Quiz 2

Question 1

Malignancy of giant cell tumor

Answer 1

90% benign
10% malignant
Osteoclastic giant cells
6th most common bone tumor

Question 2

Giant cell tumor history

Answer 2

20-40 yo

More commonly malignant in males

Question 3

Signs and symptoms of Giant Cell Tumor

Answer 3

Intermittent, aching pain
Localized swelling and tenderness
Restricted joint movement
The pathologic fracture that occurs in 30% of people may be the only source of symptoms

Question 4

Giant Cell Tumor Location

Answer 4

Metaphyseal and extending to subarticular (85%)
Distal femur, proximal tibia, distal radius, proximal humerus
Most common benign tumor of the sacrum; patella

Question 5

Plain film findings of Giant Cell Tumor

Answer 5

eccentric, expansile
Thinned cortex and expanded
Aggressive appearance with cortical break and soft tissue mass but no sclerosis or periosteal response

Question 6

Prognosis and treatment of Giant Cell Tumor

Answer 6

No radiographic differentiation of benign versus malignant
Curretage and packing with bone chips or wide local excision
Possible recurrence

Question 7

What is the most common benign skeletal tumor?

Answer 7

Osteochondroma

35% of all benign bone tumors

Question 8

Signs and symptoms of Osteochondroma

Answer 8

Asymptomatic (pushes on vessels or nerves)
May restrict joint motion
Hard, painless mass near joint
Pathologic fracture possible
Pain, rapid growth, growth after maturity may indicate malignant degeneration

Question 9

Plain film findings of Osteochondroma

Answer 9

Bony exostosis
Cartilage cap may calcify
Projects away from the joint
Sessile version produces asymmetric widening

Question 10

Indications for malignant transformation of benign tumors

Answer 10

>30 y.o.
Pain
Growth after skeletal maturity
Change  on  sequential  studies
Dispersal of calcifications in cap
Osseous  destruction
Soft  tissue  mass
Thickened  cartilaginous  cap, >1.5cm (CT, MRI)

Question 11

Prognosis and treatment of osteochondroma

Answer 11

Most require no treatment
May be resected for cosmetic purposes
Subungal exostosis requires removal

Question 12

Characteristics of hereditary Multiple Exostosis

Answer 12

Multiple osteochondromas (10-100’s)
Dx occurs at 2-10 years old
Painless lumpy joints
25% have malignant degenration

Question 13

Hemangioma types

Answer 13

Cavernous: vertebrae, skull, common
Capillary: flat or long bones

Question 14

Characteristics of hemangioma

Answer 14

Most common benign tumor fo the spine
Seen after 40
Most asymptomatic

Question 15

In what cases of hemangioma can neurological compromise be possible?

Answer 15

Ballooning of vertebral body
Extension of tumor into central canal
Pathologic fracture
Hemorrhage

Question 16

Plain film findings of hemangioma

Answer 16

Commonly in spinal and skull
Spine: vertebral body, courderoy cloth, body expansion is rare
Skull: Lytic lesion with spoke-wheel appearance

Question 17

DDX list for hemangioma, paget, osteoporosis

Answer 17

Hemangioma: Single lesion, normal cortex, occasional body expansion
Paget: Single or multiple lesions, thickened cortex, common body expansion
Osteoporosis: Multiple lesions, thinned cortex, no body expansion

Question 18

Soft tissue hemangioma presentations

Answer 18

Masses frequently contain phelboliths

Maffuci syndrome

Question 19

Gardner syndrome triad

Answer 19

45%
Multiple osteomas
Colonic polyps
Soft tissue fibromas

Polyps are considered premalignant

Question 20

Bone Island (enostosis)

Answer 20

Solitary discrete area of sclerosis
Usually asymptomatic
Any age but more common in adults

Question 21

Common places for bone islands

Answer 21

Pelvis, sacrum, proximal femur

Uncommon in spine

Question 22

DDx for bone islands

Answer 22

osteoblastic metastasis, osteoid osteoma, osteoma

Question 23

DDX list for osteoblastic metastasis, osteoid osteoma, osteoma against bone island

Answer 23

osteoblastic metastasis - Bone scan, no brush border
osteoid osteoma - pain, nidus
osteoma - location, surface contour

Question 24

Pain characteristics of osteoid osteoma

Answer 24

Painful, rigid scoliosis

Classic  symptoms (65-75%):  increasingly severe, deep, aching pain
not relieved by rest, worse at night, relieved by aspirin

Question 25

Location of osteoid osteoma

Answer 25

Can occur in any bone (most commonly cortical) 70% in long bones, especially proximal femur, 20% phalanges, 10% in spine, mostly neural arch lumbar > cervical > thoracic

Question 26

Plain film findings of osteoid osteoma

Answer 26

80% cortical lesion: lucent round/oval nidus | Intramedullary and intrascapular lesions (hip)

