Tumor Flashcards
Orthopedic Tumor Essentials (82 cards)
0
Q
Name some negative prognostic characteristics of osteosarcoma.
A
- Poor response to Neo adjuvant chemo (% necrosis)
- Tumour size (> 8 cm is bad)
- Patient age (old is bad)
- Higher stage of Tumor
- Anatomical site (central is bad)
1
Q
General treatment for bone sarcoma?
A
- Neo adjuvant chemotherapy, multi-agent
- Re-stage with imaging to assess for interim progression/metastases and pre-op planning
- Wide resection
- Chemotherapy - use response to pre-op chemo to prognosticate (% necrosis of surgical pathology) and target therapy
2
Q
What does GCT look like on MRI?
A
Dark on T1 and T2
4
Q
Histopathology of GCT?
A
Multinucleated giant cells.
May see bone.
Mononuclear stromal cells
5
Q
What sarcoma has flat epithelial cells on pathology?
A
Synovial sarcoma
8
Q
What Tumor has characteristic fluid levels on MRI?
A
ABC
9
Q
What colour is chondroid matrix on staining?
A
Blue
10
Q
Seven questions for evaluating bone lesion on x-ray?
A
- Where is it
- What is it doing to bone?
- What is bone doing to it?
- Periosteal reaction?
- Soft tissue component?
- Pathological fracture?
- Matrix?
11
Q
Where is the most common place for sarcomas to metastasize?
A
- Lungs
2. Another bone
12
Q
Common locations of ABC?
A
Femur > tibia > spine
14
Q
What does it mean if a Tumor is biphasic?
A
It contains both epithelial and mesemchymal neoplastic cells
15
Q
What is special about biphasic sarcomas in terms of metasteses?
A
They can go to lymph nodes, which is unusual for sarcomas.
Also they metastasize to locations other than the lungs.
16
Q
What are the three biphasic sarcomas?
A
- Synovial sarcoma
- Angiosarcoma
- Mixed liposarcoma
17
Q
Name two enchondroma syndromes.
A
- Olliers
2. Maffuccis
18
Q
What mutation is characteristic of fibrous dysphasia?
A
G-Protein mutation
19
Q
What is the approach to neoadjuvant chemotherapy for pre-operative malignant bone tumour?
A
Multiagent chemotherapy
- Methotrexate
- cisplatin
- Doxorubicin
- Ifosfamide
20
Q
What colour is bone matrix on staining?
A
Pink
21
Q
What is the primary difference between sarcomas and carcinomas? (In terms of lineage)
A
Carcinomas = epithelial
Sarcomas = mesemchymal
22
Q
Name the basic biopsy principles.
A
- Biopsy through involved compartment
- Use extensile incision (usually longitudinal)
- Meticulous hemostasis
- Do not create multiple planes
- Bring out drains in line with incision (so the tunnel can be removed easily if wide resection is needed)
- Can biopsy soft tissue component of bone tumour
23
Q
Components of systemic staging for malignant tumour?
A
CT chest, abdo, pelvis (chest most important)
Bone scan (skip metasteses, second most common site is bother bone)
Blood work: lytes (calcium), albumin, spep, upep, ALP, LDH
24
Q
Components of local staging?
A
MRI to characterize lesion (of entire bone)
Biopsy (can do soft tissue mass)
Send for pathology and cultures Adequate hemostasis Good lesional tissue Use pathology to prognosticate
25
Q
Histology of ewings sarcoma?
A
Small round blue cells
26
Q
Differential for small round blue cells on histology?
A
Ewing's sarcoma Lymphoma Osteomyelitis Multiple myeloma Histiocytosis Rhabdomyosarcoma Neuroblastoma
27
Q
What kind of matrix does ewings usually have?
A
None
28
What are the main steps in treatment of malignant bone tumour?
