Unit 1 SG Flashcards
(93 cards)
1
Q
Aggressive = fast growing (not necessarily malignant). Key features:
A
Long zone of transition (ZOT)
Cortical disruption
Soft tissue involvement
2
Q
Malignant (characteristics)
A
Laminated
Spiculated
3
Q
Number of Lesions: Solitary (MC)
A
Ex: Simple Bone Cyst (SBC); Osteosarcoma
4
Q
Number of Lesions: Multiple Lesions (Multiplicity)
A
Polyostotic presentation - multiple bones
Monostotic presentation - one bone
Multiplicity - multiple lesions
Ex: Metastatic Dz; multiple myeloma
5
Q
Longitudinal Location: Diaphyseal Tumors (FEMALE)
A
Fibrous Dysplasia Eosinophilic Granuloma Myeloma Admentanoma Lymphoma (Non-Hodgkin’s) Ewings Sarcoma
6
Q
Longitudinal Location: Diametaphyseal
A
Non-Ossifying Fibroma (NOF)
7
Q
Longitudinal Location: Metaphyseal Tumors
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SBC
Osteosarcoma
8
Q
Longitudinal Location: Metaphyseal-Epiphyseal
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Giant Cell Tumor (can grow into epiphysis but ALWAYS in metaphysis)
ABC (can grow into epiphysis)
9
Q
Longitudinal Location: Epiphyseal
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Chondroblastoma (only tumor that ORIGINATES in epiphysis)
10
Q
Axial Location: Central
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Dead center of AP and Lat
Ex: Enchondroma; SBC; Fibrous Dysplasia
11
Q
Axial Location: Eccentric
A
MC seen overall. Central on AP and off-center on Lat; still primary in medullary cavity
Ex: Osteosarcoma; Giant Cell
12
Q
Axial Location: Cortical
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Overlies the cortex on AP or Lat; DDx from eccentric medullary; may overlie the medulla some, but primarily in cortex
Ex: Osteoid osteoma; Fibrous Cortical Defect (FCD)
13
Q
Axial Location: Parosteal (AKA Juxtacortical)
A
Radiolucent cleft between tumor and cortex; mostly outside the bone but still attached to periosteum
Ex: Juxtacortical chondroma; parosteal osteosarcoma
14
Q
Axial Location: Soft Tissue
A
Not connected to bone at all
Ex: Myositis ossificans
15
Q
Skeletal Location: Skull
A
Osteoma
16
Q
Skeletal Location: Hand
A
Enchondroma (MC benign tumor of hand)
17
Q
Skeletal Location: Vertebra
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Hemangioma (MC benign tumor of vertebra
18
Q
Location: Malignant Tumors
A
Tend to like ANTERIOR vertebral bodies
19
Q
Location: Benign Tumors
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Tend to like POSTERIOR elements of vertebral bodies
20
Q
Location: epidermoid Cysts (Terminal Tufts)
A
MC fingers and toes; result of trauma that drives epithelial tissue into bone where it continues to grow
21
Q
Morphologic Features: Size
A
Most malignant or aggressive tumors >6cm
22
Q
Morphologic Features: Margination
A
Can you clearly define the margins/ZOT? Is indicator of aggressiveness
Poor/wide ZOT = aggressive (aka imperceptible)
Clear/narrow ZOT - good (aka sharp); generally not malignant. Indicative of slow-growing process
23
Q
Morphologic Features: Bone Destruction - Geographic
A
MC indicative of slow-growing lesion (least aggressive). Tends to be sharply marginated, circumscribed, uniformly lytic
24
Q
Morphologic Features: Bone Destruction - Moth-Eaten
A
“Iffy” (usually malignancy or infection)
2-5mm in size
Outer margins poorly defined
Inner margins (moth holes) are well defined
25
Morphologic Features: Bone Destruction - Permeative
Most aggressive
Multiple holes <1mm
Poor ZOT
26
Morphologic Features: Matrix Characterization
Internal to bone, but extracellular to lesion
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Morphologic Features: Matrix Characterization - Calcification
Most tumors have radiolucent matrix, SOME calcify/ossify
Dystrophic calcification: calcification due to devitalized tissue
