Bone tumors Flashcards
When is the bone malignancy metastatic and when is it primary?
1) Metastatic in adult age group
2) Primary in pediatric age group
Describe bone tumor
- It is the growth of abnormal cells in the bone that does not fulfill a function
- It forms 0.2% of human tumor burden
- Primary malignant bone tumors makes 1% of all malignant tumors
What are the different classification of bone tumors?
- Based on the tissue of origin:
1) Bone
2) Cartilage
3) Fibrous tissue
4) Bone marrow
5) Blood vessels
6) Mixed
7) Uncertain origin
How do we diagnose bone cancer?
1) History
2) Physical examination
3) Investigations (Series of plain X-rays, biopsy, etc)
How do we evaluate bone neoplasm?
1) Age
2) Sex
3) Morphology of the tumor (border, bone destruction, periosteal reaction, matrix, soft tissue mass)
4) Single or multiple
5) Location of the tumor (which bone & where in the bone)
How do we evaluate bone cancer?
1) Gait (for example limping is caused by a compression to the common peronial nerve)
2) Observe mass, swelling or any deformity
3) Palpate (tender, cold, warm, fluctuant)
4) NV exam
5) Lymph node examination
6) Abdominal exam for masses
What causes the pain in bone tumors?
1) Weakening of the bone (due to imminent fracture, pathological fracture, bone destruction)
2) Exerting local pressure on the periosteum, surround soft tissue, or nerves
How to evaluate a lump/swelling?
1) Site
2) Size
3) Shape
4) Skin cover
5) Recent changes
6) Mobility
7) Tenderness
What is meant by effusion?
It is the collection of fluid in the joint, and its clinical presentation (limitation of movement)
- It is one of the clinical pictures of bone tumors
What are some of the signs that the tumor has metastasized?
1) Pathological fracture
2) Spinal instability
3) Spinal cord compression (bowel & bladder dysfunction)
4) Metastatic organ function (dyspnea to lung metastasis)
What characterizes a pathological fracture?
1) Large lytic lesions
2) Weak bone (with varying densities in the site of fracture)
3) Sclerotic borders
What are the bone tumors characterized for children and young adults?
1) Primary osteosarcoma
2) Ewing’s sarcoma
Is chondrosarcomas common in children and middle age patients?
NO
What is the commonest skeletal malignancy in ppl over 40?
Metastatic cancer
- Multiple myeloma
- Chondrosarcoma
What is meant by giant cell tumor?
- Locally aggressive lesions in the epiphysis
- It has a lucrative structure
- Occurs exclusively in skeletally mature patients (20-50 yrs, with closed epiphysis)
What pathologies can give all types of X-rays (Well-defined, ill-defined, & sclerotic)?
Bone Infection
What is the importance of the location of the tumor?
Some tumors almost exclusively occurs at specific sites
1) Central or eccentric
2) Cortex or medulla
3) Epiphysis, metaphysis or diaphysis
In which location is chondroblastoma most common?
1) <30 years epiphysis
Why do we need a plain radiograph?
1) Cheap
It yields:
1) Bone maturity
2) Site of lesion (epiphysis, metaphysis, or diaphysis)
3) Border of lesion (sharp, narrow zone of transition)
4) Type of bone destruction (geographic, moth-eaten, permeative)
5) Periosteal reaction (interrupted or solid)
6) Matrix of the lesion
7) Nature and extent of soft tissue involvement
8) Cortical changes
What are the questions that follows a radiographic examination?
1.Does the tumor have a well-defined margin?, Is there a rim of sclerotic bone? The presence of a well-defined margin and a sclerotic rim strongly suggests a benign non-growing lesion
- Is there evidence of significant cortical expansion or destruction? These findings are seen with locally aggressive or malignant tumors
- Is there an associated periosteal reaction and, if so, of what type?
- Does the lesion produce mineralized matrix (osteoid or cartilage)?
- Is there a soft tissue mass?
In which location is NOF (non-ossifying fibroma) most common?
