Orthopedic Neoplasm (CMPP)

Most malignancy of the bones are usually from

Metastasis

What defines the treatment of bone neoplasm

Type of Tumor

Primary or Metastatic

Extent of Tumor

Who do we refer bone neoplasms to

Orthopedic Surg ± Oncology

Whatt imaging may be needed in work-up orthopedic neoplasms

XR

CT / MRI

Bone Scan

What is the most reliable indicator of malignancy risk

Hx of Prior Malignancy

What are some red flags for bone malignancy

Pain, unrelieved by rest, nocturnal

Weight loss

Night sweats

Fatigue

Pathologic fracture

Swelling or palpable deformity

what lab may be elevated for orthopedic neoplasms

Alk Phos w/o GGT

What cancers can be test with AFP

Liver

Testicular

Liver Tumor Marker

AFP

Testicular Tumor Marker

AFP

b-hCG

LDH

Prostate tumor markr

PSA

Ovarian Tumor Marker

CA-125

Pancreatic Tumor Marker

CA 19-9

Breast Tumor Markers

CA 15-3

CA 27

CA 29

Colorectal Tumor Marker

CEA

Lung Tumor Markers

CEa

CYFRA 21-1

NSE

Stomach Tumor Markers

CA 72-4

CEA

Bladder Tumor Markers

NMP22

BTA

What information on bone neoplasms can gained from XR

Location

Border

periosteal reaction

matrix

How can we describe location of bone neoplasms

Specfic bone

Epihysis / Metaphysis / Diaphysis

How can we describe borders of bone neoplasms

Well-defined with or without sclerosis (geographic)

Moth eaten

Permeative

How can we describe matrix of bone neoplasms

Lytic - empty hole

Blastic - increased bone

Calcifications

Ground glass

Arcs and rings

How can we describe periosteal reaction of bone neoplasms

Onion skinning

Starburst

What tumor commonly presents with onion skinning periostealr reaction

Ewing Sarcoma

When is CT used for bone neoplasms

setting of metastatic disease

MRI can best assess what aspects of bone neoplams

Tumor Size

Local IO and extraosseous extent

identify both hypervascular and necrotic areas within tumor

What benefit can technetium bone scans provide

evaluate entire skeleton for the presence of multiple lesions

What can cause false positives on technetium bone scan

previous trauma

What cancers commonly spread to bone

Breast

Lung

Thryoid

Kidney

Prostate

Most Common Primary Bone Tumor

MM

Follwed by osteosarcoma

What are the types of benign bone tumor

Osteoid Forming

Chondrioid Forming

Fibrous

Cystic

Giant Cell Tumors

Hemangioma

Types of Osteoid Forming Benign Bone Tumors

Osteoid Osteoma

Osteoblastoma

Osteofibrous Dysplasia

Types of Chondrioid Forming Benign Bone Tumors

Enchondroma

Osteochondroma

Periosteal Chondroma

Chondroblastoma

Chondromyxoid Fibroma

Types of Fibrous Benign Bone Tumors

Fibrous Cortical Defect

Nonossifying Fibroma

Fibrous Dysplasia

Types of Cystic Benign Bone Tumors

Simple Bone Cyst

Aneurysmal Bone Cyst

Epidermoid Cyst

Osteoid Osteoma

Benign bone-forming tumor characterized by a small radiolucent nidus (<1 to 1.5 cm)

Who most commonly gets osteoid osteomas

Teenage males

Risk Factors for Osteoid Osteoma

None

Where is the most common site for osteoid osteoma

Promixal Femur

Presentation of Osteoid Osteoma

Progressively increasing pain worse at night

Limp

Decreased ROM

Swelling and Tenderness

Pain quickly relieved by NSAIDs

Nidus

The source of infection / disease

Why does pain of osteoid osteoma go away with NSAIDs

The tumor makes prostaglandins

Osteoid Osteoma

Osteoid Osteoma

How do Osteoid Osteomas appear on XR

small, round lucency (nidus) with a sclerotic margin

Preferred Moduality for dx of Osteoid Osteoma

CT

Why don’t we use MRI for osteoid osteomas

Cab be obscured by soft tissue involvement

Treatment Options for Osteoid Osteoma

Percutaneous radio frequency ablation

Curettage and bone grafting:

En bloc resection

Percutaneous radio frequency ablation

Uses radio frequencies passed beneath the skin through a needle to kill the tumor cells by heating them to a high temperature

Curettage and bone grafting:

tumor is scraped out of the bone

Remaining cavity is packed with donor bone tissue (allograft) or bone chips taken from another bone (autograft)

