di imaging II exam 3 malignant tumors

-oma ending meaning

tumor

tumor definition

lesion formed by an abnormal growth of cells

benign tumor

abnormal tissue masses which are not cancers

malignant tumor

synonymous with cancer and are usually named using -carcinoma, -sarcoma, or -blastoma

cancer

term used for disease in which abnormal cells divide without control and are able to invade other tissues

carcinoma

any malignant cancer that arises from epithelial cells

sarcoma

cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue

lymphoma and leukemia

malignancies derived from hematopoietic cells

blastoma

a tumor (usually malignant) which resemble an immature or embryonic tissue

metastasis

new tumors that appear far from the original tumor

geographic hole in bone

one big ol hole - least aggressive hole - “if i’ve gotta have one this would be it”

moth-eaten hole

multiple holes in bone that vary in size and shape

permeative holes

many small holes that invade the whole bone - ‘ugliest, most aggressive hole to have’

differential diagnosis by predictive factors

age, incidence, skeletal location, interosseous location, tumor appearance, clinical presentation

75% of malignancies are due to what?

metastatic disease

most common primary malignant tumor in adults is what?

multiple myeloma

most common primary malignant tumor in children?

osteosarcoma

most common benign osseous tumor?

osteochondroma

most common benign spinal tumor?

hemangioma

common locations in the skeleton for tumor growth?

hemopoietic tissue, notochordal remnants, areas of rapid bone growth, places of abundance of interosseous nerves

what is the zone of transition?

where good/healthy bone turns into bad/tumor ridden bone

geographic bone destruction

least aggressive pattern and usually presents as a solitary lesions larger than 1 cm - indicative of a slow growing lesion and has a short zone of transition (easily removable) - margin is well defined, can be smooth or lobulated

moth-eaten bone destruction

moderate degree of aggressiveness with numerous small holes ~2-5mm in size - longer zone of transition than geographic and margins are not well defined

permeative bone destruction

most aggressive growing lesions with numerous mall holes 1mm in size - wide zone of transition and poorly demarcated or imperceptible borders - could see cortical destruction

mnemonic for differential diagnosis of solitary lucent bone lesions

FOGMACHINES

fibrous dysplasia

occurs at any age - has no periosteal reaction

osteoblastoma

like and aneurysmal bone cyst - located in the spine

giant cell tumor

epiphysis is closed, epiphyseal location abuts articular surface - nonsclerotic margin

metastasis/myeloma

usually seen in those over age 40

aneurysmal bone cyst

expansile tumor that occurs in those under 30

chondroblastoma (chondromyxoid fibroma)

no calcified matrix - mention when considering non-ossifying fibroma

hyperparathyroidism (brown tumors)/hemangioma

look for other signs of hyperparathyroidism if suspecting this

infection

always included in differential - history will help if suspecting this

non-ossiyfing fibroma

usually occurs in those under 30 and is juxtacortical

eosinophilic granuloma/enchondroma

occur in those under 30 - calcified matrix (except in phalanges)

solitary bone cyst

usually occur in those under 30 and centrally in the bone

cortical changes to look for

buttressing/thickening, endosteal scalloping (erosion of inner cortex), splitting or tunneling, thinning with or without expansion, penetration with or without periosteal reaction

periosteum

membrane that lines the outer surface of all bones, except area covered by articular cartilage

periosteal reaction

formation of new bone in response to injury or other stimuli of the periosteum surrounding the bone

patterns of periosteal reactions

buttressing, single layer, multiple layers/laminated/onion-skinned, spiculated, codman’s triangle (the worst)

buttressing/solid periosteal reaction

when additional layers of new bone are added to the exterior creating an expanded osseous contour - usually associated with slow growing, benign lesions - can look similar to stress fracture so make sure to check for breaks as well

laminated/layered/onion skin periosteal reaction

multiple layers of new bone - alternating layers of lucency and opacity with alternating growth - can be thin or thick - can be seen in slow or aggressive lesions, classically associated with Ewing’s though

spiculated periosteal reaction

linear radiating spicules of new bone - when perpendicular to the bone is known as ‘hair on end’ - when radiating from a central focus it’s ‘sunburst’ - often associated with highly aggressive lesions such as osteosarcoma

codman’s triangle

a triangular elevation of periosteum seen as the peripheral lesion-cortex junction - one of the most aggressive forms of periosteal reaction but may also be seen with benign tumors, infections, or other disorders

cartilaginous matrix

can be ring or arc like, flocculent, small crystals, popcorn like, stippled

benign tumors with cartilaginous matrix

enchondroma, osteochondroma, chondroblastoma, chondromyxoid fibroma

malignant tumor with cartilaginous matrix

chondrosarcoma

what is the most common benign cartilaginous tumor in the hand?

