Bone Path II Quiz 1 Flashcards
What are the categories of bone disease?
Congenital, Arthritis, Tumor, Blood, Infection, Trauma, Endocrine, Soft Tissues (CATBITES)
What are some clues to have a preliminary analysis of bone disease? (7)
1) Age 2) Sex 3) Race 4) History 5) Number of lesions 6) Symmetry of lesions 7) Systems involved
what are the 4 different types of imaging modalities?
1) Plain film 2) Computed tomography (CT) 3) MRI 4) Bone scan
what type of imaging is the 1st choice for osseous lesions/
Plain Film
How much bone loss is required to be seen on the film?
30-50%
Are CT often used for tumor, infection and arthritis?
no
What is the difference between CT and plain film?
Same basic imaging as plain film, more detail
What does CT detect? (3)
1) Detects more subtle osseous changes (lytic destruction, cortical integrity) 2) Detects subtle periosteal response 3) Detects subtle calcification
Which typ of imaging provides excellent evaluation of marrow?
MRI
Does MRI provide good evaluations of cortex and trabeculae?
No, poor eval of cortex and trabeculae
What are some properties of MRI? (5)
1) Better evaluation of extent of lesion 2) more information regarding matrix 3) Visualize soft tissue mass 4) Evaluate larger areas 5) Evaluate impact on surrounding structures
What is another name for a bone scan?
Radionuclide imaging; scintigraphy
What are “hot spots” on a bone scan?
areas of increased uptake (black) where areas of increased metabolic activity are found
are bone scans specific or sensitive?
very sensitive (3-5% bone loss) but not specific
Do bone scans provide good anatomic detail?
No, poor anatomic detail
what are the aspects of a bone to evaluate? (5)
1) Shape 2) Size 3) Cortex 4) Trabeculae 5) Overall radiographic density
What are the aspects of osseous anatomy to evaluate? (11)
1) cortex 2) periosteum 3) endosteum 4) cancellous bone 5) trabeculae 6) cellular marrow 7) fat and hematopoietic tissue 8) Epiphysis 9) Metaphysis 10) Diaphysis 11) Physis
what are the 6 types of tumor types?
1) Metatstatic 2) Primary 3) benign 4) malignant 5) Quasimalignant 6) Tumor-like processes
what is a malignant tumor?
A tumor that may metastasize
What is a quasimalignant tumor?
Giant cell, some are benign, some are malignant
Which types of tumors would you refer to an internist?
Metastasis and multiple myeloma (may go to oncologist/ rheumatologist)
Which types of tumors or conditions would you refer to an orthopedic surgeon?
Primary malignancies, painful benign lesions, lesions with significant risk of complications (pathologic fractures, effect on growth, malignant trasformation) and infection
Which types of tumors would you document and not refer?
Asymptomatic, benign lesions without significant risk of complications
what are the 12 aspects to analyze a lesion?
1) Skeletal location
2) Position within the bone
3) Site of origin
4) Joint changes
5) Shape
6) Size
7) Margination
8) Cortical integrity
9) Behavior of the lesion
10) Matrix
11) Periosteal response
12) Soft tissue changes
when do most mets occur?
In patients >40
when are most primary benign cancers found in patients?
In patients < 30
Are tumors more common in males or females?
Males
Is race usually a helpful differentiation for neoplasms? What is the exception?
No, race is not often helpful with neoplasm, Ewing’s sarcoma is exception since it is less common in blacks
What are some red flags for cancers? (5)
1) weight loss 2)fatigue 3) malaise 4) recurrent infection 5) pain pattern
What are some lab findings found with cancers?
Increased ESR or CRP; changes on CBC; change in serum calcium, phosphorus, alkaline phosphatase, total protein; change in acid phosphatase; protein electrophoresis
Are most neoplasms solitary or non solitary?
most neoplasms are solitary
what are some exceptions to solitary neoplasms?
