What is the mc location to find Stage 4 Paget's?
Femur
What are the radiologic signs of stage 4 Paget's?
Shepherd's crook, bone tumor in lungs
What is the shepherd's crook deformity?
Coxa vara -- body weight bends proximal femur
Where should Skinner's line be?
Through the fovea centralis
Which bone tumor mc spreads to lungs?
Osteosarcoma
Which disease has normal bone reabsorbtion, but resorbed bone is replaced by an abnormal proliferation of isomorphous fibrous tissue?
Fibrous dysplasia
What is the fundamental lesion of fibrous dysplasia?
Bone spicules in a fibrous matrix
When do the lesions of fibrous dysplasia occur?
Ages 8-14
What 2 signs accompany the lesions of fibrous dysplasia?
Deformity and bowing, cafe au lait spots
These spots have which type of margins in fibrous dysplasia?
Coast of Maine" -- irregular
Is fibrous dysplasia mc mono or polystatic?
Monostatic
What type of bone tissue is involved with fibrous dysplasia?
Cancellous
What is McCune Albright syndrome?
Polystatic fibrous dysplasia, cafe au lait spots, and endocrine dysfunction (precocious puberty)
McCune Albright is mc in?
Females
What are the 2 mc locations for monostatic fibrous dysplasia?
Femur, ribs
What are its X-ray signs of monostatic fibrous dysplasia?
Geographic ground glass lesion, with thick sclerotic border, cortical thinning and scalloping
What are the X-ray signs for polyostatic fibrous dysplasia?
pseudofractures/deformities, sclerosis of skull and facial bones, pseudoarthrosis of lower extremities
Familial fibrous dysplasia of the jaw is aka?
Cherubism
The triad of cafe au lait spots (Coast of California), fibroma mollescum (soft, raised lesions on skin), and kypho-scoliosis is called?
Neurofibromatosis 1
Neurofibromatosis 1 is aka?
Von Recklinghausen's disease
What are the signs & symptoms of Neurofibromatosis 1 in the skull?
Pulsating exopthalmus, optic nerve involvement
What are the signs & symptoms of Neurofibromatosis 1 in the spine?
Back pain, deformity, peripheral nerve dysfunction
What are the 3 mc x-ray signs of Neurofibromatosis 1 in the skull?
Bare Orbit", macrocrania, asterion defect
What is the mc x-ray finding of Neurofibromatosis 1 in the spine?
Kypho-scoliosis
What are 3 other spinal x-ray findings of Neurofibromatosis 1?
Enlarged IVF, posterior body scalloping of MANY vertebrae, intrathoracic menigiocele
What is the mc x-ray sign in the ribs of Neurofibromatosis 1?
Twisted ribbon appearance
What x-ray sign can be found in one extremity or digit with Neurofibromatosis 1?
Focal giantism
Neurofibromatosis 2 is aka?
Central Neurofibromatosis
Which Neurofibromatosis is mc?
Neurofibromatosis 1
What is the diagnostic feature of Neurofibromatosis 2?
Bilateral acoustic schwanoma
What are the 4 classes of bone tumors?
Primary malignant, secondary malignant, metastatic malignant, and benign
What is the mc class of bone tumor?
Primary malignant
What is the mc primary malignant bone tumor?
Multiple myeloma
To what 3 sites does multiple myeloma mc metastasize?
Lung, liver, bone
What 3 ways do primary malignant bone tumors spread?
Direct extension, lymphatic, hematogenous
What is the mc route of metastasis to bone?
Hematogenous
What are the 3 early symptoms of primary malignant bone disease?
Progressive bone pain, worse at night, not relieved by aspirin
What are the 4 later symptoms?
No appetite, weight loss, jaundice, acidic fluid accumulation
Which osteosarc is mc, blastic or lytic?
Lytic
Describe the margins of a lytic mass?
Poorly defined, mottled, and moth-eaten
Which primary malignant bone tumor is easiest to see?
Blastic
What part of the bone is mc affected by primary malignant tumors?
Medulla
What imaging is most sensitive for metastatic tumors?
MRI
What weightings are used to find the pathology?
T1 and T2
What is the mc location of metastatic tumors?
Spine
What is the 2nd mc location of metastatic tumors?
Ribs / sternum
What is 3rd mc of metastatic tumors?
Pelvis
What is the least common location of metastatic tumors?
Hands / feet
Which type of tumor has no soft tissue mass, no periosteal response, doesn't expand bone, and involves multiple sites?
Metastatic
Which type of tumor has a prominent soft tissue mass, periosteal reaponse, and expands bone at a solitary site?
Primary
When there is a history of malignancy, you should always?
X-ray
In blastic metastasis, you can't see the cortex because?
