MSK Oncology

Question 1

two most common aggressive bone lesions in >40

Answer 1

metastatic carcinoma or myeloma.

Question 2

common aggressive bone lesions in under 40

Answer 2

sarcomas. in under 40, consider a primary bone malignancy

Question 4

general protocol if someone presents with an enlarging soft tissue mass

Answer 4

(any age) =
r/o primary muscle/soft tissue malignancy (soft
tissue sarcoma); ultrasound, MRI

Question 5

describe the difference between benign and malignant solid tumors.

Answer 5

Question 6

a sarcoma is a malignant tumor of connective tissue of ____ origin.

Answer 6

of mesenchymal origin; fat muscle cartilage bone nerves and blood vessels.

Question 7

T/F a sarcoma also has epithelial cell origin

Answer 7

false. not epithelial cells/galndular tissue or haematopoeitic

Question 8

aT/f there are benign sarcomas

Answer 8

false. they are all aggressive.

Question 9

Question 10

patient presentation of bone sarcomas

Answer 10

remember that older people are more likely to have metastatic, vs younger people are more likely to have primary bone disease.

pain is the most common symptoms of malignant in bone. pain not believed by sleep or rest. NIGHT PAIN

Question 11

T/F Benign bone lesions have an associated soft tissue mass that is causing the weakening of the bone

Answer 11

false. it originates in the bone. no assocaited soft tissue mass. more likely to be a malignant bone lesion.

Question 12

• Right shoulder pain
• 2 physicians, 1 physiotherapist = rotator cuff pain
• 6 months later = arm swelling/soft tissue mass

Answer 12

these have ill defined borders, no sclerotic rim or septations which would indicae a benign bone lesion.

a malignant bone lesions = poorly defined bordes, periosteal reaction, cortical erosoin, soft tissue mass.

this looks more malignant. it has a wide zone of transition/permeative.

this is a classic osteosarcoma. the physicians shouldve been wierded out that a 16 year old has rotate cuff pain.

Question 14

outline the types of periosteal reaction

Answer 14

Question 15

Answer 15

Question 16

benign or malignant?

25yo female Hip pain Rest and activity

Answer 16

• benign. this is a bone cyst.
• sclerotic border, well defined, no obvious periosteal reaction. Well demarcated lesion on the neck of the femur. Because it’s well demarkatd, it’s most likely benign. But it is still causing blood supply cut off to the femoral head and can predispose her to fracture.

Question 17

30yo male Ankle pain Getting better. benign or malignant?

Answer 17

benign/indolent. well demarkated. this is called an aneyrysmal bone cyst.

Question 18

10yo male Shoulder pain Pain all the time Swelling around deltoid

benign or malignant?

Answer 18

Proximal humerus lesion Bone forming

• ill defined soft tissue mass. can see a shadowing on the XRAY

AGGRESSIVE/MALIGNANT

Question 19

bone sarcoma work up

Question 20

Why should you get a CT scan or bone scan instaed of just xray?

Answer 20

CT chest so you can see if there is metastasis to the lungs. Metastatic disease is the most important predictor of survival.

both tests are more sensitive and can see more htan an Xray

Question 21

single most important
predictor of survival (of cancer)

Answer 21

metastatic disease

• Bone sarcomas rarely metastasize to sites other than
  bone/lung

Question 23

3 primary bone sarcomas

Answer 23

1. osteosarcoma
2. chondrosarcoma
3. ewin sarcoma.

More common in early stages of life because of rapid skeletal division and growth.

Question 24

type of periosteal reaction common seen in osteosarcoma vs ewing sarcoma

Answer 24

osteosarcoma. looks more like codmans triangle/spiculated periosteal reaction.

in ewing sarcoma, it has a classic lamellate moth eaten perisoteal appearance.

Question 25

population distribution of osteosarcoma

Answer 25

bimodal distribution

• 10-25yo (MAJORITY)
• >50yo (post-radiation; Paget’s disease of bone)
• usually caught when it’s already high grade.
  Vast majority are aggressive, high grade, pathologic fractures.

