Bone and soft tissue tumours

Question 1

What is sarcoma?

Answer 1

Malignant bone tumour

Malignant soft tissue tumour

Question 2

Bone tumour

Answer 2

Benign (very common)
Malignant
-Primary (<30yo) : Osteosarcoma ( around knees)
:Ewing’s sarcoma
-Secondary (>50yo) : from Breast CA ( to vertebrae)

Question 3

Commonest primary bone malignancy in younger pts

Answer 3

Osteosarcoma

Question 4

Commonest primary bone malignancy in older pt

Answer 4

Myeloma

Question 5

What is myeloma

Answer 5

Cancer of plasma cells
Plasma cells make antibodies
Abnormal plasma cells making abnormal antibodies

Question 6

Most common soft tissue tumour you would see?

Answer 6

Lipoma ( benign adipose tissue tumour)

Question 7

Hx: Presenting history of any tumour

Answer 7

Pain in limbs ( weakened by benign/malignant tumour->under strees-->risk of fracture-->feel as pain)
   -Pain at night in limb/back + rest
   -ALWAYS Think of Bone tumours
Mass (if advanced stage)
Incidental abnormal XRay

Question 8

Bone tumour always think of this sign

Answer 8

PAIN-not activity related

-getting worse at rest and night

Question 9

Do benign bone tumours have pain?

Answer 9

Yes,if large enough to weaken the bone

Question 10

Which benign bone tumour can cause pain?

Answer 10

Osteoid osteoma

• is a very small tumour in end of femur/tibia
• tense pain at night
• Classically relieved by NSAIDs

Question 11

PE: Physical Examination of tumour?

Answer 11

Gen health ( weight loss if cancer progresses)
Measure the mass
Location
Shape
Consistency
Mobility of mass-stuck to skin/deeper tissue?
Tenderness (not tender is malignant)
Local Temp
Neurovascular deficits( tumour can invade BV and n. –>change in power,sensation,circ.)

Question 12

***Signs of malignant tumour (soft tissue and bone) from a swelling-IMPORTANT

Answer 12

• Rapidly growing
• Hard, fixed, craggy ( irregular) surface, indistinct margins (malignant!)
• Non-tender on palpation, but assoc with deep ache, esp worse at night ( if tender is inflammatory,non-tender is malignant)
• Beware: may be painless ( beware! esp in soft tissue sarcoma painless usually, bone sarcoma is PAINFUL)
• Recurred after previous excision ( soft tissue sarcoma)

Be suspicious of malignant tumour until proven otherwise

Question 13

Why do a biopsy?

Answer 13

To define what the tumour is (histology) and then decide Tx

Question 14

What should you do before a biopsy?

Answer 14

1. Bloods (UnE, LFT)
2. Xray of affected limb
3. CXR ( for metatstatic bone cancer to lungs;lung secondary cancer)
4. MRI ( check extent)
5. Bone scan
6. CT chest,abdo,pelvis ( for LN metastases)

Question 15

Types of investigation for bone tumour

Answer 15

*Plain Xray
*MRI
- can see extent of invasion, anatomical relationships eg BV ,LN,nerves,fascia
-specifically for lipoma ( no need to do other investigations
CT
-for osteoid osteoma,
-check lungs for metastases ( majority sarcoma metatstasise to lungs)
Bone scan
-Technetium 99m

Question 16

What is myositis ossificans?

