Metastatic disease

Question 1

what is the most common sinister complication of any malignancy and often leads to progression of disease and eventually death

Answer 1

metastasis

Question 2

what is the MC malignant tumor of the skeleton

Answer 2

metastatic bone tumors

Question 3

__% of all malignant tumors are metastatic in origin

__% are primary malignant tumors

Answer 3

70%

30%

Question 4

most malignant tumors of bone are metastases from primary extraskeletal areas such as

Answer 4

breast 
lung 
prostate
kidney 
thyroid 
bowel

Question 5

primary __ may also metastasize

Answer 5

sarcomas

Question 6

with exception of the following tumors __ and __, almost all tumors have reported incidence of mets to the spine

Answer 6

CNS

basal cell carcinoma in the skin

Question 7

metastatic bone tumors usually spread via what

Answer 7

hematogenous route

others include lymphatics or by direct extension

Question 8

which bones are predisposed to developing osseous metastases

Answer 8

bones rich in red marrow aka axial skeleton, skull, and proximal extremities

involvement distal to elbow and knee are rare

Question 9

what is drop metastases

how does it spread

Answer 9

intracranial lesions that lead to extramedullary metastasis

spread via CSF to spinal cord

Question 10

what kind of enhancement is needed to view leptomeningeal metastasis spread by drop metastasis

Answer 10

sugar coating enhancement

Question 11

metastasis to the skeleton is as common as to the __ and __

Answer 11

liver and lung

Question 12

cancers of the __ __ __ __ account for 80% of all metastatic cancers to bone

Answer 12

breast
prostate
lung
kidney

Question 13

what is responsible for 70% of all bony metastasis

what does this increase risk for

Answer 13

female breast cancer

increase risk of pathological compression fracture

Question 14

what results in 60% of all skeletal metastases

what results in 25% of all skeletal metastases

Answer 14

prostate carcinoma

lung carcinoma

Question 15

metastasis usually occurs when in life

Answer 15

over the age of 40

Question 16

metastatic osseous lesions in children < 5 years old are usually due to

Answer 16

neuroblastoma

Question 17

metastatic osseous lesions in people 10-20 years old are usually due to

Answer 17

ewings sarcoma
and
osteosarcoma

Question 18

metastatic osseous lesions in people 20-35 years old are usually due to

Answer 18

hodgkins lymphoma

Question 19

what are clinical features of metastatic bone tumors

Answer 19

pain 
recent weight loss 
cachectic 
anemia and fever in advanced stages 
pathological fracture 
insidious onset of pain with bouts of remission and exacerbation 
persistent and nocturnal pain 
may not have pain or symptoms

Question 20

its not unusual to find osseous metastases __ years after treatment of a primary tumor

Answer 20

10-15 years

common in mastectomies for breast cancer

Question 21

what are some lab markings that may indicate metastatic bone tumors

Answer 21

increased ESR

increased serum Ca if lytic mets - otherwise normal

increased alk phos if blastic mets

PSA and acid phosphatase - increased if prostate capsule rupture

Question 22

what do you do if patient has prostate cancer and bone pain

Answer 22

perform bone scan irrespective of PSA value

Question 23

what is an example of direct extension of metastatic bone tumors

Answer 23

uterine carcinoma spread to pelvis via direct extension via surgery

Question 24

how do metastatic bone tumors spread via hematogenous spread

Answer 24

tumor cells enter THIN WALLED VEINS

arterial walls are thick and resistant to tumor emboli entering

Question 25

what are the most common hematogenous spread metastatic tumors

Answer 25

lungs liver axial skeleton

Question 26

how do metastatic bone tumors spread via lymphatic spread

Answer 26

not common due to lack of lymphatic channels in bone marrow tumor cells can be filtered and trapped to begin to grow in lymph nodes in the body

Question 27

what is implantation or seeding metastasis

Answer 27

spread through fluids in a body cavity ex - malignant cells rupture from the primary tumor and are released into the thoracic or peritoneal cavity - drop mets is also an example

