1.4 - Malignant Bone Tumors

Tumor

_____ = neoplasm = erratic growth

Benign

Will not kill the patient

Malignant

Will kill the patient if untreated

- Malignancy

- Carcinoma

- Sarcoma

- Aggressive

Primary malignant

Primary site in bone

Metastasis

Primary spreads to other location

Skeletal metastasis

Spreads to bone

- Osteoid osteoma

- Osteochondroma

- Osteoblastoma

State the benign osseous tumors

Osteosarcoma

State the malignant osseous tumors

- Chondroblastoma

- Enchondroma

- Osteochondroma

State the benign cartilaginous tumors

Chondrosarcoma

State the malignant cartilaginous tumors

- Fibroma

- Non-ossifying fibroma

State the benign fibrous tumors

Fibrosarcoma

State the malignant fibrous tumors

Lipoma

State the benign fat tumors

Liposarcoma

State the malignant fat tumors

Skeletal metastasis

_____ is the most common malignant tumor

Extraskeletal sites

Skeletal metastasis arises from primary _____

- Breast

- Lung

- Prostate

- Kidney

- Thyroid

- Bowel

20-35%

_____ of all patients with malignancy will get skeletal metastasis

- Often the cause of death

- Lesions tend to be multiple

- Solitary lesions in only 10% of cases

- Age 50-75

- Bone pain (nocturnal)

- Pathologic fracture

- History of cancer

- Unexplained weight loss

- Anemia

- Fever

- Soft tissue mass

- Deformity

State the clinical findings of skeletal metastasis

15

Metastases may occur _____ years later

- Pain is persistent

- Symptoms may be minimal

Malignant melanoma

ID skin cancer

Osteolytic destruction

ID skeletal metastasis

Osteoblastic deposition

ID skeletal metastasis

Elevation of:

- Erythrocyte sedimentation rate (ESR)

- Serum Calcium (lytic) (often normal)

- Alkaline Phosphatase (blastic)

- Acid Phosphatase (prostate)

- Prostate Specific Antigen (prostate)

State the laboratory findings of skeletal metastasis

- Hematogenous

- Direct

- Lymphatic

State the pathways of extension of skeletal metastasis

Hematogenous

What is the most common pathway of extension of skeletal metastasis?

Batson's venous plexus

Prostate cancer can metastasize to the lumbar spine via ____

- 75%

- 15%

- 10%

Skeletal metastasis radiologic patterns of disease

- Osteolytic = _____

- Osteoblastic = _____

- Mixed = _____

Osteolytic

ID radiologic pattern of disease

Osteoblastic

ID radiologic pattern of disease

Mixed

ID radiologic pattern of disease

- Bone scan

- Radiography

- CT

- MR

State the imaging techniques for skeletal metastasis

Bone scan

ID imaging technique

3-5%

Bone scans require _____ of destruction (highly sensitive)

Radiography

ID imaging technique

30-50%

Radiography requires _____ of destruction (insensitive)

CT

Used for sensitive/specific bone detail

MR

Used for sensitive/specific soft tissue and marrow

10%

_____ of skull lesions are blastic

Winking owl sign

- Missing pedicle

- Soft tissue mass

- Vertebral body destruction

Vertebra plana

Pathologic vertebral body collapse

Renal cell carcinoma

Diagnosis?

- Missing inferior articular process

Diffuse

ID pelvic osteoblastic pattern

Punctate

ID pelvis osteoblastic pattern

Prostate carcinoma

Diagnosis?

>45

Blastic metastasis age

+++

Blastic metastasis increased density

-

Blastic metastasis enlargement

-

Blastic metastasis anterior scalloping

+++

Blastic metastasis alkaline phosphatase

+++

Blastic metastasis PSA

>50

Paget Disease age

+++

Paget Disease increased density

+++

Paget Disease enlargement

-

Paget Disease anterior scalloping

+++

Paget Disease alkaline phosphatase

-

Paget Disease PSA

20-40

Hodgkin Lymphoma age

+++

Hodgkin Lymphoma increased density

-

Hodgkin Lymphoma enlargement

+++

Hodgkin Lymphoma anterior scalloping

++

Hodgkin Lymphoma alkaline phosphatase

-

Hodgkin Lymphoma PSA

- Renal

- Adrenal

- Thyroid

- Skin (melanoma)

Blow-out metastasis (RATS)