Mets 2) Multiple myeloma 3)hereditary conditions (hereditary multiple exocytosis, Ollier’s and neurofibromatosis)
Where in the skeleton are typically where more metastatic cancers are found?
Axial skeleton
Where in the skeleton are typically where more primary cancers are found?
Appendicular
what cancers are found in the epiphysis?
Chondroblastoma (start and live in epiphysis) or giant cell tumor (starts in metaphysis and ends up in epiphysis, only type that does that)
what cancers are found in the diaphysis?
Round cell lesions (marrow based)
what cancers are found in the metaphysis?
Everything other than chondroblastoma and round cell lesions
what cancers are found in the vertebral body?
more malignancies
what cancers are found in the posterior elements?
More benign
What is required to differentiate epiphyseal lesions from?
Arthritis
What are two types of epiphyseal lesions?
Chondroblastoma and Giant cell tumor
When are chondroblastoma formed?
Most before growth plate closure
When are giant cell tumors formed?
Most after growth plate closure
What are two types of epiphyseal-metaphyseal lesions?
Aneurysmal bone cyst and giant cell tumors
What is special about aneurysmal bone cysts?
Only benign lesion to cross growth-plate
What is the only type of primary tumor to cross the epiphysis and metaphysis?
Giant cell tumor
In which area of the bone are most lesions found?
Metaphyseal lesions
Why is the metaphysis the most common place for lesions?
1)Most metabolically active region 2)Very vascular region
What are the different types of metaphyseal lesions? (9)
1) Enchondroma
2) Fibrous cortical defect
3) Nonossifying fibroma
4) Osteoid osteoma
5) Osteochondroma
6) Simple bone cyst
7) Chondrosarcoma
8) Fibrosarcoma
9) Osteosarcoma
What are the different types of metaphyseal-diaphyseal lesions? (6)
1) Chondrosarcoma
2) Osteosarcoma
3) Multiple myeloma
4) Osteoid osteoma
5) Non-ossifying fibroma
6) Chondromyxoid fibroma
What kind of tumors are diaphyseal lesions usually?
Mostly marrow related or “round cell” tumors
What are the different diaphyseal lesions? (3)
1) Multiple myeloma
2) Ewing’s sarcoma
3) Non-Hodgkin’s lymphoma
What are the different terms to describe tumor site of origin? (4)
1) Medullary (central or eccentric) 2) Cortical 3) Periosteal 4) extraosseous
Are malignancies larger or smaller?
Malignancies are larger (>6 cm), benign smaller
What is a long lesion in a long bone usually?
Fibrous dysplasia
What are the two types of margination?
Wide zone of transition and narrow zone of transition
What constitutes a wide zone of transition? (3)
1) Hazy or ill-defined margin 2) imperceptible margin 3) aggressive
What constitutes a narrow zone of transition? (3)
1) Distinct or definite margin 2) Sclerotic margin 3) Benign
What are the different descriptors of cortical integrity? (6)
1) Cortical thinning
2) Endosteal scalloping
3) Cortical thickening
4) Cortical expansion
5) Cortical destruction
6) Pathologic fracture
What are the characteristics of a osteolytic lesion? (3)
1) Geographic 2) Moth-eaten 3) permeative
What are the characteristics of a osteoblastic lesion? (4)
1) New bone formation (poorly formed, less strength) 2) Reactive sclerosis 3) Overlying density of periosteal response 4) Sequestrum (necrotic bone)
What is better to assess fat?
CT and MRI
What are the different periosteal responses? (5)
1) Solid 2) Single Layer 3) Laminated 4) Spiculated 5) Codman’s triangle
What are some properties of a benign tumor? (3)
1) Short zone of transition, especially sclerotic margin
2) Single, small lesion
3) Solid periosteal response
What are some properties of a malignant tumor? (6)
1) Cortical destruction (break through outer cortex)
2) Periosteal response
3) Laminated, Codman’s triangle, spiculated
4) Wide zone of transition
5) Soft tissue mass
6) Associated lab changes
What is an age characteristic of benign tumors?
