MSK Tumors Flashcards
(87 cards)
1
Q
Which type of tumor is more malignant in nature?
A
Sarcomas.
2
Q
Benign tumor, cartilage of origin and MC in 10-30 yrs of age?
A
Osteochondroma, Enchondroma.
3
Q
Malignant tumor, cartilage in origin and MC in >60 yrs of age?
A
Chondrosarcoma.
4
Q
Benign tumor, bone in origin and MC in 10-30 yrs of age?
A
Osteoid Osteoma, Osteoblastoma.
5
Q
Malignant tumor, bone in origin and MC in 10-30 yrs of age?
A
Osteosarcoma.
6
Q
Malignant tumor, marrow in origin and MC in 10-30 yrs of age?
A
Ewing Sarcoma.
7
Q
Malignant tumor, marrow in origin and MC in >50 yrs of age?
A
Multiple Myeloma.
8
Q
Benign tumor, fibrous tissue/uncertain origin and MC in 20-30 yrs of age?
A
Giant Cell Tumor.
9
Q
Describe the invasiveness of benign tumors?
A
- Well-defined, slerotic borders.
- Lack of soft tissue mass.
- Solid periosteal reaction.
- Geographic bone destruction.
10
Q
Describe the invasiveness of malignant tumors?
A
- Interrupted periosteal reaction.
- ‘Moth-eaten’ or permeative bone destruction.
- Soft-tissue mass.
- Wide-zone of transition.
11
Q
What is the most common cause of destructive bone lesions in adults?
A
Bone Metastasis.
12
Q
What is the most common site of bone metastasis?
A
The thoracic spine.
13
Q
In general, what are the most common sites of metastasis?
A
Lung and liver; bone is 3rd.
14
Q
What are the most common malignancies that metastasize to the bone?
A
“BLT with a KP (KP = kosher pickle).
-Breast, Lung, Thyroid, Kidney, Prostate.
15
Q
What are other common sites of bone metastasis?
A
Bone #1 followed by Proximal Femur, Pelvis, Ribs, Shoulders.
16
Q
What is a common cause for pathologic fractures?
A
Bone metastasis.
**Bone mets will dramatically shorten survival once present; 6-48 months (also depends on primary CA).
17
Q
Where are most Osteoid Osteomas located (bone) and site (part of bone)?
A
Location = proximal femur > Tibia Diaphysis > spine.
Site = >50% in long bone Diaphysis.
18
Q
Where are most Osteoblastoma’s located (bone) and site (part of bone)?
A
Location = Vertebral column > proximal humerus > hip.
Site = >35% in posterior elements of the spine.
19
Q
Describe the lesion of an Osteoid Osteoma?
A
- Benign; small (1.5-2cm), discrete, PAINFUL lesion.
- Originates in the CORTEX of bone.
- Osteoid rich NIDUS in highly vascular connective tissue.
- MC in long bones (Proximal femur).
- M>F, ped population (5-25y/o).
20
Q
Tumor that most often presents as PAIN, most commonly at NIGHT, that is constant and progressive and relieved by NSAIDs?
A
Osteoid Osteoma.
*Localized soft tissue swelling, erythema, tenderness and deformity can be present.
21
Q
Diagnosis of Osteoid Osteoma and DDx?
A
- Always start w/an XR.
- F/U CT to determine location/size of nidus (1.5-2cm).
- BONE SCAN.
- MRI cautiously.
DDx - Stress Fx, Osteomyelitis, Ewing’s Sarcoma/Osteoblastoma.
22
Q
Treatment and Prognosis of Osteoid Osteoma?
A
Treatment:
- 1st line = Non-Operative, Pain mgmt (50% respond to NSAIDs).
- Operative if fails medical mgmt.
Prognosis:
- Untreated…pain resolves in 3 yrs, lesion in 5-7 yrs.
- Surgical resection w/resolution of Sx in days to wks.
23
Q
Gradual, progressive, dull or achy pain with NO relief with NSAIDs?
A
Osteoblastoma.
**Neuro Sx if spine involved; also swelling, limping, muscle atrophy.
24
Q
Osteoid Osteoma’s “Big Brother?”
A
Osteoblastoma
25
Describe an Osteoblastoma lesion?
* *Benign; locally 'AGGRESSIVE, EXPANSILE' w/extension into soft tissue.
- 66% cortically based.
- NIDUS >2cm.
