Test #1 Flashcards
Osteomas have a predilection for what site in the body?
Skull
Enchondromas have a predilection for what part of the body?
Hand
Hemangiomas have a predilection for what site in the body?
Vertebra
Where is the M/C location for a Ewing’s Sarcoma?
Shaft of the femur in younger people
Can show up in pelvis if pt is older
Examples of tumors that predominate in areas of red or hematopoietic marrow
Ewings
Lymphoma
Myeloma
Majority of bone tumors & infections arise in which part of the bone?
Metaphysis
Bone tumors typically arise in locations where the homologous normal cells are _________
Most active
This is caused by a puncture wound that forces epithelial cells into the bone where it grows & develops into a cyst
Epidermoid cyst
If a lesion involves the vertebral body is it more likely to be malignant or benign?
Malignant
If a lesion is more likely to involve the pos. vertebra is it more likely to be malignant or benign?
Benign
A “cleavage line” usually indicates what type of lesion location?
Parosteal location
Malignant or aggressive lesions tend to be small or large at time of discovery?
Large except for:
Fibrous dysplasia
Simple Bone Cyst
ABC
If a lesion is longitudinal in shape then it tends to be malignant or benign?
Benign
If a lesion is pleomorphic (round-shape) then it tends to be malignant or benign?
Malignant
An imperceptible zone of transition of a lesion indicates what?
It’s malignant
If the zone of transition of a lesion is sharp, it indicates what?
It’s benign
What are the 3 types of lesion margins?
A margin w/ sharp demarcation by sclerosis
A margin w/ sharp demarcation & no sclerosis
A margin w/ an ill-defined region
What are 2 types of lesions that typically have a sharp margination?
Fibrous dysplasia
SBC
What are 2 examples of lesions w/ an imperceptible margination?
Metastasis
Infections
What % of cancellous bone must be destroyed before evidence is noted on conventional films?
30%-50%
What are the 3 patterns of bone destruction?
Geographic pattern
Moth-eaten pattern
Permeative pattern
Which 2 patterns of bone destruction indicate malignancy or infection?
Moth-eaten pattern
Permeative pattern
What are the characteristics of the Geographic pattern of bone destruction?
Least aggressive pattern Circumscribed & uniformly lytic Tend to be sharply marginated May be trabeculated M/C indicative of a slow-growing lesion
What are characteristics of the Moth-eaten pattern of bone destruction?
Multiple small or moderate sized lucenies (2-5mm)
Margins are frequently ill-defined
Longer zone of transition
Indicative of aggressive lesions
What are characteristics of the Permeative pattern of bone destruction?
Multiple holes <1mm in size
Poorly demarcated, not easily separated from normal bone
Areas of destruction may coalesce
Indicative of a very aggressive lesion
What is the dominate internal extracellular substance of a lesion called?
Matrix
Most tumors have what type of matrix?
Radiolucent matrix
This type of calcification occurs in devitalized (dead) tissue
Dystrophic calcification
This type of calcification results from abnormal calcium metabolism
Metastatic calcification
This type of matrix has a diffuse to hazy, fluffy, cotton, or cloud-like appearance
Osseous matrix
This type of matrix has a stippled, flocculent, arc or ring-like, popcorn-like, comma shaped appearance
Cartilage matrix
This type of matrix has a smoky, hazy, or ground glass appearance
Fibrous matrix
This type of matrix is hard to identify on plain film if it is intraosseous
Fat matrix
What are the two types of osseous matrix?
Tumor new bone (confined to bone)
Reactive new bone (seen in soft tissue)
What are the characteristics of Tumor New Bone?
New bone produced by osteogenic tumors
Fluffy, cloud-like in appearance
May appear homogenous or inhomogenous
What lesion is an example of Tumor New Bone?
Osteosarcoma
This type of osseous matrix lays down new bone in response to a stimulus
Reactive New Bone
What two lesions are examples of reactive new bone type of osseous matrix?
