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Flashcards in Bone neoplasms Deck (59):

What is the Most common primary bone cancer in children and young adults?



Define osteosarcoma

Malignant bone tumor producing immature bone cells


What are the characteristics of chondrosarcoma?

1. 3rd -7th decade of life, MC >50yrs
2. Trunk (pelvis) and proximal limbs (Pelvis, prox. femur, prox. humerus, distal femur, ribs) develops in cartilage cells
3. Slow growing, malignant bone tumor producing cartilaginous matrix
4. Mets rare


What are the characteristics of Ewing's sarcoma?

1. 15-25 yo most common
2. Most often in long bones (femur, but also tibia, humerus, fibula), but may develop in almost any bone or soft tissue, commonly in flat or long bones


What is the 2nd most common bone cancer in kids?

Ewing’s sarcoma


What are the characteristics of osteosarcoma?

1. Affects 10-20 yo and > 65 yo
2. In adults, > 40 yo, cases are frequently asst w/ Paget’s disease of bone
3. 3% of osteosarcomas can be attributed to prior radiation therapy


What are the sxs of osteosarcoma?

1. Presenting complaint usually pain in a long bone
A. Femur, tibia, humerus
2. Localized pain or swelling for weeks-months
A. Pain often worse @ night & w/ activity
3. May present w/ loss of function, soft tissue mass or limp
A. i.e. swollen knee or knee pain (initially thinking sports injury)
4. Pathological fracture is common
5. Fatigue
6. Fever
7. Unexplained wt loss


What dx studies are used for osteosarcoma?

1. Xray
2. MRI
3. Bone scan
4. CT scan chest
5. Bone biopsy


What may show up on an xray for osteosarcoma?

1. May not always show any abnormalities, other than STS
2. “Sunburst” pattern
A. Periosteal rxn
3. Codman’s triangle
A. Tumor starts in center of bone and pushes cortex laterally, forming a triangle
4. Tumor may present as a mixed lytic and sclerotic appearance, a soft tissue mass with ossification apparent


Why is an MRI used for osteosarcoma?

Assesses tumor size and extent of disease


Why is a bone scan used for osteosarcoma?

Evaluates whole skeleton


Why is a bone biopsy used for osteosarcoma?

Makes definitive diagnosis


What is conventional osteosarcoma?

1. intramedullary high-grade
A. 90% of osteosarcomas
B. Metaphysis of long bones


How is osteosarcoma treated?

1. Surgical excision (limb salvage) or amputation depending on extent of tumor
2. Adjuvant chemotherapy prior to surgery, then chemotherapy after surgery


What is the px for osteosarcoma?

1. Prognosis is improving
A. 60-70% long term rates
B. Mortality d/t lung mets


What are the sxs of chondrosarcoma?

1. Mass on affected bone
A. Feeling of pressure around the mass
2. Pain worse @ night
3. Pain not relieved w/ rest
4. Pain may be present for years, then inc gradually over time


What dx studies are used for chondrosarcoma?

1. Xray
2. CT scan
3. MRI


What are the xray results for chondrosarcoma?

1. Fusiform, lucent defect w/ scalloping of inner cortex and periosteal reaction
2. Stippled calcification of cartilage matrix


What is the treatment for chondrosarcoma?

1. Wide surgical excision for Low grade chondrosarcomas
A. approx. 85% survival rate
2. Slow-growing
A. Chemotherapy not effective
B. Relatively radioresistant


What are the sxs of ewing's sarcoma?

1. Localized pain or swelling of few wks or mos. duration- presenting complaint
2. Minor trauma, may be initiating event that calls attention to bone lesion
3. Pain worse at night
4. Aggravated by exercise
5. +/- distinct soft tissue mass, if present, firmly attached to bone and moderate to severely tender to palpation
6. Swelling of affected limb w/ erythema overlying mass can be found
7. Fever, fatigue, wt loss, or anemia present only 10-20% of pts @ presentation


What are the dx studies for ewing's sarcoma?