- M>F, ped pop 10-30 yrs.
- MC in Axial Skeleton (40%); cervical spine, sacrum.
- Also seen in long bones (metadiaphysis, distal diaphysis).
26
Diagnostic imaging used for Osteoblastoma?
1. Always start with XR! 2-3 views.
2. F/U CT to fully evaluate.
3. MRI -- interpret w/caution, compare to XR/CT.
4. Bone Scan -- 'hot' focal uptake.
27
Treatment and Prognosis of Osteoblastoma?
Treatment:
* *SURGERY is standard of care.
- Excision vs Curettage; depends on location.
Prognosis:
- 80-90% cure rate.
- 10-20% recurrence....start process over again.
28
MC BENIGN bone tumor?
OsteoCHONDRoma.
-35-40% of benign bone tumors, 15% of ALL bone tumors.
29
An outward overgrowth of CARTILAGE and bone in the METAPHYSEAL bone at the GROWTH PLATE?
Osteochondroma.
30
Causes and Incidence/prevalence of Osteochondromas?
Causes:
-Salter Harris Fx, surgery, radiation therapy.
Incidence:
- Ped. (Growing) population; 10-30yrs, usu. before 20.
- M=F.
- MC see NEAR JOINTS (Knee - 50%, Proximal humerus).
31
A PAINLESS BUMP that continues to get "bigger;" often ASYMPTOMATIC and found incidentally?
Osteochondroma.
* *Sx are dependent on location, size, affects on surrounding structures.
- Near a tendon = pain with activity.
- Numbness/Tingling = near a nerve.
- Change in blood flow/limb color = near vascular bundle.
32
Imaging studies used for diagnosis of Osteochondroma?
1. XR! 2-3 view.
- -pedunculated vs sessile.
2. CT to better characterize in some areas (pelvis, scapula).
3. MRI only if concerned for malignancy or if symptomatic to better delineate soft tissue anatomy.
33
Treatment and prognosis of Osteochondroma?
Treatment:
- Conservative, observation.
- If Sx, consider surgical excision.
Prognosis:
- <2% recurrence rate after surgical resection.
34
A benign, INTRAMEDULLARY neoplasm of hyaline cartilage? Incidence?
Enchondroma.
- MC in 20-40yrs; skeletally mature pt's.
- M=F.
- MC seen in appendicular skeleton in tubular bones, such as the HANDs and FEET (50%), proximal humerus, femur.
35
What must Enchondroma be differentiated from?
Chondrosarcoma.
36
What is the pathophysiology of Enchondroma?
Growth plate remnants that are not resorbed and either persist or begin to grow in the medullary canal on the metaphyseal side of the growth plate.
37
Clinical presentation of Enchondroma?
1. 'Asymptomatic.'
2. Often incidental finding.
3. Pain from impending (or complete) pathologic fracture, esp. in hands/feet.
38
Imaging studies used for diagnosis of Enchondroma?
1. XR -- sharply defined edges.
- characteristic location, r/o suspicious lesions.
- NO gross bone destruction.
- NO periosteal reaction.
- NO soft tissue mass.
2. 'CT' and MRI to differentiate from Chondrosarcoma.
3. Tissue Bx only obtained intra-operatively if treating a pathologic Fx and no other suspicious features.
39
Treatment and prognosis of Enchondroma?
Treatment:
- OBSERVATION is standard of care.
- Surgery for Fx (hands, feet...curettage and bone graft).
Prognosis:
- Excellent.
- Recurrence after surgery, 2-15%; suggests malignant transformation (5% of cases).
40
A common (18-23%) BENIGN tumors that is locally AGGRESSIVE with significant bone destruction and local recurrence?
Giant Cell Tumor.
**Occasionally mets (bone, lungs 2-4%); not common.
41
Incidence of Giant Cell Tumor?
- F>M.
- 3rd decade; pt's in 20s.
- Usually in EPIPHYSIS of long bones.
- Around the KNEE (>50%); then distal femur, prox tibia, prox humerus, distal radius.
42
Clinical presentation of Giant Cell Tumor?
1. Pain...night pain associated w/tumor expansion.
2. Swelling.
3. Deformity.
4. Joint effusion.
5. Decreased ROM around affected joint; depends on size.
6. Antalgic gait...may indicate pain.
43
Diagnostic tools for Giant Cell Tumor?
1. 'XR':
- occurs w/closed growth plate, about articular surface.
