rad III MT combo

how does metastasis affect MRI

-loss of normal bright marrow signal on T1 image

-dark on T1 and bright on T2

what is the MC contrast agent used on MRI

gadolinium

what is a contraindication for gadolinium

kidney pathology

what are the common metastasis locations

axial skeleton (40%)

ribs and sternum (12%)

pelvis (10%)

skull proximal long bones (10%)

what is acral metastasis

Metastasis distal to the elbows/knees

rare

what most commonly causes acral metastasis

primary tumor of lung, breast, or kidney

what determines metastasis location

hematopoietic potential

T/F: acral metastasis doesn't jump joint spaces

true (cartilage acts as a barrier)

what is the earliest sign of vertebral body metastasis

-subtle loss of density in contrast to adjacent vertebral bodies

-dark on T1 and bright on T2

what is a pathological compression fracture

loss of anterior and posterior vertebral body height

aka for pathological compression fracture

vertebra plana

universal compression fracture

pancake vertebra

what are the most common causes of pathological compression fracture

osteoporosis

metastatic disease

multiple myeloma

what is the most common cause of vertebra plana in children

eosinophilic granuloma

what is the top cause of lytic lesion in kids

eosinophilic granuloma

what can neoplastic weakening and destruction of the endplates cause

formation of malignant schmorl's node --> intrabody disc herniation

what can cause induced kyphosis

Vertebral body collapse (malignancy, infection, compression fx)

what is ivory vertebrae

whitening of VB

what 3 conditions are ivory vertebrae seen with

osteoblastic mets

paget's

hodgkin's lymphoma

what are the characteristics of ivory vertebrae with osteoblastic mets

normal size and shape with normal anterior body

over 40 years old

what are the characteristics of ivory vertebrae with paget's

enlarged vertebral body

squaring off of anterior body

bone softening

over 50 years old

what are the characteristics of ivory vertebrae with Hodgkin's lymphoma

anterior scalloping of vertebral body from enlarged lymph nodes

20-40 years old

at what stage does lymphoma spread to bone

stage 4

what is the most common cause of pedicle destruction

mets

what are the name signs of loss of pedicle cortical outline

one eyed pedicle sign

winking owl sign

blind vertebrae

where is pedicle destruction most common

lower thoracic spine

lumbar spine

what are the differentials for pedicle metastasis

congenital agenesis

destruction of pedicle from ABC, osteoblastoma

how do you differentiate congenital pedicel agenesis from pedicle mets

stress hypertrophy of opposite pedicle in congenital agenesis

how does multiple blastic lesions of the pelvis look

snowball appearance

what causes pelvis mets

seeding from viscera via batson's venous plexus

what imaging modality has higher detection rates than plain film for pelvis mets

CT

how does skull metastasis present

multiple, well-defined holes of various sizes without sclerotic border --> swiss cheese skull

what is the name sign for multiple myeloma in the skull

raindrop skull

how does metastasis appear in the ribs

permeative holes or blastic lesions

T/F: ribs are 4x more likely to be involved in metastasis than sternum

true

what name sign can be seen with metastasis of the ribs and sternum

extrapleural sign (cat under the rug)

how many shades of grey are there on xray

256

how many shades of grey are on CT

~2000

what is used to help locate metastatic lesion of ribs and sternum

CT

-bone window

-soft tissue window

-parenchymal window high resolution

why are the proximal extremities common sites of metastasis

rich marrow space and prominent vascular supply

what are the characteristics of proximal extremities metastasis

-blastic, lytic, or mixed with or without pathological fracture

-rarely crosses joint space

what is an example of a pathological fracture in the proximal extremities

non traumatic avulsion of the lesser trochanter

what erosion can be seen with proximal extremities metastasis

cookie bite erosion --> erosion of outer cortex

what is the most common cause of cookie bite erosion

mets from bronchogenic carcinoma

what is the normal prevertebral soft tissue measurement in front of C2

no more than 6 mm

what is the normal prevertebral soft tissue measurement in front of C6

no more than 22 mm

what are the 4 most common primary malignancies of bone

multiple myeloma

osteosarcoma

chondrosarcoma

ewing's sarcoma

which primary malignancies of bone are in older people

multiple myeloma (50-70 yo)

chondrosarcoma (40-60 yo)

which primary malignancies of bone are in young people

osteosarcoma (10-25 yo)

ewing's sarcoma (10-25 yo)

aka for multiple myeloma

kahler's disease

what is multiple myeloma

malignant proliferation of plasma cells in marrow

what are the characteristics of multiple myeloma

-secretion of monoclonal globulin (IgG)