Metastatic calcification: due to disturbance of Ca metabolism (hyperparathyroidism)
28
Morphologic Features: Matrix Characterization - Types (COFF)
Cartilage/Chondro
Osseous/Osteo
Fibrous/Fibro
Fat
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Morphologic Features: Matrix Characterization - Types - Cartilage/Chondro
Calcified matrix; stippled, arc, ring-like, comma, popcorn
Ex: Chondrosarcoma, Enchondromas, Osteochondroma
30
Morphologic Features: Matrix Characterization - Types - Osseous/Osteo
Hazy, fluffy, cotton, cloud
Tumor new bone - can extend past cortex into soft tissue. Ex: Osteosarcoma
Reactive new bone - rarely extends beyond cortex. Ex: Prostatic metastasis (blastic)
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Morphologic Features: Matrix Characterization - Types - Fibrous/Fibro
Ground-glass, frosted glass, smeared chalk appearance
Ex: Fibrous dysplasia
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Morphologic Features: Trabeculation
Fine vs thick “soap bubbles”
33
Morphologic Features: Periosteal Response
Fundamental response to bone dz (bone forming irritants) that causes lifting of periosteum (blood, pus, edema, granulation tissue, neoplasm)
MC in children
2 basic patterns: Uninterrupted & Interrupted
34
Morphologic Features: Periosteal Response - Uninterrupted
Benign/slow-growing. Single layer of new bone
Ex: Osteoid osteoma; stress fx; hypertrophic pulmonary osteoarthopathy (HPO)
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Morphologic Features: Periosteal Response - Interrupted
Laminated/Layered - “onion skin” multi-layered. Ex: Ewing’s Sarcoma
Spiculated - most aggressive. “Hair on end”/perpendicular or “sunburst”/radiating from central point. Ex: Osteosarcoma
Codman’s Triangle - aka periosteal cuff/buttress. May accompany malignant or benign tumors/infections
36
Morphologic Features: Soft Tissue Mass
Bone + soft tissue involvement (primary malignant tumor).
Benign tumors usually DON’T have soft tissue mass, except 4: Giant Cell; ABC; Osteoblastoma; Osteoid Osteoma
Infections MAY have soft tissue components (osteomyelitis). Generally obliterate myofacial planes and may cross joint spaces.
Tumors displace myofacial planes and DO NOT cross joint spaces
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Metastatic Bone Tumors
MC osseous malignancy; usually from epithelial malignancy
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Metastatic Bone Tumors: MC Primary Malignancy Sites - Male
Prostate - blastic metastasis
Lung - lytic metastasis
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Metastatic Bone Tumors: MC Primary Malignancy Sites - Female
Breast - lytic and blastic metastasis
Thyroid
Kidney
Cervix
40
Metastatic Bone Tumors: MC Primary Malignancy Sites - Kids
<5yoa:
Neuroblastoma - lytic metastasis
Hodgkins Lymphoma - blastic metastasis
10-20yoa:
Ewing’s Sarcoma
Osteosarcoma
41
Metastatic Bone Tumors: Clinical Manifestations
MC 4th decade
MC presentation insidious onset, progressive, bone pain
42
Metastatic Bone Tumors: Laboratory
Basic bone profile to distinguish between metastasis and myeloma
```
ESR (erythrocyte sedimentation rate)
Ca - MC w/ osteoLYTIC tumors
Alk Phos - MC w/ osteoBLASTIC tumors
Proteins - MC w/ multiple myeloma
Uric Acid - MC w/ multiple myeloma
```
43
Metastatic Bone Tumors: Dissemination
Hematologic (MC); via Batson’s plexus in spine
Direct extension; pan-coast tumor, surgery
44
Metastatic Bone Tumors: Imaging Procedures
Bone Scintigraphy - procedure of choice for SCREENING b/c sensitive, cost-effective and see “whole body” simultaneously.
Works well for everything BUT Enostoma and Multiple Myeloma
45
Metastatic Bone Tumors: Distribution of Metastasis
From MC to LC (tumors don’t corss joints, infections do!)
