2015 Tumor (Whisper & Sing)

Front 1

• ppx:75% of pt < 20 yrs, + 6 M incrg knee pain & PE-recently noticed mass in knee. (prox hum, prox fem, dis fem, prox tib)
• xray/ct:Expansive, eccentric and lytic lesion with bony septae & MRI- Fluid levels & Edema in surrounding tissue
• risk factors-hx of prior radiation
• >histo=high grade sarcoma with mitotic figures with intervening cellular areas & lakes of blood mixed with malignant cells

2.What is the most likely dx,

-DDX & MC compliation?

Back 1

1.-dx=Telangietic Osteosarcoma

-DDx-ABC:Aneurysmal Bone Cyst

mcc=pathologic fx increased risk of recurrence

Hint 1

• • Gentics mutations-oncogenes: c-fos, c-myc, HER2/neu
    • tumor suppressor genes-Rb-1, p53,

Front 2

• px:75% of pt < 20 yrs, + 6 M incrg knee pain & PE-recently noticed mass in knee. (prox hum, prox fem, dis fem, prox tib)
• xray/ct:Expansive, eccentric and lytic lesion with bony septae & MRI- Fluid levels & Edema in surrounding tissue
• risk factors-hx of prior radiation

2.What is the most appropriate first step in management & dx,

DDX ->TX?

Back 2

2.multi-agent neoadjuvant chemotherapy (ex. adriamycin, cis-platinum, methotrexate, and ifosfamide) x 8-12 wks

• surgical resection (limb-salvage /amputation),
• additional adjuvant chemo x 6-12 Mths.
• dx=telangiectatic osteosarcoma
• DDX-ABC's=intralesional curettage & BG

Front 3

• px:75% of pt < 20 yrs, + 6 M incrg knee pain & PE-recently noticed mass in knee. (prox hum, prox fem, dis fem, prox tib)
• xray/ct:Expansive, eccentric and lytic lesion with bony septae & MRI- Fluid levels & Edema in surrounding tissue
• risk factors-hx of prior radiation

3.most important predictor of good outcome DX?

& poor outcome,

Back 3

• 98% necrosis with chemo = good prognostic sign,
• dx=telangiectatic osteosarcoma
• poor=advanced tumor stage is most important indicator
• increased lactate dehydrogenase (LDH) and alkaline phosphatase (ALP)
• expression of multi-drug resistance (MDR) gene

Front 4

1. -dx & DDX
2. -tx
3. -MCComplic

Back 4

1. -dx=Telangietic Osteosarcoma

   
   

   -ddx-ABC:Aneurysmal Bone

2. -multi-agent neoadjuvant chemotherapy, surgical resection, additional adjuvant chemotherapy for 6-12 months.
3. -increased risk of recurrence with displaced, pathologic fx

Hint 4

1. increased risk of recurrence with displaced, pathologic fx

Front 5

• px:20-50 yo f/male c/o thumb swelling and pain x6 M. He denies a hx of trauma or previous problems with the thumb.
• xray/ct:benign-appearing, well-defined in diaphysis; calcified “popcorn stippled” no endosteal disruption or erosion.
• (risk factors-calcified phleboliths)

1. next best diagnostic study to confirm dx, (looking for) & DDx, MC comorbidity causing complication?
2. if no pain#2 diagnostic study Dx?

Back 5

1 skeletal survey r/o Ollier's dz (multiple enchondromatosis) & Maffucci's syndrm

ddx=Bone infarct, Low grade chondrosarcoma

• angiomas=Maffucci's syndrome

2.Bone scan r/o chondrosarcoma , enchondroma & dx polyostotic dz

Front 6

• px:20-50 yo f/male c/o thumb swelling and pain x6 M. He denies a hx of trauma or previous problems with the thumb.
• xray/ct:benign-appearing, well-defined in diaphysis; calcified “popcorn stippled” no endosteal disruption or erosion.
• (risk factors-calcified phleboliths)
• dx,

1What is the most appropriate first step in management & DDX & TX?

Back 6

dx-enchondroma

-if NO Pain, tx=observance & repeat radiographs in 3-6 months

-if PAIN, tx= Curretage and bone grafting

ddx-bone infact tx-observ, Low grade chondrosarcoma tx- wide excision ray resection or partial hand amputation.

Front 7

• px:20-50 yo f/male c/o thumb swelling and pain x6 M. He denies a hx of trauma or previous problems with the thumb.
• xray/ct:benign-appearing, well-defined in diaphysis; calcified “popcorn stippled” no endosteal disruption or erosion.
• (risk factors-calcified phleboliths)

poor outcome,

-DX?

