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the most common malignancy of bone
metastatic carcinoma
the most common pathway for metastasis ...
hematogenous -- via blood stream
cancer cells spread into bones rich in red marrow...what kind of bone is this
flat bones
examples of flat bones
pelvis, vertebral bodies, ribs, skull
True or False: the majority of metastatic lesions are lytic
True - pressure erosion on trabeculae by a growing neoplasm. The others are blastic or mixed.
are most primary malignant bone tumors in the extremities or the axial skeleton
extremities
are most secondary malignant bone tumors in the extremities or the axial skeleton
axial skeleton: spine, ribs, pelvis
compare origination sites of primary and secondary malignant bone tumors
Primary: originate w/in connective tissue: bone, cartilage
Secondary: originate in epithelial tissue: breast, prostate, lung
compare the usual patient age of primary and secondary malignant bone tumors
Primary: <35 y/o
Secondary: >40 y/o
are primary malignant bone tumors common in the spine?
are they aggressive?
uncommon in spine
they're aggressive and deadly (but are fortunately less common overall)
what are common complaints of metastatic carcinoma
insidious onset of pain, but is progressive, remissions and exacerbations, worse at night, pathological fracture
the most common site for metastasis of metastatic carcinoma is where?
spine: most commonly in the lumbars and thoracics b/c there's a higher blood supply. also in vertebral bodies and pedicles
which neoplasm of bone might you see the destruction of a single pedicle?
what else might you see
metastatic carcinoma
might also see focal osteoperosis, pathological compression fracture (flat like a pancake)
difference between metastatic carcinoma and mutiple myeloma on X-ray (the radiolucency)
Met. carcinoma: larger areas
Mult. myeloma: smaller circles "punched out lesions"
what's commonly found in lab work in a patient with metastatic carcinoma
elevated ESR, alkaline phosphatase
if prostate metastasis: elevated acid phosphatase
malignant proliferation of plasma cells-- leads to an overproduction of immunoglobulin which infiltrates bone marrow
multiple myeloma
the most common primary malignancy in bone
multiple myeloma
increased destruction and decreased production of normal antibodies
multiple myeloma
lytic destruction of bone in multiple myeloma leads to osteoperosis..what causes it?
stimulation of osteoclast activating factor (OAF) by myeloma cells--leads to pathological vertebral collapse
most common symptoms of multiple myeloma
1. Pain-worse during the day, common in back and ribs, progresses from intermittent to continuous
2. bacterial infection - primary cause of death
3. renal failure-second most common cause of death
why are bacterial infections common in multiple myeloma
b/c immune system is compromised
punched out lesions
seen in multiple myeloma - most common in bones with hematopoietic potential (skull, pelvis, clavicles, ribs)
what do you see in the lab report of multiple myeloma patients
1. reversed albumin to globulin ratio
2. M-protein spike
3. Bence-Jones proteinuria
what's the prognosis for multiple myeloma?
what's the treatment?
not good: 90% of patients die w/in 3 years
radiation, chemotherapy, analgesics, maintain ambulation
second most common cause of primary bone cancer
what age group is most common and why
osteosarcoma
10-25 years old b/c of increased cell turnover due to growth
where does osteosarcoma arise?
in medullary cavity, penetrates and breaks cortex, invades soft tissue
(commonly at metaphysis)
what are common symptoms of osteosarcoma and where is it more common
-pain, swelling of affected area
-most commonly arise at the metaphysis (b/c of increased cell turnover there) in long bones
-knee (distal femur/proximal tibia)
-proximal humerus
the majority of people that die from osteosarcoma have metastasis where
in the lungs
also to bones and kidneys
what percentage of osteosarcoma lesions are blastic or lytic/mixed
50% blastic
50% lytic or mixed
disruption of the cortex --> periosteal response
osteosarcoma
what do you find in the labs of osteosarcoma pts?
