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1

Most common malignant tumors of bones?

Mets (25x MC than 1˚)

2

What are the MC primary malignancy sites?

Lung
Breast
Renal
Prostate cancer

3

Mets targets what are?

Axial skeleton, skull, proximal extremities (blood)

4

What is acral metastasis

The rare occurrence of mets distal to the knee or elbow

5

What is primary malignancy in women vs men?

Breast = women, then thyroid, kidney, uterus

Prostate = men, then lung

6

Most patients are how old?

Over 40

7

Malignancy under 5 yo is usually what malignancy?

Neuroblastoma

8

Malignancy under age 10-20 yo is usually?

Ewing sarcoma
Osteosarcoma

9

Malignancy age 200-35 is usually what disease?

Hodgkin lymphoma

10

What % of people have bone pain?

70%

Insidious, remission/exacerbation, persistent, nocturnal

11

Patients with suspected metastasis should get what lab studies

ESR
CBC
Chem screen
UA

12

What are the 3 routes of mets?

- Hematogenous is MC via arteries
- Direct invasion soft tissues
- Lymph dissemination (unusual)

13

What imaging is needed for mets? (4)

Plain radiograph
CT
MRI
Bone scan (nuclear imaging)

14

What does mets look like on radiograph?

75% osteolytic (moth-eaten, permeative)
15% osteoblastic

15

What is a “blow-out” pattern?

Large, very expansile, solitary
Suggests renal or thyroid primary

16

40% of mets occurs in what location?

Spine

Thoracic and lumbar MC

17

What is the MC cause of missing pedicle?

Osteolytic mets

18

3 MC causes of ivory vertebra

Osteoblastic mets
Paget’s disease (cortical thickening, expansion)
Lymphoma (Hodgkin) (anterior body scalloping)

19

MC cause of extrapleural sign?

Rib mets

20

Skeletal metastasis is most common where?

28% ribs and sternum

12% pelvis
10% skull
10% long tubular bones

21

Management plan for mets?

Identify primary site
Identify extent of mets
Manage P and bone loss

22

What are 3 meds commonly for managing mets.

Steroids and NSAIDS
Bisphosphonates to manage osteoblastic activity

23

What are the 4 MC primary malignancies of bone? And MC ages of people to get them? (Hint: MOCE)

Multiple myeloma (50-70 y.o.)
Osteosarcoma (10-25 y.o.)
Chondrosarcoma (40-60 y.o.)
Ewing’s sarcoma (10-25 y.o.)

In order of age:
O + E = 10-25 yo
C = 40-60 yo
MM = 50-70 yo

24

What age group gets Multiple myeloma?

50-70 y.o.

25

What age group gets Osteosarcoma?

10-25 y.o.

26

What age group gets Chondrosarcoma?

40-60 y.o.

27

What age group gets Ewing’s sarcoma?

10-25 y.o.

28

Where is MM located usually?

Similar as mets (axial skeleton, proximal femur and humerus, skull) PLUS long bones: the whole humerus, femur, tibia, fibula, radius, ulna.

29

What are signs and Sx of MM?

Bone pain (worse with activity and weight bearing, pathologic fx)
Anemia
Proteinuria
Renal disease
Weight loss/cachexia
Osteoporosis
Amyloidosis
Bacterial infections (esp. respiratory)

30

How do you dx MM?

Blood screening:
- anemia
- thrombocytopenia
- elevated ESR
- hyperuricemia, hypercalcemia
- elevated serum proteins
--> M spike with electrophoresis is diagnostic
- Benjones protein in urine
- bone marrow aspirate shows increased number of bone marrow plasma cells

31

Multiple, well-defined, round osteolytic defects: “punched out” defects and endosteal scalloping

Severe generalized osteopenia

High incidence pathologic Fx

This suggests what disease?

MM

32

Where does MRI, bone scan, CT play a role in detecting MM?

MRI very sensitive to marrow changes
Bone scan is usually negative
CT does not play a major role

33

What is the Prognosis of MM?

Prognosis is poor

34

Complications of MM? (3)

Pathologic fx
Renal failure
Respiratory infection

35

Tx for MM?

Targeted drug therapy
Chemotherapy
Bone marrow transplant

36

What is the concern with a solitary plasmacytoma?

70% develop MM within 5 years

37

Geographic
Lytic
Highly expansile
“Soapy bubbly”

If this is seen on radiograph, what do you think it might be?

solitary plasmacytoma

38

What location does solitary plasmacytoma favor?

MC Thoracic Spine
20% Rib, sternum, classical, scapula

39

Median age for solitary plasmacytoma

55

40

What is solitary plasmacytoma

Localize plasma cell neoplasm

41

What is a malignant neoplasm which forms osteoid called?

