Goldstein List Flashcards by Mark Miller

Tumour incidence in orthopaedic surgery (highest → lowest) (5)

Metastatic disease
Benign soft tissue
Benign bone
Malignant soft tissue
Malignant bone

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Bone tumour presenting complaints (4)

Soft tissue mass
Incidental finding
Painless bony mass
Painful bone lesion
Pathologic fracture

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Enneking classification of malignant bone tumors (5)

IA: low grade, intracompartmental
IB: low grade, extracompartmental
IIA: high grade, intracompartmental
IIB: high grade, extracompartmental
III: metastatic

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Enneking classification of benign bone tumors (3)

1: latent
2: active
3: aggressive

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AJCC staging of bone sarcomas (4)

Stage I: low grade
o A: < 8 cm
o B: > 8 cm
Stage II: high grade
o A: < 8 cm
o B: > 8 cm
Stage III: “skip metastases” in the same bone
Stage IV: distant metastases
o A: pulmonary
o B: non-pulmonary (including other bones

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AJCC soft tissue sarcoma staging (4)

Stage I: low grade
Stage II: high grade
Stage III: high grade, deep, large (T2b)
Stage IV: metastatic
o T:
 1 - ≤ 5 cm
 2 - > 5 cm
 a – superficial
 b – deep
o N: nodal involvement
o M: distant metastasis

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Most common metastatic tumors to bone (5)

Breast
Lung
Thyroid
Prostate
Renal cell
(B.L.T. with Pickle on Rye)

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Principles of biopsy (9)

Longitudinal incision
in line with definitive resection
Approach soft tissue mass or weakened bone
Avoid N/V structures
Don’t raise flaps
Through muscle
Avoid joints, growth plates and neurovascular structures
Frozen section to confirm lesional tissue
Meticulous hemostasis
Drain as needed distal and in-line with wound
Bonus: oval window in bone if needed.
Send tissue for culture if infection is on the differential

Never biopsy a fracture (pathology mimics osteosarcoma)

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Tumour suppressor syndromes (6)

Familial melanoma (p161NK4a – melanoma, osteosarcoma and chondrosarcoma)
Familial adenomatous polyposis (APC – colonic adenomas and desmoids tumours)
Hereditary retinoblastoma (RB – retinoblastoma and osteosarcoma)
Li-Fraumeni syndrome (p53 – osteosarcomas and breast cancer)
Multiple hereditary exostosis (EXT1/2 – osteochondromas and chondrosarcomas)
Neurofibromatosis (neurofibromin – neurofibromas and sarcomas)

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Findings of McCune Albright syndrome (4)

Polyostotic fibrous dysplasia
Cafe-au-lait spots (“Coast of Maine”)
Precocious puberty
Endocrine abnormalities

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Diagnostic criteria for Neurofibromatosis Type 1 (Von Recklinghausen’s disease) – requires 2 of 7 cardinal features (7)

> 6 cafe-au-lait spots (“Coast of California” 15 mm in adults/5 mm in kids)
≥ 2 Lisch nodules (#2)
Axillary freckling (Crowe’s sign)
≥ 2 neurofibromas or 1 plexiform neurofibroma
Optic glioma
a distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosis.
First degree relative with NF-1 as per these criteria

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Steps involved in the metastatic cascade (7)

Proliferation
Angiogenesis
Detachment
Dissemination
Adherence
Extravasation
Proliferation
(P.A.D.D.A.E.P.)

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Signs of hypercalcemia (10)

Early (5)
o Polyuria
o Polydypsia
o Anorexia
o Weakness
o Fatigue
Late (5)
o Nausea/vomiting
o Psychiatric problems
o Vision problems
o Cardiac abnormalities
o Coma

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Multiple Bone lesion

Malignant
-Metastatic
-Multiple myeloma
Benign
-Familial osteochondromatosis
-Ollier’s (multiple enchondromas)
-Maffucci’s (enchondromas and hemangiomas)
-fibrous dysplasia (McCune-Albright)
-EG
Non-Tumor
-multifocal osteomyelitis
-Paget’s

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Epiphyseal lesions (3 + others)

Chondroblastoma
GCT
Clear cell chondrosarcoma (MALIGNANT)– NEED TO RULE THIS OUT IN AN ADULT!
Telangiectatic osteosarcoma
Infection (Brodie’s abscess)
EG

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Metaphyseal lesions (8)

Malignant (4)
o Malignant fibrous histiocytoma
o Osteosarcoma
o Chondrosarcoma
o Metastases
Benign (4)
o Osteochondroma
o NOF
o ABC
o UBC

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Diaphyseal lesions

Adamantinoma
Eosinophilic granuloma
Infection/Fracture/Callus
Osteoid osteoma/Osteoblastoma
Ewing’s sarcoma
Myeloma/lymphoma/fibrous dysplasia
(A.E.I.O.U. and sometimes Y.)