1. Neo adjuvant chemotherapy
2. Re-stage with imaging for response to therapy and operative planning
3. Surgery - limb sparing vs. amputation
4. Post-operative chemotherapy - use pathology to prognosticate
29
What Tumor stains for MIC2 antigen?
Ewing's sarcoma. This is how you differentiate it from other small round blue cell tumors.
30
For ewings sarcoma, what blood markers should be added to the typical malignant work up and why?
CBC, esr and crp to differentiate it from osteomyelitis
In ewings esr will be up (but not crp?)
31
You are working up a malignant looking tumor. It is bright on T2 with liquid, purulent looking gross pathology and no osteointegration matrix. what is it?
Ewing's sarcoma
32
What do the terms onion skinning and sunburst refer to on radiographs? Which Tumors are each characteristic of?
Types of periods teal reaction
Onion skinning = ewings
Sunburst = osteosarcoma
33
Olliers is characterized by:
A) multiple enchondromas, hemangiomas, lymphangiomas
B) multiple enchondromas in a unilateral distribution
C) auto-dominant transmission, multiple enchondromas and osteochondromas
B
34
What blood markers can be used to measure bone turnover?
ALP, LDH
35
What Tumor is usually epiphyseal in skeletally immature with chicken wire calcifications?
Chondroblastoma
Also has mononuclear chondroblasts
36
What findings differentiate chondrosarcoma from a benign lesion?
1) myxoid matrix - may still have chondroid matrix, but generally the more myxoid the higher the grade
2) cortical thinning or thickening
3) soft tissue mass
4) invasion of haversian system
37
What is Denosumab?
RankL inhibitor. This is a ligand for the Rank receptor and acts as a signal for bone removal. Denosumab is an analogue and used in GCT tumours to prevent bone turnover.
38
A translocation of chromosome 11 and 22 resulting in a chimeric protein is characteristic of what Tumor?
Ewing's sarcoma
Translocation results in EWS gene
39
Which sarcoma is radio/chemo resistant?
A) liposarcoma
B) osteosarcoma
C) chondrosarcoma
D) Ewing's sarcoma
C) chondrosarcoma
40
Does radiation have a role in treatment of Ewing's sarcoma?
Yes, if wide resection is technically difficult or if a Tumor was inadequatly resected based on pathology
41
Maffuccis is characterized by:
A) multiple enchondromas, hemangiomas, lymphangiomas
B) multiple enchondromas in a unilateral distribution
C) auto-dominant transmission, multiple enchondromas and osteochondromas
A
42
What is the malignant transformation rate for multiple exostosis syndrome?
1-3%
43
"Pop corn densities" are useful in differentiating what secondary malignancy from its benign precursor?
Secondary chondrosarcoma from enchondroma.
45
What part of an osteochondroma is usually the site for secondary malignant transformation?
Cartilage cap
46
Which chondrosarcoma variant is typically epiphyseal?
Clear cell chondrosarcoma
47
Host lamellar bone entrapment is characteristic of what malignancy?
Chondrosarcoma
48
PVNS typically contains which pigment?
Hemosiderin deposits
49
What primaries metastasize to bone?
```
Lymphoma
Melanoma
Visceral carcinomas:
Breast
Prostate
Lung
Kidney
Thyroid
```
50
What part of bone does ewings usually occur?
Diaphysis
51
Enchondromatosis is characterized by:
A) multiple enchondromas, hemangiomas, lymphangiomas
B) multiple enchondromas in a unilateral distribution
C) auto-dominant transmission, multiple enchondromas and osteochondromas
C
52
Who gets Ewing's sarcoma?
White males aged 10-20
54
At what age does metastases become more common than primary bone malignancy?
40
55
What primary bone malignancies are more likely in patients over 40?
Plasmocytoma (solitary myeloma)
Primary lymphoma of bone
Chondrosarcoma
MFH
56
Physical exam for metastasis with unknown origin must include?
Thyroid exam
Lung exam
Abdomen exam
Breast/prostate exam
57
Bloodwork for metastasis with unknown origin?
