DiIm2 Exam 3 Flashcards
What is the most common bone malignancy we’ll see?
Metastatic Disease (70%)
What is the most common primary malignant tumor in adults?
Multiple Myeloma
What is the most common primary malignant tumor in kids?
Osteosarcoma
What is the most common benign osseous tumor?
Osteochondroma
What is the most common benign spinal tumor?
Hemangioma
What 4 areas of the skeleton do tumors like to be?
- Red bone marrow (hemopoietic tissue)
- Notochord remnants
- Areas of rapid bone growth
- Areas w/ many interosseous nerves
Of the 3 patterns of bone destruction, which is the least aggressive?
Geographic; usually slow-growing, solitary lesion with well defined margins
How would you describe a moth-eaten pattern of bone destruction?
Numerous, small holes with poorly defined margins; moderately aggressive
What is the most aggressive pattern of bone destruction?
Permeative; aggressive, rapidly-growing lesion creating numerous small holes w/ poorly defined borders.
What is buttressing?
Additional layers of new bone added to outside of bone; associated w/ slow growing lesions
What tumor do we associate onion-skinning with?
Ewing’s Sarcoma
With what tumor do we associate a ‘sunburst’ or spiculated periosteum?
Osteosarcoma
What is a codman’s triangle?
Triangular elevation of periosteum; most aggressive of periosteal rxns.
What is the only type of tumor matrix we can see on x-ray?
Osseous; everything else will look like a hole
If a cartilaginous matrix tumor somewhat calcified, what would it look like on x-ray?
C-shapes, popcorn balls (flocculent), small dots
Are bony expansion & a periosteal reaction seen w/ primary or secondary neoplasms?
Primary
What is the difference in the size of the lesion when comparing primary neoplasms w/ secondary neoplasms?
Primary-Large (bigger than 3cm)
Secondary-Small (less than 1cm)
What is still the number one imaging modality for tumors?
Plain film
Lytic mets in a female likely come from the ___ whereas lytic lesions in males usually come from the ___.
Lytic Female–>breast
Lytic Male–>lung
Blastic mets in a female likely come from the ___ whereas blastic lesions in males usually come from the ___.
Blastic Female–>breast
Blastic Male–>prostate
Expansile, soap-bubbly mets likely come from which 2 primary sources?
Either kidney or thyroid
What is the most common means of metastasis?
Hematogenous (via the blood) thru the BATSONS VENOUS PLEXUS
What is the Batson’s Venous Plexus?
valveless system draining organs; runs along the spine
Serum calcium would be elevated in ____ mets.
Lytic; because the bones being destroyed so the calcium ends up in the blood
What age do we typically see metastatic disease?
40+ y.o.
What are some red flags for metastatic disease?
Unexplained weight loss, sickly-looking, anemic, fever
What are the top 3 sites for mets?
Spine, Ribs, Sternum
If a patient has acro-metastasis, where is the primary site most likely?
Lung cancer
What is generally a good thing to see when further examining pedicle destruction?
Contralateral compensation; indicates just a congenital pedicle absence. If no compensation, pedicle destruction likely caused by mets
What is the most common cause of pathologic collapse of the vertebra? 2nd? 3rd?
1st MC-Traumatic fx (osteoporosis)
2nd MC-Metastatic carcinoma
3rd MC-Multiple myeloma
If you saw a pathologic collapse of the vertebra in a kid, what are you thinking?
Eosinophilic granuloma
What are the top 3 causes of a solitary ivory vertebra?
Pagets Dz,
Hodgkins lymphoma,
Osteoblastic metastasis
__-___% of bone must be gone before it’s noticeable on x-ray?
30-50%
What is osteopoikilosis?
Multiple, well-defined bone islands that occur around major joints; no pain or abnormal biomechanics=congenital variant
What is the age and sex of preference for multiple myeloma?
50-70y.o
Males (2:1)
Word association: M-spike?
