-
Osteoma
- Primary- originates in bone
- Bone forming- tumor formed from bone cells
- Benign- controlled bone cell growth
- #3 MC benign tumor
- Frequency- common
-
Location of Osteoma
- MC structure in bone- cortex
- MC bone region- metaphyseal
- Common sites
- - likes cranial vault
- -affinity to sinus
- --frontal
- --ethmoid
- -mandible
-
-
-
Appearance of Osteoma
- Size < 2cm
- Dense compact bone mass
- Looks like bone snowball
- Trabecular or spongy-permeative
- Ivory or compact- solid
- Round or oval
- Originate from & project away from cortex
- Never found in medullary cavity
- Radiopaque- white
- Well defined cortical mass
- Solitary
-
Gardner's Syndrome
- Syndrome of multiple harmartomanous tumors
- Harmartoma- made of same cells as host tissue w/o organization or fxn
- Have multiple osteomas
- Have fibrous soft tissue tumors- usually abdominal
- Have multiple colonic polyps
- 100% malignant generation rate
- Will have colon cancer
-
Differential for Osteoma
- Enosteoma or bone island- tumor like
- Can look like osteoma
- Have different locations (Bone islands do NOT occur in the skull-osteoma MC in skull)
- Key-inside medullary cavity (osteoma is NEVER in medullary cavity)
- -often against endosteal cortical surface
- Different age group- MC in adults (osteoma- no age of incidence)
-
Osteoid Osteoma
- Primary- originates in bone
- Bone forming- tumor formed from bone cells
- Benign- controlled bone cell growth
-
Location of Osteoid Osteoma
- MC structure in bone- cortex
- 3 structures in bone
- -cortical- MC
- -intramedullary- cancellous
- -subperiosteal
- MC bone region- metaphysis
- Common sites
- - Likes long tubular bones
- -50% affinity to
- --femur- trochanter, neck
- --tibia
- -10-15% in spine
- --like posterior arch-lamina, pedicle, AP, SP
- --60% lumbar
-
Age for Osteoid Osteoma
- Under 30
- 2nd to 3rd decade incidence- 11-30 yoa
- Peak in teenage years
- Male - 2:1
-
Pain with Osteoid Osteoma
- YES
- Focal or point pain- patient can point to it
- Worse at night
- Tend to have antalgic scoliosis- lean into
- -on concave side of scoliosis
- Relieved by OTC analgesics- aspirin
- Removed nidus by surgery-low reccurence
- Localized swelling
- Limited motion
- Painful limp
- Stiffness & weakness of joint
-
Appearance of Osteoid Osteoma
- Radiolucent- dark
- Size <2cm
- Nidus <1 cm
- Generates dense localized solid periosteal response
- -may cover tumor
- -looks like existing cortex- expansile density
- Cortical bone thickening
- Sclerosis
- Shows up on bone scan
-
Differential for Osteoid Osteoma
- Form of osteomyelitis- bone infection
- Brodie's abscess
- -same pain
- -same look- except halo rim of sclerosis
- -localized radiolucent nidus
- -key- nidus BIGGER than 2cm in diameter
-
Osteoblastoma
- Primary
- Bone forming
- Benign
-
Location of Osteoblastoma
- MC structure in bone- cortex
- MC bone region- metaphysis
- Common sites
- -affinity to spine (30-50%)
- --like posterior arch appendages- TP, SP, AP
- -femur
- -foot
- -ankle
-
Age for Osteoblastoma
- Under 30 yoa
- 1st to 7th decade of life- 1-70 yoa
- Teenager- 70%
- Male 2:1
- Less common than osteoid osteoma- very rare
-
Pain w/ Osteoblastoma
- YES
- Symptomatic-insidious pain
- No fever
- No trauma
- Possible point tenderness
- Not necessarily worse at night
- May not be relieved by OTC drugs
- Unresponsive to care after several months
- May have motion restriction
- Not easily palpable
- Surgically removed
-
Appearance of Osteoblastoma
- Larger than osteoid osteoma- many cm in size
- ALWAYS geographic grossly expansile lesion
- Purely radiolucent to speckled calcification to sclerotic