1. Xray
2. MRI w/ gadolinium
3. CT guided needle biopsy
4. Bone scan


What are the xray results in ewing's sarcoma?

1. "Moth-eaten” pattern w/ very poorly defined margins
2. "onion skin" periosteal rxn


What is the treatment for primary bone neoplasms?

1. Treatment for localized disease of Osteosarcoma and Ewing’s Sarcoma
A. Chemotherapy, surgery, chemotherapy


What is the px of ewing's sarcoma?

1. approx. 5-yr survival with localized disease (no mets) is 70%
2. 10-30% of pts have metastasis at time of diagnosis
3. Younger the age of child tends to have a better prognosis


Bone Metastasis is more likely to come from what type of cancers?

(70% in females) Breast, renal cell (kidney), prostate, lung, thyroid, stomach, intestinal


What are the most common sites of bone mets? and why?

1. Pelvis
2. Spine
3. Ribs
4. Humerus
5. Femur
Bc these bones have a good blood supply


Define Complex regional pain syndrome (CRPS)

1. Characterized by persistent pain of limb, swelling, erythema, shiny appearance of affected limb


What is the etiology of CRPS?

1. Thought to cause pain by release of inflammatory mediators and pain-producing peptides by peripheral nerves
2. Pathogenesis is unclear, but seems to involve a reflex arc after inciting event
A. Frequently follows an injury to limb, surgery, or after a stroke


What is stage 1 CRPS?

1. Pain, burning, sensitivity to hot/cold
2. Clammy / diaphoretic limb


What is stage II CRPS?

Soft tissue edema


What is stage III CRPS?

1. Most severe stage
2. Limitation of movement


What are the general sxs of CRPS?

1. Swelling
2. Erythema, shiny
3. Claw limb
4. Burning pain


What are the treatment options for CRPS?

1. Pain control
B. Amitriptyline
C. Gabapentin or Pregabalin
D. Severe pain may need to prescribe opioid instead of NSAID, but narcotics may not help nerve pain

2. Physical Therapy / Occupational Therapy
3. Smoking Cessation
4. Patient education
5. Psychological counseling
6. Sympathetic nerve blocks
7. Stellate ganglion blocks
8. Dorsal column stimulators



Define Paget's disease of bone

1. Uncommon, chronic bone disease that affects about 1% of the population in the US
2. Rapid isolated bone repair (accelerated rate of bone remodeling)
A. enlarged bone growth (large and dense)
B. soft bones (soft and weak bones)
C. typically involves one or more bones of pelvis, spine, hips, thighs, skull and arms


What dx studies are used for paget's dz of bone?

1. Detected incidentally on x-ray: patchy appearance
A. typically affects pelvis, lumbar spine, hips, femurs, skull
2. Serum alkaline phosphatase (ALP) inc
A. d/t rapid new bone turnover
3. Bone scan or MRI: determines extent of bone involvement


What are the sxs of paget's disease?

1. Most people with Paget’s disease of bone are asymptomatic!
2. if sxs present, pain due to bone overgrowth and deformity of affected bone/limb


What is the treatment for Paget's disease of bone?

1. Acetaminophen or NSAIDs for pain assoc w/ Paget’s
2. Bisphosphonates
A. dec pain & helps regulate bone-building process to stimulate more normal bone growth
B. often leads to clinical remission of disease
C. Reclast (Zoledronic acid) IV
3. Surgery for arthritis caused from Paget’s disease is effective in reducing pain and improving function


Define osteomylitis

1. Serious Bone Infection caused by:
A. Hematogenous spread of bacteria
B. Invasion from a direct site of infection
C. Skin breakdown (venous ulcers) in setting of vascular insufficiency


What bones are commonly affected by osteomyelitis?

1. Long bone hematogenous osteomyelitis- The most common region of bone is metaphysis
A. In children, long bones affected more commonly
B. In adults, vertebrae affected most commonly


What is the pathophys of osteomyelitis?