Back 7

poor-multiple enchondromas and soft-tissue angiomas ; risk of malignant transformation up to 100%

-enchondroma

Front 8

1. -dx & DDX
2. -tx
3. 3 MCComplic

Back 8

1. dx-enchondroma
2. ddx-CSA. bone infact
3. Malignant transformation ollier's <30% muffucci-100%

Hint 8

Front 9

• -10-20 yo, painful 2^to irritation of tendons
• XR/CT:well-demarcated, shallow cortical defect
• punctate mineralization (calcification)
• histo bland hyaline cartilage, small chondroid cells in lacunar spaces

1. dx
2. DDx
3. What is the most appropriate treatment for this tumor?

Back 9

1dx=Periosteal chondromas

• -ddx-chondrosarcoma
• -tx=Marginal excision including the underlying cortex

Front 10

1. dx
2. tx

Back 10

1. Periosteal chondromas

2. Marginal excision including the underlying cortex

Hint 10

Front 11

1. -dx
2. -tx
3. -MCComplic

Back 11

1. Chondromyxoid Fibroma,-intralesional curretage and bone grafting (or PMMA

   
   
   • Recurrence
     • occurs in 25% of cases

Hint 11

Front 12

1. -based on histology image what is the Dx & def?
2. -tx
3. -describe histo

Back 12

1. -synovial chondromatosis=proliferative disease of the synovium +cartilage metaplasia=>multiple intra-articular loose bodies
2. -open or arthroscopic synovectomy and loose body resection -severe symptoms affecting range of motion
3. cartilage nodules are primarily visible on MRI
4. discrete hyaline cartilage nodules in various stages of calcification and ossification
5. -chondrocytes
   • mild atypia
   • binucleate cells
   • occasional mitoses

Hint 12

• knee is most common location

Front 13

47-year-old man presents with right groin pain.

1. -dx & def
2. -tx
3. -MC MRI finding?

Back 13

1. -synovial chondromatosis & benign metaplastic process which requires symptomatic treatment
2. -open or arthroscopic synovectomy and loose body resection -severe symptoms affecting range of motion
3. -knee-cartilage multiple intra-articular loose bodies

Hint 13

multiple intra-articular loose bodies

Front 14

• Hx: young adults 30-50 M>F, pain in 1 jnt->persists for months, or even yrs, does not ease w/exercise, steroid injection or heat tx,
• PT => restriction of ROM
  • no weight loss
  • pain & swelling
    • pain worse with activity
  • PE:mechanical sx + stiffness
  • knee MC location
• decreased ROM
  • + warmth, erythema, or tenderness
  
  
  1. -next best study to confirm dx
  2. -what is the next most appropriate step in Management?
  3. -outcome & tX?

Back 14

1. -if xray neg stippled calcification then 2-MRI synovial chondromatosis
2. -arthroscopic synovectomy and loose body resection
3. -treatment is symptomatic but may help prevent degenerative joint changes

Hint 14

• occasional chromosome 6 abnormalities have been found

Front 15

1. -based on histology image what is the Dx & def?
2. -tx?
3. -describe histology

Back 15

1. -Synovial Sarcoma, Malignant soft tissue sarcoma which arises near joints, but rarely within the joint, cellular origin of synovial sarcoma is unknown, but it is not the synovial cell or any cell involved in the synovium

2. -wide surgical resection with adjuvant radiotherapy + chemo

3. -classical synovial sarcoma shows a biphasic appearance with two typical cell types

4. spindle cells (fibrous type of cells)
   • relatively small and uniform and found in sheets of malignant appearing cells with minimal cytoplasm and dark atypical nuclei
5. epithelial cells
   • gland, nest, or cyst like cells

Hint 15

• -most common sarcoma found in young adults
• most common malignant sarcoma of the foot

Front 16

A 22-year-old female has a painful foot mass. regional lymphadenopathy

-XR/CT- calcification in the soft tissue mass ?

1. -What is the most likely dx & def?
2. tx
3. tumor stains pos? 4

Back 16

1. -Synovial Sarcoma, Malignant soft tissue sarcoma which arises near joints, but rarely within the joint

2. wide surgical resection with adjuvant radiotherapy, chemotherapy may improve both local control and overall survival

3. vimentin
4. epithelial membrane antigen
5. sporadic S-100

epithelial cells stain positive for keratin

Hint 16

• chromosomal translocation t(X;18) is observed in more than 90% of cases

• translocation forms the SYT-SSX1, 2, or 4 fusion protein

Front 17

29-year-old male presents with deep pain & swelling of the Rt foot. He first noticed pain and swelling 1 year ago, which has been steadily increasing over this time. He denies any recent trauma, travel or systemic symptoms. XR- calcification in the soft tissue mass

dx?