Question 27

treatment for osteoid osteoma

Answer 27

``` Surgical exision (must remove nidus entirely, spinal lesions may require bone grafting after surgery) Commonly treated with radiofrequency ablation being used ```

Question 28

DDX list for painful scoliosis

Answer 28

Osteoid osteoma - sclerotic pedicle Aneurysmal bone cyst - lucent Osteoblastoma - lucent

Question 29

Location and age of osteoblastoma

Answer 29

40% in neural arch of spine 30% in long bone metaphysis, diaphysis 30% hands, feet, skull, face 70% <20 y.o.; 3-78 y.o

Question 30

Signs and symptoms of osteoblastomas

Answer 30

Spinal lesions: painful scoliosis* Pain is typically less severe, not nocturnal, not relieved by aspirin Local tenderness, palpable mass in extremities Local muscle spasm, rigidity, referred pain, spinal stenosis

Question 31

Plain film findings of osteoblastomas

Answer 31

Spine: Expansile lytic lesion, rim of sclerosis, 4-6 cm Extremities: Lytic, expansile; epiphysis usually spared; cortex thinned; lucent nidus >2cm Rapid increase in size

Question 32

Treatment for osteoblastoma

Answer 32

Surgical resection/excision Radiantion/chemotherapy for aggressive or unresectable Percutaneous ablation

Question 33

Enchondroma frequency and age

Answer 33

2nd most common benign tumor Cartilaginous Most common age 10-30 y.o

Question 34

Enchondroma location

Answer 34

50% in hands or feet (most common tumor of phalanges) 50% femur, tibia, humerus, ribs Lesions near axial skeleton more often symptomatic Lesions near axial skeleton higher potential for malignant transformation

Question 35

Radio findings of enchondroma

Answer 35

``` Lytic, geographic Expansile Thinned cortex, endosteal scalloping Metaphyseal-diaphyseal Calcification (cartilage) in 50% No periosteal reaction; no soft tissue mass ```

Question 36

Treatment and prognosis of enchondroma

Answer 36

Malignant transformation is rare but the likelihood increases with multiple lesions Surgical removal for deforming or painful

Question 37

Enchondromatosis can be due to which two diseases?

Answer 37

Ollier Disease: Multiple enchondromas, usually unilateral, monomelic (may cause growth change, shortened limb, severe deformities); Malignant transformation rate 25-50%; Chondrosarcoma Maffucci syndrome: Multiple enchondromatosis soft tissue hemangiomas (venous malformations), phleboliths Rare; malignant transformation rate up to 25%

Question 38

Characteristics of chondrobalstoma

Answer 38

``` Cartilaginous Usually seen before epiphyseal closure Most patients 5-25 y.o. Mild, dull pain Local tenderness, swelling, effusion ```

Question 39

Chondrobalstoma location

Answer 39

Epiphyseal: May extend to metaphysis Apophyseal: Greater trochanter, greater tuberosity, femur, tibia, humerus, tarsals, pelvis 2/3 lower extremity; 50% at knee

Question 40

Appearance of chondroblastoma

Answer 40

``` Lytic, geographic Epiphyseal / Apophyseal Eccentric (most) Sharp zone of transition Rim of sclerosis Calcification in 50% Periosteal response possible (solid) ```

Question 41

Chrondroblastoma ddx with clear cell chondrosarcoma and giant cell tumor

Answer 41

Clear cell chondrosarcoma: Older patients, Larger mass Giant cell tumor: Larger, no sclerotic border, no calcification, skeletally mature (growth plates closed)

Question 42

ChondroblastomaTreatment & Prognosis

Answer 42

Pathologic fracture can occur Growth disturbance / limb length discrepancy Surgical removal (curettage) and bone grafting Local recurrence in up to 20%

Question 43

Nonossifying fibroma and fibrous cortical defect

Answer 43

FCD: 2-8 yo - less than 2cm in cortex NOF: 8-20 yo - greater than 2cm extends into medullary cavity Not true neoplasm Frequent spontaneous resolution over 2-4 years 30-40% of children have FCD

Question 44

Fibrous Cortical Defect/Nonossifying Fibroma lesions and location

Answer 44

Large (>8cm) lesions more likely symptomatic Pathologic fracture possible (only reason for treatment) Most common sites Lower extremity (90% in tibia or fibula) and humerus Also ribs, ilium