Multiple myeloma (also know M-spike is seen on protein electrophoresis)
Are multiple myeloma lesions usually painful?
Yep, usually first initial symptom
Where do multiple myelomas love to be?
Axial skeleton (Vertebra, skull, pelvis)
Ribs
Clavicle & Scap
Femur & Humerus
Word association: Raindrop skull?
Multiple myeloma
What is a solitary plasmacytoma?
Localized form of MM (before it’s spread); rare to catch at that stage
How does solitary plasmacytoma present?
Expansile lesion usually in the vertebra but SPARES the posterior elements; 70% will progress into MM
What is the 2nd most common primary malignant bone tumor overall?
Osteosarcoma
What is the bimodal distribution of osteosarcoma?
Appears commonly at two different ages; 10-25y.o. then again after 60y.o.
Are osteosarcomas more likely to affect males or females?
Males (3:2)
What are the clinical features of osteosarcoma?
Insidious pain, swelling with pain becoming more severe and persistent.
Where are osteosarcomas going to present: epiphysis, metaphysis, diaphysis?
Metaphysis
In young osteosarcoma cases, the tumor likes ____ bones, but in older osteosarcoma cases, the tumor likes ___ bones.
Young (Under 30y.o)= Cylindrical bones
Old (over 50y.o.)=flat bones
Where is it normal to see phleboliths?
Near the pelvic rim; if they are more central something (in this case tumor) is pushing them into the center
What is a parosteal osteosarcoma?
Lesion not in central canal but the edge of the bone; least invasive & is easily resectable
T/F: Osteosarcoma has a good 5 year survival rate with amputation and chemo.
True: 75% with both therapies; amputation alone only 20% have 5 yr survival
What is the age and sex preference for chondrosarcomas?
Over 50 y.o.
Males (2:1)
T/F: Chondrosarcomas have a late onset of pain, but grow rapidly and are aggressive.
False: late onset of pain, slow growing, less aggressive
Where do chondrosarcomas love to be?
Pelvis, Prox humerus, Femoral neck, Ribs, Sternum
T/F: If one has pain with a chondrosarcoma, it has a higher malignant potential than a non-painful chondrosarcoma.
True
What is the survival rate of chondrosarcomas with early surgery?
90%
What is the second most common primary bone tumor of kids?
Ewing’s Sarcoma
What is the age and sex preference for Ewings?
10-25 y.o. (same as osteosarcoma)
Males (1.3: 1)
Do Ewings present w/ pain?
Yes, severe localized pain, with palpable soft tissue mass
How do you differentiate osteosarcoma from Ewings?
Ewings–> likes midshaft (diaphysis)
Osteosarcoma–>likes growth plates (metaphysis)
What is the age and sex preference for giant cell tumors?
20-40 y.o.
No sex preference 1:1
T/F: Females are more likely to have a malignant giant cell tumor than males.
True
What areas do the giant cell tumors love to be in?
Knee, wrist (distal radius), sacrum near SI, prox humerus
What is the most common benign tumor of the sacrum?
Giant cell tumor
What are some special rad features of giant cell tumors?
One big lesion (may be expansile), eccentric (off to side of medullary canal), extends to the subarticular region
What is ‘bone packing’?
Take bone chips from the ilium and fill in an area of tumor. Healing process takes over and heals like a fracture would.
T/F: Malignant giant cell tumors have a good 5 year survival rate.
False 10%…the good news is only 20% are malignant; the majority are benign giant cell tumors
What is the age of occurrence for solitary osteochondromas?
Younger than 20y.o. (also no sex preference)
Are osteochondromas usually symptomatic?
No, painless hard mass that only hurts if it gets fractured
T/F: Osteochondromas are always benign.
False: If they become painful or start growing again later in life–>malignant transformation
A ___ osteochondroma has a stalk-like base whereas a ___ osteochondroma has a broad base.