Degenerative sclerosis
Metastasis
What are the characteristics of cartilage matrix?
Many cartilage tumors produce matrix calcification
Extent & frequency of pathologically evident calcification is usually greater than seen on xray
Stipple, flocculent, pop-corn, ring-like appearance
What are examples of lesions assoc. w/ cartilage matrix?
Chrondrosarcoma
Enchondromas
Chondroblastomas
What are characteristics of a fibrous matrix?
Uniform increase in radiodensity
Smokey or hazy, ground glass appearance
Often difficult to identify
What is an example of a lesion assoc. w/ fibrous matrix?
Fibrous dysplasia
What is the trabeculation pattern assoc. w/ a giant cell tumor?
Delicate or thin
What is the trabeculation pattern assoc. w/ an ABC?
Delicate, horizontal possibly extending into the soft tissue
What is the trabeculation pattern assoc. w/ a hemangioma?
Honeycombed, striated, radiating
What is the trabeculation pattern assoc. w/ a NOF?
Lobulated
This is a key factor is assessing the growth rate of a lesion
Cortical integrity
What are the 3 types of appearances assoc. w/ cortical integrity?
Cortical erosion
Cortical Penetration
Cortical Expansion
Which of the 3 types of cortical integrity appearances implies malignancy or infection?
Cortical Penetration
This type of cortical integrity appearance is caused by slow growing medullary tumors that erode the inner cortex producing a lobulated or scalloped appearance
Cortical Erosion
This is a frequent feature of cartilaginous & fibrous tumors
Endosteal scalloping
This type of cortical integrity appearance is the result of progressive endosteal erosion together w/ periosteal bone formation. It is generally a sign of a benign, medullary tumor, however may be the result of a slow-growing malignancy
Cortical expansion
This is a fundamental response of bone to disease in which the Haversian system allows spread of the bone forming irritant causing the periosteum to lift
Periosteal response
What layer is the new bone formed by in a periosteal response?
Cambium layer
What is the latent period seen in a periosteal response?
10-21 day latent period
What age group if a periosteal response more often seen?
Children b/c the periosteum is more easily lifted in children
What are examples of bone forming irritants that can cause a periosteal response?
Blood Pus Neoplasm Edema Granulation Tissue
This is a type of periosteal response that is solid or simple & most often benign
Uniterrupted responses
This type of periosteal response is AKA a laminated or layered (onion-skin) periosteal response, Spiculated periosteal response, or Codman’s triangle & also indicates malignancy or infection
Interrupted Response
This periosteal response causes a continuous layer of new bone that attaches to the outer cortical surface. It may be undulating, smooth, elliptical & is related to a slow form of irritation
Solid Periosteal Response
What lesions are assoc. w/ a solid periosteal response?
Osteoid osteoma
Stress Fx
Venous stasis
HPO (hypertrophic pulmonary osteoarthropathy)
What is the M/C cause of hypertrophic pulmonary osteoarthropathy (HPO)?
Bronchogenic carcinoma
This type of periosteal response has alternating layers of opaque & lucent densities & can be seen w/ slow growing & aggressive tumors & infections
Laminated Periosteal Response AKA layered, onion-skin, lamellated
What lesion is assoc w/ a laminated periosteal response?
Ewings Sarcoma
This type of periosteal response has fine lines of new bone oriented perpendicular to the cortex or radiating from a point source. Usually indicative of very aggressive bone tumors
Spiculated periosteal response AKA Perpendicular, brushed whiskers, hair-on-end, sunburst
What lesions is assoc. w/ Spiculated Periosteal Responses?
Osteosarcoma
This results from the subperiosteal extension of the lesion & may accompany malignant, benign tumors or infections
Codman’s triangle AKA Codman’s angle, periosteal cuff
When you see an aggressive bone lesion in a child, you should think of what 3 things?
Osteosarcoma
Ewings Sarcoma
Infection
Benign tumors & tumor-like conditions typically do not exhibit soft tissue extensions except for?