Pancoast tumor

- Lung cancer that occurs in the superior sulcus

- Bronchogenic carcinoma

- Rib and spine destruction

- Horner's syndrome

Multiple myeloma

Most common primary malignant tumor of bone

27%

Multiple myeloma accounts for _____ of biopsied bone tumors

10%

Multiple myeloma accounts for _____ of hematologic malignancies

- Age 50-70 (75%)

- M:F, 2:1

- Common in the black population

- Pathologic fractures

- Bone pain

- Weakness and fatigue

- Anemia

- Fever

- Weight loss

- Bleeding

State the clinical findings of multiple myeloma

Red

Plasma cells originate in _____ bone marrow

Antibodies

Plasma cells produce _____ (gammaglobulins - IgG, IgA, IgM, IgE, IgD)

Dyscrasia

Multiple myeloma is considered a plasma cell "_____"

Multiple myeloma

- Uncontrolled plasma cell and antibody production

- Local environment rich in inflammatory biochemistry

• Increased bone lysis

• Decreased bone production

- Normal radiographs

- Diffuse osteopenia

State the early imaging findings of multiple myeloma

- Punched-out lucencies

- Vertebral collapse

- Diaphyseal osteolytic lesions

- Pedicles may be spared

- Bone scan often normal

State the late imaging findings of multiple myeloma

Raindrop skull

ID imaging finding of multiple myeloma

Hand involvement

ID imaging finding of multiple myeloma

- Anemia

- Thrombocytopenia

- Hypercalcemia

- Elevated plasma proteins (reversed A:G ratio)

- Bence Jones proteinuria

- Hyperuricemia

State the lab findings of multiple myeloma

- Radiotherapy

- Chemotherapy

- Bone marrow transplant

- Thalidomide

State the treatments for multiple myeloma

90%

_____ of patients with multiple myeloma die within 3 years

Osteosarcoma

_____ is the 2nd most common primary malignant bone tumor

Kids

Osteosarcoma is the most common primary malignant bone tumor in _____

20%

Osteosarcoma accounts for _____ of all primary malignant bone tumors

- Age 10-25 (75%)

- M:F, 2:1

- Painful swelling of involved limb

- Metaphysis

- 3.5-7% occur in spine

- Elevated serum alkaline phosphatase

State the clinical findings of osteosarcoma

- 50%

- 25%

- 25%

Osteosarcoma pathology:

- Sclerotic: _____

- Lytic: _____

- Mixed: _____

Osteosclerotic

ID type of osteosarcoma

Osteolytic

ID type of osteosarcoma

80%

Osteosarcoma has an _____ survival rate

- Chemotherapy

- Amputation

- Limb salvage surgery

State osteosarcoma treatments

Cannonball metastasis

Osteosarcoma lung metastasis

Secondary osteosarcoma

Malignant degeneration of benign process

- Paget disease

- Fibrous dysplasia

- Osteochondroma

Radiation therapy

State treatment for secondary osteosarcoma

Chondrosarcoma

- 3rd most common primary malignant bone tumor

- 10% of all primary malignant bone tumors

- Primary or secondary forms

- Age 40-60

- M:F, 2:1

- Pain late in disease

- Large soft tissue mass

- Severe pain after pathologic fracture

- Local excision

- Segmental resection

- Amputation

State treatment for chondrosarcoma

90%

Chondrosarcoma has a _____ 5-year survival after surgery

Ewing's Sarcoma

- 7% of all primary malignant bone tumors

- 4th most common primary malignant bone tumor

- Lower incidence among the black population in the US and Africa

- Age 10-25

- M:F, 2:1

- Localized pain and swelling

- May mimic infection: fever, anemia, ESR

- Most common 1º malignant bone tumor to metastasize to bone

State clinical features of Ewing's Sarcoma

Diaphyseal permeative lesion

- Laminated periosteal reaction (25-50%)

- Lytic or mixed destruction

- Pathologic fracture (5%)

State imaging findings of Ewing's Sarcoma

- Amputation for lesions about knee

- Radiotherapy and chemotherapy in early lesions

State treatment for Ewing's Sarcoma

35%

Ewing's Sarcoma has a _____ 5-year survival

Non-Hodgkin's Lymphoma

- "Primary Lymphoma"

- Rare extranodal lymphoma

- Skeletal involvement in 30% of patients

- 3-4% of all primary malignant bone tumors