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Chris Ortho > Tumor > Flashcards

Tumor Flashcards

Orthopedic Tumor Essentials

0
Q

Name some negative prognostic characteristics of osteosarcoma.

A
  1. Poor response to Neo adjuvant chemo (% necrosis)
  2. Tumour size (> 8 cm is bad)
  3. Patient age (old is bad)
  4. Higher stage of Tumor
  5. Anatomical site (central is bad)
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1
Q

General treatment for bone sarcoma?

A
  1. Neo adjuvant chemotherapy, multi-agent
  2. Re-stage with imaging to assess for interim progression/metastases and pre-op planning
  3. Wide resection
  4. Chemotherapy - use response to pre-op chemo to prognosticate (% necrosis of surgical pathology) and target therapy
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2
Q

What does GCT look like on MRI?

A

Dark on T1 and T2

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4
Q

Histopathology of GCT?

A

Multinucleated giant cells.
May see bone.
Mononuclear stromal cells

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5
Q

What sarcoma has flat epithelial cells on pathology?

A

Synovial sarcoma

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8
Q

What Tumor has characteristic fluid levels on MRI?

A

ABC

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9
Q

What colour is chondroid matrix on staining?

A

Blue

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10
Q

Seven questions for evaluating bone lesion on x-ray?

A
  1. Where is it
  2. What is it doing to bone?
  3. What is bone doing to it?
  4. Periosteal reaction?
  5. Soft tissue component?
  6. Pathological fracture?
  7. Matrix?
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11
Q

Where is the most common place for sarcomas to metastasize?

A
  1. Lungs

2. Another bone

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12
Q

Common locations of ABC?

A

Femur > tibia > spine

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14
Q

What does it mean if a Tumor is biphasic?

A

It contains both epithelial and mesemchymal neoplastic cells

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15
Q

What is special about biphasic sarcomas in terms of metasteses?

A

They can go to lymph nodes, which is unusual for sarcomas.

Also they metastasize to locations other than the lungs.

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16
Q

What are the three biphasic sarcomas?

A
  1. Synovial sarcoma
  2. Angiosarcoma
  3. Mixed liposarcoma
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17
Q

Name two enchondroma syndromes.

A
  1. Olliers

2. Maffuccis

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18
Q

What mutation is characteristic of fibrous dysphasia?

A

G-Protein mutation

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19
Q

What is the approach to neoadjuvant chemotherapy for pre-operative malignant bone tumour?

A

Multiagent chemotherapy

  1. Methotrexate
  2. cisplatin
  3. Doxorubicin
  4. Ifosfamide
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20
Q

What colour is bone matrix on staining?

A

Pink

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21
Q

What is the primary difference between sarcomas and carcinomas? (In terms of lineage)

A

Carcinomas = epithelial

Sarcomas = mesemchymal

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22
Q

Name the basic biopsy principles.

A
  1. Biopsy through involved compartment
  2. Use extensile incision (usually longitudinal)
  3. Meticulous hemostasis
  4. Do not create multiple planes
  5. Bring out drains in line with incision (so the tunnel can be removed easily if wide resection is needed)
  6. Can biopsy soft tissue component of bone tumour
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23
Q

Components of systemic staging for malignant tumour?

A

CT chest, abdo, pelvis (chest most important)

Bone scan (skip metasteses, second most common site is bother bone)

Blood work: lytes (calcium), albumin, spep, upep, ALP, LDH

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24
Q

Components of local staging?

A

MRI to characterize lesion (of entire bone)

Biopsy (can do soft tissue mass)

 Send for pathology and cultures
 Adequate hemostasis
 Good lesional tissue
 Use pathology to prognosticate
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25
Q

Histology of ewings sarcoma?

A

Small round blue cells

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26
Q

Differential for small round blue cells on histology?

A 
Ewing's sarcoma
Lymphoma
Osteomyelitis
Multiple myeloma
Histiocytosis
Rhabdomyosarcoma
Neuroblastoma
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27
Q

What kind of matrix does ewings usually have?

A

None

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28
Q

What are the main steps in treatment of malignant bone tumour?

A
  1. Neo adjuvant chemotherapy
  2. Re-stage with imaging for response to therapy and operative planning
  3. Surgery - limb sparing vs. amputation
  4. Post-operative chemotherapy - use pathology to prognosticate
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29
Q

What Tumor stains for MIC2 antigen?