Question 45

FCD/NOFRadiographic Appearance

Answer 45

``` Lytic, ovoid Sclerotic border Diametaphyseal, eccentric Thins, may expand cortex Appears sclerotic when healing due to osteoblastic activity Multiple lesions with neurofibromatosis ```

Question 46

Characteristics of simple bone cyst

Answer 46

3% of primary bone lesions Not true neoplasm; fluid-filled cyst Usually found in teenagers: Asymptomatic unless fractured, 2/3 undergo pathologic fracture

Question 47

Simple bone cyst locations

Answer 47

Proximal humerus: 50-60% Proximal femur: 30% - less commonly: talus, calcaneus, iliac wing Metaphyseal, immediately adjacent to physis Latent cysts shift toward diaphysis Central

Question 48

Simple bone cyst radiographic findings

Answer 48

``` Geographic, lytic Short zone of transition Broad-based at physis, narrows toward diaphysis Mild bone expansion “Fallen fragment” sign with fracture ```

Question 49

Simple bone cyst prognosis and treatment

Answer 49

Surgical treatment is recommended due to high fracture rate 30-40% recurrence rate with curettage Steroid injection into cyst reduces recurrence

Question 50

Aneurysmal bone cyst characteristics

Answer 50

Highly expansile (or aneurysmal) cystic cavity filled with numerous blood-filled channels 5-20 y.o. Pain and swelling either acute or more insidious onset Pathologic fracture common

Question 51

Aneurysmal bone cyst location

Answer 51

Long tubular bones 50-60%: Most common benign tumor of clavicle Spine & Sacrum: Posterior arch, painful scoliosis

Question 52

Aneurysmal bone cyst radio findings

Answer 52

``` Highly expansile Lytic, septated Eccentric Markedly thinned cortex Metaphyseal, may extend to epiphysis (only benign tumor to cross growth plate) Periosteal response more common ```

Question 53

Aneurysmal bone cyst treatment and prognosis

Answer 53

Surgical curettage & bone grafting Recurrence rate ~20% Secondary ABC: GCT, osteosarcoma, simple bone cyst, NOF, fibrous dysplasia

Question 54

Intraosseous lipoma characteristics

Answer 54

``` Rarest primary benign tumor Wide age range Asymptomatic Metaphysis; calcaneus Lytic, geographic, sclerotic border “Target” or “doughnut-shaped” sequestrum = central density CT or MRI shows fat matrix ```

Question 55

Paget's disease characteristics

Answer 55

Osteitis deformans Largely asymptomatic Increased osteoclastic activity with immature weak bone

Question 56

Etiologies of Paget's disease

Answer 56

Viral infection + hereditary factors Others: Inflammatory disorder, endocrine disorder, autoimmune disorder, inborn error of connective tissue metabolism, vascular disorder, neoplasm

Question 57

Pagets disease clinical features

Answer 57

Rare before age 40 Localized pain & tenderness Hypervascularity leads to focal increased temperature Increased bone size Deformities/pathologic fracture may occur Polyostotic High-output congestive heart failure may result

Question 58

Phases of Paget's disease

Answer 58

Phase 1: osteoclastic activity Phase 2: osteoclastic + osteoblastic activity Phase 3: osteoblastic activity Phase 4: malignant degeneration (1-3%)

Question 59

Appearance of Paget's disease

Answer 59

``` Usually diagnostic, bone scan can identify additional sites Increased or decreased bone density Coarsened trabeculae Thickened cortex Bone expansion ```

Question 60

Paget's disease location

Answer 60

Usually polyostotic Pelvis, femur, skull, tibia, vertebrae, clavicle, humerus, ribs Lower extremity > upper extremity Right side > left side Spinal: most common at mid lumbar (L3-L4), lower thoracic, upper cervical

Question 61

Paget DiseaseRadiographic Signs

Answer 61

Skull: osteoporosis circumscripta; cottonwool appearance Spine: picture frame vertebra; ivory vertebra Pelvis: brim or rim sign, protrusio acetabuli Femur and tibia: blade of grass or candle flame appearance

Question 62

Complications of paget's disease

Answer 62

Skull: osteoporosis circumscripta; cottonwool appearance Spine: picture frame vertebra; ivory vertebra Pelvis: brim or rim sign, protrusio acetabuli Femur and tibia: blade of grass or candle flame appearance Psuedofractures Stenosis - Spinal, Bone expansion, deformity, pathologic fracture, upper thoracic and lumbar spine m/c Cranial - Hearing loss, cranial nerve compression Malignant degeneration - 1-3%, Higher incidence in humerus, lower in vertebrae, Osteosarcoma, fibrosarcoma, chondrosarcoma, Lytic destruction within Pagetic bone, Cortical destruction, Usually no periosteal response, Soft tissue mass, Cannonball mets to lung

Question 63

Lab changes with Paget's disease

Answer 63

Increased serum alkaline phosphatase possible - produced as bone attempts to rebuild Increased urinary hydroxyproline Normal serum calcium and phosphorus

Question 64

Treatment and prognosis of Paget's disease

Answer 64

Bisphosphonates - Reduces osteoclastic activity Supportive braces Slow progression