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Clin Med III: MSK > Bone Tumors > Flashcards

Bone Tumors Flashcards

1
Q

2 types of bone tumors

A
  1. primary: from bone cells
  2. secondary: mets from breast, prostate, lungs, thyroid & kidneys
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2
Q

what genes normally help cells grow and divide / help cells stay alive

A

Proto-oncogenes

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3
Q

what two “benign” bone tumors weaken the bone?

A
  1. Osteoid osteoma
  2. Osteochondroma
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4
Q
  • Dull ache
  • Worse with activity
  • Progresses over time
  • +/- soft tissue mass firmly attached to bone
  • Constitutional sx are late findings (mets)

what type of bone tumor

A

malignant

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5
Q

initial imaging study of choice for bone tumors?

A

XR

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6
Q

on XR

  • Well-defined or sclerotic border
  • Sharp zone of transition
  • Small size or multiple lesions
  • Confinement by natural barriers (eg, growth plate, cortex)
  • Lack of destruction of cortex
  • Lack of extension into soft tissue

what type of bone tumor?

A

benign

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7
Q

characteristics of a malignant bone tumor on XR

A
  • Poorly defined borders
  • Cortical destruction (“moth-eaten” or permeative pattern)
  • Spiculated or interrupted periosteal reaction
  • Extension into the soft tissue
  • Large size
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8
Q

A benign, well-defined, expansile lesion with regular destruction of cortical bone and a peripheral layer of new bone.

A

Chondromyxoid fibroma

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9
Q

A locally aggressive lesion w/ cortical destruction, expansion and a thin, interrupted peripheral layer of new bone.

A

Giant cell tumor

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10
Q

other w/u for bone tumor after XR

A
  1. CT scan - Best for assessing metastatic disease in thorax
  2. MRI - Determines tumor size, extent of intraosseous and extraosseous involvement, Add contrast for bx
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11
Q

Cartilage-forming tumors

A
  1. Osteochondromas
  2. Enchondroma
  3. Chondroblastoma
  4. Fibrous lesions
  5. Cystic tumors
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12
Q

osteoid osteoma is an overgrowth of bone tissue arises from ?

A

osteoblasts

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13
Q

osteoid osteoma MC where on the bone?

A

In long bones - femur MC

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14
Q

As bone tissue proliferates, a _____ is formed

osteoid osteoma

A

nidus surrounded by sclerotic bone

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15
Q

a centrally located disorganized mixture of small blood vessels, trabecula (tiny rods of bone), and osteoid (unmineralized bony tissue)

A

Nidus

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16
Q

The nidus secretes _____ leading to the pain associated with this tumor

A

prostaglandins

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17
Q
  1. Localized, deep, constant, aching pain
    - Worse at PM, waking patient up; occasionally worse with activity and ETOH use1
    - Improves with NSAID or ASA
  2. +/- palpable mass, tenderness overlying the lesion, neurologic symptoms
  3. Atypical juxta-articular presentation
    - Pain in joint (hip - MC) with walking with limp
    - Referred pain to the knee
A

osteoid osteoma

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18
Q

w/u for osteoid osteoma

A
  1. XR
  2. CT w/ IV contrast - preferred imaging following XR
  3. Radionuclide Scanning (aka Bone Scan)
  4. MRI with gadolinium
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19
Q

osteoid osteoma findings on XR?

A
  1. sclerosis around a lucent nidus (< 1.5 cm)
  2. Varying presentations
    - Calcified nidus = radiopaque point called the bell
    - Nidus close to bone surface may appear like fx
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20
Q

indications for CT w/ Contrast for osteoid osteoma?

A
  1. X-ray appears abnormal, but nidus isn’t visible
  2. Residual or recurrent tumor is present
  3. Tumor in a critical area - Spine, Femoral neck
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21
Q
  1. Indicated when XR is normal
  2. More sensitive > XR

what imaging for osteoid osteoma?
what is the diagnostic finding?