A

Ewing’s sarcoma. This is how you differentiate it from other small round blue cell tumors.

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30
Q

For ewings sarcoma, what blood markers should be added to the typical malignant work up and why?

A

CBC, esr and crp to differentiate it from osteomyelitis

In ewings esr will be up (but not crp?)

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31
Q

You are working up a malignant looking tumor. It is bright on T2 with liquid, purulent looking gross pathology and no osteointegration matrix. what is it?

A

Ewing’s sarcoma

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32
Q

What do the terms onion skinning and sunburst refer to on radiographs? Which Tumors are each characteristic of?

A

Types of periods teal reaction

Onion skinning = ewings
Sunburst = osteosarcoma

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33
Q

Olliers is characterized by:

A) multiple enchondromas, hemangiomas, lymphangiomas
B) multiple enchondromas in a unilateral distribution
C) auto-dominant transmission, multiple enchondromas and osteochondromas

A

B

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34
Q

What blood markers can be used to measure bone turnover?

A

ALP, LDH

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35
Q

What Tumor is usually epiphyseal in skeletally immature with chicken wire calcifications?

A

Chondroblastoma

Also has mononuclear chondroblasts

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36
Q

What findings differentiate chondrosarcoma from a benign lesion?

A

1) myxoid matrix - may still have chondroid matrix, but generally the more myxoid the higher the grade
2) cortical thinning or thickening
3) soft tissue mass
4) invasion of haversian system

37
Q

What is Denosumab?

A

RankL inhibitor. This is a ligand for the Rank receptor and acts as a signal for bone removal. Denosumab is an analogue and used in GCT tumours to prevent bone turnover.

38
Q

A translocation of chromosome 11 and 22 resulting in a chimeric protein is characteristic of what Tumor?

A

Ewing’s sarcoma

Translocation results in EWS gene

39
Q

Which sarcoma is radio/chemo resistant?

A) liposarcoma
B) osteosarcoma
C) chondrosarcoma
D) Ewing’s sarcoma

A

C) chondrosarcoma

40
Q

Does radiation have a role in treatment of Ewing’s sarcoma?

A

Yes, if wide resection is technically difficult or if a Tumor was inadequatly resected based on pathology

41
Q

Maffuccis is characterized by:

A) multiple enchondromas, hemangiomas, lymphangiomas
B) multiple enchondromas in a unilateral distribution
C) auto-dominant transmission, multiple enchondromas and osteochondromas

A

A

42
Q

What is the malignant transformation rate for multiple exostosis syndrome?

A

1-3%

43
Q

“Pop corn densities” are useful in differentiating what secondary malignancy from its benign precursor?

A

Secondary chondrosarcoma from enchondroma.

45
Q

What part of an osteochondroma is usually the site for secondary malignant transformation?

A

Cartilage cap

46
Q

Which chondrosarcoma variant is typically epiphyseal?

A

Clear cell chondrosarcoma

47
Q

Host lamellar bone entrapment is characteristic of what malignancy?

A

Chondrosarcoma

48
Q

PVNS typically contains which pigment?

A

Hemosiderin deposits

49
Q

What primaries metastasize to bone?

A 
Lymphoma
Melanoma
Visceral carcinomas:
   Breast
   Prostate
   Lung
   Kidney
  Thyroid
50
Q

What part of bone does ewings usually occur?

A

Diaphysis

51
Q

Enchondromatosis is characterized by:

A) multiple enchondromas, hemangiomas, lymphangiomas
B) multiple enchondromas in a unilateral distribution
C) auto-dominant transmission, multiple enchondromas and osteochondromas

A

C

52
Q

Who gets Ewing’s sarcoma?

A

White males aged 10-20

54
Q

At what age does metastases become more common than primary bone malignancy?

A

40

55
Q

What primary bone malignancies are more likely in patients over 40?

A

Plasmocytoma (solitary myeloma)
Primary lymphoma of bone
Chondrosarcoma
MFH

56
Q

Physical exam for metastasis with unknown origin must include?

A

Thyroid exam
Lung exam
Abdomen exam
Breast/prostate exam

57
Q

Bloodwork for metastasis with unknown origin?