Pedunculated-stalk
Sessile-broad
Where as sessile osteochondromas most common in the body?
Humerus & Scapula
Where are pedunculated osteochondromas most common?
Knee, hip, ankle
Word association: coat hanger exostosis?
Solitary osteochondroma (pedunculated variety)
Where should you never see a osteochondroma?
Skull bones because they don’t utilize endochondral ossification
Supracondylar processes grow ____the joint whereas osteochondromas grow ____ the joint.
Supracondylar process-towards the joint
osteochondromas-away from the joint
What is the autosomal dominant condition characterized by multiple osteochondromas?
Hereditary Multiple Exostosis (HME)
aka Diaphyseal Achalasia
When is hereditary multiple exostosis most common and is there a sex preference?
2-10 y.o.
Males (2:1)
T/F: Having a foreshortened extremity is a complication of HME.
True
T/F: The more exostoses you have, the more likely to have malignant transformation.
True
What is a madelung deformity?
Associated w/ HME; curving of radius over a shortened ulna
Where are exostoses most common in HME?
Metaphysis of long bones
What are the 2 tumor-like conditions we discussed?
Simple bone cyst
Aneurysmal bone cyst
What are the contents of a simple bone cyst?
Fluid (serous)
What is the age and sex preference for simple bone cysts?
3-14y.o
Males (2:1)
How can you tell a giant cell tumor from a simple bone cyst?
GCT: usually achy pain, eccentric, 20-40y.o
SBC: asymptomatic unless fx, central lesion, 3-14y.o.
Where do simple bone cysts like to be?
Central part of prox humerus, prox femur, calcaneal neck
Word association: truncated cone appearance?
Simple bone cyst
If you see a fallen fragment sign, what lesion are we looking at?
Simple bone cyst
What is the most effective treatment for a simple bone cyst?
drain fluid, & inject steroids
What is the non-neoplastic, expansile lesion filled w/ blood?
Aneurysmal bone cyst
What is the age & sex preference for aneurysmal bone cysts?
10-30y.o.
FEMALES**
T/F: Aneurysmal bone cysts usually occur following a trauma.
True
T/F: Like solitary plasmacytomas, aneurysmal bone cyst usually spare the posterior elements of vertebrae.
False: Love to be in the spine in that neural arch
What are the two types of aneurysmal bone cysts?
Fusiform or rounded
How could you tell a giant cell tumor from a ABC?
ABC-10-30yo, NOT subarticular
GCT: 20-40yo, subarticular
What are the clinical features of osteoblastomas?
10-20y.o. (MC males 2:1) with dull pain that came on gradually, may have swelling and tenderness
Where do osteoblastomas love to be?
Spine (in the posterior arch structures), Long bones, bones of hands and feet
Excluding bone marrow biopsy, what is the best confirmatory test for multiple myeloma?
Protein electrophoresis–looking for the M spike
Word association: Bence Jones proteinuria?
Multiple myeloma
Which benign lesion is characterized by extreme pain that gets worse at night but aspirin relieves the pain?
Osteoid osteoma
What is the age and sex preference for osteoid osteoma?
10-25y.o. & male preference
What bones does the osteoid osteoma love to be in?
Prox femur, prox tibia, prox humerus, spine (posterior elements but non expansile)
Word association: Nidus with reactive sclerotic rim?
Osteoid osteoma
Which imaging is used for diagnosing osteoid osteoma?
CT
What is the ‘double density sign’?
Osteoid osteoma on bone scan has really high activity over nidus, and slightly less activity over reactive thickening. (black with dark grey rim)
T/F: Osteoid osteomas turn malignant in 10% of diagnosed cases.
False. No malignant potential
Which benign tumor only comes about in membranous bones?
Osteomas
At what age do most osteomas occur?
Adulthood
Where do we most often see osteomas?
Paranasal sinuses (frontal & ethmoid)
What is the age and sex preference for enchondromas?
