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Toronto Notes 2019 Bone Tumours
• radiographicfindings
■ characteristic periosteal reaction: Codman’s triangle (Figure 56) or “sunburst” spicule formation
(tumour extension into periosteum)
■ destructive lesion in metaphysis may cross epiphyseal plate
• management:completeresection(limbsalvage,rarelyamputation),neo-adjuvantchemo;bonescan– rule out skeletal metastases, CT chest – rule out pulmonary metastases
• prognosis:70%survival(high-grade);90%survival(low-grade)
Chondrosarcoma
• malignantchondrogenictumour
• primary(2/3cases)
■ previous normal bone, patient >40 yr; expands into cortex to cause pain, pathological fracture
• secondary(1/3cases)
■ malignant degeneration of pre-existing cartilage tumour such as enchondroma or osteochondroma
■ age range 25-45 yr, better prognosis than primary chondrosarcoma
• symptoms:progressivepain,uncommonlypalpablemass
• radiographicfindings:inmedullarycavity,irregular“popcorn”calcification
• treatment:unresponsivetochemotherapy,treatwithaggressivesurgicalresection+reconstruction;
regular follow-up X-rays of resection site and chest
• prognosis:10yrsurvival90%forlow-grade,20-40%forhigh-grade
Ewing’s Sarcoma
• malignant,smallroundcellsarcoma
• mostoccurbetween5-25yrold
• floridperiostealreactioninmetaphysesoflongbonewithdiaphysealextension
• metastasesfrequentwithouttreatment
• signs/symptoms:presentswithpain,mildfever,erythema,andswelling;anemia,increasedWBC,ESR,
LDH (mimics an infection)
• radiographicfindings:moth-eatenappearancewithperiosteallamellatedpattern(“onion-skinning”) • treatment: resection, chemotherapy, radiation
• prognosis–70%survival,worstprognosticfactorisdistantmetastases
Multiple Myeloma
• proliferationofneoplasticplasmacells
• mostcommonprimarymalignanttumourofboneinadults(~43%)
• 90%occurinpeople>40yrold,M:F=2:1;twiceascommoninAfrican-Americans
• signs/symptoms:localizedbonepain(cardinalearlysymptom),compression/pathologicalfractures,
renal failure, nephritis, high incidence of infections (e.g. pyelonephritis/pneumonia), systemic
(weakness, weight loss, anorexia)
• labs: anemia, thrombocytopenia, increased ESR, hypercalcemia, increased Cr
• radiographicfindings:multiple,“punched-out”well-demarcatedlesions,nosurroundingsclerosis,
marked bone expansion • diagnosis
■ serum/urine immunoelectrophoresis (monoclonal gammopathy)
■ CT-guided biopsy of lytic lesions at multiple bony sites
• treatment:chemotherapy,bisphosphonates,radiation,surgeryforsymptomaticlesionsorimpending
fractures – debulking, internal fixation
• prognosis:5yrsurvival30%;10yrsurvival11% • seeHematology,H49
Bone Metastases
• mostcommoncauseofbonelesionsinadults;typicallyage>40
• 2/3frombreastorprostate;alsoconsiderthyroid,lung,kidney
• usuallyosteolytic;prostateoccasionallyosteoblastic
• maypresentwithmechanicalpainand/ornightpain,pathologicalfracture,hypercalcemia • bonescanforMSKinvolvement,MRIforspinalinvolvementmaybehelpful
• treatment:paincontrol,bisphosphonates,stabilizationofimpendingfracturesifMirel’sCritera>8 (ORIF, IM rod, bone cement)
Table 27. Mirel’s Criteria for Impending Fracture Risk and Prophylactic Internal Fixation
Orthopedics OR49
Figure 60. X-ray of femur chondrosarcoma
Signs of Hypercalcemia
“Bones, Stones, Moans, Groans, Psychiatric overtones”
CNS: headache, confusion, irritability, blurred vision
GI: N/V, abdominal pain, constipation, weight loss
MSK: fatigue, weakness, unsteady gait, bone and joint pain
GU: nocturia, polydipsia, polyuria, UTIs
Most Common Tumours Metastatic to Bone
Breast Lung
Kidney
Thyroid
Melanoma
Prostate
Breast Lung
Kidney
Variable
Number Assigned
Lower extremity Moderate Mixed
1/3-2/3 diameter
Site Upper arm
Pain Mild
Lesion Blastic
Size <1/3 bone diameter
BLT with a Kosher Pickle Breast
Lung
Thyroid
Kidney Prostate
1
2
3
Peritrochanteric Severe
Lytic
>2/3 diameter