Bone + Soft Tissue Tumours Flashcards
1
Q
Malignant primary bone tumours presentation
A
• PAIN!!!
○ INCREASING - IMPENDING # (esp. in lower limb) ○ UNEXPLAINED ○ DEEP-SEATED BORING ACHE/NATURE ○ NOCTURNAL/NIGHT PAIN; WORSE at NIGHT ○ ANALGESIA eventually INEFFECTIVE ○ NON-MECHANICAL/UNRELATED to EXERCISE
* DIFFICULTY WGT. BEARING * DEEP SWELLING ○ 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 * JOINT EFFUSION * LOSS of FUNCTION ○ LIMP = esp. CHILD & YOUNG PT. ○ REDUCED JOINT MOVEMENT ○ STIFF BACK = esp. CHILD & YOUNG PT. • PATHOLOGICAL # - e.g. # in unexpected pt., # in unexpected place, # not improving/deteriorating ○ MANY CAUSES = OSTEOPOROSIS COMMONEST, PRIMARY BONE TUMOUR (BENIGN/MALIGNANT) is ONE of the RAREST ○ MINIMAL TRAUMA + Hx of PAIN PRIOR to # • DEFORMITY - e.g. fixed flexion deformity of knee * NEUROVASCULAR EFFECTS * SYSTEMIC EFFECTS of NEOPLASIA • May be ASYMPTOMATIC
2
Q
Malignant primary bone tumours investigations
A
- X-RAYS = BONE DESTRUCTION, NEW BONE GROWTH, PERIOSTEAL ELEVATION/REACTION, SOFT TISSUE SWELLING
- MRI○ INVESTIGATION of CHOICE = V. SENSITIVE
○ V. GOOD for showing:§ INTRAOSSEOUS (INTRAMEDULLARY) EXTENT of TUMOUR § EXTRAOSSEOUS SOFT TISSUE EXTENT of TUMOUR § JOINT INVOLVEMENT § SKIP METASTASES § EPIPHYSEAL EXTENSION
○ DETERMINES RESECTION MARGINS
- MRI○ INVESTIGATION of CHOICE = V. SENSITIVE
3
Q
Malignant primary bone tumours management
A
- CHEMOTHERAPY
- SURGERY○ LIMB SALVAGE poss. For MOST CASES = response to chemotherapy
○ Consider NEUROVASCULAR STRUCTURE INVOLVEMENT = may result in limb salvage not being poss.
○ PATHOLOGICAL #s
○ POORLY PERFORMED BIOPSY
○ Get clear margin of normal tissue ~ tumour (ideally want fascia ~ it - try to balance tumour removal > preserving function), if tumour disturbed - will recur; no surgery unless extent of tumour known - RT - post-op
- MDT = RADIOLOGISTS, ONCOLOGISTS, SURGEONS, PLASTICS etc.
- SURGERY○ LIMB SALVAGE poss. For MOST CASES = response to chemotherapy
4
Q
Osteosarcoma
A
COMMONEST PRIMARY MALIGNANT BONE TUMOUR in YOUNGER PT.
○ PEAK AGE INCIDENCE: 10 - 25yrs ○ METAPHYSES of LONG BONES esp. ~ KNEE ○ 2ndary OSTEOSARCOMA may appear in bone affected by PAGET'S DISEASE/AFTER IRRADIATION ○ MANAGEMENT: NEOADJUVANT CHEMOTHERAPY + SURGERY
5
Q
Myeloma
A
COMMONEST PRIMARY MALIGNANT “BONE” TUMOUR in OLDER PT. = BONE PROBLEMS + MULTIPLE LYTIC LESIONS + -VE ISOTOPE BONE SCANS as plasma cells are affected not osteocytes
6
Q
Chondrosarcoma
A
MORE COMMON as its INCIDENCE INCREASES W/ AGE
○ PEAK AGE INCIDENCE: 45 - 60 yrs ○ Can arise by itself/from malignant transformation of chondromas ○ AXIAL SKELETON ○ X-RAY: POPCORN CALCIFICATION typical MANAGEMENT: SURGICAL EXCISION; DON'T RESPOND to CHEMOTHERAPY/RT
7
Q
Ewing’s sarcoma
A
V. AGGRESSIVE BONE TUMOUR
○ PEAK AGE INCIDENCE: 10 - 18 yrs ○ MALIGNANT ROUND CELL TUMOUR = LONG BONES typically DIAPHYSIS & LIMB GIRDLES ○ MANAGEMENT: CHEMOTHERAPY + RT + SURGERY
8
Q
Metastatic bone disease sites in order of freq. for all secondaries
A
○ VERTEBRAE > PROXIMAL FEMUR > PELVIS > RIBS > STERNUM > SKULL
• BONE MOST COMMON SITE for SECONDARY, AFTER LUNG & LIVER (bony met much more common that primary tumour esp. > 50yrs)
