Malignant bone tumours Flashcards
systemic symptoms
weight loss loss of appetite fatigue more likely in patients over 60
red flags that there is metastatic cancer affecting bone
constant pain - may be severe and is usually worse at night systemic symptoms unexplained skeletal pain in over 60s - more likely to develop malignant cancer unexplained skeletal pain in under 25s - shouldn’t happen
characteristics of primary malignant bone tumours
can occur in children not uncommonly misdiagnosed as muscle pain - presentation is often late so metastases have occurred
X-ray signs of a primary malignant bone tumour
substantial ill-defined bone swelling - urgent investigation and referral aggressive and destructive signs cortical destruction periosteal reaction - raised periosteum producing bone new bone formation - sclerosis as well as lysis from destruction extension into surrounding soft tissue envelope
what is osteosarcoma?
the most common primary malignant tumour producing bone pretty aggressive
who gets osteosarcoma?
younger - adolescence, early adulthood proximal femur, proximal humerus and pelvis are the common sites
what is the metastatic spread of osteosarcoma?
haematogenous not lymphatic spread 10% have pulmonary metastases at diagnosis
what is the treatment for osteosarcoma?
it is not radiosensitive but adjuvant chemotherapy can prolong survival
what is chondrosarcoma?
a cartilage producing bone tumour mainly in the older age group - 45 can be very large and slow to metastasise normally in the pelvis/proximal tumour
how is chondrosarcoma managed?
not radiosensitive and unresponsive to adjuvant chemotherapy
the prognosis depends on histological grading - majority are low grade
how do you grade a sarcoma?
the degree of differentiation/proliferation (miotic count)
presence of coaguative necrosis
what are fibrosarcoma and malinant fibrous histiocytoma
fibrous malignant primary bone tumours
In abnormal bone e.g. bone infarct, fibrous dysplasia, post irradiation or Paget’s disease
fibrosarcoma occurs in adolescents and young adults
what is Ewing’s sarcoma?
a malignanr tumour of the primitive cells in the marrow
the 2nd most prevalent bone tumour
has the poorest prognosis
how does ewing’s sarcoma present?
in 10-20 year olds
symptoms (associated):
fever
raised inflammatory markers
warm swelling
may be misdiagnosed as osteomyelitis
how is ewing’s sarcoma treated?
radiosensitive and chemosensitive
how are primary bone tumours managed?
staging investigations
bone scan
CT chest
MRI & CT - to determine the extent of the tumour and muscle nerve and vessel involvement
biopsy - histological diagnosis & grading prior to definitve surgery
surgery: remove the tumour and surrounding tissue
amputations used to be common
limb salvage surgery since the chemo’s better now
wide margin 3-4cm
biopsy tract removed with the tumour
joints involved need reconstructed
adjuvanr chemotherapy and radiotherapy:
neo-adjuvant chemotherapy (prior) - can improve survival
80% survival rate
what is lymphoma?
cancer which begins in the lymphocytes
round cells of the lymphocytic system/ macrophages
primary lymphoma in the bone
non-hodgkins lymphoma from marrow
pelvis and femur are common sites
treatment - surgical resection
Metastatic lymphoma
any lymphoma can metastasise to the bone (20%)
treatment:
splenomegaly
radiotherapy or chemotherapy
survival less than 2 years
What is myeloma?
malignant B cell proliferation from the marrow
solitary lesion = plasmacytoma
multiple lesions = multiple myeloma
how does myeloma present?
in 45-65
weakness
back pain
bone pain
fatigue
weight loss
may have marrow suppression - anaemia,recurrent infection
may present with pathologic fracture
how is myeloma diagnosed?
plasma protein electophoresis - high paraprotein levels
early morning urine collection - Bence Jones protein assay
x rays
lytic lesions - not usually an osteoblastic response to the osteoclastic bone reabsorptoin - metastases may not be detected on bone scan
How is myeloma treated?
plasmacytoma = radiotherapy
multiple myeloma = chemotherapy (5yrs< 30%)
bones most frequently involved in metastatic bone cancer
vertebra
pelvis
ribs
skull
humerus
long bone of lower limb
type of metastases from breat carcinoma
blastic (sclerotic/ lytic metastases
mean survival 24-26 months
type of metastases from prostate carcinoma
sclerotic metastases
osteoblastic activity - pathologic fractures are more likely to heal
radiotherapy and hormone manipulation - reduce fracture risk
survival with prostatic bone metastases around 45% at 1 year
type of metastases from lung carcinoma
lytiv bony lesions
mean survival 6 months with bone metastases
type of metastases from renal cell carcinoma
large, very vascular lytic “blow out” bony metastases
can bleed tremendously with biopsy or surgery
single bone metastasis and primary tumour amenable to resection (nephrectomy) - surgery
multiple bone metastases mean survival 12-18 months
symptoms of bone metastases
pain - initially can be misdiagnosed as muscle pain
any pain with red flags should be investigated at least by x ray
pathological fracture
investigations if bone lesion found on x-ray in over 45
primary bone tumour needs to be excluded - bone scan, MRI
bone scan - exclude primary bne umour, demonstrate extent of metastases
if multiple - primary tumour should be found
breast exam
PR exam
CXR - pulmonary lesion
Blood tests:
serum calcium - hypercalcaemia
LFTs
plasma protein electropheresis - myeloma
FBC
U&E
what are the indications that there is a risk of impending fracture because of a bone metastases
very painful lesions - especially on weight bearing
lesions occupying >50% of the diameter of the bone
cortical thinning
“at risk areas” - subtrochanteric area of the femur
skeletal stabilisation/ joint replacement should be done
when should surgery be done for metastases
fractures/impending fractures - stabilization using long ords (intramedullary nails)
destruction of joint (acetabulum, femoral head) - joint replacement
surgery has a high risk of DVT and prophylaxis must be given
chemo and radiotherapy after surgery
how should painful lesions not to be at risk of impending fracture be managed?
bisphosphates and radiotherapy
spinal cord compression - advanced spinal metastases
radiotherapy or surgical decompression (anterior or posterior)