```
Spep/upep
CBC
Esr
Lytes
Liver enzymes
Psa
Alp
LDH
```
58
Imaging for metastasis with unknown origin?
```
Chest X-ray
X-ray of involved bone
Any painful extremities
Bone scan
If suspect myeloma, skeletal survey
Consider MRI of bone lesion
Ct chest/abdo/pelvis
```
59
What are characteristics of a metastasis on X-ray?
Lytic
Permeative
Diaphysis/metadiaphysis
Proximal long bone or spine
60
What primaries are most likely to present as metastasis with unknown origin?
Lung and kidney (because they are more likely to be occult)
61
What primary is very vascular, requiring embolization of lesions primary to ORIF?
RCC
| Thyroid
62
Describe the Enneking system for classifying malignant tumours.
Three factors: Grade, site and metasteses
Grade is high or low
Site is intracompartmental (enclosed by natural barriers) or extracompartmental
```
IA = low grade intracompartmental
IB = low grade extracompartmental
IIA = high grade intracompartmental
IIB = high grade extracompartmental
III = any metastsesis
```
63
Which type of liposarcoma does not require adjuvant radiotherapy?
Well differentiated liposarcoma
64
What benign tumour is characterized by fatty infiltration of sub synovial connective tissue?
Lipoma aborecens
65
Name the 5 subtypes of liposarcoma.
```
Well differentiated liposarcoma
Myxoid liposarcoma
Pleomorphic liposarcoma
Dedifferentiated liposarcoma
Mixed-type liposarcoma
```
66
What is the most common sarcoma in the foot?
Synovial sarcoma
67
Synovial sarcoma is a misnomer. What percentage of these tumours actually arise is a major joint?
10%
68
Describe the Enneking system for classifying malignant tumours.
Three factors: Grade, site and metasteses
Grade is high or low
Site is intracompartmental (enclosed by natural barriers) or extracompartmental
69
Options for fixation of a met? (Be general)
1. ORIF
Plate with cement versus nail
2. Arthroplasty
3. Endoprosthesis
70
Which primary can have mets distal to knee and elbow?
Lung
71
Which primary has worst prognosis once mets are present in bone?
Lung
72
Ddx for lytic lesion in greater than 40 year old
1. Mets
2. MM
3. Lymphoma
4. Metabolic (browns Tumor)
5. Sarcoma
73
Benign aggressive lesions? (3)
GCT, ABC, osteoblastoma
74
Episyphyseal lesions?
Chondroblastoma, infection, GCT
75
Enchondromas always central metaphyseal t/f?
True
76
Benign bone lesion in spine is usually what?
Osteoblastoma
77
Age range for GCT?
20-40
78
GCT location mainly?
Prox tibia, distal femur
proximal humerus, distal radius
I.e. Where a lot of growth occurs
79
Ddx for multiple giant cell containing lesions?
Multifocal GCT
| Browns Tumor
80
Distal radius lytic lesion DDH? (4)
GCT
Abc
Chondrosarcoma
Telientatic osteosarcoma
81
GCT histology?
Mononuclear cells with Uniformly distributed multinucleated giant cells
82
GNAS mutation?
Polyostotic fibrous dysplasia
| Mcune Albright syndrome
83
Metastatic Tumor that is blastic?
Prostate
84
Older than 40 , blastic lesion DDx (4)?
```
Metastases (prostate)
Bone island
Bone infarct
Osteoblastoma
Infection
```
85
Differential for small round cell tumour?
Small-round-cell tumor differential (by age)
```
< 5 yrs: neuroblastoma or leukemia
5-10 yrs: eosinophilic granuloma
5-30 yrs: Ewing's sarcoma
>30 yrs: lymphoma
> 50 yrs: myeloma
```
86
Do osteochondroma transform into high or low grade chondrosarcoma?
Low grade
87
Chrondroblastomas are located where?
Epiphysis