1. -next best study to confirm dx (2) DX?
2. -what is the next most appropriate step in Management?
3. most important predictor of good outcome vs poor?

Back 17

1-Synovial Sarcoma,

-genetic/karyotyping, blood/BM chrom translocation t(X;18)

• fusion protein=>SYT-SSX1, 2, or 4
• Immunostaining ->
  • • vimentin, epithelial membrane antigen EMA
    • sporadic S-100, keratin
    
    
    1. wide surg resection with adjuvant radiotherapy,+ chemo
    2. stage with LN Bx, pre-surgery or post-surgery->, chemotherapy
    3. poor-lung mets MC large, deep, and high grade sarcomas
    4. good-low histologic grade, no mets

Hint 17

• overall prognosis is poor
  • 5 year survival is approximately 50%
  • 10 year survival is approximately 25%

Front 18

mn-epiphyseal tumors

Back 18

1. chondroblastoma,
2. giant cell,
3. clear cell sarcoma

Front 19

• occasional chromosome 6 abnormalities have been found, DX

Back 19

Synovial Chondromatosis

Hint 19

multiple intra-articular loose bodies

Front 20

def Metaplasia, in contrast to neoplasia, is a process? ex? tx?

Back 20

• where one cellular phenotype transforms into another cellular phenotype, each non-cancerous
• examples are the synovial transformation to chondroid tissue in synovial chondromatosis
• symptomatic treatment

Hint 20

-multiple intra-articular loose bodies

-Synovial Chondromatosis

Front 21

In a older adult with loss of joint space treatment of painful synovial chondromatosis of the hip is? young adult tx?

Back 21

1. arthroplasty is recommended.
2. Arthroscopic removal of loose bodies

Hint 21

Front 22

chromosomal translocation t(X;18) is observed in more than 90% of cases, dx?

Back 22

Synovial Sarcoma

Hint 22

Front 23

translocation forms the SYT-SSX1, 2, or 4 fusion protein, dx

Back 23

Synovial Sarcoma

Hint 23

biphasic appearance with two typical cell types

Front 24

• which sarcomas, the lung is most common site of metastasis?

Back 24

Synovial Sarcoma

Hint 24

biphasic appearance with two typical cell types

Front 25

soft tissue sarcomas which can metastasize to lymph nodes, mn

Back 25

RACES

1. rhabdomyosarcoma
2. Angiosarcoma
3. Clear cell sarcoma
4. epitheliod sarcoma
5. synovial sarccoma

Front 26

• most common sarcoma found in young adults (15-40 years)

Back 26

1. synovial sarccoma

Hint 26

biphasic appearance with two typical cell types

Front 27

it is the most common malignant sarcoma of the foot

Back 27

1. synovial sarccoma

Hint 27

biphasic appearance with two typical cell types

Front 28

1. -based on histology image what is the Dx & def?
2. -tx?
3. -describe histology

Back 28

1. -Malignant Peripheral Nerve Sheath Tumor, peripheral nerve or neurofibroma aka. neurofibrosarcoma or malignant schwannoma
2. -wide surgical resection + radiation, in general, treated as high-grade sarcoma, chemotherapy not useful
3. spindle cells with wavy nuclei resembling fibrosarcoma
4. -

Hint 28

• Immunohistochemistry
  • positive S100 stain
  • keratin staining is negative
  • - The MRI shows the classic "target sign" on fluid sensitive imaging.

Front 29

• soft-tissue mass

• most arise from large nerves (sciatic, brachial plexus)
• motor and sensory deficit of the affected nerve
• -A 45-year-old man presents for evaluation of 6 months of radicular buttock pain.
• -next best study to confirm dx (2)
• -what is the next most appropriate step in Management?
• most important predictor of good outcome vs poor?

Back 29

1. -Immunohistochemistry
   • positive S100 stain
   • keratin staining is negative->Malignant Peripheral Nerve Sheath Tumor
2. -wide surgical resection ( should include entire affected nerve) + radiation, treated as high-grade sarcoma, perform preoperative adjuvant radiation chemotherapy not useful
3. -poor-most cases associated with NF-1, 30% (5-year survival)

Hint 29

Genetics

• most cases associated with NF-1

Front 30

• Prst:soft-tissue mass

• most arise from large nerves (sciatic, brachial plexus)
• motor and sensory deficit of the affected nerve
• -histo-spindle cells with wavy nuclei resembling fibrosarcoma
• -serial MRI may show enlargement of previous benign nerve sheath lesion suggesting malignant transformation
• -Bone scan, mildly positive