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Lesions with circumferential bone involvement (3)

Infection
Lymphoma
Ewing’s sarcoma

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Surface bone lesions (5)

Parosteal osteosarcoma
Periosteal osteosarcoma
Periosteal chondroma
Myositis ossificans
Sessile osteochondroma

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Cortically-based lesions (3)

Adamantinoma
Chondromyxoid fibroma
Non-ossifying fibroma
Osteofibrous dysplasia

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Flat bone tumours (5)

Hemangioma
Fibrous dysplasia
Chondrosarcoma
Ewing’s sarcoma
Metastases

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Lesions of the vertebral body (9)

Infection
GCT
Hemangioma
Metastases
Multiple myeloma/plasmacytoma
Lymphoma
Chondrosarcoma
Osteosarcoma
Ewing’s

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Lesions of the posterior elements of the vertebra (3)

Aneurismal bone cyst
Osteoid osteoma
Osteoblastoma

Note: Anterior spine = mets, myeloma, neurofibroma, hemangioma, GCT, EG, TB infection

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Benign latent lesions (6)

Enchondroma
Eosinophilic granuloma
Infection
Non-ossifying fibroma
Osteochondroma
Unicameral bone cyst

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25. Benign aggressive lesions (5/6)

- Osteoblastoma - Chondroblastoma - Aneurysmal bone cyst* - Giant cell tumour - Chondromyxoid fibroma *think about telangiectatic osteosarcoma

26. “Bubbly” lesions in the pediatric tibia

- Adamantinoma - Fibrous dysplasia - Osteofibrous dysplasia - NOF

27. Malignant-looking lesions in peds:

- Osteosarcoma - Ewing’s - Infection - EG - Leukemia

28. Sacral tumours (5)

- Metastases - Aneurysmal bone cyst - Chordoma - Giant cell tumour - Ewing’s

29. Lesions on both sides of a joint (8)

- Hemophilia - Infection - Pannus (inflammatory arthropathy – RA) - PVNS - CPPD (pseudogout) - Arthritis - Tuberculosis - Synovial chondromatosis - (H.I.P.P. C.A.T.S.)

30. Tibial lesions in kids with a benign osteoblastic periosteal response (3)

- Stress fracture - Osteoid osteoma - Infection

31. Pediatric malignant-looking lesions (6)

- Osteosarcoma - Ewing’s sarcoma - Hematologic malignancy (leukemia/lymphoma) - Metastases (rhabdomyosarcoma/Wilm’s tumor/neuroblastoma/retinoblastoma) - Infection - Eosinophilic granuloma

32. Bone-forming tumours (4)

- Osteoid osteoma - Osteoblastoma - Osteoma - Osteosarcoma

33. Cartilage-forming tumours (6)

- Enchondroma - Osteochondroma - Chondroblastoma - Chondromyxoid fibroma - Periosteal chondroma - Chondrosarcoma

34. Fibrous tumors of bone (5)

- Non-ossifying fibroma - Fibrous dysplasia - Osteofibrous dysplasia - Fibrosarcoma - Malignant fibrous histiocytoma of bone

35. Vascular lesions of bone (3)

- Hemangioma - Hemangioendothelioma - Angiosarcoma of bone

36. Lytic lesions with coarse trabeculae (5)

- Aneurysmal bone cyst - Hemangioma - Sarcoidosis - Paget’s disease - Fibrous dysplasia

37. Small round blue cell tumours (8)

- Ewing’s sarcoma/PNET - Leukemia - Lymphoma - Metastatic neuroblastoma/retinoblastoma/Wilm’s - Multiple myeloma - Rhabdomyosarcoma - Hepatoblastoma - Desmoplastic round cell tumour

