Disease Profiles: Tumours and Swellings Flashcards
How would you manage an enchondroma which has previously caused a fracture or appears to be at risk of causing a fracture?
Enchondroma scraped out (curettage) and filled with bone graft to strengthen the bone
Name two benign lesions from which a chondrosarcoma can arise
Enchondroma, osteochondroma
Describe the appearance of bony metastases from a prostate cancer primary
Sclerotic
Describe the histology of a ganglion cyst
Space with myxoid material
Describe the management of myositis ossificans
Observation, intervene only if symptoms demand
If intervening, must wait until maturity of ossification (6-12 months), otherwise risk of recurrence
When is surgery indicated in bone metastasis?
Usually indicated regardless of prognosis as a paliative procedure
Describe the management of nodular fasciitis
None - reassurance, self-liming course
What is Ewing’s sarcoma?
Primary bone tumour of the endothelial cells of the bone marrow, characterised by bone loss
What is Multiple Hereditary Exostosis (MHE)?
Autosomal dominant hereditary disorder that causes the development of multiple osteochondroma
What are MRIs and CTs used for in investigating a primary bone tumour?
Dermine local extent of tumour and involvement of muscles, nerves and vessels
Which form of primary bone tumour are not radiosensitive and are unresponsive to adjuvant chemotherapy?
Chondrosarcomas
Which investigations would you perform in suspected fibrous dysplasia?
X-ray, bone scan
What is multiple myeloma?
Malignant disease of the plasma cells of the bone marrow
Describe the management of bursitis
With inflammatory bursitis the fluid component of the swelling usually subsides but a thickened bursal sac may be left
Recurrence may occur and excision may be required but problems can occur with scarring
Where do giant cell tumours of bone commonly occur?
Occur in the metaphyseal region, tend to involve the epiphysis and can extend to the subchondral bone adjacent to the joint
Commonly occur around the knee and in the distal radius but can occur in other long bones, the pelvis and the spine
What is a simple bone cyst?
Single cavity benign fluid filled cyst in a bone
What is chondrosarcoma?
Cartilage producing primary bone tumour - malignancy of chondrocytes
What is a ganglion cyst?
Outpouchings of the synovium lining of joints and filled with synovial fluid
What causes a ganglion cyst?
Weakness of the synovial joint - can be developmental (e.g. juvenile Baker’s cyst) or secondary to joint damage/arthritis (e.g. adult Baker’s cyst)
When might a giant cell tumour of bone require joint replacement?
Very aggressive lesions with cortical destruction
What is an osteoid osteoma?
Benign bone-forming tumor that typically occur in children
Which out of fibrosarcoma and malignant fibrous histiocytoma tends to affect adolescents/YAs?
Fibrosarcoma
Describe the clinical presentation of an enchondroma
Many are indicental and usually asymptomatic but they can weaken the bone leading to pathological fracture
Describe the clinical presentation of an osteoid osteoma
Intense constant pain, worse at night due to the intense inflammatory response
Which investigations would you perform in suspected myositis ossificans?
X-ray and MRI
Where do enchondromas occur?
Femur, humerus, tibia and small bones of the hand and feet
Where do aneurysmal bone cysts occur?
In the metaphyses of many different long bones, flat bones and vertebral bodies
What blood tests should be performed in suspected bone metastasis?
Serum calcium (for hypercalcaemia), LFTs (to look for liver mets), plasma protein electrophoresis (for myeloma), full blood count and U&E
Describe the management of a ganglion cyst
Usually resolve with time but excision may be required for localized discomfort or cosmesis
Needle aspiration may be attempted but recurrance is common
The historic treatment of striking the wrist with a heavy book (‘bible technique’) to burst the swelling is not advised
What causes an aneurysmal bone cyst?
Small arteriovenous malformation
Which patient groups are most likely to develop osteosarcoma?
Most cases seen in adolescence and early adulthood
2nd peak in the eldery assocaited with Paget’s
What can cause an abscess on a limb?
Cellulitis, bursitis, penetrating wound or infected sebaceous cysts
What is an enchondroma?