1. -What is the most likely dx & def?
2. -tx
3. -tumor stains pos? 4

Back 30

1. Malignant Peripheral Nerve Sheath Tumor, neurofibrosarcoma or malignant schwannoma
2. wide surgical resection + radiation, include entire affected nerve
3. Immunohistochemistry
   • positive S100 stain
   • keratin staining is negative

Hint 30

MRI shows the classic "target sign" on fluid sensitive imaging

Front 31

1. -mn-small round blue cell
2. -age group, factoid

Back 31

LERNM

1. -Lymphoma middle age, cd45,
2. -Ewings young ad, 11:22CD99;
3. -Rhabdo-kids desmin;
4. -Neuroblastoma-infants NSB,NB84;
5. -Myeloma (older)-SPEP/UPEP, IHC.IgG/A

Front 32

MC CA that develops as a result of chronic draining wounds from osteomyelitis sinus tracts or pressure sores or burn scar?

Back 32

Marjolin’s ulcers=> squamous cell carcinoma

Front 33

can arise following irradiation and poly-vinyl chloride exposure., tumor in the hand often has central necrosis that is manifested with overlying skin changes.?

-most appropriate step in Management? DX?

tx?

Back 33

-angiography helps determine the extent of the lesion and may show metastasis" and MR imaging is valuable for evaluating the size and extent of the lesion.

-angiosarcoma.

• -wide surgical resection
  • indications
    • treatment of choice
    • relatively insensitive to chemotherapy and radiation
  • -amputation
    • indications
      • to achieve local control of disease
      • very aggressive tumor

Hint 33

specimen stains positive for CD31 endothelial marker

Front 34

• most common subungual malignancy
• MC located dorsum of hand and forearm
• primary risk factor is excessive exposure to ultraviolet radiation

Back 34

squamous cell carcinoma

Front 35

classic clinical presentation is the triad of fingertip pain, tenderness, and sensitivity to the cold

Back 35

Glomus Tumor

Front 36

• clinical presentation is the triad of fingertip pain, tenderness, and sensitivity to the cold
• Physical exam
  • small bluish nodule
  • often difficult to see, especially in the subungual location
  • nail ridging or discoloration is common

Back 36

Glomus Tumor

Front 37

• a syndrome characterized by multiple intramuscular myxomas associated with monostotic or polyostotic fibrous dysplasia

Back 37

Mazabraud's syndrome

Front 38

• MRI
• homogeneous appearance
• bright T2 signal
• dark T1 signal
• intramuscular location of _____ is important to differentiate from ______ which occurs in anintermuscular location

Back 38

myxomas

myxoid liposarcoma,

Front 39

1) intramuscular location, 2) relatively homogenous appearance on MRI,

3) bright T2/dark T1 signal - suggesting a myxoid tumor,

4) bland, hypo-cellular myxoid appearing histology that does not show cellular atypia in the relatively homogenous cells without nuclear atypia, mitotic figures, or high nuclear to cytoplasmic ratio.

1. dx
2. tx
3. syndrome characterized by multiple intramuscular myxomas associated with monostotic or polyostotic fibrous dysplasia
4. intermuscular location important to differentiate from a ____

Back 39

1. -Intramuscular Myxomas
2. -. local surgical excision is the treatment of choice and recurrence is extremely rare observation indications
   • for asymptomatic lesions
3. -Mazabraud's syndrome
4. myxoid liposarcomas

Front 40

Several methods exist to predict the risk of pathologic fracture. These include (3)

Back 40

1. -the presence of significant functional pain
2. > 50% destruction of cortical bone
3. formal staging systems
   • Harington's criteria
   • Mirel's criteria

Front 41

Harington's criteria vs Mirels criteria compare contrast

- in Mirels criteria
score___suggests prophylactic fixation

Back 41

Harington's criteria

• > 50% destruction of diaphyseal cortices
• > 50-75% destruction of metaphysis (> 2.5 cm)
• Permeative destruction of the subtrochanteric femoral region
• Persistent pain following irradiation

• Mirels criteria
  score > 8 suggests prophylactic fixation

  
  

  Score

  
  

  -Site

  
  

  -Pain

  
  

  -Lesion

  
  

  -Size

  
  

Front 42

• following surgery refer the patient to radiation oncology for post-operative radiotherapy treatment to
  • (3)

Back 42

1. -decrease pain
2. -slow progression
3. -treat remaining tumor burden not removed at surgery

Front 43

In terms of life expectency,___& ___have the worst median survival (<6 months) and 5 year survival (<5%) when bone metastases are present.

Back 43

lung cancer and melanoma

Front 44

if the diagnosis of malignancy or aggressive tumor is favored, or a soft-tissue mass greater than 5cm in diameter is present, ____prior to biopsy.

