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Orthopedics > Bone Tumours > Flashcards

Bone Tumours Flashcards

1
Q

Where and when do primary and secondary ossification centres appear in long bone?

A

Primary - centre of the diaphysis during intrauterine life.

Secondary - each epiphyseal end sometime after birth.

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2
Q

How do bone tumours typically present?

A
  1. Pain
    - Unexplained limb pain >1 month
    - Pain at night
  2. Swelling
  3. Pathological fracture
  4. Incidental finding - most primaries
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3
Q

What are the 3 forewarning signs of malignancy on X-ray?

A
  1. Cortical destruction
  2. Periosteal reaction
    - Fuzzy line outside of cortex
    - Also seen with # or infection
  3. Zone of transition
    - Sclerotic margin = narrow zone
    - Diffuse margin - more aggressive
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4
Q

List 6 clinical indicators of malignancy?

A
  1. Pain (>1 month, at night)
  2. Swelling
  3. Tenderness
  4. Warmth
  5. X-ray changes (3 signs)
  6. Rapid growth of a lesion
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5
Q

What investigations are indicated if bone malignancy is suspected?

A
  1. X-ray
  2. Bone scans
  3. CT
  4. MRI
  5. ESR - raised
  6. ALP - raised
  7. Biopsy
    Refer to specialist centre early
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6
Q

Recite the mnemonic for benign bone tumours

A

ABC FFG OO

Aneurysmal bone cyst
Bone cyst
- Simple, unicameral or solitary
Chondroma
- Aka endrochondroma
Fibrous cortical defect
- Aka nonossifying fibroma
Fibrous dysplasia
Giant cell tumour
Osteochondroma
Osteoid osteoma
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7
Q

Expansile cysts that usually affect under 30s. Patients present with pain. MRI shows multiple fluid levels.

A

Aneurysmal bone cyst (benign tumour)

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8
Q

What is the pathognomonic sign for aneurysmal bone cysts, as seen on MRI?

A

Multiple fluid levels

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9
Q

How are symptomatic aneurysmal bone cysts treated?

A

Curette out cyst and fill with bone graft.

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10
Q

In which bones and in whom do simple bone cysts most commonly occur?

A

Proximal humerus and femur.
Young patients.
Usually asymptomatic.

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11
Q

When might you see the ‘fallen fragment sign’?

A

Specific radiological sign for a unicameral bone cyst with pathological fracture. Part of the thinned cortex ‘falls’ into the fluid-filled cyst.

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12
Q

Differentiate between Ollier’s disease, Maffucci’s syndrome and metachondromatosis.

A 
Multiple enchondromas present in 3 disorders:
Ollier disease 
- Sporadic (more common) 
- Unilateral distribution
Maffucci's syndrome
- Sporadic
- Associated with hemangiomas 
Metachondromatosis 
- Autosomal-dominant 
- Both multiple osteochondromas and enchondromas.
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13
Q

What are (endo)chrondromas and which bones are most commonly affected?

A

The most common benign tumours of hyaline cartilage

Commonest site: phalanges. Can affect other long bones.

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14
Q

A 43 year-old man presents with ongoing pain and swelling in his hands and feet. X-ray findings reveal cystic lesions of the phalanges. Which condition is it important to exclude?

A

Low-grade chondrosarcoma - may develop from benign cystic lesions (chondromas)

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15
Q

What is a nonossifying fibroma and how does it typically present?

A

Aka fibrous cortical defect.

  • Benign defect of cortex
  • Common: incidental finding on X-ray in 20% of children
  • Nonpainful
  • Usually affects metaphysis
  • Usually spontaneously regress
  • Rarely seen after age 30
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16
Q

Differentiate between monostotic and polystotic fibrous dysplasias

A

Fibrous dysplasia = areas of bone are replaced by fibrous tissue.

Monostotic = localised

  • Solitary segment affected
  • More common (70-80%)
  • Unknown cause
  • Incidental X-ray finding or presents as pathological # with pain

Polystotic = generalised

  • 20-30%, several bones affected
  • Presentation: progressive deformity (bending, enlargement), pain and pathological fracture
  • X-ray: ground glass or smokey
  • Elephant man?!
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17
Q

What is McCune-Albright syndrome?

A

A rare condition in which polyostotic fibrous dysplasia occurs in association with café au lait spots and (in females) precocious puberty (endocrinopathies).

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18
Q

In whom and in which bone(s) are giant cell tumours most commonly seen?

A

Occur in young adults (always after fusion of growth plate) usually around knee (lower femur or upper tibia) and always abut the articular surface.

