Bone and soft tissue Tumours Flashcards
Bone tumours can be?
Benign
Malignant - primary
- secondary
Where do sarcoma’s arise from
Malignant tumours arising from connective tissues
Where do sarcomas spread along and to?
fascial planes
Haematogenous spread to lungs
What benign tumours are common
skeleton
bone tumour in patient >50 years is likely to be?
metastatic
Name some benign bone forming tumours
osteoid osteoma, osteoblastoma
name a malignant bone forming tumour
osteosarcoma
Name some benign Cartilage-forming tumours
enchondroma, osteochondroma
Name a malignant Cartilage-forming tumour
chondrosarcoma
name a benign fibrous tissue tumour
fibroma
name some malignant fibrous tissue tumours
fibrosarcoma, malignant fibrous histiocytoma (MFH)
Name benign vascular tissue tumours
haemangioma, aneurysmal bone cyst
name a vascular malignant tissue tumour
angiosarcoma
Adipose tissue tumour - benign
lipoma
Adipose tissue tumour - malignant
liposarcoma
Marrow tissue tumours - malignant
Ewing’s sarcoma, lymphoma, myeloma
Benign tumours that rarely metastasise
Giant Cell tumours (GCT)
Tumour-like lesions - benign
simple bone cyst,
fibrous cortical defect
Most common primary bone tumour in younger patient uk
osteosarcoma
commonest primary malignant “bone” tumour in older patient?
Myeloma
A common history from patient will include
Pain
mass
Abnormal x-rays - incidental
Bone Tumours - PAIN
Bone tumour symptoms
pain
- activity related
- progressive pain at rest & night
What may benign tumours present with ?
activity related pain if large enough to weaken bone
eg , osteoid osteoma
Examination of a tumour will include what (lots)
General health measurements of mass location shape consistency mobility tenderness local temperature neuro-vascular deficits
Investigations of bone tumours (4)
Plain x-rays - most useful for bone lesions
Calcification - synovial sarcoma
Myositis ossificans
Phleboliths in haemangioma
inactive x-rays have? (3)
clear margins
surrounding rim of reactive bone
cortical expansion can occur with aggressive benign lesions
X-rays - aggressive - what will they show - detailed (3)
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
Why use a CT scan? what is it good for ? (4)
Assessing ossification and calcification
integrity of cortex
best for assessing nidus in osteoid osteoma
Staging - primarily of lungs
Isotope bone scans are used for what ? (4)
Staging for skeletal metastasis
Multiple lesions - osteochondroma, enchondroma, fibrous dysplasia & histiocytosis
Frequently negative in Myeloma
Benign also demonstrate increased uptake
What is MRI accurate for?
limits of disease both within and outside bone
MRI is specific for what (3-4)
Lipoma, haemangioma, haematoma or PVNS.
Other investigations
Angiography:
superseeded by MRI
Psuedoaneurysms, A-V malformations
Embolisation of vascular tumours - Renal, ABC
PET:
may be useful for investigating response to chemo
What tests should be completed before a bone biopsy takes place (5)
Bloods X-rays of affected Limb & Chest MRI of lesion Bone Scan CT Chest, abdo & pelvis
biopsy - is it needle core vs open
Malignant Primary Bone Tumours (7)
Cardinal features Increasing pain unexplained pain Deep-seated boring nature Night pain Difficulty weight-bearing Deep swelling
Main malignant primary bone tumours (3)
Osteosarcoma
Ewings sarcoma
Chondrosarcoma
Clinical features of osteosarcoma (8)
pain loss of function swelling pathological fracture joint effusion deformity neurovascular effects systemic effects of neoplasia
Osteosarcoma - pain features (5)
cardinal feature
increasing pain - impending # (esp. lower limb)
analgesics eventually ineffective
not related to exercise
DEEP BORING ACHE, WORSE AT NIGHT !!
Clinical features OSTEOSARCOMA - loss of function is common - what do patients develop (3)?
limp reduced joint movement stiff back (esp. child)
Clinical features OSTEOSARCOMA - swelling - features ? (5)
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
Osteosarcoma can develop from a
pathological fracture
osteosarcoma - investigations - what will a VG show
MRI scan
investigation of choice - very sensitive
VG for showing
intraosseous (intramedullary) extent of tumour
extraosseous soft tissue extent of tumour
joint involvement
skip metastases
epiphyseal extension
determines resection margins
Treatment of osteosarcoma and Ewing’s tumours
disease free goal
chemo and radio therapy
surgery
What tumours are benign but aggressive
cartilage tumours
all patients with a soft tissue tumour suspected of being malignant should be referred to?
a specialist Tumour Centre
What are suspicious signs of a soft tissue tumour 3)
deep (i.e. deep to deep fascia) tumours of any size
subcutaneous tumours > 5 cm
rapid growth, hard, craggy, non-tender
Beware of swelling which Is? wha may it be?
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
Where is the most common site for
Metastatic Bone Disease
lung and liver then bone bone - secondary
Breast cancer commonly metastasises to
bone
melanoma commonly metastasises to
lung
Breast cancer is the commonest primary cancer which metastasises to bone. Which bone does it most commonly metastasise to ?
vertebrae
- femur - pelvis - ribs- sternum - skull
7 commonest primary cancers which metastasise to bone
LUNG - smoker, sputum cyto BREAST PROSTATE - osteosclerotic KIDNEY - solitary, vascular THYROID -follicular Ca GI TRACT- - FOB, endoscopy, Ba studies MELANOMA
survival after pathological fracture depends on?
type of tumour -e.g. bronchial Ca. 1 y
Pathological fracture: PREVENTION (3)
early chemotherapy / DXT
prophylactic internal fixation - lytic lesion + increasing pain &/or 2.5 cm diameter &/or 50% cortical destruction
use of bone cement (not signif. affected by DXT)
Fracture Risk Assessment - scoring system is called?
Mirel’s
Pathological fracture: PREVENTION - when should you be careful
what bones do you do?
embolisation esp. renal, thyroid - wait 48h before surgery
only one long bone at a time
aim for early painless weight-bearing + mobilisation
# of non-WB skeleton (e.g. humerus) can be treated conservatively, but re-# freq.
Never assume that a lytic lesion (especially solitary) is?
metastatic
Prophylactic fixation of long bone mets is ?
generally easier for the surgeon and less traumatic for the patient.
Fixation of pathological fractures or lytic lesions, especially around the hip/proximal femur have a high?
FAILURE RATE
Cemented hip prosthesis have?
a low failure rate
What is generally required for spinal metastases
decompression and stabilisation
Ratios for soft tissue tumours
what are 80% of deep sarcomas
5cm 150:1 for sarcoma
>5cm 20:1 >10cm 6:1 Deep seated tumours 4:1
> 5cm
Soft tissue Timur features (5)
main imaging technique
painless mass deep to deep fascia any mass >5cm any fixed, hard or indurated mass any recurrent mass
MRI
Sarcoma bone pain features (4)
persistency
increasing
non-mechanical
nocturnal or at rest