Giant-cell
ABC
Osteoblastomas
What non-neoplastic conditions may exhibit a soft tissue component?
Osteomyelitis
What do soft tissue changes include?
Displaced overlying skin lines
Altered myofascial planes
Density changes (opacity vs lucency)
What do tumors do to myofascial plane lines?
Displace them
What do infections do to myofascial plane lines?
Obliterates them
How do infections & tumors differ when it comes to joint spaces?
Infections may cross joint spaces & the open physis, whereas tumors generally do not. Exceptions: ABCs will cross growth plates, chordromas
Osseous dissemination of cells originating from a primary malignant neoplasm
Metastatic bone tumor
What is the M/C osseous malignancy?
Metastasis
What are the M/C primary sites of metastatic bone tumors?
Breast Prostate Lung Kidney Thyroid Bowel
What are the least common sites of metastatic bone tumors?
CNS tumors
basal cell carcinoma of the skin
Primary malignant tumors arise in what type of bone?
Normal bone
Secondary malignant tumors arise in what type of bone?
diseased bone
Bone tumors usually metastasize through the _______ whereas other tumors usually go through the ______
Blood;Lymph
What are the M/C primary tumors that lead to metastasis in females?
Breast
Thyroid
Kidney
Cervix
What are the M/C primary tumors that lead to metastasis in males?
Prostate
Lung
Bladder
What are the M/C primary tumors that lead to metastasis in children?
<5 yoa - neuroblastoma
10-20 yoa - Ewings & osteosarcoma
What is the leading primary tumor that causes osteolytic metastasis in females?
Breast
What is the leading primary tumor that causes osteolytic metastasis in males?
Lung
What is the leading primary tumor that causes osteolytic metastasis in children?
Neuroblastoma
What is the leading primary tumor that causes osteoblastic metastasis in females?
Breast
What is the leading primary tumor that causes osteoblastic metastasis in males?
Prostate
What is the leading primary tumor that causes osteoblastic metastasis in children?
Hodgkins
What age group is metastasis M/C in?
after the 4th decade
What is the M/C presentation of metastasis?
Bone pain at the site, insidious in onset & progressive
What is the M/C complication of metastasis?
Pathologic fx
What are some clinical manifestations of metastasis?
may be asymptomatic; bouts of excerbation/remission
May see a soft tissue mass
Weight loss, cachetic (state of ill health), anemia, fever
Where do a majority of metastatic lesions occur?
In the spine
What are some lab values that would show an altered value?
ESR Calcium Alkaline Phosphatase Acid Phosphatase & PSA Proteins
What lab value could help distinguish b/w metastatic & myeloma?
Proteins
What is the M/C pathway for metastatic dissemination?
Hematologic frequently via Batson’s plexus
What is the imaging procedure of choice for metastasis screening?
Bone scintigraphy
What are the M/C (H-to-L) skeletal locations for metastasis?
Vertebrae Ribs & Sternum Pelvis Skull Prox. long bones
Are metastatic tumors more often osteolytic or osteoblastic?
Osteolytic
What are radiographic features of osteolytic metastasis?
Cortical & trabecular destruction
Moth-eaten or permeative pattern
Wide zone of transition
May be expansile
What are radiographic features of osteoblastic metastasis?
Localized or diffuse increased radiopacity Scattered pattern (Snow-ball) Poorly defined margins
What are some radiographic features that differentiate metastasis from a primary tumor?
Usually multiple sites
Usually no periosteal response
Rarely a soft tissue mass
Rarely expands bone
What are the M/C primaries assoc. w/ a blow-out metastasis?
Thyroid & kidney
What are some characteristics of a blow-out metastasis?
Often highly expansile & bubbly
May be solitary
Often mimics a primary malignancy
FOGMACHINES is the mnemonic for expansive lesions of bone. What do the letters stand for?