Patient under 30 years old
What size of a tumor is characteric of benign tumors?
Lesion under 6 cm
What type of cortical destruction is characteristic of benign tumors?
No cortical destruction
What type of periosteal response is characteristic of benign tumors?
Solid periosteal response; some laminated or Codman’s triangle;
not spiculated
What type of destruction is characteristic of benign tumors?
Geographic lytic destruction
What type of margination is characteristic of benign tumors?
Sharp margination; especially sclerotic margin
Is there any soft tissue mass associated with benign tumors?
No soft tissue mass
What is an age characteristic of primary malignancy tumors?
All ages (see specific lesions)
What size of a tumor is characteric of primary malignancy tumors?
Lesions over 6cm
How many bones are usually involved with benign and primary malignancy tumors?
A single bone (monostotic)
What type of cortical destruction is characteristic ofprimary malignancy tumors?
Cortical destruction
What type of periosteal response is characteristic of primary malignancy tumors?
Spiculated periosteal response; some laminated or Codman’s
triangle
What type of destruction is characteristic of primary malignancy tumors?
Moth-eaten or permeative lytic lesion
What type of margination is characteristic of primary malignancy tumors?
Indistinct margins
Is there any soft tissue mass associated with primary malignancy tumors?
Soft tissue mass
What is an age characteristic of metastatic tumors?
Patients over 40 years old
How many bones are usually involved with metastatic tumors?
Multiple bones, Polyostotic lesions
What type of cortical destruction is characteristic of metastatic tumors?
Cortical destruction
What type of periosteal response is characteristic of metastatic tumors?
No periosteal response
What type of destruction is characteristic of metastatic tumors?
Moth-eaten or permeative lytic lesions
What type of margination is characteristic of metastatic tumors?
Indistinct margins
Is there any soft tissue mass associated with metastatic tumors?
Occasional soft tissue mass
What is the most common malignant tumors of bone?
Metastasis
How much more common is metastasis than primary malignancies of the bone?
25 X
What % of malignant bone tumors are metastatic?
70%
What are the most common primary sites for metastasis?
sites are breast, lung, prostate, kidney, thyroid, and bowel
What are the target sites of metastasis in the bones?
target sites include axial skeleton, skull, proximal extremities
where is it rare to see metastasis?
Rare distal to knee or elbow; a.k.a. acral metastasis
How common is skeletal metasis?
Skeletal metastasis may be as common as liver or lung mets; 20-35% of all patients with malignancies
Breast, prostate, lung and kidney primaries are responsible for what % of metastasis?
80%
In women, what primary is responsible for 70% of metastasis?
Breast primary in 70% women; thyroid, kidney, uterus common
In men, what primary is responsible for 60% of metastasis?
Prostate primary in 60% men; lung primary in 25%
What % of metastasis are solitary lesions?
10%
What age range are metastasis most common in?
Most patients over 40 years old
What age range are neuroblastoma most common in?
Under age 5
What age range are ewing’s sarcoma or osteosarcoma most common in?
Age 10-20
What age range are Hodgkin’s lymphoma most common in?
Age 20-35
How often is there pain with metastasis?
Pain in 70% (insidious, remission/exacerbation), persistent, nocturnal)
What type of fractures are common with metastasis?
Pathologic fracture
What are some systemic signs of metastasis?
Weight loss, cachexia, anemia, fever in advanced stages but many patients are asymptomatic
With metastasis, when will neurologic symptoms be present?
Neurologic symptoms may be present with spine involvement
How long can it take for metastasis to follow a primary neoplasm?
May follow diagnosis and treatment of the primary neoplasm by 10-15 years
what lab values can be seen with metastasis?
May see increased ESR, serum calcium (lytic), or alkaline phosphatase (blastic)
are lab changes assosciated with metastasis consistent?