- May not cause scoliosis
-
Differential for Osteoblastoma
- Osteoid osteoma
- Tumor like similar
- Order of differential
- -Aneurysmal bone cyst
- --more common occurrence in spine
- --have preceding trauma
- -giant cell tumor
- -osteoblastoma
- Forms of osteomyelitis
- Brodie's abscess
- -similar pain
- -same look
- -localized radiolucent nidus
- -nidus BIGGER than 2 cm
- Ominous conditions for this age group
- Do NOT have central spinal tendency
- -Ewing sarcoma
- -Osteosarcoma
- -Infection- would have had fever sometime earlier
-
Osteosarcoma
- Primary
- Bone forming
- Malignant- uncontrolled bone cell growth
- -#2 primary malignant bone tumor- 20%
- Incidence- 4-5/million
-
Types of Osteosarcoma's
- Central-72%
- -Sclerotic-75%
- -Lytic-25% (moth eaten, permeative lysis)
-
Location of Osteosarcoma
- MC structure in bone- medullary
- MC bone region- metaphysis
- Common sites
- -tubular bone
- --loves distal femur
- --knee joint (15%)
- --shoulder joint
-
Age for Osteosarcoma
- Teenagers
- 2nd to 3rd decade- 11-30 yoa
- Under 30 yoa
- -if under 40-metastasis or MM
- -if under 30- Ewing, non-Hodgkins, osteosarcoma
- Male 2:1
-
Pain with Osteosarcoma
- YES
- Insidious onset
- Progressively worsening pain
- Persistent deep boring pain
- Painful swelling
- BAD in young patients
- Uncommon tumor- poor outcome
- Lab- increased alkaline phosphatse
-
Appearance of Osteosarcoma
- Radiodense- white
- Alignment ok
- -Shenton's ok
- Bone NOT ok
- -may be fuzzy geographic
- -Codman's triangle below sclerosis
- -permeative or mottled
- -sclerotic calcification
- -long zone of transition
- -spiculated periosteal reaction- hard to see w/ sclerosis
- --spicule- goes perpendicular
- -can cross metaphysis by way of creating bridges across
- --aka direct extension
- --can extend to diaphysis
- cartilage ok
- -no jt space narrowing(if narrowed, infection or inflammatory)
- Soft tissue mass
- -tendency to create large mass
- -creates bone in mass
- -cumulus cloud appearance
- -high metastasis tending to be in lung-75%
- --aka cannonball lesion
-
Differential for Osteosarcoma
- Ewing sarcoma- pain & fever that mimics infection
- -feel worse systemically
- Non-Hodgkin's lymphoma-feel good
- Leukemia- young
- -primary vascular tumor
- Neuroblastoma- very young
- Osteomyelitis-infection
-
Osteosarcomatosis
- Multifocal (multiple osteosarcomas)
- Under 10 yoa
- Universal bad outcome (usually fatal)
- Attacks tubular bone
- Sclerotic
- Mixed w/ lucency
-
Parosteal Osteosarcoma
- Primary
- Bone forming
- Malignant
- 4%
-
Location of Parosteal Osteosarcoma
- MC structure in bone- cortex
- MC bone region- metaphysis
- Common sites
- -distal femur- 50%
- -proximal tibia & humerus- 25%
- Parosteal- around bone
- -growing from host
-
Age for Parosteal Osteosarcoma
4th to 5th decade- 31-50
-
Pain w/ Parosteal Osteosarcoma
- YES
- Dull, achy
- 5 year survival rate- 70% after amputation
-
Appearance of Parosteal Osteosarcoma
- Radiodense- white
- Mushroom growth coming out of cortex
- Has bony stalk- lobulated sessile
- Has larger head on stalk
- Has daughter tumors in soft tissue
- Dense & sclerotic
- Cleavage plane- string sign
-
Differential for Parosteal Osteosarcoma
Post-traumatic myositis ossificans- halo rim
-
-
Location of Periosteal Osteosarcoma
- MC structure in bone- cortex
- MC bone region- metaphysis
- Periosteal- around periosteum of bone
- -not in medullary cavity
- -sandwiched b/w periosteum & cortex
- -does NOT invade host bone
-
Pain with Periosteal Osteosarcoma
- YES
- Better prognosis than parosteal
-
Appearance of Periosteal Osteosarcoma
- Occurs underneath periosteum
- Non-homgenous density
-