Vertebra: MC metastasis go to spine (specifically VB and pedicle of T&L Spine)
Ribs & Sternum: Extrapleural sign - pushes pleura towards lungs. MC from osteoLYTIC metastasis
Skull: osteoLYTIC metastasis. MC primary breast/thyroid (holes are larger and not as well defined)
46
Metastatic Bone Tumors: Radiographic Features - OsteoLYTIC
MC osseous malignancy is osteolytic metastasis
Earliest radiographic manifestation, focal loss of bone density
MC cause of pedicle destruction; winking owl sign; one-eyed pedicle; blind vertebra (if both pedicles missing)
47
Metastatic Bone Tumors: Radiographic Features - OsteoBLASTIC
Poorly defined margins = wide ZOT
Ivory Vertebra - MC caused by:
~Osteoblastic Metastasis - VB size NOT changed; older ppl
~Paget Dz - VB INCREASES in size; older ppl
~Hodgkins - Anterior VB scalloping from enlarged lymph nodes/aorta; young ppl
48
Metastatic Bone Tumors: Characteristics of Metastasis vs Primary Tumor
Usually NO periosteal response
Rarely a soft tissue mass
Rarely expands bone
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Metastatic Bone Tumors: Blow-Out Metastasis
LARGE lytic lesion
MC primary sites - Thyroid; Kidney
Often expansile and bubbly
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Metastatic Bone Tumors: OsteoLYTIC Malignancies (FOGMACHINES)
```
Fibrous Dysplasia
Osteoblastoma
Giant Cell
Metastasis/ Myeloma
ABC
Chondroblastoma/Chondromyxoidfibroma
Hemangioma/Hyperparathyroid
Infection
Non-Ossifying Fibroma
Enchondroma/Eosinophilic
SBC
```
51
Round Cell Tumor Type (MEN)
If you see diaphysis involvement, need to think Round Cell Tumor
MEN:
~Myeloma
~Ewing’s Sarcoma
~Non-Hodgkin’s Lymphoma
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Multiple Myeloma
AKA: Myeloma, Kahler’s Dz
MC primary osseous malignancy
Generalized, many lesions = multiple myeloma
Single osseous lesion = solitary plasmacytoma (much less common); ~50yoa
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Multiple Myeloma: Signs/Symptoms
CARDINAL symptom is PROGRESSIVE LBP (bone pn), aggravated by exercise and weight bearing.
MC in older patients
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Multiple Myeloma: Laboratory Features
```
Increased serum electrophoresis (most diagnostic)
Normocytic/normochormic anemia
Rouleaux Formation (clumping of RBC’s)
Increased ESR
Thrombocytopenia
Increased Ca
Increased Uric Acid
Proteinuria (BENCE JONES proteins)
```
55
Multiple Myeloma: Locations
MC lower T&L Spine
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Multiple Myeloma: Advanced Imaging & Radiographic
Bone Scintigraphy unreliable
Well-defined “punched-out” lytic lesions is key radiographic difference between MM and Osteolytic Metastasis (OLM)
57
Multiple Myeloma: Radiographic - Spine
Loss of bone density is EARLIEST manifestation; sharply defined end-plates that are “thin” is key indicator of VB bone loss. Males w/ osteopenic bone loss is RED FLAG!
Wrinkled vertebra = pathological collapse
Pedicle Sign: MM spares pedicles; OLM eats pedicles
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Multiple Myeloma: Prognosis
MC cause of death is pneumonia
| 2nd MC is renal failure
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Ewing’s Sarcoma
Connective tissue sarcoma in bone marrow.
4th MC primary osseous malignancy
MC <25yoa
***Mimics osteomyelitis radiographically and labs
60
Ewing’s Sarcoma: Signs and Symptoms
Increasing local PAIN over months; if progressive pain over days/weeks = osteomyelitis
Fever, malaise & ESR
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Ewing’s Sarcoma: Location
MC primary osseous malignancy that metastasizes to bone. Metastasizes to lung also, frequent and early.
Young pt’s MC femur and tibia
>20yoa MC pelvis
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Ewing’s Sarcoma: Radiographic
Laminated periosteal response, “onion-skin”
Saucerization of cortex d/t pressure from soft tissue mass; ***Easy dx of Ewing’s Sarcoma
DDx - Osteomyelitis
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MC Primary Osseous Malignancies (MOCE)
Multiple Myeloma
Osteosarcoma
Chondrosarcoma
Ewing’s Sarcoma
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Non-Hodgkin’s Lymphoma
AKA: Primary bone lymphoma, histocytic lymphoma, lymphosarcoma, reticulum cell sarcoma
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Non-Hodgkin’s Lymphoma: Sign’s and Symptoms
25-50 yoa
MC primary osseous malignancy to initially present as pathologic fx
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Non-Hodgkin’s Lymphoma: Locations
MC Femur diaphysis
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Non-Hodgkin’s Lymphoma: Radiographic
NO periosteal response b/c usually older pt’s
DDx: Ewing’s Sarcoma, Paget Dz
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Hodgkin’s Lymphoma
Usually metastasis from primary Systemic Hodgkin’s in chest, liver, spleen; rarely a primary bone lesion
MC initial symptom is pain, that increases w/ alcohol consumption
MC site is VB in lower T-Spine & upper L-Spine
69
Hodgkin’s Lymphoma: Radiographic
Ivory Vertebra; scalloping of anterior VB
MC form osteoLYTIC
MC presentation polyostotic
Exuberant periosteal response
DDx: presence of anterior VB scalloping on ivory vertebra ELIMINATES osteoBLASTIC metastasis and Paget Dz
70
Osteosarcoma
Both primary and secondary can metastasize.