37. Small round blue cell tumours by age

By age: <5: leukemia, neuroblastoma 5-10: EG 5-30: Ewing’s >50: Multiple myeloma

38. Lytic lesions of bone in patients > 40 years old (7)

- Metastatic disease - Myeloma - Lymphoma - Infection - GCT - Hyperparathyroidism - Primary bone tumors

39. Lesions associated with secondary ABC (6)

- Chondroblastoma (30%) - Osteoblastoma (25%) - Non-ossifying fibroma - Fibrous dysplasia - GCT - CMF

40. Lesions causing mineralization of soft tissue (9)

- ***Benign*** o Lipoma o Hemangioma o Myositis ossificans o Synovial chondromatosis o Pseudogout (CPPD) o Calcific tendonitis - ***Malignant*** o Synovial sarcoma o Liposarcoma o Angiosarcoma

41. Diseases that can present with multiple soft tissue masses (5)

- Neurofibromatosis - Hemangiomas (Mafucci’s) - Myxomas (Mazabraud’s) - Lymphoma - Liposarcoma

42. Deep soft tissue tumors (7)

- Benign (4) o Lipoma o Hemangioma o Myxoma o Peripheral nerve sheath tumour - Benign aggressive (2) o Fibromatosis o Hemangiopericytoma - Malignant (1) o Soft tissue sarcoma - (4,2,1)

43. Soft tissue sarcomas that metastasize to lymph nodes (5)

- Synovial sarcoma - Clear cell sarcoma (melanoma of soft parts) - Angiosarcoma - Rhabdomyosarcoma - Epithelioid sarcoma - (S.C.A.R.E.)

44. Soft tissue tumors that are bright on STIR

- Schwannoma - Cysts - Myxoid liposarcoma

45. Types of oncologic surgical margins (4)

- Intralesional - Marginal - Wide - Radical

46. Tumour reconstruction options (4)

- Endoprosthesis - Osteoarticular/intercalary allografts - Allograft-prosthetic composites - Vascularized fibular autograft

47. Indications for excision of an osteochondroma (6)

- Soft tissue inflammation - Frequent traumatic injury - Cosmetic abnormality - Causing deformity - Nerve/vascular irritation - Concern for malignant transformation

48. Risk factors for malignant transformation of an osteochondroma (6)

- Multiple lesions - Proximal lesions - Recurrent lesions - Growth after skeletal maturity - Painful lesions - Cartilage cap > 2 cm thick

49. Principles of osteochondroma excision (4)

- Extensile incision to visualize entire base - Do not disturb the cartilage cap - Amputate lesion at base of stalk - Don’t take too much cortical bone to prevent fracture

50. Indications for amputation in musculoskeletal oncology (5)

- Negative margins cannot be achieved with limb salvage - Morbidity of limb salvage too high - Limb salvage will not give adequate function - Tumor unresponsive to neoadjuvant chemo/radiation - Involvement of a major neurovascular bundle

51. Osteosarcoma chemotherapy (4)

- Doxorubicin - Methotrexate - Adriamycin - Cis-platinum - Ifosfamide - (M.A.C.I.)

52. Ewing’s sarcoma chemotherapy (4)

- Cyclophosphamide - Adriamycin - Vincristine - Dactinomycin - (C.A.Ve.D)

53. Soft tissue sarcomas that respond to chemotherapy (5)

- Synovial sarcoma - Ewing’s/PNET - Angiosarcoma - Rhabdomyosarcoma - Extraskeletal Osteosarcoma - (S.E.A.R.O.)

54. Complications of radiation therapy (7)

- Growth arrest - Joint contractures - Fibrosis - Fracture (osteopenia) - Radiation dermatitis - Wound healing problems - Secondary malignancy

55. Principles of surgical treatment of metastatic disease (7)

- Careful patient selection - Address all areas of weakened bone - Immediate stability of constructs - Adequate durability of constructs - Preoperative embolization for vascular tumours - Cement for bone defects - Cemented arthroplasty components

56. Advantages of prophylactic stabilization of metastatic lesions (6)

- Decreased morbidity - Decreased Perioperative pain - Shorter OR - Faster recovery - Shorter hospital stay - Ability to co-ordinate care with oncology team

57. Components of Mirel’s Criteria for prophylactic stabilization of long-bone metastases (4)

- Pain (mild, moderate, mechanical) - Appearance (blastic, mixed, lytic) - Shaft involvement (< 1/3, 1/3-2/3, > 2/3) - Site (UE, LE, peritrochanteric) - (P.A.S.S.)