- typically lucent (dark), eccentrically located w/in the bone.
- extensive bony destruction, cortical breakthrough, soft tissue expansion.
2. 'CT':
- absence of bone and mineralization in lesion.
3. 'MRI'
4. 'Tissue Bx' -- during surgery.
- -multinucleated giant cells...NEED to be removed.
44
Treatment of Giant Cell Tumor?
1. 'Surgery' -- excision vs curettage, reconstruction/stabilization.
2. Radiation and embolization when surgery not feasible (Pelvis).
45
Prognosis of Giant Cell Tumor?
- Gen. GOOD.
- Local recurrence in 20% of cases.
- Pulm. mets causes death in 16-25% of reported cases.
- occasional malignant transformation to sarcoma.
46
BENIGN disease of 'abnormal bone remodeling'?
Paget's Disease of Bone.
*Usually MULTIFOCAL (polyostotic) vs Monostotic (single bone).
47
What is Paget's Disease of Bone?
'Excessive bone resorption' (osteoclast overactivity) and 'abnormal new bone formation' (osteoblast compensation) cause 'woven bone that is weaker' (structurally disorganized mosaic of bone).
48
What are the 3 phases of Paget's Disease of Bone?
1. Lytic -- osteoclast phase, bone turnover up to 20x the normal.
2. Mixed -- osteoblasts create new bone, abnormal w/irregular deposition of collagen fibers (instead of linear).
3. Sclerotic -- bone formation is disorganized (woven) and weaker than normal; allows marrow to be infiltrated by excessive fibrous connective tissue and blood vessels; hypervascular.
49
Incidence of Paget's Disease of Bone?
1. Older adults, uncommon under 55.
2. MC in Caucasian.
3. M=F.
4. MC sites...axial skeleton (pelvis and spine); long bones, skull.
- -Femur > pelvis > tibia > skull > spine.
50
Clinical presentation of Paget's Disease of Bone?
1. Often 'Asymptomatic' (70-90%), incidental w/Fx.
2. Bone PAIN -- dull, constant, deep.
- -sometimes 2/2 to Fx.
3. Arthritis.
4. Excessive WARMTH 2/2 increased vascularity.
5. DEFORMITY -- long bone bowing.
51
Diagnosis of Paget's Disease of Bone?
1. 'Elevated Alk Phos' (BSAP - bone specific alk phos).
2. Serum Ca++ and Phosphate levels should be normal.
3. 'XR' of painful area.
- -lytic lesion w/sharp borders, thickened cortex and irregular appearance.
4. 'Bone Scan' -- whole body to assess extent of Paget's.
**DO NOT do a full skeletal survey w/XR.
52
Prognosis of Paget's Disease of Bone?
1. GOOD overall.
2. High Morbidity -- pain, Fx, deformity.
- -Increased vascularity = excessive bleeding after Fx or surgery.
53
Treatment of Paget's Disease of Bone?
1. 'Bisphosphonates' -- standard of care w/serial monitoring of markers.
- -Alendronate (FOSOMAX) is 1st line.
2. Ca + Vitamin D Supplementation.
3. Calcitonin.
4. Surgery in cases of unstable Fx and severe arthritis.
- -THA most common, IMN fixation preferred over ORIF.
- -HO is common complication w/surgery.
54
What is a deadly complication of Paget's Disease of bone?
Sarcomatous degeneration:
- sudden increase in pain or swelling.
- malignant; rapid and fatal.
- 5-10% of cases w/extensive skeletal involvement.
- Male > Female.
- Best evaluated by MRI.
55
2nd MC (25%) MALIGNANT, primary bone tumor made of cartilage?
Chondrosarcoma.
56
What are the 2 types of Chondrosarcoma?
1. Primary:
- -Low-grade (1 and 2, 85%), High-grade (3, 15%), Dedifferentiated (most Malignant).
2. Secondary:
- -Arises from Benign lesions (Osteochondroma, Enchondroma, etc).
57
Incidence of Chondrosarcoma?
- 'Older Adults' (>40yrs).
- Males > Females.
- Predilection for LONG BONES (45%), AXIAL skeleton (pelvis 25%)...MC Hip and Pelvis.
58
Clinical presentation of Chondrosarcoma?
1. PAIN - deep, dull, achy pain.
2. Slowly growing mass.
3. Bowel/Bladder obstruction 2/2 to mass effect in pelvis.
4. Pathologic Fx (50% of Dedifferentiated cases).
59
Imaging studies used for diagnosis of Chondosarcoma?