Lab changes may be inconsistent and are dependent on type, extent, and fluctuations in activity of tumor
What lab tests should be evaluated with suspected mets?
Patients with suspected mets should be evaluated with ESR, CBC, chem screen and UA
What are the three routes of metastasis?
1) Hematogenous 2) Direct Invasion 3) Lymphatic dissemination
What is the most common route for metastasis?
Hematogenous; most common; usually via veins
what is direct invasion of metastasis?
Direct invasion; soft tissue tumors near bone; uterus to iliac bones; surgical implantation of tumor cells; “downstream” seeding unusual except CNS
What is lymphatic dissemination?
Lymphatic dissemination; unusual, especially to bone
What are the 3 imaging for metastasis?
1) Plain film 2) Computed tomography (CT) 3) Bone scan
which imaging is the first clinical choice for metastasis and how much bone destruction is required to be visible?
Plain film: usually 1st clinical choice; requires 30-50% bone destruction
what is computed tomography used to assess with metastasis?
detects cortical bone involvement and soft tissue mass; limited overall use
What is another name for a bone scan?
syntigraphy
how much bone destruction is required for bone scans to detect it and how is this achieved?
bone scan: demonstrates as little as 3-5% destruction; agent is concentrated in areas of high metabolic activity = “hot spot”; 5% with mets have normal scan
What % of abnormal bone scans have normal radiographs?
40% with abnormal scans have normal radiographs
how early can bone scans detect abnormalities before radiographic changes?
may detect as early as 18 months before radiographic changes
Are bone scans specific?
No, but the full skeleton is evaluated at once
What is MRI for metastasis used for?
Large areas can be evaluated and Changes detected as early or earlier than bone scan
what type of signal intensity is relative to marrow for T-1 weighted images on MRI?
hypointense
what type of signal intensity is relative to marrow for T-2 weighted images on MRI?
Hyperintense
What % of plain film appearance shown are lytic metastatic lesions and how do they appear?
75% of metastatic lesions lytic and they appear as moth-eaten or permeative
What % of plain film appearance shown are blastic metastatic lesions and how do they appear?
15% of metastatic lesions blastic
What % of plain film appearance shown are mixed metastatic lesions and how do they appear?
10% mixed
What is a “blow-out” pattern of metastasis?
large, very expansile, solitary; suggests renal or thyroid primary
What are 5 characteristics of primary malignancy?
1) Expansion of bone
2) Periosteal response
3) Solitary lesion
4) Lesion over 10cm
5) Soft tissue mass
What are 3 characteristics of metastasis?
1) 70% of malignancies
2) 2-4cm lesions
3) Multiple lesions
What % of mets occurs in the spine?
40%
Which areas of the spine are most common for spinal mets?
Thoracic and lumbar most common; atlas is an infrequent site
what are the types of pathologic fractures associated with spinal metastasis?
Pathologic fracture: compression or vertebra plana; malignant Schmorl’s node
Are IVD involved with spinal metastasis?
No, Very rarely involve IVD
what aspect of the vertebra is most commonly affected with spinal mets?
Most commonly affects vertebral body and Most common cause of a missing pedicle is osteolytic mets ddx
What is a missing pedicle also known as?
“winking owl”, “one-eyed pedicle”, “blind vertebra” sign
what are two DDX for a missing pedicle?
osteolytic mets and agenesis
What is an ivory vertebra?
Opaque vertebra
What are the 3 most common causes of ivory vertebra?
1) Osteoblastic metastasis
2) Paget’s disease: cortical thickening, expansion
3) Hodgkin’s lymphoma: anterior body scalloping
What % of skeletal mets affects the ribs and sternum? Are ribs or sternum higher incidence?
28%; ribs 4x incidence to sternum; rib mets most common cause of extrapleural sign
What % of skeletal mets affects the pelvis?