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19
Q

Which is the commonest tumour of the bone?

A

Osteochondroma - aka “exostosis”, a cartilage-capped outgrowth. Arise from metaphysis, especially about knee. M>F (3:1)

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20
Q

A patient presents with a bony lump. X-ray shows a cauliflower-shaped projection from bone that is smaller than the size to touch. What is the most likely diagnosis?

A

Osteochondroma - if symptomatic, excise tumour.

Chondrosarcoma - if it changes in size after skeletal maturity.

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21
Q

A 20 year old patient presents with ongoing leg pain which is relieved by aspirin. X-ray shows a small radiolucent area surrounded by dense sclerosis which appears as a hot spot on a bone scan. What is the most likely diagnosis and how would you treat?

A

Osteoid osteoma - a benign tumour (

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22
Q

How does an osteoblastoma differ to an osteoid osteoma?

A

An uncommon primary bone tumour with clinical and histological similarities to osteoid osteoma, but larger (2-6 cm). Usually benign and related to spine.

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23
Q

In whom do osteosarcomas most commonly occur?

A

Males > females (3:1)
Primary: adolescents (under 20)
Secondary: over 50s (due to Paget’s disease)

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24
Q

What is the main symptom of osteosarcoma?

A

Pain, especially nocturnal

+/- local tenderness

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25
Q

What are the radiological features of osteosarcoma?

A

X-ray:

  • Metaphyseal, translucent, destructive lesion
  • Expands through cortex, lifts, periosteum
  • Codman’s triangle
  • ‘Sun-ray’ appearance
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26
Q

What is Codman’s triangle?

A

Radiographic feature:

Triangular area of new subperiosteal bone, created when a lesion raises the periosteum away from the bone

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27
Q

What are ‘sun-ray’ and ‘sunburst’ appearances caused by?

A

Sun-ray appearance occurs with rapidly-growing lesions
- Streak of calcification
- Periosteum has no time to lay down thin shell of bone
- Sharpey’s fibers stretch out, perpendicular to the bone
When these fibres ossify, they produce a pattern sometimes called “sunburst” periosteal reaction

28
Q

How are malignant bone tumours treated and what is their prognosis?

A
  1. Chemotherapy - except chondrosarcomas
  2. Resection
    - Amputation
    - Or wide local excision (allograft or prosthesis)

Five-year survival

  • Osteosarcoma: 60%
  • Chondrosarcoma: 50%
29
Q

Name the rare malignant tumour that arises from bone marrow, usually in young patients.

A

Ewing’s sarcoma - boys > girls

30
Q

True or false: most Ewing’s sarcomas occur in diaphysis of long bones

A

True - especially femur, also tibia and humerus

31
Q

True or false: osteosarcomas tend to be metaphyseal

A

True

32
Q

A 25 year-old patient presents with a painful pelvic swelling that is warm and tender. X-ray shows an onion-skin appearance. What is the diagnosis?

A

Ewing’s sarcoma - occasionally misdiagnosed as osteomyelitis

33
Q

What causes an ‘onion skin’ appearance on X-ray?

A

Several layers of periosteal new bone around destructive lesion - seen in Ewing’s sarcoma

34
Q

A 45 year-old patient presents with a painful swelling in pelvis. X-ray shows an expanding radiolucent lesion with flecks of calcification. What is the diagnosis?

A

Chondrosarcoma - usually affects older patients (40+)

35
Q

Describe the two types of chondroma/chondrosarcoma

A
  1. Subperiosteal chondroma: arises on surface of bone
    - Sometimes in cartilage-covered cap of osteochondroma
  2. Endochondroma: arises within medulla of bone
    - Either slow-growing malignancy or benign chondroma that becomes malignant
36
Q

True or false: chondrosarcomas tend to be treated with chemotherapy before excision

A

False - Rx by excision or amputation since they metastasise late

37
Q

Which malignant tumours are more common in younger patients (under 30)?

A
  1. Osteosarcoma

2. Ewing’s sarcoma

38
Q

Which malignant tumours are more common in older patients (over 40)?

A
  1. Chondrosarcoma
  2. Myeloma
  3. Metastases
39
Q

Which cancers most commonly metastasise to bone?

A

‘Bone Tumours are Rarely Bony Primaries’

  1. Breast
  2. Thyroid
  3. Renal
  4. Bronchus
  5. Prostate
40
Q

True or false: most metastases are osteoclerotic lesions

A

False - majority are lytic lesions
Exception: prostate - usually osteosclerotic
However, breast and thyroid are sometimes osteosclerotic

41
Q

Which bones do secondaries tend to metastasise to?

