Bone and Soft Tissue Tumours Flashcards
What are the types of bone tumour?
•Benign
- Malignant
- primary
- secondary
What are the types of soft tissue tumour?
- Benign
* Malignant
What is a sarcoma?
Malignant tumour arising from connective tissue
How do sarcomas spread?
- Spread along fascial lines
- Haematogenous spread to lungs
- Rarely to regional lymph nodes
Which sarcomas spread to lymph nodes?
•Rhabdomyosarcomas
•Epithelioid sarcomas
•Synovial sarcomas
(originate in the synovial of joints)
Are bone tumours common?
- Benign bone tumours are common
- Malignant tumours are rare
- Bony secondaries are very common
What is a bone tumour in an over 50 likely to be?
Metatstatic
What are benign bone-forming tumour known as (2)?
•Osteoid osteoma
•Osteoblastoma
(proximal femur, worsen at night)
What are malignant bone-forming tumours known as (1)?
•Osteosarcoma
What are benign cartilage-forming tumours known as (2)?
- Enchondroma
* Osteochondroma (can become malignant)
What are malignant cartilage-forming tumours known as (1)?
•Chondrosarcoma
What are benign fibrous tissue tumours known as (1)?
•Fibroma
What are malignant fibrous tissue tumours known as (2)?
- Fibrosarcoma
* Malignant fibrous histiocytoma (MFH)
What are benign vascular tissue tumours known as (2)?
- Haemangioma
* Aneurysmal bone cyst
What are malignant vascular tissue tumours known as (1)?
•Angiosarcoma
What are benign adipose tissue tumours known as (1)?
•Lipoma
What are malignant adipose tissue tumours known as (1)?
•Liposarcoma
What are malignant marrow tissue tumours known as (3)?
- Ewing’s sarcoma
- Lymphoma
- Myeloma
Describe Giant Cell Tumours (GCTs)
Benign (as they don’t tend to metastasis), locally destructive and can rarely metastasise
What are benign tumour-like lesions called?
- Simple bone cyst
* Fibrous cortical defect
What are the incidence of primary bone tumours in the UK?
- Osteosarcoma 3/million/year
- Chondrosarcoma 2/million/year
- Ewing’s Tumour 1.5/million/year
- Malignant fibrous histiocytoma (MFH) <1/million/year
What is the most common primary malignant bone tumour in the younger patient?
Osteosarcoma
What is the most common primary malignant “bone” tumour in the older patient?
Myeloma (bone marrow)
How would a bone tumour present in a history?
- Pain - progressive pain at rest and at night
- Mass
- Incidental x-ray finding
How may benign bone tumours present with pain?
Activity-related pain if they are large enough to weaken bone (osteoid osteoma)
What do you look for in examination of bone tumour?
- General health
- Measurements of mass
- Location
- Shape
- Consistency
- Mobility
- Tenderness
- Local temperature
- Neuro-vascular deficits
What are the investigations used to image bone tumours?
- X-ray
- CT
- Isotope bone scan
- MRI
What may show up on an x-ray?
- Calcification - synovial sarcoma
- Myositis ossificans - looks like egg shell
- Phleboliths - in haemangioma
How do inactive tumours present on an x-ray?
- clear margins
- surrounding rim of reactive bone
- cortical expansion can occur with aggressive benign lesions
How do aggressive tumours present on an x-ray?
•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
How is a CT useful to image bone tumours?
- Assessing ossification and calcification
- Integrity of cortex
- Best for assessing nidus in osteoid osteoma
- Staging - primarily of lungs
How is an isotope bone scan useful to image bone tumours?
- Staging for skeletal metastasis
* Multiple lesions - osteochondroma, enchondroma, fibrous dysplasia & histiocytosis
How is an isotope bone scan less useful to image bone tumours?
- Frequently negative in Myeloma
* Benign also demonstrate increased uptake
How is an MRI scan useful to image bone tumours?
- Study of choice
- Size, extent, anatomical relationships
- Accurate for limits of disease both within and outside bone
- Specific for Lipoma, haemangioma, haematoma or PVNS.
How is an MRI scan less useful to image bone tumours?
Non-specific for benign vs. malignant
What other investigations can be used for bone tumours?
Angiography:
superseeded by MRI
Psuedoaneurysms, A-V malformations
Embolisation of vascular tumours - Renal, ABC
PET:
may be useful for investigating response to chemo
What must be done before a biopsy is taken?
- Bloods
- X-rays of affected Limb & Chest
- MRI of lesion
- Bone Scan
- CT Chest, abdo & pelvis
- CAN SPREAD TUMOUR IF BIOPSY DONE POORLY
What are the cardinal features of a malignant bone tumour?
•Increasing pain •Unexplained pain •Deep-seated boring nature •Night pain •Difficulty weight-bearing •Deep swelling (Osteosarcoma, Ewings sarcoma, Chondrosarcoma) (CASE STUDIES ON PP)
What are the clinical features of osteosarcoma (malignant bone)?
- pain
- loss of function
- swelling
- pathological fracture
- joint effusion
- deformity
- neurovascular effects
- systemic effects of neoplasia
What is the cardinal feature of osteosarcoma and how does it present?
- PAIN
- increasing pain - impending # (esp. lower limb)
- analgesics eventually ineffective
- not related to exercise
- DEEP BORING ACHE - WORSE AT NIGHT
How does loss of function present in osteosarcoma?
- limp
- reduced joint movement
- stiff back (esp. child)
How does swelling present in osteosarcoma?
- 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
How does a pathological fracture present in osteosarcoma?
- 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 # !!
How is osteosarcoma treated?
- Chemotherapy (1st)
- Surgery (2nd)
- Radiotherapy (potentially)
How is surgery used to treat osteosarcoma?
- 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
How is surgery used to treat osteosarcoma?
- 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
Describe metastatic bone disease
- 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
What are the most common cancers to metastasise to bone?
- LUNG - smoker; CXR, sputum cytology
- BREAST - commonest; examine!
- PROSTATE - osteosclerotic 2; PR, PSA
- KIDNEY - solitary, vascular; IVP + US, angiography & embolise
- THYROID - esp. follicular Ca; examine
- GI TRACT - FOB, endoscopy, Ba studies, markers
- MELANOMA - examine!
[neuroblastoma (of adrenal medulla) - aet. <4 y]
How do pathological fractures affect the prognosis?
- 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
How are pathological fractures prevented?
- early chemotherapy / DXT
- prophylactic internal fixation
- use of bone cement (not signif. affected by DXT)
What system is used to do fracture risk assessment?
Mirel’s Scoring System (in images)
How is fixation used?
- 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.
Key points of metastatic bone disease
- 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)
What is the most common soft tissue tumour?
Lipoma
What are the ratios of solitary lipoma:sarcoma?
- <5cm 150:1 for sarcoma
- > 5cm 20:1
- > 10cm 6:1
- Deep seated tumours 4:1
(80% of deep sarcomas are > 5 cm)
What are the features of soft tissue tumours?
- painless
- mass deep to deep fascia
- any mass >5cm
- any fixed, hard or indurated mass
- any recurrent mass
How are soft tissue tumours imaged?
MRI