Osteosarcoma

42

Where are Osteosarcoma usually located?

80% Intramedullary (knee)
10-15% Surface/juxtacortical
5% extra skeletal

43

What percentage of Osteosarcoma are primary vs secondary?

75% primary in 10-20 yo

25% secondary = older patients d/t malignant degeneration of benign lesion or Paget’s

44

What are signs and Sx of Osteosarcoma?

- Painful swelling
- Pain increases with activity
- Pathologic Fx possible
- Onset of Sx to Dx often >6months

45

“Cumulus cloud” appearance
Cortical destruction, aggressive periosteal response, soft tissue mass
Location: metaphysis of long bone (75% of them)
Appearance: sclerotic (50% of the time)

If you saw this on plain film, what would you think?

Osteosarcoma

46

What is the role of MRI, CT, bone scan with Osteosarcoma?

MRI is used in planning Tx (determine extend of lesion and relationship to vessels and nerves)

Chest CT and Bone scan detects metastasis

47

What is the prognosis for Osteosarcoma

Mets to lungs common, mets to other bones possible

48

To for Osteosarcoma

Aggressive surgical resection often includes amputation

Mets to lung “cannonball metastasis”

Radiation therapy

Chemotherapy

49

“Cannonball mets”

Osteosarcoma
Ewing sarcoma

50

What kind of Osteosarcoma accounts for 5% all Osteosarcoma?

Parosteal Osteosarcoma

51

How fast does Parosteal Osteosarcoma grow?

Slow

52

What are the symptoms of Parosteal Osteosarcoma?

Similar to osteosarcoma:

- Painful swelling
- Pain increases with activity
- Pathologic Fx possible

53

Age range of Parosteal Osteosarcoma?

30-50yo

54

Dense, juxtacortical mass with stalk to cortex and NO periosteal response

Parosteal Osteosarcoma

DDx: myositis ossificans (MO) because they looks so similar (see slide 60)

55

How do you know its Parosteal Osteosarcoma and not MO?

PO: stalk attaches to cortex. Central portion is more dense and less dense at periphery, grows over time

MO: separated from the bone. Less dense in the middle. Gets smaller over time.

56

What is secondary Osteosarcoma?

Malignant degeneration of benign lesion

57

What are the 4 most common benign lesions to turn into secondary osteosarcoma if they undergo malignancy? (3 + 1 special one)

Paget’s disease
Fibrous dysplasia
Osteochondroma —> osteosarcoma

Enchondroma —> chondrosarcoma THEN osteosarcoma

(—> signifies malignant changes)

58

What is the age range of chondrosarcoma?

40-70 yo MC
(Though 20-90 possible)

59

What gender gets chondrosarcoma?

M>F 2:1

60

chondrosarcoma is what % of primary bone malignancies

25% primary bone malignancies are chondrosarcoma

61

Cartilaginous matrix?

Think chondrosarcoma

62

It’s possible for these 2 lesions, when they undergo malignancy, to become chondrosarcoma:

Enchondroma
Osteochondroma

63

Signs and Sx of chondrosarcoma?

Deep, dull, achy pain
Sometimes mild limp, limited ROM
Soft tissue swelling/ mass possible
Hx of 2-5 years

64

Lab findings for chondrosarcoma?

Typically WNL

65

What is the MC location for chondrosarcoma? (2)

Where else can you find it? (6)

Any bone preformed in cartilage.
MC: pelvic, proximal femur

Also: proximal humerus, ribs, scapula, distal femur, proximal tibia, craniofacial bones

Metaphyseal or diaphyseal; clear-cell in epiphysis (<2%)

66

What is the MC benign tumor of the hand?

Enchondroma

67

What is the MC primary malignancy of hand, sternum, scapula?

Chondrosarcoma

68

Large, lytic, poorly defined
Calcification in 70% “popcorn,” “stippled,” “arcs and rings”
Large soft tissue mass
Endosteal scalloping

Plain film findings for?

Chondrosarcomaa

69

Chondrosarcoma and Enchondroma look very similar. What is the main difference?

[answer here]

70

What is the prognosis for chondrosarcoma?

Slow progression
High 5-year survival rate w/ early Tx

Grade 1 = 90% survival rate
Grade 3 = 30% survival rate

71

Tx for chondrosarcoma?

Surgical resection

(Radiation and chemo have limited use)

72

Are mets common with chondrosarcoma?

No

73

What is an uncommon subtype of chondrosarcoma?

clear cell chondrosarcoma

74

Where is clear cell chondrosarcoma located? What does it look like?

