Tumors

Question 1

Tumors and tumor-like lesions of bone. Present how? 4

Answer 1

1. Persistent skeletal pain and swelling
2. Limitation of motion
3. Spontaneous fracture
4. Proceed with clinical, radiographic, lab and biopsy exam

Question 2

Tumors and tumor-like lesions of bone: What are the three types of tumors?

Answer 2

1. Osteoblastic connected tissue tumors
2. Cartilage tumors
3. Bone

Question 3

What are the tumors in the following categories:
1. Osteoblastic connected tissue tumors? 2

2. Cartilage tumors? 3
3. Bone? 3

Answer 3

1. Osteoblastic connected tissue tumors
   - Osteoid osteoma
   - Osteosarcoma
2. Cartilage tumors
   - Enchondromas
   - Chondromyxoid fibromas
   - Chondrosarcomas
3. • Giant Cell
   • Chondroblastomas
   • Ewing’s sarcoma

Question 4

How would you treat the following:

1. Osteoid osteoma?
2. Osteosarcoma?

Answer 4

1. Osteoid osteoma
   - Pain usually relieved by aspirin
2. Osteosarcoma
   - Resection and chemotherapy

Question 5

Tumors and tumor-like lesions of bone:
1. Giant cell are mostly benign or malignant?

2. Chondroblastomas: benign or malignant?
3. Ewing’s sarcoma prognosis?

Answer 5

1. 50% are benign
2. Almost always benign
3. 50% mortality rate in spite of chemotherapy, radation and surgery

Question 6

RED FLAGS FOR TUMORS?

5

Answer 6

1. Night pain,
2. constant pain,
3. unusual symptoms,
4. no improvement with conservative management,
5. or general symptoms such as fever, malaise, weakness
6. Unexplained mass, especially in the thigh

Question 7

RED FLAGS on xray findings?

3

Answer 7

X-ray findings with

1. lytic or blastic bone changes,
2. soft tissue calcification or
3. periosteal reaction

Question 8

Evaluation of tumors?

Answer 8

1. Physical exam and x-rays for most
2. Possible bone scan, CT scan, MRI, chest x-rays/CT for more high risk lesions
3. Consider
   - lab tests
4. consults/referral Oncologist, Path, etc

Question 9

Whch labs to evaluate for tumors? 3

Answer 9

1. CBC
2. calcium, phosphorous
3. alk phos

Question 10

If you have a patient that has weakness, anemia and is over 40 what do you have to R/O?

Answer 10

MM

Question 11

What are you looking for on CT with evaluaiton of bone tumors?

Answer 11

history of calcifications

Question 12

1. If suspecting Malignancy after XRAY you must order a what?
2. What lab would be elevated in lots of bone breakdown?
3. Bottom line need to what?

Answer 12

1. CT
2. ALK phos= lots of bone breakdown
3. biopsy

Question 13

1. Who should the biopsy be performed by?
2. How should the biopsy be dissected?
3. Consult for what?

Answer 13

1. Ideal if performed by “ultimate” surgeon
2. Longitudinal and stay in one compartment
3. Consult to plan incision

Question 14

What would be the different in trying to decide whether to observe, excise or refer in malignant vs benign tumors of the bone?

Answer 14

1. Clearly benign-observation versus excision/curettage
2. Possibly malignant- consider referral to Regional Cancer Center having teams of pathologists, radiologists, surgeons, and oncologists and radiation therapists

Question 15

How do we classify tumors? 3

Answer 15

1. Bony versus soft tissue
2. Benign versus malignant
3. Primary versus metastatic

Question 16

MALIGNANT BONE TUMORS
Prognosis greatly improved in recent years with dedicated referral centers, pre-op chemotherapy, limb-sparing procedures, etc.

4

Answer 16

1. Osteosarcoma
2. Ewing’s
3. Soft tissue tumor
4. Mets

Question 17

Second most common primary bone tumor after myeloma?

Answer 17

OSTEOSARCOMA

Question 18

OSTEOSARCOMA

1. High risk of what?
2. What percent of all bone sarcomas?
3. What years?
4. Gender?
5. Where?
6. Xray findings?
7. Other imaging?

Answer 18

1. high risk mets (poor prognosis!)
2. 20% of all bone sarcomas
3. second decade (10-20YO)
4. male equal female
5. appendicular (50% knee)
6. x-rays mixed lytic/sclerotic with cortical destruction (Codman’s triangle, “star burst” periosteal reaction, etc)
7. MRI

Question 19

EWING’S

1. Highly what?
2. Path looks like what?
3. Xray findings? 5
4. Prognosis?

Answer 19

1. Highly anaplastic
2. small round cell tumor in sheets
3. • long bone diaphyses,
   • lytic,
   • moth-eaten,
   • indistinct margins,
   • “onion skin”
4. survival rates now 80 to 90% with pre-op chemotherapy (versus 20%)

