Lab: Neoplasia & Metastasis

Question 1

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

Are the changes in the bones of this skull osteolytic or osteoblastic?
Does it appear aggressive?

Answer 1

Osteolytic, appears aggressive

multiple myeloma

Question 2

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

His lab results are as follows:

• ESR normal
• WBC normal
• RBC decreased (anemia)
• Urinalysis positive for proteins

Which proteins were likely in the urine?

Answer 2

Bence-Jones proteins

multiple myeloma

Question 3

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

Is the zone of transition of these lesions long or short?
Is there evidence of cortical disruption or periosteal lifting?

Answer 3

Long zone of transition
Cortical disruption and periosteal lifting (purple arrow)

multiple myeloma

Question 4

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

Given that this patient has a normal ESR and WBC count, but presents with anemia and proteinuria, what is their diagnosis?

Answer 4

Multiple myeloma

“rain drop” skull; no inflammatory signs

Question 5

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

The presence of Bence-Jones proteins in the urine will lead to what sequela of this disease?

Answer 5

Renal failure

multiple myeloma

additionally: osteolysis causes hypercalcemia

Question 6

What is the most common primary malignant bone tumor?

Answer 6

Osteosarcoma

Question 7

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

What would explain this patient’s lab result of anemia?

Answer 7

• Flat bones (intramembranous) are responsible for making bone marrow
• Multiple myeloma is osteolytic and destroys bone marrow
• Less bone marrow means less red blood cells

Question 8

Your 55-year-old male patient is usually lively, but has recently been withdrawn and tired. He complains of back pain and has lost some weight recently without explanation. You perform soft tissue work on his back and order blood work and radiographs.

A biopsy is taken from this patient. After seeing “rain drop” lesions in their skull and finding Bence-Jones protein in their urine, what would you expect the histological composition of the biopsy to be?

Answer 8

Lesions have sheets of plasma cells with varying degrees of differentiation

multiple myeloma

Question 9

A 50-year-old female presents with elbow pain. She has no history of cancer and no other cardinal signs of inflammation. Radiographs are taken of her elbow.

Is this lesion likely aggressive?

Answer 9

Yes: cortex completely disrupted, long zone of transition

secondary bone tumor: metastatic from breast

Question 10

This is a case of metastatic prostate cancer.

Is this an osteolytic or blastic expression?
Is the zone of transition long or short?
Is the cortex affected?

Answer 10

Mixed osteolytic/blastic
Long zone of transition
Cortex disrupted

Question 11

This is a case of metastatic prostate cancer.

How might this patient present in your office?

Answer 11

• Unexplained weight loss
• Anemia with fatigue
• Pain
• Abnormal labs
• Possible fever with late stage disease

Question 12

What is the difference between a primary and secondary bone tumor?

Answer 12

Primary is malignant neoplasia of bone tissue origin
Secondary is metastatic (always malignant) disease moved to bone

Question 13

Primary bone tumors make up ___% of bone malignancy in the US
Secondary bone tumors make up ___%

Answer 13

Primary: less than 30%
Secondary: 70%

Question 14

What are the four most common primary bone malignancies?

Answer 14

• Osteosarcoma (primary or secondary)
• Chondrosarcoma
• Ewing sarcoma
• Multiple myeloma

Question 15

What are some examples of benign primary bone tumors?

Answer 15

• Osteoma
• Osteochondroma

Question 16

What are three pathologies that have multiple large osteolytic lesions in bone as seen?

Answer 16

• Metastatic tumors (secondary bone neoplasia)
• Multiple myeloma (primary bone neoplasia)
• Chronic osteomyelitis (chronic infection)

Question 17

What condition is shown in this spine?

Answer 17

Chronic infection/osteomyelitis

cortical destruction and lytic migration into multiple tissue types (bone and disc)

Question 18

This was a 75-year-old male. Tissue biopsy reveals malignant plasma cells.

What is the correct diagnosis?

Answer 18

Multiple myeloma

plasma based

Question 19

The skeleton can be affected by spread through Batson’s venous plexus.
What is the term for this type of spread of neoplasia?

Answer 19

Hematogenous spread

Question 20

Which areas of the skeleton are most affected by spread through Batson’s venous plexus?

Answer 20

• Thoracolumbar spine
• Vertebrae (in general)
• Pelvis
• Ribs
• Skull
• Sternum

Question 21

This is a primary bone tumor.
Is it malignant or benign?

Answer 21

Malignant

Ewing sarcoma

disrupted cortex (purple arrow), lifted periosteum (red arrow)

Question 22

Where did this tumor originate in the bone?

Answer 22

Originated in mid diaphysis medullary cavity and expanded outwards

Ewing sarcoma

Question 23

A tissue biopsy is performed on this specimen and reveals small, round, closely packed, malignant cells.

What is the most likely pathology?

Answer 23

Ewing sarcoma

primary malignant bone neoplasia

Question 24

Note the appearance indicated by the purple arrow.
What would create this appearance?
Is this aggressive?