Back 44

that these should be referred to an orthopedic oncologist

Front 45

clinician must be able to classify the patient as having (4)

Back 45

1. - non-progressive primary benign bone tumor
2. -progressive primary benign bone tumor
3. -primary malignant bone tumor,
4. -metastatic bone tumor.

Front 46

If the clinical and radiographic information favors a diagnosis of malignant or aggressive benign bone tumor, then___.

Back 46

-then clinician should refer the patient to an experienced orthopaedic oncologist without performing additional diagnostic tests or a biopsy. If a soft-tissue mass is 5 cm in diameter or larger on physical examination, and especially if it is deep to the fascia, the patient should also be referred to an orthopaedic oncologist, without additional evaluation or biopsy, because of the relatively high probability that the mass is malignant.

Front 47

If a soft-tissue mass is 5 cm in diameter or larger on physical examination, and especially if it is deep to the fascia, then bx yes no? ____, why?

Back 47

- patient should also be referred to an orthopaedic oncologist, without additional evaluation or biopsy,

-because of the relatively high probability that the mass is malignant.

Front 48

diagnostic strategy was simple and highly successful for the identification of the site of an occult malignant tumor before biopsy in patients who had skeletal metastases of unknown origin. tx plan? 7 steps

Back 48

-1:medical history & physical examination;=occult primary site of the malignant tumor in three patients (8 per cent), breast, bladder, kidney

-2:routine laboratory analysis;

-3:plain xr of the involved bone

4;XR chest-carcinoma of the lung (43 %).

-5: whole-body technetium-99m-phosphonate bone scintigraphy;

-6:CT-C-15%/A/P-13% K/L/Colon

-7:biopsy of the most accessible osseous lesion-8%

Front 49

On the basis of the biopsy alone, we were unable to identify the primary site of the malignant tumor in ___of the patients.

Back 49

(65 per cent)

Front 50

-diagnostic strategy was simple and highly successful for the identification of the site of an occult malignant tumor before biopsy in patients who had skeletal metastases of unknown origin

-what % success?

Back 50

(85 per cent)

Front 51

the___ is the most common site for all boney metastasis,

Back 51

spine

Front 52

the _____ is the most common site for pathologic fracture secondary to metastasis to bone.

Back 52

proximal femur

Front 53

A 43-year-old women presents with a long-standing history of pain at the tip of her right non-dominant middle finger. Pain is exacerbated by cold weather. She denies systemic symptoms or preceding trauma. She has seen a number of physicians but no formal diagnosis as been made. Physical examination reveals no distinct mass or color change. Pain is reproduced by palpating over the ulnar nail bed of her distal middle finger.

-xray=>pressure erosion of the underlying bone and an associated deformity of the bone cortex

1. -next best study to confirm dx (2)
2. -what is the next most appropriate step in Management?
3. most important predictor of good outcome vs poor?

Back 53

1. -Glomus Tumor-
2. MRI images, respectively. There is a well-defined nodular lesion in the distal middle finger. The small lesion (usually <7mm) is mildly hyperintense on proton density-weighted image and markedly hyperintense on T2-weighted scans.

Hint 53

triad of fingertip pain, tenderness, and sensitivity to the cold.

Front 54

1. -based on histology image what is the Dx & def?
2. -tx?
3. -describe histology

Back 54

1. dx-glomus tumor, glomus body is a perivascular temperature regulating structure frequently located at the tip of a digit or beneath the nail
2. excision with no recurrence
3. well-defined lesion lacking cellular atypia or mitotic activity
   • small round cells with dark nuclei
   • associated small vessels in a hyaline/myxoid stroma
4. can show gland-like or nest structures, separated by stromal elements

Hint 54

triad of fingertip pain, tenderness, and sensitivity to the cold.

Front 55

1. -based on histology image what is the Dx & def?
2. -tx?
3. -describe histology

Back 55

1. -Angiosarcoma, malignant and very aggressive tumor that derives from endothelium of blood vessels
2. -wide range of treatments have been proposed including resection, forequarter amputation, adjunctive radiation, and chemotherapy depending on the extent, metastasis, and aggressiveness of the lesion.
3. -vascular channels with neoplastic cells that have abundant eosinophilic cytoplasm and large nuclei with mitotic figures.

Hint 55

-

• hallmarked with
  • overlying skin changes

-CD31 is a sensitive marker for angiosarcoma

Front 56

34-year-old male with an eleven-year history of hand exposure to polyvinyl chloride presents with hand pain, but no constitutional symptoms. Physical exam shows lesions involving the nail-folds of the thumb, long, and ring finger as well as several soft-tissue masses in the palm.

