Bone Tumors Flashcards
(110 cards)
1
Q
2 types of bone tumors
A
- primary: from bone cells
- secondary: mets from breast, prostate, lungs, thyroid & kidneys
2
Q
what genes normally help cells grow and divide / help cells stay alive
A
Proto-oncogenes
3
Q
what two “benign” bone tumors weaken the bone?
A
- Osteoid osteoma
- Osteochondroma
4
Q
- Dull ache
- Worse with activity
- Progresses over time
- +/- soft tissue mass firmly attached to bone
- Constitutional sx are late findings (mets)
what type of bone tumor
A
malignant
5
Q
initial imaging study of choice for bone tumors?
A
XR
6
Q
on XR
- Well-defined or sclerotic border
- Sharp zone of transition
- Small size or multiple lesions
- Confinement by natural barriers (eg, growth plate, cortex)
- Lack of destruction of cortex
- Lack of extension into soft tissue
what type of bone tumor?
A
benign
7
Q
characteristics of a malignant bone tumor on XR
A
- Poorly defined borders
- Cortical destruction (“moth-eaten” or permeative pattern)
- Spiculated or interrupted periosteal reaction
- Extension into the soft tissue
- Large size
8
Q
A benign, well-defined, expansile lesion with regular destruction of cortical bone and a peripheral layer of new bone.
A
Chondromyxoid fibroma
9
Q
A locally aggressive lesion w/ cortical destruction, expansion and a thin, interrupted peripheral layer of new bone.
A
Giant cell tumor
10
Q
other w/u for bone tumor after XR
A
- CT scan - Best for assessing metastatic disease in thorax
- MRI - Determines tumor size, extent of intraosseous and extraosseous involvement, Add contrast for bx
11
Q
Cartilage-forming tumors
A
- Osteochondromas
- Enchondroma
- Chondroblastoma
- Fibrous lesions
- Cystic tumors
12
Q
osteoid osteoma is an overgrowth of bone tissue arises from ?
A
osteoblasts
13
Q
osteoid osteoma MC where on the bone?
A
In long bones - femur MC
14
Q
As bone tissue proliferates, a _____ is formed
osteoid osteoma
A
nidus surrounded by sclerotic bone
15
Q
a centrally located disorganized mixture of small blood vessels, trabecula (tiny rods of bone), and osteoid (unmineralized bony tissue)
A
Nidus
16
Q
The nidus secretes _____ leading to the pain associated with this tumor
A
prostaglandins
17
Q
- Localized, deep, constant, aching pain
- Worse at PM, waking patient up; occasionally worse with activity and ETOH use1
- Improves with NSAID or ASA - +/- palpable mass, tenderness overlying the lesion, neurologic symptoms
- Atypical juxta-articular presentation
- Pain in joint (hip - MC) with walking with limp
- Referred pain to the knee
A
osteoid osteoma
18
Q
w/u for osteoid osteoma
A
- XR
- CT w/ IV contrast - preferred imaging following XR
- Radionuclide Scanning (aka Bone Scan)
- MRI with gadolinium
19
Q
osteoid osteoma findings on XR?
A
- sclerosis around a lucent nidus (< 1.5 cm)
- Varying presentations
- Calcified nidus = radiopaque point called the bell
- Nidus close to bone surface may appear like fx
20
Q
indications for CT w/ Contrast for osteoid osteoma?
A
- X-ray appears abnormal, but nidus isn’t visible
- Residual or recurrent tumor is present
- Tumor in a critical area - Spine, Femoral neck
21
Q
- Indicated when XR is normal
- More sensitive > XR
what imaging for osteoid osteoma?
what is the diagnostic finding?
