Bone pain - Pathology Flashcards
What suffix do you generally use for benign tumours?
‘Oma’
What suffix do you use for malignant tumours?
‘Sarcoma’
What is the term used to describe a benign tumour of osteoblasts?
Osteoma
What is the term used to describe a malignant tumour of osteoblasts?
Osteosarcoma
What is the name given to a benign tumour of chondrocytes?
Chondroma
What is the name given to a malignant tumour of chondrocytes?
Chondrosarcoma
Lisst the 3 common benign primary bne tumours
- Osteochondroma
- Osteoid osteoma
- Giant cell tumour of bone
Osteochondroma
a) What is an osteochondroma and what is it composed with?
b) Which bones does it commonly affect?
c) Predominanace
d) Age diagnosed
e) Imaging features
f) Treatment
a) A benign tumour - overgrowth of cartilage and bone. It is composed with an overlying cap known as exostoses
b) Metaphysis of long bones
c) Male predominance - M:F = 3:1
d) Most commonly diagnosed in under 30s
e)
- Continuity of the cortex and medullary cavity of the lesion with that of the parent bone
- Pednucleated lesions typically point away from the nearest joint
f) Surical excision of symptomatic lesions or concerns of malignant transformation = curative if all cartilaginous cap is removed
What tumour is being shown on this x-ray? Describe the x-ray
This is pednucleated osteochondrama (often point away from the nearest joint as seen in this image)
There is continuity of the cortex and medullary cavity of the lesion with that of the parent bone.
Osteochondromas are composed with an overlying cap known as exostoses as seen in the images below. If the cap is irregular or excessively thick, especially in an adult, what must you exclude?
Secondary chondrosarcoma
Osteoid osteoma
a) What type of tumour is it? and what is it characterized by?
b) Which bones does it commonly affect?
c) Predominanace
d) Age diagnosed
e) Clinical presentation
f) Imaging features
g) Treatment
h) Prognosis
a) Benign tumour forming neoplasm of osteoblasts. It is characterized by a limited growth potential
b) Cortex of diaphysis or metaphysis of long bones, usually of the lower limb
c) Male predominance - M:F = 2:1
d) Most commmonly diagnosed in under 30s
e) Often presents with night pain and tenderness relieved by NSAIDs
f) Imaging (x-ray) shows a well-defined central radiolucent nidus surrounded by dense sclerosis
g) CT guided radiofrequency ablation (minimally invasive) or complete surgical excision of the nidus (curative)
h) Complete surgical excision of the nidus is curative
What tumour is being shown o this x-ray? Describe the x-ray
Osteoid osetoma
Central nidus surrounded by scelerotic bone
Osteoid osetoma and osteoblastoma have similar histologic features but differ clinically and radiologically. Describe 3 difference between the two
- Osteoid osteoma is <2 cm in size whereas osteoblastoma is >2cm in size
- Osteoid osteoma involves diaphysis and metaphysis of long bones usually in lower limb whereas osteoblastoma involves posterior components of the vertebrae (laminae and pedicles) more frequently
- Pain from osteoid osteoma is better with NSAIDs (Oooooh that’s better) where as pain in osteoblastoma is unresponsivenes to NSAIDs
Giant cell tumour
a) What type of tumour is it? Why is it called a giant cell tumour?
b) Which bones does it commonly affect?
c) Predominanace
d) Age diagnosed
e) Clinical presentation
f) Imaging features
g) Treatment
a) A locally agressive and rarely metasizing neoplasm. It is so called because muli-nucleated osteoclast type giant cells dominate the histological picture
b) Metaphysis and epihysis of long bones, usually femur, tibia and radius
c) Slight female predominance - M:F = 1:1.4
d) Middle age (Median age of diagnosis is 35 years)
e) Usually presents with pain, swelling and reduced ROM (can be similar to symptoms of arthritis)
f) ‘Soap bubble’ lytic lesion at the end of a long bone.
g) Curettage (defect filled with cement)/joint replacement/amputation
What tumour is being shown on this x-ray? Describe the x-ray
Giant cell tumour
X-ray of distal radius which contains a soap bubble lesion in the metaphysis and epiphysis of the distal radius
List the top 3 most common maligant bone tumours
- Osteosarcoma
- Chondrosarcoma
- Ewing sarcoma
Osteosarcoma
a) Desccribe the type of tumour it is
b) Which bones does it commonly affect?
c) Predominanace
d) Age diagnosed
e) Risk factors
f) Genetic features
g) Clinical presentation
h) Imaging features
i) Management
l) Prognosis
a) A tumour consisting of malignant proliferation of osteoblasts
b) Metaphysis of long bones
c) Slight male predominance- M:F = 1.6:1
d) Most common malignant bone tumour in children
e)
- Paget’s disease
- Previous history/chemotherapy
- Some inherited conditions (Familial retinoblastoma syndrome and Li-Freumeni syndrome)
f) Mutations of tumour supressor gene p53 and Rb are commonly seen
g) Commonly presents with pain, swelling, limping/limited ROM and it can present with metastatic symptoms
h)
- X-rays show combination of bone destruction and formation
- Soft tissue calcification produces ‘suburst’ appearance
- Lifting of periosteum known as ‘Codman’s triangle’
i) Surgical resection of all gross disease + chemotherapy
What is the tumour shown in the x-ray? Describe the x-ray
Osteosarcoma
The x-ray shows a case of osteosarcoma which involves a sunburst appearance of the metaphysis of the distal fibula extending onto the posterior aspect of the tibia and also involving the calcaneum below.
