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Primary Benign bone forming tumors
- Tumor originates in bone
- Tumor formed from bone cells
- Benign-controlled cell growth
- All start with osteo
- Osteoma
- Osteoid Osteoma
- Osteoblastoma
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Malignant bone forming tumors
- Uncontrolled bone cell growth
- Horrible prognosis
- All called Osteosarcomas
- Conventional osteosarcoma- 72%, Central sclerotic~75%, lytic~25%
- Parosteal- 4%
- Periosteal-1%
- Multifocal/osteosarcmatosis-1%
- Osteosarcoma of jaw-6%
- Post radiation osteosarcoma-4%
- Osteosarcoma in paget's dx-3%
- Osteosarcoma degeneration from benign condition-1%
- Telangiectatic-3%
- Dedifferentiated chondrosarcoma-3%
- Extraskeletal-<1%
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Cartilage forming tumor
- Tumor formed from cartilage cells
- Cartilage growing in wrong place
- Cartilage normally forms physis & articular cartilage
- Has chondro in name
- ALWAYS radiolucent- dark
- May have some calcium mixed in
- Fondness for calcium
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Benign cartilage forming tumors
- Chondroma/Enchondroma
- Solitary osteochondroma
- Chondromyxoid Fibroma/Fibromyxoid chondroma
- Chondroblastoma
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Malignant cartilage forming tumors
- Uncontrolled cartilage cell growth
- 3 types
- Primary chondrosarcoma- arise de novo-originates by itself
- -1/3 of chondrosarcomas
- Secondary chondrosarcoma-from pre-existing benign tumor(2/3)
- -central chondrosarcoma-from enchondroma
- -peripheral - from osteochondroma
- Clear cell chondrosarcoma- mistaken fro chondroblastoma, low grade
- Extra skeletal chondrosarcoma- rare
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Giant cell tumor of bone/osteoclastoma
Exists on its own- quasimalignant
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Marrow tumors (Round cell tumors)
- ALL malignant
- Ewings sarcoma
- NHL of bone/Reticulum cell carcinoma
- Multiple Myeloma
- -classical
- -myelomatosis
- -plasmacytoma
- -Extra osseous MM
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Vascular & Connective tissue tumors
- Benign- hemangioma
- Malignant-fibrosarcoma
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Notochord remnant tumor
Chordoma
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Metastatic tumors in bone
- MC skeletal malignancy
- Tumor originates external to bone
- Spread of tumors from one place to another
- 3 mechanisms of cancer cell spread
- -Blood-hematogenous-MC mechanism of spread & MC spread to skeleton
- -Lymphatic system
- -Contiguous direct extension
- Always malignant (MC malignant bone tumor)
- Osteolytic mets
- Osteoblastic mets
- Mixed mets
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Tumorlike Conditions
- Mimics tumor based on radiographic appearance
- -geographic radiolucent-dark
- -well defined
- -sclerotic margin (thin or thick)
- -short zone of transition
- Solitary bone cyst/Unicameral bone cyst
- Aneurysmal bone cyst
- Fibrous cortical defect & nonossifying fibroma
- Fibrous dysplasia
- "Brown Tumor" of hyperparathyroidism
- Pseudotumors of hemophilia
- Large arthritic cysts/geode
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ABC's of how to look at a film
- Alignment
- -articular alignment
- -bone alignment
- Bone
- -periosteal rxn
- -trabeculation
- -pattern of bone destruction
- -shape change
- -bone density
- Cartilage
- -joint space (uniform or nonuniform)
- -symmetry (bilateral or unilateral)
- Soft tissue
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CATBITES
- Where we go looking for answers
- Major categories of bone & joint disease
- Congenital
- Arthritis
- Trauma
- Blood
- Infection
- Tumor
- Endocrine, nutritional, metabolic
- Soft tissue
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Tumor
- aka Neoplasm
- Cellular growth
- Benign- controlled cellular growth
- Malignant- uncontrolled cellular growth- spreads from somewhere else- metastasis
- Bone is multicellular tissue
- Any cell can produce a tumor
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Skeletal metastasis
- Doesn't kill
- Makes miserable-painful with secondary major complications
- Metastatic- spreads somewhere else
- No benign metastatic tumors
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Tumor like
- Looks like tumor but not
- Mimics tumor based on radiographic appearance