A
- Radionuclide Scanning (aka Bone Scan)
- “Double density”
22
Q
- Less accurate < CT d/t reactivity of bone from edema surrounding lesion
- Often used to assess cases not confirmed by XR or CT
A
MRI with gadolinium
23
Q
mgmt for osteoid osteoma
A
- OTC tx, serial imaging q 4-6 mo
- symptomatic / uncontrolled - refer, surgical intervention - Resection vs radiofrequency ablation vs cryotherapy; Removal of nidus
24
Q
T/F: osteoid osteomas can resolve spontaneously over several years
A
T
25
* Morphologically and genetically similar to osteoid osteoma
* slow growing
* May be more aggressive = more bony and soft tissue destruction
* Nidus > 2 cm²
dx?
osteoblastoma
26
osteoblastoma MC location?
**Posterior column of spine** → spinous process, lamina, and pedicles
27
1. Chronic pain (dull and achy) → **Unrelieved by NSAIDs**
1. sx dependent on tumor location
- LE → limp
- Spinal cord/nerve root compression → limp or neurologic sx
- Spine → scoliosis
1. Rarely any systemic sx
osteoblastoma
28
w/u and findings for osteoblastoma
1. **_XR_** - **Well-circumscribed radiolucent lesion (nidus) > 2 cm**; Thin shell of peripheral new bone separating it from surrounding soft tissue; Spinal lesions **extend into soft tissue**
2. **CT** - _indicated for all osteoblastoma_
3. MRI
4. **Bx** - core needle vs open bx
29
mgmt for osteoblastoma
1. **surgical resection** - Curettage and burring followed by bone grafting; Marginal resection
1. _+/- Post-surgical radiation_ if entire lesion can not be resected
30
when is marginal resection performed for osteoblastoma?
1. **Reserved for more aggressive tumors**
1. Results in more healthy bone being removed
31
prognosis for osteoblastoma
1. Reported recurrence rate 10-20%
1. relapse associated w/ inadequate resection of primary lesion - Some lesions may not be able to be fully resected due to location (i.e. spine)
32
1. MC solitary, benign bone tumor
1. **Benign, cartilage-capped bony projection** on the external surface of a bone - Osteocartilaginous exostosis
1. Males > females
1. MC present in 2nd decade
OSTEOCHONDROMA
33
osteochondroma MC happens where?
* **knee** and **proximal humerus**
* Other common sites: pelvis and scapula
34
osteochrondroma occurs adjacent to what layer/part of the bone?
when does tumor stop growing?
* epiphyseal growth plate
* when growth plates close
35
causes of osteochondroma
1. Solitary tumors – unknown
1. Hereditary multiple osteochondromas (HMO)
- genetic mutation in tumor suppressor genes EXT1 or EXT2
36
* MC **asx** and found incidentally on imaging
* **Painless mass** near a joint or on axial skeleton
* **Mechanical sx** - Bursitis over exostosis; Irritation to tendons, muscles, or nerves
* **Painful mass assoc w/ local trauma**
* **Growth plate dysfunction** - Varus or valgus deformity; Shortening of long bone
osteochondroma
37
w/u for osteochondroma and findings?
1. XR - **Bone spur** that extends away from joint
1. CT/MRI - further assess lesions not defined on XR (Pelvis, scapula, spine)
- Helps with localization and surgical planning
- MRI preferred if looking at soft tissue
38
mgmt for osteochondroma
1. **Asx** - **No intervention,** **annual w/ clinical exam**; any change → MRI
1. Surgical excision
1. Refer to orthopedic oncology if surgical excision is considered
39
Surgical excision indications for osteochondroma
* Large lesion, associated with deformity and functional limitations
* Concern malignant transformation
40
complications of osteochondroma
1. < 1% risk of **chondrosarcoma**
- **Higher risk in _HMO_**
- Suspected if: New onset growth of lesion, New onset pain, Rapid growth of lesion
41
prognosis of osteochondroma
1. Solitary osteochondromas
- Excellent local control w/ surgical excision
- recurrence rate < 2%
2. Hereditary multiple osteochondromas
- Monitor for growth defects and neuro changes (spinal lesion)
42
* A **benign cartilage forming tumor** that develops in **bone marrow of long bones**
* Lesions replace normal bone with hyaline cartilage
enchondroma
42
enchondroma growth occurs where on the bone?
| pathophys
from metaphysis into diaphysis
*Theory: lesion arises in growth plate d/t failure of downregulation of growth plate chondrocytes*
43
enchondroma MC occurs where?
