Tumors Flashcards
Tumors and tumor-like lesions of bone. Present how? 4
- Persistent skeletal pain and swelling
- Limitation of motion
- Spontaneous fracture
- Proceed with clinical, radiographic, lab and biopsy exam
Tumors and tumor-like lesions of bone: What are the three types of tumors?
- Osteoblastic connected tissue tumors
- Cartilage tumors
- Bone
What are the tumors in the following categories:
1. Osteoblastic connected tissue tumors? 2
- Cartilage tumors? 3
- Bone? 3
- Osteoblastic connected tissue tumors
- Osteoid osteoma
- Osteosarcoma - Cartilage tumors
- Enchondromas
- Chondromyxoid fibromas
- Chondrosarcomas - Giant Cell
- Chondroblastomas
- Ewing’s sarcoma
How would you treat the following:
- Osteoid osteoma?
- Osteosarcoma?
- Osteoid osteoma
- Pain usually relieved by aspirin - Osteosarcoma
- Resection and chemotherapy
Tumors and tumor-like lesions of bone:
1. Giant cell are mostly benign or malignant?
- Chondroblastomas: benign or malignant?
- Ewing’s sarcoma prognosis?
- 50% are benign
- Almost always benign
- 50% mortality rate in spite of chemotherapy, radation and surgery
RED FLAGS FOR TUMORS?
5
- Night pain,
- constant pain,
- unusual symptoms,
- no improvement with conservative management,
- or general symptoms such as fever, malaise, weakness
- Unexplained mass, especially in the thigh
RED FLAGS on xray findings?
3
X-ray findings with
- lytic or blastic bone changes,
- soft tissue calcification or
- periosteal reaction
Evaluation of tumors?
- Physical exam and x-rays for most
- Possible bone scan, CT scan, MRI, chest x-rays/CT for more high risk lesions
- Consider
- lab tests - consults/referral Oncologist, Path, etc
Whch labs to evaluate for tumors? 3
- CBC
- calcium, phosphorous
- alk phos
If you have a patient that has weakness, anemia and is over 40 what do you have to R/O?
MM
What are you looking for on CT with evaluaiton of bone tumors?
history of calcifications
- If suspecting Malignancy after XRAY you must order a what?
- What lab would be elevated in lots of bone breakdown?
- Bottom line need to what?
- CT
- ALK phos= lots of bone breakdown
- biopsy
- Who should the biopsy be performed by?
- How should the biopsy be dissected?
- Consult for what?
- Ideal if performed by “ultimate” surgeon
- Longitudinal and stay in one compartment
- Consult to plan incision
What would be the different in trying to decide whether to observe, excise or refer in malignant vs benign tumors of the bone?
- Clearly benign-observation versus excision/curettage
- Possibly malignant- consider referral to Regional Cancer Center having teams of pathologists, radiologists, surgeons, and oncologists and radiation therapists
How do we classify tumors? 3
- Bony versus soft tissue
- Benign versus malignant
- Primary versus metastatic
MALIGNANT BONE TUMORS
Prognosis greatly improved in recent years with dedicated referral centers, pre-op chemotherapy, limb-sparing procedures, etc.
4
- Osteosarcoma
- Ewing’s
- Soft tissue tumor
- Mets
Second most common primary bone tumor after myeloma?
OSTEOSARCOMA
OSTEOSARCOMA
- High risk of what?
- What percent of all bone sarcomas?
- What years?
- Gender?
- Where?
- Xray findings?
- Other imaging?
- high risk mets (poor prognosis!)
- 20% of all bone sarcomas
- second decade (10-20YO)
- male equal female
- appendicular (50% knee)
- x-rays mixed lytic/sclerotic with cortical destruction (Codman’s triangle, “star burst” periosteal reaction, etc)
- MRI
EWING’S
- Highly what?
- Path looks like what?
- Xray findings? 5
- Prognosis?
- Highly anaplastic
- small round cell tumor in sheets
- long bone diaphyses,
- lytic,
- moth-eaten,
- indistinct margins,
- “onion skin”
- survival rates now 80 to 90% with pre-op chemotherapy (versus 20%)
SOFT TISSUE TUMORS
1. Why is the diagnosis challenging? 2
- Will present how?