In the setting of osteomyelitis, focus of infection in the metaphysis via nutrient artery leads to spread in the bone marrow -> inflammatory exudate in the marrow -> inc intramedullary pressure w/ extension of exudate into the bone cortex -> can rupture thru to periosteum
A. If this occurs, the periosteal blood supply to the bone is interrupted, leading to bone damage and necrosis


Who is more likely to get osteomyelitis?

1. Normal bone is highly resistant to infection
2. Immunocompromised patient or trauma (i.e., open fracture) pt @ inc’d risk for osteomyelitis


What are the MC affected bones of osteomyelitis?

1. Most commonly involves vertebral bones, then, clavicle and pelvis


Who gets hematogenous osteomyelitis?

1. Results from bacteremia, assoc. w/
Sickle cell disease, IV drug users, DM or elderly
2. 20% of osteomyelitis cases in adults
3. 85% of osteomyelitis in children


Who gets osteomyelitits from direct spread of infection?

1. Prosthetic joint replacement
2. Decubitus/Pressure ulcer
3. Neurosurgery
4. Trauma (soft tissue infections that spread to bone)
A. Step on nail
B. Open frx


Who gets osteomyelitits asst. w/ vascular insufficiency?

1. Pts w/ DM & chronic vascular insuff. at risk for this type of osteomyelitis
A. Very challenging infection
B. Foot and ankle most common


What are the sxs of osteomyelitis from vascular insufficiency?

1. Foot or ankle ulcers
A. Pt presents with the ulcer but does not appear impressive >2cm
2. Bone pain muted d/t neuropathy
3. Fever often absent too
4. Bedside diagnostic clue
A. Chronic, poorly healing soft tissue wounds
5. Ability to pass sterile probe through ulcer to bone


What are the risk factors for Hematogenous Osteomyelitis?

1. Sickle Cell Disease
A. Salmonella
2. IV drug use
A. Staph aureus
B. Pseudomonas
C. Serratia
3. DM
4. Elderly
5. Immunocompromised


What are the risk factors for Osteomyelitis from direct spread of infection?

1. Staph aureus & Staph epidermidis most common
A. Prosthetic joint replacement
B. Decubitus ulcer
C. Neurosurgery
D. Posttraumatic- open frx


What are the sxs of Hematogenous Osteomyelitis?

1. Sudden onset high fever & chills
2. Pain & tenderness involved bone
3. Cellulitis
A. Localized skin infection
4. Septic arthritis can cause osteomyelitis if it is not treated


What dx studies are used for osteomyelitis?

1. Labs
A. CBC w/ diff
2. X-ray
3. MRI
4. Wound culture
5. Bone biopsy or blood culture


What are the xray results in osteomyelitis?

1. Soft tissue swelling
A. Early stages
2. Erosion of bone & elevation periosteum
B. ~ 2 weeks after sxs
3. Periosteal elevation, cortical disruption and medullary involvement may be present


What is the most sensitive test for osteomyelitis?

1. MRI, shows extent of infection


Why is a bone biopsy or culture performed for osteomyelitis?

organism ID


What is the treatment for osteomyelitis?

1. Surgery
A. Debridement of necrotic bone
2. IV Antibiotics in hospital
A. Usually at least 6 weeks
B. Peripherally inserted central catheter (PICC line)
-When pt goes home


What abx can be used for MSSA in osteomyelitis?

1. Nafcillin
2. Oxacillin
3. Cefazolin


What abx can be used for MRSA in osteomyelitis?

1. Vancomycin


What abx can be used for coagulase negative staphylococci in osteomyelitis?

1. Vancomycin


What abx can be used for gram negative organisms (including pseudomonas) in osteomyelitis?

1. Ciprofloxacin
2. Levofloxacin
3. Ceftazidime
4. Cefepime


What empiric abx can be used for osteomyelitis?

Vancomycin PLUS an agent with activity against gram negative organism