Bone and Soft Tissue Tumours

Question 1

What is Sarcoma?

Answer 1

Malignant tumours arising from connective tissues

Question 2

How can sarcoma spread?

Answer 2

Spread along fascial planes

Haematogenous spread to lungs

Rarely to regional lymph nodes

Question 3

What forms of sarcoma will rarely spread to lymph nodes?

Answer 3

Rhabdomyosarcomas
Epithelioid sarcomas
Synovial sarcomas

Question 4

A bone tumour in a patient >50y is likely to be what?

Answer 4

Metastatic

Question 5

How common are:

• Benign tumours of skeleton
• Malignant tumours of skeleton
• Bony secondaries?

Answer 5

Benign = common
Malignant = RARE
Secondaries = Very common

Question 6

Name 2 benign bone forming tumours?

Answer 6

Osteoid osteoma

Osteoblastoma

Question 7

Name a malignant bone forming tumour?

Answer 7

Osteosarcoma

Question 8

Name 2 benign cartilage-forming tumours

Name 1 malignant cartilage-forming tumour

Answer 8

Benign:

• Enchondroma
• Osteochondroma

Malignant:
-Chondrosarcoma

Question 9

Name 1 benign and 2 malignant fibrous tissue tumours

Answer 9

Benign: fibroma

Malignant:

• Fibrosarcoma
• Malignant fibrous histiocytoma (MFH)

Question 10

Name 2 benign and 1 malignant vascular tissue tumours

Answer 10

Benign:

• haemangioma,
• aneurysmal bone cyst

Malignant:
-angiosarcoma

Question 11

Name 1 benign and 1 malignant adipose tissue tumours

Answer 11

benign: lipoma

Malignant: liposarcoma

Question 12

Name 2 malignant marrow tissue tumours

Answer 12

Ewing’s sarcoma
Lymphoma
Myeloma

Question 13

What is the commonest primary malignant bone tumour in younger patients?

What is the commonest primary malignant “bone” tumour in older patients?

Answer 13

Younger = osteosarcoma

Older = Myeloma

Question 14

What is the pain like in bone tumours?

Answer 14

Activity related

Progressive pain at rest and at night

Question 15

When will benign tumours of bone present with activity related pain?

Answer 15

If large enough to weaken bone

osteoid osteoma

Question 16

How do you examine thses lumps?

What are you looking at?

Answer 16

General health
Measurements of mass
Location
Shape
Consistency
Mobility
Tenderness
Local temperature
Neuro-vascular deficits

Question 17

What are the investigations for these tumours?

Answer 17

Plain X-rays
-Most useful for bone lesions

Calcification - synovial sarcoma

Myositis ossificans

Phleboliths in haemangioma

Question 18

What is myositis ossificans?

Answer 18

Myositis ossificans comprises two syndromes characterized by heterotopic ossification (calcification) of muscle.

Question 19

What is a phlebolith?

Answer 19

A phlebolith is a small local, usually rounded, calcification within a vein. These are very common in the veins of the lower part of the pelvis, and they are generally of no clinical importance. When located in the pelvis they are sometimes difficult to differentiate from kidney stones in the ureters on X-ray.

Question 20

How can you tell is a growth/ lesion is inactive from an x-ray?

(3 marks)

Answer 20

Clear margins

Surrounding rim of reactive bone

Cortical expansion can occur with aggressive benign lesions

Question 21

How can you tell if a growth/ lesion is aggressive on an x-ray?

Answer 21

Less well defined zone of transition between lesion and normal bone (permeative growth)

Cortical destruction = malignancy

Periosteal reactive new bone growth occurs when the lesion destroys the cortex

-Codman’s triangle, onion-skinning or sunburst pattern

Question 22

What is Codman’s traingle?

Answer 22

Codman triangle (previously referred to as Codman’s triangle) is the triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone

Question 23

What is CT good for in bone tumours?

4 points

Answer 23

Assessing osification and calcification

Integrity of cortex

Best for assessing nidus in osteoid osteoma

Staging - primarily of lungs

Question 24

What are isotope bone scans good for in bone tumours?

Answer 24

Staging for skeletal metastasis

Multiple lesions - osteochondrome, enchondroma, fibrous dysplasia and histiocytosis

Benign also demonstrate increased uptake

Question 25

Isotope bone scans are frequently negative in what?

Answer 25

myeloma

Question 26

What are MRI scans good for in bone tumours?

Answer 26

Study of choice Size, extent, anatomical relationships Accurate for limits of disease both within and outside bone Specific for lipoma, haemangioma, haematoma or PVNS Non-specific for benign vs. malignant

Question 27

What investigations should you carry out before biopsy? | 5 marks

Answer 27

Bloods X-rays of affected limb and chest MRI of lesion Bone scan CT chest, abdo and pelvis

Question 28

What are the cardinal features of malignant primary bone tumours?

Answer 28

``` Increasing pain Unexplained pain Deep-seated boring nature Night pain Difficulty weight-bearing Deep swelling ```

Question 29

What are the clinical features of osteosarcoma?

Answer 29

- Pain - Loss of function - Swelling - Pathological fracture - Joint effusion - Deformity - Neurovascular effects - Systemic effects of neoplasia

Question 30

Describe the pain in osteosarcoma | what is its character? how bad is it? is it related to exercise?

Answer 30

Cardinal feature Increasing pain - impending fracture (esp. lower limb) Analgesics eventually ineffective Not related to exercise DEEP BORING ACHE, WORSE AT NIGHT

Question 31

What is the swelling ("tumour") like in osteosarcoma?

Answer 31

Generally diffuse in malignancy Generally near end of long bone Once reaching noticeable size, enlargement may be rapid Warmth over swelling + venous congestion = active Pressure effects e.g. intrapelvic

Question 32

What should you remember about pathological bone fracture primary bone tumour?

Answer 32

Many causes of pathological fracture of which this is one of the rarest c.f. osteoporosis commonest

Question 33

What are the treatments for bone tumours?

Answer 33

Goal is to make free of disease Chemotherapy Surgery Radiotherapy TEAM!!

Question 34

What are the suspicious signs of soft tissue tumours? | signs they may be malignant

Answer 34

Deep (i.e. deep to deep fascia) tumours of any size Subcutaneous tumours >5cm Rapid growth, hard, craggy, non-tender

Question 35

What features of a swelling are considered suspicious of malignant tumour until proven otherwise?

Answer 35

Rapidly growing Hard, fixed, craggy surface, indistinct margins Non-tender to palpation, but assoc. with deep ache, esp. worse at night BEWARE- may be painless recurred after previous excision

Question 36

List the common sites of secondary metastatic bone tumours from most common to least (6 marks)

Answer 36

``` Vertebrae Proximal femur Pelvis Ribs Sternum Skull ```

Question 37

What are the 7 commonest primary cancers which metastasise to bone?

Answer 37

``` Lung Breast (commonest) Prostate Kidney Thyroid (esp follicular) GI tract Melanoma ```

Question 38

How can you prevent pathological fractures in bone tumour disease?

Answer 38

Early chemo/ DXT prophylactic internal fixation - lytic lesion + increasing pain and/or 2.5cm dam and/or 50% cortical destruction Use of bone cement

Question 39

What score assessment can you use for fracture risk assessment?

Answer 39

Mirel's scoring system