Osteosarcoma of Jaw
- 6%
- Mandible
- Sclerotic
- Older patient group
-
Post-radiation Osteosarcoma
- 4%
- Due to therapeutic radiation therapy
- In radiated bone
-
Osteosarcoma in Paget's Dx
- 1%
- Serious malignant degeneration of Paget's disease
- Lytic central osteosarcoma
- Order of development in Paget's disease
- 1. Osteosarcoma- #2 primary malignant bone tumor
- 2. Fibrosarcoma- #5
- 3. Chondrsoarcoma- #3
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Chondroma/Enchondroma
- Primary
- Cartilage
- Benign
- Common- #2 MC benign tumor
- Types
- Chondroma- extrinsic
- Enchondroma- intrinsic
-
Forms of Chondroma/Enchondroma
- Monostotic- single
- Polyostotic- multiple
-
Location of Chondroma/Enchondroma
- MC structure in bone- medullary
- MC bone region- metaphysis
- Common sites- small tubular bones of hand
- -Hand
- --MC benign tumor of hand
- -Phalanx
- --More common on ulnar side
- --Proximal end
-
Age of Chondroma/Enchondroma
- Before 30 yo
- 2nd to 3rd decade incidence- 11-30
-
Pain w/ Chondroma/Enchondroma
- NO
- Found by accident- traumatic determinism
- Can degenerate into chondrosarcoma
- -central- medullary
- --typically form these
- --will start to hurt
-
Appearance of Chondroma/Enchondroma
- Developmental lesion- quirk of development
- Ectopically located in medullary cavity
- Cartilage growing in wrong place
- Radiolucent- dark
- Geographic
- Short zone of transition
- Well defined border
- Often expansile
- Start eccentrically in bone
- Have an affinity for calcium- like to calcify
- -50% enchondromas will have
- Speckled calcification aka snowflake calcification
- Soft tissue enlargement
-
Differential for Chondroma/Enchondroma
- Fibrous dysplasia
- -especially of polyostotic
- -not purely radiolucent
- Mostly smoky appearance
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Enchondromatosis
- aka Ollier's disease
- Polyostotic- multiple lesions
- Can be quite deforming
- Site- femur & tibia
- -common malignancy areas- pelvic & shoulder
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Maffuci's Syndrome
- Ollier's plus soft tissue hemangioma
- Soft tissue hemangiomas- due to distended blood vessel
- Produce phleobiths- calcification
- Very rare
- Site- hand
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Common cystic lesion in phalanges, tubular bone, hands, feet
- Arthritis w/ synovial cysts
- -especially gout, geode
- Bone cyst
- -tumor-like disorder
- Enchondroma
- -occasionally low-grade chondrosarcoma
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Uncommon cystic lesions in phalanges, tubular bone, hands, feet
- Angioma
- Cystic osteomyelitis
- Leprosy
- Metastasis
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Solitary Osteochondroma
- aka exostosis- external bone growth
- aka osteocartilaginous exostosis
- Primary
- Cartilage
- Benign
- #1 MC benign bone tumor
- -50% of all benign bone tumors
- -10-15% of all primary benign bone tumors
- 3 forms
- Solitary-MC
- Few
- Dozens- hereditary
-
Location of Solitary Osteochondroma
- MC structure in bone- BOTH
- MC bone region- Metaphysis
- Constantly stays as metaphysis even during growing years- migrates
- Common sites- tubular bones
- -femur
- -tibia-
- -humerus
- -found in metaphysis of large tubular bone
-
Age for Solitary Osteochondroma
-
Pain w/ Solitary Osteochondroma
- NO
- Found by accident
- Can feel it, but not hurt
- Pain & growth- indicate malignancy
-
Appearance of Solitary Osteochondroma
- Dense & sclerotic
- Ectopic epiphyseal tissue growing in wrong place
- Growing off side of metaphysis
- Key radiographic features
- -Integral part of host bone