10-30y.o. & no sex preference (1:1)
T/F: The closer the enchondroma is to the axial skeleton, the more malignant potential it has.
True
What is Ollier’s Disease?
Nonhereditary; multiple enchondromas affecting hands and feet, usually present in childhood (AKA Enchondromatosis)
What is the term for having multiple soft tissue hemangiomas in addition to having Ollier’s Disease?
Maffucci Syndrome
How do the soft tissue hemangiomas of Maffucci Syndrome appear on x-ray?
Small calcific densities around the soft tissue of the hands
What is the age and sex preference for hemangiomas?
30-40y.o. and FEMALE PREFERENCE!
T/F: Hemangiomas are asymptomatic unless they expand and cause cord compression.
True
Where do we see hemangiomas most frequently?
Vertebral bodies, and calvarium (preferably the frontal bone)
Which neoplasm will demonstrate accentuated vertical trabeculae on a single vertebra? What if it’s on multiple vertebrae?
Single-hemangioma, or paget’s
Multiple-osteoporosis
T/F: Hemangiomas will present with a honey-comb appearance on CT.
False: honey-comb/corduroy/accordion on XRAY
on CT, it’s the ‘polka-dot appearance’
What is the peak incidence age for chondroblastomas?
5-25y.o.
Are chondroblastomas more common in males or females?
Males
Which painful, benign lesion likes to be in the apophyses or epiphyses?
Chondroblastoma
What is the most common age for seeing fibrous cortical defects? Peak age?
Common 2-10y.o. w/ peak from 7-8y.o.
How can you tell an osteoid osteoma from a fibrous cortical defect?
AGE!
FCD-2-10
OO is from 10-25
T/F: Bone packing is a frequent treatment for fibrous cortical defects.
False: They spontaneously regress
T/F: Nonossifying fibromas are usually seen eccentrically in the metadiaphyseal region of lower extremity long bones.
True
Are non-ossifying fibromas painful?
No
What is a fibroxanthoma?
The easy cheat if you can’t discern whether it’s a non-ossifying fibroma, a fibrous cortical defect, or fibrous dysplasia
What is the age preference for fibrous dysplasia lesions?
0-20y.o.
Polyostotic fibrous dysplasia with endocrine dysfunction and café-au-lait spots?
McCune Albright Syndrome
Which lesion will you see the ‘rind sign’ with?
Fibrous dysplasia; thickened rim of sclerosis somewhere around the lesion (doesn’t have to be symmetrically thickened)
What is the age and sex preference for Paget’s?
Males, elderly (I’m confused by his stats so over 55 or 85 y.o.)
What are the phases of Paget’s?
- Lytic phase where bones architecture is lost
- Mixed between lytic & blastic
- Blastic phase but bone being laid down has so structure so it’s soft and weak
- Malignant degeneration (rare though)
Where does Paget’s like to be?
Pelvis, vertebra, skull, proximal femur (& other long bones)
In the long bones, how does Paget’s progress?
Starts subarticular and works towards the diaphysis
Word association: Osteoporosis circumscripta
Paget’s; well defined lysis of frontal and occipital regions
What can be a first sign that someone may have Paget’s affecting the skull?
Hat doesn’t fit due to cortical expansion; important b/c blastic mets on the skull look similar to Pagets but blastic mets have NO cortical reaction.
Word association: Candle flame or blade of grass sign?
Paget’s; lytic edge usually affecting long bone cortex
What is the ‘rim sign’?
Thickening of the iliopectineal line of the pubic bones; associated w/ Paget’s
T/F: The picture frame vertebra (& eventual ivory vertebra) are part of the lytic phase of Paget’s.
False: blastic phase
What’s the difference between a vertebral hemangioma and Paget’s affecting a vertebra?
Hemangiomas & Paget’s both have accentuated vertical trabecular but Pagets will also have cortical thickening around the body