58. Indications for resection and megaprosthetic replacement for subtrochanteric metastases (5)

- Periarticular destruction precluding internal fixation - Displaced pathologic fracture - Radio-resistant lesion - Solitary lesion - Salvage of failed internal fixation

59. Poor prognostic factors for Ewing’s sarcoma (6)

- Location (spine/pelvis) - Elevated LDH - Size > 100 cm3 - < 90% necrosis with neoadjuvant chemotherapy - Metastatic disease at presentation - Non-pulmonary metastases

60. Poor prognostic factors for osteosarcoma (6)

- Higher stage (#1) - Elevated LDH - Elevated alkaline phosphatase - < 90% necrosis with neoadjuvant chemotherapy - Pelvic location - Secondary tumour (radiation, Paget’s)

61. Prognostic factors for soft tissue sarcoma (6)

- Grade (#1) - Metastases - Size of tumor (> 5 cm) - Depth of tumor (subfascial) - Location of tumor (axial) - Histopathologic subtype (“bad actors” – same ones that go to lymph nodes and Ewing’s)

62. Risk factors for malignant transformation of enchondroma (5)

- Large - Lytic with bone expansion - Cortical thinning - Painful - Soft tissue mass

63. Signs predictive of chondrosarcoma vs. enchondroma (7)

- Large size - Axial location (pelvis) - Older patient - Multiple lesions - Hot on bone scan - Pain (especially at night) - Local recurrence

64. Indications for biopsy of an enchondroma (4)

- Change in size - Pain - Permeative lysis - Endosteal erosion

65. Risk factors for local recurrence of ABC after surgical treatment (5)

- Young age - Open physes - Stage (Campanacci staging system I-V) - Type of surgical removal - Resulting margin

66. Campanacci staging of aneurysmal bone cysts (5)

- Type I: central cyst with intact bone profile - Type II: central cyst with enlarged bone - Type III: eccentric cyst with minimal bone expansion - Type IV: subperiosteal cyst with superficial cortical erosion - Type V: cortical destruction with cyst expansion into the soft tissues

67. Campanacci staging of giant cell tumors (3)

- Stage I: benign latent lesion with normal bone morphology - Stage II: benign active lesion with cortical expansion - Stage III: benign aggressive lesion with cortical disruption

68. XR findings of Telangiectatic osteosarcoma (6)

- Expansile lesion - Metaphysis/epiphysis (epicentre is the metaphysis) - Geographic lysis - Wide zone of transition - Osteoid matrix - Internal septations and fluid-fluid levels

69. Glomus triad:

a. Pain b. Cold intolerance c. Purple d. Xray shows dorsal shelled out lesion

70. Rad Sensitive Tumours:

a. Myeloma b. Lymphoma c. Leukemia d. Breast e. Prostate f. Lung

71. Rad Resistant:

a. Thyroid b. Renal c. GI d. Melonoma

72. Synovial Tumors (3):

a. PVNS b. lipoma arborescens c. synovial chondromatosis d. also need to consider synovial sarcoma

73. Common translocations:

a. 11:22 – Ewing’s b. 9:22 – Chondrosarcoma c. X:18 – Synovial sarcoma d. 12:22 – clear cell sarcoma e. 12:16 – myxoid liposarcoma

75. Surface lesions:

a. parosteal osteosarcoma b. myositis ossificans c. ?periosteal sarcoma

76. Metastatic pattern with lymph nodes spread: “SCARE”

a. Synovial sarcoma b. Clear cell sarcoma c. Angiosarcoma d. Rhabdomyosarcoma e. Epithelial sarcoma

77. “Classic locations”

a. Chordoma – sacrum b. Enchondroma – phalanges c. Chondrosarcoma – pelvis

78. Standard chemotherapy regimen for bone sarcoma (4 – MACI):

a. Methotrexate b. Adriamycin/doxorubicin c. Cisplastin d. Iphopsphamide

79. Standard chemotherapy regimen for soft tissue sarcomas (2):

a. Adriamycin/doxorubicin b. Iphosphamide

Epiphyseal lesions:

clear cell chondrosarcoma, GCT, chondroblastoma