Bone Tumours Notes

Bone Tumours

Malignant tumours

Presentation

• Non-specific pain often worse at night

• Limb swelling

• Restricted movement

• Pathological fractures

Hx:

• Mechanical pain (weakened bone)

• Pain preceding a fracture

• Weight loss

• Fever

• PMH malignancy/infection (ask about type, treatment, remission follow-up)

• Anaemia

Red flags

• Systemic features inc

  • Weight loss

  • Tiredness

  • Change in bowel habit

  • Coughing

  • Smoking history

Examination:

• General and focussed

• Lymph nodes

• Affected limb

• Potential sites of primary e.g breast, thyroid, prostate

Investigations

Bloods:

• FBC – Hb for anaemia (microcytic is common in malignancy – low Fe count) Low level bleeding or infiltration of bone marrow

• Calcium – Raised = medical emergency = nerve conduction problems (treat with bisphosphonates)

• Alk. Phos sometimes raised. LFTs deranged due to mets in liver

• Platelets – thrombocytopaenia

• U+E – check renal function (hypercalcaemia can cause dehydration)

Xrays:

• Bone destruction

• New bone formation

• Soft tissue swelling

• Periosteal elevation

Advanced imaging:

• Bone scan (nuclear med) to identify other lesions (show silent secondary deposits)

• CT + MRI assess extent of tumour and infiltration of surrounding structures

If doubt still persists – biopsy and send for microbiology and histology (biopsy track considered contaminated)

Staging = radioisotope scan and CT chest/abdo/pelvis

Differential diagnosis

• Developmental e.g bone cyst

• Iatrogenic

• Trauma e.g avulsions

• Infection e.g TB, osteomyelitis

• Lymphoma

• Stress fracture

Questions when assessing bone tumours

• Where is the lesion?

• Solitary/multiple

• Cystic?

• Calcified centre?

• Well-defined margins

• Cortical destruction

• Periosteal reaction

Multiple Myeloma

Most common primary bone tumour (40%)

Malignant B-cell proliferation disorder of bone marrow

Presents >50 yrs

Effects on bone due to marrow-cell proliferation and increased osteoclast activity = lytic lesions throughout the skeleton and osteoporosis

Presentation

• Weakness

• Backache

• Bone pain

• Pathological fractures

• Hypercalcaemia = thirst, polyuria, abdominal pain

• Anaemia

Investigations

• Bloods

  • Increased viscosity

  • Increased creatinine

  • Raised ESR and calcium

  • Anaemia

  • Serum plasma electrophoresis (abnormal band present)

  • Do and ECG if raised calcium level

• Urinalysis

  • Shows Bence Jones proteins (Ig light chain produced by neoplastic cells)

• Xrays

  • Generalised osteoporosis (exclude other causes)

  • Punched-out lesions of skull “pepper pot skull” pelvis and femur (multiple lytic lesions – rule out generalized secondary mets)

Management

• Pain relief

• Stabilisation of fractures (+/- prophylactic fixation)

• Correct hypercalcaemia (bisphosphonates)

• Chemotherapy/radiotherapy

• Erythropoetin

• Dialysis

• Bone marrow transplant (can be curative)

Osteosarcoma

An osteogenic tumour. Highly malignant. Very rare but second most common primary bone tumour.

Clinical features

• Found at areas of most growth (knee, prox. humerus)

• Male adolescents and peak in eldery

• Fast growing – spreads from periosteum into surrounding tissues

• Mostly high grade malignant

• Metastasise early (to lungs)

• Increased ESR and alk. Phos

Risk factors: Pagets, genetics, radiation exposure

Features from history

• Night pain increasing in severity

• +/- lump, swelling, tenderness

Investigations

• Bloods

  • Raised ESR, raised ALP

• Imaging

  • Xray – lytic sclerosis, sunray spickules, bone destruction, periosteal lift. +/- lung mets

  • CT – staging

• Biopsy needed for definitive diagnosis and staging

Treatment

• Neoadjuvant chemotherapy to shrink tumour

• Excision/amputation/bone replacement

• Further chemo

• 50% 5 year survival

Chondrosarcoma

Rare – affects older people (40s-50s)

Can be a secondary change in pre-existing benign lesion

Features

• Pelvis, ribs, proximal femur + humerus (metaphysis of long bones but mostly axial skeleton)

• Slow growing

• Rarely metastasis

Imaging

• Radiolucent area with calcification flecks

• Bone destruction

• CT/MRI should be done before biopsy if osteochondroma increases in size as suspicious if its turned malignant

Treatment

• Surgical resection (wide excision)

• Prosthetic replacement

• Slow growth = late mets

• Chemo and radiotherapy resistant

Giant...

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