipose tissue tumour.

A

Liposarcoma

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15
Q

Name some malignant marrow tissue tumours.

A
  • Ewing’s sarcoma
  • Lymphoma
  • Myeloma
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16
Q

What are the features of giant cell tumours (GCT)?

A

Benign, locally destructive and can rarely metastasise

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17
Q

Name some benign tumour like lesions.

A
  • Simple bone cyst

- Fibrous cortical defect

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18
Q

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

A

Per million population per year

  • Osteosarcoma: 3
  • Chondrosarcoma: 2
  • Ewing’s sarcoma: 1.5
  • Malignant fibrous histiocytoma: <1
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19
Q

What is the commonest primary malignant bone tumour in young patients?

A

Osteosarcoma

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20
Q

What is the commonest primary malignant bone tumour in older people?

A

Myeloma

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21
Q

What history do bone tumours present with?

A
  • PAIN
  • Mass
  • Abnormal x-ray (incidental)
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22
Q

Describe the pain associated with bone tumours.

A
  • Activity related

- Progressive pain at rest and night

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23
Q

How might benign tumours present?

A

-Activity related pain if large enough to weaken the bone (can occur in osteoid osteomas)

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24
Q

What should be noted on examination when someone presents with a bony mass?

A
  • General health
  • Measurements of mass
  • Location
  • Shape
  • Consistency
  • Mobility
  • Tenderness
  • Local temperature
  • Neuro-vascular deficits
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25
Q

What investigations should be carried out?

A
  • Plain x-rays (most useful for bone
  • CT
  • Isotope bone scan
  • MRI (study of choice)
  • Angiography
  • PET
  • Biopsy
26
Q

How do inactive tumours appear on x-ray?

A
  • Clear margins
  • Surrounding rim of reactive bone
  • Cortical expansion can occur with aggressive benign lesions
27
Q

How do aggressive tumours appear on x-ray?

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)
28
Q

Give examples of what may be seen on x-ray?

A
  • Calcification in synovial sarcoma
  • Myositis ossificans
  • Phleboliths in haemangioma
29
Q

What is the role of CT in diagnosing bone and soft tissue tumours?

A
  • Assessing ossification and calcification
  • Integrity of cortex
  • Best for assessing nidus in osteoid osteoma
  • Staging - primarily of lungs
30
Q

What role do isotope bone scans play in diagnosing bone and soft tissue tumours?

A
  • Staging for skeletal metastasis
  • Multiple lesions - osteochondroma, enchondroma, fibrous dysplasia & histiocytosis
  • Frequently negative in Myeloma
  • Benign also demonstrate increased uptake
31
Q

What is the role of MRI in diagnosing bone and soft tissue tumours?

A
  • Size, extent, anatomical relationships
  • Accurate for limits of disease both within and outside bone
  • Specific for Lipoma, haemangioma, haematoma or PVNS.
  • Non-specific for benign vs. malignant
32
Q

What may PET scans be useful in?

A

Investigating response to chemo

33
Q

What is angiography used for?

A
  • Pseudo aneurysms, AV malformations

- Embolisation of vascular tumours: renal, ABC

34
Q

What work up must be carried out before biopsy?

A

Complete work up

  • Bloods
  • X-rays of affected limb and chest
  • MRI of lesion
  • Bone scan
  • CT chest, abdomen and pelvis
35
Q

How can we differentiate between benign and malignant?

A
  • History
  • Clinical findings
  • Radiological features
  • Biopsy – needle core vs. Open
  • Treatment
  • Reconstruction
36
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
37
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
38
Q

What are the features of the pain associated with bone tumours?

A
  • Cardinal feature
  • Increasing pain with impending fracture (especially lower limb)
  • Analgesics eventually ineffective
  • Not related to exercise
  • DEEP BORING ACHE WORSE AT NIGHT
39
Q

What loss of function may occur with bone tumours?

A
  • Limp
  • Reduced joint movement
  • Stiff back (especially child)
40
Q

What are the features of swelling associated with bone tumours?

A
  • Generally diffuse in malignancy
  • Generally near end of long bone
  • Once reaching noticeable size, enlargement may be rapid
  • Warmth over swelling and venous congestion=active
  • Pressure effects
41
Q

What is a pathological fracture?

