Cortex - Pathology this is apparently wrong use a book

Question 1

what is the commonest benign bone tumor ? and briefly describe it

Answer 1

osteochondroma - which produces a bony outgrowth on the external surface with a cartilaginous cap. Can produce local pain.

Question 2

what does any bone lesion growing in size or producing pain require ?

Answer 2

an excisional biopsy

Question 3

what type of genetic disorder could be causing multiple osteochondroma ?

Answer 3

an autosomal dominant hereditary disorder.

Question 4

what is an enchondroma and is it benign or malignant ?

Answer 4

it is an intramedullary and usually metaphyseal cartilaginous tumour caused by failure of normal enchondral ossification at the growth plate.

it is benign - usually asymptpmatic

Question 5

where do enchondromas usually occur ? and what do they put people at risk of ? - what can be done to treat them?

Answer 5

Endchondromas can occur in the femur, humerus, tibia and small bones of the hand and feet.

they can cause pathological fractures - if this occurs or someone is at risk of one then they may be scrapped out (curettage) and filled with bone graft to strengthen the bone.

Question 6

what is a simple bone cyst and is it begnin or malignant ? and where are they usually found ?

Answer 6

is a single cavity benign fluid filled cyst in a bone.

(usually in the proximal humerus and femur) although they can occur in the talus or calcaneus

it is benign

Question 7

what is an aneurymsal bone cyst ?

Answer 7

it is a benign tumour which contains lots of chambers which are filled with blood or serum. Lesion is locally aggressive causing cortical expansion and destruction and is usually painful.

They are thought to be due to a small arteriovenous malformation. They can occur in the metaphyses of many different long bones, flat bones (ribs, skull) and vertebral bodies.

Question 8

what does both simple bone cysts and aneurysmal bone cysts put the patient at risk of and how is it treated ?

Answer 8

puts them at risk of pathological fractures and is treated by curettage and bone grafting - possibly stabilisation as well or bone cement using instead of graft

Question 9

what is a giant cell tumour of bone ?

Answer 9

They consist of muli‐nucleate giant cells and can also be locally aggressive and they also have a liking for the metaphyseal region but tend to involve the epiphysis and can extend to the subchondral bone adjacent to the joint.

it is a benign tumour but 5% can metastasie to the lungs

Question 10

where do giant cell tumours usually occur ?

Answer 10

most commonly occur around the knee and in the distal radius but can occur in other long bones e.g. pelvis and the spine

Question 11

what is the characteristic appearance of giant cell tumours on X-ray?

Answer 11

soap bubble appearance

Question 12

are giant cell tumours painful ? and what do they put someone at risk of? (besides metastasis)

Answer 12

yes they are and puts patient at risk of pathological fractures

Question 13

what is the treatment of giant cell tumours ?

Answer 13

Treatment is intralesional excision with use of phenol, bone cement or liquid nitrogen to destroy remaining tumour material and reduce the risk of recurrence. Very aggressive lesions with cortical destruction may need joint replacement.

Question 14

describe what fibrous dysplasia is

Answer 14

is a disease of a bone usually occurring in adolescence where a genetic mutation results in lesions of fibrous tissue and immature bone.

Question 15

what characteristic deformity can fibrous dysplasia cause ?

Answer 15

shepherds crook appearance caused by Extensive involvement of the proximal femur

Question 16

what is the treatment of fibrous dysplasia ?

Answer 16

Bisphosphonates may reduce pain and pathologic fractures should be stabilized with internal fixation and cortical bone grafts used to improve strength. Simple intralesional excision alone has a very high recurrence rate.

Question 17

what is an osteoid osteoma ? and is it benign or malignant ?

Answer 17

it is a benign tumour.

is a small nidus (a place in which something is formed or deposited) of immature bone surrounded by an intense sclerotic halo

Question 18

where/when do osteoid osteomas commonly present ?

Answer 18

They most commonly occur in adolescence and common sites include the proximal femur, the diaphysis of long bones and the vertebrae

Question 19

what is the predominant clinical feature of osteoid osteomas ?

Answer 19

is intense constant pain, worse at night due to the intense inflammatory response - NSAIDS greatly reduce the pain

Question 22

what is used to diagnose an osteoid osteoma tumour ?

Answer 22

can be seen on x ray but bone scan (intense uptake seen) or CT is used to confirm the diagnosis.

Question 23

what is the treatment of an osteoid osteoma tumour if it fails to resolve itself?

Answer 23

may require CT guided radiofrequency ablation or en bloc excision.