* **MC – hands and feet**
* Other sites: Humerus, Femur, Tibia, Ribs
44
* A non-hereditary, acquired **genetic mutation** resulting in **multiple enchondromas**, often with a **unilateral predominance**
* Usually presents before age 10
Enchondromatosis
45
s/s of enchondroma
* **MC asx**
* **Widening of the bone, Angular deformity, Limb-length discrepancy**
* Pain from pathologic fx MC in wt bearing bones
46
w/u for enchondroma
1. XR
2. Bone scan - Test negative if uncomplicated; Areas of activity = pathologic fx or malignant dx (chondrosarcoma)
3. CT/MRI - r/o ddx of chondrosarcoma or bone infarct
4. Bx - If painful w/o fracture = r/o chondrosarcoma
47
XR findings of enchondroma
1. Centrally located
1. Round or oval
1. Well circumscribed
1. Sclerotic border
1. Lobulations are often seen inside the lesion
48
mgmt for enchondroma
1. Small, **asx**- **Monitor** w/ exam and imaging
1. **Sx**/**pathological fx risks** - _Curettage & bone grafting_
- heal fx before curettage
49
Pathologic Fx Risk Factors
1. wt bearing bone
1. >25 mm in diameter
1. Involving > 50% of diameter of cortex
50
prognosis of enchondroma
1. _Solitary_: **self-limiting**, continued growth possible
1. **Recurrence rare** after curettage & graft
1. long bones & pelvis: can transform into **chondrosarcomas**
- Rare in solitary lesions
- 50% of enchondromatosis
51
A benign cartilage-forming tumor that usually arises in the epiphyses or apophyses of long bones
CHONDROBLASTOMA
52
chondroblastoma MC sites?
1. **Epiphysis of proximal humerus**
1. Distal femur
1. Proximal tibia
53
s/s of chondroblastoma
* Chronic **pain - mild and progressive**; **constant** and **unrelated to activity**
* Joint stiffness and swelling
* Localized tenderness
* Dec ROM
* Joint effusion
* Muscle atrophy
* **Limp** in wt bearing lesions
54
XR finding of a small, **well-defined lesions with sclerotic border** that may cross the physis (growth plate)
dx?
chondroblastoma
55
tx for chondroblastoma
surgery - curettage and bone grafting
56
complication of chondroblastoma?
**Benign pulm mets**
* CXR in all; follow w/ CT w/ IV contrast if any suspicious areas are present
* resectable and curable
57
* **Abnml fibrous tissue** and **trabecular bone** replaces nml bone marrow and bone tissue = **bone weakness**
* Resulting in Fx or deformity
* Lesion is **slow growing** and often appears during periods of bone growth
fibrous dysplasia
58
associated genetic condition with fibrous dysplasia?
**McCune-Albright Syndrome**
Polyostotic lesions, ipsilateral café-au-lait spots, precocious puberty
59
common sites for fibrous dysplasia
1. Proximal femur
1. Tibia
1. Skull/maxilla
1. Ribs
60
s/s of fibrous dysplasia
* **MC asx**
* **Pain/tenderness** as fibrous tissue expands into bone or fx happens
* Bone deformity - **Shepherd’s Crook**, Scoliosis, leg length discrepancy, **Facial asymmetry**
* Rib deformities
* Swelling
* Waddling gait
61
XR shows Lytic lesion with “ground-glass” appearance
dx?
fibrous dysplasia
62
indications to use bone scan for fibrous dysplasia?