En bloc resection (Bone)

Surgical removal of bone containing the tumor

Internal fixation with pins may restore structural integrity of the bone

Enchondroma

Benign cartilage-forming tumors that develop in the medulla (marrow cavity) of long bones

Enchondromatosis

a syndrome of multiple Enchondroma

Forms of Enchondromatosis

Ollier disease

Maffucci syndrome – can also have vascular malformations

Who is most likely to present with a Enchondroma

Teens

Who is most likely to present with encondromatosis

children <10 years

What is the most common sites for enchondroma

tumor of the HAND (#1)

Also likes humerus and femur

Presentations of Enchondroma

Many will be asymptomatic until fracture

deformity due to widening of the bone

limb-length discrepancy

enchondromatosis in skull – headache and cranial nerve palsy

Enchondroma

Enchondroma

enchondromatosis

Preferred Test for Enchondramas

XR

How do enchondromas appear on XR

Lesion(s) often oval, well-circumscribed

Sclerotic or non-sclerotic margins

Central lucent lesion – may include matrix calcifications

Endosteal scalloping

What are flags that would indicate a bone tumor is not an enchondroma

gross bone destruction

periosteal reaction

soft tissue mass

Endosteal scalloping

resorption of the inner surface of bone cortex;

appears as indentations or erosions on the normally smooth margin of the bone's inner layer

What bone tumor presents with endosteal scalloping

Enchondroma

Treatment for Asymptomatic and Small Enchondrma

Observation

Who gets actual treatments for enchondroma

Long bones due to risk of fracture with weight-bearing bone

>25 mm in diameter

Involve >50 percent of the diameter of the cortex

Treatment for Symptomatic Enchondramsas

Curettage and Graft

Untreated enchondrams can transform into

Chondrosarcoma

What are signs that enchondrams have undergone malignany transformation into chondrosarcoma

worsening pain

Usually after skeletal maturity

Enchondroma

Osteochondroma

Cartilage-capped bony spur arising on the external surface of a bone

Marrow cavity of the spur is continuous with the cavity of the underlying bone

Cap of cartilage is the source of growth

Where do osteochondrmas appear from

escaped physeal cells

What conditions do you se osteochondrmas with

Hereditary multiple osteochondromas (HMO)

Hereditary multiple exostoses (HME)

Osteochondroma

Osteochondroma

Presentation of Osteochondroma

painless mass – often found near a joint or on the axial skeleton

painful when associated with local trauma or with pathologic fracture

decreased range of motion

deformity

short stature,

limb length discrepancy,

varus/valgus deformities

Test of Choice for Osteochondroma

XR

Indications for MRi for Osteochondroma

Concern for adjacent soft tissue impingement

New focal pain at site, not apparent by X-ray

Concern for chondrosarcomatous (malignant) transformation

Indications for Excising Osteochondromas

Local irritation or deformity

Concern for malignant transformation

Simple Bone Cyst

Fluid-filled lesion with a fibrous lining

Simple Bone Cyst

Peak Incidence for Simple Bone Cysts

0-20 years

Most Common Sites for Bone Cysts

Proximal humerus

femur

Preesentation of Bone Cysts

localized pain,

decreased function/failure to use extremity

limp

Pathologic fracture

Test of Choice for Bone Cysts

XR

How do bone cysts appear on XR

Well-marginated cystic lesion of metaphysis or metadiaphysis without reactive sclerosis

"Fallen leaf" sign

"Fallen leaf" sign

Fragment of bone falls to the bottom of the cyst

Bone Cyst

Treatment for Simple Bone Cysts

Observation with Serial XR q4-6months

Activity Restriction due to Fracture Risk

Aspiration and Methylprednisolone Injection (Large)

Surgery (Rare)

Giant Cell Tumors

Non-malignant but locally aggressive osteolytic skeletal neoplasm

Giant Cell Tumors

Peak Incidence with Giant Cell Tumors

20-40 y/o

What condition are Giant Cell Tumors seen in

Paget’s Disease

Where do giant cell tumors form

meta-epiphyseal region of the long bones, usually around the knee

what is highly expreessed in giant cell tumors

RANK ligand

Presentation of Giant Cell Tumor

Pain

Swelling

Limitation of ROM

Pathologic Fracturee

Giant Cell Tumor

How do Giant Cell Tumors present on XR

expansile, eccentric, lytic lesion in epiphysis and adjacent metaphysis

Absence of matrix calcification and periosteal reaction