- Geographic radiolucent-dark
- Well defined
- Sclerotic margin- thin or thick
- Short zone of transition
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Osteoma
- Common tumor-#3 benign tumor
- Intramembranous origin- skull, cranial vault
- -favorite area- paranasal sinus
- Asymptomatic-no pain
- Frequency- see 1/year
- Originate from & project AWAY from cortical surface
- Never in medullary cavity
- Dense sclerotic lesion
- Usually solitary
- Can be multipe- Gardner's syndrome
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Osteoid Osteoma
- Less common
- Symptomatic-very painful
- Radiolucent
- Less than 2cm in size
- 10-15% in spine
- Can be medullary, cortical, or subperiosteal
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Osteoblastoma
- Rarest of 3 benign tumors
- Symptomatic
- 33-50% in spine
- Like appendages of posterior arch- TP, SP, AP
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Central Osteosarcoma
- Located in medullary cavity
- 70-72%
- Teenager patient group
- -sclerotic central osteosarcoma 75% of central type
- -lytic central osteosarcoma
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Parosteal osteosarcoma
- par= around
- Surface variant
- 4% of osteosarcoma
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Periosteal osteosarcoma
- Surface variant
- 1% of osteosarcomas
- Reasonable prognosis
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Osteosarcomatosis
- Multifocal variant
- 1% of osteosarcoma
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Osteosarcoma of Jaw
- 6% of osteosarcoma
- Older patient group- 30-40yoa
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Post-radiation Osteosarcoma
- 4% of osteosarcoma
- Due to therapeutic radiation- 3-4000 rad x 5 days x 6 weeks
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Osteosarcoma from Paget's Disease
3% of Osteosarcomas
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Osteosarcoma from degeneration of previous benign lesions
- 1% of osteosarcoma
- i.e. fibrous dysplasia become OS
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Telangiectatic Osteosarcoma
- Vascular dilation
- 3% of osteosarcoma
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Dedifferentiated Osteosarcoma
- Pathologist has difficulty differentiating its origin
- 3% of osteosarcomas
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Chondroma
- aka Enchondroma
- Ectopic cartilage growing in wrong place
- Can be medullary- enchondroma
- Can be cortical- juxtacortical or cortical chondroma
- #2 benign bone tumor
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Solitary osteochondroma
- aka Exostosis
- Cartilage is dominant part but contains bone
- Ectopic epiphyseal tissue growing in wrong place- part of physis
- Project away from bone
- #1 benign bone tumor
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Chondromyxoid fibroma
- aka fibromyxoid fibroma
- Junk tumor- mucus, cartilage, fibrous tissue
- Loves tibia
- Symptomatic- very painful
- Uncommon
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Chondroblastoma
- Epiphysis is common region- bone ends
- Also apophyseal areas
- Symptomatic-very painful
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Central Chondrosarcoma
- Inside bone- medullary
- Originate from enchondroma
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Peripheral Chondrosarcoma
- External to bone-cortical
- Originate from solitary osteochondroma
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Giant cell tumor
- aka Osteoclastoma
- Soap bubble appearance
- Radiolucent-dark
- Classic geographic
- Love metaphysis & epiphyseal area of long tubular bone
- Symptomatic- painful
- 80% benign
- Quasi-malignant
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Ewing tumor
- Laminated periosteal reaction
- Under 30 yo
- Typically teenagers
- Can not generate bone
- No affinity for calcium
- Purely radiolucent-dark
- MC malignant tumor in first decade
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Primary reticulum cell sarcoma
- aka non-Hodgkin's Lymphoma
- Lymphatically derived tumor originating in skeleton
- Classified as extra-nodal lymphoma
- Uncommon
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Multiple myeloma
- punched out lesion
- raindrop skull
- MC primary malignant bone tumor
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Solitary plasmacytoma
- subtype of MM