A 
Axial skeleton (red marrow)
- Spine, pelvis, ribs, proximal and of long bones
42
Q

How do secondary bone tumours tend to present?

A
  1. Local pain

2. Pathological fracture

43
Q

How are pathological fractures treated?

A

Internal fixation - as they tend not to heal

44
Q

How do secondary bone tumour tend to be treated?

A
  1. If local - radiotherapy

2. If multiple - palliative (poor prognosis)

45
Q

True or false: most benign lesions are seen <30 years of age

A

True

46
Q

True or false: a new bone tumour in the elderly is more likely to be malignant

A

True

47
Q

What is the best test for diagnosis and staging of bone tumours?

A

Dx: X-ray
Staging: CT or MRI
Histology grade
- Most important prognostic feature of sarcomas
- Essential for staging of most bone tumour types

48
Q

What are the most common benign lesions in the under 20s?

A 
ABC FFG OO
- Endochondroma
- Giant cell tumour
\+ Osteoblastoma
\+ Chondroblastoma
\+ Chondromyxoid fibroma
\+ Eosinophilic granuloma
49
Q

What are the most common malignant tumours in the under 20’s?

A
  1. Osteosarcoma
  2. Ewing’s sarcoma
  3. Metastatic neuroblastoma
  4. Leukaemic involvement

In younger patients think osteosarcoma or Ewing’s sarcoma!

50
Q

What are the most common benign lesions in 21-40 year olds?

A
  1. Endochondroma

2. Giant cell tumour

51
Q

What are the most common malignant tumours in 21-40 year olds?

A

Chondrosarcoma

In older patients think chondrosarcoma, myeloma and mets!

52
Q

What is the most common benign lesion in the over 40s and in which bones does it commonly arise?

A

Osteoma - facial bones, skull

53
Q

What are the most common malignant lesions in the over 40s?

A
  1. Metastatic tumours
  2. Myeloma
  3. Leukaemic involvement
  4. Chondrosarcoma
  5. Osteosarcoma (Paget’s associated)
  6. Malignant fibrous histiocytoma
  7. Chordoma

In older patients think chondrosarcoma, myeloma and mets!

54
Q

True or false: most secondary bone tumours have favoured sites within long bone

A

False - this is true of primaries

55
Q

Diaphyseal cortical lesion

A

Osteoid osteoma

56
Q

Diaphyseal intramedullary lesion

A
  1. Fibrous dysplasia
  2. Endochondroma
  3. Ewing’s sarcoma
  4. Lymphoma
  5. Myeloma
57
Q

Metaphyseal cortical lesion

A
  1. Non-ossifying fibroma

2. Osteoid osteoma

58
Q

Metaphyseal intramedullary lesions

A
  1. Osteosarcoma
  2. Chondrosarcoma
  3. Fibrosarcoma
  4. Osteoblastoma
  5. Endochondroma
  6. Fibrous dysplasia
  7. Simple bone cyst
  8. Aneurysmal bone cyst
59
Q

Epiphyseal lesions

A
  1. Chondroblastoma - rare, open growth plates

2. Giant cell tumour - closed growth plates

60
Q

Metaphyseal exostosis

A

Osteochondroma

61
Q

What are the commonest sites for an osteosarcoma?

A

Primary: locally invasive (metaphysis)
- Around knee (distal femur/proximal tibia)
- Proximal humerus
Secondary: femur, humerus, pelvis

62
Q

Where do osteosarcomas commonly metastasise to?

A

Often metastasises to lung via blood

63
Q

Where do chondrosarcomas commonly arise and where do they spread to?

A

Common sites: central portions of skeleton:
- Pelvis, proximal femur, ribs, sternum, shoulder girdle

Spreads to lungs and skeleton

64
Q

What is a giant cell tumour?

A

Uncommon, benign bone tumour. Contains a profusion of multinucleate osteoclast type giant cells. Usually benign but may become locally aggressive and metastasise. Arises during 5th decade. Female predominance

65
Q

In which bones are osteoblastomas commonly found?

A

Vertebral column

66
Q

What are Homer-Wright rosettes?

A

Small round blue cells arranged in rosettes with a neurofibrillar centre - pathobiologic marker for Ewing’s sarcoma

67
Q

What is a chordoma?

A

A rare slow-growing neoplasm thought to arise from cellular remnants of the notochord. Chordomas can arise from bone in the skull base and anywhere along the spine (neuraxis).
Commonest locations:
1. Cranially at the clivus
2. Sacrum

Orthopedics (18 decks)

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