Question 24

true or false - Malignant primary bone tumours are very rare when considered alongside other forms of primary malignancy. On the other hand, metastatic cancer affecting the skeleton is common.

Answer 24

true

Question 25

what are the red flags for identifying cancer of the bone ?

Answer 25

Metastatic cancer affecting bone tends to produce a constant pain which may be severe and is usually worse at night.

Systemic symptoms may also be present (weight loss, loss of appetite, fatigue).

you should investigate patients over 60 with unexplained skeletal pain as they are more likely to have a cancer and also patients under 25 as they should not have unexplained skeletal pain

Question 27

what does any unexplained persistent skeletal type pain warrant ?

Answer 27

an X-ray

Question 28

what does substantial ill-defined bony swelling warrant ?

Answer 28

urgent investigations as it could be caused by a bone cancer

Question 29

what signs do primary bone tumours shown on x ray ?

Answer 29

Show aggressive and destructive signs including cortical destruction, a periosteal reaction (raised periosteum producing bone), new bone formation (sclerosis as well as lysis from destruction) and extension into the surrounding soft tissue envelope.

Question 30

what is the msot comon type of primary bone tumour ?

Answer 30

osteosarcoma - tumour which produces bone

Question 31

who/where is osteosarcomas usually seen in?

Answer 31

Most cases are seen in younger age groups (adolescence and early adulthood) with 60% involving the bones around the knee. Other sites include the proximal femur, proximal humerus and pelvis.

Question 32

what can be used palliatively to prolonge a terminal patient with osteosarcoma ?

Answer 32

not radiotherapy but chemo does

Question 33

what is a chondrosarcoma ?

Answer 33

is a cartilage producing primary bone tumour. Can be very large and are slow to metastasize. (is malignant type tumour)

Question 34

what age group does chondrosarcomas tend to occur in ?

Answer 34

tends to occur in an older age group (mean age 45).

Question 37

where do chondrosarcomas tend to be found ?

Answer 37

in the pelvis or proximal femur

Question 38

do chondrosarcomas response to chemo or radiotherapy ?

Answer 38

not so far

Question 39

what are Fibrosarcoma and Malignant Fibrous Histiocytomas

Answer 39

Are fibrous malignant primary bone tumours which tend to occur in abnormal bone (bone infarct, fibrous dysplasia, post irradiation, Paget’s disease). Fibrosarcona tends to affect adolescents or young adults.

Question 40

what is ewings sarcoma?

Answer 40

is a malignant tumour of primative cells in the marrow. It is the 2nd most prevalent primary bone tumour and has the poorest prognosis.

Question 41

what is the most frequent ages that ewings sarcoma occurs in ?

Answer 41

between the ages of 10 to 20

Question 42

what are some of theb associated signs and symptoms of ewings sarcoma ? also is it radio and chemo sensitive ?

Answer 42

fever, raised inflammatory markers and a warm swelling and may be misdiagnosed as osteomyelitis. Yes it is

Question 43

describe the treatment of primary bone tumours

Answer 43

usually involves surgery to remove the tumour and surrounding tissue to reduce the risk of recurrence. limb salvage surgery has equivalent success rates and better functional outcome than amputations. Typically a bone tumour is removed with a wide margin of 3‐4cm of bone and a cuff of normal muscle all around. The biopsy tract is also removed with the tumour. The joint involved needs reconstruction with special joint replacements which are typically much bigger than standard replacements to counteract the extensive bone loss.

adjuvant chemo and radiotherapy are given if appropriate

Question 44

what are the investigations used to stage a primary bone tumour ?

Answer 44

usually include bone scan and CT chest. MRI and CT are useful to determine the local extent of the tumour and the involvement of muscle, nerves and vessels. Biopsy is required for histological diagnosis and grading prior to definitive surgery

Question 45

what are the primary malignant tumour which commonly metastasise to bone - in order of frequency (5)

Answer 45

Breast carcinoma

Prostate carcinoma

Lung carcinoma

Renal cell carcinoma

Thyroid adenocarcinoma

Question 46

if a lesion is found on x ray what should be done to exclude a primary bone tumour

Answer 46

by bone scan and occasionally MRI

Question 47

what is the treatment of pathological fractures or impending fractures

Answer 47

Fractures or impending fractures are treated with stabilization using long rods (intramedullary nails) whilst if there is destruction of a joint (eg acetabulum or femoral head) the joint replacement may be a better option. Surgery has a high risk of DVT and prophylaxis must be given. Chemotherapy and radiotherapy may be given after surgery.