12% and careful evaluation of sacral ala and pelvic brim is needed
What % of skeletal mets affects the skull and are they usually blastic or lytic?
10% to skull: 90% will be lytic; usually well-defined
what % of skeletal mets affects the long tubular bones? Which bones are often affected?
10% to long tubular bones: mostly proximal femur and humerus
Who would you refer a patient with mets to?
Internist referral may be most appropriate and Referral to orthopedic, spine or neurosurgeon may be appropriate for specific bone lesions
what are the management goals of mets? (3)
1) Identify and treat primary neoplasm 2) Identify extent of mets (Bone, lung, liver, brain, kidney, etc) 3) Treat bone mets with biphosphates to inhibit osteoclast activity; radiation therapy to affect bone lesions; surgery to prevent pathologic fracture
What are the 4 most common primary malignancies of bone?
MOCE, 1) Multiple Myeloma 2) Osteosarcoma 3) Chondrosarcoma 3)Ewing’s sarcoma
What age does multiple myeloma usually affect?
50-70 years old
What age does osteosarcoma usually affect?
10-25 years old
What age does chondrosarcoma usually affect?
40-60 years old
What age does Ewing’s sarcoma usually affect?
10-25 years old
What primary neoplasm maskes up 27% of biopsied bone tumors?
Multiple myeloma
What % of 50-70 year olds with primary malignacies have multiple myeloma?
75% and it is rare before 40
Do males or females have a greater chance of multiple myeloma?
Males, 2:1
Where are common sites for multiple myeloma to invade?
Similar to mets sites (axial skeleton) and humeral and femur diaphyses
What are the signs and symptoms of multiple myeloma? (11)
1) Anemia due to proliferating plasma cells
2) Lytic destruction of bones
3) Abnormal serum protein and urinary protein
4) Renal disease
5) BONE PAIN - Pathologic fracture in 20%
6) Weight loss
7) Fever
8) Cachexia
9) Osteoporosis
10) Amyloidosis (10%)
11) Bacterial infections (esp.. respiratory)
What are the characteristics of the bone pain due to multiple myeloma? (4)
1) Intermittent, then continuous, increasing severity 2) Worse during day 3) Aggravated by exercise and weight bearing 4)Often better at night and with rest
What are some laboratory changes found with multiple myeloma? (9)
1) Normocytic, normochromic anemia
2) Thrombocytopenia
3) Elevate ESR
4) Hyperuricemia, hypercalcemia
5) Elevated serum proteins; reversed A/G ratio
6) Protein electrophoresis is diagnostic – “M-spike”
7) Bence Jones protein in urine
8) Rouleaux formation
9) Bone marrow aspirate strongly diagnostic
What is the pathology of multiple myeloma?
Plasma cell neoplasm: “round cell” neoplasm; increased osteoclastic activity
What is myeloma kidney?
precipitation of proteins in tubules; renal failure second most common cause of death
What is secondary amyloidosis?
The deposition of proteins. Found in15%; kidney, heart, GI tract, liver, spleen, rarely joints
What is seen on plain film for multiple myeloma? (3)
1)Multiple, well-defined, round, osteolytic defects; “punched out” defects (80%); some endosteal scalloping; no reactive sclerosis; osteoblastic <3%, except following treatment 2) Severe, generalized osteopenia 3) High incidence of pathologic fracture
What are the most frequent sites for multiple myeloma to be seen on plain films?
Most frequent sites: bones with active hematopoietic tissue; same as metastasis
Are bone scans usually positive with multiple myeloma?
No, Bone scan usually negative– 10% of lesions positive
What advanced imaging is sensitive to marrow changes?
MRI very sensitive to marrow changes
What is the prognosis of multiple myeloma?
Poor prognosis, Palliative care
What is the treatment of multiple myeloma?
Control complications due to excessive protein production and excretion, hypercalcemia, hypercalcuria, hyperuricemia
What is solitary plasmacytoma?