A
  • Radionuclide Scanning (aka Bone Scan)
  • “Double density”
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22
Q
  • Less accurate < CT d/t reactivity of bone from edema surrounding lesion
  • Often used to assess cases not confirmed by XR or CT
A

MRI with gadolinium

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23
Q

mgmt for osteoid osteoma

A
  • OTC tx, serial imaging q 4-6 mo
  • symptomatic / uncontrolled - refer, surgical intervention - Resection vs radiofrequency ablation vs cryotherapy; Removal of nidus
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24
Q

T/F: osteoid osteomas can resolve spontaneously over several years

A

T

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25
Q
  • Morphologically and genetically similar to osteoid osteoma
  • slow growing
  • May be more aggressive = more bony and soft tissue destruction
  • Nidus > 2 cm²

dx?

A

osteoblastoma

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26
Q

osteoblastoma MC location?

A

Posterior column of spine → spinous process, lamina, and pedicles

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27
Q
  1. Chronic pain (dull and achy) → Unrelieved by NSAIDs
  2. sx dependent on tumor location
    - LE → limp
    - Spinal cord/nerve root compression → limp or neurologic sx
    - Spine → scoliosis
  3. Rarely any systemic sx
A

osteoblastoma

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28
Q

w/u and findings for osteoblastoma

A
  1. XR - Well-circumscribed radiolucent lesion (nidus) > 2 cm; Thin shell of peripheral new bone separating it from surrounding soft tissue; Spinal lesions extend into soft tissue
  2. CT - indicated for all osteoblastoma
  3. MRI
  4. Bx - core needle vs open bx
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29
Q

mgmt for osteoblastoma

A
  1. surgical resection - Curettage and burring followed by bone grafting; Marginal resection
  2. +/- Post-surgical radiation if entire lesion can not be resected
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30
Q

when is marginal resection performed for osteoblastoma?

A
  1. Reserved for more aggressive tumors
  2. Results in more healthy bone being removed
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31
Q

prognosis for osteoblastoma

A
  1. Reported recurrence rate 10-20%
  2. relapse associated w/ inadequate resection of primary lesion - Some lesions may not be able to be fully resected due to location (i.e. spine)
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32
Q
  1. MC solitary, benign bone tumor
  2. Benign, cartilage-capped bony projection on the external surface of a bone - Osteocartilaginous exostosis
  3. Males > females
  4. MC present in 2nd decade
A

OSTEOCHONDROMA

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33
Q

osteochondroma MC happens where?

A
  • knee and proximal humerus
  • Other common sites: pelvis and scapula
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34
Q

osteochrondroma occurs adjacent to what layer/part of the bone?
when does tumor stop growing?

A
  • epiphyseal growth plate
  • when growth plates close
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35
Q

causes of osteochondroma

A
  1. Solitary tumors – unknown
  2. Hereditary multiple osteochondromas (HMO)
    - genetic mutation in tumor suppressor genes EXT1 or EXT2
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36
Q
  • MC asx and found incidentally on imaging
  • Painless mass near a joint or on axial skeleton
  • Mechanical sx - Bursitis over exostosis; Irritation to tendons, muscles, or nerves
  • Painful mass assoc w/ local trauma
  • Growth plate dysfunction - Varus or valgus deformity; Shortening of long bone
A

osteochondroma

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37
Q

w/u for osteochondroma and findings?

A
  1. XR - Bone spur that extends away from joint
  2. CT/MRI - further assess lesions not defined on XR (Pelvis, scapula, spine)
    - Helps with localization and surgical planning
    - MRI preferred if looking at soft tissue
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38
Q

mgmt for osteochondroma

A
  1. Asx - No intervention, annual w/ clinical exam; any change → MRI
  2. Surgical excision
  3. Refer to orthopedic oncology if surgical excision is considered
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39
Q

Surgical excision indications for osteochondroma

A
  • Large lesion, associated with deformity and functional limitations
  • Concern malignant transformation
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40
Q

complications of osteochondroma

A
  1. < 1% risk of chondrosarcoma
    - Higher risk in HMO
    - Suspected if: New onset growth of lesion, New onset pain, Rapid growth of lesion
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41
Q

prognosis of osteochondroma

A
  1. Solitary osteochondromas
    - Excellent local control w/ surgical excision
    - recurrence rate < 2%
  2. Hereditary multiple osteochondromas
    - Monitor for growth defects and neuro changes (spinal lesion)
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42
Q
  • A benign cartilage forming tumor that develops in bone marrow of long bones
  • Lesions replace normal bone with hyaline cartilage
A

enchondroma

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42
Q

enchondroma growth occurs where on the bone?

pathophys

A

from metaphysis into diaphysis

Theory: lesion arises in growth plate d/t failure of downregulation of growth plate chondrocytes

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43
Q

enchondroma MC occurs where?