increased alkaline phosphatase b/c of new bone growth
what is the treatment for osteosarcoma
amputation
chemotherapy
(up to 75% survival at 3yrs if no metastasis)
a malignant tumor of chondrogenic origin which arises from chondroblasts and remains cartilagenous throughout its evolution
chondrosarcoma
malignant or benign:
chondrosarcoma
malignant
malignant or benign:
osteosarcoma
malignant
malignant or benign:
multiple myeloma
malignant
malignant or benign:
metastatic carcinoma
malignant
malignant or benign:
Ewing's sarcoma
malignant
malignant or benign:
osteochondroma
benign
third most common primary malignancy of bone
chondrosarcoma
age group of chondrosarcoma
male vs. females
40-60 yrs old
males 2x females
common symptoms and locations of chondrosarcoma
pain and swelling (may exist for years prior to diagnosis)
pelvis and proximal femur (50%)
expansile, frequently breaks cortex --> periosteal response
chondrosarcoma and osteosarcoma
common findings on x-ray of chondrosarcoma
-endosteal scalloping
-large round radiolucent lesion expanding the cortical margin (bubbly, wispy on outside of bone)
-mottled (speckled) calcification w/in tumor matrix
-periosteal response--> laminated or spiculated
-soft tissue mass
does chondrosarcoma have a better or worse pronosis than other primary bone malignancies?
can it metastasize to the lungs?
better
local excision of lesion/amputation
90% 5 year survival w/ early surgery
can metastasize to lungs
a highly malignant primary bone tumor arising from primitive stem cells.
a round cell tumor (tumor is sheets of round cells)
Ewing's Sarcoma
typical age group of Ewing's sarcoma
male vs female
10-25 years (peak is 15 years old)
males 2x females
where in the body is Ewing's sarcoma found and where in the bone does it arise?
50% in long bones (especially the femur)
50% in flat bones (especially the pelvis)
arise within the medullary cavity
extremely undifferentiated sheets of small round cells arise within the medullary cavity
Ewing's Sarcoma
symptoms of Ewing's Sarcoma
SH RP
fever, anemia, elevated WBCs and ESR
True or False:
1. Ewing's sarcoma is aggressive
2. Ewing's sarcoma does not commonly spread to lungs
3. Ewing's sarcoma does not metastasize to bones
1. true: extremely agressive
2. false: commonly spreads to lungs
3. false: early and frequent skelatal metastasis, leading to extensive bone destruction
is Ewing's sarcoma lytic, sclerotic or both
Mixed - with destructive diaphyseal lesion
breaks cortex --> periosteal response
osteosarcoma, chondrosarcoma, Ewing's sarcoma
cortical saucerization
Ewing's sarcoma
what might not be able to differentiate Ewing's from other marrow neoplasms
biopsy
treatment for Ewing's sarcoma
surgery, chemotherapy, radiation
the most common benign tumor of bone
osteochondroma
another name for osteochondroma
exostosis
a bony projection from the external surface of endochondral bone with a cap of hyaline cartilage
osteochondroma
names for different amount of involved bones with osteochondroma
solitary osteochondroma
multiple " "
osteochondromatosis/ hereditary multiple exostosis (HME)- average 10
age range for osteochondroma
males vs females
75% are <20 years old
males 2 or 3x females
where does osteochondroma arise and where is it commonly found
arises from the epiphyeal cartilage growth plate.. metaphysis of knee, humerus
when does osteochondroma stop growing
with the closure of the growth plate
symptoms of osteochondroma
most are asymptomatic
hard, painless lump
1% of osteochondroma metastasizes into
chondrosarcoma
what percent of HME (Hereditary Multiple Exotosis: AKA osteochondromatosis) patients develop malignant degeneration?
what symptoms do they have
20% malignant degeneration
pain, renewed growth
what do you see on x-rays of osteochondroma patients
cartilage cap
spotty calcification
most are pedunculated (stick out) others are sessile (flat)
project away from the bone b/c of pull from muscles
cortical and trabecular bone are continuous with the host bone ??
x-ray differences between benign and malignant margins
benign: well defined margin "short zone of trasition"
malignant: ill-defined, ragged, "long zone of transition"
bone cortex x-ray differences between benign and malignant tumors
benign: intact, may be expanded or dense
malignant: broken or destroyed
periosteal response differences between benign and malignant tumors on x-ray
benign: none, sparse or solid
malignant: spiculated, may be laminated, Codman's Triangle ??
enthesophathy- inflammation is most marked at the enthesis, the transitional region where ligament attaches to bone
ankylosing spondylitis
typical age range for ankylosing spondylitis
late 20s to 40s (similar to psoriatic arthritis and Reiter's syndrome)
symptoms of ankylosing spondylitis
articular disease: insidious, low back pain diffuse, into buttocks, muscle spasm, limited motion in lumbars, limited chest expansion
extra articular disease: fatigue, weight loss, low grade fever, conjunctivitis, uveitis, oligoarthritis, Achilles tendinitis
do symptoms of AS improve with exercise
yes
ROM for AS:
symmetric or asymmetric
symmetrically decreased
how does the spinal curves change in patients with AS
loss of lumbar lordosis and increased dorsal kyphosis (could lose cervical lordosis too)
treatment for AS
-maintain motion, normal posture and activity (often use NSAIDS in order to do this)
-heat, hot shower
-hard bed
-extension exercises
spontaneous atlantoaxial subluxation may occur with what disease?
