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MSK > Bone and Soft Tissue Tumours > Flashcards

Bone and Soft Tissue Tumours Flashcards

1
Q

What are the types of bone tumour?

A

•Benign

  • Malignant
  • primary
  • secondary
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2
Q

What are the types of soft tissue tumour?

A
  • Benign

* Malignant

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3
Q

What is a sarcoma?

A

Malignant tumour arising from connective tissue

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4
Q

How do sarcomas spread?

A
  • Spread along fascial lines
  • Haematogenous spread to lungs
  • Rarely to regional lymph nodes
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5
Q

Which sarcomas spread to lymph nodes?

A

•Rhabdomyosarcomas
•Epithelioid sarcomas
•Synovial sarcomas
(originate in the synovial of joints)

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6
Q

Are bone tumours common?

A
  • Benign bone tumours are common
  • Malignant tumours are rare
  • Bony secondaries are very common
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7
Q

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

A

Metatstatic

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8
Q

What are benign bone-forming tumour known as (2)?

A

•Osteoid osteoma
•Osteoblastoma
(proximal femur, worsen at night)

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9
Q

What are malignant bone-forming tumours known as (1)?

A

•Osteosarcoma

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10
Q

What are benign cartilage-forming tumours known as (2)?

A
  • Enchondroma

* Osteochondroma (can become malignant)

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11
Q

What are malignant cartilage-forming tumours known as (1)?

A

•Chondrosarcoma

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12
Q

What are benign fibrous tissue tumours known as (1)?

A

•Fibroma

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13
Q

What are malignant fibrous tissue tumours known as (2)?

A
  • Fibrosarcoma

* Malignant fibrous histiocytoma (MFH)

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14
Q

What are benign vascular tissue tumours known as (2)?

A
  • Haemangioma

* Aneurysmal bone cyst

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15
Q

What are malignant vascular tissue tumours known as (1)?

A

•Angiosarcoma

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16
Q

What are benign adipose tissue tumours known as (1)?

A

•Lipoma

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17
Q

What are malignant adipose tissue tumours known as (1)?

A

•Liposarcoma

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18
Q

What are malignant marrow tissue tumours known as (3)?

A
  • Ewing’s sarcoma
  • Lymphoma
  • Myeloma
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19
Q

Describe Giant Cell Tumours (GCTs)

A

Benign (as they don’t tend to metastasis), locally destructive and can rarely metastasise

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20
Q

What are benign tumour-like lesions called?

A
  • Simple bone cyst

* Fibrous cortical defect

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21
Q

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

A
  1. Osteosarcoma 3/million/year
  2. Chondrosarcoma 2/million/year
  3. Ewing’s Tumour 1.5/million/year
  4. Malignant fibrous histiocytoma (MFH) <1/million/year
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22
Q

What is the most common primary malignant bone tumour in the younger patient?

A

Osteosarcoma

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23
Q

What is the most common primary malignant “bone” tumour in the older patient?

A

Myeloma (bone marrow)

24
Q

How would a bone tumour present in a history?

A
  • Pain - progressive pain at rest and at night
  • Mass
  • Incidental x-ray finding
25
Q

How may benign bone tumours present with pain?

A

Activity-related pain if they are large enough to weaken bone (osteoid osteoma)

26
Q

What do you look for in examination of bone tumour?

A
  • General health
  • Measurements of mass
  • Location
  • Shape
  • Consistency
  • Mobility
  • Tenderness
  • Local temperature
  • Neuro-vascular deficits
27
Q

What are the investigations used to image bone tumours?

A
  • X-ray
  • CT
  • Isotope bone scan
  • MRI
28
Q

What may show up on an x-ray?

A
  • Calcification - synovial sarcoma
  • Myositis ossificans - looks like egg shell
  • Phleboliths - in haemangioma
29
Q

How do inactive tumours present on an x-ray?

A
  • clear margins
  • surrounding rim of reactive bone
  • cortical expansion can occur with aggressive benign lesions
30
Q

How do aggressive tumours present on an 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

31
Q

How is a CT useful to image bone tumours?

A
  • Assessing ossification and calcification
  • Integrity of cortex
  • Best for assessing nidus in osteoid osteoma
  • Staging - primarily of lungs
32
Q

How is an isotope bone scan useful to image bone tumours?

A
  • Staging for skeletal metastasis

* Multiple lesions - osteochondroma, enchondroma, fibrous dysplasia & histiocytosis

33
Q

How is an isotope bone scan less useful to image bone tumours?

A
  • Frequently negative in Myeloma

* Benign also demonstrate increased uptake

34
Q

How is an MRI scan useful to image bone tumours?

A
  • Study of choice
  • Size, extent, anatomical relationships
  • Accurate for limits of disease both within and outside bone
  • Specific for Lipoma, haemangioma, haematoma or PVNS.
35
Q

How is an MRI scan less useful to image bone tumours?

A

Non-specific for benign vs. malignant

36
Q

What other investigations can be used for bone tumours?