r/o polyostotic disease
63
tx fibrous dysplasia
1. **asx - monitor** w/ serial exams and imaging
2. **Curettage & bone grafting**; recurrence HIGH
- _Avoided in peds_: high rate of recurrence
3. **IV bisphosphonates**
4. Rigid fixation w/ intramedullary implant
5. Refer to endo if polyostotic lesions present
64
A destructive, deforming, slow growing benign fibro-osseous lesion
ossifying fibroma
65
MC sites for ossifying fibroma
* **tibia and fibula - < 10 y/o** – peaks 1-5 y/o
* **mandible - adults**
66
s/s of ossifying fibroma
* **Localized, firm swelling**
* **Tibia bowed** anteriorly or anterolaterally
* **painless**
* _Pain_ - associated with pathologic fx
67
XR finding of ossifying fibroma
* Well-circumscribed **intracortical** lesion
* Cortex expanded and thinned, with multiple radiolucencies (lytic appearing)
68
tx for ossifying fibroma
1. **Asx - monitored**, repeat imaging q 6 mo
1. **Resection, curettage & bone grafting _after skeletal maturity_**
- curative
- performed before: risk of recurrence
69
* **benign, non-aggressive** tumor that consists mainly of **fibrous tissue**
* **MC benign bone lesion in children**
nonossifying fibroma
70
MC sites for nonossifying fibroma
* Distal **femur**
* distal and proximal **tibia**
71
s/s of nonossifying fibroma
* **MC asx**
* Larger lesions = **bone weakness = fx**
72
XR for nonossifying fibroma
1. **Small, well-defined, eccentric, lytic lesions**
1. MC **distal diaphysis/metaphysis**
1. Sometimes multiple lesions may occur
73
tx nonossifying fibroma
1. **Asx small - none**
1. Indications for curettage and grafting:
- Lesions **> 50% of bone diameter**
- Lesions in **high stress area** (distal femur)
74
* simple bone cysts or solitary bone cysts
* **Non-cancerous fluid filled lesions with fibrous lining**
unicameral bone cysts
75
MC sites for unicameral bone cysts
1. Proximal humerus
1. Proximal femur
76
s/s unicameral bone cysts
1. Asx until pathologic fx - pain, limp, or inability to use extremity
1. Lesions occurring within a growth plate - **growth plate dysfunction & limb length discrepancy**
77
XR:
* **Well defined, cystic lesions** at metaphysis or metadiaphysis
* involves **entire diameter of bone**
* Pathologic fx - **“fallen leaf” or “fallen fragment” sign**
dx?
unicameral bone cysts
78
tx for unicameral bone cysts
1. **resolution after skeletal maturity**
2. **Asx - Observe** w/ serial XR q 4-6 mo; Activity restrictions
3. _risk of fx_ - **Cyst Aspiration and injection** of methylprednisolone or bone marrow
4. **Curettage & bone grafting - for larger cysts** that compromise the structural integrity of bone
79
* A benign, rapidly growing and destructive blood-filled lesion
* Lesions are usually solitary
* Females > males
* MC in adolescents
aneurysmal bone cyst
80
MC sites for aneurysmal bone cysts
1. Tibia
1. Femur
1. Posterior vertebral elements
1. Pelvis
1. Humerus
1. Fibula, foot, hand, ulna, radius
81
s/s of aneurysmal bone cysts
1. **Localized pain, tenderness & swelling**
1. Limp if wt bearing bone is affected
1. Lesions in spine = neuro s/s
1. Lesions at growth plate = stunt growth
82
XR shows:
* Aggressive, expansile, lytic metaphyseal lesion with sharp borders
* “Eggshell” sclerotic rim
* “Soap bubble”
dx?
aneurysmal bone cysts
83
tx for aneurysmal bone cysts
1. **Excision, curettage & bone grafting**
- Adjuvant chemical cauterization or cryotherapy
2. **Selective arterial embolization** before surgery
- angiography to locate feeding artery to cyst
- Insert object (spring/foam) into feeding artery to create an emboli
84
MC malignant bone tumor
Arise from an overgrowth of malignant osteoblasts
osteosarcoma
85
MC sites for osteosarcoma
**metaphysis** of long bones
1. Distal femur
1. Proximal tibia
1. Proximal humerus
86
2 peaks in incidence of osteosarcoma?