ankylosing spondilitis
hallmark is involvement of SI joint
ankylosing spondilitis
x-ray findings for AS
loss of SI joint definition (white line)
local osteoperosis, erosions with reactive sclerosis, bony ankylosis (bamboo spine)
5 things you'll see on the x-ray of an AS patient's SI joint
-loss of joint definition "pseudowidening"
-erosions and reactive sclerosis
-bony ankylosis
-involves lower 2/3 of the joint
-involves iliac side > sacral side
where does AS spread to after the SI joint
thoracolumbar jxn
then lumbosacral jxn
is there decreased or preservaton of disc space in AS?
osteophytes or syndesmophytes?
-preservation of disc space (decrease joint space at apophyseal and costovertebral jts.)
-syndesmophytes- occurs over mult. segments "bamboo spine"
lab findings for AS
+ HLA-B27
- RA
increased ESR (erythrocyte sedimentation rate)
Auspitz sign
thimble pitting
Ray's sign
pencil in cup
fluffy new bone
Psoriatic arthritis
chronic skin disorder characterized by proliferation of the epidermis, small amt of patients have an associated arthropathy
psoriatic arthrisits
differences b/t AS and psoriatic arthritis
P.A. has skin condition, starts in extremities before SI joint and spine, asymmetrical syndesmophytes, preserved joint space
1 large joint (ex knee) and 1-2 interphalangeal joints
dactylitis "sausage digit"
psoriatic arthritis
lab findings for psoratic arthritis
+HLA-F27
- RF
increased ESR
differences between RA and psoriatic arthritis
Involves DIPs, +HLA-B27, nail changes, sausage digits, bone proliferation, axial involvement
conjunctivitis, urethritis, arthritis
Reiter's syndrome
majority of cases are venereal in origin
Reiter's syndrome
3 things on x-ray RA and Reiter's syndrome have in common and one difference
Same: soft tissue swelling, uniform loss of joint space, marginal erosions
Difference: RS has periostitis with fluffy new bone
Lover's heel
Reiter's syndrome-
soft tissue swelling, erosions, fluffy periostitis at insertions of Achilles and plantar tendons
how often is the SI joint involved in Reiter's?
50% involve SI
in Reiter's Syndrome are the SI joints bilateral and asymmetrical?
are there syndesmophytes
yes
yes, syndesmophytes are sloppier than AS
lab findings for Reiter's syndrome
+HLA-B27
-RF
increased ESR
a group of GI disorders producing articular abnormalities
enteropathic arthropathy
which two GI disorders are most commonly associated with enteropathic arthropathy
ulcerative colitis and Crohn's disease ( regional enteritis)
True or False: Enteropathic arthropathy spinal changes is identical to AS with SI joint changes
True
what percent of people with enteropathic arthropathy develop arthritis?
when does it resolve
15%
resolves in 1-3 months w/o permanent damage
what are the lab findings for enteropathic arthropathy
+HLA-B27
-RF
defect in purine metabolism
gout
what kind of crystals are found in the joint tissue
monosodium urate crystals
typical age group of gout
male vs female
>30 years old
95% of patients are male
stages of gout
asymptomatic hyperuricemia
acute gouty arthritis
chronic gouty athritis
tophus formation
is gout insidious or acute
acute
what joint is most commonly affected with gout
1st metatarsophalangeal joint
also other MTP jts, ankle, knee, hands
AKAs for Calcium Pyrophosphate Dihydrate Crystal Depsition disease
CPPD, pseudogout, chondrocalcinosis
typical age group for CPPD
>30 y/o
peaks at 60 y/o- older than gout patients
when the CPPD crystals deposit in joint cartilage do they cause degeneration of cartilage and loss of joint space
yes b/c of inflammatory response of synovium
what is acute CPPD similar to?
RA or gout - hot, swollen, tender joints
what is chronic CPPD similar to?
DJD - bony swelling, crepitus, stiffness, loss of joint space
what do you see on x-rays of CPPD?
chondrocalcinosis-calcification of articular artilage (white line of calcification)
-esp knee or shoulder
Loss of joint space, subchondral sclerosis, osteophytes, deformity
how do you differenciate b/t CPPD and DJD?
lab findings for CPPD: crystals, in extremities, chondrocalcinosis