A

A fracture that occurs with minimal trauma, history of pain prior to fracture and underlying disease

42
Q

What is the investigation of choice in bone tumours?

A

MRI scan

43
Q

What are MRI scans very good at showing in bone tumours?

A
  • Intraosseous (intramedullary) extent of tumour
  • Extraosseous soft tissue extent of tumour
  • Joint involvement
  • Skip metastases
  • Epiphyseal extension
44
Q

What are the treatments for bone tumours?

A

Goal is to make free of disease

  • Chemotherapy
  • Surgery
  • Radiotherapy
45
Q

When is surgery used in the treatment of bone tumours?

A
  • Limb salvage in most cases
  • Consider involvement of neurovascular structures
  • Pathological fractures
  • Poorly performed biopsy
46
Q

Where should patients with a soft tissue tumour that is suspected to be malignant be referred?

A

Specialist tumour centre

47
Q

What are suspicious signs in soft tissue tumours?

A
  • Deep (i.e. deep to deep fascia) tumours of any size
  • Subcutaneous tumours > 5 cm
  • Rapid growth, hard, craggy, non-tender
48
Q

Beware of swelling which is…

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

Suspicious of malignant tumour (primary or secondary) until proven otherwise

49
Q

How does the incidence of metastatic bone tumours compare to primary bone tumours?

A

Secondary bone tumour 25x more common than primary

50
Q

How common are bone secondaries?

A

Bone most common site for secondary after lung and liver

51
Q

Name a cancer which commonly spreads to the bone.

A

Breast

52
Q

How do sites of bony metastasis vary?

A

Order of frequency

  • Vertebrae
  • Proximal femur
  • Pelvis
  • Ribs
  • Sternum
  • Skull
53
Q

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

A
  • Lung
  • Breast
  • Prostate
  • Kidney
  • Thyroid
  • GI tract
  • Melanoma
54
Q

What does survival after pathological fracture depend on?

A

Type of tumours

  • Bronchial cancer <1 year
  • Breast with soft tissue mets 12-24 months

In general, approx. 50% of patients with pathological fractures will survive >6 m, & 30% 1 y

55
Q

How are pathological fractures prevented?

A

-Early chemotherapy/DXT
-Prophylactic internal fixation
-+/- Bone cement
-Embolisation
-Only one long bone at a time
Aim for early painless weight bearing and mobilisation
-Fracture of non-WB skeleton can be treated conservatively but frequent refracture

56
Q

What system is used for fracture risk in metastatic bone disease?

A

Mirel’s scoring system

57
Q

What are the components of Mirel scoring system?

A

Site

  1. UL
  2. LL
  3. Peritrichanter

Pain

  1. Mild
  2. Moderate
  3. Severe

Lesion

  1. Blastic
  2. Mixed
  3. Lytic

Size

  1. <1/3
  2. 1/3-2/3
  3. > 2/3
58
Q

What are the key points for metastatic bone disease according to the BOA working party?

A
  • Prognosis is improving
  • Never assume a lytic lesion is metastasis
  • Metastatic pathological fractures rarely unite, even if stabilised
  • Prophylactic fixation of long bone mets is generally easier for the surgeon and less traumatic for the patient
  • Mirel scoring system
  • High failure rate of fixation of path# around hip/proximal femur. Lower failure rate for cemented hip prosthesis
  • Use traction and splintage while performing investigations and conducting MDT before fixing path#
  • Decompression and stabilisation of spinal mets
  • Constructs should be weight bearing and last the patient’s lifetime
  • Solitary renal mets should be excised
  • Each trauma group requires a lead clinician for MBD
  • Use of MDT
59
Q

What is the commonest soft tissue tumour?

A

Lipoma

60
Q

How does the incidence of lipoma compare to sarcoma?

A
  • <5cm 150:1
  • > 5cm 20:1
  • > 10cm 6:1
  • Deep seated 4:1
61
Q

What are the clinical features of soft tissue tumours?

A
  • Painless
  • Mass deep to deep fascia
  • Any mass >5cm
  • Any fixed, hard or indurated mass
  • Any recurrent mass
62
Q

What imaging study should be carried out for soft tissue tumours?

A

MRI

Systems: MSK AB (43 decks)

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