1) <30 years, cortex of the diaphysis of the bone
In which bone location is ABC (Aneurysmal bone cyst) most common?
1) <30 years, Cortex in the metaphysis
In which bone location is SBC (Simple bone cyst) most common?
1) <30 years, Medulla of the diaphysis
In which bone location is Giant cell most common?
1) >30 years, epiphysis of the bone
In which location is osteosarcoma most common?
1) <30 years, metaphysis-diaphysis of the bone
Which two pathologies can occur in any location in the bone?
Lymphoma and infections
Which lesions are most common in the metaphysis of the bone?
1) Non-ossifying fibroma (NOF)
2) Osteoid osteoma
What are the lesions most common to the diaphysis intramedullary region?
1) Ewing’s sarcoma (long bone diaphysis lesion, <30 years, eccentric)
2) Lymphoma
3) Myeloma
4) Fibrous dysplasia
5) Enchondroma
What are the common metaphyseal intramedullary lesions?
- Malignant:
1) Osteosarcoma
2) Chondrosarcoma (pelvis bone tumor)
- Benign:
1) Enchondroma (in the phalanges)
2) Fibrous dysplasia
3) Simple bone cyst
4) Aneurysmal bone cyst
Tumors in the epiphysis of long bones are mostly what?
1) Giant cell tumor
2) Chondroblastoma
What does the size of a lesion suggest?
The greater the size of a lesion the more likely for it to be malignant
How to investigate the border of a tumor?
1) If it has a Narrow zone of transition (lesion is clear) it is most probably benign
2) Lesions with a wild zone of transition (difficult to see where the lesion started and where it ends) it is most likely to be malignant
If the lesion invaded the periosteum it is most probably what type of lesion?
Osteosarcoma (mostly with wide zone of transition)
What is the periosteal response?
- Bones respond to lesions by making new bone
1) If the margins are sclerotic and the periosteum is orderly formed and remodeled then it is a good sign (as the tumor grows slowly)
2) If the periosteum is necrotic (rapidly growing tumor behind it), and it has a poorly organized new bone then it is a bad sign
SOLID - LAMELLATED - SPICULATED (sunburst is seen here) - CODMAN’S TRIANGLE (most malignant, due to the elevation of the periosteum to degree that breaks it)
Describe the stages in the periosteal response
1) Periosteal elevation (due to occult osteoid osteoma)
2) Multilaminated periosteal reaction (acute osteomyelitis)
3) Sun-burst (rxn in osteosarcoma)
What type of periosteal reaction is evoked by a slow growing tumor?
Focal cortical thickening (buttress), leading to the sunburst effect
What is suggested if the cortex is eroded?
It suggest that the lesion is malignant
What are the different types of matrixes produced by a lesion?
1) Soft tissue matrix (most tissue have a soft tissue matrix, it is radio-lucent “lytic” on X-ray)
2) Cartilage matric (calcified rings, arcs, dots)
3) Osteoid matrix (increase radio-density)
What are some examples of cancers that forms a bony matrix?
1) Osteoid osteoma (in the cortex of the diaphysis)
2) Osteosarcoma
What are the different cartilage forming cancers?
1) Osteochondroma
2) Chondroblastoma (in the medulla of the epiphysis)
3) Enchondroma (eccentric just below the metaphysis)
4) Chondrosarcoma (>30 years in the medulla of the diaphysis below the metaphysis)
What is suggested if there is a soft-tissue mass involved in a tumor?
A aggressive malignant tumor
What are the management steps taken when expecting cancer?
1) Lab work: (CBC, ESR, PH, Etc)
2) Biopsy
How to treat benign tumors?
1) If it is a simple bone cyst like NOF, then you can inject it with intralesional injection no need for a surgery
2) If symptomatic: Excision, curettage, maybe bone grafting
How to treat aneurysmal bone cyst?
1) Open reduction
2) Internal fixation
3) Curettage
4) Bone grafting
How to treat sarcoma?
1) Surgery
2) Chemotherapy chemotherapy is controversial, if it was metastatic then we must also do chemotherapy
If it was soft-tissue