- --cortex goes into lesion
- --medullary cavity & trabeculation go into lesion
- -Types of morphological shape
- --Pedunculated- elongated stalk (bony part)
- ---Most frequent
- ---ALWAYS point away from nearest jt
- ---knee, hip, ankle
- -Sessile- broader, wider attachment
- --do NOT point
- --humerus & scapula
- ---Luschka't tubercle- superior angle of scapula
- Can get large in size
- Hyaline cartilage cap surrounds bone
- Stalk is bone
- Cauliflower shaped cap is cartilage
- If cap not calcified-not visible
-
Differential for Solitary Osteochondroma
- So distinct- NO differential
- Parosteal or periosteal osteosarcoma
- -symptomatic- painful
- -appearance sclerotic
- osteochondroma- no pain, mottled appearance
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Hereditary Multiple Exostosis
- Inherited autosomal dominance
- 2-10
- Pain- NO
- Metaphyseal deformity- aplasia
- -especially in sessile type
- Aclasia- secondary symptom
- -rubs against muscle, nerve, blood vessel
- Cartilage cap can become malignant- peripheral chondrosarcoma
- Bayonet deformity- wrist
- More lesions, more likely to be malignant
- -2% for single exostosis
- -20% for HME
- Mottled appearance
-
Chondromyxoid Fibroma
- aka fibromyxoid chondroma
- Primary
- Cartilage
- Benign
- Incidence- less common
-
Location of Chondromyxoid Fibroma
- MC common structure in bone- medullary
- MC bone region- Metaphysis
- -can migrate to epiphysis
- Common sites
- -loves tibia- 50%
- --proximal 1/3
-
Age for Chondromyxoid Fibroma
- Before 30
- 2nd to 3rd decade incidence- 11-30
- 5th to 6th decade incidence- 41-60
-
Pain w/ Chondromyxoid Fibroma
- YES
- Symptomatic- painful
- Found due to pain
- Insidious onset
-
Appearance of Chondromyxoid Fibroma
- Endosteal scalloping
- Soap bubble appearance
- Geographic
- Expansile
- Eccentric oval or round
- Well-defined margin
- Short zone of transition
- Radiolucent- white
- Absence of arthritis
-
Differential for Chondromyxoid Fibroma
- Giant cell tumor- soap bubble & appears at metaphysis
- Chondroblastoma- starts at metaphysis
- Geode- arthritis
- Osteoblastoma- radiodense & mottled
-
Chondroblastoma
- aka Codman's tumor
- Primary
- Benign
- Incidence- less common
-
Location of Chondroblastoma
- MC structure in bone- 90% medullary, 10% cortical
- MC bone region- epiphysis
- -can migrate to metaphysis & apophysis
- Common sites- long tubular bones
- -femur
- -pelvis
- -knee
- -shoulder
-
Age for Chondroblastoma
- Before 30
- 2nd to 3rd decade incidence- 11-30
- Male 2:1
-
Pain w/ Chondroblastoma
- YES
- Mild, dull pain
- Pain to adjacent bone
- Found due to pain
- Can be insidious onset
- Local tenderness
- Swelling
-
Appearance of Chondroblastoma
- Geographic
- Ovoid
- Fluffy cotton wool calcification- chicken wire calcification
- Well defined margin
- Short zone of transition
- Radiolucent
- Expansile
- Thin sclerotic margin
-
Differential for Chondroblastoma
- Giant cell tumor- older age group
- Chondromyxoid fibroma- starts at metaphysis
- Geode- must have arthritis
- Osteoblastoma- radiodense & mottled
-
Chondrosarcoma
- Primary
- Cartilage
- Malignant
- #3 primary malignant bone tumor
- 2 regions
- Central- intramedullary
- -much more common
- Peripheral- external to bone
-
3 types of Chondrosarcoma
- Primary- de novo & nothing pre-existing
- -central region
- -1/3 of chondrosarcomas originate by itself
- Secondary- degenerate from something pre-existing such as benign version
- -most likely from chondroma or osteochondroma
- -may be central or peripheral
- -2/3 of chondrosarcomas originate from pre-existing
- Clear Cell
- -central region
-
Location of Chondrosarcoma
