41 - bone and soft tissue tumours

what is sarcoma

malignant connective tissue tumour that spreads along fascial planes

where does sarcoma often spread to

haematogenous spread to LUNGS

what are the benign bone forming tumours

osteoid

osteoma

osteoblastoma

what are the malignant bone forming tumours

osteosarcoma

what are the benign cartilage forming tumours

endochondroma, osteochondroma

malignant cartilage forming tumours

Chondrosarcoma

benign fibrous tissue tumours

fibroma

malignant fibrous tissue tumours

fibrosarcoma, malignant fibrous hystiocytoma (MFH)

benign vascular tissue tumours

haemangioma

aneurysmal bone cyst

malignant vascular tissue tumour

angiosarcoma

benign adipose tissue tumour

lipoma

malignant adipose tissue tumour

Liposarcoma

marrow tissue tumours - malignant

Ewings sarcoma

lymphoma

myeloma

what is the most common primary malignant bone tumour in younger patients

osteosarcoma

what is the commonest primary malignant bone tumour in older patient’s?

myeloma

tumour-like lesions

simple bone cyst

fibrous cortical defect

malignant bone tumour symptoms

pain that's activity related and progressive pain at rest and night

examination for bone tumours

general health

measurement of mass

location

shape

consistency

mobility

tenderness

local temperature

neuro-vascular deficits

what swelling signs are suspicious of a malignant tumour

rapidly growing

hard, fixed, craggy surface, indistinct margins

non-tender to palpation

associated with deep ache worse at night

may be painless

recurred after previous excision

investigations for bone tumours

plain X-ray most useful for bone lesions

- clear margins

- surrounding rim of active bone

- cortical expansion

what can cortical expansion occur with

aggressive benign lesions

where does calcification occur in?

synovial sarcoma

aggressive signs on X-ray that indicates malignancy

cortical destruction

•less well defined zone of transition between lesion and normal bone (permeative growth)

•Periosteal reactive new bone growth occurs when the lesion destroys the cortex.

 - Codman’s triangle, onion-skinning or sunburst pattern

what is CT good for visualising in bone tumours

ossification and calcification

integrity of cortex

best for assessing nidus in osteoid sarcoma

staging - lungs

what are isotopes bone scans used for

staging for skeletal metastasis

multiple lesions

what is the imaging modality of choice of BOTH bone and soft tissue tumours

MRI

•size, extent, anatomical relationships

•Accurate for limits of disease both within and outside bone

•Specific for Lipoma, haemangioma, haematoma or PVNS.

•Non-specific for benign vs. malignant

what is PET useful for

investigating response to chemo

what needs to be done before biopsy

full work up

- bloods

- X-rays of affected limb and CXR

- MRI of bone lesion

- bone scan

- CT, chest, abdomen and pelvis

cardinal features of malignant primary bone tumours

increasing pain

weight loss

unexplained pain

deep seating boring nature

night pain

difficulty weight bearing

deep swelling

osteosarcoma clinical features

pain

loss of function

swelling

pathological fractures

joint effusion

deformity

neurovascular effects

systemic effects of neoplasia

pain cardinal features that point to osteosarcoma

increasing unexplained pain not relieved by analgesia and not related to exercise

deep ache worse at night

who does osteosarcoma affect more and which sites

men

distal femur and proximal tibia

swelling cardinal features in osteosarcoma

diffuse in malignancy

generally near end of long bone

warmth over swelling and venous congestion = ACTIVE

pressure effects e.g. intrapelvic

investigations for osteosarcoma

MRI

loss of function features in osteosarcoma

limp

reduced joint movement

stiff back esp. child

treatment of osteosarcoma

surgery and chemotherapy

treatment of Ewings sarcoma

chemotherapy

surgery

radiotherapy

are cartilage tumours benign or malignant

benign but aggressive

what is the commonest soft tissue tumour

lipoma

suspicious signs that point to soft tissue malignancy and need to be referred to a specialist tumour centre

deep - deep to deep fascia tumour

subcutaneous growth >5cm

rapid growth

hard

craggy

non-tender

soft tissue tumour signs

•painless

•mass deep to deep fascia

•any mass >5cm

•any fixed, hard or indurated mass

•any recurrent mass

imaging study for soft tissue tumour

MRI

swelling of soft tissue - malignancy

suspicious until proven otherwise

- rapidly growing

- hard

- craggy

- fixed and indistinct margins

- non-tender to palpate but deep ache at night

- key be painless

what are the most to least common cancers to metastasise to bone

1. breast

2. lung

3. prostate

4. kidney

5. thyroid

6. GI

7. melanoma

what type of metastatic bone disease is more common: primary or secondary

secondary > primary

where does breast and melanoma commonly metastsise to?

breast to bone

melanoma to lung

order of frequency in sites for secondary metastatic bone disease

vertebrae

proximal femur

pelvis

ribs

sternum

skull

prevention of pathological fracture

early chemotherapy/DXT

prophylactic internal fixation

+- use of bone cement

embolisation

what is used for fracture risk assessment

mirel’s scoring system

when surgery is indicated for spinal metastases what is required

both decompression and stabilisation