Bone Cancer & Soft Tissue Tumors Flashcards
Bone Tumors
overview (blastic v lytic)
how are they typically found
Overview
- bone tumors: majority are benign
- blastic lesion: built-up/overgrowth = appear radiodense (white) on xray
- lytic lesions: breakdown of bone = appear radioopaque (dark)
- most often determined if benign or cancerous on xray: but biopsy can be needed
Typically found
- incidental finding
- pt. symptomatic and imaging done
- bone lesions found during survellience of malignant disease
Characterisitcs of bengign v malignant lesions on bone
Benign
- pain exacerbated with activity
- no constitutional symptoms
- can have pathologic fractures
- incidentally found
Malignant
- alwasy consider malignacy in 40+
- dull, achy pain that progresses overtime
- pathologica fractures
- soft tissue masses accompanying
- constitutional symptoms (MM, lymphoma, mets of other cancers)
How will benign v malignant look on x-ray
x-ray plains are highly suggestive of diagnosing tumor
Benign
- well-defined
- nonaggressive in growth
- no cortical destruction or periosteal reaction
Malignant
- lytic lesions (darker)
- destructive
- ill-defined boarders & aggressive
- moth-eaten
- cortical destrcution: weak
- periosteal reaction
when is xray good
MRI
CT
Bone Scan
bone biopsy
for bone tumors
X-ray is usually good enough to dx.
CT: better at looking at bone detail
MRI: good for soft tissue and marrow infiltration
Bone Scan: to see trauma, tumor or infection but doesnt destinguish which is which
Bone Biopsy
- done under local anesthesia: or conscious sedation
- rarely done open in the OR
- ortho surgeon decides: its a CT guided procedure
Osteochondroma (Benign)
Etiology
Etiology
- most common benign tumor; cartilage forming
- when a piece of growth plate cartilage separates and herniates through periosteal bone at the growth plate; creates cartialge cap mushroom shape
- increased incidence with radiation/trauma
- can grow & then involute when child reaches skeletal maturity
Presentation
- asymptomatic mostly; found incidentally
- pain & swelling are MC symptoms
- visable deformity possibel
- neurovascualr impigment (common at femer: lumabr spinal nerves)
- pathologic fractures
- common in long bones around the knee
Osteochonroma
Diagnosis
Treatment
Diagnosis
- X-ray findings : cartilagous cap on tumor
- typically in the metaphysis & grow AWAY from the nearest joint space
- biopsy not needed
Lab Testing
- can do genetics if concerned for Trevor disase or have multiple osteochrondromas
Management
- serial xray monitoring
- larger/symptomatic tumors = surgery
- surgery if complications like….
- fractures at stalk
- blood vessel displacement
- compression of nerves
- bursa formation and pain
Rare but could transform to chrondrosarcoma (or osteosarcoma at base of stalk/where its bone)
rapid, painful and cap > 2cm = risk of cancer
Giant Cell Tumor (benign)
Etiology
Etiology
- females: becuase growth during pregnancy or OCP use
- typically: after skeletal maturity
- if locally aggressive: cortical thinning and remodeling bone is possible
Symptoms
- loacl pain - relieved with rest
- palpable mass
- joint stiffness/effusion if near one
- neruo sz. if spinal lesions & pathologic fractures (rarely)
Where
- Distal Femur (MC)
- proximal tibia
- distal radius
- sacrum
- proximal humerus
- MOST are near knee
Giant Cell Tumor
Diagnosis
Treatment
risk of malignancy
Diagnosis (benign)
x-ray: see well-defined lytic/cystic lesion with eccentric growth (circular)
typically in epiphysis
CT: can help assess margins of the tumor and if its effecting cortical bone
MRI: can show margins at the most detail; but not helpful for cortical bone
biopsy: not helpful: showing giant cells
Treatment
- bone curettage/scraping & filling in defect with filler or graft : wont come back if good margins (but might impact limb function)
- reduce recurrance: use polymethacrylate to fill
- argon based cryotherapy
- sclerosing (zinc, nitrogen) agents
- oral bisphosphonates (help repair?)
Malignancy Risk
- low; but does have an ability to spread to lungs (not considered mets tho?)