enchondroma

osseous matrix

variable size radiodense areas - may occupy parts of or entire lesion - can be homogenous or inhomogenous with increased density changes/sclerosis

benign tumors with osseous matrix

osteoma, osteoblastoma, osteochondroma, osteoid osteoma

malignant tumor with osseous matrix

osteosarcoma

benign tumors with fibrous matrix

fibrous dysplasia, desmoplastic fibroma, non-ossifying fibroma, fibrous cortical defect, ossifying fibroma

malignant tumor with fibrous matric

fibrosarcoma

primary bone neoplasia

bone tumor starts in the bones - typically will see bone expansion, lesions over 6cm periosteal reactions, and the presence of a soft tissue mass

secondary bone neoplasia

metastatic - begins in another part of the body and spreads to the bone -far more common and often originate from cancers like breast, lung, or prostate - typically won’t see bone expansion, lesion sizes under 6cm, and multiple/numerous lesions

what is the third most common site of metastatic disease?

bone (usually from breast, prostate, or lung cancer - via hematogenous spread)

metastatic bone disease

arises from a primary extra-skeletal site - represents 70% of all malignancies, most common primary sites are breast, prostate, lung, kidney, thyroid, and bowel - may either be blastic, lytic, mixed, or expansile

primary site of origin for metastasis in females

breast cancer is most common with 80% being lytic and 10% blastic

primary site of origin for metastasis in males

prostate is the most common with 80% being blastic

is lunch cancer mostly lytic or blastic?

lytic

pathways of metastasis

hematogenous dissemination (blood) is the most common at times via vertebral/barton’s venous plexus - lymphatic dissemination - direct extension

possible serologic findings for metastatic disease

ESR, serum calcium, alkaline phosphatase (blastic), acid phosphates and/or PSA antigen (prostate), serum protein, A/G ratio, protein electrophoresis

clinical features of metastatic disease

most patients are past 4th decade of life - may have recent weight loss, appear cachetic, anemic, and with fever - initial sign may be pain and pathologic fracture - pain is usually persistent and nocturnal

what’s acral metastasis and what is it likely due to?

lytic metastasis distal to elbow and knees (most common in hands/feet) - most likely to be seen with primary lung cancer

osteolytic metastasis

caused by tumor activation of osteoclasts and pressure form the proliferating neoplasm on surrounding trabecular structures and cortices that create the osteolytic lesion - the trabeculation is being resorbed as the marrow is replaced by neoplastic tissue

osteoblastic metastasis

increased density in osteoblastic metastasis is due to laying down of new bone, which is non-neoplastic, and is reactive response to the tumor

when would you see blow-out metastasis?

with renal and thyroid cancers - soap bubbly appearance

radiographic features of vertebral metastasis

ivory vertebra, pedicle destruction, pathologic collapse, focal osteoporosis of a body, malignant schmorl’s node formation

reasons for why a pedicle would be missing

congenitally absent, destructive (tumor - primary bone tumor ABC, osteoblastoma - soft tissue tumor neurofibroma - secondary tumor lytic metastasis - infection), surgical

reasons for pathologic collapse/fracture in adults

osteoporosis (traumatic fracture), lytic metastasis carcinoma, multiple myeloma, paget’s disease, infection

reasons for pathologic collapse/fracture in kids

eosinophilic granuloma (histiocytes ted to conglomerate to form erosive and expanding lesions)

steps for when lab results look like it’s lytic mets

bone scane, MRI (anything that has a hot spot from the bone scan), biopsy - PET scan can happen at any point

steps for when lab results look like it’s multiple myeloma

PEP (looking for M spike), skeletal survey, MRI, biopsy (looking for >10% plasma cells)

solitary ivory vertebra causes

paget’s disease. hodgkin’s lymphoma (more common to occur with this than non-hodgkin’s), osteoblastic metastasis, osteomyelitis (fungal or chronic), degenerative sclerosis, idiopathic

if someone between the ages 20-40 has an ivory vertebra, what should you think of first as a diagnosis?

lymphoma (the other 2 don’t really happen in this age range)

if you see multiple ivory vertebrae, what should you think?

blastic metastasis

what’s a bone island?

an area of well-differentiated mature bone tissue within the marrow - also referred to as enostosis/enostoma - osseous matrix - can occur in any bones and can come and go away - sometimes borders can look like tumors so got to be careful with these (if patient is old enough for blastic metastasis to occur, then make sure it’s not that before saying it is this)

osteopoikilosis

multiple bone islands - tends to occur in the pubic rami and femoral head areas

what would be the course of action if blastic metastasis is possible when you see a bone island?

