cancer, mammography and bone tumours

Question 1

what is cancer?

Answer 1

• when there is a change to our DNA, possible due to damage, this genetic material can mutate
• the instructions given by the nucleus of the cell become confused, and cells that should be at rest, instead begin to divide and grow in and out of control manner. they do not reach cell maturity
• this can lead to cancer, and it can start in any cell of the body
• when these cells grow and divide to replicate, they develop into a tumour

Question 2

benign tumours

Answer 2

typically:
- similar to normal cells
- slow growing
- do not spread
examples:
adenoma, chondroma, fibroma, hemangioma, lipoma, lymphangioma, menigioma, myoma, neuroma, osteoma

Question 3

malignant tumours

Answer 3

typically:
- made of cancer cells
- fast growing
- spread into surrounding tissues
- can spread to other parts of the body to form secondary tumours (metastasis)
examples:
astrocytoma, carcinoma, glioma, lymphoma, sarcoma, blastoma

Question 4

CT staging

Answer 4

• a CT scan can demonstrate the size of the primary cancer and if there is any evidence of spread
• often involves 60-70s chest/abdo/pelvis in one acquisition or a 30s chest and 70s abdo/pelvis

Question 4

immature skeleton

Answer 4

• when diagnosing a bone tumour, patient age is an important piece of information as it can determine what type of lesion it may be

Question 5

lesion processes

Answer 5

benign process - uniform destruction with sharply defined border
likely malignant process - patchy areas of destruction with ragged borders
aggressive / malignant process- permeative, ill defined area spreading through marrow space

Question 6

narrow zone of transition

Answer 6

• can see where the lesion begins and ends
• slow growing
• non-agressive
• changes from normal to abnormal bones over a narrow area
• unlikely to be malignant

Question 7

wide zone of transition

Answer 7

• cannot see where to lesion begins and ends
• fat growing
• aggressive
• changes from normal to abnormal bones over a wide area
• is aggressive, may be malignant

Question 8

description of tumours

Answer 8

• eccentric or central - is lesion in the centre of the bone or one the periphery
• expansile or non expansile - is lesion contained within the normal confines of the bone or has it enlarged the bone width. can be benign or malignant though more commonly malignant lesions that grow the periosteal confines
• lytic or sclerotic - lytic lesions appear less dense than surround bone whereas sclerotic lesions appear more dense than surrounding bone

Question 9

bone cells

Answer 9

osteogenic cells - in the peritoneum
osteoblasts - bone builders
osteocytes - mature osteoblasts found in the lacuna
osteoclasts - reabsorb bone

Question 10

the periosteum

Answer 10

• responsible for laying down new bone if the existing bone is stretched, torn or inflamed. this irritation to the bone can be caused by trauma, tumour or infection
• new bone cells are formed at the periosteum and so if the bone is disrupted due to trauma, tumour or infection, the bone will try to heal
• the nature of the healing process can help us to differentiate between aggressive and non-aggressive conditions

Question 11

lamellate periosteal reaction

Answer 11

• if the lesion grows in steps intermittently
• the periosteum may have time to lay down a thin later before the lesion grows again
• onion peel type effect
• known as lamellation

Question 12

sunburst periosteal reaction

Answer 12

• if the lesion grows at a rapid rate consistently
• the Sharpey’s Fibres connecting the periosteum to the bone become stretched and ossify to look like small hairs
• this is known as a sunburst or sunburst sign

Question 13

conman triangle periosteal reaction

Answer 13

• if the lesions grows very quickly
• only the leading edge of the periosteum ossifies
• this is sometimes seen in the transition zone between normal and abnormal bone

Question 14

simple bone cysts

Answer 14

• cavity filled with interstitial fluid
• often leads to fracture
• typically proximal humerus/femur
• 90% occur in males under 20
• usually contained within bone
• Lucent with sclerotic rim
• narrow zone of transition

Question 15

aneurysmal bone cysts

Answer 15

• cavity filled with blood
• common cause is trauma
• mostly long bones
• mostly females 10-30 yr olds
• similar to simple bone cyst but expansile
• Lucent with sclerotic rim
• narrow zone of transition

Question 16

subchondral cyst

Answer 16

• cyst filled with synovial fluid
• often associated with OA
• close to joints beneath the cartilage
• elderly patient due to OA link
• small, lytic
• narrow zone of transition

Question 17

osteoid osteoma

Answer 17

• benign
• painful at night
• mostly long bones
• children and adolescents
• males more common
• usually <1.5cm
• Lucent centre
• surrounding sclerosis
• solid periosteal reaction

