Primary Malignancies

Question 1

What is the most common primary malignancy?

Answer 1

MM (27%) (then osteosarcoma then chondrosarcoma then Ewing’s)

Question 2

Which primary malignancy is a proliferation of plasma cells which infiltrate the bone marrow?

Answer 2

MM

Question 3

What is the age range for MM?

Answer 3

5-8th decade (75% are of ages 50-70 years)

Question 4

Which gender is more likely to have MM?

Answer 4

Males

Question 5

Which is more common: MM or metastasis?

Answer 5

Still metastasis….

Question 6

Which two bone tumors are the only ones that are more common in females compared to males?

Answer 6

Hemangiomas and aneurysmal bone cyst (“bloody ones”)

Question 7

What is the most common cause of death in patients with MM?

Answer 7

Recurrently bacterial infections

Question 8

What is the primary rad finding for MM?

Answer 8

Deossification of bone

Question 9

What is the usual presentation of a bone scan in those with MM?

Answer 9

Negative

Question 10

What are some laboratory findings that can be seen with MM?

Answer 10

Elevated ESR, plasma proteins, serum calcium, and serum phosphorus with thrombocytopenia, and rouleaux formation

Question 11

What is the rouleaux formation that is commonly seen with MM?

Answer 11

Stacks or aggregates of RBCs seen on blood smear

Question 12

What protein finding is commonly seen in 80-90% of those with MM?

Answer 12

Protein electrophoresis with “M-spike”

Question 13

Detection of which protein in the urine can be found in 40% of MM patients?

Answer 13

Bence Jones proteins

Question 14

What is the best test for MM besides the obvious biopsy?

Answer 14

M-spike protein electrophoresis

Question 15

What are the common locations for a solitary plasmacytoma?

Answer 15

Vertebra > pelvis > skull > sternum > ribs

Question 16

What is the term for a tumor that is a localized form of plasma cell proliferation?

Answer 16

Solitary plasmacytoma

Question 17

How does a solitary plasmacytoma typically present?

Answer 17

Soap bubbly, highly expansile lesion

Question 18

What is unique about the expansion of a solitary plasmacytoma in what it chooses to spare?

Answer 18

Posterior elements (of vertebrae)

Question 19

What radiographic sign on an PA chest film can indicate a possible solitary plasmacytoma?

Answer 19

Extrapleural sign

Question 20

What is an extrapleural sign?

Answer 20

Something in the pleural space pushing lungs inward

Question 21

What type of thoracic spine change can be seen with solitary plasmacytomas of multiple levels?

Answer 21

Gibbus formation

Question 22

What is the Gibbus formation?

Answer 22

Acute angular kyphotic thoracic spine changes causing wedges (think multiple solitary plasmacytomas)

Question 23

“Rain drop skull” is associated with which neoplasm?

Answer 23

Multiple Myeloma

Question 24

What is the best imaging used to detect MM?

Answer 24

Conventional radiography

Question 25

How can an MRI help detect MM?

Answer 25

Marrow changes (2nd best test)

Question 26

What is the cause of the appearance of a "rain drop skull" seen with MM?

Answer 26

Multiple holes of various sizes in the skull

Question 27

In only what specific location of the body is cortical thinning considered a normal pattern of aging?

Answer 27

Deltoid tuberosity of the humerus

Question 28

What type of MRI is best to be used for MM detection?

Answer 28

STIR (contrast enhanced T1)

Question 29

What is usually the prognosis for MM?

Answer 29

Poor (5 year survival 20%)

Question 30

Which tumor is a primary malignant tumor of undifferentiated connective tissue which forms neoplastic osteoid and is also the second most common primary malignant bone tumor overall?

Answer 30

Osteosarcoma

Question 31

What is the most common primary malignant bone tumor in children and young adults?

Answer 31

Osteosarcoma

Question 32

What is the age range for osteosarcoma?

Answer 32

BIMODAL: 10-25 and again after age 60

Question 33

What is the most common form of osteosarcoma?

Answer 33

Central

Question 34

Do osteosarcomas grow slowly or quickly?

Answer 34

QUICK

Question 35

Osteosarcomas most commonly attack which joint of the body?

Answer 35

Knee (50%)

Question 36

What is the most common location for an osteosarcoma?

Answer 36

Distal femur (40%) with 75% occurring in metaphysis next to growth plate

Question 37

Are osteosarcomas usually lytic or blastic?

Answer 37

Blastic (50%)

Question 38

Where is an osteosarcoma likely to metastasize to?

Answer 38

Lungs (cannonball metastasis)

Question 39

What periosteal reaction is associated with an osteosarcoma?

Answer 39

Sunburst/Codman's triangle

Question 40

What is the area of a radiolucent line that can sometimes be seen between the long bone and the present osteosarcoma on X-ray?

Answer 40

"String sign" (shows that bone and tumor are not fully attached)

Question 41

Why does the age range for osteosarcoma also include those over 60?

Answer 41

Secondly osteosarcomas can arise from Paget's disease which has the age distribution of over 60

Question 42

What is the third most common primary malignant bone tumor?

Answer 42

Chondrosarcoma (10%)

Question 43

Chondrosarcomas can be found anywhere except for what location?

Answer 43

SKULL (think about it....skull is made from intramembranous ossification NOT endoCHONDRAL)

Question 44

What is the age range for a chondrosarcoma?

Answer 44

Over 50

Question 45

Do chondrosarcomas develop slowly or quickly?

Answer 45

SLOWLY

Question 46

What are some common locations of chondrosarcomas?

Answer 46

Proximal humerus, femoral neck, ribs/sternum, pelvis

Question 47

What type of calcified appearance is seen with chondrosarcomas?

Answer 47

Popcorn matrix with C-shaped calcifications

Question 48

Why must chondrosarcomas be treated by excision only?

Answer 48

Cartilage doesn't typically respond to radiation and/or chemotherapy

Question 49

What is the 4th most common primary malignant bone tumor?

Answer 49

Ewing's sarcoma

Question 50

What is the 2nd most common primary malignant bone tumor in children?

Answer 50

Ewing's sarcoma

Question 51

What is the age range for Ewing's?

Answer 51

10-25 (peak at 15 years)

Question 52

What is the most common location for Ewing's?

Answer 52

Long tubular bones like the femur, tibia, humerus, fibula (60%) but the other 40% is in flat bones like the pelvis

Question 53

Does Ewing's have a better prognosis in long or flat bones?

Answer 53

Long bones

Question 54

How can we differentiate Ewing's from an osteosarcoma/

Answer 54

``` Ewing's = diaphysis Osteosarcoma = metaphysis ```

Question 55

Is a Ewing's sarcoma a blastic or lytic lesion?

Answer 55

Lytic

Question 56

What is the most identifiable radiographic finding of Ewing's?

Answer 56

Onion-skin periosteal reaction

Question 57

What observational clinical finding is commonly seen with patients who have a Ewing's sarcoma?

Answer 57

Soft tissue mass and swelling (55%)

Question 58

To where does Ewing's commonly metastasis?

Answer 58

Skeleton (lungs would be second most common)