Question 48

what are painful lesions thought not to be at risk of impending fracture treated with ?

Answer 48

Painful lesions thought not to be at risk of impending fracture can be treated with bisphosphonates and radiotherapy (if radiosensitive).

Question 50

what can spinal cord compression which can occur with advanced spinal metastases be improvewd with treatment with ?

Answer 50

radiotherapy or surgical decompression (anterior or posterior).

Question 51

what is the questions you should be asking when someone has a soft tissue swelling ?

Answer 51

The usual history taking for a localized swelling applies including how long the lump has been present, whether it is painful, if it is growing or fluctuating in size and whether it is solitary or multiple

Question 52

what are the 11 things to look for when examming a soft tissue swelling ?

Answer 52

Site

Size

Definition – well defined or ill defined

Consistency – cystic, solid, soft, hard

Surface – smooth or irregular

Mobility or Fixity – to skin or deep tissues

Temperature – abscess

Transilluminable – fluid filled

Pulsatility

Overlying skin changes

Local lymphadenopathy

Question 53

what are the two types of soft tissue swelling you can get and give a couple examples of them

Answer 53

they can be either diffuse (as in synovitis or oedema) or local (inflammatory swellings (bursitis, rheumatoid nosules), infection (abscess) etc)

Question 54

what are the features suggestive of a benign soft tissue neoplasm

Answer 54

smaller size, fluctuation in size (malignant tumours don’t regress in size), cystic lesions, well‐defined lesions, fluid filled lesions and soft / fatty lesions

Question 55

what are features suggestive of a malignant soft tissue neoplasm ?

Answer 55

larger lesions (>5cm), rapid growth in size, a solid lesion, an ill‐defined lesion, an irregular surface, associated lymphadenopathy and systemic upset (weight loss, loss of apetite, fatigue).

Question 56

any soft tissue swelling where the nature of the swelling is unknown may require what?

Answer 56

may need imaging by MRI (or ultrasound to confirm a cystic lesion) or biopsy for histological diagnosis and referral to a specialist is advised

Question 57

Benign soft tissue tumours can involve any of the non‐bony connective tissues, nerves or vessels. T or F ?

Answer 57

true

Question 58

what is the commonest benign soft tissue tumour and describe it?

Answer 58

lipoma is the most common - it is a neoplastic(a new and abnormal growth of tissue in a part of the body) proliferation of fat. Usually occurs in the subcutaneous fat but can occur in muscle.

Question 59

what is the giant cell tumour of tendon sheath ?

Answer 59

Is a small firm swelling usually found on the flexor tendon sheath of a finger. They may or may not be painful and can erode bone if large enough. Macroscopically they are pigmented lesion and histologically contain multinucleated giant cells and haemosiderin.

Question 60

what is likely to happen if a giant cell tumour of tendon sheath is excised?

Answer 60

likely to reoccur

Question 61

this tumour is similar to the giant cell tumour of tendon sheath but in a synovial joint (commonly the knee), what is it known as?

Answer 61

Pigmented Villonodular Synovitis (PVNS).

Question 62

what are malignant soft tissue tumours arising from connective tissues known as in general?

Answer 62

sarcomas

Question 63

what do angiosarcomas arise from?

Answer 63

is a malignant tumour from blood vessels

Question 64

what do fibrosarcomas and malignant fibrous histiocytomas arise from?

Answer 64

arise from fibrous tissue

Question 65

what do liposarcomas arise from ?

Answer 65

arsies from fat

Question 66

what do Rhabdomyosarcomas arise from ?

Answer 66

arise from skeletal muscle

Question 67

what does synovial sarcomas arise from ?

Answer 67

originates in the synovial lining of joints or tendons.

Question 68

what age do sarcomas commonly arise in ?

Answer 68

50 to 70 but can occur at any age

Question 69

what is a ganglion cyst ?

Answer 69

it is a soft tissue swelling which occurs around a synovial joint or a synovial tendon sheath. It may form as a result of herniation or out‐pouching of a weak portion of joint capsule or tendon sheath.

Ganglion cysts are well‐defined, may be quite firm and readily transilluminate. Excision may be required for localized discomfort or cosmesis.

Question 70

what is a bursa ?

Answer 70

is a small fluid filled sac lined by synovium around a joint which prevents friction between tendons, bones, muscle and skin.

Question 71

what do abscesses arise from and what is the treatment for them ?

Answer 71

Abscesses on a limb can occur from cellulitis, bursitis, penetrating wound or infected sebaceous cysts. Abscesses will not resolve with antibiotics alone and require incision and drainage.