Question 18

giant cell tumour

Answer 18

• > 90% benign
• made of osteoclasts
• mostly long bones
• Around epiphysis
• eccentric
• mostly adults
• lytic
• expansile
• narrow zone of transition
• non sclerotic margin

Question 19

enchondroma

Answer 19

• benign
• cartilaginous origin
• most common in the hand and wrist
• most common in 10-30 yr olds
• lytic
• can be expansile
• narrow zone of transition
• no periosteal reaction

Question 20

osteochondroma

Answer 20

• benign
• bony growth
• long bones
• any age but 18 most common
• irregular bony growth
• eccentric from cortex
• cartilaginous cap

Question 21

non-ossifying fibroma

Answer 21

• benign
• made of osteoclasts similar to GCTs
• mainly the metaphysics of long bones
• mostly <30
• twice as common in males
• no periosteal reaction
• inc. sclerosis over time
• narrow zone of transition
• sclerotic rim

Question 22

osteosarcoma

Answer 22

• malignant
• bone forming
• long bones
• most common in young 10-20 yr olds
• destuctive
• aggressive periosteal reaction
• wide zone of transition

Question 23

Ewing’s sarcoma

Answer 23

• malignant
• bone and soft tissue variations
• long bones and flat bones
• occurs in younger people
• destructive moth eaten appearance
• lamellated periosteal reaction
• wide zone of transition
• 40% sclerotic

Question 24

osteomyelitis

Answer 24

- bone infection - infection impedes blood flow = bone death (necrosis) - bony matrix is destroyed - usually as a result of fracture, infection, surgery - treatment involves surgical debridement, IV antibiotics or antibiotic beads inserted into cavity

Question 25

avascular necrosis

Answer 25

- cell death due to interrupted blood supply - can be caused by infection, chronic steroid use, HIV, diabetes, trauma - most commonly seen in the head and neck of femur

Question 26

multiple myeloma

Answer 26

- cancer of plasma cells found in bone marrow - typically occurs in the spine, cell and ribs but can occur anywhere - imaged using whole body MRI or whole body low dose CT - XR skeletal survey if these modalities aren't available

Question 27

osteogenesis imperfects

Answer 27

- known as brittle bone disease - gene defect - a result of a collagen deficiency - bones do not develop and form as they should, weaker thinner and more fragile - deformities may occur

Question 28

osteomalacia

Answer 28

- adult form of rickets - due to low vitamin D or low calcium or phosphorus - causes an overall decrease in bone density - narrow bands of decalfication

Question 29

osteoporosis

Answer 29

- deficiency in the bone due to a reduction bone formation leading to bones more likely to fracture - caused by lack of vitamin C, old age and reduced oestrogen levels

Question 30

Paget's disease

Answer 30

- disorder of bone renewal and remodelling - osteoclasts are larger and more active than usual - osteoblasts respond by building more bone than needed - can lead to pain and deformity - limbs can curve causing mobility issues - prone to fracture

Question 31

embryology - milk line

Answer 31

- milk line - lactogenic ridges - most of this tissue atrophies -> single island - accessory breast tissues - supernumerary nipples

Question 32

gestational timeline

Answer 32

- milk line develops - milk line atrophies leaving single island of lactogenic tissue - 15-20 buds grow from island down into tissue - nipple develops as shallow indentation - connective tissue and fibres form - suspensory ligaments

Question 33

TDLUs

Answer 33

- most important part of the breast - normal physiological function - lactation - breast disease - seen as dense on mammo

Question 34

congenital abnormalities

Answer 34

- accessory break tissue - islands of lactogenic tissue can develop in more than one area - commonly in axillary region - failure of breast development - genetic disorders (turners), radio/chemotherapy and Polands syndrome (under development of pectoral muscle)

Question 35

hormonal changes

Answer 35

puberty - rising oestrogen / progesterone causes changes that increase breast size - areola increases in size and darkness - asymmetrical development is common - gynaecomastia cyclical - hormonal changes during cycle - variation in size of epithelial cells - can affect mammogram procedure pregnancy - rises in oestrogen, progesterone and prolactin - growth in the epithelium - lobules engorge - reduced sensitivity in mammography post childbirth - progesterone decreases and prolactin remains - signals mammary gland to start lactating - tubular system fills and empties milk each time breast feeding occurs

Question 36

breast cancer

Answer 36

- most common in UK - 30% of people cancers - prevalence is increasing - lots of treatment options - prognosis dependent of stage of cancer

Question 37

breast cancer development

Answer 37

- genetic mutations - inherited - many different types - metastatic - axillary lymph