A 
Spep/upep
CBC
Esr
Lytes
Liver enzymes
Psa
Alp
LDH
58
Q

Imaging for metastasis with unknown origin?

A 
Chest X-ray
X-ray of involved bone
Any painful extremities
Bone scan
If suspect myeloma, skeletal survey
Consider MRI of bone lesion
Ct chest/abdo/pelvis
59
Q

What are characteristics of a metastasis on X-ray?

A

Lytic
Permeative
Diaphysis/metadiaphysis
Proximal long bone or spine

60
Q

What primaries are most likely to present as metastasis with unknown origin?

A

Lung and kidney (because they are more likely to be occult)

61
Q

What primary is very vascular, requiring embolization of lesions primary to ORIF?

A

RCC

Thyroid

62
Q

Describe the Enneking system for classifying malignant tumours.

A

Three factors: Grade, site and metasteses

Grade is high or low
Site is intracompartmental (enclosed by natural barriers) or extracompartmental

IA = low grade intracompartmental
IB = low grade extracompartmental
IIA = high grade intracompartmental
IIB = high grade extracompartmental
III = any metastsesis
63
Q

Which type of liposarcoma does not require adjuvant radiotherapy?

A

Well differentiated liposarcoma

64
Q

What benign tumour is characterized by fatty infiltration of sub synovial connective tissue?

A

Lipoma aborecens

65
Q

Name the 5 subtypes of liposarcoma.

A 
Well differentiated liposarcoma
Myxoid liposarcoma
Pleomorphic liposarcoma
Dedifferentiated liposarcoma
Mixed-type liposarcoma
66
Q

What is the most common sarcoma in the foot?

A

Synovial sarcoma

67
Q

Synovial sarcoma is a misnomer. What percentage of these tumours actually arise is a major joint?

A

10%

68
Q

Describe the Enneking system for classifying malignant tumours.

A

Three factors: Grade, site and metasteses

Grade is high or low
Site is intracompartmental (enclosed by natural barriers) or extracompartmental

69
Q

Options for fixation of a met? (Be general)

A
  1. ORIF
    Plate with cement versus nail
  2. Arthroplasty
  3. Endoprosthesis
70
Q

Which primary can have mets distal to knee and elbow?

A

Lung

71
Q

Which primary has worst prognosis once mets are present in bone?

A

Lung

72
Q

Ddx for lytic lesion in greater than 40 year old

A
  1. Mets
  2. MM
  3. Lymphoma
  4. Metabolic (browns Tumor)
  5. Sarcoma
73
Q

Benign aggressive lesions? (3)

A

GCT, ABC, osteoblastoma

74
Q

Episyphyseal lesions?

A

Chondroblastoma, infection, GCT

75
Q

Enchondromas always central metaphyseal t/f?

A

True

76
Q

Benign bone lesion in spine is usually what?

A

Osteoblastoma

77
Q

Age range for GCT?

A

20-40

78
Q

GCT location mainly?

A

Prox tibia, distal femur
proximal humerus, distal radius

I.e. Where a lot of growth occurs

79
Q

Ddx for multiple giant cell containing lesions?

A

Multifocal GCT

Browns Tumor

80
Q

Distal radius lytic lesion DDH? (4)

A

GCT
Abc
Chondrosarcoma
Telientatic osteosarcoma

81
Q

GCT histology?

A

Mononuclear cells with Uniformly distributed multinucleated giant cells

82
Q

GNAS mutation?

A

Polyostotic fibrous dysplasia

Mcune Albright syndrome

83
Q

Metastatic Tumor that is blastic?

A

Prostate

84
Q

Older than 40 , blastic lesion DDx (4)?

A 
Metastases (prostate)
Bone island
Bone infarct
Osteoblastoma
Infection
85
Q

Differential for small round cell tumour?

A

Small-round-cell tumor differential (by age)

< 5 yrs: neuroblastoma or leukemia
5-10 yrs: eosinophilic granuloma
5-30 yrs: Ewing's sarcoma
>30 yrs: lymphoma
> 50 yrs: myeloma
86
Q

Do osteochondroma transform into high or low grade chondrosarcoma?

A

Low grade

87
Q

Chrondroblastomas are located where?

A

Epiphysis

Chris Ortho (7 decks)

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