Tumors of Bone

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Tumors of Bone

• Patrick Henderson, M-IV
• USCSOM
• August 28, 2007

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Intro

• Bone tumors are very diverse in morphology and
  biological potential (can be no big deal or
  rapidly fatal)
• MOST bone tumors are benign lesions
• Most benign lesions are seen lt30 years of age
• A new bone tumor in the elderly is more likely to
  be malignant
• No bone is safe (though most primaries are in
  long bones)
• Locale in the bone gives important Dx info
• More common benign lesions typically present as
  incidental findings (non-painful, stable size)
• Be cautious with painful lesions and those that
  grow relatively fast (over weeks or months)
• Pathological fracture can be the first sign of
  tumor

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• Bone neoplasms are very difficult to diagnose
  specifically on radiologic testing alone
• So why is radiology important?
• Exact location of lesion
• Extent of growth/metastasis
• Aggressiveness
• Best test for Dx X-ray
• Best test for staging CT or MRI
• Quick shout out to the pathologists histologic
  grade is the most important prognostic feature of
  bone sarcomas and essential for staging most of
  the bone tumor types.

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CasesFind the lesion
Example
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CasesFind the lesion
Example
RIGHT THERE!
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Case I

• 16 yr old white male with pain in his left upper
  arm.
• Mild swelling and tenderness
• Pain progressively getting worse for 3 months
• Recent onset of mild fever

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Imaging
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Imaging

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Biopsy material showed a highly cellular,
infiltrative neoplasm consisting of sheets of
tightly packed, round cells with very scant
cytoplasm ("round blue cell tumor"). Occasional
Homer-Wright rosettes were identified. Other
fields showed extensive necrosis.
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Dx Ewings Sarcoma (or PNET)

• 2 primary bone malignancy in kids (5-15 is most
  common age group
• Much more common in Caucasians
• Typically in the diaphysis of long tubular bones
  or in large flat bone
• Lytic tumor w/ permeative margins extending into
  the soft tissue
• Periostial rxn creates sheets of reactive bone in
  an onion-skin fashion

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Another most excellent example of onion-skinning
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Case II

• 33 yr old black female with sudden severe hand
  pain after very minor trauma.
• Completely healthy otherwise.
• All labs normal

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Dx Enchondroma

• Benign cartilagenous tumors but hard to
  distinguish from a low grade chondrosarcoma
• Acral bones-- the most common primary hand tumor
• Usually solitary, usually incidental finding
  (non-painful unless associated with fracture)
• Get hand films and look for dec. lucency but not
  so much as a cyst (more ground-glass) w/ or w/o
  areas of stippled calcifications or rings

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For boards and wards

• Multiple enchondromas ____________
• Multiple enchondromas hemanigiomas of soft
  tissue _____________

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For boards and wards

• Multiple enchondromas Olliers Dz
• Multiple enchondromas hemangiomas of soft
  tissue Maffucci syndrome

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Case III

• 50 yr old white male with back pain
• Mainly lower spine/sacral pain, progressive 8
  months
• New onset rectal pain and constipation

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CT guided FNA confirmed
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Dx Chordoma

• Arises from notochord remnants. Thus is typically
  midline along the spine and usually at the ends
  (Sacrococc or occ/cervical jxn)
• MalesgtFemales, middle age
• staining w/ S-100 and epithelial markers
• Locally invasive until very late in disease where
  mets can go to the lungs, LN, skin.

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Case IV

• 21 yr old male with new onset chest pain today,
  worse on inhalation.
• ROS significant for an ongoing aching leg pain
  for the past 6 months which he has put off seeing
  a doctor for.

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Dx The dreaded Osteosarcoma

• 1 primary bone malignancy
• Associated with RB1 and p53 gene mutations
• 1000x greater risk w/ Hx of hereditary
  retinoblastoma
• Member of the Li-Fraumeni Syndrome family
• Bimodal age spike young and elderly
• 75 ltage 20
• Osteosarcoma in elderly usually from predisposing
  mechanism (secondary)
• Paget Dz, bone infarcts, history of radiation,
  etc
• Most patients die from pulmonary complications
  after metastatic seeding of the lungs (ex
  pneumothorax)

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• Metaphysial tumor
• 60 at the knee (distal femur or prox tibia)
• Radiographic terms to know
• Codmans Triangle
• Sunburst periostial formation
• AKA Hair on end

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For the future Surgeons

• Rotationplasty is a new solution to disfiguring
  surgical resections of lower limb sarcomas

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Quick Hits
Gout
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• Incidental finding on knee xray

Fabella posterior sesmoids or little confused
knee caps
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13 yr old boy with superior tibial pain, r/o
neoplasm w/ xray shows
Osgood Schlatter
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Metastatic Disease

• Most common malignant lesion of bone
• Bone is 3 on the list of favorite places for
  mobile cancers to go
• Malignant lesions are more likely to be in axial
  bones
• Typically multifocal BUT renal and thyroid
  carcinomas are notorious for producing only a
  solitary lesion
• Can be lytic, blastic, or both
• Lung is Lytic, Prostate Produces, Breast does Both

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Mets (cont)

• Adults
• Lung
• Prostate
• Breast
• Kidney

• Kids
• NB
• Wilms
• OS
• Ewings
• Rhabdomyosarcoma

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The End
Thanks for your attention and good luck on
applications!
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Bibliography

• Robbins and Cotran, Pathological Basis of
  Disease, 7th Edition
• MD Murphey, MR Robbin, GA McRae, DJ Flemming, HT
  Temple, and MJ KransdorfThe Many Faces of
  Osteosarcoma RadioGraphics 1997 17 1205
• William R. Reinus, Louis A. Gilula IESS
  CommitteeRadiology of Ewing's sarcoma
  Intergroup Ewing's Sarcoma Study
  (IESS)RadioGraphics 1984 4 929-944.
• Washington Univ. in St. Louis (website)
• Harvard Medical School (website)
• Learning Radiology.com (website duh)
• Bonetumor.org (Youre not even reading this are
  you?)