Quiz 1 - malignancies of bone Flashcards
1
Q
Most common malignant tumors of bones?
A
Mets (25x MC than 1˚)
2
Q
What are the MC primary malignancy sites?
A
Lung
Breast
Renal
Prostate cancer
3
Q
Mets targets what are?
A
Axial skeleton, skull, proximal extremities (blood)
4
Q
What is acral metastasis
A
The rare occurrence of mets distal to the knee or elbow
5
Q
What is primary malignancy in women vs men?
A
Breast = women, then thyroid, kidney, uterus
Prostate = men, then lung
6
Q
Most patients are how old?
A
Over 40
7
Q
Malignancy under 5 yo is usually what malignancy?
A
Neuroblastoma
8
Q
Malignancy under age 10-20 yo is usually?
A
Ewing sarcoma
Osteosarcoma
9
Q
Malignancy age 200-35 is usually what disease?
A
Hodgkin lymphoma
10
Q
What % of people have bone pain?
A
70%
Insidious, remission/exacerbation, persistent, nocturnal
11
Q
Patients with suspected metastasis should get what lab studies
A
ESR
CBC
Chem screen
UA
12
Q
What are the 3 routes of mets?
A
- Hematogenous is MC via arteries
- Direct invasion soft tissues
- Lymph dissemination (unusual)
13
Q
What imaging is needed for mets? (4)
A
Plain radiograph
CT
MRI
Bone scan (nuclear imaging)
14
Q
What does mets look like on radiograph?
A
75% osteolytic (moth-eaten, permeative)
15% osteoblastic
15
Q
What is a “blow-out” pattern?
A
Large, very expansile, solitary
Suggests renal or thyroid primary
16
Q
40% of mets occurs in what location?
A
Spine
Thoracic and lumbar MC
17
Q
What is the MC cause of missing pedicle?
A
Osteolytic mets
18
Q
3 MC causes of ivory vertebra
A
Osteoblastic mets
Paget’s disease (cortical thickening, expansion)
Lymphoma (Hodgkin) (anterior body scalloping)
19
Q
MC cause of extrapleural sign?
A
Rib mets
20
Q
Skeletal metastasis is most common where?
A
28% ribs and sternum
12% pelvis
10% skull
10% long tubular bones
21
Q
Management plan for mets?
A
Identify primary site
Identify extent of mets
Manage P and bone loss
22
Q
What are 3 meds commonly for managing mets.
A
Steroids and NSAIDS
Bisphosphonates to manage osteoblastic activity
23
Q
What are the 4 MC primary malignancies of bone? And MC ages of people to get them? (Hint: MOCE)
A
Multiple myeloma (50-70 y.o.)
Osteosarcoma (10-25 y.o.)
Chondrosarcoma (40-60 y.o.)
Ewing’s sarcoma (10-25 y.o.)
In order of age:
O + E = 10-25 yo
C = 40-60 yo
MM = 50-70 yo
24
Q
What age group gets Multiple myeloma?
A
50-70 y.o.
25
What age group gets Osteosarcoma?
10-25 y.o.
26
What age group gets Chondrosarcoma?
40-60 y.o.
27
What age group gets Ewing’s sarcoma?
10-25 y.o.
28
Where is MM located usually?
Similar as mets (axial skeleton, proximal femur and humerus, skull) PLUS long bones: the whole humerus, femur, tibia, fibula, radius, ulna.
29
What are signs and Sx of MM?
```
Bone pain (worse with activity and weight bearing, pathologic fx)
Anemia
Proteinuria
Renal disease
Weight loss/cachexia
Osteoporosis
Amyloidosis
Bacterial infections (esp. respiratory)
```
30
How do you dx MM?
Blood screening:
- anemia
- thrombocytopenia
- elevated ESR
- hyperuricemia, hypercalcemia
- elevated serum proteins
- -> M spike with electrophoresis is diagnostic
- Benjones protein in urine
- bone marrow aspirate shows increased number of bone marrow plasma cells
31
Multiple, well-defined, round osteolytic defects: “punched out” defects and endosteal scalloping
Severe generalized osteopenia
High incidence pathologic Fx
This suggests what disease?
MM
32
Where does MRI, bone scan, CT play a role in detecting MM?
MRI very sensitive to marrow changes
Bone scan is usually negative
CT does not play a major role
33
What is the Prognosis of MM?
Prognosis is poor
34
Complications of MM? (3)
Pathologic fx
Renal failure
Respiratory infection
35
Tx for MM?
Targeted drug therapy
Chemotherapy
Bone marrow transplant
36
What is the concern with a solitary plasmacytoma?
70% develop MM within 5 years
37
Geographic
Lytic
Highly expansile
“Soapy bubbly”
If this is seen on radiograph, what do you think it might be?
solitary plasmacytoma
38
What location does solitary plasmacytoma favor?