Localized plasma cell neoplasm
Where are the favored sites of solitary plasmacytoma?
Favored sites: mandible, ilium, vertebrae, ribs, proximal femur, scapula
How does solitary plasmacytoma look in plain film?
Geographic, lytic, highly expansile, “soap bubbly”
What does solitary plasmacytoma have a 70% chance of becoming?
70% develop multiple myeloma within 5 years
What is an osteosarcoma?
Undifferentiated connective tissue produces neoplastic osteoid
What are the 5 clinical types of osteosarcoma?
1) Central osteosarcoma 2) Multicentric osteosarcoma 3) Parosteal osteosarcoma 4) Secondary osteosarcoma 5) Extraosseous osteosarcoma
What % of all primary malignancies of bone are osteosarcoma?
20%
What age does osteosarcoma usually affect?
10-25 year old and in older patients it is likely due to malignant degeneration of a benign process
Do males or females have a greater chance osteosarcoma?
Males 2:1
What are some signs and symptoms of osteosarcoma? (5)
1) Painful swelling at site; traumatic determinism common 2) Pain initially insidious and transitory; becomes severe and persistent 3) Systemic signs unusual; possible fever 4) Onset of symptoms to diagnosis often > 6 months 5) Increase alkaline phosphatase
Where is osteosarcoma usually found using plain films?
75% in metaphysis of long bone - Especially distal femur, proximal tibia, proximal humerus and 20% in flat bones
What are the different types of presentations of osteosarcoma on plain films?
50% sclerotic, 25% lytic (permeative); 25% mixed
How does osteosarcoma look like on plain film?
1) Ossification of mass common “cumulus cloud” appearance
2) Cortical disruption; spiculated periosteal response, soft tissue mass
What advanced imaging is used to determine the extent of the lesion in the bone and soft tissues and its relationship to vessels and nerves?
MRI
What are chest CT and bone scans used for with osteosarcoma?
To detect metastasis
Where should osteosarcoma patients be referred?
Referral to pediatric orthopedist or oncologist
Where is a common place for osteosarcoma to metastasize to?
Metastasis to lungs common (“cannonball mets”); also to other bones
What type of osteosarcoma is more aggressive?
Purely lytic lesions more aggressive
What are some treatment options of osteosarcoma? (3)
1) Radiation therapy
2) Chemotherapy
3) Resection; amputation
What type of primary bone malignancy accounts for 1% of primary bone malignancies?
Parosteal osteosarcoma
What is different with parosteal osteosarcoma compared to osteosarcoma?
Slower growing; similar symptoms and sites to central osteosarcoma
What is the age range for parosteal osteosarcoma?
Age range 30-50 y.o.
What is a DDX of parosteal ostesarcoma?
Myositis ossificans
What is seen on plain film for parosteal osteosarcoma?
Dense, juxtacortical mass with stalk to cortex; no periosteal response
What are some characteristics of parosteal osteosarcoma? (3)
1) Stalk attaches to cortex
2) Central portion more dense; periphery less dense
3) Grows over time
What are some characteristics of myositis ossificans? (3)
1) Separated from bone
2) Less dense centrally; periphery of denser cortical bone
3) Smaller over time
What is a secondary osteosarcoma?
Malignant degeneration of a benign lesion such as: – Paget’s disease – Fibrous dysplasia – Osteochondroma – Enchondroma
What is a condrosarcoma?
Tumor of carilaginous matrix
What are the two types of chondrosarcoma?
1) Primary
2) Malignant degeneration
- Enchondroma
- Osteochondroma
What % of primary bone malignancies does chondrosarcoma make up?
10%
What age range is most common for chondrosarcoma?
40-60 y.o. most common; range 20-90
What gender is more common to experience chondrosarcoma?
