bone and soft tissue tumours Flashcards
sarcoma
malignant tumours arising from connective tissues
spread along fascial planes
haematogenous spread to lungs
Bone tumours
primary malignant not common
secondaries common
Bone forming tumours
benign- osteoid osteoma, osteoblastoma
malignant- osteosarcoma
Cartilage- forming tumours
benign- enchondroma
osteochondroma
malignant- chondrosarcoma
fibrous tissue
fibroma
fibrosarcoma
malignant fibrous histiocytoma
vascular tissue
benign: haemangioma
angiosarcoma
adipose tissue
lipoma
liposarcoma
marrow tissue tumours
Malignant: Ewing’s sarcoma
lyphoma
myeloma
Giant cell tumours
locally destructive, rarely metastasize
osteosarcoma
commonest primary malignant bone tumour in younger patient
3 per million
myeloma
commonest primary malignant bone tumour in older patient
Bone tumours
pain activity related increasing progressive unrelenting
soft tissue
painless
osteoid osteoma
painful benign tumour
investigations
isotope bone scan FBC (anaemia), blood film ESR, CRP Ca++, phosphate, Alk Phos LFTs (metastatic spread) plasma protein electrophoresis (Igs- myeloma) PSA( prostate) exclude leukemia and infection plain x rays synovial sarcoma- calcification phleboliths in haemangiomas fat density in lipoma
Xrays
inactive: clear margins cortical expansion can occur malignant: less well defined zone of transition (permeative growth) cortical destruction= malignancy periosteal reactive-new bone growth occurs because of^ CODMAN'S TRIANGLE SUNBURST PATTERN ONION SKINNING
Bony destruction and periosteal reaction
plain radiographs
CXR 80%
MRI scan
best for showing intraosseous soft tissue extent joint involvement skin lesions epiphyseal extenstion aid to determine resection margins specific for lipoma haemangioma haematoma Non specific for benign vs malignant
CT
assessing ossification and calcification
integrity of cortex
good for subtle bony cortical destruction
best for assessing nidus in osteoid osteoma
STAGING -lungs
isotope bone scans
staging for skeletal metatasis benign also uptake multiple lesions- osteochondroma entochondroma fibrous dysplasia histiocytosis -ve in myeloma
isotope bone scans
technetium
detect skeletal sread
non specific but sensitive
angiography
defines vascular characteristics
renal metastasis
biopsy
open
core
excision
malignancy
size
histological grade
metastases
soft tissue- depth
low grade
well differentited
few mitoses
moderate cytological atypia
< 25% risk for metastases
High grade
stage II
poorly differentiated
high mitotic rate
high cell /matrix ratio
compartments
IA and IIA contained within well defined anatomical compartments (barriers to tumour growth) cortical bone articular cartilage fascial septa joint capsule IB & IIB extend beyond compartment of origin III lesion has metastasised regardless of size or histological grade
osteosarcoma
pain- not related to exercise deep boring ache, worse at night loss of function swelling pathological fracture joint effusion stiff back
swelling in osteosarcoma
warmth+ venous congestion
pressure effects
near end of long bone
chemotherapy
70% survival rate 5 year
less well defined for adult soft tissue
not used for cartilaginous/ low grade
adjuvant therapy
resection and reconstruction
wide surgical margins marginal with adjuvant osteoarticular allograft endoprosthetic reconstruction rotaionoplasty
surgical margins
intralesional
marginal
wide
radical
Amputation vs salvage
will survival be affectd
short long term morbidity
function of limb compared to prosthesis
recurrence
radiontherapy sensitivity
cell position in cell cycle
tissue oxygenation
DNA damage repair
inability to undergo apoptosis
exceptions to radiotherapy
most are radioresistant
multiple myeloma
lymphoma
ewings
metastic carcinoma
radiotherapy
reduce local recurrence of soft tissue sarcome
pre operatively to reduce tumour volume
complications: skin, osteonecrosis, sarcoma- 10 yrs
hereditary multiple exostoses
autosomal dominant
cartilage capped bony outgrowths typically near physes of long bones
sessile/ pedunculated
periochondrol covering similiar to growth plate
benign bone tumour
suspicious tumours
deep tumours
subcu > 5cm
rapid growth, hard craggy, non tender but associated with deep ache ie worse at night
previously excised swellings recurring
metastatic bone disease
breast commonly goes to bone
melanoma commonly goes to lung
order of frequency:
vertebrae> proximal femur> pelvis> ribs> sternum> skull
7 commonest primary cancers metastasizing to bone
LUNG- smoker, CXR, sputum cytology BREAST- commonest Prostate- osteosclerotic Kidney- solitary, vascular, angiography &embolise, IVP and US Thyroid- esp follicular Ca GI tract- FOB, endoscopy Melanoma- examine
pathogenesis of metastasis
local invasion of normal stromal cells by primary tumour
-increased local pressure + dissection by tumour cells along lines of least resistance
-tumour cells invade local lymphatics& vessels point of embolisation
Tumour emboli normally destoyed by killer cells, vascular turbulence
surviving tumour emboli embedded and adherent to distant capillary bed of preffered organ
mechanism of bone invasion
red marrow bones only eg vertebrae, ribs
rare distal to knee elbow usually suqamous Ca lung
vertebral valveless weins of bateson
breast prostate renal-> plexus-> bone
hypercalcemia
nausea vomiting anorexia lethargy confusion coma
pathological fracture
prophylactic internal fixation
mirel’s scoring system
fixation of pathological fractures or lytic lesions
high failure rate
never rush to fix fracture check if metastatic
summary
bone tumours:
unexplained pain
hard fixed swelling
Soft tissue tumours: swelling > 5 cm any swelling deep to deep fascia may be painless recurring swelling