MC Thoracic Spine
| 20% Rib, sternum, classical, scapula
39
Median age for solitary plasmacytoma
55
40
What is solitary plasmacytoma
Localize plasma cell neoplasm
41
What is a malignant neoplasm which forms osteoid called?
Osteosarcoma
42
Where are Osteosarcoma usually located?
80% Intramedullary (knee)
10-15% Surface/juxtacortical
5% extra skeletal
43
What percentage of Osteosarcoma are primary vs secondary?
75% primary in 10-20 yo
25% secondary = older patients d/t malignant degeneration of benign lesion or Paget’s
44
What are signs and Sx of Osteosarcoma?
- Painful swelling
- Pain increases with activity
- Pathologic Fx possible
- Onset of Sx to Dx often >6months
45
“Cumulus cloud” appearance
Cortical destruction, aggressive periosteal response, soft tissue mass
Location: metaphysis of long bone (75% of them)
Appearance: sclerotic (50% of the time)
If you saw this on plain film, what would you think?
Osteosarcoma
46
What is the role of MRI, CT, bone scan with Osteosarcoma?
MRI is used in planning Tx (determine extend of lesion and relationship to vessels and nerves)
Chest CT and Bone scan detects metastasis
47
What is the prognosis for Osteosarcoma
Mets to lungs common, mets to other bones possible
48
To for Osteosarcoma
Aggressive surgical resection often includes amputation
Mets to lung “cannonball metastasis”
Radiation therapy
Chemotherapy
49
“Cannonball mets”
Osteosarcoma
| Ewing sarcoma
50
What kind of Osteosarcoma accounts for 5% all Osteosarcoma?
Parosteal Osteosarcoma
51
How fast does Parosteal Osteosarcoma grow?
Slow
52
What are the symptoms of Parosteal Osteosarcoma?
Similar to osteosarcoma:
- Painful swelling
- Pain increases with activity
- Pathologic Fx possible
53
Age range of Parosteal Osteosarcoma?
30-50yo
54
Dense, juxtacortical mass with stalk to cortex and NO periosteal response
Parosteal Osteosarcoma
DDx: myositis ossificans (MO) because they looks so similar (see slide 60)
55
How do you know its Parosteal Osteosarcoma and not MO?
PO: stalk attaches to cortex. Central portion is more dense and less dense at periphery, grows over time
MO: separated from the bone. Less dense in the middle. Gets smaller over time.
56
What is secondary Osteosarcoma?
Malignant degeneration of benign lesion
57
What are the 4 most common benign lesions to turn into secondary osteosarcoma if they undergo malignancy? (3 + 1 special one)
Paget’s disease
Fibrous dysplasia
Osteochondroma —> osteosarcoma
Enchondroma —> chondrosarcoma THEN osteosarcoma
(—> signifies malignant changes)
58
What is the age range of chondrosarcoma?
40-70 yo MC
| Though 20-90 possible
59
What gender gets chondrosarcoma?
M>F 2:1
60
chondrosarcoma is what % of primary bone malignancies
25% primary bone malignancies are chondrosarcoma
61
Cartilaginous matrix?
Think chondrosarcoma
62
It’s possible for these 2 lesions, when they undergo malignancy, to become chondrosarcoma:
Enchondroma
| Osteochondroma
63
Signs and Sx of chondrosarcoma?
Deep, dull, achy pain
Sometimes mild limp, limited ROM
Soft tissue swelling/ mass possible
Hx of 2-5 years
64
Lab findings for chondrosarcoma?
Typically WNL
65
What is the MC location for chondrosarcoma? (2)
Where else can you find it? (6)
Any bone preformed in cartilage.
MC: pelvic, proximal femur
Also: proximal humerus, ribs, scapula, distal femur, proximal tibia, craniofacial bones
Metaphyseal or diaphyseal; clear-cell in epiphysis (<2%)
66
What is the MC benign tumor of the hand?
Enchondroma
67
What is the MC primary malignancy of hand, sternum, scapula?
Chondrosarcoma
68
Large, lytic, poorly defined
Calcification in 70% “popcorn,” “stippled,” “arcs and rings”
Large soft tissue mass
Endosteal scalloping
Plain film findings for?
Chondrosarcomaa
69
Chondrosarcoma and Enchondroma look very similar. What is the main difference?
[answer here]
70
What is the prognosis for chondrosarcoma?
Slow progression
High 5-year survival rate w/ early Tx
Grade 1 = 90% survival rate
Grade 3 = 30% survival rate
71
Tx for chondrosarcoma?
Surgical resection
| Radiation and chemo have limited use
72
Are mets common with chondrosarcoma?
