MSK malignancy Flashcards by Maria Keriakos

Which types of bone and surrounding tissue tumours are rare?

primary malignant bone tumours

tumours of soft tissue

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Which is the most common tumour pathology of bone ?

bone mets

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which sarcomas affect adolescents?

osteosarcoma

Ewing’s sarcoma

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Give an example of a sarcoma whose incidence increases with age

chondrosarcoma

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what is a sarcoma?

malignant tumour of connective tissue

think connection is when things ‘SAR COMing together’

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what is a carcinoma?

malignant epithelial/endothelial tumour

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Are sarcomas more common in males or females?

males

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Are soft tissue tumours more common in males or females?

equal distribution between makes and females

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what age group tends to get the most soft tissue tumours?

incidence increases with age - peaks at 64-80 yrs old

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What features of a history are important in MSK tumours?

age = epidemiology
presenting complaint - mass, growing in size?, pain, loss of function, socrates
history of PC - duration of symptoms, full pain/mass history, how the issue came pt the pt’s attention, anything that makes it worse/better, lump in more than one site?
PMH
DH- drugs and drug history
FH
SH - current level of function? - affects treatment and epidemiology

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What are the red flags for MSK tumours?

pain at rest 
pain at night 
lump present - tender, enlarging, deep to fascia and above 5cm in diameter 
loss of function
neurological symptoms 
unwell/weight loss

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What are the aspects of examination for MSK tumours?

look, feel, move

look at the pt as a whole, look at all four limbs, how they walk, lumps, scars, transilluminescence
feel - for masses, size, shape, painful, smooth, irregular, tethered to skin or deep tissues
move - what function do they have when they move, range of motion, neurovascular status

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What initial investigations are done for MSK tumours?

blood tests - FBC, U/E, Ca2+, ALP
XR
ultrasound 
CT
MRI
Technetium bone scan

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If someone has widespread bone mets, what will happen to their calcium?

it will be high

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What is a CT scan good for here?

assessing bone quality 
solid tumours 
staging using CT chest, abdo, pelvis if mets suspected 
3D reconstruction of bony lesions
helps plan for surgery

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What is an MRI scan good for here?

reactive changes of soft tissue/ bone marrow
periosteal and endosteal reactions
skip lesions
can do whole body MRI to stage

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what is a technetium bone scan good for?

assessing skeletal mets
can see how fast blood is flowing into a lesion, whether there is capillary dilation ie inflammation around a lesion, whether there is increased bone turnover

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What is an XR good for here?

can look at the bone density, zone of transition, periosteal reaction
lytic or sclerotic (benign)
is the border well defined or irregular
can distinguish between benign and malignant

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What are the characteristics of a malignant bone tumour on XR?

periosteal reaction
wide zone of transition (from abnormal bone to normal bone)
increased density
ill-defined lesion

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What are the special signs of periosteal reactions seen on XR?

Codman’s Triangle
Sunburst appearance
Onion-skin appearance

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Is the tumour likely to be benign or malignant with sunburst appearance?

malignant

In which cancers is the sunburst appearance seen?

osteosarcoma

Ewing’s

what is ultrasound scan good for here?

assessing soft tissues

can differentiate normal and abnormal and solid V. cystic

How is a technetium bone scan taken?

Inject the radioactive isotope and the gamma camera takes pictures at different times

what should you do if you suspect a primary bone or soft tissue sarcoma?

discuss the pt with MDT before proceeding with ANY invasive intervention

If a malignant process is found to be occurring, what is the next line of investigation?

biopsy

What are the principles of taking a biopsy for MSK tumours?

- needs to be done by the operating surgeon or consultant radiologist in the specialist centre where the operation will be carried out - longitudinal incision in line with the planned incision for future surgical procedure - shortest route to tumour, ie little soft tissue disturbance - Access only one muscular compartment - Ensure sample(s) is representative of tumour - Meticulous Haemostasis (also, use a Tourniquet) - Drain to be placed in line with Incision - Send sample(s) to BOTH Histology and Microbiology

How is local staging done?

XR of the WHOLE bone | MRI to assess skip lesions

What scans are good for staging distally?

CT chest, abdo, pelvis technetium bone scans whole body MRI

how are MALIGNANT MSK tumours GRADED?

by the Enneking system G0 - histologically benign G1 - low grade malignant G2 - high grade malignant

What does G0 mean in grading?

histologically benign, well differentiated, resembling the cell of origin, low mitotic count

What does G1 mean in grading?

``` low grade malignant moderate differentiation few mitosis local spread only low risk of mets ```

what does G2 mean in in grading?

high grade malignant poorly differentiated - don't look anything like their tissue of origin frequent mitoses high risk of mets

how are BENIGN MSK tumours GRADED?

Grade 1 - latent grade 2 - active grade 3 - aggressive

What does grade 1 benign mean?

LATENT well defined margin grows slowly and then stops may heal spontaneously very low risk of recurrence

What does grade 2 benign mean?

ACTIVE progressive growth limited by natural barriers well defined margin but may expand and thin cortical bone negligible recurrence after marginal resection

What does grade 3 benign mean?

AGGRESSIVE growth not limited by natural barriers eg GCT mets present in 5% of pts high recurrence after marginal resection, so extended resection is needed

How are malignant MSK tumours STAGED?

TNM system

What does the prefix 'rhabdomyo-' mean?

smooth muscle

What does the prefix of a tumour tell you?

the tissue of origin eg chondro-, osteo-, lipo-, rhabdomyo-

what does the suffix of a tumour tell you?

whether it is benign or malignant eg -oma, -carcinoma, -sarcoma, -blastoma

What happens if the tissue of origin is unclear?

the tumour will be described by its cellular appearance eg small cell carcinoma

If the tumour doesn't resemble any kind of normal tissue, what is it called?

pleomorphic

Which type of tumours tend to permeate through bone, benign or malignant?

malignant

Which types of tumour tend to have a sclerotic rim, benign or malignant?

benign

What steps would you go through when describing an XR with a suspected tumour?

``` Name, DOB, time the XR was taken Describe radiographic view Describe anatomical location Epiphysis / metaphysis / diaphysis Bone forming / cartlilage forming Bone destruction / bone reaction Talk about the zone of transition ```

Name 3 types of bone cysts in children

Unicameral Bone Cyst (UBC) Aneurysmal Bone Cyst (ABC) Fibrous dysplasia

Name 3 types of destructive bone lesion in a young adult ie adolescent

osteosarcoma Ewings giant cell tumour infection is a differential

Name 6 types of destructive lesion in over 50s

``` osteosarcoma chrondrosarcoma mets myeloma/lymphoma GCT ``` differential is infection

In which part of the bone is mets most likely to occur and why?

in the metaphysis as this is where there is anastamoses ie good blood supply to the bone