MC form is primary, <25yoa
Secondary malignancies arise from BENIGN primary disorder, whereas metastatic dz arises from a primary MALIGNANCY
MC cause of secondary osteosarcoma is malignant degeneration of Paget Dz, 60-80yoa
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Osteosarcoma: Signs and Symptoms
Bone Pain
Pyrexia (fever)
Cachexia (wasting)
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Osteosarcoma: Location
MC is eccentric presentation
MC metaphysis of distal FEMUR
Anytime there are sclerotic changes w/ bone pain around the knee = osteosarcoma
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Osteosarcoma: Radiographic - 3 Presentations
~MC sclerotic w/ soft tissue tumor new bone (B-day present)
~Lytic
~Mixed
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Osteosarcoma: Radiographic
MC in metaphysis BEFORE epiphyseal plate closure (may travel to epiphysis after)
MC tumor new bone - radiopaque within soft tissue lesion produces cumulus cloud appearance
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Osteosarcoma: Radiographic - Aggressive Periosteal Response
Sunburst is classic sign
Cannonball metastasis - looks like cannonball lesions in lungs. MC primary osseous malignancy to metastasize to LUNGS
Hair-On-End
Codman’s Triangle
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Osteosarcoma: Laboratory
Alkaline phosphatase - elevated d/t tumor new bone
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Parosteal Osteosarcoma
AKA: Periosteal or Juxtacortical Osteosarcoma
MC at posterior aspect of distal femur
25-40yoa
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Benign Bone Tumors
4 MC painful benign bone tumors (in order): Osteoid Osteoma; Osteoblastoma; ABC; Giant Cell
(First 3 like spine, Giant cell does not)
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Osteoma
Looks like enostoma; found in skull or sinuses. Enostoma’s DON’T occur in skull!
MC 15-35yoa
Gardner’s Syndrome - autosomal dominant, familial polyposis
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Osteoma: Signs and Symptoms
May block ostia (opening that connects sunuses to nasal cavity) of paranasal sinuses
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Osteoma: Complications
Proptosis - eyes popped out
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Osteoma: Locations
MC skull, paranasal sinuses, mandible
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Osteoma: Radiographic
Round or oval; well circumscribed
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Osteoma: Triad
Intestinal Polyposis - almost always undergo malignant degeneration
Multiple Osteomas
Soft Tissue Tumors
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Bone Islands
AKA Enostoma; small solitary foci of sense bone within spongiosa
Usually very stable
MC pelvis and proximal femur (if seen in skull = osteoma)
Metaphysis or epiphysis - NEVER diaphysis
DDx: Osteoblastic metastasis
86
Bone Islands: Radiographic
MC <1cm
Thorn-like radiations or brush border
Scintigraphy = NO uptake (great way to differentiate from osteoblastic metastasis - esp in older pt’s)
~Always ask for old films; if no significant change in several years = bone island
~If pt has prostate cancer, always get scintigraphy
87
Osteoid Osteoma
Nidus - radiolucent lesion <1cm CLASSICALLY surrounded by sclerosis (reactive new bone)
Highly vascular - usually demonstrates vascular blush on angiography
DDx: Brodies Abscess (appears identical; vascular blush in OO helps differentiate)
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Osteoid Osteoma: Signs and Symptoms
10-25yoa
HALLMARK: local pain, worse at night, relieved by activity and aspirin
Focal soft tissue swelling/tenderness
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Osteoid Osteoma: Locations
MC proximal femoral neck (metaphysis and diaphysis)
Vertebral arch
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Osteoid Osteoma: Types
MC Intracortical - in or attached to cortex, usually accompanied w/ plenty of cortical thickening and sclerosing
Intramedullary - little sclerosing
Subperiosteal
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Osteoblastoma
AKA giant osteoid osteoma
MC 10-20yoa
Osteoblastoma and osteoid osteoma are MC causes of scoliosis provoked by pn (neoplastic scoliosis)
DDx: If painful osteolytic lesion in neural arch of young pt, it’s either osteoblastoma or ABC
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Osteoblastoma: Location
MC VB’s posterior arch
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Osteoblastoma: Radiographic
Expansile w/ egg-shell thin cortical rim
Usually lytic