Chondrosarcoma
a) Which bones does it commonly affect?
b) Predominanace
c) Age diagnosed
d) Clinical presentation
e) Imaging features
f) Management
a) Commonly arises in the axial skeleton, especially the pelvis, shoulder, and ribs
b) Predominance in male - M:F = 2:1
c) Middle age to older adults (in 40’s)
d) Usually present as painful progessively enlarging masses
e) Flocculent or popcorn like calcifications - destory cortex & form tissue mass
f)
- Wide surgical excision
- Chemotherapy
What malignant tumour does this? Desribe the x-ray
Osteochondroma
The x-ray of the pelvis shows a large exophytic growth arising from the right iliac bone with a chondroid matrix. It shows the characteristic rings and arcs pattern of calcification.
Ewing sarcoma
a) Which bones does it commonly affect?
b) Predominanace
c) Age diagnosed
d) Clinical presentation
e) Imaging features
f) Treatment
a) Diaphysis of long bones
b) Slight male predominance - M:F = 1.5:1
c) 80% less than 20 years of age
d) Localised, painfull mass or swelling, commonly in the long bones of the arms and lengs
e)
- “Onion-skin” periosteal reaction - Due to uneven tumour
- “Sunburst” or “hair-on-end” perosteal reaction - beacuse in steady tumour growth Sharpe’s fibres (the tiny fibres that connect the periosteum to the bone) becomes streched out perpendicular to the bone and ossify
f)
- 1st line treatment usually: Neoadjuvant chemotherapy and surgery
- Radiotherapy for inaccessible sites - less effective
Here are two x-rays. What are the names for these two specific radiological features? What tumour is being show?
Ewing sarcoma
List the 3 main pathways of tumour spread to bone
- Haematogenous or lymphatic spread (most common)
- Direct extension
- Intraspinal seeding (via the Batson plexus of veins)
List the 5 carcinoma primary sites which most commonly metastasise to bone.
- Breast
- Lung
- Thyroid
- Kidneys
- Prostate
(BLT with ketchup and pickles)
Which 3 tumours commonly metastasise to bone in children?
- Neuroblastoma (a primitive tumour derived from the neural crest).
- Wilms tumour (a malignant kidney tumour).
- Rhabdomyosarcoma (a malignant tumour of skeletal muscle).
List 3 treatment options for metastatic carcinoma
- Chemo/radiotherapy
- Bisphosphonates
- Surgery (to stabilise pathological fractures)
A pathologist issues the following report on a pedunculated bone tumour taken from the lower femoral metaphysis of a 20-year-old male patient. The tumour was pointing away from the knee joint. “There is a cap of hyaline cartilage which is undergoing endochondral ossification and which merges with the underlying trabecular bone. There are no atypical features”. What tumour is being described here?
An osteochondroma (exostosis).
A 25-year-old male presents with severe pain at night in his upper right thigh, which is relieved by aspirin. An x-ray shows a 1.1 cm lucency in the cortex of his right femur with a surrounding rim of reactive bone formation. Under the microscope, this shows a central nidus consisting of osteoid trabeculae separated by a vascular fibrous stroma. The nidus has a sharp margin which interfaces with a surrounding rim of mature bone. Which tumour is being described here?
This is an osteoid osteoma.
(Osteoblastoma is like an osteoid osteoma but is larger than 2 cm and involves the posterior components of the vertebrae and the pain does not respond to aspirin. In addition these tumours do not induce a marked bony reaction)
Which bone tumour has a soap bubble appearance on x-ray and involves the epiphysis of long bones in young adults?
Giant cell tumour of bone.
List 3 risk factors for osteosarcoma? Explain them
- Familial retinoblastoma
- Paget’s disease
- Previous history/chemotherapy
How does the pathologist make the diagnosis of osteosarcoma?
Under the microscope, osteosarcomas show a proliferation of malignant osteoblasts producing osteoid.
List 3 tumour suppressor genes that are involved in the pathogenesis of osteosarcoma.
- Retinoblastoma (Rb)
- p53.
- CDKN2A. This gene encodes 2 tumour suppressors (p16 and p14)
List 2 oncogenes which are over-expressed in low-grade osteosarcomas.
- MDM2, which inhibits p53.
- CDK4, which inhibits Rb.
What causes the sunburst pattern seen with osteosarcoma on imaging?
This occurs when the tumour grows quickly and the periosteum does not have enough time to lay down a new layer and instead the Sharpey’s fibres stretch out perpendicular to the bone.
Desrcibe the differences between benign and malignant tumours
There are cytological differences between benign and malignant cells. How do you distinguish a benign cell from a malignant cell?
Fill in the missing boxes
Fill in the missing boxes
Which tumour has the grade and why? Suggest what grades the two tumours are
Tumour 2 has the higher gade beacuse it is poorly differentianted and resembles the parent tissue the least