-histo-malignant cells associated with vascular structures

-xr- eccentric, purely lytic, metaphyseal and diaphyseal lesions, with no visible matrix mineralization

1. -next best study to confirm dx
2. -what is the next most appropriate step in Management?
3. -outcome?

Back 56

1. -"angiography-determine the extent of the lesion and may show metastasis"
2. -MR for evaluating the size and extent of the lesion.
3. -CD31 is a sensitive marker for angiosarcoma
4. resection, forequarter amputation, adjunctive radiation, and chemotherapy depending on the extent, metastasis, and aggressiveness of the lesion.
5. -poor, high local failure rate and amputation is often required
6. propensity for lymphatic spread
7. metastases to lung is common

Front 57

• Prophylactic fixation is preferred to fixation of actual pathological fracture due to (3)

Back 57

• • shorter operative time
  • decreased morbidity
  • quicker recovery

Front 58

if biopsy suggests primary neoplasm of bone (like sarcoma)

-next steps 5

Back 58

1. - may benefit from neoadjuvant chemo/radiotherapy
2. close wound
3. refer to local sarcoma center
4. prior to surgical stabilization,
5. surgical treatment of primary sarcoma will contaminate entire bone with sarcoma and affect ability to perform limb-salvage surgery

Front 59

if biopsy suggests primary neoplasm of bone (like sarcoma) then Radiation therapy

• indications(

Back 59

low Mirels' score

Front 60

• goals of fixation

Surgical fixation primary neoplasm of bone (like sarcoma) 3

Back 60

• maximize ability for immediate mobilization and weight-bearing
• protect the entire bone in setting of systemic or metastatic disease
• optimize implant choice in the context of the patient's overall prognosis

Front 61

• femur with
  • peritrochanteric lesions
    • tx?
  • femoral neck and head lesions
    • tx?

Back 61

• intramedullary nail
• hemiarthroplasty

Front 62

mn-metaphyseal tumor

Back 62

• mn MOCA-

1. Mets, MFH,
2. OSA,
3. CSA,
4. ABC

Front 63

mn-diaphyseal tumor

Back 63

• A,E,I,O,U,Y+METS

1. A-Adamantanoma,
2. E-EG & Enchondroma
3. I-Infection,
4. O-OO/OB,
5. U-Ewings Sar,
6. Y-mYeloma, lYmphoma, fibrous dYsplasia

• METS-PT Barnum Likes Kids Yes Yes
• Prostate-PSA; Thyroid-us; Breast-Mamo; Lung-cxr; Kidney CT abd mYeloma-SPEP/UPEP, skeletal survey; lYmphoma-CT C/A/P

Front 64

1. mn-spine

Back 64

A&P And -Anterior

My Mets Love Home Games:

-My-myeloma,

-METS-mets

-L-LCH, Langerhand histocytosis

-H-hemangiomas,

G-GCT:

:POO Ass-Post-OO, OB ABC

Front 65

2 mn-tumors in sacrum

Back 65

-midline-chordoma

-MAGE-

-METS, MFH

-ABC,

-GCT,

-Eccentric-

Front 66

mn- STS LN mets

Back 66

RACES through the Lymph

--Rhabdo,

-Angiosarcoma,

-Clear Cell Sarc,

-Epithelioid,

-Synovial

Front 67

• Prognosis of bone cancer depends on the following variables (5)

Back 67

• 1. -overall stage of disease, extent to which a cancer has developed by spreading. chest imaging to look for pulmonary metastases + bone scan
  2. -presence of metastasis
  3. -skip (discontinous) lesions within the same bone
  4. -histologic grade
  5. -tumor size

Front 68

two systems - one for malignant lesions and one for benign lesions based on what?

Back 68

• malignant lesions are defined using Roman numerals (e.g. I, II, III)

• Stage

  
  

  Grade

  
  

  Site (1)

  
  

  Metastasis

• benign lesions are defined using Arabic numbers (1,2,3)

• Stage

  
  

  Grade

  
  

  Size

  
  

  Depth

  
  

  Node

  
  

  Metastasis

  
  

  5 yr. survival

Front 69

• e.g. osteosarcoma most commonly presents as stage___

Back 69

IIB

Front 70

prerequisites& prior to a biopsy & purpose

Back 70

purpose: is to confirm a suspected diagnosis

• CBC, platelets, coagulation studies
• cross-sectional imaging to evaluate local anatomy
• treatment center performing biopsy must be capable of proper diagnosis and treatment

Front 71

4 Indications for Biopsy

Back 71

Indications for Biopsy

• 1. A-Aggressive bone or soft tissue lesions
  2. B-soft tissue lesions Bigger > 5cm, deep to fascia, or overlying bone/neurovascular structures
  3. C-C(s)olitary bone lesions in a patient with history of Carcinoma
  4. -D-in Doubt Dx in a symptomatic pt

Front 72

• When a biopsy is NOT indicated 3

Back 72

• When a biopsy is NOTindicated
  1. -Asymptomatic latent bone lesions
  2. -Symptomatic active Bone lesions which appear entirely Benign on imaging
  3. -soft tissue lesion which are completely benign on MRI don't necessarily need a biopsy (e.g. lipoma, hemangioma)

Front 73

MC Types of Biopsy frequently used for sarcoma

Back 73

Core biopsy

Front 74

radiograph that shows a ill-defined lytic lesion with cortical expansion with calficifications suggest what type of process & most likely dx??