- Geographic soap bubble lesion
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Myelomatosis
- Subtype of MM
- Lose bone density-osteopenia (>40 widespread osteopenia)
- More common
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Classic Multiple Myeloma
- Subtype of MM
- Punched out lesion, small, <2cm, well defined, radiolucent
- MC
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Extraosseous Multiple Myeloma
- Subtype of MM
- Very rare
- Occurs in nasopharynx
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Metabolic bone disease causing diffused osteopenia
- Osteoporosis
- Hyperparathyroidism
- Osteomalacia
- Neoplasm
- -Children-leukemia (MC cause of bone loss in children)
- -Adult- MM
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Top 3 benign bone tumors
- 1. Solitary osteochondroma
- 2. Chondroma
- 3. Osteoma
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Top 5 Primary Malignant Bone Tumors
- MOCEF
- 1. MM (30/million)
- 2. Osteosarcoma (4-5/million)
- 3. Chondrosarcoma
- 4. Ewing's sarcoma
- 5. Fibrosarcoma (1.5/million)
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Hemangioma
- Common
- Occurs in many places
- Spine is common site
- Not much in differential
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Fibrosarcoma
- Very rare
- #5 primary malignant bone tumor
- Purely lucent- dark
- Destructive
- Can not generate bone
- No affinity for calcium
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Chordoma
- Originate from remnants of notochord
- Site specific- spine, coccyx, sacrum
- MC- clivus of Blumenbach of skull
- Likes cervicals also- C2 body (3rd MC place)
- Destructive
- Slow growing
- Malignant
- Middle age
- Fairly rare
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Solitary bone cyst
- aka Unicameral bone cyst
- asymptomatic- no pain
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Aneurysmal bone cyst
Symptomatic-painful
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Enosteoma
- aka Bone island
- Similar to osteoma
- Always found in medullary cavity
- Dense sclerotic lesion
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Preferential site of origin
- Most occur in metaphysis
- Diaphysis
- -Marrow tumor-marrow is first thing that changes
- --Myelom
- --Ewing's sarcoma
- --Reticulum-cell carcinoma- non-Hodgkin's lymphoma
- Epiphysis
- -Chondroblastoma (primary cartilage forming benign tumor)
- -Giant cell tumor (quasi-malignant)
- --Primary tumor
- --painful
- --Originates from mature skeleton
- --Originate metaphyseal
- --Migrate to bone end
- --Over 20 yoa
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Geode
- MC cystic radiolucency in epiphysis- dark
- Must have arthritis
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Preferential time of origin
- 1. Benign tumor & tumor like happen almost ALWAYS before 30 yoa
- -Exception- giant cell tumor to 30+ yoa
- 2. Remember MOCEF for malignant
- M=60+/- yoa
- O=20+ yoa
- C=50+/- yoa
- E=20 yoa
- F=40 yoa
- Parosteal osteosarcoma=40+ yoa
- Reticulum cell sarcomas=30+ yoa
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Metastasis
- 70% of malignant tumors
- Destructive by replacement
- No decade immune to metastasis
- 80% of all osseous metastasis found in axial skeleton
- 90% in axial skeleton & skull
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Lytic Metastasis
- 75%
- Moth eaten typically
- Can be geographic
- Well or ill defined
- Permeative
- Punched out skull
- 30-50% destruction before see on x-ray- may not be visible
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Male metastasis
- 60% prostate- blastic
- 25% lung- lytic
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Female metastasis
70% breast- lytic
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Big 6 MC malignancies that spread to skeleton
- Derived from past medical History
- Breast
- Lung
- Prostate
- Kidney
- -Nephroblastoma aka Wilm's tumor
- -#1 tumor in pediatric
- Ewing's- primary malignant bone tumor
- Neuroblastoma
- -#2 malignancy in pediatric
- -Under 5 yoa
- -Average 2.5 yoa
- -Originates in sympathetic chain or adrenal medulla
- -Tend to end up in skeleton & cranial vault
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4 Key Questions for tumors
- Radiographic appearance- what does it look like
- Location- where is it located
- Symptoms- does it hurt
- Age- how old are you
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