- Where will the tumor be found?
- Type of resection? 4
- Challenging –
- history rarely helpful,
- x-rays usually negative - Small (less than five centimeter) superficial cystic lesions usually benign/observed
- Large deep solid tumors-studies/biopsy
- Type of resection-
- intralesional,
- marginal,
- wide,
- radical
Sot tissue tumors:
Class based on apparent differentiation such as? 7
- Fibrous
- Lipomatous
- Smooth muscle
- striated muscle
- vascular
- synovial
- neurologic
Sot tissue tumors:
Class based on apparent differentiation.
1. What are some fibrous tumors? 2
- What are some lipomatous tumors? 2
- Fibrous
- Dupuytren’s
- desmoid - Lipomatous
- lipoma
- liposarcoma
What is the most common cause of bone distruction in adults?
METASTATIC BONE DISEASE
Which cancers commonly mets to bone?
4
Initial presentation may be to the orthopedist with what?
- breast,
- lung,
- prostate,
- kidney
back pain
Cancer typically goes to which bones?
4
- Spine,
- ribs,
- pelvis,
- proximal limb girdles most common
Common pitfalls in bone tumors? 4
Tx? 3
- assume metastatic,
- not recognizing that a fracture is pathologic,
- inadequate workup/planning/fixation,
- not knowing when to refer
Treatment-
- fracture risk,
- function,
- palliation
Benign Bone Tumors
4
- Osteochondroma
- Osteoid Osteoma
- Bone Cyst
- Nonossifying fibroma
Most common (35 to 50%) of benign and 20 to 15% of all primary bone tumors?
OSTEOCHONDROMA
OSTEOCHONDROMA
- What is it?
- Where?
- Gender?
- Years?
- Causes what kind of problems?
- Not true neoplasms
- Knee/proximal humerus,
- 2:1 males
- Second and third decades
- Mostly mechanical problems/compression, space occupying
OSTEOCHONDROMA
- Stops growing when?
- IMaging? 2
- Tx?
- Stops growing at skeletal maturity (if they dont then think of something else)
- CT first. MRI if unclear
- Surgery- completely excise cartilage and perichondrium
How big are osteochonrdomas?
1-2cm
OSTEOID OSTEOMA
- Characteristics? 3
- Years?
- Gender?
- Where? 3
Benign
- Nidus-
- well demarcated,
- bone forming,
- up to one centimeter. - Second/Third decade-
- male to female 3:1
- Long bones lower extremity,
- cortex,
- posterior elements lumbar spine
Approximately 10% of benign bone tumors and 2-3% of all primary bone tumors
OSTEOID OSTEOMA
- Characteristics? 3
- Imaging? 2
- Tx? 2
- Dull/sharp pain,
- worse at night,
- better with aspirin/NSAIDs
- X-ray/CT
- En bloc resection (CT, X-rays)-gotta remove everything/lymph drainage etc
- Percutaneous radiofrequency ablation
UNICAMERAL BONE CYST
- Ages?
- gender?
- Where?
- what is different about this?
- Ages 5-15,
- boys 3:1 over girls
- 50-60% proximal humerus
- Not true cyst
UNICAMERAL BONE CYST
- Where is it? what does it look like?
- Imaging?
- Tx? 2 Reoccurrence rates?
- Central radiolucent lesion metaphyseal side of growth plate, long bones
- MRI if unclear
- -Curettage/graft-
20% to 45% recurrence
-Needle aspiration and several steroid injections at two month intervals-
10% recurrence
What is FCD-NOF?
Fibrous cortical defect/non ossifying fibroma
Fibrous cortical defect/non ossifying fibroma
- Common when?
- Neoplastic?
- Where?
- Common in childhood
- Non-neoplastic
- Metaphysis of long bones (knee)
Approximately 5% of benign primary bone tumors
FCD-NOF
- Which decades?
- Shaped? 2
- Tx- if weakening bone?
- If fractured? 3
- First two decades
- Oval elongated radiolucent,
- well marginated
- If weakening bone then curettage/graft
- Fracture-
- immobilize,
- observe,
- sometimes lesion heals