Entire bone is very thick
A snowball pattern indicates?
Blastic metastasis
A single snowball may be a?
Bone island
If you see a single snowball you should?
Send out for bone scan
What is a lytic pattern that expands bone and mimics a primary malignancy?
Blow out metastasis
What are the 2 mc primaries leading to blow out metastasis?
Kidney and thyroid
What is the mc cause of a missing spinous?
Metastatic disease
A missing atlas posterior arch may be?
Metastatic disease OR agenesis
Winking owl sign indicates?
Osteolytic metastasis
What disease tends to spare the pedicle?
Multiple myeloma
In pt <30 yoa, the 3 mc reasons for missing a pedicle are?
Aneurysmal bone cyst, osteoblastoma, neuroblastoma
MC route of metsasis to the spine is?
Batson's plexus
Well-defined punched-out lesions that do not uptake on bone scan are?
Multiple myeloma
Cortical metastasis is mc from?
Lung
MC primary bone tumors in order?
Multiple myeloma, osteosarc, chondrosarc, Ewing's
A neoplastic bone and osseous matrix formed by connective tissue cells is?
Osteosarc
Which osteosarcoma is mc, conventional or juxtacortical?
Conventional
Who gets conventional osteosarcoma?
Male, 10-25
A patient with a osteosarcoma presents with?
Intermittent pain
If diagnosis of an osteosarcoma is delayed, patient may present with?
Pathologic fracture, pneumothorax, or pain /swelling around knee
What are the 2 mc locations of a conventional osteosarcoma?
Distal femur, proximal tibia
What is the mc x-ray presentation of an osteosarcoma?
Increased bone density, aggressive periosteal response, soft tissue mass
What is the classic sign of an osteosarcoma?
Spiculated sunburst periosteal response
Periosteal osteosarcoma is one type of?
Juxtacortical osteosarc
What tumor is found in the diaphysis and metaphysis?
(NOF) Non Ossifying Fibroma
What is the mc monostatic tumor?
Osteoid osteoma
What tumor is mc in skull?
Osteoma
What tumor is mc in spine?
Hemangioma
What tumor is mc in knee/proximal fumur?
Osteosarcoma
What tumor is mc in hands?
Enchondroma
What 2 tumors are mc in metaphysis?
Osteosarcoma, (ABC) aneurismal bone cyst
What 2 tumors are mc in diaphysis?
Ewing's, myeloma, and non-Hodgkin's lymphoma
What tumor is mc in epiphysis AND metaphysis?
Giant cell, (ABC) aneurysmal bone cyst
What tumor is mc in epiphysis?
Chondrobalstoma, Giant cell tumor in younger people
What 2 tumors are parosteal?
Parosteal Osteosarcoma, Juxtacortical chondroma
What 2 tumors are mc central?
Endchondroma, bone cyst
What are the 4 large >6cm tumors?
Fibrous Dysplasia, (ABC) aneurismal bone cyst, (SBC) simple bone cyst, and Giant cell tumor
What 2 tumors are cortical?
Osteoid osteoma, Fibrous cortical defect
Which 4 tumors are mc eccentric?
Ewing's, Giant cell, Osteosarcoma, and Chondromyxoid fibroma
What are 2 characteristics of simple bone cysts?
3-13 in number, located in the proximal humerous
What lesion is found in soft tissue?
Myositis ossificans
Medullary scalloping means?
Central or eccentric
What is the dominant internal extracellular substance of a tumor?
Matrix
Imperceptable margination is AKA?
Wide zone of transition
This matrix type appears as ground glass or smokey?
Fibrous matrix
This matrix type appears as stippled, flocculent, popcorn, ring, comma, or arc like?
Cartilage matrix
A lesion with a sharp, sclerotic margin is most likely?
Slow-growing
Which lesion has a sharp margin, but is aggressive?
Multiple myeloma
This matrix type appears as diffuse, hazy, cotton, or cloud like?
Osseous matrix
This type of cartilage tumor matrix occurs in devitalized tissue?
Dystrophic
Which 2 geographic lesions are aggressive?
Solitary plasma cytoma, multiple myeloma
Which tumor forms new bone?
Osteosarcoma
Which 2 lesions lay down reactive new bone?
Degenerative sclerosis, metastasis
Acid phosphatase is only active with which cancer?
Prostate
What are the mc osteoblastic tumors in each sex?
Female- breast male- prostate
What are the mc osteolytic tumors in each sex?
Female- breast male- lung
What is the difference between calcification and ossification?
Calcification is disorganized
Localized cortical expansion indicates?
Slow-growing tumor
Localized cortical penetration indicates?
Aggressive tumor
Local cortical erosion indicates?