Fibrous dysplasia Osteoblastoma Giant Cell Metastatic disease/myeloma ABC - Aneurysmal bone cyst Cartilaginous tumors Hyperparathyroid cyst (Brown tumor)/Hemangioma Infection NOF - Non ossifying fibroma Enchondroma/Eocinophilic granuloma Simple bone cyst
What areas of the spine are the M/C sites for metastasis?
Lumbar & thoracic (Body & pedicle)
Metastasis is the M/C cause of destruction of what part of the vertebra?
Pedicle
What sign is assoc. w/ pedicle destruction caused by metastasis?
Winking Owl Sign or One-eyed pedicle
What are the 3 M/C causes of ivory vertebrae?
Osteoblastic metastasis (Normal size)
Pagets (Enlarged)
Hodgkins (Scalloping)
What sign does osteolytic metastasis cause in the ribs?
Extrapleural sign (M/C cause)
Where is the M/C location for metastasis in the distal extremities?
The foot
What is the M/C primary to metastasize into the distal extremities?
Lung
What type of metastasis is M/C’ly seen in the skull?
Osteolytic
This is AKA Kahler’s disease. M/C primary osseous malignancy
Multiple myeloma
Multiple myeloma is a malignant proliferation of what type of cells?
Plasma cells
What is the M/C cause of death from multiple myeloma?
Pneumonia/respiratory failure
What is the 2nd M/C cause of death from multiple myeloma?
Renal disease
What age group is most affected by multiple myeloma?
50-70 years of age
Who is affected by multiple myeloma more, males or females?
Males 2:1
What are some typical symptoms of multiple myeloma?
fever & fatigue related to anemia
Progressive pain, M/C low back, aggravated by exercise & weight bearing
What are hematology lab features of multiple myeloma?
Normochromic normocytic anemia
Thrombocytopenia
Marked rouleax formation
Increased ESR
What are the biochemical lab features of multiple myeloma?
Increased serum Ca Increased serum uric acid Hyperglobulinemia w/ reverse A/G ratio M spike on serum protein electrophoresis Bence Jones proteinuria
What are the M/C skeletal locations for multiple myeloma?
Lower T-spine & L-spine
Skull
Pelvis
Ribs
What is the best imaging method for identifying multiple myeloma?
X-rays
What is the earliest manifestation of multiple myeloma on an xray?
Loss of bone density
What is a pathological collapse of a vertebra assoc. w/ multiple myeloma called?
Wrinkled vertebra
What is a pedicle sign?
multiple myeloma spares the pedicles early in the disease
What is the radiographic hallmark of multiple myeloma?
sharply circumscribed, purely osteolytic, punch-out lesions
multiple myeloma in the skull is known as?
Rain drop skull
Severe & diffuse bone destruction assoc. w/ multiple myeloma M/C’ly occurs where?
Pelvis
Sacrum
Where is expansion of bone assoc w/ multiple myeloma M/C?
Ribs
Long bones
Pelvis
This is a highly expansile, geographic lesion typically a soap bubble appearance. Localized form of multiple myeloma.
Solitary plasmacytoma
What are the M/C sites of a solitary plasmacytoma?
Mandible
Pelvis
Vertebrae
Ribs
What is the ddx for multiple myeloma?
Osteolytic metastasis
Osteoporosis
Possibly NHL
What is the ddx for solitary plasmacytoma?
Blow-out metastasis
Brown tumor
Fibrous dysplasia
Giant-cell
What % of solitary lesions develop into multiple myeloma?
70%
4th M/C primary osseous malignancy. Distinctive small, round cell primary sarcoma, probably arising from the connective tissue of bone marrow
Ewings Sarcoma
Types of round cell tumors?
Ewings Sarcoma
non-Hodkins lymphoma
Multiple Myeloma
What are the 2 M/C osseous malignancies under 25yrs of age?
Osteosarcoma
Ewings Sarcoma
What age group/gender is most affected by ewings sarcoma?
5-25yoa, male 2:1
What are symptoms assoc. w/ ewings sarcoma?