9
Q
7 commonest primary cancers that metastasise to bone
A
1st 4 much more common
1. LUNG = SMOKER, CXR, SPUTUM CYTOLOGY 2. BREAST = COMMONEST, EXAMINE 3. PROSTATE = OSTEOSCLEROTIC SECONDARY, DRE, PSA 4. KIDNEY = SOLITARY, VASCULAR, IV/CT PYELOGRAM + USS, ANGIOGRAPHY & EMBOLISE 5. THYROID = esp. FOLLICULAR CANCER, EXAMINE 6. GI TRACT = FOB/FIT, ENDOSCOPY, BARIUM STUDIES, MARKERS 7. MELANOMA = EXAMINE NEUROBLASTOMA of ADRENAL MEDULLA = AETIOLOGY < 4yrs
10
Q
Prevention of pathological #
A
• EARLY CHEMOTHERAPY/DXT
• PROPHYLACTIC INTERNAL FIXATION: ○ LYTIC LESION + INCREASING PAIN &/or ○ ≥ 2.5 cm DIAMETER &/or ○ ≥ 50% CORTICAL DESTRUCTION ○ BETTER w/ MIREL'S SCORING SYSTEM ○ For LONG BONE METS = generally easier for surgeons & less traumatic for pt. * ± USE of BONE CEMENT (not significantly affected by DXT) * EMBOLISATION esp. THYROID, RENAL - WAIT 48hrs BEFORE SURGERY (RENAL may BLEED PROFUSELY) * ONLY 1 LONG BONE AT A TIME - may present w/ both femurs * AIM for EARLY PAINLESS WGT.-BEARING + MOBILISATION * # of NON-WGT.-BEARING SKELETON (e.g. humerus) can be TREATED CONSERVATIVELY, but RE# FREQ.
11
Q
Pathological # management
A
• METASTATIC PATHOLOGICAL # RARELY UNITE, EVEN IF STABILISED
○ HIGH FAILURE RATE = fixation of pathological #/lytic lesions - esp. ~ hip/proximal femur ○ LOW FAILURE RATE - cemented standard/tumour hip prostheses ○ NEVER RUSH to FIX PATHOLOGICAL # = TRACTION/SPLINTAGE will suffice while INVESTIGATIONS performed & SURGICAL INTERVENTION discussed w/ LEAD CLINICIAN for metastatic bone disease (MBD) & other appropriate colleagues ○ SPINAL METS = when surgery indicated, BOTH DECOMPRESSION & STABILISATION generally req. ○ SPINAL & APPENDICULAR CONSTRUCTS should both ALLOW IMMEDIATE WGT.-BEARING + aim to LAST PT.' LIFETIME ○ RADICALLY EXCISE SOLITARY RENAL METASTASES where poss. ○ EACH TRAUMA GROUP REQ. LEAD CLINICIAN for MBD ○ TREATMENT w/I CONTEXT of MDT
assessment via mirel’s scoring system (> 8 - prophylactic fixation recommended prior to RT)
12
Q
Cartilage tumours presentation
A
- DEEP (i.e. DEEP to DEEP FASCIA) TUMOURS of ANY SIZE
- S/C TUMOURS > 5cm
- RAPID GROWTH, HARD, INDURATED, CRAGGY, NON-TENDER/PAINLESS MASS
- ANY RECURRENT MASS
○ RAPIDLY GROWING ○ HARD, FIXED, CRAGGY SURFACE, INDISTINCT MARGINS ○ NON-TENDER to PALPATION but ASSOC. w/ DEEP ACHE, esp. WORSE at NIGHT ○ BEWARE = may be PAINLESS ○ RECURRED AFTER PREVIOUS EXCISION
13
Q
Cartilage tumours referral algorithm
A
ALL PT. w/ SOFT TISSUE TUMOUR SUSPECTED of being MALIGNANT = should be REFERRED to SPECIALIST TUMOUR CENTR
* IS THE MASS DEEP-SEATED? * IS THE MASS > 5 cm? * IS THERE OTHER EVIDENCE of MALIGNANCY? e.g. rapid growth, firm consistency ○ IF YES TO ANY QUESTION = REFER to SPECIALIST ○ IF NO TO ANY QUESTION = CONTINUE ALONG ALGORITHM, LAST QUESTION ELICITS NO = ASK PT. to RETURN if MASS INCREASES in SIZE/OTHER SYMPTOMS DEVELOP
14
Q
Cartilage tumours investigations
A
MRI
15
Q
Cartilage tumours management
A
- SURGICAL EXCISION w/ WIDE MARGINS + ADJUVANT RT
- ADJUVANT CHEMOTHERAPY w/ DOXORUBICIN may be appropriate
- CHILDREN: often respond well to CHEMOTHERAPY