Benign intramedullary and usually metaphyseal cartilaginous tumour caused by failure of normal enchondral ossification at the growth plate
Which patient group is most likely to develop an osteoid osteoma?
Adolescence
Where do chondrosarcomas commonly develop?
Tend to be found in the pelvis or proximal femur
Describe the clinical presentation of myositis ossificans
History of trauma, initial soft swelling, harness develops over several weeks
What is a giant cell tumour of the tendon sheath?
Benign nodular tumour found on the tendon sheath of the hands and feet
Describe the management of a sebaceous cyst
May require excision and/or biopsy
What is myositis ossificans?
Abnormal calcification of a muscle haematoma following trauma
What is bursitis?
Inflammation of the synovium-lined sacs (bursa) that protect bony prominences and joints
Which patient group is most likely to develop an enchondroma?
Commonest in 20-50 year olds
What is polyostotic fibrous dysplasia?
More than one bone affected
What feature of an aneurysmal bone cyst causes pain?
Cyst is locally aggressive causing cortical expansion and destruction
Where is osteosarcoma most common?
60% involve the bones around the knee (distal femur/proximal tibia), other sites include proximal femur, proximal humerus and pelvis
What is osteosarcoma?
Malignant tumour which produces bone
What is an osteochondroma?
A benign lesion derived from aberrant cartilage from the perichondral ring which produces a bony outgrowth on the external surface with a cartilaginous cap
Which patient group is most likely to develop Ewing’s sarcoma?
Affects young people 5-25 years of age, most common age 10-20
Bony lesions may not show up on x-rays until more than what percentage of the cortical bone is lost?
50%
What causes bursitis?
Repeated pressure or trauma
How will an enchondroma appear on imaging?
Usually lucent but can undergo mineralisation with a patchy sclerotic appearance
Describe the clinical presentation of a bone metastasis
Bone pain, cancer red flags, may be pathological fracture
Describe the clinical presentation of fibrous dysplasia
Bone pain and deformities, pathological fractures
Describe the x-ray findings of a giant cell tumour of bone
Characteristic ‘soap bubble’ appearance
Where do simple bone cysts commonly occur?
Metaphyseal in long bones (usually in proximal humerus and femur), although they can occur in the talus or calcaneus
Describe the management of a mucous cyst
Based on symptoms - can be left alone and will disappear over time, excision if particularly deep/cracked nail ridges, or constant discharge
Which patient group is most likely to develop multiple myeloma?
Elderly patients
Describe the management of a bone cyst which appears to be at risk of causing a pathological fracture
Treatment with curettage and bone grafting +/- stabilisation
What investigations would you perform for a benign bone lesion?
X-ray, further imaging if needed e.g. CT, MRI, bone scan
Describe the pathophysiology of a giant cell tumour of the tendon sheath
Regenerative hyperplasia with inflammatory process
Where does Ewing’s sarcoma commonly occur?
Usually found in diaphysis of long bones - distal femur, proximal tibia
Describe the x-ray findings of an aneurysmal bone cyst
Chambers may be visible
When may surgery be curative for renal cell carcinoma with bone metastasis?
If there is only a single bone metastasis and the primary tumour is amenable to resection
Where do sebaceous cysts commonly occur?
Commonly occur on face, trunk and neck but can also occur on limbs
Why do osteochondromas require close observation?
Small risk of malignant transformation (<1%) - any lesion growing in size or causing pain may require excision
Describe the appearance of bony metastases from a renal cell carcinoma primary
Large and very vascular lytic ‘blow out’ bony metastases - can bleed tremendously with biopsy or surgery
Describe the clinical presentation of a ganglion cyst
Well-defined round swellings which occur around a synovial joint or a synovial tendon sheath - commonly arise around the wrist, can also occur in feet and knees
Painless, may feel tight, mobile skin but cyst fixed to underlying structures
What causes the angular deformities sometimes seen in fibrous dysplasia?
Defective mineralisation
Why is a ganglion cyst not a true cyst?
No epithelial lining
Describe the clinical presentation of nodular fasciitis
Rapidly growing lesion < 5cm, usually circumscribed
What is nodular fasciitis?