Osteoblastoma (Benign)
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- bone forming tumor (benign)
Symptoms
- dull, achy pain NOT relieved with NSAIDS
- affects spine and pelvic girdle
- can have neurologic or scolosis (late in life)
Diagnosis
- imaging is variable : bone biopsy is often needed
- looks malignant because it grows fast and destroys: but isnt
- MRI helpful in spine
Management
- radiofrequency ablation, cryo or laser
- surgical resection if lesion doesnt respond
- recurrance rate is high
RARE risk of malignancy
Osteoid Osteoma (benign)
Etiology
-Symptoms
Etiology
- benign, bone forming tumor
Symptoms
- pain with pain worsening at night
- relieved by NSAIDS
- in lg:femur or tibia
- in spine: scoliosis late in life
Diagnosis
- Xray: shows radiolucent: darker area in cortex; small < 1.5 cm
- mostly in shaft of long bone
Management
- percut. radiofrequency, thermal or laser
- recurrance possible if not all zapped originall
will NOt become sarcomas: rarely aggressive osteoblastoma
Aneurysmal Bone Cyst (Benging)
Etiolgy
Etiology
- blood-filled multiloculated cavities containting osteoclasts, giatn cells and reactive woven bone
- can be a result of prior trauma, prior giant cell tumors or genetic
- mostly in femer, tiibia, humerus or fibula
Symptoms
- stiffness, swelling & pain
- limited ROM if near a joint
- nero symptoms if in spine
Diagnosis
- Xray: eccentric lesions lytic with thin cortex
- soap bubble appearance
- CT: shows more detail about margins and fluid
- MRI more detail about seta and hemorrhage
- incisional biopsy is recommented to diagnose
Treatment
- curettage with or without grafting
- then sclerotherapy
Rare risk of malignancy: higher if radiation expsoure
Fiberous Dysplasia (Benign)
etiology
Symptoms
diagnosis
Treatment
Etiology
- bone forming tumor
- due to gene mutations
- monostotic ( 1bone)
- polystotic (multiple) mcCune Albright syndrome
Symptoms
- asymtompatic
- some ahve dull, achy pain
- estorgen sensitive: pregancy and menstral cycle related
- swelling, deformities or fracutres
Diagnosis
- Xray: show darker radiolucent areas with ground glass appearance overtime
- in femur, tibia, skull or facial bones (facial and ribes = monostatic)
- MRI: help deliate boarders
Treatment
- monitor with xrays
- diet and exercise for good bone health
- bisphosphates or densumab
- pregab. for pain
- can curettage
history or radition increase risk of becoming malignant
Enchondroma (benign)
Etiology
Symptoms
Etiology
- cartilage forming tumor
Symptoms
- incidental on th etubualr long bones, hands and feet
- pathologic fractures
Diagnosis
- Xrays: rings and arcs in the lesion show layering of minerals
- may need MRI
Simple bone Cyst (Benign)
Etiology
- a true bone cyst: fluid filled and surrounded by mesothial cells
Symptoms
- mostly incidental findings
- pain or pathologic fracture
- kids = proximal humerus or femur
Diangosis
- xrays are used : clean margins no bubbles
- CT/MRI for detail
Treatment
- if low risk for fracture: conservative with mointoring xrays
- injection of steroids into cyst
- cuterrage and fill
- placement with nails has 100% heal rate
very rare to malignancy
Enostosis
bone islands
- benign bone tuors forming in axial skeleton and metaphysis of long bones
dx via xray seeing small oval lesions with spiculated margins
if increasing siz or painful, reevaluate for cancer
no treatment needed
NOT risk for cancer
Osteosarcoma (cancer)
Etiology
Etiology
- osteogenic sarcoma: most common primary tumor of the bone
- differentiated, dediff. or undeiff determiens how bad it is
- higher in kids at growth spurt age
- most: spontaneous (no prior lesion)
- can come from benign tumors, osteomyleitis or pagets, RB!, or other pre-cancerous conditions
Presentation
- at the knee: distal femur or proximal tibia
- severe pain: at night time
- fevers
- local sweling
- palpabale mass
- pathologic fracture
any pt. with suspected osteosarcoma should be made NWB because of risk of fractures
Osteosarcoma
Diagnosis
Diagnosis
X-rays
- variable in appearance
- blastic or destructive lesions
- assocaited with soft tissue masses
- “sunburst or hair on end” appearance
- Codman triangle: see triangles at the marign showing periosteal elevation and bone formation
- cortical involvement
MRI
- wiht and without contrast to see extent and NV invovlement
- always get entire bone to assess for skip lesions: mets of the cancer in the same bone
Biopsy
- alwasy indicated in suspected osteosarcoma
- after dx. CT scan of cehst and bone to look for mets
Osteosarcoma
Treatment
- depends on subtype of the osteosarcoma
- neoadjuct chemo
- resection (limb salvage)
- adjuct chemo
if low grade tumor: curative resection alone can be done and no chemo
- ## worse stage, older age, bad marigns, axial skeleton and lack of imporvement with chem show worse prognosis