Answer 16

Ectopic bone forming within muscles
-due to head injury, blast injury
Is not a tumour

Question 17

What can you see on Xray

Answer 17

Got fracture (pathological) due to tumour
Cortical destruction ( malognancy)
Periosteal reaction occurs when lesion destroys cortex
-new bone forms in response to injury to periosteum, is a healing process
- Sunburst pattern ( tumour bursting out of bone)
-Codman’s triangle

Question 18

Purpose of CT

Answer 18

-assess ossification and calcification
-*check lungs for staging ( bone sarcoma often
metastasise to lungs)
-best for assessing osteoid osteoma

Question 19

Purpose of bone scan

Answer 19

• Staging for skeletal metastasis ( often from breast cancer)
• benign bone tumour can show up too if got high cell turnover–>high isotope uptake
• negative in myeloma

Question 20

Purpose of MRI

Answer 20

The Golden Choice

• size, extent,anatomical relationships of tumour
• to determine resection margin

Downside: non-specific for benign or malignant

Question 21

**Malignant primary bone tumours (Osteosarcoma, Ewing’s sarcoma) cardinal features?

Answer 21

• ** PAIN
  - Increasing pain
  - Unexplained pain
  - Deep-seated boring nature pain ( v diff from osteoarthritis pain)
  - Night pain (diff from osteoarthritis)
• Difficulty weight-bearing
• Deep swelling—>always think MPBT

Question 22

***Any bone tumour SnS

Answer 22

Pain

• persistent
• increasing pain
• at rest
• at night

Vague deep seated mass

Do Xray

Question 23

Difference between osteosarcoma and Ewing’s sarcoma

Answer 23

• Osteosarcoma more common than Ewing’s
• Ewing’s responds to radiotherapy, osteosarcoma no
• osteosarcoma is a bone-forming tumour
• Ewing’s sarcoma is a bone marrow tumour

Question 24

Age range of osteosarcoma

Answer 24

10-30yo and predominantly Male

Question 25

Site of osteosarcoma

Answer 25

Around the knee - Distal femur - Proximal tibia

Question 26

***Clinical features of any bone tumour (benign/malignant)

Answer 26

- PAIN *** - DEEP BORING ACHE WHICH GETS WORSE AT NIGHT (MALIGNANCY) - increasing pain-->impending fracture ( esp lower limb) - not related to physical activity( persistent, not mechanical pain, is boring pain) - beware of pt that keep coming back due to pain - loss of function - due to pain - reduced joint movement - *stiff back (esp children) - swelling - gen near end of long bones - once reached noticeable size, enlarges rapidly (wk on wk) - a lot of bloodflow so is warm - pressure on nearby structures - pathological fracture (benign / malignant) - minimal trauma + history weeks of pain before the fracture - osteoporosis most common cause rather than bone tumour -joint effusion if tumour is next to joint - deformity - neurovascular effects - systemic effects of neoplasia - low fever,loss of appetite,weight loss

Question 27

What treatment for bone tumours?

Answer 27

Chemotherapy ( to shrink tumour) Surgery (to resect) Radiotherapy ( Ewing's can, Osteosarcoma cannot, is the distinguishing factor between the two)

Question 28

What is the goal of treatment for bone tumours

Answer 28

Make free of disease

Question 29

The commonest primary CA to metastasise to bone?

Answer 29

Breast CA

Question 30

Primary CA which metastasise to bones?