A
  • MC – hands and feet
  • Other sites: Humerus, Femur, Tibia, Ribs
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44
Q
  • A non-hereditary, acquired genetic mutation resulting in multiple enchondromas, often with a unilateral predominance
  • Usually presents before age 10
A

Enchondromatosis

45
Q

s/s of enchondroma

A
  • MC asx
  • Widening of the bone, Angular deformity, Limb-length discrepancy
  • Pain from pathologic fx MC in wt bearing bones
46
Q

w/u for enchondroma

A
  1. XR
  2. Bone scan - Test negative if uncomplicated; Areas of activity = pathologic fx or malignant dx (chondrosarcoma)
  3. CT/MRI - r/o ddx of chondrosarcoma or bone infarct
  4. Bx - If painful w/o fracture = r/o chondrosarcoma
47
Q

XR findings of enchondroma

A
  1. Centrally located
  2. Round or oval
  3. Well circumscribed
  4. Sclerotic border
  5. Lobulations are often seen inside the lesion
48
Q

mgmt for enchondroma

A
  1. Small, asx- Monitor w/ exam and imaging
  2. Sx/pathological fx risks - Curettage & bone grafting
    - heal fx before curettage
49
Q

Pathologic Fx Risk Factors

A
  1. wt bearing bone
  2. > 25 mm in diameter
  3. Involving > 50% of diameter of cortex
50
Q

prognosis of enchondroma

A
  1. Solitary: self-limiting, continued growth possible
  2. Recurrence rare after curettage & graft
  3. long bones & pelvis: can transform into chondrosarcomas
    - Rare in solitary lesions
    - 50% of enchondromatosis
51
Q

A benign cartilage-forming tumor that usually arises in the epiphyses or apophyses of long bones

A

CHONDROBLASTOMA

52
Q

chondroblastoma MC sites?

A
  1. Epiphysis of proximal humerus
  2. Distal femur
  3. Proximal tibia
53
Q

s/s of chondroblastoma

A
  • Chronic pain - mild and progressive; constant and unrelated to activity
  • Joint stiffness and swelling
  • Localized tenderness
  • Dec ROM
  • Joint effusion
  • Muscle atrophy
  • Limp in wt bearing lesions
54
Q

XR finding of a small, well-defined lesions with sclerotic border that may cross the physis (growth plate)

dx?

A

chondroblastoma

55
Q

tx for chondroblastoma

A

surgery - curettage and bone grafting

56
Q

complication of chondroblastoma?

A

Benign pulm mets

  • CXR in all; follow w/ CT w/ IV contrast if any suspicious areas are present
  • resectable and curable
57
Q
  • Abnml fibrous tissue and trabecular bone replaces nml bone marrow and bone tissue = bone weakness
  • Resulting in Fx or deformity
  • Lesion is slow growing and often appears during periods of bone growth
A

fibrous dysplasia

58
Q

associated genetic condition with fibrous dysplasia?

A

McCune-Albright Syndrome

Polyostotic lesions, ipsilateral café-au-lait spots, precocious puberty

59
Q

common sites for fibrous dysplasia

A
  1. Proximal femur
  2. Tibia
  3. Skull/maxilla
  4. Ribs
60
Q

s/s of fibrous dysplasia

A
  • MC asx
  • Pain/tenderness as fibrous tissue expands into bone or fx happens
  • Bone deformity - Shepherd’s Crook, Scoliosis, leg length discrepancy, Facial asymmetry
  • Rib deformities
  • Swelling
  • Waddling gait
61
Q

XR shows Lytic lesion with “ground-glass” appearance

dx?

A

fibrous dysplasia

62
Q

indications to use bone scan for fibrous dysplasia?