1. 'XR':
- -lytic or blastic lesion, cortical changes.
- -intralesional "POPCORN" mineralization.
- -RINGS and ARC, multilobulated.
2. 'MRI' -- to assess marrow, soft tissue involvement.
3. 'CT' -- determine cortical involvement.
- -endosteal 'scalloping' (signifies Chondrosarcoma from Enchondroma).
- -90% cortical breach.
4. 'Bone Scan' -- "hot" in all grades, helps establish mets.
60
Treatment of Chondrosarcoma?
1. Cartilage lesions typically resistant to Chemo/radiation.
2. Surgery:
- -Curettage of low-grade extremity lesions.
- -Excision for grade 2 or 3 lesions, or grade 1 in pelvis.
61
Prognosis of Chondrosarcoma?
*Histology correlates with prognosis.
* 5 yr survival rates:
- -Grade 3 has a 25% recurrence rate, >30% mets.
62
What is the most common type of primary malignant bone tumors in children and young adults.?
Osteosarcoma.
63
Where does Osteosarcoma occur? Most common sites?
Occurs in 'Metaphyseal Long Bones,' where new tissue forms as CHILDREN grow.
* Most common sites...near joints:
- Distal Femur (40%).
- Proximal Tibia (16%).
- Proximal Humerus (15%).
64
Where is the most common place that Osteosarcoma metastasis to?
Lungs...15-20% of pt's w/mets.
65
Incidence of Osteosarcoma?
- PED population, MC in ages 10-25 yrs.
- Often occurs during growth spurts in TEENAGE years.
- Boys > Girls, AA > Caucasian.
**2nd peak in older adults >60.
66
History and Physical findings of Osteosarcoma?
1. MILD PAIN for wks to months; insidious onset.
2. Bone pain.
3. Limp.
4. SWELLING or soft tissue mass, often near joint limiting ROM.
5. Unexpected Fx; rare.
6. Systemic Sx (rare) -- fevers, night sweats, SOB, etc.
7. Rarely see LAD.
67
Diagnostic studies in Osteosarcoma?
1. Labs mostly normal, elevated serum Alk Phos in more advanced disease.
- -High ALP correlation to Pulm mets.
- -High LDH correlation to poorer prognosis.
2. 'XR' - 2 views.
3. MRI to assess local spread -- intraosseous extension and degree of soft tissue involvement.
- -also helps eval the growth plate; 75-88% of metaphyseal tumors cross the growth plate into epiphysis.
4. CT, PET, Bone scan help in staging and surgical planning.
5. TISSUE BIOPSY!!
- -needs to be done by an Ortho Oncologist; the one who will be doing the resection.
68
Treatment and prognosis of Osteosarcoma?
Treatment:
- Only cure is SURGICAL, aggressive resection and often amputation.
- CHEMOTHERAPY before and after surgery.
- Not responsive to radiation therapy.
Prognosis:
-5 yr survival after adequate treatment...70%.
69
What is the 2nd MC primary malignant bone tumor in kids...approx. 15% of primary bone tumors?
Ewing's Sarcoma.
70
Where does Ewing's Sarcoma occur? MC sites?
1. Location = Usually in the DIAPHYSIS (shaft) of LONG bones and in FLAT bones (pelvis, scapula).
2. Sites:
- -Long bones, 55% = Femur, Tibia, Humerus.
- -Flat bones, 40% = Pelvis, scapula, ribs.
***But it can start anywhere in the body; 85% in bones, 15% in soft tissues.
71
Where does Ewing's Sarcoma typically arise from and MC sites of mets?
*Arises from the medullary cavity.
* Mets to bone marrow and lungs:
- -BM: thrombocytopenia = petechiae, purpura.
- -Lungs: asymmetric breath sounds, rales, etc.
72
Incidence of Ewing's Sarcoma?
1. Very rare; 1 per 1 million per year.
2. Mostly PED pop, but can affect any age.
3. MC in 5-25 yrs.
4. Peaks in LATE TEENAGE yrs; 65% in 2nd decade.
5. Boys > Girls.
6. White > AA (9x higher).
73
Clinical presentation of Ewing's Sarcoma?
1. PAIN -- typically, 1st symptom.
2. "Painful bump that keeps getting bigger" -- rapidly growing.