Answer 30

``` Paired midline organs primary CA - Breast (commonest) - Lung - Prostate - Kidney - Thyroid GI tract Melanoma ```

Question 31

Most common site of metastasis

Answer 31

1. Lung 2. Liver 3. Bone

Question 32

Common sites of secondary metastasis on bone

Answer 32

Vertebrae** > Prox femur>pelvis>ribs>sternum>skull

Question 33

The commonest primary CA metastasises to lungs

Answer 33

melanoma

Question 34

Secondary bone CA is more common than primary bone CA?

Answer 34

YES

Question 35

Term for : -A fracture that happens due to diseased/weakened bone ( not injury) -the bone breaks under very light force that normally doesn't fracture a healthy bone?

Answer 35

Pathological fracture

Question 36

Extra: Types of pathological fracture?

Answer 36

- Vertebral fracture - Fracture of neck of femur - Distal radius fracture(Colles' wrist fracture/dinner fork deformity)

Question 37

Prevention of pathological fracture?

Answer 37

- Early chemotherapy - Deep X ray therapy - Surgery: - Prophylactic internal fixation using Mirel's scoring system ( score 8 or more) - done one long bone at a time ( risk of showering emboli during surgery)

Question 38

Aim of prophylaxis of pathological fracture ?

Answer 38

Early painless weight-bearing and mobilisation

Question 39

What is Mirel's scoring system?

Answer 39

- Tool useful for management of bone tumours - identifies patients who would benefit from prophylactic fixation if they have high enough risk (Mirel score 8 or more) of pathological fracture - if get score of 8 or more, prophylactic fixation is suggested prior to radiotherapy ( don't do radiotherapy as 1st step as will fracture the bone before you can fix it)

Question 40

What is prophylactic fixation?

Answer 40

Fixation - Putting screws/wires into bone for bone surgery/ bone repair -Prevent the (high risk of fracture ) bone from fracturing

Question 41

Survival rate of breast CA with bone metastases?

Answer 41

many years

Question 42

Survival rate of breast CA with soft tissue metastases?

Answer 42

1-2 years only

Question 43

Another criteria for prophylactic internal fixation besides Mirel's scoring system?

Answer 43

Lytic lesion (spots of bone tissue destroyed)+ increasing pain+/- >2.5cm diameter+/- >50% cortical destruction

Question 44

Bone metastases | What is a lytic lesion?

Answer 44

Spots of bone tissue destroyed

Question 45

Bone metastases | What is a blastic lesion?

Answer 45

Filled with extra bone cells

Question 46

Treatment for pathological fracture of hip/ proximal femur?

Answer 46

Cemented hip prostheses | ( not internal fixation)

Question 47

Should you rush to fix a pathological fracture?

Answer 47

No, use traction and splintage while waiting for other investigations/discussing surgical intervention

Question 48

What is required when surgery for spinal metastases?

Answer 48

Decompression of spinal cord and stabilisation-->make pt mobile

Question 49

Soft tissue tumour | If lesion<5cm, what is it?

Answer 49

Very likely to be lipoma rather than sarcoma

Question 50

Soft tissue tumour | If lesion is deep seated (below fascia) , what is it?

Answer 50

Think sarcomas

Question 51

The larger the tumour gets (>5cm), the more likely you should suspect sarcoma rather than lipoma?

Answer 51

YES man

Question 52

***Top 3 Suspicious signs of malignant soft tissue tumour?

Answer 52

- Deep tumours of any size (deep to deep fascia) - Subcutaneous tumour>5cm - Any mass with rapid growth,hard, craggy ( irregular surface),non-tender

Question 53

What should you do if pt suspected of malignant soft tissue tumour?

Answer 53

Refer to specialist tumour centre

Question 54

***Malignant soft tissue tumour (soft tissue sarcoma) features incl the top 3 signs

Answer 54

- painless—hence get bigger pt not worried (benign/malignant), malignant (soft tissue sarcoma) can get pain if it is large enough to impinge on nerves - mass deep to deep fascia (malignant) - any mass >5cm (malignant) - any fixed, hard, irregular surface mass (malignant) - any recurrent mass after excision (malignant)

Question 55

Imaging study of choice for soft tissue tumour

Answer 55

MRI

Question 56

Is soft tissue sarcoma or bone sarcoma or both painful?

Answer 56

Only bone sarcoma is painful Soft tissue sarcoma usually painless , it can be painful if it is large enough to impinge on nerves

Question 57

Difference between benign soft tissue tumour (lipoma) and malignant/sarcoma soft tissue tumour (liposarcoma)?

Answer 57

Lipoma (benign soft tissue tumour) vs Liposarcoma ( malignant soft tissue tumour) Site: everywhere thigh, retroperitoneum Physical feature: Smooth Irregular and hard Moveable with fingers Fixed, stuck to other tissues Growth rate : Slow growth Rapid growth Recurrence: Rare Common ( even after excision) BOTH ARE usually PAINLESS (unless they get so big they impinge on nearby nerves)