Scalloping (fibrous and cartilaginous)
What are 3 interrupted periosteal responses of aggressive tumors?
Laminated, Spiculated, and Codman's triangle
Which slow growing lesion is malignant?
Giant cell tumor
What 3 benign tumors exhibit soft tissue extensions?
Giant cell, ABC, and Osteoblastomas
A lesion that leaves debris and destroys bone segmentally is most likely?
Infection
What 3 tumors have an aggressive response in young people?
Osteosarcoma, Ewing's sarcoma, and Osteomyelitis
One tumor that obliterates the cortex is?
Osteolytic metastasis
Which non-neoplastic tumor might exhibit soft tissue components?
Osteomyelitis
What 5 irritants form bone?
Blood, pus, neoplasm, edema, granulation tissue
What two diseases form a solid periosteal response?
Hypertrophic pulmonary osteoarthropathy, osteoid osteoma
What are the 3 types of interrupted periosteal response?
Laminated, spiculated, Codman's triangle
What disease forms a laminated periosteal response?
Ewing's
What 2 diseases form a spiculated periosteal response?
Osteosarcoma, benign hemangioma
Periosteum progressively lifted by an irritant is called?
Codman's triangle
Codman's triangle was thought pathognomic for?
Osteosarcoma
Codman's triangle may also result from?
Granuloma, infection
What causes erosion of bone?
Pressure on outside of bone
Name 3 lesions that erode vertebral bodies?
Ostelytic METS, Myeloma, and Plasma Cytoma
What are the mc locations for bone resorbtion?
Terminal tufts and clavicles
What 3 soft tissue changes accompany tumors?
Displaced skin, altered myofascial planes, increased or decreased density
How are tumors differentiated from infections and edema at myofacial plane lines?
Tumors- displace myofacial plane lines - infections, edema - obliterate myofacial plane lines
T/F Generally tumors don't cross joints or open physes?
True
The only two exceptions of joint crossing tumors are?
Chondrosarcoma - crosses joint whereas anurysmal bone cyst - crosses open physis
Osteitis deformans is aka?
Paget's disease
In which countries is Paget's mc?
GB, NZ, AUS, Northern US
What are its key pathlogic features of Paget's?
Disordered and extremely active bone remodeling
What is the histologic hallmark of Paget's?
Mosaic pattern
What is stage I Paget's called?
Osteolytic destructive or monophasic
Which cells are most active in stage I Paget's?
Osteoclasts
What are the mc sites in stage I Paget's?
Skull, tibia
What is stage II called?
Combined, mixed, reparative, or biphasic
What is its pathologic hallmark of stage II Paget's?
Excessive and disorganized bone formation
What are the mc sites of stage II Paget's?
Pelvis and proximal femur
What is stage III Paget's called?
Sclerotic, ivory, or cool
What happens in stage III Paget's?
Osteoclast activity decreases, abnormal bone deposition continues, then declines
What are the mc locations for stage III Paget's?
Pelvis, vertebra
What usually follows stage III Paget's?
Stage II
What follows stage II Paget's?
Stage I or III
Does Paget's skip stages Paget's?
No
How often does stage III go to stage IV Paget's?
Rarely
How often does Paget's reach stage IV?
0.9%-2%
What is stage IV Paget's called?
Malignant degeneration
What is the key pathologic feature in stage IV Paget's?
Many different phases in different bones same time
What follows stage IV Paget's?
Osteosarcoma or fibrosarcoma
What is the mc stage of Paget's seen radio graphically?
Stage II
What are the lab features of Paget's?
Increased alkaline phosphatase and urinary hydroxyproline, normal calcium and phosphorus
Who gets Paget's?
Males over 40
What are the mc symptoms of Paget's?
Dull pain at rest & at night, increasing hat and shoe size
What is the first imaging study that should be done in Paget's?
Bone scan
What are the primary radiologic features of Paget's?
Cortical thickening, bone enlargement, coarse trabecular pattern, increased bone density
What are the secondary radiographic features of Paget's?
Subarticular extension, pseudofracture, bowing deformity, pathologic fractures
What is the mc cause of VBAI?
Stenosing of foramen d/t Paget's
Stage I Paget's in the skull is called?
Osteoporosis circumscripta
Thickening of diploic space in stage II is called?
Cotton wisp appearance
Stage II in spine shows as?
Picture frame appearance or squared off vertebra
Vertial accentuation of trabecula in stage II is called?
Hemangiomatous appearance
Stage III in spine shows as?
Ivory vertebra
What causes ivory vertebrae?
Increased bone deposition and compression fractures
How can ivory vertebrae affect the nervous system?
Spinal stenosis
What is the mc location to see Paget's?
Pelvis
What signs may be seen in the pelvis?