Ewing Sarcoma (Cancerous)
Etiology
Symptoms
Etiology
- primary bone cancer which forms spontaneously
- assocaited with radiation as a child
- childhood blood malignancy (ALL, AML)
Symptoms
presents VERY similar to ostemyelitis
- severe pain, commonly in the diaphysis of long bones (middle part)
- flat bones, presenting with back pain/bladder/bowel dysfunction
- fever
- swelling in the affected area
- on labs: anemic, leukocytosis, elvated ESR
if suspected dx. need to place pt on NWB status for risk of pathologic fractures
Ewing Sarcoma
Diagnosis
Treatment
Diagnosis
- X-ray: poor maring, moth eaten appearance
- onion-skin appearance: layers of periosteal reaction and new forming bone
- sunburst lesions
- codmans triangle (periosteal reaction to new bone formation)
- MRI: should be done in all pt. to determine extent of the tumor
Biopsy
- done after MRI: shows giant blue cells
consider additional studies
- CT of chest and bone to assess spread & bone marrow biopsy (inward spread)
Treatment
- surgical resection if possible
- neoadjut. chemo and adjuct chemo
- if can do surgery: chemo and radiation
- poor prognosis: 50% survival
- worse prognosis if spine or pelvis involvement
Chondrosarcoma
Etiology
Symptoms
Etiology
- cancer forming tumors of cartilagous bone
- can occur as a priamry tumor or malignant transformation from others
- renewed growth of a osteochrodroma after skeletal maturity should be sus
Symptoms
- pain
- pathologica fractures
- tend to affect long bones and pelvis
- can have bowl/bladder symptoms if pelvic
Chrondrosarcoma
Diagnosis
Treatment
Diagnosis
- Xary: shows lytic and blastic lesions
- see popcorn chondroid matrix calcifications
CT or MRI for pelvic tumors
Treatment
- resistant to radation
- surgery to ressect the tumor is mainstay
- pretty good prognosis
what cancers commonly metastize to the bone
what type of lesions (lytic or blastic)
how will they present
Mets: always consider the risk of spread to bone in cancer pt. with back, bone and limb pain (could be inital presentation too)
Renal = lytic lesions
Lung = Lytic Lestions
Breast = mixed, often blastic
Prostate = mixed, often blastic
Thyroid = lytic
Presentation
- lower extremity pain with weight bearing
- bone pain
- back pain
- alwasy consider mets in those 40+
METs to bone
PE and Labs
Imaging
PE
- local/pain tenderness at sight
- limited ROM of joint
- palpable soft tissue mass
- LAD (focal)
Labs
- CBC
- BMP
- ESR/CRP
- tumor specific ones & screenings (mammograms)
Imaging
- x-ray is primary imaging mode
- - ill-defined boarders
- come from medullary cavitiy and spread to cortex
- pathologic fractures
- lytic or blastic appearance
then after xray - get BMD or PEt (to find primary lesion)
CT of chest/abd. can be done if you need to find the primary tumor
Biopsy to identify the primary cancer source
METs to bone
treatment
involved multiple specialties
- if they arent at risk for a fracture = external beam radiation is good
- internal radiation can be good for inaccessible lesions, cry and replace defect
- bisphosphonates/denosumab to increase bone activity could be good
Multiple Myleoma - bone appearance
labs
xray findings
Labs
- CBC, ESR/CRP
- SPEP, UPEP : urine/serum protein electrophoresis
- quantitative serum immongl. levels
- serum light chain assay & beta 2
Xray findings
- moth-eaten appearance
- multiple lesions on the one bone
Lymphoma- Bone Involvlement
commone sites it spreads to
presentations by bone
lymphoma to bone is common at some point (bone or lymph spread)
spine: common
- erosing of the anteriolateral vertebrae
- vertebral height not affected: so tehy dont get compression or wedge fractures
- a single, dense vertebrae can be seen “ivory vertebrae
Pelvis: mixng or sclerosing lesions
Ribs: lytic
Long bones: endosteal scalloping of the cortex
spine and pelvis most common
Malignant Soft Tissue Tumors (names)
- rhabdomyosarcoma
- dermatofibrosarcoma protuberans
- leiomyosarcoma
- liposarcoma
- synoviodsarcoma
How to evaluate soft tissue tumors for malignancy
what needs imaging
US findings
MRI
CT
majority of soft tissue tumos are benign
if imaging is needed = MRI
- masses > 5cm
- enlarging/growing
- irregulat shape
- fixed to deeper structures
can biopsy
- excise
- needle: FNA
US
- can show size, marigins, cystic or not, vascualrity, etc.
- smooth, roung and looks uniform = benign
- irregulat shape, septae, hyopechoic (dark) = cancerous
MRI
- most accurate modality
- shows nearby structures
- evaluate necorsis, boarders
- intenistiy and how deep it si
CT
- reserved for those who cannoy do MRI
- good for vascularitiy
Management of Soft Tissue Tumors
Low -Risk Features
- < 5cm, stable, superfiscal to fascial plane
- follow up weeks/months
- excise if they want it removed
High-Risk Featrues
- > 5cm, firm, rapid growht
- get MRI sasp and refer out