- MC structure in bone- Both
- MC bone region- metaphysis
- Common sites
- -Pelvis
- -Proximal femur
- --MC primary malignant bone tumor of hand, chest wall
- --3rd MC primary malignant bone tumor of pelvis
-
Age for Chondrosarcoma
- B/w 40-60
- 4th to 6th decade- 31-60
- Male 2:1
-
Pain w/ Chondrosarcoma
- NO
- Later have pain
- 90% survival rate after surgery
-
Appearance of Chondrosarcoma
- Mottled appearance
- Speckled calcification
- Geographic
- Soap bubble appearance
- Grossly expansile
- Cartilage cap continues to grow
- Solid periosteal reaction
-
Differential for Chondrosarcoma
- Chondroblastoma
- Giant cell tumor
-
Giant Cell Tumor
- aka osteoclastoma
- Primary
- Cartilage
- Quasi-malignant- semi-controled cartilage cell growth
- -80% benign
- -more malginant in males
-
Location of Giant Cell Tumor
- MC structure in bone- medullary
- MC bone region- epiphysis
- -can migrate to metaphysis
- Common sites- typically like large tubular bones
- -femur- distal
- -humerus- proximal
- -radius- distal
- --distal radius- greatest potential of malignancy
- -posterior arch
- -sacrum- MC common spinal site
- --MC benign tumor of sacrum
- -60% in distal knee
- -MC neoplasm of patella
-
Age for Giant Cell Tumor
- B/w 20-40
- 3rd to 4th decade incidence 21-40
- Benign female 3:1
- Malignant male 3:1
-
Pain w/ Giant Cell Tumor
- YES
- Deep boring pain
- Localized swelling
- Tenderness
- Insidious onset
- Malignant- poor prognosis
- -10% chance alive in 5 years
-
Appearance of Giant Cell Tumor
- Geographic
- Soap bubble appearance
- Grossly expansile
- Well defined margins
- Joint space preserved
- Tumor goes up to edge of subarticular bone
-
Differential for Giant Cell Tumor
- Chondroblastoma- age
- Central chondrosarcoma
- Infection-can get into jt space
- Geode- must have arthritis
-
Ewing's Sarcoma
- aka Round cell tumor
- Primary
- Marrow
- Malignant
- #4 MC primary malignant bone tumor
-
Location of Ewing's Sarcoma
- MC structure in bone- medullary
- mc bone region- diaphysis
- Common sites
- -Affinity for diaphysis-large tubular bone 50%
- --femur
- --tibia
- --humerus
- --fibula
- -flat bone-40%
- --pelvis
- Younger- peripheral skeleton
- Older- axial skeleton
-
Age for Ewing's Sarcoma
- Under 30
- Typically b/w 10-25
- 2nd decade incidence- 11-20
- MC primary malignant tumor in 1st decade- 1-10
- Unusual for under 5
- Male 2:1
- Lower affinity in blacks
-
Pain w/ Ewing's Sarcoma
- NO
- Insidious onset
- Deep aching bone pain
- Worsening pain
- Systemically feel ill
- Episodic fever
- Mimics infection
- Localized pain w/ swelling
- Soft tissue mass palpable
- Increase ESR
- Leukocytosis
-
Appearance Ewing's Sarcoma
- In tubular bone
- -moth eaten
- -permeative osteolysis
- Cortical saucerization- wide & shallow localized divot of bone destruction in periosteum
- Laminated periosteal reaction- onion skin
- Short spiculation- trimmed whisker appearance
- In flat bone
- -geographic
- -soap bubble
-
Metastasis of Ewing's Sarcoma
- MC primary malignant bone tumor to metastasize to bone
- Skip lesion
- Secondary spread to lung
- 5 year survival rate- 5%
-
Differential for Ewing's Sarcoma
- Lytic osteosarcoma
- Leukemia
- Osteomyelitis- more diaphyseal for infection
-
Non-Hodgkin's Lymphoma
- aka primary reticulum cell sarcoma
- aka round cell tumor
- Primary
- Marrow
- Malignant
- Primary lymphoma occuring outside lymphatic system
- Skeletal extranodal non-Hodgkin's lymphoma
-
Location of Non-Hodgkin's Lymphoma
- MC structure in bone- medullary
- MC bone region- diaphysis
- Common sites
- -Large tubular bones
- --Femur
- --Tibia
- --Humerus
- Non-Hodgkin's- originates from B-cell lymphocyte