Males, 2:1
What are some signs and symptoms of chondrosarcoma? (3)
1) Pain; swelling; often very late
2) Symptoms due to mass may be most prominent
3) Duration of symptoms 2 years (75%) to 5 years
Where are chondrosarcoma often found? (3)
1) Any bone preformed in cartilage
– Most commonly pelvis and proximal femur; also proximal humerus, ribs, scapula, distal femur, proximal tibia, craniofacial bones
2) Metaphyseal or diaphyseal; clear-cell in epiphysis (<2%)
3) Most common primary malignancy of hand, sternum, scapula
What are the plain film findings for chondrosarcoma? (4)
1) Large, lytic; poorly defined
2)Calcification in 2/3
– “popcorn”, “stippled”, “arcs and rings”
– More calcification = less aggressive
3) Large soft tissue mass
4) Endosteal scalloping
What is a clear cell chondrosarcoma? (3)
1) Round, sharply marginated lytic lesion in epiphysis
2) May or may not have sclerosis or calcifications
3) Indistinguishable from chondroblastoma
Who would you refer a patient with chondrosarcoma to?
Referral to orthopedist
How is the progression of chondrosarcoma like?
Usually slow progression
What is the survival rate like for chondrosarcoma?
High 5-year survival rate with early treatment
What is the treatment of choice for chondrosarcoma?
Surgical removal is treatment of choice; not radiation
Is mets common for chondrosarcoma?
Mets uncommon
What is Ewing’s Sarcoma?
Marrow cell tumor; “round cell”
What % primary bone malignancies are Ewing’s sarcoma?
7% of primary bone malignancies
What population is Ewing’s sarcoma uncommon in?
Blacks
What age range is Ewing’s sarcoma found in?
10-25 y.o
What gender is more common to experience Ewing’s Sarcoma?
Males 2:1
What are the signs and symptoms of Ewing’s Sarcoma? (3)
1) Localized pain and swelling; local warmth, tenderness, and dilated veins
2) Frequently palpable soft tissue mass
3) Systemic signs include fever, anemia, leukocytosis, increased ESR
– Clinically mimics infection
Where are the favored sites of Ewing’s sarcoma?
1) Long bones (70%) – Femur, tibia, fibula, humerus 2) Diaphysis is classic location 3) Flat bones (25%) – Pelvis, ribs, scapula 4) Spine only 5%
What is seen on plain film for Ewing’s sarcoma?
1) Permeative, usually mixed pattern, wide zone of transition
2) Laminated periosteal response in25-50%
3) Cortical saucerization an early sign
Who do you refer Ewing’s Sarcoma patients out to?
Referral to pediatric
Does Ewing’s sarcoma metastasize?
Yes, Frequent and early skeletal mets
– Most common primary malignant bone tumor to metastasize to bone
Where is the most common metastasis location d/t Ewing’s Sarcoma?
Common metastasis to lungs
How is the prognosis for Ewing’s Sarcoma?
Poor prognosis
– Improved with early diagnosis
What treatment is there fore Ewing’s Sarcoma?
Radiation, chemotherapy, surgical resection / amputation
How common is Fibrosarcoma?
Rare; 2% of primary bone malignancies
What age range is most common for fibrosarcoma?
Most common in 30-50 y.o.; range 4-83 y.o.
Where does fibrosarcoma usually affect?
Usually major long bones
– 50% at knee
What are some common signs and symptoms of fibrosarcoma?
Pain, swelling; average 2 years of symptoms before diagnosis
What are some plain film findings for fibrosarcoma? (3)
1) Highly destructive, expanding, lytic lesion
2) Huge soft tissue mass
3) Usually no periosteal reaction
Does fibrosarcoma metastasize?
Yes, Metastasizes late; to lung, liver, lymph, brain, et al.
What is the prognosis of fibrosarcoma?
Poor prognosis
– Frequent local recurrence (up to 80%)
What is the treatment of choice for fibrosarcoma?
Amputation usually treatment of choice
What is malignant fibrous histiocytoma?