Question 72

Sebaceous cysts and implantation dermoids can occur on a limb and may require excision and/or biopsy. T or F ?

Answer 72

true

Question 73

what causes inflamed bursae ?

Answer 73

usually occur after repeated pressure or trauma

Question 74

what may bursitis present as ?

Answer 74

may present as a soft tissue swelling include pre‐patellar bursitis, olecranon bursitis and bunions (bursitis over the medial 1st metatarsal head in hallux valgus).

Bacterial infection can cause a bursal abscess (usually from a small wound on the limb) and gout may cause a bursitis.

Question 75

who does osteochondritis commonly affect and what causes it ?

Answer 75

Tends to occur in children and young adults and may be due to increased physical activity with repetitive stress (compression or traction). May be a link with familial predisposition.

Question 76

how does osteochonditis ?

Answer 76

(Recurrent) Impact or traction injuries cause bleeding and oedema within the bone, resulting in capillary compression. Bone necrosis ensues resulting in compression, fragmentation or separation of bone (and overlying cartilage if intra‐articular) which may cause flattening and incongruence of a joint or a pothole on the surface. Pain and progression to arthritis at a young age if a joint is involved may follow.

Question 77

1. when osteochondritis causes compression affecting the 2nd metatarsal head what is it known as ?
2. when it is affecting the navicular bone ?
3. when it is affecting the lunate of the carpus ?
4. when it is affecting the capitellum of the elbow ?
5. when it causes vertebral compression ?
   options: Freiburg’s disease, kholers disease, keinblocks disease, panners disease, scheuermanns disease

Answer 77

1. Freiburg’s disease
2. kholers disease
3. keinblocks disease
4. panners disease
5. scheuermanns disease

Question 78

where does traction osteochondritis occur?

Answer 78

occurs at an apophysis (a bony tubercle where a tendon attaches) including the tibial tubercle (known as Osgood Schlatter disease) and the calcaneus (known as Sever’s disease).

Question 79

what is osteochondritis dissecans ?

Answer 79

Fragmentation with separation of bone and cartilage within a joint

Question 80

what are the sites that are particularly predisposed to osteochondritis dissecans ?

Answer 80

lateral part of medial femoral condyle in the knee, anteromedial talar done, superomedial femoral head and the humeral capitellum)

Question 81

what are some of the symptoms of osteochondritis dissecans ?

Answer 81

Pain and effusions ensue and locking can occur with giving way of weight bearing joints.

Question 82

compression types of osteochonditis will not settle with few or no ongoing problems ? true or false

Answer 82

false - they may settle with few or no going problems

Question 83

traction osteochondritis is self limiting and settles with rest ? T or F

Answer 83

true

Question 84

what can be done is a joint is damaged by osteochondritis ?

Answer 84

osteotomy (surgical realignment of a bone ) can shift the load in a joint from a damaged area to an undamaged area (especially knee or Freiburg’s disease).

Question 85

what can osteochondritis dissecans be treated with ?

Answer 85

by pinning of unstable fragments or removal of detached fragments.

Question 86

what is avascular necrosis (AVN) and what areas are commonly affected by it ?

Answer 86

is an ischaemic necrosis of bone predominantly in adults.

the femoral head, the femoral condyles, the head of the humerus, the capitellum, the proximal pole of the scaphoid and the proximal part of the talus. (fracrues of some of these areas can be the cause of the AVN)

Question 87

what are the two most common identifiable causes of AVN ? and how do they cause AVN?

Answer 87

alcoholism and steroid (ab)use.

They cause AVN by altertering fat metabolism which can result in mobilization of fat into the circulation which can sludge up the capillary system and promote coagulation within prone areas of bones and the increased fat content of the marrow can compress venous outflow from the bone causing stasis and ischaemia. primary hyperlipedemia can result in AVN the same way.

Question 88

what are some other causes of AVN ?

Answer 88

Thrombophilia, sickle cell diease and antiphospholipid deficiency in SLE which all serve to increase coagulability.

Question 89

what scan is used to identify early AVN before radiogrpahic appearances have occurred?

Answer 89

MRI

Question 90

what is the treatment of AVN if the articular surface of the bone is still intact ?

Answer 90

drilling can be performed under fluoroscopy to “decompress” the bone, prevent further necrosis and help healing.

Question 91

what is the treatment of AVN if the articular surface has collapsed?

Answer 91

generally joint replacement is usually required in the hip, knee or shoulder to control symptoms. Fusion can be considered in the wrist or foot/ankle.