A

r/o polyostotic disease

63
Q

tx fibrous dysplasia

A
  1. asx - monitor w/ serial exams and imaging
  2. Curettage & bone grafting; recurrence HIGH
    - Avoided in peds: high rate of recurrence
  3. IV bisphosphonates
  4. Rigid fixation w/ intramedullary implant
  5. Refer to endo if polyostotic lesions present
64
Q

A destructive, deforming, slow growing benign fibro-osseous lesion

A

ossifying fibroma

65
Q

MC sites for ossifying fibroma

A
  • tibia and fibula - < 10 y/o – peaks 1-5 y/o
  • mandible - adults
66
Q

s/s of ossifying fibroma

A
  • Localized, firm swelling
  • Tibia bowed anteriorly or anterolaterally
  • painless
  • Pain - associated with pathologic fx
67
Q

XR finding of ossifying fibroma

A
  • Well-circumscribed intracortical lesion
  • Cortex expanded and thinned, with multiple radiolucencies (lytic appearing)
68
Q

tx for ossifying fibroma

A
  1. Asx - monitored, repeat imaging q 6 mo
  2. Resection, curettage & bone grafting after skeletal maturity
    - curative
    - performed before: risk of recurrence
69
Q
  • benign, non-aggressive tumor that consists mainly of fibrous tissue
  • MC benign bone lesion in children
A

nonossifying fibroma

70
Q

MC sites for nonossifying fibroma

A
  • Distal femur
  • distal and proximal tibia
71
Q

s/s of nonossifying fibroma

A
  • MC asx
  • Larger lesions = bone weakness = fx
72
Q

XR for nonossifying fibroma

A
  1. Small, well-defined, eccentric, lytic lesions
  2. MC distal diaphysis/metaphysis
  3. Sometimes multiple lesions may occur
73
Q

tx nonossifying fibroma

A
  1. Asx small - none
  2. Indications for curettage and grafting:
    - Lesions > 50% of bone diameter
    - Lesions in high stress area (distal femur)
74
Q
  • simple bone cysts or solitary bone cysts
  • Non-cancerous fluid filled lesions with fibrous lining
A

unicameral bone cysts

75
Q

MC sites for unicameral bone cysts

A
  1. Proximal humerus
  2. Proximal femur
76
Q

s/s unicameral bone cysts

A
  1. Asx until pathologic fx - pain, limp, or inability to use extremity
  2. Lesions occurring within a growth plate - growth plate dysfunction & limb length discrepancy
77
Q

XR:
* Well defined, cystic lesions at metaphysis or metadiaphysis
* involves entire diameter of bone
* Pathologic fx - “fallen leaf” or “fallen fragment” sign

dx?

A

unicameral bone cysts

78
Q

tx for unicameral bone cysts

A
  1. resolution after skeletal maturity
  2. Asx - Observe w/ serial XR q 4-6 mo; Activity restrictions
  3. risk of fx - Cyst Aspiration and injection of methylprednisolone or bone marrow
  4. Curettage & bone grafting - for larger cysts that compromise the structural integrity of bone
79
Q
  • A benign, rapidly growing and destructive blood-filled lesion
  • Lesions are usually solitary
  • Females > males
  • MC in adolescents
A

aneurysmal bone cyst

80
Q

MC sites for aneurysmal bone cysts

A
  1. Tibia
  2. Femur
  3. Posterior vertebral elements
  4. Pelvis
  5. Humerus
  6. Fibula, foot, hand, ulna, radius
81
Q

s/s of aneurysmal bone cysts

A
  1. Localized pain, tenderness & swelling
  2. Limp if wt bearing bone is affected
  3. Lesions in spine = neuro s/s
  4. Lesions at growth plate = stunt growth
82
Q

XR shows:
* Aggressive, expansile, lytic metaphyseal lesion with sharp borders
* “Eggshell” sclerotic rim
* “Soap bubble”

dx?

A

aneurysmal bone cysts

83
Q

tx for aneurysmal bone cysts

A
  1. Excision, curettage & bone grafting
    - Adjuvant chemical cauterization or cryotherapy
  2. Selective arterial embolization before surgery
    - angiography to locate feeding artery to cyst
    - Insert object (spring/foam) into feeding artery to create an emboli
84
Q

MC malignant bone tumor
Arise from an overgrowth of malignant osteoblasts

A

osteosarcoma

85
Q

MC sites for osteosarcoma

A

metaphysis of long bones

  1. Distal femur
  2. Proximal tibia
  3. Proximal humerus
86
Q

2 peaks in incidence of osteosarcoma?