No
73
What is an uncommon subtype of chondrosarcoma?
clear cell chondrosarcoma
74
Where is clear cell chondrosarcoma located? What does it look like?
Epiphysis
Round, sharply marinated lytic lesion
75
What bones is clear cell Chondrosarcoma MC found in?
Proximal long bones
76
Will clear cell chondrosarcoma have sclerosis or calcification/
Maybe
77
How do you distinguish clear cell chondrosarcoma from chondroblastoma?
Cannot.
78
Who gets Ewing sarcoma?
10-25 yo
| M>F
79
Ewing sarcoma is what % of primary malignancies?
7%
80
Marrow cell tumor
“Round cell”
What kind fo tumor is this?
Ewing sarcoma
81
Signs and Sx of Ewing sarcoma
Localized P and swelling, local warmth, tenderness, dilated veins
Palpable soft tissue mass
Systemic signs: fever, anemia, leukocytosis, increased ESR
82
Location of Ewing sarcoma
70% Long bones (Femur, tibia, humerus: and diaphysis is classic location)
25% Flat bones (pelvis, ribs, scap)
5% spine
83
What long bones does Ewing sarcoma MC show up in
Humerus
Femur
Tibia
Fibula
84
Permeative lytic destruction w/ wide zone of transition
Aggressive periosteal response (25-50%): sunburst, laminated, codman
Sclerosis seen in up to 40%
What problem do these plain film findings suggest?
Ewing sarcoma
85
Prognosis for Ewing sarcoma
Poor
86
Tx for Ewing sarcoma
Chemotherapy is mainstay
- radiation
- surgical resection/amputation
Commonly mets to lungs “cannonball mets”
87
What is the MC primary malignant bone tumor to mets to bone?
Ewing sarcoma
88
What is a rare <2% primary bone malignancy?
Fibrosarcoma
89
Fibrosarcoma is MC in what age group
30-50 yo
90
Where is Fibrosarcoma located commonly
Major long bones
| 50% at knee
91
What is Sx for Fibrosarcoma
Pain, swelling
| Ave 2 yrs before Dx
92
Highly destructive, expanding, lytic lesion
Large soft tissue mass
No periosteal reaction
What do these radiograph findings suggest?
Fibrosarcoma
93
What is prognosis for Fibrosarcoma
Poor
Frequent local recurrence up to 80%
94
What is Tx for Fibrosarcoma
Amputation
95
When and where does Fibrosarcoma metastasize?
Mets late to Lung, liver, lymph, brain
96
What is the MC soft tissue sarcoma in adults?
Malignant fibrous histiocytoma (MFH)
97
What is histologically similar to fibrosarcoma?
Malignant fibrous histiocytoma (MFH)
98
What location does Malignant fibrous histiocytoma (MFH) affect?
50% Lower extremity
| 20% upper extremity
99
Sx of Malignant fibrous histiocytoma (MFH)?
Painless, solid mass usually
100
Where does Malignant fibrous histiocytoma (MFH) mets?
Lungs
101
What is a rare <1% primary bone malignancy?
Chordoma
102
What originates from notochord remnants?
Chordoma
103
What age group is Chordoma
30-70 yo
| M>F
104
What is the only primary malignancy to cross the IVD?
Chordoma
105
Prognosis of Chordoma?
Poor
| Difficult surgical resection
106
What vertebra is Chordoma MC in?
C2
107
```
Midline lesions
Lytic destruction
Cortical expansion
Calcification in 50%
Soft tissue mass
```
What do these findings suggest?
Chordoma
DDx: lytic mets, chondrosarcoma, GCT, ABC, plasmacytoma
108
What is 3-4% of primary bone malign?
Lymphoma of bone
109
What is the prognosis for Lymphoma of bone
Better than most primary bone malignancies
110
Age and gender of Lymphoma of bone?
20-50 yo
| M>F
111
What is rare, extranodal lymphoma?
Lymphoma of bone
112
Signs and sx of Lymphoma of bone
```
Local intermittent pain
Dull, aching, not relieved by rest
Generally healthy pt
Over 50% have Sx > 1 year
Palpable mass or swelling
```
113
MC location for Lymphoma of bone
Lower extremities, pelvis, spine
114
Permeative, moth-eaten lytic destruction
Minimal periosteal response
Soft tissue mass
Pathologic Fx common
These radiograph findings suggest?
Lymphoma of bone
115
What is usually secondary to systemic Hodgkin?
Hodgkin Lymphoma of bone
10-20% patients with Hodgkin develop skeletal involvement
116
What is the MC sx of Hodgkin Lymphoma of bone
Pain
117
MC location for Hodgkin Lymphoma of bone?
Vertebral body
| “Ivory vertebra”
118
Hodgkin Lymphoma of bone is polyostotic in
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