Benign proliferation of fibroblastic and myofibroblastic cells
Which out of osteosarcoma and chondrosarcoma is more common and more aggressive?
Chondrosarcoma
Describe the histological findings of a giant cell tumour of bone
Consist of multi-nucleated giant cells
Describe the management of fibrous dysplasia
Bisphosphonates may reduce pain
Stabilisation + bone grafts for pathological fractures
Describe the clinical presentation of a simple bone cyst
May be asymptomatic and an incidental finding (usually x-ray of child/YA) but can weaken the bone leading to pathological fracture
Describe the clinical presentation of a giant cell tumour of bone
Painful mass/swelling, may cause pathological fracture
Describe the examination findings of a primary bone tumour
Swelling and erythema over joint (especially in Ewing’s sacroma)
Palpable mass
Name 2 genetic causes of a primary bone tumour
Li Fraumeni syndrome (p53), familial retinoblastoma (RBI)
What causes a simple bone cyst?
Growth defect in the physis
Describe the management of a lipoma
Based on symptoms - can be left alone, excision if causing symptoms
Describe the management of an aneurysmal bone cyst
Curettage and grafing or use of bone cement
Describe the x-ray findings of a malignant bone tumour
Cortical destruction, a periosteal reaction, new bone formation (sclerosis and lysis), reactive cortical thickening (chondrosarcoma) and extension into the surrounding soft tissue envelope
What causes fibrous dysplasia?
Genetic mutation results in lesions of fibrous tissue and immature bone
Describe the clinical presentation of a giant cell tumour of the tendon sheath
Firm, discreet swelling, usually on volar aspect of digits but can occur in toes
May or may not be tender
Describe the x-ray and MRI findings in myositis ossificans
Peripheral mineralisation
Describe the clinical presentation of a primary bone tumour
Persistent, increasing pain usually not associated with movement
Pain is well localised and worse at night
Pathological fracture
What are fibrosarcoma and malignant fibrous histiocytoma?
Fibrous malignant primary bone tumours which tend to occur in abnormal bone e.g. bone infarct, post radiation
Describe the CT findings of an osteoid osteoma
Small nidus of immature (woven) bone surrounded by an intense sclerotic halo (osteoblastic rim)
Describe the clinical presentation of an aneurysmal bone cyst
Painful mass/swelling, pathological fracture
Describe the clinical presentation of an osteochondroma
Painless, hard lump, commonly near the knee (distal femur/proximal tibia)
May be symptoms with activity - pain from tendons, numbness from nerve compression
List the five primary cancers which commonly metastasise to bone, in order of most to least common
Breast, prostate, lung, renal cell carcinoma, thyroid cancer
Which x-ray views should be used in investigating a malignant bone tumour?
AP and lateral including joint above and below
What are the 4 main features of multiple myeloma?
Hypercalcaemia, anaemia, renal impairment and bone pain
Which patient group is most likely to develop nodular fasciitis?
Young adults
What are lipomas?
Most common benign soft tissue tumour - neoplastic proliferation of fat
Which site in the body do around 5% of giant cell tumour of bone metastasise to?
The lung - benign pulmonary GCT
Which investigation would you perform in suspected nodular fasciitis?
Biopsy
Which patient group is most likely to develop a mucous cyst?
Females, 40-60 years
Which patient group is most likely to develop a chondrosarcoma?
Older age group - mean age 45
What would a bone scan show in fibrous dysplasia?
Show intense increase in uptake during development but the lesion usually becomes inactive
List some features of bone metastasis which indicate risk of impending pathological fracture, meaning skeletal stabilization or joint replacement may be required
Lesions which are very painful (especially on weight bearing), those which occupy >50% of the diameter of the bone, those with cortical thinning and those in ‘at risk areas’ (e.g. subtrochanteic area of the femur)
Describe the clinical presentation of a mucous cyst
Painful raised swelling of DIP joint or just distal to the joint
Small initially but increase in size, as size increases skin becomes thin and may rupture
Can fluctuate in size If very large can damage the nail and cause a ridge
Are the majority of chondrosarcoma high or low grade?