Question 28

some tumors form large quantities of fluid called can this be taken away

Answer 28

ascites yes but fluid rapidly returns

Question 29

does ascites always indicate cancer or tumor

Answer 29

no, there must be evidence of malignant cells

Question 30

what is the clinical presentation of ascites where doe bowels displace xray findings

Answer 30

central displacement of the loops of the bowl - displacement of bowels out of the pelvis uniform grayness of the abdomen loss of definition of the edge of the liver and spleen

Question 31

what is another term for batsons venous plexus

Answer 31

epidural venous plexus

Question 32

describe the features of batsons venous plexus

Answer 32

epidural vertebral veins valveless functions as venous lake or pool sluggish, reversal, arrested blood flow

Question 33

what can change or alter the flow of blood in the batsons plexus that will lead to reflux of blood to the ____

Answer 33

changes in intra-abdominal or intra-thoracic pressure PARAVERTEBRAL PLEXUS - cancer cells go directly to bones bypassing liver and lungs

Question 34

the prostatic venous plexus can drain directly into the ___ which provides pathological basis for early metastatsis to the pelvis, lumbar spine, and axial skeleton

Answer 34

vertebral venous plexus

Question 35

___ is the initial presentation in 10% of patients with systemic cancer 2% of symptomatic patients have no systemic disease 90% of patients present with what? 50% of patients present with what? 5-10% of patients present with what?

Answer 35

spinal metastasis 90% bone or back pain radicular pain 50% sensory and motor dysfunction bowel and bladder dysfunction 5-10% cord compression

Question 36

what is always an ominous symptom in a patient with systemic cancer

Answer 36

bone pain at night | mc in metastatic disease to the spine

Question 37

what tumor is typically associated with metastatic cancer from the prostate gland

Answer 37

osteoblastic/sclerotic tumor invading L1 malignant schmorls nodes

Question 38

lytic metastasis needs at least __% of bone destruction of the appendicular skeleton before seen on xray plain film

Answer 38

30%

Question 39

what causes the lytic lesions in lytic metastasis

Answer 39

pressure from proliferating metastatic cells creating lytic lesions in the cortex and trabeculae destruction due to osteoclast stimulating cytokines secreted by the tumor cells

Question 40

what plays a large role in the formation of lytic lesion in metastatic disease what does it affect first

Answer 40

osteoclasts affects marrow first, then cortex

Question 41

what is myelography what can be seen

Answer 41

contrast is inserted into thecal sac via subarachnoid space via fluoroscopic control herniated disc

Question 42

blastic metastasis is due to what

Answer 42

bone reacts to tumor cells by laying down nonneoplastic bone futile attempt at bone repair enlargement of lesions and development of new lesions is a grave clinical sign**

Question 43

what are benign conditions that stimulate blastic metastasis

Answer 43

pagets disease osteopoikiliosis osteopetrosis sarcoidosis

Question 44

bone scan can pick up alterations of __ % of metabolic activity

Answer 44

3-5%

Question 45

describe the features of techneticum

Answer 45

low radiation dose 6 hour half life radiation material taken up by areas of high metabolic activity

Question 46

osteoblastic response to tumor cells results in __ bone scan

Answer 46

+

Question 47

what are conditions that are associated with + bone scans

Answer 47

``` pagets fibrous dysplasia fractures osteomyelitis osteoid osteoma arthritidies ischemic necrosis ```

Question 48

you can see a positive bone scan __ months before you see the disease on xray

Answer 48

18 months

Question 49

what is the sensitivity of bone scan compared to plain film

Answer 49

>50-80% bone scan better than xray

Question 50

lesion may need to be __ cm before you see it on xray

Answer 50

> 1.5 cm

Question 51

what is CT useful for

Answer 51

cortical bone involvement

Question 52

what is MRI useful for

Answer 52

soft tissue mass formation or lesions

Question 53

what is STIR useful for

Answer 53

helpful to detect metastatic bone lesions up to 91%

Question 54

most metastatic bone tumors are lytic or blastic

Answer 54

lytic - 75%