Epiphysis

Round, sharply marinated lytic lesion

75

What bones is clear cell Chondrosarcoma MC found in?

Proximal long bones

76

Will clear cell chondrosarcoma have sclerosis or calcification/

Maybe

77

How do you distinguish clear cell chondrosarcoma from chondroblastoma?

Cannot.

78

Who gets Ewing sarcoma?

10-25 yo
M>F

79

Ewing sarcoma is what % of primary malignancies?

7%

80

Marrow cell tumor
“Round cell”

What kind fo tumor is this?

Ewing sarcoma

81

Signs and Sx of Ewing sarcoma

Localized P and swelling, local warmth, tenderness, dilated veins

Palpable soft tissue mass

Systemic signs: fever, anemia, leukocytosis, increased ESR

82

Location of Ewing sarcoma

70% Long bones (Femur, tibia, humerus: and diaphysis is classic location)

25% Flat bones (pelvis, ribs, scap)

5% spine

83

What long bones does Ewing sarcoma MC show up in

Humerus
Femur
Tibia
Fibula

84

Permeative lytic destruction w/ wide zone of transition

Aggressive periosteal response (25-50%): sunburst, laminated, codman

Sclerosis seen in up to 40%

What problem do these plain film findings suggest?

Ewing sarcoma

85

Prognosis for Ewing sarcoma

Poor

86

Tx for Ewing sarcoma

Chemotherapy is mainstay
- radiation
- surgical resection/amputation

Commonly mets to lungs “cannonball mets”

87

What is the MC primary malignant bone tumor to mets to bone?

Ewing sarcoma

88

What is a rare <2% primary bone malignancy?

Fibrosarcoma

89

Fibrosarcoma is MC in what age group

30-50 yo

90

Where is Fibrosarcoma located commonly

Major long bones
50% at knee

91

What is Sx for Fibrosarcoma

Pain, swelling
Ave 2 yrs before Dx

92

Highly destructive, expanding, lytic lesion

Large soft tissue mass

No periosteal reaction

What do these radiograph findings suggest?

Fibrosarcoma

93

What is prognosis for Fibrosarcoma

Poor

Frequent local recurrence up to 80%

94

What is Tx for Fibrosarcoma

Amputation

95

When and where does Fibrosarcoma metastasize?

Mets late to Lung, liver, lymph, brain

96

What is the MC soft tissue sarcoma in adults?

Malignant fibrous histiocytoma (MFH)

97

What is histologically similar to fibrosarcoma?

Malignant fibrous histiocytoma (MFH)

98

What location does Malignant fibrous histiocytoma (MFH) affect?

50% Lower extremity
20% upper extremity

99

Sx of Malignant fibrous histiocytoma (MFH)?

Painless, solid mass usually

100

Where does Malignant fibrous histiocytoma (MFH) mets?

Lungs

101

What is a rare <1% primary bone malignancy?

Chordoma

102

What originates from notochord remnants?

Chordoma

103

What age group is Chordoma

30-70 yo
M>F

104

What is the only primary malignancy to cross the IVD?

Chordoma

105

Prognosis of Chordoma?

Poor
Difficult surgical resection

106

What vertebra is Chordoma MC in?

C2

107

Midline lesions
Lytic destruction
Cortical expansion
Calcification in 50%
Soft tissue mass

What do these findings suggest?

Chordoma

DDx: lytic mets, chondrosarcoma, GCT, ABC, plasmacytoma

108

What is 3-4% of primary bone malign?

Lymphoma of bone

109

What is the prognosis for Lymphoma of bone

Better than most primary bone malignancies

110

Age and gender of Lymphoma of bone?

20-50 yo
M>F

111

What is rare, extranodal lymphoma?

Lymphoma of bone

112

Signs and sx of Lymphoma of bone

Local intermittent pain
Dull, aching, not relieved by rest
Generally healthy pt
Over 50% have Sx > 1 year
Palpable mass or swelling

113

MC location for Lymphoma of bone

Lower extremities, pelvis, spine

114

Permeative, moth-eaten lytic destruction
Minimal periosteal response
Soft tissue mass
Pathologic Fx common

These radiograph findings suggest?

Lymphoma of bone

115

What is usually secondary to systemic Hodgkin?

Hodgkin Lymphoma of bone

10-20% patients with Hodgkin develop skeletal involvement

116

What is the MC sx of Hodgkin Lymphoma of bone

Pain

117

MC location for Hodgkin Lymphoma of bone?

Vertebral body
“Ivory vertebra”

118

Hodgkin Lymphoma of bone is polyostotic in

2/3