Bone, cartilage and soft tissue tumors

Overall, primary bone and cartilage tumors are very ___

• rare

What are the possible causes of bone and cartilage tumors and soft tissue sarcomas? (2)

• genetic mutations (P53 and RB1)

• previous radiation exposure

___ is more indicative of prognosis than stage for bone and cartilage tumors and soft tissue sarcomas?

• Grade

What staging system is used for bone and cartilage tumors and soft tissue sarcomas?

• TNM staging system

What is the most common form of spread for bone and cartilage tumors and soft tissue sarcomas?

• blood (not lymph)

What is the most common site of primary bone sarcomas and why?

• Epiphyseal plate due to rapid cell proliferation

What are the two common specific sites for primary bone sarcomas?

• distal femur

• proximal tibia

___ is much more common than primary bone cancer

• metastatic bone cancer

What are three most common primary cancers associated with bone metastasis?

• prostate cancer

• breast cancer

• lung cancer

What is the most common site for mets in bone and cartilage tumors and soft tissue sarcomas?

• Lung

Most common incidence of primary bone cancer is during what stage in life and why?

• adolescence because bones are growing rapidly

Bone and cartilage tumors and soft tissue sarcomas are common in what gender?

• males

True of false: bone and cartilage tumors are chemo sensitive but radio-resistant

• TRUE

What are osteolytic lesions and what do they lead to?

• lesions with decreased bone density that appear darker on images

• lead to pathologic fractures

What are osteoblastic lesions?

• excess bone formation/density that appear as very white spots on images

What is the most common presenting symptom for bone and cartilage tumors?

• pain in the affected area

Vertebral lesions in bone and cartilage tumors lead to what complications? (2)

• nerve issues

• spinal cord compression

Bone cancers that have smooth borders on x-ray tend to be___; those that are ragged tend to be___, meaning soft tissue extension

• benign

• malignant

What is the most common primary bone tumor?

• osteosarcoma

Osteosarcoma is more common in what age groups?

• children and young adults

What is the pattern of osteosarcomas on x-ray?

• Sunburst pattern

What is the most common prognostic indicator for osteosarcoma?

• presence of mets

Osteosarcomas may also exhibit what?

• skip metastases (another lesion on the same bone)

Osteosarcomas are most common in what bones?

• long bones

What are treatments for osteoscarcomas (2)?

• chemo first, surgery, then chemo again

• radiation not very effective (used if surgery is not an option or positive margins)

Chondrosarcomas develop where?

• in cartilage cells (chondro=cartilage)

Chondrosarcomas are more common in what age group?

• adults (rare in children)

How do chondrosarcomas grow and what is the grade?

• most are slow-growing and low grade (don’t spread)

What bone tumors are commonly found in the pelvis and femur? (2)

• Chondrosarcomas

• Ewing sarcoma

What is the treatment of choice for chondrosacrcomas?

• Surgery! (chemo and radiation are not very effective)

What are Malignant Fibrous Histiocytoma- fibrosarcoma?

• tumors that produce fibrous connective tissue

Characteristics of MFH-Fibrosarcoma? (2)

• high-grade malignant

• aggressive with high recurrence rates

MFH-Fibrosarcoma occur in what parts of the body?

• bone and soft tissue

Treatments for MFH-Fibrosarcoma? (3)

• surgery

• radiation only if inoperable or residual disease after surgery (not radiosensitive)

• chemo for recurrence

What is the 2nd most common childhood bone cancer?

• Ewing sarcoma

Ewing sarcoma occurs in what parts of the body?

• can occur in bone or soft tissue

Ewing sarcoma is ____ to chemo and radiation

• radiosensitive

What is the appearance of Ewing sarcoma on x-ray images

• onion peel appearance

Treatments for Ewing sarcoma?

• chemo, then surgery, then chemo + radiation

Multiple myeloma is also known as what?

• plasmacytoma

Multiple myeloma is blood cancer of what cells?

• blood cancer of B lymphocyte plasma cells in bone marrow

In Multiple myeloma, what does low growth fraction tumor mean? (2)

• only small fraction of tumor cells are actively dividing while majority are in G0

• could take years (1-10) before treatment is necessary

Treatment for Multiple myeloma is usually ____ because there is no ____ yet

• palliative

• cure

Where does Multiple myeloma occur in the body?

• occurs in many bones throughout the body

Multiple myeloma is associated with what lesions?

• osteolytic lesions

Treatments for Multiple myeloma? (2)

• chemo + radiation to alleviate pain and prevent bone fractures

• Autologous stem cell transplant may help to control disease

What is the radiation dose for Multiple myeloma?