A
  1. Early adolescents
  2. Adults over 65 y/o
87
Q

RF for osteosarcoma

A
  1. h/io irradiation or chemotherapy
  2. Paget disease, fibrous dysplasia, and other benign bone lesions
  3. Genetic predisposition
88
Q

s/s osteosarcoma

A
  1. Pain & swelling - 1st and MC
    - worsened w/ activity
  2. Palpable mass
  3. Limping if in wt bearing area
  4. Limited ROM if located in the joint
  5. Systemic sx not present
89
Q

XR findings of osteosarcoma

A
  • Both osteolytic and/or osteoblastic lesions
  • “moth eaten”
  • tumor extends thru periosteum = spiculated reaction, “starburst”
  • Codman’s Triangle → new bone formation at periosteum
90
Q

what intervention is used for each lesion after osteosarcoma is identified on bone scan?

A

CT/MRI

  • CT - best for defining bone destruction & the pattern of calcification
  • MRI - better for defining intramedullary & soft tissue extension
91
Q

tx osteosarcoma

A
  1. Refer
  2. Core needle or open bx
  3. Pre- and post-op chemo w/ limb sparing surgery
92
Q

T/F: osteosarcomas are radioresistant

A

T

93
Q
  • A tumor arising from chondrocytes (cartilage producing cells)
  • MC after 50 y/o
A

chondrosarcoma

94
Q

MC sites for chondrosarcoma

A
  • pelvic and shoulder girdle
  • Other: diaphysis of long bones
  • Rarely seen in the spine & craniofacial bones
95
Q

RF for chondrosarcoma

A
  1. Questionable genetic component
  2. MC from normal cartilage cells but may also stem from previous benign bone or cartilage tumor
    - Enchondromas
    - Multiple osteochondromas
    - Ollier Disease (Enchondromatosis) → a cluster of enchondromas that affect the hands
96
Q

s/s of chondrosarcoma

A
  1. Deep, dull aching pain; progressive
  2. Worse at PM
  3. Neuro sx if compresses NV bundle - MC in pelvic lesions
  4. Limited ROM if near a joint
  5. Sx of pathologic fx
97
Q

XR findings of chondrosarcoma?

A
  1. bony contour thinned & expanded
  2. Multiple surface erosions → “endosteal scalloping”
  3. Lesion > 5 cm
98
Q
  • chondrosarcoma MC mets to what part of the body?
  • how to eval?
A

lungs - get CT w/ contrast

98
Q

tx chondrosarcoma

A
  1. Refer
  2. Surgical excision
99
Q

A rare, peripheral primitive neuroectodermal tumor that can proliferate in the bone and/or soft tissue

A

Ewing sarcoma

100
Q

cause of Ewing sarcoma

A

translocation between chromosomes 11 and 22

101
Q

MC sites for ewing sarcoma

A

pelvis and femur

102
Q

s/s of ewing sarcoma

A
  • Localized pain & swelling; worse at PM or w/ activity
  • Palpable mass
  • Neuro deficits if compression of spinal cord or peripheral nerve
  • constitutional sx = mets (F, fatigue, wt loss, anorexia)
103
Q

XR findings of ewing sarcoma

A
  • Poorly marginated destructive lesion
  • “Onion skin” appearance - Due to a periosteal reaction
104
Q

tx for ewing sarcoma

A
  1. Multi-drug chemo w/ surgery +/- radiation
    - Radiation if full resection of tumor is not possible
105
Q

MC metastasizing cancers

A
  1. Breast
  2. Lung
  3. Thyroid
  4. Kidney
  5. Prostate
106
Q

s/s mets bone disease

A
  1. Pain over metastatic location
  2. pathologic fx
  3. Anemia
107
Q

w/u for mets bone disease

A
  1. XR - 1st
  2. Bone scans
  3. PET scans
  4. MRI
  5. Bx - definitive dx & determine primary site
108
Q

tx for mets bone disease

A
  1. radiation + pain medication
  2. Chemo
  3. Bisphosphonates
  4. Surgery if inc risk for fx

Clin Med III: MSK (14 decks)

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