1. Early adolescents
1. Adults over 65 y/o
87
RF for osteosarcoma
1. h/io irradiation or chemotherapy
1. Paget disease, fibrous dysplasia, and other benign bone lesions
1. Genetic predisposition
88
s/s osteosarcoma
1. **Pain & swelling - 1st and MC**
- **worsened w/ activity**
1. **Palpable mass**
1. **Limping** if in wt bearing area
1. Limited ROM if located in the joint
1. Systemic sx _not_ present
89
XR findings of osteosarcoma
* Both **osteolytic** and/or **osteoblastic** lesions
* **“moth eaten”**
* tumor extends thru periosteum = spiculated reaction, **“starburst”**
* **Codman’s Triangle** → new bone formation at periosteum
90
what intervention is used for each lesion after osteosarcoma is identified on bone scan?
**CT/MRI**
* CT - best for defining bone destruction & the pattern of calcification
* MRI - better for defining intramedullary & soft tissue extension
91
tx osteosarcoma
1. Refer
1. Core needle or open bx
1. **Pre- and post-op chemo w/ limb sparing surgery**
92
T/F: osteosarcomas are radioresistant
T
93
* A tumor arising from chondrocytes (cartilage producing cells)
* MC after 50 y/o
chondrosarcoma
94
MC sites for chondrosarcoma
* **pelvic and shoulder girdle**
* Other: diaphysis of long bones
* Rarely seen in the spine & craniofacial bones
95
RF for chondrosarcoma
1. Questionable genetic component
1. MC from normal cartilage cells but may also stem from previous benign bone or cartilage tumor
- Enchondromas
- Multiple osteochondromas
- Ollier Disease (Enchondromatosis) → a cluster of enchondromas that affect the hands
96
s/s of chondrosarcoma
1. **Deep, dull aching pain; progressive**
1. **Worse at PM**
1. Neuro sx if compresses NV bundle - MC in pelvic lesions
1. Limited ROM if near a joint
1. Sx of pathologic fx
97
XR findings of chondrosarcoma?
1. **bony contour thinned & expanded**
1. Multiple surface erosions → **“endosteal scalloping”**
1. Lesion **> 5 cm**
98
* chondrosarcoma MC mets to what part of the body?
* how to eval?
lungs - get CT w/ contrast
98
tx chondrosarcoma
1. Refer
1. **Surgical excision**
99
A rare, peripheral primitive neuroectodermal tumor that can proliferate in the bone and/or soft tissue
Ewing sarcoma
100
cause of Ewing sarcoma
translocation between chromosomes 11 and 22
101
MC sites for ewing sarcoma
pelvis and femur
102
s/s of ewing sarcoma
* **Localized pain & swelling; worse at PM or w/ activity**
* **Palpable mass**
* Neuro deficits if compression of spinal cord or peripheral nerve
* **constitutional sx = mets** (F, fatigue, wt loss, anorexia)
103
XR findings of ewing sarcoma
* **Poorly marginated** destructive lesion
* **“Onion skin”** appearance - Due to a periosteal reaction
104
tx for ewing sarcoma
1. **Multi-drug chemo w/ surgery +/- radiation**
- Radiation if full resection of tumor is not possible
105
MC metastasizing cancers
1. Breast
1. Lung
1. Thyroid
1. Kidney
1. Prostate
106
s/s mets bone disease
1. Pain over metastatic location
1. pathologic fx
1. Anemia
107
w/u for mets bone disease
1. XR - 1st
1. Bone scans
1. PET scans
1. MRI
1. **Bx - definitive dx & determine primary site**
108
tx for mets bone disease
1. **_radiation + pain medication_**
1. **Chemo**
1. **Bisphosphonates**
1. Surgery if inc risk for fx