Answer 24

Laminating periosteal reaction
Aggressive

Ewing sarcoma

Question 25

An 80-year-old woman presents with headaches and occasional dizziness. She has recently fallen and hit her head, resulting in some bruising and external wounds. She has a history of diabetes mellitus, hearing loss, and advanced arthritis. To rule out fracture, radiographs are taken. What are the effects on the cortex? Are the changes osteoclastic or osteolytic?

Answer 25

Cortex is dramatically thickened (outward) Mixed blastic and lytic changes | osteitis deformans (Paget disease) ## Footnote cotton wool skull

Question 26

An 80-year-old woman presents with headaches and occasional dizziness. She has recently fallen and hit her head, resulting in some bruising and external wounds. She has a history of diabetes mellitus, hearing loss, and advanced arthritis. To rule out fracture, radiographs are taken. What pathologies have we discussed that may have this appearance?

Answer 26

* **Osteitis deformans (Paget disease)** * Secondary bone tumors (can be mixed reaction)

Question 27

An 80-year-old woman presents with headaches and occasional dizziness. She has recently fallen and hit her head, resulting in some bruising and external wounds. She has a history of diabetes mellitus, hearing loss, and advanced arthritis. To rule out fracture, radiographs are taken. Blood work indicates normal ESR and CRP, but an elevated alkaline phosphatase levels. Based on the radiograph and this information, what pathology is likely present?

Answer 27

Osteitis deformans (Paget disease)

Question 28

Given that this patient has Paget disease, what is expected to be found in biopsy?

Answer 28

* Irregular woven bone * Intertrabecular fibrosis * High vascularity * Deep resorption lacunae * Multiple, large osteoclasts

Question 29

This is a biopsy of a mixed osteoblastic and lytic bone neoplasia. Trabeculae has coarsened and the cortex has thickened. The biopsy shows irregular woven bone with intertrabecular fibrosis. The red portions in this image evidence high vascularity. Higher magnifications show resorption of lacunae with many large osteoclasts. What pathology is present?

Answer 29

Pagets disease (osteitis deformans)

Question 30

This patient has Pagets disease/osteitis deformans. What term describes this pathology when it affects one bone? Two or more bones? All bones?

Answer 30

One bone: **monostotic** Two or more bones: **polyostotic** All bones: **systemic**

Question 31

An older patient is reporting that his hats are fitting tighter lately. You know he has a history of osteoarthritis and wears hearing aids. You notice his jaw is mishapen and when asked about any trauma, he reports he's lost a few teeth in the past year and had a low impact fracture through his shin recently. Upon examination, your patient displays cerebellar gait changes. He experiences pain when performing spinal extension, but is palliated in flexion. Without further radiographs or labs, what bony pathology is on your differential diagnosis?

Answer 31

Pagets disease/osteitis deformans ## Footnote note: possible pathological "banana" fracture of sabre shin, "hat doesn't fit" is possible cortical thickening in skull

Question 32

A 10-year-old male presents with pain and swelling in the right lower extremity after a sharp pain while running during football. He can no longer put weight on his leg. You note swelling and tenderness of the right ankle. The boy describes a throbbing pain during examination. What type of injury is indicated by the discontinuity at the orange arrow?

Answer 32

Pathological fracture: closed, non-comminuted, oblique

Question 33

A 10-year-old male presents with pain and swelling in the right lower extremity after a sharp pain while running during football. He can no longer put weight on his leg. You note swelling and tenderness of the right ankle. The boy describes a throbbing pain during examination. What lesions are present in this radiograph?

Answer 33

* Fracture * Osteolytic geographic lesion with sclerotic border: **non-ossifying fibroma**

Question 34

A 10-year-old male presents with pain and swelling in the right lower extremity after a sharp pain while running during football. He can no longer put weight on his leg. You note swelling and tenderness of the right ankle. The boy describes a throbbing pain during examination. Does the cortex of the affected bone appear to be disrupted?

Answer 34

Only disrupted by fracture, not by lesion | non-ossifying fibroma

Question 35

This is a T1 weighted MRI of a 10-year-old male's ankle. Note the intact periosteum. Does this lesion have a short or long zone of transition? Is it likely aggressive?

Answer 35

Short zone of transition Non-aggressive | non-ossifying fibroma

Question 36

Non-ossifying fibroma occurs in individuals 8-19 years of age. What is another term for this condition?

Answer 36

Fibrous cortical defect

Question 37

The blue arrow points to non-ossifying fibroma/fibrous cortical defect. What is the most common treatment for these lesions? What is the typical outcome?

Answer 37

Most common treatment is monitor (leave alone) Typically spontaneously resolves (replaced by normal bone) ## Footnote if symptomatic: curettage and bone graft

Question 38

In this case of non-ossifying fibroma, the lesion (blue arrow) occupies more than 15% of the bone's diameter. What does this increase the risk of?

Answer 38

Pathological fracture (orange arrow)

Question 39

Which bones are most affected by non-ossifying fibromas?

Answer 39

Metaphyseal regions of tibia/femur, cortically located

Question 40

What syndromes or other conditions may sometimes be associated with non-ossifying fibromas, particularly when they occur in multiples?

Answer 40

Multiple fibrous cortical defects: * Neurofibromatosis type I * Jaffe-Campanacci syndrome (cafe au lait spots)