Question 26

classic areas of osteosarcoma

Answer 26

• head of humerus/deltoid area
• distal femur and head of femur
• tibial area
• iliac crest

Question 27

Answer 27

osteosarcoma. note the poor demarcation.

Question 28

T/f an osteosarcoma often presents with systemic signs

Answer 28

false. bone disease rarely is metastatic. but they often do presnt late in the gmame with a high grade bone tumor with painful bone mass/limb joint swelling, possible pathological fracture and bone pain.

Question 29

general management of bone sarcoma in peds

Answer 29

• chemotherapy for 10-12 weeks
• local control with surgery or radiation or both
• consolidative chemotherapy after.
• plus routine imaging after that.

Question 30

you suspect osteosarcoma. what do you do?

Answer 30

1. protected weightbearing with brace or cane or something to prevent fracture
2. local MRI imaging
3. systemic imaging with bone scan and CT chest to see mets
4. urgen referral to an oncology center,

Question 31

mutation of the __- gene has a higher predisposition for developing osteosarcoma and reoccurrence.

Answer 31

Rb1 gene.

Question 32

is chonrdrosarcoma more common in aadults of children. what site is more likely to get a chondrosarcoma?

Answer 32

peak incidence 40-70 years of age. it’s the second most common primary bone sarcoma. it’s more likely to present in the pelvis.

Question 33

T/F; like osteosarcoma, chondrosarcoma can be treated with chemo and radiation before and afer surgery

Answer 33

FALSE. not chemo sensitive. not radiation sensitive. this is purely surgical disease.

Question 34

on xray, it’s hard to differentiate between chondrosarcoma and osteosarcoma. how do you do it?

Answer 34

look for growth plates. if you see growth plates its probably an osteosarcoma because condrosarcoma usually presents in the 40-60 age group.

Question 35

Answer 35

chondrosarcoma. note the fibrous cartilage growing out of control

Question 36

presentation of a chondrosarcoma

Answer 36

• kind of like osteosarcoma but they may have more pelvic pain/pelvic fullness.

Question 37

for chondrosarcoma, _____ ___ is the most important progranostic indicator

Answer 37

histological grade is the most important prognostic indicator.

grades 1-3

Question 38

general treatment for osteosarcoma

Answer 38

multimodal chemotherapy and negative margin resection

BUT in chondrosarcoma, it’s only surgical reparation. it is not repsonsive to chemo.

Question 40

T/F ewing sarcoma forms cartilage, similar to a chondrosarcoma

Answer 40

false. it doesn’t form bone or cartilage.

Question 41

what incidence/population does ewing sarcoma affect most and at what location?

Answer 41

peak incidence 10-20 years, more likely to present in the pelvis; diaphysis of long bones.

Question 42

T/F: ewing sarcoma is both chemo and radiation senstive

Answer 42

true.

Question 43

ares most affected by ewing sarcoma

Answer 43

• pelvis
• fibular shaft.

Question 44

this is a pediatric patient

Answer 44

this is eqing sarcoma. look at the moth -eaten perisoteral reaction.

Question 45

Answer 45

ewing sarcoma

Question 46

Answer 46

chondrosarcoma

Question 47

T/F ewing sarcoma has systemic symptoms on presentation

Answer 47

TRUE. unlike chondrosarcoma and osteosarcoma, ewing sarcoma has systemic signs such as weightloss, fever, hcills, malaise.

Question 48

characteristic presentation of ewing sarcoma

Answer 48

• bone pain
• painful bone mass
• ***RIB MASS (ASKINS TUMOR)
• SYSTEMIC SIGNS/SYMPTOMS
• pathological fracture
• soft tissue fracture.

Question 49

Just like osteosarcoma or chondrosarcoma suspicion, you do protected weightbearing, local MRI imaging, and bone scan and CT chest and refer to an oncology center. what other test should you run if you suspect a ewing sarcoma?

Answer 49

a BONE MARROW ASPIRATE.

Question 50

treatment of ewing sarcoma

Answer 50

multimodal chemotherapy or radiation therapy plus a negative margin resection.

Question 51

bone sarcoma summary