Back 74

-lytic appearance with cortical expansion suggests a malignant and aggressive process.

-calficifications suggest a chondroid tumor

high grade chondrosarcoma.

Front 75

A 53-year old female presents to your community hospital with right shoulder pain of 2 weeks duration, night sweats, and loss of appetite. Her past medical history is significant for hypertension only. A radiograph is performed and is shown in Figure A. What is the most appropriate next step in management.

Back 75

Referral to an orthopaedic oncologist

Front 76

Indications of External beam irradiation 3 with ex's

Back 76

1. -Definitive control (primary malignant bone tumors)-Ewing sarcoma/primative neuroectodermal tumor
2. Adjuvant to surgical excision-soft tissue sarcomas-
3. -Palliative care and impending fracture fixation-metastatic bone disease

Front 77

tumors that are not radiosensitive

Back 77

GI and renal tumors

Front 78

• ___ Gray: tissue will likely not heal

Back 78

> 60

Front 79

• ___Gray: usually leads to uncomplicated tissue healing

Back 79

< 45

Front 80

• risk factors for post radiation fracture
  • -Hx-2,
  • -Bone 3-
  • -other1-

Back 80

• -Hx-age & female Sex
• -Bone -1 anterior femoral compartment resection
• -bone -2 periosteal stripping
• -bone 3- osteoporosis
• -radiation dose

Front 81

A 63-year-old female sustains a subtrochanteric femoral fracture after a fall in her home. Five years ago she underwent resection of a left thigh leiomyosarcoma with adjuvant radiotherapy. Which of the following is not a known risk factor for development of pathologic fracture post radiotherapy?

1. Female

2. Age

3. Dose of radiotherapy

4. Periosteal resection during sarcoma removal

5. Adjuvant chemotherapy

Back 81

(5)chemotherapy as an adjuvant treatment has not been shown to increase the risk of post-radiation fracture.

Front 82

A 50-year-old female presents to your office with worsening knee pain of 6 months duration. Radiographs are shown in Figure A and B. She is otherwise healthy and very active. She insists that something be done today to treat her symptoms. Your initial treatment would include

1. Intra-articular cortisone injection now and referral to sarcoma center

2. Staging including chest imaging and bone scan

3. Neoadjuvant chemotherapy

4. Neoadjuvant radiotherapy

5. Limb salvage with mega-prothesis

Back 82

2-hx & XR suggest a potentially malignant process in this pt

-prior to instituting any tx, she needs complete staging.

-Starting treatment prior to full oncologic workup (even if the radiographs suggest a giant cell tumor) including chest imaging to look for pulmonary metastases and a bone scan can have devastating consequences.

-If her pain is so severe that something needs to be done today, admit her for parenteral narcotics and tumor work-up. Pending her work-up, she may need chemo/radiotherapy, referral to a sarcoma center, and limb salvage surgery.

Hint 82

Front 83

define test for Starting treatment ?

Back 83

Staging= chest imaging to look for pulmonary metastases + bone scan

Front 84

history and radiographs suggest a potentially malignant process ---next 2 steps in management?

-most important NOT to do?

Back 84

1. -complete staging =chest imaging to look for pulmonary metastases + bone scan
2. -full oncologic workup/called the metastatic workup,
3. -prior to instituting any treatment,

Front 85

metastatic lesion of unknown primary workup ?

Back 85

1. CT-C/A/P=85 %
2. blood examination and liver function tests
3. bone scan

Front 86

metastatic lesion of suspected based on hx & PE primary workup what is Dx and w/u ?

-BRCA1 or BRCA2 genes in African-American M

Back 86

prostate-PSa

Front 87

metastatic lesion of suspected based on hx & PE primary workup what is Dx and w/u ?

-BRCA genes & p53 in F

Back 87

F=breast-mamograph

Front 88

metastatic lesion of suspected based on hx & PE primary workup , what is Dx and w/u ?

-had head or neck radiation treatments in childhood

Back 88

thyroid- U/S

Front 89

metastatic lesion of suspected based on hx & PE primary workup , what is Dx and w/u ?