Thickened cortex, coarse trabecular pattern, brim or rim sign, obliteration of Kohler's teardrop, protrusio acetabuli
What is the 2nd mc location to see Paget's?
Femur
What are the 4 key signs of Paget's in the femur?
Incresed bone density, bone enlargement, cortical thickening, prominent trabeculae, Ward's triangle
What is the 2nd mc site to see Stage I Paget's?
Tibia
What are the 3 mc signs of Paget's in the tibia?
Blade of grass appearance, saber sheath, pseudofractures on anterior tibia
What is the blade of grass appearance?
V-shaped (or dagger-shaped) lucency pointing down
What is the saber sheath?
Anterior bowing of tibia
Who gets a perioseal osteosarcoma?
Males 25-40
What is the mc location of a perioseal osteosarcoma?
Posterior proximal humerus
What is its 2nd mc location of a perioseal osteosarcoma?
Posterior distal femur
How does the prognosis of a perioseal osteosarcoma compare with conventional osteosarcoma?
Better
What is the mc malignancy of hand, sternum, and scapula?
Malignant chondrosarcoma
Malignant chondrosarcoma is aka?
Primary central chondrosarcoma
Describe a malignant chondrosarcoma lesion?
Osteolytic lesion with calcifications in the matrix
What is the pattern of calcification of a malignant chondrosarcoma?
Spiculated or flocculated arcs or rings
Endosteal scalloping of a malignant chondrosarcoma indicates?
Cartilaginous or fibrous tumor
A soft tissue mass with calcifications in it indicates?
Advanced lesion
What primary bone tumor forms this lesion?
Chondrosarcoma
Cartilaginous tumor with calcification must be?
Chondrosarcoma or enchondroma
Hereditary multiple exostoses are?
Multiple osteochondromas
What do multiple osteochondromas degenerate into?
Malignant chondrosarcoma
A well-marginatedlytic lesion in the pubic ramus with calcification in the matrix is considered primary or secondary?
Secondary chondrosarcoma
A primary malignancy that produces the largest soft tissue mass, with bone sequestration and doesn't have bone or cartilage in thematrix is?
Fibrosarcoma
What is the 5 year survival rate of a fibrosarcoma?
30 %
Who gets a fibrosarcoma?
Males, 20-60
A fibrosarcoma is mc found near what joint?
Knee
What are the symptoms of a fibrosarcoma?
Pain and swelling
Patient presents with pain, swelling, a soft tissue mass with dilated blood vessels, and a fever, but not warm skin. Likely diagnosis is?
Ewing's
Who gets Ewing's sarcoma?
Males 5-25
What are the mc locations for a Ewing's sarcoma?
Femur, tibia
What is the mc primary osseous malignancy to matastasize to bone?
Ewing's sarcoma
What is its 5 year survival rate for a Ewing's sarcoma?
35%
What is its mc periosteal response of a Ewing's sarcoma?
Hair on end
What is the mc osseous malignancy to present with a pathologic fracture?
Non-Hodgkins Lymphoma
Who gets non-Hodgkins lymphoma?
Female 20-40
What is its mc location for non-Hodgkins lymphoma?
Lower extremity
What is its periosteal response for non-Hodgkins lymphoma?
None
What is its 5 year survival rate of non-Hodgkins lymphoma?
60-70%
What is the mc osseous malignancy?
Multiple myeloma
What is the pathology of multiple myeloma?
Abnormal proliferation of plasma cells in bone
Who gets it multiple myeloma?
Males, 50-70
What is the first symptom of multiple myeloma?
Low back pain
40% of patients with multiple myeloma have ______ in urine.
Bence Jones protein
What is its mc location for multiple myeloma?
Spine
What does multiple myeloma show on a bone scan?
Nothing
What is the hallmark of multiple myeloma?
Multiple punched out lesions
What is the 3 year survival rate for multiple myeloma?
10%
What large osteolytic midline lesion crosses joints and causes bowel and bladder problems?
Chordoma
Who gets a chordoma?
Males over 40
What is its mc location for a chordoma?
Sacrum / coccyx
What is the prognosis if a chordoma spreads to the spine?
Die in <3 years
What is the mc benign tumor of the sacrum?
Giant cell
Who gets Giant cell tumors?
Age 20-40
Who is more likely to have a benign Giant cell tumor?
Females
What are the signs and symptoms of a Giant cell tumor?
Tenderness, swelling, soft tissue mass
What is its mc location of a Giant cell tumor?
Knee
What are the differentials for a Giant cell tumor?
Goes to end of bone, soft tissue mass smaller than fibrosarcoma
What is the 5 year survival rate if the Giant cell tumor is malignant?
5-8%