3. Persistent pain, NIGHT PAIN, exacerbated by exercise.
4. Localized SWELLING.
5. Low fever.
6. Limping.
74
Imaging studies used to diagnose Ewing's Sarcoma?
1. 'XR' -- start with a simple XR!
- -"permeative bone destruction," lamellated new bone formation, CODMAN triangle.
- -mottled, moth eaten, onion skinning, raised periosteum in triangle shape.
2. MRI to further eval bone and soft tissues.
3. CT to eval for Mets.
4. 'Tissue Biopsy'
- -by specialist ONLY.
- -Histology has a homogenous appearance w/small, round blue cells.
75
Treatment for Ewing's Sarcoma?
1. Chemo to shrink tumor.
2. Surgery to remove.
3. Radiation to destroy any remaining cancer cells.
76
Prognosis of Ewing's Sarcoma?
1. 70% cure rate if localized disease.
2. If diagnosed after METS or spread, survival is <30%.
- -better prognosis if mets to lungs only.
3. Distal tumors > central (pelvis).
77
What makes up 1% of ALL malignancies and is the MC primary bone malignancy in adults?
Multiple Myeloma
78
Neoplastic proliferation of PLASMA CELLS that presents with skeletal lesions?
Multiple Myeloma.
79
What is the pathophysiology of Multiple Myeloma?
Cancer cells accumulate in bone marrow -- crowd out healthy blood cells (plasma cells are made in red marrow and produce Abs/IGs) -- the neoplastic cells or abnormal plasma cells produce ineffective IGs/antibodies (proteins) and decrease the production of RBCs, WBCs, Platelets.
80
What are the common IGs produced by neoplastic cells of Multiple Myeloma?
1. Heavy Chains - IgG (MC; monoclonal protein spike), IgA, IgM.
2. 'LIGHT CHAINS - Bence Jones Proteins.'
81
Incidence of Multiple Myeloma?
1. >40 yrs, median age 60.
2. M > F.
3. MC in AAs.
82
Where is Multiple Myeloma most commonly found?
In the 'AXIAL SKELETON -- Vertebrae.'
| --ribs, skull, shoulder girdle, pelvis, long bones.
83
Risk factors associated with multiply myeloma?
1. Age >50, men, AA.
2. MM often preceded by MGUS > SMM.
- -MGUS: Monoclonal gammopathy of undetermined significance.
- -SMM: Smoldering MM (often asymptomatic, observation until progresses to active MM).
84
Clinical presentation of Multiple Myeloma?
1. 'Localized BONE PAIN' -- intermittent progressing to constant.
- -low back pain...'Lumbar Spine' MC site.
2. Pathologic Fx.
3. FATIGUE/Weakness.
4. Frequent infections (resp or urinary) due to weakened immune system.
5. Spinal Cord Compression -- back pain, weakness, numbness, dysesthesias in legs (painful burning or pricking).
85
Imaging studies in Multiply Myeloma?
1. 'XR' with "moth eaten" lytic lesions.
- -only visible after >50% destruction occurs.
- -'Obtain Skeletal XR Survey' ... bone scans are often cold.
2. MRI more sensitive for pelvis/spine.
86
Labs used for diagnosis of Multiple Myeloma?
1. CBC, CMP, ESR, CRP
- -Neutropenia, 'ANEMIA,' Thrombocytopenia (depressed CBC).
- -Elevated Creatinine, Ca++, ESR.
- -'SPEP with M Spike.' -- PANCE.
2. Urine: 24 hr urine.
- -'PROTEINURIA' (>1g/24hrs).
- -'UPEP = Bence Jones Proteins (IgG light chains).' - PANCE.
3. 'Bone Marrow Aspirate and Biopsy'
- - >10% plasma cells = MM.
* SPEP - serum protein electrophoresis.
* UPEP - urine protein electrophoresis.
87
Treatment and prognosis of Multiple Myeloma?
Treatment:
- -Incurable.
- -Multi-agent CHEMO, +/-stem cell 'transplant,' +/- 'Bisphosphonates.'
- -'SURGICAL STABILIZATION +RADIATION' for symptomatic lesions and impending Fx or Spinal Cord Compression.
- -'Corticosteroid' Injections for Spinal compression.
Prognosis:
- -Median Survival...3 yrs from diagnosis.
- -5 yr survival rate of 30%.
- -10 yr survival rate 11%.
