1	Case Correlations OSCE Review TUMORS
2	How to approach tumors: Pay attention to hx: age of patient Analyzing the lesion: location metaphyseal, epiphyseal, diaphyseal type of tisssue involved position of lesion in transverse plane: Soft tissue Medullary Cortical Periosteal
3	How to approach tumors: Analyzing the lesion: pattern of destruction lytic vs blastic vs mixed aggressiveness periosteal reactions matrix of lesion osseous, cartilage or fibrous
4	Case 1
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6	Metastatic Bone Disease From another primary site 70% of all malignancies. Either lytic or blastic breast, prostate, lung and kidney.
7	Metastatic Disease most patients 4th decade weight loss anemic pain and pathological fracture as initial finding
8	Metastatic Disease What is the MC primary sites in males and females? female: breast cancer male: prostate cancer primary from lung is the 2^nd MC primary site in both males and females What is the pattern of bone destruction in metastatic disease from the primaries above? mets from breast: 80% lytic 10% blastic mets from prostate: 80% to 90% blastic mets from lung: mainly lytic
9	What other imaging can you use and what are their advantages over plain film? bone scan CT /MRI
10	Bone Scan Accurate Sensitive (4%-ve) Inexpensive Whole body scan for other mets sites Generally available
11	MRI most sensitive expensive no whole body scan tumor staging
12	CT bone anatomy tumor staging
13	Case 2
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15	"Primary malignancies are 30%" Primary malignancies are 30% of all malignancies most common is multiple myeloma (27% of all malignancies) Others: osteosarcoma chondrosarcoma Ewing’s sarcoma
16	Multiple Myeloma malignant proliferation of plasma cells usually 50-70 years of age M:F ratio is 2:1 may show anemia, osteoporosis, renal disease Why does multiple myeloma cause renal disease ? Bence-Jones protein in 40% (IgG and IgA most commonly elevated)
17	Case 3
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19	Osteosarcoma Primary malignant tumor of bone 2 age ranges of incidence: 1) 10-25 years of age 2) over 60 years of age 75% in 10-25 year range 2:1 male predominance painful swelling of involved site
20	What is a perisosteal reaction? Continous benign Discontinous malignant and aggressive Laminated (onion skin) Radiating, spiculated (sunburst)
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23	Case 4
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25	Chondrosarcoma age of presentation is 40-60 years of age development of large soft tissue mass metaphyseal or diaphyseal location “popcorn” matrix in 66%; laminated or spiculated periosteal reaction
26	Case 5
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29	Ewing’s Sarcoma 4th most common primary malignant tumor localized pain and swelling at the site symptoms may simulate an infection involves femur, tibia and fibula most commonly WBC’s may be elevated
30	Radiology typically diaphyseal permeative bone destruction with “onion skin” periosteal rxn cortical “saucerization” (beveling) is characteristic
31	Case 6
32	Giant Cell Tumor metaphysis subarticular location radiolucent eccentric “soap bubble” radiological differentiation of benign and malignant is not feasible
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34	Hemangioma blood vessel lesion mc benign of the spine vertical corduroy cloth appearance
35	Case 8
36	Osteochondroma bony exostosis 75% occur below 20 years of age pedunculated sessile A.K.A. “coathanger” exostosis.
37	What is the name of the condition where there are multiple osteochondroma? Hereditary multiple exostosis (HME) or diaphyseal aclasis usuaIly found between 2 and 10 years knees, shoulders, forearms commonly involved familial chance of malignancy is increased to 20%
38	Case 9
39	Simple Bone Cyst A fluid-filled cyst 75% found in the proximal humerus and femur expansile geographic defect centrally located “fallen fragment” sign
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41	Aneurysmal Bone Cyst A non-neoplastic solitary lesion filled with blood-antecedent history of trauma age range is 5-20 years of age 60% occur in females 80% found in femur, tibia and spine spinal ABC primarily involves the neural arch
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43	Enchondroma the most common benign tumor of the hand usually involves distal skeleton geographic, possibly expansile lytic lesion stippled or punctate calcification
44	What is the name of the disease where there are multiple enchondromas? Ollier’s disease/multiple enchondromatosis metacarpals and phalanges greater chance of malignancy malignant degeneration to chondrosarcoma
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46	Osteoid Osteoma produces pain-worse at night: very intense-relieved by aspirin predisposed to neural arch DDx aneurysmal bone cyst and osteoblastoma the tumor = nidus usually evokes a sclerotic response
47	Case 13
48	Non-Ossifying Fibroma Represents faulty ossification of bone are solitary, radiolucent, eccentric large lesions may weaken bone has a dense rim and short zone of transition histiologically and radiographically similar to fibrous dysplasia Fibrous Cortical Defect A small non-ossifying fibroma
49	Case 14
50	Tumor-like Diseases Paget’s Disease (Osteitis Deformans) >40 yoa, 2:1 male prevalence Symptoms vary Etiology unknown Recent studies suggest a slow viral infection Lab findings: + Alkaline Phosphatase + urinary hydroxyproline excretion Hypercalcemia, hypercalciuria
51	Paget’s Disease Radiology: Location: -Pelvis sacrum -Femur -Skull -tibia -vertebra -& others Stages: Osteolytic Mixed Sclerotic/Ivory Malignant Degeneration
52	Paget’s Disease Radiology: -changes in bone density -cortical thickening -bone expansion -coarsened trabeculae -bowing deformities -protrusio acetabuli, basilar impression -pathological fracture
53	Paget’s Disease Complications: Urinary calculi Cranial nerve palsy High output heart failure Malignant degeneration Rare <40 yoa MC in femur Types: osteosarcoma, fibrosarcoma, chondrosarcoma
54	Case 15
55	Case 15
56	Case 16
57	Case 17
58	Case 18
59	Case 19
60	Case 20
61	Case 21
62	Case 22
63	Case 23
64	Case 24
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