Bone and Soft Tissue Tumours Flashcards
1
Q
What are the types of bone tumour?
A
•Benign
- Malignant
- primary
- secondary
2
Q
What are the types of soft tissue tumour?
A
- Benign
* Malignant
3
Q
What is a sarcoma?
A
Malignant tumour arising from connective tissue
4
Q
How do sarcomas spread?
A
- Spread along fascial lines
- Haematogenous spread to lungs
- Rarely to regional lymph nodes
5
Q
Which sarcomas spread to lymph nodes?
A
•Rhabdomyosarcomas
•Epithelioid sarcomas
•Synovial sarcomas
(originate in the synovial of joints)
6
Q
Are bone tumours common?
A
- Benign bone tumours are common
- Malignant tumours are rare
- Bony secondaries are very common
7
Q
What is a bone tumour in an over 50 likely to be?
A
Metatstatic
8
Q
What are benign bone-forming tumour known as (2)?
A
•Osteoid osteoma
•Osteoblastoma
(proximal femur, worsen at night)
9
Q
What are malignant bone-forming tumours known as (1)?
A
•Osteosarcoma
10
Q
What are benign cartilage-forming tumours known as (2)?
A
- Enchondroma
* Osteochondroma (can become malignant)
11
Q
What are malignant cartilage-forming tumours known as (1)?
A
•Chondrosarcoma
12
Q
What are benign fibrous tissue tumours known as (1)?
A
•Fibroma
13
Q
What are malignant fibrous tissue tumours known as (2)?
A
- Fibrosarcoma
* Malignant fibrous histiocytoma (MFH)
14
Q
What are benign vascular tissue tumours known as (2)?
A
- Haemangioma
* Aneurysmal bone cyst
15
Q
What are malignant vascular tissue tumours known as (1)?
A
•Angiosarcoma
16
Q
What are benign adipose tissue tumours known as (1)?
A
•Lipoma
17
Q
What are malignant adipose tissue tumours known as (1)?
A
•Liposarcoma
18
Q
What are malignant marrow tissue tumours known as (3)?
A
- Ewing’s sarcoma
- Lymphoma
- Myeloma
19
Q
Describe Giant Cell Tumours (GCTs)
A
Benign (as they don’t tend to metastasis), locally destructive and can rarely metastasise
20
Q
What are benign tumour-like lesions called?
A
- Simple bone cyst
* Fibrous cortical defect
21
Q
What are the incidence of primary bone tumours in the UK?
A
- Osteosarcoma 3/million/year
- Chondrosarcoma 2/million/year
- Ewing’s Tumour 1.5/million/year
- Malignant fibrous histiocytoma (MFH) <1/million/year
22
Q
What is the most common primary malignant bone tumour in the younger patient?
A
Osteosarcoma
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
How may benign bone tumours present with pain?
Activity-related pain if they are large enough to weaken bone (osteoid osteoma)
26
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
27
What are the investigations used to image bone tumours?
* X-ray
* CT
* Isotope bone scan
* MRI
28
What may show up on an x-ray?
* Calcification - synovial sarcoma
* Myositis ossificans - looks like egg shell
* Phleboliths - in haemangioma
29
How do inactive tumours present on an x-ray?
* clear margins
* surrounding rim of reactive bone
* cortical expansion can occur with aggressive benign lesions
30
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
31
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
32
How is an isotope bone scan useful to image bone tumours?
* Staging for skeletal metastasis
| * Multiple lesions - osteochondroma, enchondroma, fibrous dysplasia & histiocytosis
33
How is an isotope bone scan less useful to image bone tumours?
* Frequently negative in Myeloma
| * Benign also demonstrate increased uptake
34
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.
35
How is an MRI scan less useful to image bone tumours?
Non-specific for benign vs. malignant
36
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
37
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
38
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)
```
39
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
40
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
41
How does loss of function present in osteosarcoma?
* limp
* reduced joint movement
* stiff back (esp. child)
42
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
43
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 # !!
44
How is osteosarcoma treated?
* Chemotherapy (1st)
* Surgery (2nd)
* Radiotherapy (potentially)
45
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
46
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
47
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
48
What are the most common cancers to metastasise to bone?
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
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
50
How are pathological fractures prevented?
* early chemotherapy / DXT
* prophylactic internal fixation
* use of bone cement (not signif. affected by DXT)
51
What system is used to do fracture risk assessment?
Mirel's Scoring System (in images)
52
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.
53
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)
54
What is the most common soft tissue tumour?
Lipoma
55
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)
56
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
57
How are soft tissue tumours imaged?
MRI