• 30 Gy in 10 fractions since it’s palliative

Giant cell tumor of bone are typically ___ with ____ control rates (good prognosis)

• benign

• high control rates

Giant cell tumor of bone are usually found where commonly found where?

• at ends of long bones (knee is common)

Treatments for Giant cell tumor of bone (2)

• surgery alone

• radiation if inoperable or recurrent disease

Most common bone tumor overall?

• metastatic bone cancer

Treatments for metastatic bone cancer (4)

• Palliative (not curable)

• Radiation to alleviate pain, prevent bone fx, prevent paralysis (spine lesions)

• Chemo if widespread bone mets

• Strontium-89 or samarium-153 injections for widespread bone mets

What is the radiation dose for metastatic bone cancer?

• 30 Gy in 10 fractions (palliative), but can deliver 30 Gy in fewer fractions using SBRT

When treating the entire long bone of an extremity, why it is important to leave a strip of soft tissue outside of the treatment volume?

• to preserve lymphatic drainage (want to avoid lymphedema)

When treating the spine for metastatic bone cancer, how can you treat? (2)

• treat involved the vertebral body, plus one vertebra above and one below

• may also see SBRT to just the one affected vertebral body

Soft Tissue Sarcomas arise from what cells?

• mesenchymal stem cells in connective tissues

Soft Tissue Sarcomas include tumors in what 4 structures?

• adipose tissue

• muscles

• nerve sheath

• blood vessels

TRUE or False: Overall Soft Tissue Sarcomas are rare, but slightly more common than primary bone/cartilage tumors

• TRUE

Soft Tissue Sarcomas are associated with what prognosis?

• poor prognosis with a high mortality rate overall

Characteristics of Soft Tissue Sarcomas?

• aggressive with high chance of recurrence and mets are common

What is the most common presenting symptom of Soft Tissue Sarcomas?

• painless mass that becomes painful as it grows bigger

What is the best imaging modality to use for the detection of Soft Tissue Sarcomas?

• MRI due to its ability to show detailed soft tissue anatomy

Where do Soft Tissue Sarcomas occur? (2)

• anywhere in the body

• most common area = extremities (proximal thigh)

How many subtypes do Soft Tissue Sarcomas have?

• over 50 pathologic subtypes

What 2 histologic types of Soft Tissue Sarcomas is most common in adults?

• liposarcomas (fat cell tumors)

• leiomyosarcomas (smooth muscle cell tumors)

What histologic type of Soft Tissue Sarcomas is common in children?

• Rhabdomyosarcoma (striated muscle cell tumor)

Along with the TNM staging system, what other staging system is used for Soft Tissue Sarcomas?

• French Federation of Cancer Centers Sarcomas Group (FNCLCC)

Treatments for Soft Tissue Sarcomas (3)

• surgery

• radiation therapy

• chemotherapy

For Soft Tissue Sarcomas, what is the surgical technique used?

• surgery using wide excision (1-2 cm of healthy tissue is removed)

For Soft Tissue Sarcomas, when is radiation delivered?

• pre or post surgery

When delivering radiation for Soft Tissue Sarcomas, what dose is required?

• High dose since STS are relatively radioresistant

When delivering radiation for Soft Tissue Sarcomas, why must a strip of tissue be left untreated?

• to avoid lymphedema

What skill must the radiation therapist use when simming extremities?

• Use critical thinking skills since patients are in pain, and extremities can be tricky to replicate everyday

For Soft Tissue Sarcomas, _____ radiation is the standard in the US

• pre-op radiation

What are the 5 advantages of preoperative radiation therapy?

1. allows for complete resection with negative margins

2. smaller treatment volume (less morbidity)

3. lower total dose required (50 Gy)

4. if tumor shrinks, less aggressive surgery

5. no delay in starting treatment (waiting for surgery to heal)

What are the 2 disadvantages of preoperative radiation therapy?

1. difficulty with wound healing (tissue is damaged from radiation)

2. gap in treatment (3 weeks following radiation for healing)

Why is Post-operative radiation necessary for Soft Tissue Sarcomas? (2)

• to eradicate any remaining cells following surgical resection

• if entire tumor can not be removed

What are the 2 advantages of post operative radiation therapy?

• allows for optimal tumor staging

• wound healing is not compromised

What are the 2 disadvantages of post operative radiation therapy?

• greater likelihood of late effects due to higher dose (up to 80 Gy) and large treatment volumes (3-6 cm margins)

• gap in treatment: 3-8 weeks after surgery when wound is healed

When and why would chemotherapy be used for Soft Tissue Sarcomas?

• uncertain what the overall benefit is of adding chemo, but may be helpful in those with mets or for children with rhabdomyosarcoma

What chemotherapy agent is most used for Soft Tissue Sarcomas?

• Doxorubicin