a BCP to include alkaline and acid phosphatase levels as well as a PSA and DRE - look at old film if possible too

MRI characteristics of metastasis

T1 is most sensitive (low signal), T2 is variable (high signal), Nh Proton Density (lesion hiding)

nonpathological fracture and degenerative MRI characteristics of metastasis

signal is linear, low T1, high T2 (edema or hemorrhage), Type I = II - III endplate changes

T1 rule of thumb

white is right concerning bone marrow on a T1 weighted MRI

primary malignant neoplasia

accounts for 30% of all malignancies - most common is multiple myeloma, followed by osteosarcoma, chondrosarcoma, and ewing’s sarcoma

what’s the most common primary malignant tumor in kids?

osteosarcoma and then ewing's ???/

multiple myeloma

malignant proliferation of plasma cells (B cells so immunoglobulins here) which infiltrates the bone marrow - most common primary malignant bone tumor and accounts for ~27% of biopsied bone tumors - >10% of hematologic malignancies, 3rd most prevalent blood cancer

clinical features of multiple myeloma (demographics)

usually in 5th-8th decade (75% between 50-70) - malignant proliferation of plasma cells with an unknown etiology - one of the round cell tumors - 2:1 M:F ratio - twice as common in African Americans, lowest in Asian Americans - tend to succumb to lung or renal problems

round cell tumors

multiple myeloma, ewing’s, non-hodgkin’s lymphoma - these have round nuclei and are rounded lesions, like to get diaphysis of long bones

clinical features of multiple myeloma (signs and symptoms)

(bone) pain is the initial cardinal symptom - unexplained weight loss and cachexia - bacterial infections (particularly respiratory) - anemia, renal disease, respiratory disease, deossification of bone, production of abnormal serum and urinary proteins (bence jones tend to be found in most cases)

why do people with multiple myeloma have kidney problems?

one of the immunoglobulins is being mass produced and chucked into the blood which is hard on the kidney - calcium is also getting dumped into blood stream from deossifying bone which is hard on the kidneys

laboratory findings of multiple myeloma

elevated ESR, thrombocytopenia, rouleaux formation (like L’s), increased serum calcium, normal to increased serum phosphorus - elevated plasma proteins in 5-60% of cases, hyperglobulinemia with reversed albumin to globulin ratio - protein electrophoresis with M spike confirmatory in 80-90% of cases, monoclonal globulin production (Ig_), bence jones proteinuria in 40% of cases, uric acid maybe elevated, bone marrow biopsy shows >10% plasma cells

CRAB mnemonic to remember the common tetrad of multiple myeloma

calcium (elevated), renal failure (increased BUN and creatinine), anemia, bone lesions

remember what hypercalcemia can causes? (cause you’ll likely see it in patients with multiple myeloma)

nausea, confusion, constipation, polyuria, and fatigue

what are the most common cancers associated with hypercalcemia?

breast, lung, and multiple myeloma

skeletal locations for multiple myeloma

areas high in red marrow (like lytic metastasis) = vertebrae (thoracic and lumbars), pelvis, skulls, ribs, clavicle, scapula, femur, and humerus

what’s another name for multiple myeloma? (might be on boards)

Kahler’s disease

solitary plasmacytoma

localized form of plasma cell proliferation - in order of most common to least location wise: vertebra, pelvis, skull, sternum, ribs - typically presents as soap bubbly and highly expansile lesion - sparing of the posterior column elements - 70% will develop into diffuse multiple myeloma form

radiologic features of multiple myeloma

conventional radiography (xrays are good), circumscribed osteolytic defects (punched out), bone scans may be normal (osteoclastic activity predominates), MRI examination sensitive for marrow changes, osteoporosis/osteopenia is most common thing to be seen, osteolytic defects in calvarium imaging (rain drop skull), osteoblastic lesions are rare <3% of cases

MRI findings for myeloma

diffuse low T1, iso (no change/normal) to increased T2 changes (use STIR), pathological fractures/, multiple wedge compression fractures, little soft tissue mass - should use contrast enhanced T1 for MM detection

treatment and prognosis for multiple myeloma

often palliative treatment, chemotherapy, radiotherapy, hydration and ambulation, 5 year survival rate is 20%

osteosarcoma

primary malignant tumor of undifferentiated connective tissue which forms neoplastic osteoid - 2nd most common primary malignant bone tumor overall - most common primary malignant bone tumor in children and young adults - unknown etiology