- Hodgkin's- originate from T-cell lymphocyte
-
Age for Non-Hodgkin's Lymphoma
- Young adults
- 3rd to 4th decade incidence-21-40 yoa
- 50% before 40
- Male 2:1
-
Pain w/ Non-Hodgkin's Lymphoma
- NO
- Feels fine
- Tremendous contraindication of symptoms vs what's going on in bone
- Minor symptamatology
-
Appearance of Non-Hodgkin's Lymphoma
- Moth eaten
- Permeative osteolysis
- Laminated periosteum
- Prone to pathological fractures-transverse
- Spiculation
- Pathologic fracture
- Soft tissue mass
- 5 year survival rate (48%)
-
Differential for Non-Hodgkin's Lymphoma
- Lytic osteosarcoma
- Osteomyelitis-more diaphyseal for infection
- Ewing's sarcoma- feel bad
-
Multiple Myeloma
- Primary- originates in marrow
- Marrow- tumor formed in marrow
- Malignant- uncontrolled marrow cell growth
- Granddaddy of primary malignant bone tumors
- -#1 MC primary malignant bone tumor
- 30/million
-
Location of Multiple Myeloma
- MC structure in bone- medullary
- MC bone region- metaphysis
- Common sites
- -multicentric- multiple bones
- -Spine- common place
- --lower thoracic or lumbar
- --typically in body
- --not usually in posterior arch
- -long bone
- -skull- raindrop
-
Age for Multiple Myeloma
- Over 40
- Typically b/w 50 to 70 yoa (75%)
- 5th to 7th decade incidence 41-70
- Male 2:1
-
Pain w/ Multiple Myeloma
- YES
- Deep bone pain- aggravated by exercise & weight bearing, better @ night, worse during day
- Weakness
- Low back pain
- Fatigue
-
4 abnormalities associated with MM
- Anemia
- -normocytic, normochromic anemia
- -nothing wrong w/ RBC
- -elevated ESR
- Deossification of red marrow bones
- Abnormal serum & urinary proteins
- -Marrow replaced w/ cancer cells
- --see spike in serum electrophoresis
- --monoclonal gammopathy- 1 group of same gamma globulin cells w/o antigenic stimulus
- --confirmed w/ bone marrow biopsy
- Renal disease
- -Bence Jones proteins clogs kidney
-
Appearance of Multiple Myeloma
- Negative on bone scan
- -plain film important for determination
- Osteoporosis-thinning of cortex
- Uniform vertebral collapse
- Well defined margin
- No sclerosis to margin
- Radiolucent-dark
- Vary in size, but less than 2 cm
-
4 presentations of osteolytic defects
- Classical- punched out lesion
- -MC presentation
- Myelomatosis- osteopenia
- -only exhibit loss of bone density
- -may want to test person exhibiting osteoporosis for MM
- --electrophoresis
- --bone biopsy
- --show up w/ compression fractures or unresponsive
- Plasmacytoma- localized subacute geographic lesion
- Extraosseous- external to bone marrow & appears in nasopharynx
- -rare
- -dysphagia, mouth breathing
-
Solitary plasmacytoma
More localized form of MM
-
Sites for solitary plasmacytoma
- Mandible
- Ilium
- Vertebra
- Rib
- Proximal femur
- Scapula
-
Age for Solitary Plasmacytoma
50% before 50 yoa
-
Pain w/ Solitary Plasmacytoma
localized
-
Appearance of Solitary Plasmacytoma
- Geographic
- Radiolucent
- Highly expansile
- Soap bubble
-
Differential for Multiple Myeloma
- Lytic osteosarcoma- not usually in spine & younger age
- Osteomyelitis- more diaphyseal for infection
- Ewing's Sarcoma- feel bad & not usually in spine
- Non-Hodgkin's lymphoma- feels ok
- Metastasis
-
Vertebral Body Lesions mnemonic
- MOM LOACH
- Metastasis
- Osteoblastoma
- MM
- Lymphoma
- Osteoid osteoma
- Aneurysmal bone cyst
- Chordoma
- Hemangioma
-
Soap Bubble Lesions mnemonic
- MEN MAC FOGS
- Metastasis
- Enchondroma
- Non-ossifying fibroma
- MM
- Aneurysmal Bone Cyst
- Chondroblastoma
- Fibrous dysplasia
- Osteoblastoma
- Giant cell tumor
- Simple bone cyst
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