-reversal of albumin to globulin ratio

-M spike in 90% of patients

-Bence jones proteinuria

-hyperuricemia

-hypercalcemia

-normochromic normocytic anemia, thrombocytopenia, elevated ESR

what could hyperuricemia in multiple myeloma patients lead to

gout

what is the normal albumin to globulin ratio

60 to 40

what is the gold standard for multiple myeloma diagnosis

sternal biopsy because of rich marrow center

what is the M spike

large amount of malignant immunoglobulin in blood

what is the most common presentation of multiple myeloma

low back pain and fatigue

worse during the day

what are clinical features of multiple myeloma

weight loss, cachexia, anemia, unexplained osteoporosis, renal disease

what may be the only early radiologic sign of multiple myeloma

generalized osteoporosis may be the only early sign

what are the later radiologic features in multiple myeloma

multiple punched out lesions of relatively even size, shape, and distribution

where is multiple myeloma seen

proximal humerus and femur

raindrop skull

pedicle sign (preservation of pedicles)

uniform compression fracture

True/false: mets and multiple myeloma also have osteoporosis

true

T/F: 90% of multiple myeloma have cold bone scan

true

what do plasma cells secrete with multiple myeloma

osteoclastic activating factor

T/F: mets doesn't like flat bone of mandible while multiple myeloma does

true

what is wrinkled vertebrae sign seen with

multiple myeloma

T/F: plasmacytoma is a solitary lesion

true

what is a localized form of multiple myeloma

Plasmacytoma

plasmacytoma has a predilection for _____

mandible, ilium, vertebrae, ribs, proximal femur, sacpula

what is the roentgen appearance of plasmacytoma

geographic lesion with expansile soap bubble internal architecture

well defined edges

slow growing

what are the differential diagnoses for bubble expansile lesion

aneurysmal bone cyst

giant cell tumor

plasmacytoma

what age group gets ABC

pre skeletal maturity: 10-25

what age group gets giant cell tumor

skeletal maturity: 20-50

what age gets plasmacytoma

older than 50

what is the 2nd most common primary malignant tumor of bone and the most common primary malignancy in children

osteosarcoma

where can 25% of osteosarcoma cases arise from

pre-existent disease such as paget's fibrous dysplasia, osteochondroma, or in a bone treated with radiation therapy

what are signs as symptoms of osteosarcoma

painful swelling

history of antecedent trauma --> calls attention to tumor

what are the 3 most common locations for osteosarcoma

distal femur

proximal tibia

proximal humerus

75% of osteosarcoma lesions are found in _____ of long bones

metaphysis

what is the most common location in 50% of cases with osteosarcoma

knee --> knee pain

T/F: an osteosarcoma metaphyseal lesion usually abuts the growth plate

true

when does osteosarcoma have the potential to cross the growth plate

if it is close to closing

50% of osteosarcoma lesions are _______

sclerotic

what is the name sign for roughened lobulated margin in sclerotic osteosarcoma lesions

cumulus cloud appearance

what are the rad features of osteosarcoma

metaphyseal ill defined

destroyed cortex

periosteal reaction

moth eaten and permeative lesion

dense sclerotic

soft tissue masses

what is the MC periosteal resopnse with osteosarcoma

sunburst, sunray

what does an MRI show for osteosarcoma

grossly abnormal

dark on T1 and bright on T2

what primary malignancies cause cannonball metastases

osteosarcoma

ewings

where does osteosarcoma commonly metastasize

lungs (75%)

bones (50%)

kidney (12%)

what must you order with osteosarcoma to check for lung metastasis

chest CT

what is the gold standard to diagnose and differentiate osteosarcoma from ewing's

biopsy

what is treatment for osteosarcoma

amputation or limb spring

chemo and radiation therapy

what does the 80% 5 year survival rate for osteosarcoma drop to with metastasis

15%

what is the 3rd most common primacy malignant bone tumor

chondrosarcoma

what can chondrosarcoma arise from

preexisting benign cartilagenous lesion such as osteochondroma or enchondroma

what age group is chondrosarcoma seen in

40-60 years old

chondrosarcoma is more prevalent in

Males

what are the signs of chondrosarcoma

pain

minor palpable swelling

(possibly asymptomatic)

which primary malignancy has hyperglycemia associated with it

chondrosarcoma

what causes hyperglycemia with chondrosarcoma

paraneoplastic syndrome from hormones produced that affect glucose metabolism

what are 50% of chondrosarcoma lesions found

pelvis, proximal femur

followed by: proximal humerus, ribs, scapula, distal femur, proximal tibia, sternum, hand, foot, spine, sacrum