Increasing local pain (several months duration)
Soft tissue mass, tender but not warm
Malaise & moderate fever
What’s the difference b/w osteomyelitis & ewings sarcoma?
Timing - osteomyelitis takes days/weeks, ewings sarcoma progresses over months
What are lab findings assoc. w/ ewings sarcoma?
Leukocytosis
Anemia
Elevated ESR
What is the classic appearance of a ewings sarcoma on a xray?
Permeative pattern of destruction involving diaphysis
Laminated periosteal response
Saucerization
Does ewings sarcoma have a narrow or wide zone of transition?
Wide
Extrinsic pressure from the soft tissue mass assoc. w/ ewings sarcoma causes what?
Saucerization
What imaging method is best for demonstrating soft-tissue & bone marrow involvement of ewings sarcoma?
MRI
What is the M/C complication of ewings sarcoma?
Metastasis to bone & lung (M/C primary osseous malignancy to metastasis to bone)
What is the ddx for ewings sarcoma?
Osteomyelitis
Metastatic neuroblastoma
NHL
Osteosarcoma
2nd M/C primary malignancy. Neoplastic osteoid & bone matrix formed by malignant cells of connective tissue
Osteosarcoma
Secondary osteosarcoma’s are assoc. w/ what diseases?
Paget’s disease
Fibrous dysplasia
What age group & gender is most affected by osteosarcomas?
10-25 yoa; Males 2:1
What lab value may be elevated w/ an osteosarcoma?
Alkaline phosphatase
Where is the M/C location for an osteosarcoma?
Distal femur (50-75% involve the knee)
Where is osteosarcoma most often seen in older pts?
Flat bones
Where do osteosarcomas typically originate?
Metaphysis
What are the periosteal responses seen w/ osteosarcoma?
Sunburst (classic)
Hair-on-end
Codman’s triangle
Occasionally laminated response
What are typical xray findings assoc. w/ osteosarcoma?
Soft tissue mass is common
Tumor new bone w/i the destructive lesion or at its periphery
Cumulus cloud appearance
What are complications assoc. w/ osteosarcoma?
Metastasis: Pulmonary (pneumothorax) & osseous
“Cannon-ball metastasis”
Pathologic fx
What is the 5 year survival rate for osteosarcoma?
Exceeds 50% (averages 20%)
Type of osteosarcoma seen in pts 25-40?
Parosteal Osteosarcoma
What are the M/C locations for a parosteal osteosarcoma?
Femoral metaphysis (M/C)
Prox. tibia
Prox. humerus
What are the radiographic features of a parosteal osteosarcoma?
Dense oval or spherical shaped mass
Attached to the cortical surface
May see a radiolucent cleft separating a portion of the mass form the bone
Most likely seen on pos. aspect of femur
What is NHL AKA?
Primary bone lymphoma
Reticulum cell sarcoma
Lymphosarcoma
Histiocytic lymphoma
What type of tumor is a NHL?
Round cell tumor (rare)
What is the criteria for primary NHL?
Initial involvement of a single bone w/ at least 6 months before distal metastasis w/o generalized NHL
What age group, gender are most affected by NHL?
25-40; 2:1 Males
What are typical symptoms assoc. w/ NHL?
Dull, aching pain & swelling of long duration at site
Minor symptoms possible present a year or more
General well-being of pt usually good
Fever & weight loss may be present
NHL is the M/C primary malignancy to give rise to what?
Pathologic fx
M/C sites for NHL?
Femur
Tibia
Humerus
What are the M/C locations of NHL in the bone?
Diaphyseal
Metaphyseal adjacent to the diaphysis
What are radiographic findings assoc w/ NHL?
permeative pattern of bone destruction
Minimal to no periosteal response
Cortex often distrupted (expansions or thickening)
Sclerotic lesions possible in vertebrae & flat bones
What type of pts are less likely to have a periosteal response?
Older pt’s
What is the ddx assoc. w/ NHL?
Systemic lymphoma
Ewing’s sarcoma
Paget’s disease
Myeloma