A

Angiography:
superseeded by MRI
Psuedoaneurysms, A-V malformations
Embolisation of vascular tumours - Renal, ABC

PET:
may be useful for investigating response to chemo

37
Q

What must be done before a biopsy is taken?

A
  • Bloods
  • X-rays of affected Limb & Chest
  • MRI of lesion
  • Bone Scan
  • CT Chest, abdo & pelvis
  • CAN SPREAD TUMOUR IF BIOPSY DONE POORLY
38
Q

What are the cardinal features of a malignant bone tumour?

A 
•Increasing pain
•Unexplained pain
•Deep-seated boring nature
•Night pain
•Difficulty weight-bearing
•Deep swelling
(Osteosarcoma, Ewings sarcoma, Chondrosarcoma)
(CASE STUDIES ON PP)
39
Q

What are the clinical features of osteosarcoma (malignant bone)?

A
  • pain
  • loss of function
  • swelling
  • pathological fracture
  • joint effusion
  • deformity
  • neurovascular effects
  • systemic effects of neoplasia
40
Q

What is the cardinal feature of osteosarcoma and how does it present?

A
  • PAIN
  • increasing pain - impending # (esp. lower limb)
  • analgesics eventually ineffective
  • not related to exercise
  • DEEP BORING ACHE - WORSE AT NIGHT
41
Q

How does loss of function present in osteosarcoma?

A
  • limp
  • reduced joint movement
  • stiff back (esp. child)
42
Q

How does swelling present in osteosarcoma?

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
43
Q

How does a pathological fracture present in osteosarcoma?

A
  • n.b. many causes, of which primary bone tumour (benign or malignant) is one of rarest, c.f. osteoporosis commonest
  • minimal trauma + h/o pain prior to # !!
44
Q

How is osteosarcoma treated?

A
  • Chemotherapy (1st)
  • Surgery (2nd)
  • Radiotherapy (potentially)
45
Q

How is surgery used to treat osteosarcoma?

A
  • Limb salvage possible for most cases - implant can be used
  • Consider involvement of neurovascular structures - blood vessels can be replaces
  • Pathological #s - limb salvage will not normally work
  • Poorly performed biopsy
46
Q

How is surgery used to treat osteosarcoma?

A
  • Limb salvage possible for most cases - implant can be used
  • Consider involvement of neurovascular structures - blood vessels can be replaces
  • Pathological #s - limb salvage will not normally work
  • Poorly performed biopsy
47
Q

Describe metastatic bone disease

A
  • secondary bone tumour 25 x commoner than primary
  • bone most common site for secondary after lung and liver
  • great differences between tumours and sites of metastases - e.g.:
  • breast commonly goes to bone (50 breast : 9 melanoma), melanoma commonly goes to lung (40 melanoma : 12 breast)
  • sites - order of frequency (for all secondaries)
  • vertebrae > proximal femur > pelvis > ribs > sternum > skull
48
Q

What are the most common cancers to 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]
49
Q

How do pathological fractures affect the prognosis?

A
  • survival after pathological fracture depends on type of tumour -e.g. bronchial Ca. ≤ 1 y
  • in breast - median survival with bone metastases hugely increased; with soft tissue metastases is 12-24 months
  • in general, approx. 50% of patients with pathological fractures will survive >6 m, & 30% ≥1 y
50
Q

How are pathological fractures prevented?

A
  • early chemotherapy / DXT
  • prophylactic internal fixation
  • use of bone cement (not signif. affected by DXT)
51
Q

What system is used to do fracture risk assessment?

A

Mirel’s Scoring System (in images)

52
Q

How is fixation used?

A
  • 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.
53
Q

Key points of metastatic bone disease

A
  • Never assume that a lytic lesion, particularly if solitary, is a metastasis.
  • Metastatic pathological fractures rarely unite, even if stabilized.
  • Prophylactic fixation of long bone mets is generally easier for the surgeon and less traumatic for the patient.
  • Use the Mirels scoring system.
  • Fixation of pathological fractures or lytic lesions, especially around the hip/proximal femur have a high failure rate. Cemented hip prostheses (either standard or tumour prostheses) have a low failure rate.
  • Never rush to fix a pathological fracture. Traction or splintage will suffice while investigations are performed and surgical intervention discussed with the lead clinician for MBD and other appropriate colleagues.
  • When surgery is indicated for spinal metastases, both decompression and stabilisation are generally required.
  • Constructs, whether spinal or appendicular, should allow immediate weightbearing and aim to last the lifetime of the patient.
  • Solitary renal metastases should, where possible, be radically excised.
  • Each trauma group requires a lead clinician for MBD.
  • Treatment should be within the context of a multi-disciplinary team.

(PHOTO UNDER OSTEOSARCOMA)

54
Q

What is the most common soft tissue tumour?

A

Lipoma

55
Q

What are the ratios of solitary lipoma:sarcoma?

A
  • <5cm 150:1 for sarcoma
  • > 5cm 20:1
  • > 10cm 6:1
  • Deep seated tumours 4:1

(80% of deep sarcomas are > 5 cm)

56
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
57
Q

How are soft tissue tumours imaged?

A

MRI

MSK (28 decks)

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