What are the two types of malignant bone tumour?
Primary
Secondary
What are sarcomas?
Malignant tumours arising from connective tissues
How does sarcoma spread?
Along fascial planes
How does sarcoma spread to the lungs?
Haematogenous spread
What does sarcoma rarely spread to?
Regional lymph nodes
What are examples of benign bone-forming tumours?
Osteoid osteoma
Osteoblastoma
What is an example of a malignant bone-forming tumours?
Osteosarcoma
What are examples of benign cartilage-forming tumours?
Enchondroma
Osteochondroma
What is an example of a malignant cartilage-forming tumour?
Chrondrosarcoma
What is an example of a benign fibrous tissue tumour?
Fibroma
What are example of malignant fibrous tissue tumours?
Fibrosarcoma
Malignant fibrous histiocytoma (MFH)
What are examples of benign vascular tissue tumours?
Haemangioma
Aneurysmal bone cyst
What is an example of malignant vascular tissue tumour?
Angiosarcoma
What is an example of benign adipose tissue tumour?
Lipoma
What is an example of malignant adipose tissue tumour?
Liposarcoma
What are examples of malignant marrow tissue tumours?
Ewing’s sarcoma
Lymphoma
Myeloma
What are benign, locally destructive tumours that rarely metastasise?
Giant cell tumours (GCT)
What are benign tumour-like lesions?
Simple bone cyst
Fibrous cortical defect
What are suspicious signs of a malignant soft tissue tumour?
Deep tumours of any size
Subcutaneous tumours >5cm
Rapid growth, hard, craggy, non-tender
What swellings should you beware of?
Rapidly growing
Hard, fixed, craggy surface, indistinct margins
Non-tender to palpation, but assoc. with deep ache, esp. worse at night
May be painless
Recurred after previous excision
Which type of bone tumour is more common: benign or malignant?
Benign
What is a bone tumour in a patient >50 likely to be?
Metastatic
What is commonest primary malignant bone tumour in younger patients?
Osteosarcoma
What is the commonest primary malignant bone tumour in an older patient?
Myeloma
How do bone tumours present?
*Pain
Mass
Abnormal x-rays, often picked up incidentally
What is the pain in bone tumours associated with?
Activity related
Progressive pain at rest & night
When might benign tumours present with activity related pain?
If large enough to weaken bone
e.g. osteoid osteoma
What should be examined in someone with suspected bone tumour?
Measurements of mass Location Shape Consistency Mobility Tenderness Local temp Neurovascular deficits
What are the investigations for suspected bone tumour?
Plain XR CT Isotope bone scan *MRI Angiography PET Biopsy
What can be seen on x-ray for suspected bone tumours?
Calcification - synovial sarcoma
Myositis ossificans
Phleboliths in haemangioma
What is seen in inactive bone on x-ray?
Clear margins
Surround rim of reactive bone
Cortical expansion can occur with aggressive benign lesions
What is myositis ossificans?
Where bone tissue forms inside muscle or other soft tissue after an injury
What is phleboliths with haemangioma?
Phleboliths are calcified thrombi found within vascular channels, often in the presence of hemangioma or vascular malformation
What can be seen in x-rays of aggressive tumours?
Less well defined zone of transition between lesion and normal bone
Cortical destruction = malignancy
Periosteal reactive new bone growth occurs when lesion destroys cortex
Codman’s triangle, onion-skinning or sunburst pattern
What is Codman’s triangle?
The triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone
What does a CT assess?
Ossification and calcification
Integrity of cortex
Assessing nidus in osteoid osteoma
Staging
What can an MRI assess?
Size, extent, anatomical relationships
Limits of disease
What is MRI not specific for?
Benign vs malignant
What is MRI specific for?
Lipoma, haemangioma, haematoma or PVNS
What should be done prior to bone biopsy?
Bloods XR MRI of lesion Bone scan CT chest, abdo, pelvis
What are the cardinal features of malignant primary bone tumours?
Increasing pain Unexplained pain Deep-seated boring nature Night pain Difficulty weight-bearing Deep swelling
What are the clinical features of osteosarcoma?
Pain Loss of function Swelling Pathological fracture Joint effusion Deformity Neuromuscular effects Systemic effects of neoplasia
What is the cardinal feature of osteosarcoma?
Pain
What is the pain like in osteosarcoma?
Deep boring ache
Worse at night
Analgesics ineffective
Not related to exercise
How does loss of function present in osteosarcoma?
Limp Reduced joint movement Stiff back (children)
How does swelling present in osteosarcoma?
Diffuse in malignancy
Near end of long bone
One noticeable size, enlargement may be rapid
Warmth over swelling
What is the commonest reason for pathological fracture?
Osteoporosis
What are the investigations for suspected osteosarcoma?
MRI
What is MRI good for showing re: osteosarcoma?
Intraosseous extent of tuour Extraosseous soft tissue extent of tumour Joint involvement Skip metastases Epiphyseal extension Determines resection margins
What is the treatment for osteosarcoma?
Surgical excision of primary lesion
Chemotherapy
Radiotherapy
What are the most common primary cancers which metastasise to bone?
Lung Breast Prostate Kidney Thyroid GI tract Melanoma
How can pathological fractures in bone tumours be prevented?
Early chemo/DXT
Prophylactic internal fixation
+/- use of bone cement
What is the scoring system for fracture risk assessment in lone bone metastasis?
Mirel’s Scoring System
What does Mirel’s Scoring system look at when assessing fracture risk in lone bone metastasis?
Site, pain, lesion, size
What is commonest soft tissue tumour?
Lipoma
What are the features of soft tissue tumours?
Painless Mass deep to deep fascia Any mass >5cm Any fixed, hard or indurated mass Any recurrent mass
What investigation is best for suspected soft-tissue tumour?
MRI