Most common soft tissue sarcoma in adults and in bone, it is indistinguishable from fibrosarcoma and it is made of primitive mesenchymal cells
What areas does malignant fibrous histiocytoma usually affect?
Lower extremity 50%; upper extremity 20%; abdominal cavity, retroperitoneum 20%; intraosseous mc around knee
What is a usual sign of malignant fibrous histiocytoma?
Painless, solid mass usually
Does malignant fibrous histiocytoma metastasize?
Yes, mets to lungs
How common is chordoma?
Rare; 1% of primary bone malignancies
Where do chordomas usually affect?
Since it is notochordal remnant origin – 85% sacrococcygeal or spheno-occipital
What age is most commonly affected by chordoma?
Any age; 40-70 y.o. most commonly
What gender is more common for chordoma?
M:F 2:1
Do chordomas invade surrounding soft tissues?
Yes
Do chordomas metastasize?
No, metastasis is uncommon
Where in the spine do chordomas usually affect?
50% sacrococcygeal
35% in clivus
15% in vertebra, especially C2
What is the only primary malignancy to cross IVD?
Chordoma
What are some plain film findings for chordoma? (4)
1) Lytic destruction
2) Cortical expansion; may increase AP diameter of sacrum
3) Calcification in 50%; 85% on CT
4) Soft tissue mass common
What are some DDX of chordoma?
lytic mets, chondrosarcoma, Giant Cell Tumor, Aneurysmal bone cyst, plasmacytoma
What is non-hodgkin’s lymphoma?
Rare, extranodal lymphoma that Initially appears as solitary bone lesion
What age range is non-hodgkin’s lymphoma usually found in and what gender is it more prevalent in?
20-50 y.o.; M:F 2:1
What is the prognosis of non-hodgkin’s lymphoma?
Prognosis better than most bone primary malignancies
What signs and symptoms are commonly seen with non-hodgkin’s lymphoma? (5)
1) Local, intermittent pain
2) Dull, aching, not relieved by rest
3) Patient generally healthy
4) Over 50% have symptoms > 1 year
5) Often palpable mass or swelling
What areas are most commonly affected by non-hodgkin’s lymphoma?
Femur, tibia, humerus most frequently affected
– Also pelvis, ribs, scapula, vertebrae
What appearance does non-hodgkin’s lymphoma present with?
1) Permeative
2) Minimal periosteal response
3) Soft tissue mass
4) Pathologic fracture very common
What is hodgkin’s lymphoma of bone?
Usually secondary to systemic Hodgkin’s
– 10-20% of patients with Hodgkin’s develop skeletal involvement; rarely primary in bone
What is the most common symptom of hodgkin’s lymphoma?
Pain most common symptom
What is the most common site of hodgkin’s lymphoma?
Most common in vertebral body
– “Ivory vertebra” (ddx blastic mets, Paget’s)
– Anterior scalloping possible
What are the different presentations of hodgkin’s lymphoma?
75% lytic; 15% sclerotic; 10% mixed
Is there usually single or multiple tumors wity hodgkin’s lymphoma?
Polyostotic in 2/3
What is a presentation of hodgkin’s lymphoma? (2)
1) Lytic in tubular bones
2) Possible exuberant periosteal response
Is synovial sarcoma common?
Uncommon
– 8-10% of soft tissue sarcomas
What age does synovial sarcoma usually affect?
30-50 y.o.
What are the common symptoms of synovial sarcoma?
Pain; soft tissue mass arising from juxtaarticular soft tissues
What are the most common places to find synovial sarcoma?
Knee, hip, ankle most common
What are some plain film findings of synovial sarcoma? (2)
1) Calcification in 1/3; fine, granular
2) Secondary bone destruction in only 10-20%; erosive changes from extrinsic pressure
What is the most useful advanced imaging for synovial sarcoma?
MRI
What is the treatment for synovial sarcoma?
Treatment: excision, radiation
What is the prognosis for synovial sarcoma?
Moderately good prognosis