Low
What would produce a ‘Shepard’s crook’ deformity on x-ray in a patient with fibrous dysplasia?
Extensive involvement of the proximal femur
Describe the management of a giant cell tumour of the tendon sheath
Based on symptoms - can be left alone, excision if causing symptoms but there is risk of recurrence
Which form of primary bone cancer can mimic infection - hot, swollen, tender joint or limb with raised inflammatory markers?
Ewing’s sarcoma
Describe the clinical presentation of a lipoma
Can be discreet or less well defined, slow-growing, painless, can be large, no overlying skin changes, characteristic consistency
Describe the management of an osteoid osteoma
Pain is greatly relieved by NSAIDs
Lesion may resolve spontaneously over time but some cases may require CT guided radiofrequency ablation or en bloc excision
Which patient group is most likely to develop a malignant primary bone tumour?
More common in young patients - 10% of childhood cancers
Describe the histological findings of nodular fasciitis
Very cellular, lots of mitoses figures, plump cells; stellate and spindle, tissue culture appearance, haemorrhage, mature towards periphery
Which patient group is most likely to develop an osteochondroma?
Common in adolescents and young adults (10-20 years)
What is an aneurysmal bone cyst?
Consists of many chambers which are filled with blood or serum
Which form of primary bone tumour are not radiosensitive but adjuvant chemotherapy can prolong survival?
Osteosarcomas
Describe the management of a primary bone tumour
Surgical removal of tumour and surrounding tissue, with joint reconstruction
Adjuvant chemotherapy/radiotherapy used if appropriate
Chemotherapy can improve survival
What is a mucous cyst?
Outpouching of synovial fluid from DIP caused by early OA
How will an osteochondroma appear on imaging?
Cartilage capped ossified pedicle
List the features suggestive of a benign soft tissue neoplasm
Smaller size, fluctuation in size (malignant tumours don’t regress in size), cystic lesions, well‐defined lesions, fluid filled lesions and soft/fatty lesions
What is fibrous dysplasia?
Benign, developmental disorder of bone that causes normal skeletal tissue to be replaced by fibrous tissue
What are bunions?
Bursitis over the medial 1st metatarsal head in hallux valgus
Describe the management of an abscess
Surgical excision and drainage
Rest, elevation, analgesia, splint
Antibiotics
What is an abscess?
Discrete collection of pus
Describe the appearance of bony metastases from a breast cancer primary
Blastic (sclerotic) or lytic
Why are pathological fractures caused by a bony prostate metastasis likely to heal?
Osteoblastic activity (sclerotic masses)
Describe the management of giant cell tumours of bone
Intralesional excision with use of phenol, bone cement or liquid nitrogen to destroy remaining tumour material and reduce the risk of recurrence
How can the risk of pathological fracture of a prostate bony metastasis be reduced?
Radiotherapy and hormone manipulation
Where does nodular fasciitis most commonly occur?
Upper extremity, history of prior trauma at the site in 25% of cases
What is a giant cell tumour of bone?
Benign tumour arising from the giant cells of the bone marrow
Name the bones which are most frequently involved with metastases
Vertebra, pelvis, ribs, skull and femurs
What is monostotic fibrous dysplasia?
Only one bone affected
Describe the clinical presentation of an abscess
Defined and fluctuant swelling, erythema, pain
History of trauma (e.g. bite, IVDU) or cellulitis
Name 3 predisposing conditions for a primary bone tumour
Paget’s, fibrous dysplasia, multiple enchondromas
Describe the appearance of bony metastases from a lung cancer primary
Lytic
Which patient group is most likely to develop fibrous dysplasia?
Usually occurs in adolescence
What is a sebaceous cyst?
Slow growing, painless, mobile discreet swellings formed by blockage of the sebaceous gland
They originate at hair follicles and fill with caseous materal (keratin)
Where do osteoid osteomas commonly develop?
Proximal femur, the diaphysis of long bones and the vertebrae
What percentage of patients with osteosarcoma have pulmonary metastases at diagnosis?
10-20%