-Cancer survivors who had radiation therapy to the chest & arsenic in drinking water

Back 89

lung- CXR

Front 90

metastatic lesion of suspected based on hx & PE primary workup , what is Dx and w/u ?

-cadmium (a type of metal), some herbicides, and organic solvents, particularly trichloroethylene. & American Indians/Alaska Natives have slightly higher rates than do whites

Back 90

kidney- CT abdomen

Front 91

metastatic lesion of suspected based on hx & PE primary workup , what is Dx and w/u ?

Back 91

myeloma-

-SPEP/UPEP

-skeletal survey

Hint 91

Front 92

metastatic lesion of suspected based on hx & PE primary workup , what is Dx and w/u ? - weakened immune systems & infection with the Epstein-Barr virus (EBV)

Back 92

lymphoma- CT-C/A/P

Front 93

Chemotherapy for cancer

• -Mechanism of action
  • -which cells are primary affected?

Back 93

-induces apoptosis

-rapidly dividing cells like the lining of the

• -gut,
• -bone marrow,
• -hair,
• -skin

Front 94

Chemotherapy good prognostic sign & very poor prognosis

Back 94

1. ->98% necrosis with chemotherapy is good
2. -expression of multi-drug resistance (MDR) gene

Front 95

• Chemotherapy Integral component of treatment along with surgical resection in ?
• NOT used in?

Back 95

• • ---osteosarcoma (intramedullary and periosteal)
  • -Ewing's sarcoma/primative neuroectodermal tumor
  • - MFH malignant fibrous histiocytoma
  • -dedifferentiated chondrosarcoma
  • _NOT=chemotherapy for soft tissue sarcoma is controversial

Front 96

Doxorubicin side effects

• aka

Back 96

• -Adriamycin.
• -dose-limiting toxicity of doxorubicin is cardiomyopathy. aka cardiac toxicity

Front 97

Bleomycin side effects

Back 97

Bleomycin is associated with pulmonary fibrosis.

Front 98

Cyclophosphamide side effects

Back 98

Cyclophosphamide is associated with myelosuppression and urotoxicity.

Front 99

Bone scan is cold

Back 99

Multiple myeloma
Melanoma

Front 100

Unknown origin•tumor 4 ex's?

Back 100

Unknown origin•

- Giant cell tumor
• -Histiocytoma•

-Adamantinoma•

-Ewing's tumor

Front 101

Epithelial Glands seen on histology 3

Back 101

Epithelial Glands seen on histology

• Synovial sarcoma (biphasic)
• Metastatic carcinoma
• Glomus tumor

Front 102

Bimorphic histology

•3

Back 102

Bimorphic histology

• Dedifferentiated chondrosarcoma
• Synovial sarcoma
• Osteosarcoma with chondroblastic features

Front 103

Multi-nucleated Giant cells present 3

•

Back 103

Giant cell tumor
• Chondroblastoma
• Aneurysmal bone cyst

Front 104

Hemosiderin pigmentation

• 3

Back 104

Hemosiderin pigmentation

• -NOF
• -PVNS
• -UBC

Front 105

CD99•

Back 105

Ewing's

Front 106

CK125• dx

Back 106

CK125• Ovarian CA

Front 107

CD138•?dx

Back 107

CD138• Myeloma

Front 108

Desmin•dx?

Back 108

Desmin• Rhabdomyosarcoma

Front 109

CK7•

Back 109

CK7• Breast CA
• Lung CA

Front 110

Vimentin

• 3

Back 110

Vimentin

• synovial sarcoma, rhabodymosarcoma, and leiomyosarcoma

Front 111

Bisphosphonate therapy 4

Back 111

-Bisphosphonate therapyMetastatic bone disease (with wide resection and radiation)
-Myeloma (with chemotherapy)
-Paget's disease (with observation)
-Fibrous dysplasia (with observation)

Front 112

Chemotherapy alone 2

Back 112

Chemotherapy aloneLyphoma
Multiple myeloma

Front 113

Wide Resection Alone

•5

Back 113

Wide Resection Alone

• -Chondrosarcoma
•- Parosteal osteosarcoma
• -Chordoma
• -Adamantinoma
• -Squamous cell (if no mets)

Front 114

Wide Resection + Irradiation - 2

Back 114

-Metastatic Bone Disease
•- Soft tissue sarcoma-high grade (angiosarcoma, synovial sarcoma, liposarcoma, desmoid tumor, MFH/fibrosarcoma)

Front 115

1. mn vertebra plana

Back 115

-M-Metts, mylemoma

-E-EG Ewings

-L-Lymoha

-T-trauma TB