Question 20

SOFT TISSUE TUMORS
1. Why is the diagnosis challenging? 2

2. Will present how?
3. Where will the tumor be found?
4. Type of resection? 4

Answer 20

1. Challenging –
   - history rarely helpful,
   - x-rays usually negative
2. Small (less than five centimeter) superficial cystic lesions usually benign/observed
3. Large deep solid tumors-studies/biopsy
4. Type of resection-
   - intralesional,
   - marginal,
   - wide,
   - radical

Question 21

Sot tissue tumors:

Class based on apparent differentiation such as? 7

Answer 21

1. Fibrous
2. Lipomatous
3. Smooth muscle
4. striated muscle
5. vascular
6. synovial
7. neurologic

Question 22

Sot tissue tumors:
Class based on apparent differentiation.
1. What are some fibrous tumors? 2

2. What are some lipomatous tumors? 2

Answer 22

1. Fibrous
   - Dupuytren’s
   - desmoid
2. Lipomatous
   - lipoma
   - liposarcoma

Question 23

What is the most common cause of bone distruction in adults?

Answer 23

METASTATIC BONE DISEASE

Question 24

Which cancers commonly mets to bone?
4

Initial presentation may be to the orthopedist with what?

Answer 24

1. breast,
2. lung,
3. prostate,
4. kidney

back pain

Question 25

Cancer typically goes to which bones? | 4

Answer 25

1. Spine, 2. ribs, 3. pelvis, 4. proximal limb girdles most common

Question 26

Common pitfalls in bone tumors? 4 Tx? 3

Answer 26

1. assume metastatic, 2. not recognizing that a fracture is pathologic, 3. inadequate workup/planning/fixation, 4. not knowing when to refer Treatment- - fracture risk, - function, - palliation

Question 27

Benign Bone Tumors | 4

Answer 27

1. Osteochondroma 2. Osteoid Osteoma 3. Bone Cyst 4. Nonossifying fibroma

Question 28

Most common (35 to 50%) of benign and 20 to 15% of all primary bone tumors?

Answer 28

OSTEOCHONDROMA

Question 29

OSTEOCHONDROMA 1. What is it? 2. Where? 3. Gender? 4. Years? 5. Causes what kind of problems?

Answer 29

1. Not true neoplasms 2. Knee/proximal humerus, 3. 2:1 males 4. Second and third decades 5. Mostly mechanical problems/compression, space occupying

Question 30

OSTEOCHONDROMA 1. Stops growing when? 2. IMaging? 2 3. Tx?

Answer 30

1. Stops growing at skeletal maturity (if they dont then think of something else) 2. CT first. MRI if unclear 3. Surgery- completely excise cartilage and perichondrium

Question 31

How big are osteochonrdomas?

Answer 31

1-2cm

Question 32

OSTEOID OSTEOMA 1. Characteristics? 3 2. Years? 3. Gender? 4. Where? 3

Answer 32

Benign 1. Nidus- - well demarcated, - bone forming, - up to one centimeter. 2. Second/Third decade- 3. male to female 3:1 4. - Long bones lower extremity, - cortex, - posterior elements lumbar spine Approximately 10% of benign bone tumors and 2-3% of all primary bone tumors

Question 33

OSTEOID OSTEOMA 1. Characteristics? 3 2. Imaging? 2 3. Tx? 2

Answer 33

1. - Dull/sharp pain, - worse at night, - better with aspirin/NSAIDs 2. X-ray/CT 3. - En bloc resection (CT, X-rays)-gotta remove everything/lymph drainage etc - Percutaneous radiofrequency ablation

Question 34

UNICAMERAL BONE CYST 1. Ages? 2. gender? 3. Where? 4. what is different about this?

Answer 34

1. Ages 5-15, 2. boys 3:1 over girls 3. 50-60% proximal humerus 4. Not true cyst

Question 35

UNICAMERAL BONE CYST 1. Where is it? what does it look like? 2. Imaging? 3. Tx? 2 Reoccurrence rates?

Answer 35

1. Central radiolucent lesion metaphyseal side of growth plate, long bones 2. MRI if unclear 3. -Curettage/graft- 20% to 45% recurrence -Needle aspiration and several steroid injections at two month intervals- 10% recurrence

Question 36

What is FCD-NOF?

Answer 36

Fibrous cortical defect/non ossifying fibroma

Question 37

Fibrous cortical defect/non ossifying fibroma 1. Common when? 2. Neoplastic? 3. Where?

Answer 37

1. Common in childhood 2. Non-neoplastic 3. Metaphysis of long bones (knee) Approximately 5% of benign primary bone tumors

Question 38

FCD-NOF 1. Which decades? 2. Shaped? 2 3. Tx- if weakening bone? 4. If fractured? 3

Answer 38

1. First two decades 2. - Oval elongated radiolucent, - well marginated 3. If weakening bone then curettage/graft 4. Fracture- - immobilize, - observe, - sometimes lesion heals